Cancer information Cancer treatment

Sarcoma. Vulva cancer

Canadian Health — Wed, 19 Nov 2008 19:41:38 +0000

Soft tissue sarcomas make up fewer than 2% of vulvar malignancies. They occur over a wide age range, including the pediatric population, and usually appear as a rapidly enlarging and painful mass. Most tumors on the vulva are related to the leiomyosarcoma group, although the fibrous histiocytomas, rhabdomyosarcomas, hemangiosarcomas, and the newly described epithelioid sarcomas may also occur on the vulva. The prognosis for such lesions is variable depending on the biologic character of the individual sarcoma, but may well be related to hematogenous metastasis. Radical vulvectomy with groin dissection has yielded the lowest incidence of recurrent disease, but many patients die rapidly.
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Superficial perineal leiomyosarcomas are rare and may be more aggressive than superficial leiomyosarcomas in general. The tumor is well differentiated and shows immunoreactivity for smooth muscle “-actin and “-desmin.
The natural history of vulvar leiomyosarcomas is characterized by an indolent protracted course and frequent local recurrence, followed by distant fatal metastases. Surgery, chemotherapy, and radiotherapy achieve palliation rather than cure.
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Dermatofibrosarcoma protuberans of the vulva is an uncommon low-grade sarcoma of dermal origin. Although wide excision is the treatment of choice, microscopic tumor projections beyond the central tumor Nodule explain the tumor’s propensity for local recurrence. Frozen sections of margins may be useful to ensure complete resection.
Epithelioid sarcoma typically involves extremities of young men and may be confused histologically with various benign and malignant processes. Epithelioid sarcoma of the vulva is a soft tissue malignancy arising from the tenosynovial tissue and can present as a painless lump of the vulva. The suggested mode of treatment can range from wide excision to radical vulvectomy with groin Node dissection.

Bartholin Gland Cancer

Canadian Health — Wed, 19 Nov 2008 16:41:36 +0000

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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Melanomas

Canadian Health — Fri, 14 Nov 2008 05:37:25 +0000

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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.

Verrucous Carcinoma

Canadian Health — Thu, 13 Nov 2008 17:37:22 +0000

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.

Paget’s Disease

Canadian Health — Wed, 12 Nov 2008 14:04:50 +0000

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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.

Prognostic Factors

Canadian Health — Wed, 05 Nov 2008 18:32:44 +0000

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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.

Vulva cancer. Treatment

Canadian Health — Fri, 31 Oct 2008 18:40:47 +0000

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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.

Vulvar cancer spreads by direct extension

Canadian Health — Fri, 31 Oct 2008 18:36:46 +0000

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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Invasive Squamous Cell Carcinoma

Canadian Health — Wed, 22 Oct 2008 13:39:09 +0000

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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.

Surgery. Vulva cancer

Canadian Health — Thu, 16 Oct 2008 15:10:53 +0000

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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.