Úlcera vulvar en paciente menopáusica. Ampliando el diagnóstico diferencial

Genital ulcers are a common reason for consultation in the emergency department, especially in Gynaecology. However, due to the low frequency of some of them, together with the wide differential diagnosis that can arise in each case, the diagnosis of these lesions can sometimes be difficult or erroneous. We present the case of a menopausal patient that consulted due to a genital ulcer, and was diagnosed with of basal cell carcinoma. The knowledge of this entity and its characteristic clinical findings, together with a correct anamnesis, will lead to an appropriate diagnostic suspicion, facilitating the management of these patients, and avoiding unnecessary examinations.     

Recommendations for the Study of Vulvar Pain in Women,Part 1: Review of Assessment Tools

IntroductionThe etiology and consequences of chronic vulvar pain are multidimensional, resulting in highly variable clinical presentations and no established treatment algorithm. Inconsistent use of measurement tools across studies is a significant barrier to drawing conclusions regarding etiology and treatment. In a companion paper, we review additional methodological challenges to the study of chronic vulvar pain and potential solutions.AimTo review and recommend assessment and measurement tools for vulvar pain and associated key outcomes.MethodsThe authors reviewed the scientific evidence related to measurement of vulvar pain and made decisions regarding recommendations via discussion and consensus.Main Outcome MeasureWe assessed measurement tools for vulvar pain and related outcomes and considered advantages and disadvantages of their use.ResultsEmpirically validated measurement tools are available and should be used uniformly across studies to support comparisons and pooling of results. There is, at times, a trade-off between advantages and disadvantages when selecting a particular tool, and researchers should be guided by their specific research aims, feasibility, and potential to gain further knowledge in the field. Researchers should incorporate a biopsychosocial assessment of vulvar pain and its consequences.Clinical ImplicationsThis review provides a comprehensive list of measurement tool recommendations for use in clinical research, and in some cases, clinical practice.Strengths & LimitationsThis expert review can guide study design and decision-making for those researching vulvar pain and its consequences. The review content and recommendations are based on expert knowledge of the literature rather than a formal systematic review.ConclusionA thorough consideration of vulvar pain assessment tools is essential for continued progress toward identifying factors involved in the development and maintenance of vulvar pain and developing empirically supported treatments.Rosen NO, Bergeron S, Pukall CF. Recommendations for the Study of Vulvar Pain in Women, Part 1: Review of Assessment Tools. J Sex Med 2020; 17:180–194.     

Characteristics and outcomes of women with adenocarcinoma versus squamous cell carcinoma of the vulva: A Japanese Gynecologic Oncology Group study

ObjectiveStudies on vulvar adenocarcinoma are lacking. Thus, we aimed to compare the characteristics and survival outcomes between vulvar adenocarcinoma and squamous cell carcinoma (SCC).MethodsThis was a preplanned sub-analysis of a previously organized nationwide retrospective observational study in Japan conducted between 2001 and 2010 (JGOG-1075S). Surgically treated women with stage I-IV vulvar invasive adenocarcinoma were compared to those with SCC. Multivariable analysis was performed to identify patient and tumor characteristics related to adenocarcinoma. Inverse probability of treatment weighting was used to balance the background differences, and a Cox proportional hazards regression model was fitted to estimate the effect of the histological type on survival.ResultsForty-eight women with adenocarcinoma were compared with 537 women with SCC. On multivariable analysis, women with adenocarcinoma were younger (median age, 64.5 vs. 70 years, adjusted odds ratio [OR] per age 0.975, 95% confidence interval [CI] 0.955–0.995, P = 0.016) and had higher positive surgical margin rates (31.2% vs. 18.4%, adjusted OR 2.376, 95% CI 1.188–4.754, P = 0.014) than those with SCC. However, according to the weighted model, the survival outcomes were comparable (hazard ratio for progression-free survival, 1.088, 95% CI 0.740–1.601, P = 0.667 and hazard ratio for overall survival, 1.008, 95% CI 0.646–1.573, P = 0.973). Similar associations were observed when the cohort was stratified by age (≤70 or >70 years), stage (I-II or III-IV), and surgical margin (negative or positive) (all, P > 0.05).ConclusionVulvar adenocarcinoma is characterized by a younger age at diagnosis and higher positive surgical margin rates than SCC, but the survival outcomes are comparable.     

Peri‐vulvar reconstruction using internal pudendal artery perforator flap in female Fournier's gangrene

Fournier's gangrene in female patients has low incidence rate but high mortality rate compared with that in males, with many cases resulting in death at acute phase. This is due to the differences in male and female genital anatomy, which should be fully understood by physicians to increase the patient's survival rate. After crossing the acute phase of the disease by an appropriate treatment, it is important to reconstruct vaginal or vulvar defects according to the patient's three‐dimensional anatomical structures. Perforator flap based on internal pudendal artery is one of the ideal reconstructive techniques to resolve the aforementioned issue. The authors intend to introduce the distinguishing characteristics of Fournier's gangrene in female patients, and the surgical techniques to reconstruct the defects after the acute phase of disease.     

Tumour-free margins in vulvar squamous cell carcinoma: Does distance really matter?

BackgroundThere is no consensus on the width of tumour-free margins after surgery for vulvar squamous cell carcinoma (VSCC). Most current guidelines recommend tumour-free margins of ≥8 mm. The aim of this study was to investigate whether a margin of <8 mm is associated with an increased risk of local recurrence in VSCC.MethodsA meta-analysis of the available literature and a cohort study of 148 VSCC patients seen at a referral centre from 2000 to 2012 was performed. The primary end-point of the cohort study was a histologically confirmed ipsilateral local recurrence within 2 years after primary treatment in relation to the margin distance.ResultsBased on 10 studies, the meta-analysis showed that a tumour-free margin of <8 mm is associated with a higher risk of local recurrence compared to a tumour-free margin of ≥8 mm (pooled risk ratio, 1.99 [95% confidence interval {CI}: 1.13–3.51], p = 0.02). In the cohort study, we found no clear difference in the risk of local recurrence in the <8 versus ≥8 mm group; however, 40% of the patients in the <8 mm group received additional treatment. Tumour-positive margin was the only independent risk factor for local recurrence in the multivariable analysis (hazard ratio, 0.21 [95% CI: 0.08–0.55]).ConclusionsThis work provides important data to question the commonly used 8-mm margin as a prognosticator for local recurrence. More research is needed to address the question of whether additional treatment improves the prognosis in patients with a tumour-free margin of <8 mm.     

The prognostic role of FIGO stage in patients with vulvar cancer: a systematic review and meta-analysis

Objective: To perform a meta-analysis examining the survival of patients with vulvar cancer based on the 2009 International Federation of Gynecology and Obstetrics (FIGO) staging system. Methods: Medline, PubMed, and Cochrane databases were searched until 20 March 2015 for prospective or retrospective studies using the terms vulvar cancer, prognostic/prognosis, survival, recurrence, lymph nodes (LNs), inguinal lymphadenectomy/excision, and staging. The primary outcome was 5 year overall survival (OS), and secondary outcomes were 5 year disease-free survival (DFS) and progression-free survival (PFS). Results: Fourteen retrospective studies were included. The 5 year OS rate decreased with increasing 2009 FIGO stage and number of LN metastasis. FIGO stage I, II, III, and IV patients had 5 year OS rates of 84.0%, 74.6%, 47.8%, and 9.4%, respectively. Pooled estimates showed that the 5 year OS was 84.5% for patients without LN metastasis, and for patients with ≥3 LN metastases the 5 year OS rate was 30.1%. Similarly, the overall 5 year DFS and PFS decreased with the increasing number of LN metastases. The 5 year DFS rate was 87.2% for patients with no LN metastasis and for patients with ≥3 LN metastases was 35.4%. The 5 year PFS rate was 86.6% for patients with no LN metastasis and for patients with ≥3 LN metastases was 27.6%. Limitations: All studies were retrospective studies. DFS and PFS rates in patients with different 2009 FIGO stages and with different mean tumor sizes were not examined due to a limited number of reports. Conclusions: More advanced 2009 FIGO stage and greater number of LN metastases are associated with worse outcomes in patients with vulvar cancer.     

股薄肌肌皮瓣修复外阴癌根治术后缺损

目的解决外阴癌根治术后较大外阴缺损的即刻修复。方法１９９２年３月～１９９５年１２月,对４例癌肿位于外阴前庭后半区,大癌肿的患者,在行根治术后即刻应用股薄肌肌皮瓣修复外阴缺损。结果术后外阴切口Ⅰ期愈合３例;Ⅱ期愈合１例,为患者合并Ⅱ型糖尿病。术后经３～６年随访,１例术后２年局部复发,再次手术后１年死于意外事故。余３例患者健在,无癌肿复发及并发症。结论外阴癌根治术后同期应用股薄肌肌皮瓣修复外阴较大缺损能大大减少并发症,提高患者的生活质量。     

外阴营养不良中fas/apol-1表达的生物学意义

探讨外阴营养不良组织中ｆａｓ／ａｐｏｌ－１（ＣＤ９５）表达与其发病机理的关系。方法采用流式细胞仪检测４２例外阴营养不良新鲜组织中ｆａｓ／ａｐｏｌ－１的表达,并取１０一正常正外阴组织作对照。结果硬化性苔鲜组织中ｆａｓ／ａｐｏｌ－１的表达高于对照组及鳞状细胞增生混合性营养不良组织中的表达。结论ｆａｓ／ａｐｏｌ－１诱导的凋亡与外阴营养不良有密切的关系。