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.
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.