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GY46 Gynecology
Gynecological Oncology Toronto Notes 2019
■ if invasive cancer present, management depends on prognostic factors, degree of fetal maturity, and patient wishes
◆ general recommendations in T1: consider pregnancy termination, management with either radical surgery (hysterectomy vs. trachelectomy if desires future fertility), or concurrent chemoradiation therapy
◆ recommendations in T2/T3: delay of therapy until viable fetus and C/S for delivery with concurrent radical surgery or subsequent concurrent chemoradiation therapy
Vulva
BENIGN VULVAR LESIONS
Non-Neoplastic Disorders of Vulvar Epithelium
• biopsyisnecessarytomakediagnosisand/orruleoutmalignancy: 1) Hyperplastic dystrophy (squamous cell hyperplasia)
◆ surface thickened and hyperkeratotic
◆ pruritus most common symptom
◆ typically postmenopausal women
◆ treatment: 1% fluorinated corticosteroid ointment bid for 6 wk
2) Lichen sclerosis
◆ subepithelial fat becomes diminished; labia become thin, atrophic, with membrane-like
epithelium and labial fusion
◆ pruritus, dyspareunia, burning
◆ ‘figure of 8’ distribution
◆ most common in postmenopausal women but can occur at any age
◆ treatment: ultrapotent topical steroid 0.05% clobetasol x 2-4 wk then taper down, can consider
long term suppression twice a week
3) Mixed dystrophy (lichen sclerosis with epithelial hyperplasia)
◆ hyperkeratotic areas with areas of thin, shiny epithelium ◆ treatment: fluorinated corticosteroid ointment
Tumours
• papillaryhidradenoma,nevus,fibroma,hemangioma
MALIGNANT VULVAR LESIONS
Epidemiology
• 5%ofgenitaltractmalignancies
• 90%SCC;remaindermelanomas,basalcellcarcinoma,Paget’sdisease,Bartholin’sglandcarcinoma
■ Type I disease: HPV-related (50-70%)
◆ more likely in younger women
◆ 90% of vulvar intraepithelial neoplasia (VIN) contain HPV DNA (usually types 16, 18)
■ Type II disease: not HPV-related, associated with current or previous vulvar dystrophy ◆ usually postmenopausal women
Risk Factors
• HPVinfection
• VIN:precancerouschangewhichpresentsasmulticentricwhiteorpigmentedplaquesonvulva(may
only be visible at colposcopy)
■ progression to cancer rarely occurs with appropriate management
■ treatment: local excision (i.e. superficial vulvectomy ± split thickness skin grafting to cover defects if
required) vs. ablative therapy (i.e. laser, cauterization) vs. local immunotherapy (imiquimod)
Clinical Features
• manypatientsasymptomaticatdiagnosis(manyalsodenyorminimizesymptoms)
• mostlesionsoccuronthelabiamajora,followedbythelabiaminora(lesscommonlyontheclitorisor
perineum)
• localizedpruritusorlesionmostcommon
• lesscommon:raisedred,whiteorpigmentedplaque,ulcer,bleeding,discharge,pain,dysuria
• patternsofspread
■ local
■ groin lymph nodes (usually inguinal → pelvic nodes) ■ hematogenous
Investigations
• ±colposcopy
• ALWAYSbiopsyanysuspiciouslesion
■ do not remove entire lesion so if malignant, site can be identified for sentinel LN injection
Any suspicious lesion of the vulva should be biopsied