Today we plan to talk about carcinoma.
The vulva.
We plan to talk on the titles of signs and
symptoms of carcinoma involving some of the pre cancerous conditions
leading to carcinoma in the vulva.
Some of the spread patterns of carcinoma,
the vulva.
Next on the treatment of invasive carcinoma,
the vulva and insight to carcinoma,
the vulva and then ending up with
prognosis of carcinoma.
The vulva and the recurrence.
Carcinoma evolve is not a common G.Y.N
malignancy and ranks after cervix,
uterus and ovary in incidents is
disturbing at this cancer,
which is the most readily accessible to diagnosis
since his external in nature,
it's not often diagnosed till late.
In its course.
The cardinal signs of vulvar carcinoma are pure itis
bleeding and a volver sore
mass,
which is more often than not overlooked.
Peratis is usually present for prolonged periods up to a year
before the diagnosis is made.
In a large series involved in large series.
Vulvar masses or Sore was were present for an average of 10 months
before the clinical or before the histological diagnosis of
Vulvar cancer was made.
This neglect is both part of the doctor's
responsibility and part of the patient's responsibility for not
seeking medical attention sooner.
The average age of the patient with carcinoma and evolve.
A invasive carcinoma is in the 60s
and secondary to an increasing population of
elderly people.
More and more evolve.
A carcinoma will be diagnosed in the future.
You can just look at a few slides over here
In a series of patients,
223 in number.
The presenting symptoms were first peratis with 81 out of
223 symptoms,
patients complaining of this revolver mass or
ulcer,
66% of patients or 66 out of
223 patients.
Volver pain 17 out of 223
and bleeding another 1700 -
223.
So again,
the first two most common symptoms are politis
and a volver mass or an ulcer
in the age distribution.
If you just disregard this top part,
which is insights or limited invasion
carcinoma evolve,
which we'll talk about a little later.
This is the invasive group here and you can see the majority of people are in
their 60s,
year old
white lesions or Luca play key as they are called,
the vulva have long been associated with vulvar carcinoma.
The common finding of coexistence,
Luca play Kia.
An invasive carcinoma of the Volvo has suggested a cause
and effect relationship between these two
lesions,
which in fact does exist but not as common
as believed by some.
A trophic and hyper characteristic changes.
Have only a small association with vulvar cancer in
our present And lead to Vulva carcinoma.
And perhaps in less than 10% of cases.
Other predisposing factors like chronic granulomas,
diseases of the vulva such as granuloma,
inguinal granuloma venereal and the young females
have been stated to cause an increased incidence of carcinoma.
The vulva.
Other associated diseases like diabetes,
obesity,
herpes valve itis and a positive
V.
D.
R.
L.
Are also associates with carcinoma that
whatever the predisposing causes and factors for carcinoma.
The Volvo known or unknown routine examination
and proper biopsy with a high index of
excuse me.
High index of suspicion is the mainstay in diagnosis
abnormal looking areas and especially those associated with luke
should be followed briefly and if they do not regress or respond to
treatment should be promptly biopsy to aid in
biopsy areas that are suspicious in blue and
a dilute solution may be painted on the vulva and
this may be washed with acetic acid and
abnormal areas will stay in blue.
This is analogous to staining the
cervix with schiller's iodine.
Where abnormal areas do not take up stain.
These abnormal areas then should be biopsied and sent for
histological examination.
Continue treatment with hormone creams steroid creams
antibiotics with no change in the lesion is to
be,
is contraindicated and
is often practiced in many situations leading to the late
diagnosis of Carvel overcast carcinoma.
We just look at some of the vulvar carcinoma and how they present in the
clinic at M.
D.
Anderson hospital.
You can see the mons pubis here with a large vulvar
carcinoma on the labia on the left labia.
Again,
an extensive vulvar carcinoma.
With early changes on the left hand side with
large fun gating carcinoma on the right hand side,
extending all the way down around the rectum
again bilateral on both sides.
Another extensive vulva carcinoma on both
sides of the vulva.
Another very extensive vulva carcinoma involving
all the vulva,
the vagina and infiltrating into the rectum
and up the vagina.
This is a vulva carcinoma now between the legs,
which you cannot see that has metastasized to a groin node
and it's causing ulceration of a groin node.
Will later be talking about the way vulvar carcinoma
spreads up to the groins and the operations involved in
taking care of this carcinoma.
Once established as an invasive carcinoma.
Vulvar cancer spreads in orally and predictable fashion
metastases reached the inguinal nodes in the
groins via the lymphatic of the mons
pubis and through the Volvo itself.
Once in the inguinal nodes,
the spread is to the nodes in the
below the angle nodes are in the femoral triangle,
in the region of the or the region of the
inguinal ligament and then to the deep nodes in the pelvis.
Only occasionally is this pattern not established
and different patterns may be established if a mass is in the central
or a clitoral lesion.
Whether it's extensive lesions,
as we've seen in those some of those slides,
if a melanoma is present or any of the cancer is present on the
mucosal surfaces of the vagina,
anus or urethra
in staging.
People with carcinoma,
the vulva.
It's all done by clinical staging and some of the
staging involves the palpitation of nodes that we
saw in that last picture in the groin.
It's been shown in a large series of patients for M.
D.
Anderson hospital that bye pal patient
alone,
you can predict Nodes will be positive
in a groin by in 70% of
cases by palpitation alone.
However,
non palpable nodes in the groin Are still
histological positive at operation.
of 30% of cases Therefore
complete surgical or movement of all known
bearing tissues is essential since 30% of them
will escape your diagnosis by Pal patient.
The operative procedure of choice is a radical valve ectomy
with removal of the involved lymph nodes involved regional
lymph nodes.
It's just a slide indicating our
surgical procedure which is on block removal which is
just removing everything in one block.
So one stage procedure,
radical valve ectomy,
bilateral mastectomies,
removal of the lymph node tissues,
the mods veneers,
the labor crew folds the perineum above the anus and the high middle
ring are the borders of the dissection and we'll see some slides of
this in a minute and this is all
irrelevant.
This is just a couple of pictures of the operative specimen to show you what is
removed.
This is a fully catheter going into the urethra
with the Volvo on either side and the anus is
still on the patient and down in here.
And this decision is carried just above the anus to
include up into the groins and you can see all the lymph nodes removed
from the groins on both sides.
This is on block,
totally done altogether.
Again,
another specimen,
you can see the same thing.
The vulvar carcinoma is right there.
Everything's removed with the lymph nodes in the groins.
one more large vulvar carcinoma on the left here,
everything's removed on block with the groins and
the lymph node bearing tissues.
Postoperative complications are
sometimes severe and severe,
not only for medical stand or doctors standpoint,
but also a nursing personnel on the ward.
Most common postoperative complication is that of wound
breakdown,
which is common for several reasons.
Secondary the large amount of tissue is removed.
As you can see on those slides,
the patients are old.
They have an increased incidence of diabetes and hypertension and
obesity,
all of which leads to poor tissue healing.
And there's always the contamination of the operative field from the
normal,
normal floor around the anus and the vagina.
This is just to illustrate some of the postoperative
features of the of the operation where
incision has been made and a large mass of tissue has
been removed in here.
As you saw on the previous slide with the skin pulled together
under tension and all the lymph nodes in the groins here are removed.
These are just some tape burns up here.
Just another view.
You can see that all the Volvo has been removed now
and all the note bearing tissue.
This big flap of tissue in here has been removed with the
vulva
that doesn't come out through clearly.
But this is a lady a couple of months after radical evolve ectomy
and you can see the classical y shaped scar.
Let's see what we got.
This is a little better one.
You can see that all the Volvo has been entirely removed.
Now this is the anus down here,
This is the urethra and this is the vagina and all the
vulva is removed.
This is just one example of a wound breakdown.
You can see it's very extensive.
This is just taken care of locally on the floors by the
nurses and by the doctors and it cleans up nicely and these are just some small
little skin grafts placed on here and this patient was entirely healed within two
weeks of doing this.
One special category which we'll talk briefly about involving
carcinoma is that of insight to cancer of the
vulva which is just confined to the very
superficial layers of cells on the volver surface.
And also another group called Limited invasion where the
cancer has not penetrated a depth of more than five
below the skin surface.
The experience at M.
D.
Anderson Hospital has shown that a less than radical procedure may
be done on these people because the
incidence of lymphoma task diseases zero so far in the
series.
The procedure of choice is called a skin involve ectomy where
just a superficial skin is taken off the vulva and
then a skin graft is taken from the thigh and placed on the vulva.
This very gives a very satisfactory cosmetic
appearance rather than
having the radical procedure as you've seen.
The close follow up is nature is mandatory with these
patients.
These are the criteria and some of the guidelines for a conservative
treatment of limited invasion
carcinoma.
The Volvo.
It is only safe if careful follow up is maintained.
The decision is made with a calculated risk saying that
you do have a limited invasive cancer but you're willing to
take out less than a radical procedure and
hope that these people can have a better cosmetic result and you can
follow them very adequately.
The patient is made aware that a repeat local resection or
evolve ectomy may be necessary in the future.
And all the treatment is simple should not
underestimate the seriousness of the condition.
Just some of the techniques involved again,
this is a Volvo that had a very early insight you
or limited invasive cancer in it.
It's just the skin has just been taken off it
area is prepared on the thigh for skin graft.
The skin graft is taken from the thigh
placed on the Volvo and
suited in place with a stent just in the vagina
and you can see that the cosmetic result of this is a lot better than the
cosmetic result of the previous radical valve ectomy.
Let's talk about some of the results now of treatment for carcinoma.
the treatment or the results and the survivals from
carcinoma evolve.
Our depended mainly on what nodal
groups or any of the lymphatic nodes were involved
with at the time of operation,
how big the lesion was initially.
Uh the overall five year survival taking
all stages of disease treated for cure
is 77% of people treated for
Carson and evolved for cure were alive at five years
and free of disease.
If the inguinal nodes were positive,
as we saw in some of those pathology specimens,
the the overall survival drops to 40%
in five years.
If the pelvic nodes are the nodes beyond the
nodes are positive.
Again,
the survival drops now to 25%
just indicating that the cancer is spreading further.
With each decrease survival.
If no nodes are positive,
there's 100% of patients that are alive at the end of
five years or have not died of volver carcinoma at the end of
five years.
Recurrences are mostly within the first two years of treatment
with an average of eight months.
And our most common right at the sites of the
so you can get that back site of the
Volvo cutaneous margin.
Right in this where the vaginal
cutaneous margin,
I'm sorry not the Volvo contains the vaginal cutaneous margin most
recurrences when they arise arise within the first two years,
right around this border where you have put the
skin to the vagina.
They are treated with either
radiotherapy or wide local excision
and the results of treatment are very good
going the wrong way.
There are some slides on the results of treatment and the results of treatment of
recurrences.
Okay,
I'm looking at 175 patients treated for cure.
Looking at the year,
this is less than one year survival down to five years
survival.
And you can see at the end of one year there's
83.4% alive of
175 patients treated for cure.
At the end of five years there's still 77.3%
of people alive and treating all cases of
carcinoma evolve including all stages.
This is just a slide to demonstrate what we do with
recurrences.
This is a group of 33 patients who returned to M.
D.
Anderson hospital with recurrent carcinoma evolve after treatment in the
standard fashion.
As we've outlined,
18 of these patients were treated with a local excision
and the rest of treatments ranging from radiotherapy to
chemotherapy to a radical excision.
The important point is that out of these 33 patients that
present with recurrent carcinoma,
66% are still alive at the end of two years.
In conclusion,
carcinoma evolve.
A is is an often neglected diagnosis with a
prolonged time between presenting symptoms and
final histological diagnosis,
High index of suspicion is necessary
and any visible lesion on the vulva should be biopsied
promptly with early treatment.
The prognosis is favorable,
and the treatment is usually that of radical surgery,
consisting of radical valve ectomy and encompassing lymph
nodes.
Close follow up is warranted for even with recurrence,
the prognosis is still favorable.
Thank you.