What Is Invasive Squamous Cell Carcinoma?

Early vulvar invasive squamous cell carcinoma is also called early vulvar squamous epithelial invasive carcinoma. It is generally considered to be the further development of early vulvar invasive squamous cell carcinoma by intraepithelial tumor (VIN). There are two types of keratinizing squamous cell carcinoma, HPV-related wart carcinoma, and basal cell-like carcinoma depending on the cause. It is more common in the labia majora, followed by the labia minora, clitoris, and perineum. It refers to the early genital invasive cancer with the maximum diameter of the cancerous foci not exceeding 2 cm and the infiltration depth 1 mm.

Basic Information

Visiting department: Oncology, Gynecology
Multiple groups: Postmenopausal women
Common locations: vulva

Common causes: Sexually transmitted diseases, viral infections, low immune function, chronic genital skin diseases, smoking, etc.
Common symptoms: Frequent urination, dysuria, burning urination, and difficulty urinating

Causes of early vulvar invasive squamous cell carcinoma

The etiology is still not completely clear, but some etiological factors related to the etiology have been found, such as sexually transmitted diseases, viral infections, chronic immune disorders of the vulva, and skin diseases.

Clinical manifestations of early vulvar invasive squamous cell carcinoma

Symptoms

Long-term refractory vulvar pruritus is a common symptom, and the course is generally longer. Itching is more important at night. Because of scratches, there are often ulcers with vulvar pain, increased secretions, and local bleeding. Other symptoms may occur depending on the location of the lesion. For example, the tumor is adjacent to the urethra or the tumor invades the urethra in advanced cases. Frequent urination, dysuria, burning urination, and difficulty urinating may occur.

2. Signs

Early invasive squamous cell carcinoma of the vulva is mostly located in the labia majora, followed by the labia minora, clitoris, and posterior union, especially the right labia majora is more common. In the early stage, pimples, nodules, or small ulcers appear locally. In the later stage, the lesions often show ulcerative cauliflower or nipple-like masses. The surface may have bloody or purulent secretions and tenderness due to ulceration and secondary infection. Often coexist with vulvar malnutrition. The clinical type of vulvar cancer has various shapes and sizes, and the color can be white, gray, pink, or dark red. The surface can be dry and clean, and it can also have secretions and necrosis. Cancer can be single or multiple. Monofocal cancer can be divided into cauliflower type and ulcer type. The outwardly growing cauliflower types are mostly well-differentiated lesions, and the ulcerous cancerous lesions are infiltrating, and most often occur in the posterior vulva, which often invades the Papillary glandular perineal body and the sciatic rectum fossa. Multifocal cancer accounts for about 1/4 of vulvar cancer. Vulvar is often pigmented. Vulvar malnutrition is often associated with diffuse lesions. Rarely small lesions are rare. Sometimes one or both groin can touch enlarged lymph nodes that are hard and fixed without tenderness. However, it should be noted that not all enlarged lymph nodes are metastatic, and the absence of enlarged lymph nodes cannot rule out lymph node metastasis. Squamous cell carcinoma that originates from the vestibular large glands, often manifests as hard edema of the labia majora near the labial lacing, but the surface skin may be good.

3. Transfer route

(1) Directly infiltrating cancerous lesions can gradually spread to the urethra, perineum, and vagina; cancerous lesions in the posterior vulva tend to invade the vaginal opening and anus. Later stages can invade the pubic bone and extend around the anus or bladder neck.

(2) Lymphatic metastasis Lymphatic metastasis is the most common and important metastasis pathway, and the lymphatic metastasis rate can reach 21% to 59%. The metastatic pathway is mainly determined by the characteristics of lymphatic drainage.

(3) Hematogenous metastasis is rare. Generally, advanced patients can metastasize to the lung.

4. Clinical staging

There are many clinical staging standards. There are currently two widely used ones. One is the surgical pathology staging method revised by the International Federation of Obstetrics and Gynecology (FIGO) in 2000, and the other is the TNM of the International Anti-Cancer Association (UICC) in 1997. Staging method.

Early vulvar invasive squamous cell carcinoma examination

1. CT scan laboratory inspection

(1) Examination of secretions and tumor markers.

(2) Cytological examination A cytological smear of suspicious lesions often shows cancer cells. Because vulvar lesions are often associated with infection, the positive rate is only about 50%.

2. Other auxiliary inspections

(1) Imaging examination In order to accurately determine the clinical stage before treatment to facilitate the objective development of a treatment plan, B-ultrasound, CT, magnetic resonance, and lymphography of lymphatics near the iliac vessels and abdominal aorta are feasible.

(2) Bladder and rectal examination Cystoscopy and rectal examination should be performed on some advanced vulvar cancers to understand the condition of the bladder and rectum.

(3) Pathological biopsy All genital vegetation, including white lesions of cauliflower ulcers and nodules, need to be biopsied . Extensive erosions without obvious lesions during biopsy. To avoid misdiagnosis due to inaccurate materials, colposcopy and / or vulvar staining with 1% toluidine blue (nuclear stain), or 1% acetic acid flushing are considered suspicious Biopsy was performed after the focus. Because inflammation and cancer can show positive results, toluidine blue staining can only be used to select the biopsy site. The depth of the lesions with combined necrosis should be sufficient, and the edges of the necrotic tissue should be taken to avoid taking only the necrotic tissue, which will affect the inspection results.

Early invasive squamous cell carcinoma of the vulva

Early invasive squamous cell carcinoma of the vulva is located on the body surface. According to history symptoms and signs, the diagnosis of clinical invasive carcinoma is not difficult. But even the more typical clinically invasive cancer should be biopsied before treatment to confirm the diagnosis and guide the treatment and estimate the prognosis.

Differential diagnosis of early genital invasive squamous cell carcinoma

Vulvar genital warts

The disease often occurs in young women, with softer, ulcer-free papillary growth, sometimes a pedicled mass, which can coexist with other sexually transmitted diseases.

2. Lesions of vulvar malnutrition

Skin lesions are extensive and diverse, and can be either keratosis, thickening, hardening or atrophy, both pigmentation, and off-white vulvar itching.

3. Other

Early invasive squamous cell carcinoma of the vulva should be distinguished from vitiligo, vulvar eczema, local ulcers and other inflammatory diseases.

Treatment of early vulvar invasive squamous cell carcinoma

The current treatment is mainly surgery, which can be supplemented with radiation therapy or drug chemotherapy for poorly differentiated cancerous tissues and intermediate and advanced cases. Those with low immune function or impaired immune function should be supplemented with treatment to improve the body's immunity.

Surgical treatment

The classic technique is extensive vulvectomy plus bilateral inguinal lymphadenectomy. The vulvar resection range includes 3/4 of the perineum, and the front should reach 3-4 cm above the clitoris. Inguinal lymph node dissection should remove all fat in the groin area, including the deep and shallow lymph nodes.

Where the cancerous lesions invade the urethral orifice, the anterior part of the urethra can be removed with the vulva. Anterior urethral resection within 2 cm of urethral sphincter function will not cause postoperative urinary incontinence.

Those with cancer invading the anterior lower vagina, middle and posterior urethra, or bladder neck, should perform a total urethral or bladder neck resection, partial vaginal resection, and urethral reconstruction. The bladder wall replaces the urethra. The urethral orifice can be placed on the lower abdominal wall, or placed on the exit of the vulvar urethra. There is also an anastomosis of the bladder after total urethral resection with the cut off the rectum, so that the urine is discharged from the anus and a transverse incision is made after the anus. For posterior incisions where cancer invades the inferior posterior wall anal canal or rectum, consideration should be given to performing partial vaginal anal canal or rectal resection and artificial anal reconstruction while performing vulvar cancer combined radical mastectomy.

2. Radiation therapy

Radiation therapy includes the use of high-energy radiation therapy machines ( ⁶⁰ Co, ¹³⁷ Cs linear accelerator, electron accelerator, etc.) for extracorporeal radiation therapy and radiation therapy needles ( ⁶⁰ Co needle, ¹³⁷ Cs needle, ¹⁹² Ir needle, Ra needle, etc.) Transplantation treatment. Although vulvar squamous cell carcinoma is sensitive to radiation, because the normal vulvar tissues cannot tolerate the optimal radiation dose for curing vulvar cancer tissues, vulvar tissues generally can only tolerate 40 to 45 Gy, and the effective therapeutic dose of squamous cell carcinoma is 55. ~ 60Gy, so the effect is not good. At present, radiotherapy is adjuvant in squamous cell carcinoma of the vulva.

The indications for the use of radiotherapy for vulvar squamous cell carcinoma can be summarized as:

(1) Inoperable cases, such as those with a high risk of surgery and too extensive cancerous lesions, which cannot be removed or have difficulty removing;

(2) Conservative surgery can be performed after first using radiotherapy;

(3) Cases with a high probability of recurrence, such as lymph node metastasis, the margin of the specimen to find cancerous lesions close to the urethra, proximal rectum, if it is difficult to completely resect the lesion, but it is difficult to retain these parts;

(4) Complementary extracorporeal radiotherapy for patients with positive lymph nodes after surgery may improve survival.

The main complications of radiation treatment of vulvar squamous cell carcinoma are: severe vulvar radiation dermatitis, vulvar radiation necrosis, urinary leakage, and urinary tract obstruction.

3. chemotherapy

Chemotherapy is currently in the adjuvant position in the treatment of early invasive squamous cell carcinoma of the vulva, and is applied to more advanced or recurrent cancer.

(1) Efficacy of a single anticancer drug. The single anticancer drugs clinically used to treat vulvar squamous cell carcinoma are: doxorubicin (adriamycin), bleomycin, methotrexate, cisplatin (cisplatin). ), Etoposide (Etoposide) Mitomycin, Fluorouracil (5-FU) and Cyclophosphamide. Among them, bleomycin, doxorubicin (doxorubicin), and methotrexate have better efficacy, and the effective rate is about 50%.

(2) The combined chemotherapy regimen includes bleomycin + mitomycin, fluorouracil (5-FU) + mitomycin and bleomycin + vincristine + mitomycin + cisplatin (cischlorine Amine platinum) and so on. The number of cases treated with the combination chemotherapy regimen is still small, but the current effect of bleomycin + mitomycin and fluorouracil (5-FU) + mitomycin is better, with an effective rate of about 60%.

The combination of chemotherapy and / or radiation therapy and surgery for advanced or relapsed patients is expected to improve survival.

Prognosis of early vulvar invasive squamous cell carcinoma

The prognosis of this disease is closely related to the size and depth of invasion of the cancerous lesions and the presence or absence of lymph node metastasis. Cancers with a maximum diameter of 2cm, an infiltration depth of 1mm, and a thickness of 5mm rarely have lymph node metastasis, and the prognosis is good.