Archive for the Vulva cancer category.
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.
Posted on October 31st, 2008 by Canadian Health in
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Significant advances have occurred in the management of squamous cell carcinoma of the vulva with the advent of conservation for unifocal lesions and limitation of pelvic lymphadenectomy. Now, full groin dissection can be avoided in some patients with stage IA vulvar carcinoma. In stage IB, contralateral groin dissection in patients with lesions smaller than 2 cm and negative ipsilateral nodes has been eliminated. Also, separate groin incisions are now used, which may reduce prolonged postoperative wound healing. The use of preoperative radiation therapy has reduced the need for exenteration in patients with advanced disease. The use of postoperative radiation to decrease the incidence of recurrence and to improve survival has been proven to be effective in a randomized trial in patients with two or more positive groin nodes. Cheap viagra super active.
Every effort should be made to reduce morbidity while retaining curative potential. Abandonment of en bloc resection with the butterfly incision, which has a significant wound separation of at least 50%, can reduce the morbidity of regional node dissection. The outcome after triple incisions is essentially equal to that of a single incision in early-stage disease.
The primary morbidities of radical vulvectomy and bilateral groin dissection are lymphedema and groin wound breakdown. Few intraoperative deaths occur, but there is a postoperative mortality rate of 5% because of the geriatric population affected. Radical vulvectomy is often complicated by problems associated with insufficient closure of a large skin defect contributing to postoperative necrosis of the suture line over the mons pubis and the inguinal areas. The gluteus maximus myocutaneous flap has been used to cover these defects. The perineal artery axial flap is useful in reconstruction of moderate defects of the perineum. Perhaps the most useful flap is a rhomboid transposition flap used to repair the perineal defect after surgery for carcinoma of the vulva.
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Age alone should not be a deterrent to surgical management of gynecologic malignant disease. Morbidity and mortality cannot be predicted from age, past history, type of operation, or preoperative laboratory studies. With careful perioperative management and attention to the unique problems of the elderly, acceptable surgical outcomes should be achieved.
Radiation therapy with megavoltage equipment using electron beam has been applied as primary treatment of extensive carcinoma of the vulva. In selected cases, radiation therapy may be given preoperatively to reduce disease and define surgical margins. Cheap hgh online at canadian pharmacy mall.
Posted on October 31st, 2008 by Canadian Health in
Vulva cancer Vulvar cancer spreads by direct extension to the adjacent structures, including the vagina and anus, and by lymphatic embolization to the regional lymph nodes. Metastases to the liver, lungs, and bones may occur. The overall incidence of lymph node metastasis of vulvar cancer is about 30%. When inguinal-femoral node metastasis is present, the rate of pelvic node metastasis is about 25%.
The incidence of groin node metastasis is related to the depth of stromal invasion, grade of the tumor, presence of lymphovascular space involvement, clinical node assessment, and age of the patient.
Lesions smaller than 2 cm in diameter with minimal stromal invasion of less than 1 mm have been designated stage IA. If these lesions have no associated lymphovascular space involvement and are well differentiated with neither any infiltrating tumor component nor confluence, there should be minimal possibility of groin node metastasis that would warrant groin dissection in all patients. The major reason for including this subset within stage I is to collect data that might indicate outcome in a large number of patients treated with a variety of operative approaches.
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Posted on October 22nd, 2008 by Canadian Health in
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Invasive squamous cell carcinoma of the vulva accounts for approximately 5% of all genital malignancies and 90% of vulvar malignancies. The disease occurs primarily in the sixth and seventh decades of life, although women age 25 years or younger can have invasive squamous cell carcinoma of the vulva also. An awareness of the possibility of invasive vulvar cancer, even in relatively young patients, should lead to prompt and thorough histologic evaluation of any vulvar lesion. There is evidence that HPV types 16 and 18 are associated with development of invasive squamous cell carcinoma of the vulva. In specimens with invasive squamous cell carcinoma, HPV type 16 or 18, or both, can be found. Canadian cialis pharmacy.
Invasive carcinoma usually presents with ulceration, friability, or induration of the surrounding tissues. Although most lesions are unifocal, surrounding lesions may arise, suggesting contact as a possible mechanism of induction of malignancy of the vulva. Most invasive carcinomas of the vulva are associated with surrounding areas of intra-epithelial neoplasia and frequently are associated with vulvar dystrophy. Despite this, vulvar dystrophy is not identified as a high-risk premalignant entity, and intraepithelial neoplasia seems to have a low rate of progression into invasive carcinoma.
The most widely used system for staging invasive carcinoma of the vulva was last modified in 1994 by the International Federation of Gynecology and Obstetrics (FIGO; see the box). It is a surgical staging system based on assessment of groin node involvement. Clinical groin node palpation is subject to a large margin of error, with even the most experienced observers acknowledging a 25-40% error rate. The rate of occult metastasis in patients with no palpable nodes or suspicious palpable nodes is as high as 25%. Ultrasonography may help detect positive groin nodes. These observations do not totally undermine the validity of clinical node assessment, but they do emphasize the importance of avoiding overreliance on clinical assessment of the status of the inguinal nodes and the importance of planning appropriate therapy. The surgical staging system is based on actual histologic evaluation of the lymph nodes and actual surgical extent of disease.
Posted on October 16th, 2008 by Canadian Health in
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Because the biologic potential of VIN or carcinoma in situ remains uncertain, conservative therapeutic measures are appropriate. Previously, complete excision of the area at risk was recommended regardless of the size of the lesion. It is now recognized that these lesions are only part of the spectrum of neoplasias that occur over the entire anogenital epithelium. Removal of the entire area at risk may not be feasible and would certainly be disfiguring. Rather than a routine total vulvectomy, wide excision of the intraepithelial neoplasia is more appropriate, particularly for unifocal lesions. Shallow skinning procedures, which remove the full thickness of epithelium of the labia majora and minora, especially over the clitoris, but leave the underlying connective tissues intact, may be used for widespread multifocal involvement. Grossly, a margin of 1-1.5 cm beyond the limits of the lesion should be removed. Primary closure may be accomplished by using rotational flaps or skin grafting. Human growth hormone online
Laser therapy for ablation of an intraepithelial lesion of vulva may be appropriate in selected cases. One of its major limitations is the loss of tissue for histologic interpretation to detect occult invasion. Laser vaporization to a depth of 1 mm including the zone of dermal necrosis should be sufficient to eradicate most epidermal lesions without skin appendage involvement. If the initial biopsy reveals involvement of adjacent hair follicles, deeper tissue destruction is necessary to achieve greater than 90% elimination of the disease. In patients treated by laser therapy, cosmetic results are excellent. Laser vaporization appears to be an effective and nonmutilating therapy and preferable for young patients with VIN. Occult VIN may be present in the adjacent epithelium. Primary lesions may remain undetected by either gross or colposcopic visualization. Therefore, laser ablation has a significant failure rate because of the incomplete ablation, but this rate may be reduced to levels comparable with that of surgical excision if careful attention is given to adequate ablation, clear margins, and histologic studies of suspicious thick lesions.