Vulvar and Vaginal Cancer

Vulvar Cancer - Vulva's Vicious Lesions

• Primarily affects postmenopausal women (peak age 65-75 years).
• Risk Factors:
  • HPV infection (types 16, 18, 31): Younger women; warty/basaloid SCC; associated with Vulvar Intraepithelial Neoplasia (VIN).
  • Chronic vulvar dermatoses (e.g., lichen sclerosus): Older women; keratinizing SCC.
  • Smoking, immunosuppression, history of cervical cancer.
• Histopathology:
  • Squamous Cell Carcinoma (SCC): >90%; keratinizing type is most common overall.
  • Melanoma: ~5%; second most common.
  • Others: Adenocarcinoma (e.g., Bartholin gland), sarcoma.
• Clinical Features:
  • Persistent vulvar pruritus (most common symptom).
  • Visible lesion: lump, ulcer, plaque (red, white, or pigmented).
  • Pain, bleeding, or discharge.
• Diagnosis: Full-thickness biopsy (e.g., Keyes punch biopsy) of any suspicious lesion is mandatory.

⭐ The labia majora is the most common site for vulvar cancer development.

Vulvar Cancer Staging & Management - Staging Showdown & Tactics

• FIGO Staging (Simplified):
  • Stage I: Tumor confined to vulva/perineum.
    • IA: ≤2cm, stromal invasion ≤1mm.
    • IB: >2cm or stromal invasion >1mm.
  • Stage II: Any size, extends to lower 1/3 urethra, lower 1/3 vagina, anus.
  • Stage III: Regional LN metastasis.
    • IIIA: 1-2 LNs (<5mm) OR 1 LN (≥5mm).
    • IIIB: ≥3 LNs (<5mm) OR ≥2 LNs (≥5mm).
    • IIIC: Extracapsular spread in LNs.
  • Stage IV:
    • IVA: Invades upper urethra/vagina, bladder/rectal mucosa, or fixed to bone.
    • IVB: Distant metastasis.
• Lymphatics: Superficial inguinal → Deep inguinal (Cloquet's node) → Pelvic.
• Management Overview:
  • Early (IA, IB, select II): Surgery: Wide Local Excision (WLE)/Radical Vulvectomy ± Sentinel LN Biopsy (SLNB)/Inguinofemoral LND.
  • Advanced (some II, III, IVA): Multimodal: Surgery, Radiotherapy (RT), Chemotherapy (Chemo) (neoadjuvant/adjuvant).
  • Metastatic (IVB): Palliative RT/Chemo.

⭐ For unifocal vulvar tumors <4cm with clinically negative groin nodes, sentinel lymph node biopsy (SLNB) is preferred over full inguinofemoral lymphadenectomy to reduce lymphedema risk and surgical morbidity.

Vaginal Cancer - Vagina's Veiled Threat

• Rare (1-2% of gynecologic malignancies); often metastatic.
• Risk Factors:
  • HPV infection (types 16, 18): Most common.
  • In-utero DES exposure: Risk for Clear Cell Adenocarcinoma.
  • History of cervical/vulvar cancer or dysplasia.
  • Immunosuppression, smoking, prior pelvic radiation.
• Histopathology:
  • Squamous Cell Carcinoma (SCC): ~85%; typically upper 1/3, posterior wall.
  • Adenocarcinoma: ~10%; includes Clear Cell (DES-related) and non-DES types.
  • Melanoma: Rare, aggressive; lower 1/3, anterior wall.
  • Sarcoma Botryoides (Embryonal Rhabdomyosarcoma): Infants/children <5 yrs; grape-like clusters. 📌 "Botryoides = Bunch of grapes"
• Clinical Presentation: Abnormal vaginal bleeding (postmenopausal, postcoital), watery/malodorous discharge, vaginal mass; late: pain, urinary/rectal symptoms.
• Diagnosis: Pelvic exam, Pap smear (may detect), colposcopy with directed biopsy.
• Staging: FIGO clinical staging.

⭐ Diethylstilbestrol (DES) exposure in utero is classically linked to Clear Cell Adenocarcinoma of the vagina, typically in young women (late teens to early 20s).

Vaginal Cancer Staging & Management - Grading Game & Guidance

• FIGO Clinical Staging (Simplified)
  • Stage I: Tumor confined to vaginal wall.
  • Stage II: Tumor invades paravaginal tissues, not to pelvic wall.
  • Stage III: Tumor extends to pelvic wall and/or causes hydronephrosis/non-functioning kidney.
  • Stage IVA: Tumor invades mucosa of bladder/rectum OR extends beyond true pelvis.
  • Stage IVB: Distant metastasis.
• Lymphatic Drainage
  • Upper ⅔ vagina → Pelvic nodes (obturator, internal/external iliac).
  • Lower ⅓ vagina → Inguinofemoral nodes.
  • 📌 Upper to Pelvic; Lower to Inguinal.
• Management Principles
  • Early (Stage I, select IIA): Surgery (radical vaginectomy + LND) or definitive RT.
  • Advanced (most Stage II, III, IVA): Primary RT (EBRT + Brachytherapy) ± concurrent Cisplatin.
  • Stage IVB: Palliative therapy (RT/Chemo).
• Histologic Grade: G1 (well-differentiated) to G3 (poorly-differentiated) impacts prognosis.

⭐ Vaginal intraepithelial neoplasia (VaIN) is a precursor lesion; SCC is the most common type (~85%).

High‑Yield Points - ⚡ Biggest Takeaways

• Vulvar Cancer: Mostly SCC; HPV (younger), lichen sclerosus (older). Key: persistent pruritus. Diagnosis: biopsy. Staging: surgical (FIGO).
• Vaginal Cancer: Mostly SCC, HPV-related. Common site: upper posterior wall. Diagnosis: biopsy. Staging: clinical (FIGO).
• Paget's Disease (Vulva): Intraepithelial adenocarcinoma; presents as red, eczematoid, pruritic lesion.
• DES Exposure: Linked to clear cell adenocarcinoma of vagina/cervix.
• Sarcoma Botryoides: Grape-like vaginal mass in infants/young girls (< 5 yrs).
• Vulvar Lymphatics: Spread to inguinofemoral nodes first; sentinel node biopsy important for early stages.