Extent Of Local Tumour Spread

Border: pushing/infiltrative. An irregular infiltrative margin has a higher incidence of nodal metastases.

Figure 27.1. Vulval carcinoma. |W

Lymphocytic reaction: prominent/sparse.

Microinvasion <3 mm: use of this nomenclature should be avoided as some of these carcinomas will have nodal metastases and invasive lesions >1 mm in depth should probably have radical surgery. Superficially invasive squamous cell carcinoma is defined as a single lesion measuring <2 cm diameter and with a depth of invasion <1 mm, i.e. pT1a.

Distance (mm) to the nearest painted surgical margin (lateral cutaneous, medial mucosal, deep subcutaneous). Involvement of vagina, urethra, perineum, anus.

FIGO is based on surgical staging, TNM on clinical and/or pathological classification. The TNM classification applies to primary carcinomas of the vulva only.

pTis carcinoma in situ pT1 tumour confined to vulva/perineum <2 cm in greatest dimension a. stromal invasion <1mm*

b. stromal invasion >1 mm pT2 tumour confined to vulva/perineum >2 cm in greatest dimension pT3 tumour of any size and invades any of: lower urethra/vagina/anus pT4 tumour invades any of: bladder mucosa/rectal mucosa/upper urethra or is fixed to pubic bone.

Invasion of bladder or rectal wall is pT3 and mucosal involvement pT4. Upper urethra (pT4) is proximal, lower urethra (pT3) is distal. Invasion of urethral wall (only) is pT3.

Spread is direct to the vagina, urethra, anus, inferior pubic and ischial rami and ischiorectal fossae.

*From the epithelial-stromal junction of the adjacent most superficial dermal papilla. Thickness is from the surface, or if there is keratinization, from the deep aspect of the granular layer to the deepest point of invasion.

TNM: T4 nTA

TNM: T4 nTA

Tumour invades any of: bladder or rectal mucosa, upper urethral mucosa; or is fixed to bone

Figure 27.2. Vulval carcinoma.

Tumour invades any of: bladder or rectal mucosa, upper urethral mucosa; or is fixed to bone

Figure 27.2. Vulval carcinoma.

5. LYMPHOVASCULAR INVASION

Present/absent. Intra-/extratumoral.

Carcinomas invading > 1 mm have a higher incidence of lymphovascular invasion and lymph node metastases and the vulval subepithelial connective tissues have a particularly rich vascular network.

6. LYMPH NODES

Site/number/size/number involved/extracapsular spread.

Regional nodes: femoral and inguinal. A regional lymphadenectomy will ordinarily include a minimum of six lymph nodes.

pN0 no regional lymph node metastasis pN1 unilateral regional lymph node metastasis pN2 bilateral regional lymph node metastasis.

Labial tumours go initially to inguinal nodes whereas clitoral lesions may go directly to deep nodes. Ulcerated tumours can produce reactive regional lymphadenopathy mimicking metastatic disease and this can be further investigated by FNA cytology.

7. EXCISION MARGINS

Distances (mm) of tumour and VIN to the nearest painted cutaneous and subcutaneous excision margins and anal, vaginal, urethral limits.

8. OTHER PATHOLOGY

Lichen sclerosus

— atrophic, or hyperplastic with hyperkeratosis (mixed dystrophy).

— associated with (5-25% of cases) but low risk (5%) of progression to carcinoma.

— overexpresses p53 and sometimes shows basal layer atypia.

Condyloma

— warty (condyloma accuminatum) or flat and caused by HPV 6/11 with koilocytosis.

Bowenoid papulosis

— brown perineal patches in young women.

— negligible risk of progression to carcinoma.

Vulval intraepithelial neoplasia (VIN) grades I/II/III

— typically multifocal and present in the adjacent epithelium of 60-70% of cases of squamous carcinoma.

— progression to carcinoma is in the order of 10-20%.

Classic or undifferentiated: includes Bowenoid/warty type (young, HPV, associated cervical and anal disease) and basaloid type (old, de novo, resembles CIN III).

Variant: simplex or differentiated VIN with maturation, hyperplasia, hyperkeratosis, variable parabasal atypia and overexpression of p53.

Prognosis

Nearly 30% of vulval squamous carcinomas have metastasized to inguinal or pelvic nodes at presentation. Prognosis relates to tumour size, an infil-trative tumour margin, depth of invasion, vascular involvement and, in particular, nodal disease. Stage I lesions have a 5-year survival of 85%, stage II 60%, stage III 40%, stage IV 20% and overall 50-75%. Treatment is by vulvectomy with uni-/bilateral inguinal lymph node dissection. A limited local excision with wide (1 cm) surgical margins may be used in early-stage (well-differentiated superficially invasive) disease or medically unfit patients. VIN III may be treated by topical therapy, laser, electroco-agulation, wide local excision, partial/total or skinning vulvectomy. Pelvic exenteration is reserved for locally extensive disease. Prognosis of malignant melanoma relates to tumour thickness and depth of invasion at the time of presentation, with average 5-year survival of 30-35%.

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