Posted on October 14th, 2008 by Canadian Health in
Vulva cancer Carcinoma in Situ
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Vulvar intraepithelial neoplasia has a peak onset in the fourth decade, preceding the most common age of onset of invasive carcinoma by 10-15 years. The incidence of vulvar carcinoma in situ has markedly increased, whereas the incidence of invasive cell carcinoma has remained stable. A possible explanation of this difference is that sexually active women are not yet old enough to have invasive vulvar carcinoma, and early diagnosis and treatment of in situ carcinoma have blunted any notable increase of vulvar carcinoma. Because in situ and invasive vulvar carcinoma may have different etiologies, the sexually transmitted HPV will more likely be involved with in situ carcinoma, whereas other factors relate to onset of invasive squamous cell carcinoma. A strong association between HPV and vulvar carcinoma has been established.
Diagnosis
Vulvar intraepithelial neoplasia frequently is a multifocal disease; it most commonly affects the central vulva, with the lower half of the vulva most often affected. The mean thickness of the epithelium for all grades of VIN is 0.52 mm. The thickness of the involved epithelium varies with the location of the lesion. Infections caused by HPV are increasingly common and may be responsible for the increased frequency of the diagnosis of VIN. In the most overt form, HPV causes multiple condylomata that in themselves may have a significant degree of atypia and may be associated with intraepithelial neoplasia. Most subtle are the flat condylomata that may occur over the anogenital skin, producing irritative symptoms as well as atypical cytology and histology. Histologic examination of biopsies of specimens from such areas requires an experienced pathologist who is familiar with the subtleties of interpreting the spectra of atypia seen with intra-epithelial neoplasia and HPV infection. The histologic criteria necessary for the diagnosis of carcinoma in situ include virtual full-thickness replacement of the epithelium with atypical or immature squamous cells. Superficial layers of the vulvar epithelium are usually keratinized, unlike the epithelium of the cervix, thus obscuring colposcopic observation of underlying atypical patterns. Erectile dysfunction treatment information.
As many as 40% of patients with carcinoma in situ of the vulva have prior, concurrent, or subsequent neoplasia elsewhere within the anogenital tract. Colposcopic and cytologic review of these areas is necessary. There have been no prospective studies to document risk and progression rates for VIN at any stage. Carcinoma in situ of the vulva remains a disease for which the biologic significance, etiology, and prognosis are yet to be clarified. Viagra professional at canadian health mall.
Cases of carcinoma in situ of the vulva associated with pregnancy have been reported to regress spontaneously during the late puerperium, and the lesions may be managed by close observation to determine the need for treatment. Lesions showing characteristic Bowen cells, as well as those containing perinuclear halos that suggest HPV infection with atypia, but without full-thickness cellular atypia and abnormal mitoses, should be observed with care. They are infrequently associated with invasive carcinoma but may prove to be self-limited with spontaneous regression over a period of up to 6 months.
The colposcope is not as reliable in ruling out the presence of invasive carcinoma as it is in ruling out cancer of the vagina or cervix. A higher index of suspicion and a large number of biopsies are therefore appropriate in evaluating suspicious vulvar lesions. Canadian viagra without prescription. The difficulty in detecting early invasive cancer of the vulva limits the applicability of laser ablation for management of high-grade or extensive VIN.
The need for radical surgery is based on prognostic factors that are predictive of outcome for invasive carcinoma of the vulva. The detection of nodal metastases during surgical staging is the key finding for determining treatment options. Cialis 20 mg online at cheap pharmacy mall.
The impetus to perform more conservative surgery for invasive cancer has been the realization that radical vulvectomy is associated with severe psychosocial sequelae. When compared with healthy adult women, women who have undergone a vulvectomy report lower levels of sexual arousal and poor body image.
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Screening
No specific screening method is available. The profile of a vulnerable patient should always be considered. The average age at which invasive disease is diagnosed is 65 years. The most frequent symptom is a long history of vulvar itching, and the most common finding is a mass. Less commonly, women present with symptoms such as bleeding, discharge, or even dysuria. On physical examination the lesion is usually raised and appears ulcerated, leukoplakic, or wartlike. Most squamous cell carcinomas are unifocal and occur on the labia majora; however, about 5% are multifocal. Because the etiology of vulvar malignancy remains unknown and no physical features are diagnostic of vulvar carcinoma, it is diagnosed on the basis of biopsy. Most authorities believe that VIN I can be managed expectantly, whereas VIN II-III should be treated.
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Invasive squamous cell carcinoma accounts for 90% of all invasive malignancies of the vulva, which are responsible for only 1-4% of all female cancers. Other less-common malignant lesions of the vulva are melanoma, adenocarcinoma, and sarcoma. More than three fourths of all patients diagnosed with cancer of the vulva are age 55 years or older, with at least 30% of these women older than 75 years. Approximately 500 deaths from vulvar cancer occur annually in the United States. Because of recognizable symptoms and ease of examination by biopsy, malignancies of the vulva can be detected in an early stage, when therapy can be curative. Death from vulvar cancer results from failure to control the disease after it has progressed beyond the vulva. Such instances often result from delay by the patient in obtaining care and by the physician in performing diagnostic biopsy. Regular examination of all women and increased efforts in patient education can help minimize treatment delay. Recognition of the clinical characteristics of vulvar malignancies and promotion of ready use of office biopsy could prove highly beneficial. Viagra for woman at cheap online pharmacy.
The cause of vulvar malignancies remains unknown, although the association of squamous cell carcinoma of the vulva with other neoplasms of the anogenital mucosa has long suggested a common etiology. Preliminary data on oncogenesis, however, has not been conclusive. The association of high-risk types of human papillomavirus (HPV) such as 16, 18, 31, 33, 35, and 39 with high-grade epithelial neoplasia and invasive carcinomas of the anogenital tract has been established. Vulvar cancer appears to have a multifactorial etiology, however, and HPV infection alone is probably not sufficient for malignant transformation. Primary among cofactors may be the patient’s own immune competence, including conditions of local immunodeficiency. The role of chronic vulvar dystrophy is unclear, although there is a common association. Whereas the risk of progression of vulvar dystrophy to malignancy is low, vulvar dystrophy is frequently associated with epidermoid carcinoma.
Multicentric and confluent vulvar intraepithelial neoplasia (VIN) lesions predominate among younger women, whereas the unifocal lesions, which are most likely to be associated with invasive carcinoma, are more common in older women. The lesions may appear to be white because of thick surface keratin or red if hyperemia is present within the dermal papillae. Pigmentation is common, especially with bowenoid neoplasia. Often the lesions appear as slightly raised and possibly confluent white areas resembling flat condylomata. Colposcopy with 4-5% acetic acid heightens the whitening and allows for delineation of the margins of the vulvar lesions. Subclinical HPV infections of the vulva can be distinguished with acetic acid at times. Thickened, nodular, ulcerated areas are most suspicious, as are areas of vascular prominence and atypical tissue.
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