Posted on November 19th, 2008 by Canadian Health in
Vulva cancer Bartholin gland cancer is a rare malignancy that should be considered in the differential diagnosis of a labial mass. The tentative diagnosis of adenocarcinoma of the Bartholin gland is based on the cytologic findings and location of the tumor. The nuclei are oval to oblong, and some cells have a peripherally displaced nucleus. The chromatinic material is slightly increased, and some nuclei have prominent nucleoli. The cytoplasm is basophilic and abundant. Microcalcifications and psammoma bodies are numerous. The prognosis is generally poor because of the aggressive metastatic tendencies of this cancer. The etiology of Bartholin gland cancer remains unknown, and No optimal plan of treatment has been established. Early detection followed by radical vulvectomy and bilateral inguinal-femoral Node dissection may improve survival.
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Posted on November 14th, 2008 by Canadian Health in
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Melanomas are the second most common vulvar malignancy and occur frequently in white women between the ages of 50 and 80 years. Melanomas may arise from preexisting lesions and occur mainly on the labia minora and clitoris. Patients at increased risk for melanoma include those with a family history of melanoma and those with dysplastic nevi elsewhere on the body. Dysplastic melanoma nevi occur in 2-5% of white adults and in one third of patients with cutaneous melanoma. Most patients present with a lump or tumor on the external genitalia, although complaints of itching, bleeding, or discharge are often described. A change in a preexisting mole may Not prompt some patients to seek attention because it is difficult to observe vulvar lesions adequately. Most pigmented lesions in this location should be excised unless they have been present and unchanged for years. Considerable debate centers viagra super active on the optimal treatment for vulvar melanoma as well as those clinical pathologic factors influencing prognosis. Primary tumors can be assessed by microstaging with the Breslow microstaging classification. According to the Breslow tumor thickness classification, a 0.75-mm depth of invasion has a 95-99% 5-year survival rating; a 0.76- to 1.49-mm thickness has a 90-95% survival rating; a 1.50- to 4.00-mm thickness has a 60-75% survival rating; and a depth of invasion greater than 4.00 mm has a survival rating of less than 50%. Tumor thickness, inguinal Node metastasis, and older age at diagnosis are independent prognostic factors. Radical vulvectomy does Not seem to improve survival compared with less radical procedures. Radical local excision for patients with malignant melanoma of the vulva is recommended canadian pharmacy. Whether patients who have more than a superficially invasive melanoma should also have inguinal lymph Node dissection is controversial.
Some investigators have observed that ulceration, tumor thickness, and positive inguinal lymph Nodes are the most important prognostic factors. A low-risk and a high-risk group of patients have been identified for recurrence. The low-risk patient has a Nonulcerative tumor less than 3 mm thick without clinical evidence of inguinal lymph Node metastases and can be treated by local excision with a 2-to 3-cm margin. The high-risk patient has a tumor that is ulcerative or more than 3 mm thick and has also been treated by local excision without elective inguinal Node dissection. If clinical suspicion of inguinal Node metastases exists, inguinal Node dissection is indicated for better local control of the disease.
Posted on November 13th, 2008 by Canadian Health in
Vulva cancer Verrucous carcinoma of the vulva is much less common than squamous cell carcinoma. The clinical and morphologic distinctions between these neoplasms are important to understand because of their contrasting biologic behavior and treatment. Verrucous lesions rarely metastasize.
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Both cancers present with symptoms of pruritus and a Noticeable mass. On examination, both tumors commonly occur on the labia and are exophytic. If infection occurs in association with verrucous carcinoma, the resulting induration of the surrounding tissue as well as reactive regional lymph Node enlargement may lead to an erroneous diagnosis of advanced squamous cell carcinoma. One third of squamous cell carcinomas are flat and ulcerative. It may be difficult to distinguish verrucous from squamous cell carcinomas.
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Verrucous carcinomas are thick neoplasms that may invade and compress the underlying stroma with pushing margins. Therefore, it is crucial to recognize the microscopic features of this well-differentiated squamous cell neoplasm so as Not to mistake it for a squamous cell carcinoma, which has the capacity to metastasize to inguinal lymph Nodes. Human papillomavirus has been implicated in the development of both of these tumors.
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The treatment of vermcous carcinoma is wide local excision. Because there may be recurrence if the surgical resection margins show signs of neoplastic involvement, the pathologist should carefully evaluate the margins. Recurrence of verrucous carcinoma connotes a poor prognosis.
Posted on November 12th, 2008 by Canadian Health in
Vulva cancer Follow-Up
Patients should be seen every 3 months for 2 years and then every 6 months for 5 years; thereafter, visits should occur annually. A pelvic examination and Pap test of the cervix, vagina, or both should be performed at each visit. Nearly all patients with groin Node recurrence do Not survive.
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Paget’s Disease
Paget’s disease of the vulva has a high recurrence and a higher incidence of invasive disease than was previously recognized. The median age of diagnosis is 64 years. About 10-15% of patients have been reported to have an associated invasive adenocarcinoma of the vulva at the time of diagnosis. Radical surgery is the preferred treatment of patients with associated invasive adenocarcinoma. Patients with superficial Paget’s disease of the vulva should be treated by local excision. Patients can require multiple procedures for recurrent superficial Paget’s disease. Rarely after initial diagnosis of superficial Paget’s disease of the vulva does invasive carcinoma develop.
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Paget’s disease of the vulva occurs most often in white postmenopausal women presenting with extreme pruritus and soreness, often of long duration. Disease appears as red or bright pink, desquamated, eczematoid areas among which are scattered, raised, white areas of hyperkeratosis. The borders appear slightly elevated and sharply demarcated. Perianal involvement is Not uncommon, but other areas of the aNogenital tract, cervix, and vagina are involved only by continuity of the lesion rather than multi-focal primary lesions. Concomitant adeNocarciNoma of the vulvar sweat glands or within the rectum has been Noted. The visible borders of the lesions, although seemingly sharp, are frequently misleading.
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Paget cells have been found deep in the epidermis. The Paget cell is of epidermal origin and represents aberrant differentiation. Dermal, multifocal, stem Paget cells have ultrastructural characteristics of secretory sweat gland cells and squamous cell carcinoma; thus, either may be a precursor. Histochemical stains yield positive reactions for intracellular mucopolysaccharide characteristic of Paget cells, which can assist in differentiating this entity from the even more unusual superficial amelanotic melanoma.
Treatment encompasses wide excision with a margin of at least 2 cm. Initial definition of the lesion margin should be evaluated by frozen section. Otherwise, the frequency of recurrence will be high. The excision should encompass more than removal of the epidermis alone. Underlying fat, superficial tendon, and muscular tissue should also be removed because of the possibility of underlying adenocarcinoma. Careful histologic review of the entire surgical specimen is necessary to rule out an underlying primary adenocarcinoma. When the underlying adenocarcinoma is present, bilateral inguinal-femoral lymphadenectomy should be performed.
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The corrected survival rate for all patients, including those with associated underlying adenocarcinoma, is approximately 90%, although intraepithelial recurrences have been reported after total excision. In about 20% of cases, these recurrences are largely avoidable with the use of fro-zen-section evaluation of the margins at the time of the primary treatment.
Posted on November 5th, 2008 by Canadian Health in
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The 5-year survival rate for operable cases is about 70%. Patients with negative groin Nodes have a 5-year survival rate of 90%, but this falls to about 50% for patients with positive Nodes. The number of positive Nodes is the single most important prognostic variable, and patients with one microscopic positive Node have a good prognosis regardless of the stage of disease (the 5-year survival rate is 94%). In a Gynecologic Oncology Group trial, patients with one or two positive groin Nodes had a 5-year survival rate of 75%, those with three or four positive groin Nodes had a survival rate of 36%, and those with five or six positive groin Nodes had a survival rate of 24%. There were No survivors among patients with seven or more positive Nodes.
Besides the number of Nodes, other factors (eg, size of a metastasis from the Node, extracapsular site of metastasis, immune response to positive Nodes) should be considered. The diameter and size of a metastasis significantly correlate with survival of patients with vulvar carcinoma. An intracapsular site smaller than 5 mm in diameter offers a 90% chance of 5-year survival compared with a 20% survival rate in patients with a metastasis larger than 5 mm and extracapsular extension. Thus, the histopathologic pattern of lymph Node invasion may distinguish patients at low and high risk for recurrence.
A standard pathology report form is helpful in identifying prognostic and staging factors and should be adopted by all institutions. Accounting for specimen preparation and fixation, a tumor-free surgical margin of greater than 8 mm on the vulva results in a high rate of local control, whereas a margin of less than 8 mm can be associated with a 50% chance of recurrence. Depth of invasion or increasing tumor thickness is associated with local recurrence. A pushing-border pattern is less likely to recur than an infiltrative growth pattern. Positive lymph vascular space invasion is predictive of recurrence. Neither clinical tumor size Nor coexisting benign vulvar pathology correlates with local recurrence. Canadian pharmacy viagra.