early invasive squamous cell carcinoma of the vulva
Introduction
Introduction to early invasive squamous cell carcinoma of the vulva Early invasive squamous cell carcinoma of the vulva is more common in the labia majora, followed by the labia minora, clitoris and perineum. Early invasive squamous cell carcinoma of the vulva refers to early vulvar invasive carcinoma with a maximum diameter of the tumor no more than 2 cm and an infiltration depth of 1 mm. basic knowledge The proportion of illness: 0.005% Susceptible people: women Mode of infection: non-infectious Complications: lung cancer
Cause
The cause of early invasive squamous cell carcinoma of the vulva
(1) Causes of the disease
Early invasive squamous cell carcinoma of the vulva is mostly developed from vulvar epithelioid lesions (VIN) and is closely related to proliferative vulvar dystrophy. Some viral infectious diseases such as human papillomavirus (HPV) infection in female lower genital tract and Patients with herpes simplex virus type II (HSVII) infection are susceptible to vulvar squamous cell carcinoma, and HPV subtypes associated with vulvar squamous cell invasive carcinogenesis are mainly 6,11,16,18 and 33, of which 16 and 33 The type can be detected in 90% of VIN sections, and long-term immune function is inhibited by multicenter vulvar squamous cell invasive carcinoma. The relationship between smoking and vulvar squamous cell invasive cancer is receiving attention.
(two) pathogenesis
Vulvar squamous cell carcinoma, in addition to most of the vulvar skin mucosa, can also occur in the large ductal epithelium excreted in the vestibular gland. This type of cancer is located in the labia fat, continuous pathological section, and can be found in cancerous and glandular ducts. Relationship between.
The tumor is similar to the general change of carcinoma in situ. The vulva may have a small superficial appearance, a high-hard ulcer or a small hard nodule. Because of itching, the vulva may have scratches, breakage, etc. White lesions or proliferative inflammatory changes.
Most of the vulvar squamous cell carcinomas under the microscope are well differentiated, with keratinized beads and intercellular bridges. The lesions of the vestibule and clitoris tend to be poorly differentiated or undifferentiated, often with lymphatic and peri-invasive invasions. It should be noted that the size, number of invasive, depth of invasive interstitial, pathological grade, presence or absence of lymphatic vessels or vascular involvement and other vulvar disorders coexisting, these factors are extremely important for guiding clinical treatment and estimation of prognosis. The histological types of vulvar squamous cell carcinoma can be classified into the following types:
(1) Keratinizing squamous cell carcinoma: the most common, accounting for 85%, it occurs in older women, cancer cells are well differentiated, characterized by excessive keratinization and keratinization, also known as differentiation or Grade I squamous cell carcinoma, but invasive.
Histomorphology: The cancer cells are arranged in layers, the cells are large but polygonal, more mature, more cytoplasm and eosinophilic, the nucleus is round or irregular, the staining is deeper, the nucleolus is visible in the shallow, and the cells are visible. The structure of the intercellular bridge, the length of the stitches at the bottom, the size and growth direction are different, and the disorder, the invading interstitial becomes a nest of many cancer cells, and there are keratinocytes and keratinized beads in the nest, sometimes the keratinized beads occupy The whole cell nest, the keratinized structure is like a vortex or onion skin, and there are few interstitial spaces between the cancer cells, and the mitotic figures are mostly at the periphery of the cell nest and at the edge of the stitch.
(2) Non-keratonizingsquamous cell carcinoma: There are many types of squamous epithelium in the vulvar mucosa, while the squamous epithelium of the vulva skin is mainly keratinized squamous cell carcinoma.
Histomorphology: The cancer tissue consists of large polygonal cells. The cells are packed into broad bands, the layers are unclear, and the cells are arranged in disorder. Although the cells are large, the nucleus is also enlarged, the atypical shape is large, the nuclear staining is different, and the nuclear ratio is large. More mitotic division, hornless beads, keratinocytes occasionally, this cancer is equivalent to moderate or fifth grade malignancy, HPV DNA detection is often negative.
(3) Basaloid cell carcinoma: consists of squamous epithelial basal cells, which are aggregated into pieces, with a nest-like distribution. The cancer cells are small, immature, with little cytoplasm and long ovate. Shape or short fusiform, deep staining, uniform size of the nucleus, increased proportion of nucleoplasm, occasional or invisible keratinocytes, this type is equivalent to poorly differentiated or sub-grade squamous cell carcinoma, in a few cases See the hollowed-out cells of nuclear shrinkage and perinuclear halo; VIN lesions can be found in the vicinity of cancer tissues; the positive rate of HPV DNA detection is high, up to 75%, this type should be associated with vulvar skin tissue, such as basal cells of the labia majora The difference in cancer is also differentiated from basal-squamous cell carcinoma, which is a basal cell carcinoma to squamous cell differentiation, and basal-like cell carcinoma is a subtype of squamous cell carcinoma.
The maximum diameter for measuring cancer does not include cancerous in situ or atypical hyperplasia, and the depth of infiltration of the cancer is measured from the epithelial and interstitial junctions or from the epithelial and interstitial junctions of the nearest dermal papilla. In the deepest part of the infiltration, the thickness of the cancer refers to the deepest part from the top of the cancer to the deepest infiltration. The difference between the two is that the depth of infiltration is the starting point from the junction of the epithelium and the interstitial, and the thickness is the starting point from the surface of the tumor including the surface epithelium. To obtain the correct measurement data, the specimen must be fixed, continuously cut into pieces, and should be sliced vertically instead of beveled.
Prevention
Prevention of early invasive squamous cell carcinoma of vulva
Early diagnosis, active treatment, and good follow-up.
Preoperative preparation:
1) Vulvar cancer is often associated with infection, and 1/1000 potassium permanganate bath is needed for 1 week before surgery.
2) Preoperative high-protein, low-slag diet, no multi-fiber foods within one week before surgery to ensure that the stool is not resolved within 1 week after surgery, reducing the infection of the vulvar wound caused by defecation.
3) Resection of the rectal anal canal should be carried out 2 days before surgery, and oral intestinal anti-inflammatory drugs.
4) The need for total cystectomy and ileal bladder surgery requires urinary tract intestinal anti-inflammatory preparation.
Complication
Early invasive squamous cell carcinoma of the vulva Complications
1, because the cancerous lesions gradually increase to the urethra, perineal body and vagina, can be combined with perineal cancer.
2, some advanced patients will have cancer cell lung metastasis, so early invasive squamous cell carcinoma of the vulva may be complicated by lung cancer.
3, due to the decline in the patient's body resistance, can lead to imbalance in the body and outside the colon, and finally lead to infection.
Symptom
Vulvar early invasive squamous cell carcinoma common symptoms pruritus vulvar ulcer nodular vulvar pain pimples
Symptom
About 10% of the early invasive squamous cell carcinoma of the vulva can be asymptomatic, and its common symptoms are genital itching, and the course of the disease is generally longer. The cause of itching is mainly caused by chronic vulvar lesions, such as vulvar malnutrition, vulvovaginitis, etc. Instead of being caused by the cancer itself, nearly half of the patients have a history of vulvar scrapie for more than 5 years. The itching is heavy in the evening. Because of the damage to the epidermis of the vulva, the symptoms are more serious, such as local ulcers, often accompanied by vulva. Pain, increased secretions, and sometimes bleeding, because many patients with vulvar squamous cell carcinoma have chronic diseases that cause itching symptoms, so the duration of symptoms before cancer is difficult to determine.
2. Signs
Lesions can occur in any part of the vulva, but mostly in the labia majora, followed by the labia minora, clitoris and posterior joints. The signs of early invasive cancer are not obvious. Local papules, nodules or small ulcers often coexist with vulvar precancerous lesions. The cancerous lesion can be either single or multiple, with minimal bilateral inguinal lymph node metastasis.
3. Transfer route
Early invasive squamous cell carcinoma of the vulva rarely metastasizes. If there is metastasis, it mainly passes through the lymphatic metastasis pathway. Therefore, the metastatic site is mainly determined by the characteristics of lymphatic drainage. The front part of the labia minora is the lymphatic flow that bypasses the clitoris and reaches the haze. In the adipose tissue of the sputum, the lymphatic vessels turn to the lateral end of the upper and lower groups of the lymph nodes, and the posterior part of the labia minora spreads laterally to the lymphatic drainage of the labia majora, and the lymphatic vessels of the labia majora flow into the reproductive tract. Wrinkles, into the upper group of the lymph nodes of the head and lateral side, the lymph nodes of the labia majora flow into the genital pleats to reach the tendon of the gracilis and the adductor longus, ending in the central group of the lymph nodes .
The combined lymphatic drainage of the posterior and perineum reaches the posterior side of the anus, and then reaches the genital folds; the lymphatic junction with the labia majora terminates in the superficial lymph nodes.
The lymphatic drainage of the clitoris is divided into two main pathways. The first is the pubic plexus lymphatic drainage. The clitoris foreskin enters the pubic sac, and then enters the femoral lymph node to the side, and the deep vaginal lymph nodes through the sacral fascia. The strip is from the clitoris to the posterior pubis, parallel to the urethra to the anterior wall of the bladder or directly into the obturator and axillary lymph nodes, so the lymphatics of the clitoris can travel around the lymph nodes to the deep pelvic lymph nodes.
It can be seen that the first group of vulvar lymphatic drainage is a superficial lymph node. The superficial lymph node is located between the superficial fascia of the abdominal wall and the sacral fascia covering the femoral artery. The deep lymph nodes are located below the blood vessel, and the lateral part of the femoral lymph node. The group penetrated the external oblique muscle tendon directly into the extra-orbital lymph nodes, and the deep-seated lymph nodes were often affected after the cancer of the inguinal shallow lymph nodes was invaded. The most recent deep deep lymph node is the Cloquet lymph node, which is located in the femoral tube below the inguinal ligament. If the inguinal superficial lymph nodes or Cloquet lymph nodes have no cancer metastasis, vulvar cancer is unlikely to invade the pelvic lymph nodes. According to the characteristics of vulvar lymphatic drainage, the cancerous foci tend to metastasize to the ipsilateral lymph nodes.
Examine
Examination of early invasive squamous cell carcinoma of the vulva
1. Secretory examination, tumor marker examination.
2. Cytological examination: smear cytology examination of suspected lesions, often seen in cancer cells, because the vulvar lesions often combined with infection, the positive rate is only about 50%.
Pathological biopsy: All living genital warts, including cauliflower stoves, ulcers, nodules, white lesions, etc., need to be examined by biopsy. When biopsy, no obvious lesions such as extensive erosions occur, in order to avoid inaccurate materials. Misdiagnosis, vaginal magnifying glass and (or) with 1% toluidine blue (nuclear stain) for vulva staining, and then washed with 1% acetic acid, determine the suspected lesions, and then biopsy, due to inflammation and cancer It can show positive results, so toluidine blue staining can only be used to select the biopsy site. The lesions with combined necrosis should have sufficient depth, and should be taken at the edge of the necrotic tissue to avoid taking only necrotic tissue and affecting the test results.
Diagnosis
Diagnosis and differentiation of early invasive squamous cell carcinoma of vulva
diagnosis
Due to the history of vulvar early invasive squamous cell carcinoma, the symptoms and signs are atypical, and often coincide with some chronic benign diseases and intraepithelial neoplasia, and invasive cancer may not be obvious, the diagnosis of subclinical early invasive cancer Difficulty, therefore, susceptibility to the vaginal suspicious lesions for cytology and histopathology to confirm the diagnosis.
Differential diagnosis
Vulvar vitiligo
It is a primary localized or generalized skin pigmentation disorder. It can often be found in other parts of the body, especially the head and face. The skin texture is normal in the affected area, and the surrounding boundary is clear. Generally no other Conscious symptoms.
2. Vulvar eczema
More common, related to allergies, there are often some physical and chemical stimuli, the lesions involving the size of the labia and its surrounding skin, the formation of irregular size, the edge is limited or quite distinct, the surrounding skin has varying degrees of infiltration and thickening, Very few scales, but because of itching, often scratching, local vitiligo-like changes, easy to be mistaken for precancerous lesions or cancer.
