docPreinvasive Disease of the Vagina and Vulva
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Preinvasive Disease of the Vagina and Vulva
Preinvasive Disease of the Vagina and Vulva Fred Ueland, MD Division of Gynecologic Oncology University of Kentucky Juneau, Alaska Examining… the External Genitalia Dorsal lithotomy position Clitoris and frenulum Urethra and anus Labia majora and minor Introitus Perineum Vulva Conditions… the Labia and Perineum Infection – HPV, HSV – Chancroid, LGV, syphilis – Molluscum contagiosum Dermatologic – Lichen sclerosus, hyperplasia Vulvar HPV Non-neoplastic Conditions Syphilis Non-neoplastic Conditions Condyloma lata Non-neoplastic Conditions Molluscum Contagiosum Non-neoplastic Conditions Squamous hyperplasia Lichen sclerosus Other dermatoses – Psoriasis – Lichen simplex chronicus – Lichen planus – Tinea Non-neoplastic Conditions Lichen Sclerosus Lichen Sclerosus Hyperkeratosis Flattened rete pegs Cytoplasmic vacuoles in basal layer “Pink staining” beneath epidermis Inflammatory infiltrate Hubbard Glacier Vulvar Intraepithelial Neoplasia Same culprit, HPV 50% asymptomatic Increasing incidence – 2 to 3 fold increase Declining age (mean = 40 years) – Tripled in white ♀ under age 35 Appearance – – White, red, or pigmented Flat, raised, macular, papillary, solitary or multifocal Vulvar Intraepithelial Neoplasia VIN VIN 3 VIN Vulvar Intraepithelial Neoplasia Vulvar Intraepithelial Neoplasia Vulvar Intraepithelial Neoplasia VIN 3 Pigmented Lesion Location of Multifocal CIS 70% 20% 45% 60% 40% 92% 30% Vulvar CIS Judson, Obstet Gynecol 2006 13,176 women with CIS and cancer Vulvar CIS increased 400% from 1973 to 2000 CIS increases with age until 50, then ↓ CA increases with age, more rapidly > 50 Vulvar CIS Jones, Obstet Gynecol 2005 Mean age CIS decreased from 50 before 1980 to 39 today 50% require 2nd treatment Synchronous cancer in 4% (vulvar, perianal, urethral) Progression in untreated 1.1-7.3 years (mean = 3.9 years) Paget’s Disease Disease of the apocrine glands – Arm pits, genital, anal regions – Fat containing sweat, odor after bacterial digestion – Excretions via hair follicle Localized or diffuse Hyperemic, well-demarcated, excoriated Prolonged, indolent course if intra-epithelial “Simultaneous” adenocarcinoma in up to 20% Simple, partial vulvectomy with FS margins Radiation can be successful, particularly when anal involvement Apocrine glands Paget’s Disease Paget’s Disease Vulvar Cancer Vulvar Cancer Diagnosis Inspection Vulvoscopy Review outside pathology Biopsy – Lidocaine – Combined diagnosis, treatment in OR Vulvar Biopsy Vulvar Biopsy Vulvar Biopsy Keyes Punch Vulvar Biopsy Vulvar Biopsy Vulvar Biopsy Gold Rush Skagway, Alaska 1898 Population grew to 10,000 (now 862) Gateway to Klondike region of Canada’s Yukon territory The “easy way” – Sail to Skagway, Alaska – Up White Pass, “Dead horse trail” – Hike to Canada and build raft – Float Yukon River to Dawson City Gold Rush Travel Challenges Pack one ton of supplies (2200 lb) - Canadian Mounties at summit “Dead horse trail” littered with abandoned gear, dead horses and mules: 20 miles, 3300 feet Tram operator 425 mile treacherous expedition to Dawson City Examining… the Clitoris Vulvar intraepithelial neoplasia – 70% may involve clitoris or frenulum Tumors Cancer – Squamous cell – Melanoma Clitoral Fibroma Examining… the Urethra Caruncle Urethral diverticulum Urethritis Condyloma Cancer – Squamous, transitional cell, melanoma Urethral Carcinoma Examining… the Vagina Atrophy Infection – HSV, HPV – Candidiasis – Bacterial vaginosis, trichomoniasis Cancer – Squamous cell, melanoma Atrophic Vaginitis Trichomonas VAIN Benedet, J. Reprod Med, 1992 Normal epithelium – Epithelial thickness = 0.28 mm – Menopausal patients 33% thinner VAIN – Epithelial thickness = 0.46 mm – No difference for menopause Recommend treatment to 1.5 mm VAIN Appearance Subtle, often multifocal Punctate, possibly raised Peau d’orange May show acetowhite changes but rarely the mosaicism of CIN VAIN Colposcopy Largest speculum Start at apex and move to introitus Aceitic acid or Lugol’s Alligator biopsy forceps AgNO3, Monsel’s solution Treatment Options VIN and VAIN Excision – Not LEEP CO2 laser vaporization Electrical vaporization (fulguration) Topical therapy – 5-FU – Aldara Surgical Excision Laser Ablation VAIN CO2 Laser Vaporization Colposcopy-assisted 15-20 watts, continuous General anesthesia Destruction depth – 1.0 to 1.5 mm Post-treatment narcotics Medical Treatment VAIN 5-Fluorouracil “Not for intra-vaginal use” – Actinic keratosis, superficial basal cell Daly et al. Obstet Gynecol, 1980 – Post-radiated VIN treated with 5-FU – bid for 10-14 days – NED for 2-5 years 8% non-healing ulcers at 6 months Pregnancy Category X Medical Treatment VAIN Daily 5-Fluorouracil Efudex 5% cream Disp: 25 gram tube Sig: Use ½ applicator (2-2.5 gm) in vagina qHS for 5 nights. Insert tampon and coat vulva with Desitin. In morning, remove tampon and allow medicine to drain into commode. Gently cleanse vulva. Medical Treatment VAIN Weekly 5-Fluorouracil Efudex 5% cream Disp: 25 gram tube Sig: Use 1/3 applicator (1.5 gm) in vagina at night weekly for up to 10 weeks. Insert tampon and coat vulva with Desitin. In morning, remove tampon and allow medicine to drain into commode. Gently cleanse vulva. Medical Treatment Aldara Immune modifier – Induces cytokines, interferon-α, lymphocytes, macrophages Actinic keratosis, superficial basal cell, external condylomata Age 12 and older 72% CR for condylomata 90% with vulvar discomfort, 15% with flu-like symptoms, 20% don’t finish therapy. Pregnancy Category C Medical Treatment Aldara Aldara 5% cream Disp: 250 mg single use packets Sig: Use 1 packet 3 times weekly qHS. Leave on for 6-10 hours and remove with mild soap and water. Use no longer than 16 weeks. Surveillance Colposcopy or vulvoscopy Cytologic screening – Cervicovaginal – Anal 4 to 6 months Smoking cessation Vaccination? Parting Thoughts… “Paratus simper disceri “ …Always prepared to learn From a doorway arch in the Vatican library
