CASE 15: BENIGN & NEOPLASTIC LESIONS OF THE VULVA & VAGINA

VULVA Treatment
Common presentation: Mechanical: Cryotherapy, electrocautery, excision, LEEP
PRURITUS (PE: discoloration, white to red lesion) then cauterize or suture the defect,
Mass: palpable protrusion from the surface of the skin, Chemical cautery:
O
o Pain (Pathology: Extensive or 2 infection) o TCA: Safe for pregnancy
Excoriation (due to itchiness) o Podophyllin: Teratogenic effect
Abnormal discharges o Imiquimod: Costly, Long time to take effect

RF: Prevention
Age: If with HPV correlation: At risk to develop cervical cancer
o Young: More exposure to STID, HPV Serotypes: Malignant - 16 & 18 & Benign - 6 & 11
o Older: Possibility of malignancy Vaccine should be given before the onset of having first
Poor hygiene sexual contact (9 years old - 25)
STID’s: HPV, multiple sexual partners 26 – 45 years old: Can still get the vaccination
Uncontrolled DM would lead to attraction of more Males: Bivalent HPV Vaccination (no cervix)
bacteria forming DDX of Vulvovaginal Candidiasis, (Itch Can have PERIANAL CANCER
O
scratch cycle or syndrome 2 to infection)
Autoimmune or Immunocompromised state: TX
chemotherapy drugs, radiotherapy, HIV, prolonged used Depends: Histological diagnosis
of corticosteroids (COPD, asthmatic patients) & Topical steroids or testosterone – apply only at the lesion
antibiotics Prolonged used of steroid: more atrophy
Previous cervical malignancy: possibility of metastasis Not only topical cream: Lichen , Condyloma & Pagets

Mass: Vulvar CA
Take note of: color, shape (dome), smoothness, lesions Most severe pathology
(papule), tip of the lesion (irregular), size, solitary or As primary malignancy is not too common
multifocal, site or location Primary concern: Is it primary or metastatic?
Most common: SQUAMOUS CELL CA (lining epithelium
Diagnostic procedures: of the vulva)
Pathology: Depend on the microscopic & abnormal cells Other kinds: BASAL CELL CA, VERRUCOUS CA,
Keye’s Punch biopsy (white patch – plaque)
Ideal for punch biopsy: patient with gross lesion or white Basal Cell CA:
discoloration in which self-medication has no effect. Ulcerated
Excision for small tissues (getting the whole area with a 2% of vulvar cases
margin of normal tissue around the abnormal tissue to TX: Wide Local Excision
compare the pathology)
Topical Dye: TOLUIDENE BLUE (Abnormal: Unstained) Bartholins Gland CA
Colposcopy: Magnifies the epithelium & see the Located: Posteroinferior lateral lesion of the vulva
microscopic changes: ↑vascularity & abnormal cells. Not cystic but firm & solid
If multiple warty lesions: get 1 sample TX: Do excision, not marsupialization
Multifocal in one area: do excision (DX & TX)
Vulvar Malignancies: Vulvectomy
VULVAR LESIONS o Simple Vulvectomy: WLE: (-) Lymphadenopathy
Leukoplakia: Whitish plaque discoloration (not a DX) o Radical Vulvectomy: (+) Lymphadenopathy
o Metastasis: Inguinal, Inguino-femoral pelvic LN
Lichen sclerosus et atropicus:
FIGO staging
Whitish diffuse appearance
Microscope: Atrophy & marked Carcinoma of the Vulva
thinning of the lining epithelium IA Tumor confined to the vulva or perineum, (-) LN
Thinness: like a cigarette paper ≤ 2cm in size with stromal invasion ≤ 1mm,
Atrophy: due to absence of E IB > 2cm in size or with stromal invasion > 1mm,

II Tumor of any size with adjacent spread

(1/3 lower urethra, 1/3 lower vagina, anus), (-) LN
Paget’s Disease:
Lesion: Beefy red, Pitting, IIIA Tumor of any size with (+) Inguino-femoral LN
Eczematoid, Weeping (i) 1 LN metastasis > 5 mm
Biopsy: Paget’s Cell (ii) 1-2 LN < 5 mm
Request: IIIB (i) > 2LN > 5 mm
o Mammography (ii) > 3LN < 5 mm
IIIC (+) LN(s) with Extracapsular spread
o Colonoscopy
Paget’s disease of the vulva maybe a metastasis from IVA (i) Tumor invades other regional structures (2/3 upper urethra,
other organs such as breast & GIT. 2/3 upper vagina), bladder mucosa, rectal mucosa, or fixed to
pelvic bone
Condyloma acuminata (ii) Fixed or ulcerated inguino-femoral LN
Cauliflower-like lesion (irregular surface) IVB Any distant metastasis including pelvic LN
Pathognomonic Finding: KOILOCYTES
Predilection: Labia, posterior forchet, Post-operative complications:
Perineal sites, perianal area (areas of contact) Wound breakdown or wound dehiscence: leading to
Do speculum: lesions can go through the cervix (external wound infection or SSI or post- operative morbidities
lesions going inwards)
TX:
Surgery
If not candidate for surgery: Radiation
If recurrent: Radiation + Chemotherapy

VAGINA
Vaginal lesions: Either primary or metastatic from the cervical area or from the uterus
Metastasis: Pelvic LN to the ovaries or malignant cells can be thrown off and attach to vaginal ___

RF:
HPV,
HIV (IS),
Previous radiation,
DES exposure in utero resulting to insult while inside the mother’s womb (DES: for threatened abortion)

Common presentation:
Abnormal vaginal bleeding
Mass, Lymphadenopathy: Advanced Stage

RF:
Post-menopausal Age: usual vaginal mucosa is atrophic, when the lesions observe are friable, hemorrhagic, or necrotic think
of malignancy

Diagnostic procedures:
Speculum exam: important to visualize the vaginal mucosa (coincides with age like atrophic vagina: old)
Biopsy
o Except: GTT: CHORIOCARCINOMA (Gestational Trophoblastic Tumors)

ChorioCA
o If there is a violaceous discoloration, ask if she did got pregnant. Past pregnancy can always lead to CC.
o Biopsy should be withheld because it is very vascular kind of tumor (neovascularization) more than any kind of cancer which
can lead to profuse bleeding with just a simple biopsy with the possibility of losing the patient
o Alternative for Biopsy: (+) β HCG titer or pregnancy test,
o TX: Chemotherapy: MTX, Aminomycin
o Adjuctive TX: Surgery (if not responsive in CT)

VAIN I – III: Usually occur at the UPPER 1/3

Malignancies
Most common malignancy: SCCA
Clear cell CA, malignant melanoma, endodermal sinus tumor (yolk sac),
Children: SARCOMA BOTYROIDES (grape like lesions)
o TX: Radiotherapy

Poor prognosis: Clear Cell CA, EST, SB

Overall: 45% 5 years survival

TX
EST: AFP (to follow up)
Radiotherapy & Chemotherapy,
Radical vaginectomy: STAGE (nobody does this anymore)

Radiotherapy Disadvantage:
Fibrosis,
Affect other organs: bladder (cystitis, proctitis) leading to bleeding, hematochezia

CASE 15
67 year old G5P5 (5005) retired school teacher complained of persistent vulvar itching since 3 months ago. External
genitalia: (+) irregularly shaped, reddish, flat lesions measuring 5x4 cm on the posterior aspect of the left labium majus.
Speculum exam & internal exam were unremarkable.

Impression: Paget's Disease

DDX: CA
Work up: vulvar biopsy: WLE(due to small size & external site)
Look for other site: Breast & GIT
Consider ChorioCA since the patient has been pregnant.
Post-pregnancy + vaginal bleeding, vulvar or vaginal
lesions: to consider CA or GC