Pre-malignant Lesions of Female Genital Tract · Pre-malignant Lesions of Female Genital Tract Jed Delmore, MD, ... Disclosure. Documented Premalignant Lesions • Vulva: Yes ...

Pre-malignant Lesions

of

Female Genital Tract

Jed Delmore, MD, FACS, FACOG

Professor, Obstetrics and Gynecology

University of Kansas School of Medicine, Wichita

Disclosure

Documented Premalignant Lesions

• Vulva: Yes

– VIN

• Vagina: Yes

– VAIN

• Cervix: Yes

– CIN

• Endometrium: Yes

– For Type I cancers, EIN

• Fallopian Tube: Yes

– STIC

• Ovary: Probably not, or No

Principles

• Rule out invasive disease

• Define extent of disease

• Do more good than harm

Treatment Selection

• Risk of progression if untreated?

• Success of treatment?

• Toxicity/complications of therapy?

• Extent or size of lesion?

• Presence or absence of symptoms?

Case #1

45 year old renal transplant patient, smokes 2

ppd. Complains of vulvar pruritis.

Exam demonstrates-

Diagnosis?

Diagnosis?

Vulvar Intraepithelial Neoplasia

• VIN I: does not exist

• VIN: Encompasses VIN 2 & 3

– VIN- Usual Type (warty, basaloid, mixed)

• Associated with invasive squamous carcinoma of

warty or basaloid type

– VIN-Differentiated type

• More common in older women, with lichen

sclerosus.

• Associated with keratinizing squamous carcinoma.

• Not HPV related

Sideri M, et al Squamous Vulvar Intraepithelial Neoplasia 2004 Modified Terminology, ISSVD Vulvar Oncology Subcommittee.J Reprod Med 2005;50:807-10.

Treatment Options

• Observation- In the face of repeated recurrences, or

something else will do her in first.

• Excision- Primary closure or skin graft

• Laser vaporization- Multiple lesions, large, or at the

introitus

• Topical therapy ( 5-FU), Imiquimod

Excision, laser or

combination

Laser or excision and graft

What if the biopsy showed this?

Diagnosis?

Case #1

45 year old renal transplant patient, smokes 2

ppd. Complains of vulvar pruritis.

Exam demonstrates- Hypo and hyper

pigmented vulvar lesions.

Bx = VIN/CIS with probable early invasion.

Treatment Options??

Case # 2

77 year old with vulvar pruritis and multiple

treatments for yeast infection.

Exam =

Diagnosis?

Diagnosis?

Case # 2

77 year old with vulvar pruritis and multiple

treatments for yeast infection.

Exam = Erythematous, excoriated epithelium

with “cake frosting” coating.

Vulvar Biopsy = Paget’s disease of the vulva

Workup and treatment??

Treatment Options

• Excision- Primary

• Laser vaporization- Poor choice due to

gland involvement

• Topical therapy ( 5-FU)-Rarely

Case # 3

38 year old G3P3, Reports a vaginal hysterectomy

for a precancerous condition three years ago.

Pap = HSIL

Colposcopy = Thickened, acetowhite epithelium at

the vaginal apex.

Now what??

VAIN II-III

Treatment Options?

Treatment Options

• Excision- I wouldn’t unless I suspected invasion.

• Laser vaporization- Yep

• Topical therapy ( 5-FU), Imiquimod- Last

resort

Case # 4

32 year old G2P2 with HSIL Pap.

Colposcopy = Acetowhite epithelium with

punctuation. Large transformation zone.

ECC and Cervical Biopsies performed.

What is a Transformation Zone??

Squamocolumnar Junction

Transformation Zone

Transformation Zone

Acetowhite Epithelium

Mosaicism

Punctation

Atypical Vasculature

Case # 4




ECC-neg, CxBx-CIN III

Treatment Options??

Treatment Options ??

• Observation ?

• Excision ?

• Laser vaporization, Cryotherapy ?

• Hysterectomy ?

Treatment of CIN 2,3

• LEEP, or conization may be used whenever

treatment is appropriate.

• Cryotherapy of Laser vaporization should be used

only after rigorously excluding invasive cancer.

• Hysterectomy is unacceptable as primary therapy

for CIN 2+

ACOG Practice Bulletin 140, December, 2013

Case # 4




What if the biopsy had shown

adenocarcinoma in situ of the cervix?

The End

Pretend the cervix is gone.

Diagnosis?

Diagnosis?

Slide # 1

Slide #2

Diagnosis ?

VAIN Treatment Outcome

VIN Therapy

Pre-malignant Lesions of Female Genital Tract · Pre-malignant Lesions of Female Genital Tract Jed Delmore, MD, ... Disclosure. Documented Premalignant Lesions • Vulva: Yes ...

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