Vulvar intraepithelial neoplasia: the concept and its application

Management of Early-Stage Vulvar Cancer

Simple Summary

Vulvar cancer is a rare gynecological malignancy that affects mainly postmenopausal women. Recently, however, an alarming increase in the rates among young women has been observed due to human papillomavirus infection. The standard treatment for vulvar cancer is surgery with or without radiotherapy as adjuvant treatment. In recent decades, sentinel lymph node biopsy has been included as part of the surgical treatment. Thus, our objective was to review and discuss the advances found in the literature about early-stage vulvar cancer. For this, we searched PubMed for publications in the English language. Relevant articles, such as the GROINS-V studies, and the GOG protocols, are presented in this review exhibiting the evolution of early-stage vulvar cancer treatment and the decrease in surgical morbidity rates.

Abstract

Vulvar cancer is a rare gynecological malignancy since it represents 4% of all cancers of the female genital tract. The most common histological type is squamous cell carcinoma (90%). This type can be classified into two clinicopathological subtypes according to the etiology. The first subtype is associated with persistent human papillomavirus infection and is usually diagnosed in younger women. The second subtype is associated with lichen sclerosus condition, and in most cases is diagnosed in postmenopausal women. Currently, an increase in first subtype cases has been observed, which raised the concern about associated mortality and treatment morbidity among young women. Vulvar cancer treatment depends on histopathology grade and staging, but surgery with or without radiotherapy as adjuvant treatment is considered the gold standard. In recent decades, sentinel lymph node biopsy has been incorporated as part of the treatment. Therefore, we sought to review and discuss the advances documented in the literature about vulvar cancer focusing on the treatment of early-stage disease. Relevant articles, such as the GROINS-V studies and the GOG protocols, are presented in this review. Additionally, we discuss key points such as the evolution of treatment from invasive surgery with high morbidity, to more conservative approaches without compromising oncologic safety; the role of sentinel lymph node mapping in the initial staging, since it reduces the complications caused by inguinofemoral lymphadenectomy; the recurrences rates, since local recurrence is common and curable, however, groin-associated, or distant recurrences have a poor prognosis; and, finally, the long-term follow-up that is essential for all patients.

Diagnosis, Therapy and Follow-up Care of Vulvar Cancer and its Precursors. Guideline of the DGGG and DKG (S2k-Level, AWMF Registry Number 015/059, November 2015

Purpose: This is an official guideline, published and coordinated by the Arbeitsgemeinschaft Gynäkologische Onkologie (AGO, Study Group for Gynecologic Oncology) of the Deutsche Krebsgesellschaft (DKG, German Cancer Society) and the Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG, German Society for Gynecology and Obstetrics). The number of cases with vulvar cancer is on the rise, but because of the former rarity of this condition and the resulting lack of literature with a high level of evidence, in many areas knowledge of the optimal clinical management still lags behind what would be required. This updated guideline aims to disseminate the most recent recommendations, which are much clearer and more individualized, and is intended to create a basis for the assessment and improvement of quality care in hospitals. Methods: This S2k guideline was drafted by members of the AGO Committee on Vulvar and Vaginal Tumors; it was developed and formally completed in accordance with the structured consensus process of the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). Recommendations: 1. The incidence of disease must be taken into consideration. 2. The diagnostic pathway, which is determined by the initial findings, must be followed. 3. The clinical and therapeutic management of vulvar cancer must be done on an individual basis and depends on the stage of disease. 4. The indications for sentinel lymph node biopsy must be evaluated very carefully. 5. Follow-up and treatment for recurrence must be adapted to the individual case.

Cytological Evaluation Correlates Poorly with Histological Diagnosis of Vulvar Neoplasias

OBJECTIVE

To determine whether cytological smears of the vulva correlate with vulvar biopsies of vulvar intraepithelial neoplasias (VINs).

MATERIALS AND METHODS

A retrospective chart review (1995-2000) was performed to identify cases of VIN and vulvar carcinoma and to correlate vulvar Pap smears with biopsy results.

RESULTS

Four hundred vulvar Pap smears were identified. Fifty of these patients had concomitant vulvar biopsies, and these cases constitute our study group. Twenty-two of these 50 women had biopsy-proven VIN or vulvar carcinoma. Only 7 (32%) of 22 patients with biopsy-proven disease had a vulvar Pap smear significant for VIN or vulvar carcinoma. The kappa statistic was 0.30 (95% CI=0.08-0.52), indicating poor agreement between vulvar cytology and biopsy results.

CONCLUSIONS

Vulvar cytological evaluation did not correlate well with tissue diagnosis of VIN; and thus, our findings do not support the use of vulvar cytology in the clinical management of VIN.

The simplex (differentiated) variant of vulvar intraepithelial neoplasia

BACKGROUND

The simplex (differentiated) variant of vulvar intraepithelial neoplasia is rarely reported. It is regarded as more likely than "classic" carcinoma in situ to be associated with invasion and can be easily mistaken for benign lesions.

OBJECTIVE

The objective was to present a case of simplex variant of vulvar intraepithelial neoplasia in a 67-year-old woman that was initially misdiagnosed as lichen simplex chronicus.

METHODS

A case report is reported and the literature is reviewed.

RESULTS

Surgical excision with a free margin of 5 mm was performed and no evidence of recurrence was noted during the follow-up period of 6 months.

CONCLUSION

The simplex vulvar intraepithelial neoplasia is an easily overlooked premalignant disease, and it can be cured with surgical treatment if diagnosed correctly and early.

Vulvar intraepithelial neoplasia: historical aspects and current status

Vulvar intraepithelial neoplasia (VIN) is the currently accepted generic designation for the spectrum of vulvar lesions with the histologic features of squamous dysplasia and squamous cell carcinoma in situ. Although several classifications of VIN have been espoused in the past 20 years, VIN can be readily classified into two principal clinicopathologic types: classic (bowenoid) VIN and simplex (differentiated) VIN. This manuscript summarizes the historical development and current status of our knowledge about VIN. Information on the clinical and pathologic aspects are detailed and illustrated, as are considerations of differential diagnosis.

Inter-observer variation in histopathological diagnosis and grading of vulvar intraepithelial neoplasia: results of an European collaborative study

OBJECTIVE

To evaluate the inter-observer variability of vulvar intraepithelial neoplasia diagnosis and grading system.

DESIGN

Prospective study.

SAMPLE

Histological sections of 66 vulvar biopsies.

METHODS

Six consultant pathologists working at different European institutions independently reviewed 66 vulvar biopsies. The following variables were investigated: specimen adequacy, gross categorisation into benign or neoplastic changes, presence of atypical cytological pattern, presence of neoplastic architectural pattern, grade of vulvar intraepithelial neoplasia, presence of histopathologic associated findings for human papillomavirus infection.

MAIN OUTCOME MEASURES

The degree of inter-observer variation for each histopathologic parameter was assessed by Kappa (kappa) statistics. The frequency and the degree of disagreement were calculated by a symmetrical agreement matrix showing the number paired classifications.

RESULTS

A good agreement (overall weighted kappa = 0.65, unweighted kappa = 0.46) was observed for grading vulvar intraepithelial neoplasia. Human papillomavirus infection associated findings and specimen adequacy were the variables with less inter-observer agreement (overall weighted kappa 0.26 and 0.22, respectively). Exact agreement between two pathologists for grade of vulvar intraepithelial neoplasia was observed in 63.6% of paired readings; the rate of paired agreement reached 73.9% considering vulvar intraepithelial neoplasia 2 and 3 as a single class. Conversely, only 5.0% of vulvar intraepithelial neoplasia 1 diagnoses were concordant in paired analysis.

CONCLUSIONS

Current terminology offers a reproducible tool in the hands of expert pathologists. While on the diagnosis of 'high grade' vulvar intraepithelial neoplasia (vulvar intraepithelial neoplasia 2 and 3) there is good agreement, the diagnostic category of vulvar intraepithelial neoplasia 1 is not reproducible.

Squamous cell carcinoma arising in Hailey-Hailey disease of the vulva

A 61-year-old woman, who was known to have Hailey-Hailey disease, presented with increasing vulval soreness. Biopsy showed vulval intraepithelial neoplasia (VIN) 3 and subsequent histology from a vulvectomy specimen showed extensive VIN with early invasive squamous cell carcinoma. This may be another example of chronic inflammation of the vulval area leading to the development of squamous cell carcinoma. However, in this case, chronic human papillomavirus may also have played a part, leading to VIN and reactivation of the Hailey-Hailey disease. We can find no previous reports of squamous cell carcinoma developing in the setting of Hailey-Hailey disease.

Human papillomavirus in dysplasia and carcinoma of the cervix in Singapore

A prospective study was conducted in Singapore in 1985 where 107 women with abnormal cervical smears were studied for cervical neoplasia and its association with the human papillomaviruses (HPV), using HPV 11, 16 and 18 DNA as probes. Cervical biopsies were performed for histology as well as for DNA Southern Blot hybridization studies to detect the presence of HPV 11, 16 or 18 genome. The prevalence of the various types of papillomavirus DNA in cervical tissue samples from cervical carcinoma and dysplasias is presented. HPV types 16 and 18 were found in 5 of 8 (63%) cases of invasive squamous cell carcinoma (SCC), in 12 of 41 (29%) cases of squamous carcinoma-in-situ (CIN 3) and in 3 of 48 (6%) cases of lower grade dysplasia. None of our cases of SCC were associated with unknown HPV types detected using a mixture of HPV 16 or 18 DNA under conditions of low stringency. These unknown HPV types were present in approximately one quarter of our cases of dysplasia of all grades.

Association of human papillomavirus infection and vulvar intraepithelial neoplasia: a morphological and immunohistochemical study of 30 cases

Thirty cases of vulvar intraepithelial neoplasia (VIN) were analyzed in order to determine the frequency of association with human papillomavirus (HPV) infection, and the relationship between this association and patient's age, extent of vulvar lesions, and coexistence with cervicovaginal neoplasia. The presence of condyloma or moderate to marked koilocytosis, now considered as morphological evidence of HPV infection, was observed in 66.6% of our cases. A search for HPV antigens, using the peroxidase-antiperoxidase (PAP) method, was performed in 13 selected cases, and positive staining was detected in 3 of them. The presence of HPV infection correlates with a mean age of 48.8 years, 50% of multicentricity of VIN and coexistence with cervical neoplasia in 30% of the cases, as opposed to a mean age of 55.5 years, 10% of multicentricity of VIN and absence of cervical neoplasia in patients without HPV infection. The demonstration of multiple foci of early stromal invasion in a 43-year-old woman, with multicentric VIN lesions associated with HPV infection, indicates that, even in the presence of such clinicopathological features, the risk of developing stromal invasion should be considered. Considerations are made in relation with the presence of HPV antigen in morphological normal epithelium adjacent to the lesion. Therapeutic implications were also investigated.

Carcinoma in situ of the vulva. Long term prognosis

Seventy-four patients with carcinoma in situ (CIS) of the vulva were followed over a 10-year period. The mean age was 52.8 years (range 21 to 90 years). Pruritus was the most common symptom. Forty per cent of the women were asymptomatic. Twenty-three per cent had a history of carcinoma in situ of the uterine cervix. Single lesions of CIS were found in the perineal area in 22 per cent, in the labia major and minor in 23 per cent, and in the clitoris in 7 per cent. Forty-two per cent of the patients had CIS in two or more of those areas. Seven of 74 patients (10%) had previously been irradiated for pelvic malignant tumours. Three women developed invasive squamous cell carcinoma of the vulva, two of them were previously irradiated. All 74 patients were treated surgically in different ways. Out of 38 women with histologically free margins of surgery, 6 had recurrence of dysplasia or CIS.

Human papillomavirus types 6 and 16 in multifocal intraepithelial neoplasias of the female lower genital tract

Five women with multifocal intraepithelial neoplasia of the lower genital tract were investigated for the presence of human papillomavirus (HPV) infection by the method of DNA-DNA hybridization which detects the viral DNA. The DNA sequences of HPV types 6 and 16 were detected in each of the five patients and in each of the areas biopsied: cervix, vagina and vulva. DNA sequences of both viral types were also found in vulval intraepithelial neoplasia grades I-III and in cervical intraepithelial neoplasia grades I and III. The detection of HPV DNAs in multifocal lesions suggests a possible common aetiology for the lower genital tract intraepithelial neoplasias.

Skin diseases of the external genitalia. Recognition and treatment

Dermatologic diseases of the genitalia are of several types: congenital diseases, acquired diseases (those caused by viruses, bacteria, fungi, or physical or chemical toxins), tumors, and atrophic dermatoses. The methods available to diagnose these diseases vary. Some conditions may be recognized by appearance alone, whereas others require histopathologic examination of involved skin for correct diagnosis. Some do not need treatment, while others call for an aggressive approach. Some types of genital dermatologic diseases, such as herpes infections and condylomata acuminata, appear to be associated with genital carcinogenesis. Patients with these diseases should be carefully examined.

Vulvar intraepithelial neoplasia and microinvasive carcinoma of the vulva

The pathological, cytological, and clinical features of vulvar intraepithelial neoplasia (VIN) are described. The rate of progression of VIN III to an invasive carcinoma is very low and spontaneous regression can occur. These features prevent the drawing of a direct analogy between vulvar and cervical intraepithelial neoplasia. The concept of microinvasive carcinoma of the vulva is discussed, and it is concluded that no satisfactory definition of this entity has been achieved.