Anal involvement by carcinoma in situ of the perineum in women

This study reviewed 20 cases of extensive squamous carcinoma in situ of the vulva and posterior perineum. Two patients had concurrent, overt invasive carcinoma of the vulva, 14 patients had concurrent extensive vulvar carcinoma in situ, three patients had previous skinning vulvectomy for carcinoma in situ, and one patient had prior treatment for invasive vulvar cancer. Six patients had microinvasive carcinoma in the perianal region, which was unsuspected in five of the women. Nineteen of the 20 patients had involvement of the anal canal, and eight patients had disease extending to, or above, the pectinate line. Nineteen patients were managed by regional resection of the involved perianal/anal skin and mucosa with split thickness skin graft. Routine resection of the anal mucosa to the pectinate line was performed, with margin checks when there was dysplasia in the anal canal. The only noteworthy, long-term adverse effect of resecting the anal mucosa and replacing it with a split thickness skin graft was occasional incontinence of flatus in three of the 19 patients. The skinning procedure with split thickness skin graft produced excellent functional and cosmetic results.     

Recurrence of high-grade squamous intraepithelial neoplasia in neovagina: case report and review of the literature

Recurrent carcinoma in situ in neovagina is rare, and the optimal modality of treatment is unclear. A 33-year-old multiparous woman was referred for vulvar intraepithelial neoplasia, vaginal intraepithelial neoplasia, and cervical intraepithelial neoplasia, underwent skinning vulvectomy with perianal excision, total vaginectomy, vaginal hysterectomy, and vaginal reconstruction with split-thickness skin graft. Ten years after initial surgery, the recurrence as a high-grade intraepithelial neoplasia in the upper one third of neovagina was detected. For that reason, the upper one third of vaginectomy with at least 5-mm tumor-free border and vaginal reconstruction with split-thickness skin graft were performed. She has attended her regular follow-up for 3 years with no evidence of disease. All patients with vaginoplasty should undergo regular follow-up. This report is the seventh such report in English literature of patients previously treated for in situ carcinoma who later developed recurrence in the graft.     

Skinning vulvectomy for the treatment of multifocal vulvar intraepithelial neoplasia

Of 108 women treated for vulvar intraepithelial neoplasia between 1977 and 1984 at the Irvine Medical Center, University of California, and the Memorial Medical Center of Long Beach, Women's Hospital, 48 with multifocal and/or widespread lesions underwent skinning vulvectomy and split thickness skin graft reconstruction. Six women in the skinning vulvectomy sample had early stromal invasion in the vulvectomy specimen. Recurrences at intervals of four to 87 months occurred in 13 patients undergoing this procedure. The risk of recurrence did not appear to be related to the status of the surgical margins because seven of 22 patients with involved margins experienced recurrence compared with six of 26 with uninvolved margins.     

CO2 laser used for cancer in situ/Bowen's disease (VIN) and lichen sclerosus in the vulvar region

The subject of this report is a surgical method, CO2 laser, for the treatment of non-invasive vulvar diseases. The combination therapy consists of skinning resection of the vulva of the central lesions and skin destruction by laser evaporation of the peripheral lesions. Over a period of five years 23 patients were treated with skinning laser resection of the vulva. Primary closure of the wound was performed in all cases. In three of the patients--two with the diagnosis of lichen sclerosus and one with Bowen's disease--who were first treated with total skinning vulvectomy, the histopathological examination revealed invasive cancer. They were treated again with total radical vulvectomy. In all cases less than 200 ml blood was lost at the time of surgery. The average duration of the operations was 25 minutes. The central section healed within eight to twelve days. All the patients with VIN were cured after the first radical treatment. The follow-up time is two to six years.     

Management of carcinoma in situ of the vulva

Concern about multicentricity and occult invasion has led authorities to recommend total vulvectomy in the management of carcinoma in situ of the vulva (VCIS). Of these considerations, only occult invasion has sufficient import to contraindicate a more conservative therapeutic approach. VCIS is being diagnosed with increasing frequency in young women for whom the deforming and sexually crippling effects of vulvectomy are especially repugnant. Because of its distinctive success in localizing preinvasive and early invasive squamous neoplasia of the cervix, colposcopy and directed biopsy were employed in evaluating all patients seen in our vulva clinic since 1971. Of 27 consecutive patients considered to have VCIS, 24 were treated either by local excision, skinning vulvectomy, topical 5-fluorouracil (5-FU), or cryosurgery. In no instance was occult invasion missed on pretreatment evaluation, and only one patient has developed a new in-situ lesion following conservative surgical therapy. Topical 5-FU therapy was unsuccessful in six of six cases. These results demonstrate that total vulvectomy for VCIS can be replaced successfully with more conservative operations.     

Recurrent carcinoma in situ of the vulva in a skin graft

Skinning vulvectomy has been a recommended treatment for carcinoma in situ of the vulva. We report a case of recurrent carcinoma in situ occurring in the skin graft of a patient with previous skinning vulvectomy.     

Vulvar intraepithelial neoplasia and skin appendage involvement

Vulvar intraepithelial neoplasia may extend into the pilosebaceous units of the hairy and non-hairy skin of the vulva, and inadequate removal may cause treatment failure. We measured with a calibrated microscope the thickness of vulvar intraepithelial neoplasia and the depth to which it extended into the underlying pilosebaceous units of the vulvar skin. The mean thickness of vulvar intraepithelial neoplasia in 329 histologic sections from 62 cases was 0.38 mm; 99.5% of all vulvar intraepithelial neoplasia measured less than 0.77 and 0.69 mm in the hairy and non-hairy skin, respectively. Sebaceous-gland and hair-follicle involvement by vulvar intraepithelial neoplasia was 21 and 32%, respectively. The mean depth of sebaceous-gland involvement was 0.77 mm in the hairy skin and 0.50 mm in its non-hairy counterpart; 99.5% of all vulvar intraepithelial neoplasias extended less than 2.03 and 1.07 mm in the hairy and non-hairy skin, respectively. The mean depth of hair-follicle involvement was 1.04 mm; 99.5% of all hair follicles were involved less than 2.55 mm. Our findings suggest that removal of vulvar intraepithelial neoplasia to a depth of 1.0 and 2.0 mm in the non-hairy and hairy skin, respectively, is appropriate for successful treatment.     

Treatment of cutaneous vulvar lesions with skinning vulvectomy

A skinning vulvectomy and split-thickness skin graft were used in the management of four women with benign vulvar disease after the failure of standard medical and surgical therapy. Three women remain free of the primary disease process, with a follow-up of 12-36 months. One woman with lichen sclerosus and another with "diffuse atrophy" developed recurrent disease in their skin grafts 45 and 96 months, respectively, after skinning vulvectomy. Symptomatic improvement was achieved subsequently in both women with the topical application of testosterone.     

Carcinoma oculto de vulva en neoplasia vulvar intraepitelial diferenciada

We present the case of a 74-year-old woman with a 2-year history of a vulvar lesion associated with pruritus. The patient was treated with multiple topical treatments but, due to the persistence of the lesion and symptoms, she was referred to our clinic. The results of biopsy of the lesion corresponded to differentiated vulvar intraepithelial neoplasia. The initial treatment was wide local excision, with the pathological finding of occult differentiated squamous carcinoma of the vulva. The lesion was treated surgically through radical vulvectomy with sentinel node biopsy, which confirmed the diagnosis of stage iB squamous vulvar carcinoma.     

外阴Paget病的临床特点与治疗分析

目的:探讨外阴Paget病的临床特点及治疗方法。方法:回顾分析8例外阴Paget病的临床资料。结果:8例外阴Paget病中7例(87.5%)为绝经后妇女,平均年龄64.5岁,5例(62.5%)以瘙痒为首发症状,4例有皮肤湿疹样改变,4例局部皮肤增厚、僵硬或有溃疡、红肿。2例合并其他部位的恶性肿瘤。8例在发现外阴病变或出现症状后5~120个月(平均43.37个月)经外阴活检组织学确诊。治疗以手术为主,8例中3例有浸润性病变或合并腺癌,扩大手术范围或术后辅助放疗,1例发展为癌。1例腹股沟淋巴结转移者也进展为癌。4例为表皮内Paget病,其中3例行局部病灶切除术或外阴单纯切除术,1例放射治疗,均未复发。结论:外阴Paget病多见于绝经后患者,症状以瘙痒为主,有就诊延迟现象。治疗以手术为主,表皮内Paget病可行外阴单纯切除术或局部病灶切除术,伴有浸润性病变、合并腺癌或淋巴结转移者常需扩大手术范围。复发常见,患者均需终生随访。     

Paget's disease of the vulva: diagnostic and therapeutic problems

Two cases of Paget's disease of the vulva are presented and the complex problem of diagnosis of this neoplasia is evaluated: all the diagnosis tests used in vulvar disease (vulvar citology, toluidine blue test) are insufficient in the presence of on eventual underlying carcinoma. In view of these considerations, the therapeutic approach is total vulvectomy.     

Guidelines for the follow-up of women with vulvar lichen sclerosus in specialist clinics

It is recommended that women with vulvar lichen sclerosus be followed in specialist clinics where difficulty exists with symptom control or where there is clinical evidence of localized skin thickening. Follow-up is also recommended for women who have previously been treated for squamous cell carcinoma of the vulva (arising in lichen sclerosus or vulvar intraepithelial neoplasia) or where the pathologist expresses concern and is unable to make a definitive diagnosis of differentiated vulvar intraepithelial neoplasia.     

Paget's disease of the vulva

Thirty-six patients with Paget's disease of the vulva were reviewed. Median age of the patients at diagnosis was 64 years (range 41-84 years). Five patients (14%) had an associated invasive adenocarcinoma of the vulva at the time of diagnosis. Of 31 patients with superficial noninvasive Paget's disease, 28 were available for follow-up. Treatment of patients with superficial Paget's disease was surgical and based on the extent of disease. Procedures performed included total vulvectomy (25), wide local excision (4), and skinning vulvectomy with skin graft (1). The median follow-up was 108 months (range 6-266 months). Twenty-two of twenty-eight patients remained free of disease. Six patients have required multiple procedures for recurrent superficial Paget's disease. Treatment of Paget's disease of the vulva is surgical. Radical surgery is the preferred treatment of patients with an associated invasive adenocarcinoma; three of five patients with an invasive adenocarcinoma were long-term survivors. Patients with superficial Paget's disease of the vulva should be treated by local excision utilizing frozen-section margin evaluation as a guide to extent of excision. Only one patient with an initial diagnosis of superficial Paget's disease of the vulva developed invasive adenocarcinoma.     

CO2 laser surgery for vulvar intraepithelial neoplasia. Excisional,destructive and combined techniques

OBJECTIVE: To evaluate CO2 laser excision, vaporization and combined techniques for treatment of vulvar intraepithelial neoplasia (VIN). STUDY DESIGN: Thirty-nine cases of VIN 3, 15 cases of VIN 2 and 9 of VIN 1, for a total of 63 patients with histologically proven VIN, underwent laser excision or vaporization under colposcopic guidance, using local anesthesia, in an outpatient setting or after day-surgery admission. Clinical aspects, cervical intraepithelial neoplasia (CIN) and vaginal intraepithelial neoplasia (VaIN) association, types of CO2 laser treatment, follow-up, recurrences and second treatments were evaluated. RESULTS: Twenty-seven (41.3%) patients underwent laser vaporization, and 37 (58.7%) with VIN 3, underwent laser excision or the combined technique. Colposcopic and biopsy examinations of patients with VIN revealed three cases of CIN 3 and nine cases of VaIN 3; two patients had concomitant VIN 3, CIN 3 and VaIN 3. Local anesthesia, using 2% carbocaine, and outpatient or day-surgery treatments were possible in all cases. A small incidence of intraoperative complications (4.8%) and absence of postoperative complications were observed. A single session was curative in 76.9% of patients treated with laser vaporization and in 78.4% of those treated with laser excision. Eleven cases of recurrent VIN and two cases of invasive vulvar carcinoma were observed during follow-up. A second laser procedure was carred out in all cases of relapsed VIN, with an overall cure rate of 96.8% after two treatments. Radical vulvectomy associated with inguinal-femoral lymphadenectomy was performed in the two cases of invasive carcinoma. CONCLUSION: CO2 laser surgery permits treatment of VIN in an outpatient or day-surgery setting under local anesthesia with excellent cosmetic and functional results. The treatment can also be adjusted to the patient's specific needs, with the possibility of calibrating the depth of the vaporized and removed tissues. Excisional treatment is the preferred method because it permits histologic evaluation of the excised tissue and detection of possible occult early invasion.     

Intraepithelial and Invasive Squamous Cell Neoplasia of the Vulva: Trends in Incidence,Recurrence, and Survival Rate in Norway

Objective: To characterize time trends in incidence of intraepithelial and invasive vulvar neoplasia, transition of intraepithelial vulvar neoplasia to invasive cancer, and survival rate based on a total population.Methods: The Cancer Registry of Norway was used to identify all Norwegian inhabitants diagnosed during 1956–1990 with squamous cell carcinoma of the vulva, and all those with intraepithelial vulvar neoplasia diagnosed during 1973–92.Results: The incidence rate of intraepithelial neoplasia increased three-fold from 1973–77 to 1988–92, and 3.4% changed into invasive disease. Multivariate analyses identified age as a significant variable. The age-adjusted incidence rate for squamous cell carcinoma was constant for the whole period. The ratio between recurrence and the total number of invasive cancer varied from 21% to 31%. The 5-year survival rates have not changed significantly over the period. Age was revealed as a strong prognostic factor, showing an excess death rate by increasing age.Conclusion: The incidence of vulvar intraepithelial neoplasia has increased substantially over the last 40 years, but that of invasive vulvar cancer has not changed appreciably.     

Sexual function and somatopsychic reactions after local excision of vulvar intra-epithelial neoplasia.

Eighteen patients, under the age of 60 years, who have been treated with local excision of the vulva, participated in the study in which sexual function and somatopsychic reactions were evaluated by personal interviews. Furthermore both objective and subjective cosmetic results were registered. After this type of operation, fewer than one-third of the patients had postoperative sexual and somatopsychic problems, whereas more than half of the patients undergoing vulvectomy did report such problems. Fourteen out of 18 patients were satisfied with the cosmetic result and in 12 of the patients no disfiguration was found. This study shows that local excision of intra-epithelial neoplasia of the vulva is far less sexually traumatic than is vulvectomy.     

CO2 Laser Total Superficial Vulvectomy: An Outpatient Treatment for Wide Multifocal Vulvar Intraepithelial Neoplasia Grade 3

The ideal treatment of large multifocal vulvar intraepithelial neoplasia grade 3 (VIN 3) in young patients is still debated. The goal is to prevent development of invasive vulvar cancer while preserving normal vulvar anatomy and function. The authors describe the case of a 37-year-old woman affected by a biopsy-proven VIN 3 involving the entire external genitalia. A total superficial vulvectomy was carried out in 2 closer sessions by CO₂ laser used in an excisional way. Both procedures were performed in an outpatient setting with the patient under local anesthesia and without suturing stitches or skin flaps. Definitive pathologic analysis confirmed VIN 3 with free margins. No intraoperative and postoperative complications were documented. Functional and anatomic outcomes were optimal, and no relapse occurred after 12 months of follow-up. Use of CO₂ laser total superficial vulvectomy shows promise of a safe and adequate treatment in selected young patients with VIN 3 involving the entire external genitalia.     

A nuclear deoxyribonucleic acid analysis of normal and abnormal vulvar epithelium

Vulvar and groin skin from 21 women with clinical squamous cell carcinoma of the vulva was compared with that from nine patients with vulvar intraepithelial neoplasia. Feulgen-stained nuclear densitometry showed a constancy of Feulgen-deoxyribonucleic acid (DNA) density in normal epithelium and all subepithelial connective tissue nuclei. At three sites--tumor edge, opposite labia, and perineum--there were significant differences in nuclear chromatin content between the two groups and also as compared with normal epithelium.     

Medical treatment of vulvar squamous cell hyperplasia.

OBJECTIVE: To evaluate symptomatic response and recurrence rates of graduated topical fluorinated corticosteroid in patients with vulvar squamous cell hyperplasia. METHODS: Nine hundred seventy-six patients with biopsy-proven vulvar squamous cell hyperplasia from 1990 to 2003 were reviewed in this retrospective study. All patients were treated with graduated topical fluorinated corticosteroid. Data were obtained from hospital records. Symptomatic remission and recurrence rates were noted following six months local therapy. RESULTS: The mean age was 42.55+/-10.93 (15-85). The remission rate was 93.8% in six months. The remission rate was non-significantly higher in postmenopausal patients than that in their premenopausal counterpart (94.9% vs 93.0%, p=0.15). The disease recurred in 6.9% of patients. Of the patients that suffered recurrence 47.5% had persistent disease initially. The patients with following factors older ages (>40 years), postmenopausal period had significantly higher recurrence rates. Four patients with recurrent disease and six patients with persistent disease in the form of vulvar intraepithelial neoplasia I-II or atypical squamous hyperplasia, were treated with skinning vulvectomy. CONCLUSION: Corticosteroid in the treatment of vulvar squamous cell hyperplasia yielded excellent response rates. In the evaluation of patients without symptomatic relief, the first step should be a vulvar biopsy to exclude the presence of atypical components.     

Vulvar intraepithelial neoplasia in adolescents with abnormal Pap smear results: a series report

OBJECTIVE: The objective of this study was to determine the prevalence of vulvar intraepithelial neoplasia (VIN) in adolescents presenting for cervical colposcopy in an adolescent gynecology office. MATERIALS AND METHODS: We conducted a retrospective chart review from 1999 to 2002 of the concomitant diagnosis of cervical intraepithelial neoplasia and VIN in our private general pediatric and adolescent practice in patients younger than 22 years of age who underwent cervical colposcopy as well as evaluation of the vulva secondary to gross and microscopic visualized lesions. RESULTS: Sixty-one patients underwent colposcopy for abnormal Pap smears; we found a 10% overall prevalence of vulvar intraepithelial neoplasia. Forty-four percent (n=27) underwent concomitant evaluation of the vulva; from these, 22% (n=6) fulfilled the characteristics of vulvar and cervical intraepithelial neoplasia. CONCLUSION: In the presence of cervical cytology abnormalities, VIN may be more common than recognized and careful screening is definitely warranted.