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Gallio N, Preti M, Jones RW, Borella F, Woelber L, Bertero L, Urru S, Micheletti L, Zamagni F, Bevilacqua F, Tondo P, Pollano B, Cassoni P, Benedetto C. Differentiated vulvar intraepithelial neoplasia long-term follow up and prognostic factors: An analysis of a large historical cohort. Acta Obstet Gynecol Scand 2024; 103:1175-1182. [PMID: 38383115 PMCID: PMC11103129 DOI: 10.1111/aogs.14814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/12/2024] [Accepted: 02/06/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Differentiated vulvar intraepithelial neoplasia (dVIN) is a high-risk preinvasive vulvar lesion and precursor of human papillomavirus-independent vulvar squamous cell carcinoma (VSCC). Due to its rarity, literature data on its malignant potential are scant. The aim of the study is to assess the risk of developing VSCC in patients surgically treated for dVIN not associated with VSCC (solitary dVIN) and the risk of VSCC recurrence in patients treated for dVIN associated with VSCC (dVIN-VSCC) at first diagnosis. MATERIAL AND METHODS A historical cohort study was performed in a northern Italy referral center for vulvar neoplasms. All consecutive women surgically treated for histologically confirmed dVIN from 1994 to 2021 were collected. Primary outcome was cancer risk or recurrent cancer risk, secondary outcomes were risk factors associated with VSCC development or recurrence. Kaplan-Meier method and log-rank test were used to estimate cancer risk or recurrent cancer risk differences and uni- and multivariate Cox regression analyses to identify risk factors associated with VSCC development in solitary dVIN and recurrence of dVIN-VSCC. RESULTS Seventy-six patients with dVIN at preoperative biopsy were included: at excisional specimens 44 were solitary dVIN and 32 were dVIN-VSCC. The absolute risk of VSCC development after solitary dVIN treatment was 43.2% with median time to to VSCC diagnosis of 25.4 months (range 3.5-128.0 months). VSCC recurrence absolute risk in treated dVIN-VSCC patients was 31.3% with median time to VSCC recurrence of 52.9 months (range 6.5-94.8 months). At uni- and multivariate regression analyses, only compliant topical ultrapotent corticosteroid treatment after solitary dVIN excision showed an ability to prevent VSCC development. No protective effect by corticosteroid treatment was shown for VSCC recurrence in dVIN-VSCC patients. Smoking was associated with higher cancer recurrence risk in dVIN-VSCC patients on both uni- and multivariate regression analyses. CONCLUSIONS Patients with dVIN have a high risk of developing both primary and recurring VSCC. Early recognition, long-term follow up, and compliant ultrapotent topical corticosteroid treatment are recommended.
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Affiliation(s)
- Niccolò Gallio
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science University Hospital, S. Anna HospitalUniversity of TurinTurinItaly
| | - Mario Preti
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science University Hospital, S. Anna HospitalUniversity of TurinTurinItaly
| | | | - Fulvio Borella
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science University Hospital, S. Anna HospitalUniversity of TurinTurinItaly
| | - Linn Woelber
- Department of GynecologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
- Dysplasia Center HamburgColposcopy Clinic at the Jerusalm HospitalHamburgGermany
| | - Luca Bertero
- Department of Medical Sciences, Pathology Unit, City of Health and Science University HospitalUniversity of TurinTurinItaly
| | - Sara Urru
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Unit of Biostatistics, Epidemiology and Public HealthUniversity of PaduaPaduaItaly
| | - Leonardo Micheletti
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science University Hospital, S. Anna HospitalUniversity of TurinTurinItaly
| | - Federica Zamagni
- Emilia‐Romagna Cancer RegistryRomagna Cancer Institute, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino AmadoriForlìItaly
| | - Federica Bevilacqua
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science University Hospital, S. Anna HospitalUniversity of TurinTurinItaly
| | - Pierluigi Tondo
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science University Hospital, S. Anna HospitalUniversity of TurinTurinItaly
| | - Benedetta Pollano
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science University Hospital, S. Anna HospitalUniversity of TurinTurinItaly
| | - Paola Cassoni
- Department of Medical Sciences, Pathology Unit, City of Health and Science University HospitalUniversity of TurinTurinItaly
| | - Chiara Benedetto
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science University Hospital, S. Anna HospitalUniversity of TurinTurinItaly
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Morrison J, Baldwin P, Hanna L, Andreou A, Buckley L, Durrant L, Edey K, Faruqi A, Fotopoulou C, Ganesan R, Hillaby K, Taylor A. British Gynaecological Cancer Society (BGCS) vulval cancer guidelines: An update on recommendations for practice 2023. Eur J Obstet Gynecol Reprod Biol 2024; 292:210-238. [PMID: 38043220 DOI: 10.1016/j.ejogrb.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/10/2023] [Indexed: 12/05/2023]
Affiliation(s)
- Jo Morrison
- Department of Gynaecological Oncology, GRACE Centre, Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton TA1 5DA, UK.
| | - Peter Baldwin
- Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Louise Hanna
- Department of Oncology, Velindre Cancer Centre, Whitchurch, Cardiff CF14 2TL, UK
| | - Adrian Andreou
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath BA1 3NG, UK
| | - Lynn Buckley
- Department of Gynae-Oncology, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, East Yorkshire HU16 5JQ, UK; Perci Health Ltd, 1 Vincent Square, London SW1P 2PN, UK. https://www.percihealth.com/
| | - Lisa Durrant
- Radiotherapy Department, Beacon Centre, Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton TA1 5DA, UK
| | - Katharine Edey
- Centre for Women's Health Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW, UK
| | - Asma Faruqi
- Department of Cellular Pathology, The Royal London Hospital, Barts Health NHS Trust, London E1 2ES, UK
| | - Christina Fotopoulou
- Department of Cellular Pathology, The Royal London Hospital, Barts Health NHS Trust, London E1 2ES, UK; Gynaecologic Oncology, Imperial College London Faculty of Medicine, London SW7 2DD, UK
| | - Raji Ganesan
- Department of Cellular Pathology, Birmingham Women's Hospital, Birmingham B15 2TG, UK
| | - Kathryn Hillaby
- Department Gynaecological Oncology, Cheltenham General Hospital, Gloucestershire, Hospitals NHS Foundation Trust, GL53 7AN, UK
| | - Alexandra Taylor
- The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
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Schechter SA, Chan MP, Muthusamy S, Skala SL, Wang GY. Interobserver Agreement Across Subspecialties for Diagnosis of Differentiated Vulvar Intraepithelial Neoplasia and Predictive Values of 20 Histologic Features. Arch Pathol Lab Med 2023; 147:1431-1437. [PMID: 36821250 DOI: 10.5858/arpa.2022-0088-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2022] [Indexed: 02/24/2023]
Abstract
CONTEXT.— Differentiated vulvar intraepithelial neoplasia (dVIN) is a human papillomavirus-independent lesion with the potential for rapid progression to invasive squamous cell carcinoma (SCC). The histopathologic features of dVIN are diverse, have overlapping characteristics with lichen sclerosus (LS) and lichen simplex chronicus (LSC), and may be diagnosed by dermatopathologists or gynecologic pathologists because of the vulva's anatomic location. OBJECTIVES.— To identify the salient histopathologic features of dVIN, particularly those that predict progression to SCC, and to evaluate interobserver agreement in diagnosing dVIN within the same subspecialty and across subspecialties. DESIGN.— One general surgical pathologist, 2 pathology-trained dermatopathologists, and 1 gynecologic pathologist blinded to the final diagnoses were asked to record 20 histopathologic features and to provide their final interpretations on cases of dVIN (n = 65), LS (n = 126), LSC (n = 112), and LS with LSC (n = 6). RESULTS.— Interobserver agreement for the 4 diagnoses and 10 histopathologic features was moderate. Logistic regression analysis indicated that keratin pearls, basal pleomorphism, and basal layer disarray were independent variables for diagnosing dVIN (coefficients 1.95, 1.97, and 0.91, respectively; P < .001) and progression to SCC (coefficients 1.96, 1.20, and 1.08, respectively; P < .001). CONCLUSIONS.— There is no single histopathologic feature pathognomonic for dVIN; however, the presence of keratin pearls, basal pleomorphism, and basal layer disarray should raise high suspicion for dVIN and concurrent SCC. Expertise in both dermatologic and gynecologic pathology is beneficial for diagnosing dVIN.
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Affiliation(s)
- Shula A Schechter
- From the Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Schechter)
| | - May P Chan
- The Department of Pathology (Chan, Skala), University of Michigan, Ann Arbor
- The Department of Dermatology (Chan), University of Michigan, Ann Arbor
| | - Selvaraj Muthusamy
- The Department of Pathology, Virginia Commonwealth University, Richmond (Muthusamy), Royal Oak, Michigan
| | - Stephanie L Skala
- The Department of Pathology (Chan, Skala), University of Michigan, Ann Arbor
- The Rogel Cancer Center (Skala), University of Michigan, Ann Arbor
| | - Grace Y Wang
- The Department of Pathology, Beaumont Health, Royal Oak, Michigan (Wang)
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4
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Mancini S, Bucchi L, Zamagni F, Baldacchini F, Crocetti E, Giuliani O, Ravaioli A, Vattiato R, Preti M, Tumino R, Ferretti S, Biggeri A, Ballotari P, Boschetti L, Brustolin A, Caldarella A, Cavallo R, Cirilli C, Citarella A, Contrino ML, Dal Maso L, Filiberti RA, Fusco M, Galasso R, Lotti FL, Magoni M, Mangone L, Masanotti G, Mazzoleni G, Mazzucco W, Melcarne A, Michiara M, Pesce P, Pinto A, Piras D, Rizzello RV, Rognoni M, Rosso S, Rugge M, Sampietro G, Scalzi S, Scuderi T, Tagliabue G, Toffolutti F, Vitarelli S, Falcini F. Trends in Net Survival from Vulvar Squamous Cell Carcinoma in Italy (1990–2015). J Clin Med 2023; 12:jcm12062172. [PMID: 36983173 PMCID: PMC10054662 DOI: 10.3390/jcm12062172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/27/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023] Open
Abstract
(1) Objective: In many Western countries, survival from vulvar squamous cell carcinoma (VSCC) has been stagnating for decades or has increased insufficiently from a clinical perspective. In Italy, previous studies on cancer survival have not taken vulvar cancer into consideration or have pooled patients with vulvar and vaginal cancer. To bridge this knowledge gap, we report the trend in survival from vulvar cancer between 1990 and 2015. (2) Methods: Thirty-eight local cancer registries covering 49% of the national female population contributed the records of 6274 patients. Study endpoints included 1- and 2-year net survival (NS) calculated using the Pohar-Perme estimator and 5-year NS conditional on having survived two years (5|2-year CNS). The significance of survival trends was assessed with the Wald test on the coefficient of the period of diagnosis, entered as a continuous regressor in a Poisson regression model. (3) Results: The median patient age was stable at 76 years. One-year NS decreased from 83.9% in 1990–2001 to 81.9% in 2009–2015 and 2-year NS from 72.2% to 70.5%. Five|2-year CNS increased from 85.7% to 86.7%. These trends were not significant. In the age stratum 70–79 years, a weakly significant decrease in 2-year NS from 71.4% to 65.7% occurred. Multivariate analysis adjusting for age group at diagnosis and geographic area showed an excess risk of death at 5|2-years, of borderline significance, in 2003–2015 versus 1990–2002. (4) Conclusions: One- and 2-year NS and 5|2-year CNS showed no improvements. Current strategies for VSCC control need to be revised both in Italy and at the global level.
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Affiliation(s)
- Silvia Mancini
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori), 47014 Meldola, Italy; (S.M.); (L.B.); (F.B.); (E.C.); (O.G.); (A.R.); (R.V.); (F.F.)
| | - Lauro Bucchi
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori), 47014 Meldola, Italy; (S.M.); (L.B.); (F.B.); (E.C.); (O.G.); (A.R.); (R.V.); (F.F.)
| | - Federica Zamagni
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori), 47014 Meldola, Italy; (S.M.); (L.B.); (F.B.); (E.C.); (O.G.); (A.R.); (R.V.); (F.F.)
- Correspondence:
| | - Flavia Baldacchini
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori), 47014 Meldola, Italy; (S.M.); (L.B.); (F.B.); (E.C.); (O.G.); (A.R.); (R.V.); (F.F.)
| | - Emanuele Crocetti
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori), 47014 Meldola, Italy; (S.M.); (L.B.); (F.B.); (E.C.); (O.G.); (A.R.); (R.V.); (F.F.)
| | - Orietta Giuliani
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori), 47014 Meldola, Italy; (S.M.); (L.B.); (F.B.); (E.C.); (O.G.); (A.R.); (R.V.); (F.F.)
| | - Alessandra Ravaioli
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori), 47014 Meldola, Italy; (S.M.); (L.B.); (F.B.); (E.C.); (O.G.); (A.R.); (R.V.); (F.F.)
| | - Rosa Vattiato
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori), 47014 Meldola, Italy; (S.M.); (L.B.); (F.B.); (E.C.); (O.G.); (A.R.); (R.V.); (F.F.)
| | - Mario Preti
- Department of Obstetrics and Gynaecology, University of Torino, 10124 Torino, Italy;
| | - Rosario Tumino
- Cancer Registry and Histopathology Department, Provincial Health Authority (ASP), 97100 Ragusa, Italy;
| | - Stefano Ferretti
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Local Health Authority, 44121 Ferrara, Italy;
| | - Annibale Biggeri
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy;
| | - Paola Ballotari
- Mantova & Cremona Cancer Registry, Epidemiology Unit, Val Padana Health Protection Agency, 46100 Mantova, Italy;
| | - Lorenza Boschetti
- Pavia Cancer Registry, Public Health Agency of Pavia, 27100 Pavia, Italy;
| | - Angelita Brustolin
- Unit of Epidemiology and Cancer Registry, Local Health Authority, 01100 Viterbo, Italy
| | - Adele Caldarella
- Tuscany Cancer Registry, Clinical and Descriptive Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), 50139 Florence, Italy;
| | - Rossella Cavallo
- Cancer Registry of Local Health Authority Salerno, 84124 Salerno, Italy;
| | - Claudia Cirilli
- Modena Cancer Registry, Public Health Department, Local Health Authority, 41126 Modena, Italy;
| | - Annarita Citarella
- Cancer Registry, Department of Prevention, Unit of Epidemiology, Local Health Authority, 82100 Benevento, Italy;
| | | | - Luigino Dal Maso
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy; (L.D.M.); (F.T.)
| | - Rosa A. Filiberti
- Liguria Cancer Registry, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Mario Fusco
- Napoli 3 Sud Cancer Registry, 80031 Napoli, Italy;
| | - Rocco Galasso
- Unit of Regional Cancer Registry, Clinical Epidemiology and Biostatistics, IRCCS-CROB, Basilicata, 85028 Rionero in Vulture, Italy;
| | - Fernanda L. Lotti
- Brindisi Cancer Registry, Local Health Authority, 72100 Brindisi, Italy;
| | - Michele Magoni
- Cancer Registry of Brescia Province, Epidemiology Unit, Brescia Health Protection Agency, 25124 Brescia, Italy;
| | - Lucia Mangone
- Epidemiology Unit, Azienda Unità Sanitaria Locale–IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy;
| | - Giuseppe Masanotti
- Section of Public Health and RTUP Register, Department of Experimental Medicine, University of Perugia, 06123 Perugia, Italy;
| | | | - Walter Mazzucco
- Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90131 Palermo, Italy;
| | | | - Maria Michiara
- Parma Cancer Registry, Medical Oncology Unit, University Hospital of Parma, 43126 Parma, Italy;
| | - Paola Pesce
- Catania, Messina and Enna Cancer Registry, 95123 Catania, Italy;
| | - Angela Pinto
- Barletta, Andria, Trani Cancer Registry, BAT Province, 76121 Barletta, Italy;
| | - Daniela Piras
- Sassari Cancer Registry, Azienda Regionale per la Tutela della Salute-ATS, 7100 Sassari, Italy;
| | - Roberto V. Rizzello
- Trento Province Cancer Registry, Unit of Clinical Epidemiology, Azienda Provinciale per i Servizi Sanitari (APSS), 38123 Trento, Italy;
| | - Magda Rognoni
- Epidemiology Unit, Cancer Registry of ATS Brianza, Health Protection Agency, 20900 Monza, Italy;
| | - Stefano Rosso
- Piedmont Cancer Registry, A.O.U. Città della Salute e della Scienza di Torino, 10123 Turin, Italy;
| | - Massimo Rugge
- Veneto Tumour Registry, Azienda Zero, University of Padova-DIMED, 35132 Padova, Italy;
| | | | - Santo Scalzi
- Catanzaro ASP Cancer Registry, 88100 Catanzaro, Italy;
| | - Tiziana Scuderi
- Trapani and Agrigento Cancer Registry, 91100 Trapani, Italy;
| | - Giovanna Tagliabue
- Lombardy Cancer Registry-Varese Province, Cancer Registry Unit, Department of Research, Fondazione IRCCS Istituto Nazionale Tumori, 20133 Milan, Italy;
| | - Federica Toffolutti
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy; (L.D.M.); (F.T.)
| | - Susanna Vitarelli
- Macerata Province Cancer Registry, University of Camerino, 62032 Camerino, Italy;
| | - Fabio Falcini
- Romagna Cancer Registry, Romagna Cancer Institute (IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) Dino Amadori), 47014 Meldola, Italy; (S.M.); (L.B.); (F.B.); (E.C.); (O.G.); (A.R.); (R.V.); (F.F.)
- Cancer Prevention Unit, Local Health Authority, 47121 Forlì, Italy
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Jamieson A, Tse SS, Proctor L, Sadownik LA. A Scoping Review of Treatment Outcome Measures for Vulvar Intraepithelial Neoplasia. J Low Genit Tract Dis 2022; 26:328-338. [PMID: 36074136 DOI: 10.1097/lgt.0000000000000698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The goal of this study is to identify a list of clinician-reported outcome measures (CROMs) and patient-reported outcome measures (PROMs) through a review of published studies reporting on any therapeutic interventions for vulvar intraepithelial neoplasia (VIN). MATERIALS AND METHODS A systematic search of published studies reporting on any therapeutic interventions for VIN was performed on MEDLINE, Embase, Cochrane Database, PsychInfo, and CINAHL from inception to September 20, 2021, based on predetermined study selection criteria. Data were extracted and analyzed by 2 authors independently using Covidence software. RESULTS Thirty two of 2386 studies identified met study selection criteria. None of the 32 studies provided an explicit definition of VIN treatment "success." The most common CROM was "clinical response to treatment." The most common scale used to measure this outcome was "complete response/partial response/no response"; however, 17 of 23 studies (73.9%) did not define these values. Laboratory CROMs were reported in 12/32 (37.5%) studies. Patient-reported outcome measures were reported in only 10 of 32 studies(31.3%) -the most common PROM was "symptoms." Only 2 of 32 studies measured PROMs related to "quality of life" domains. Adverse events/treatment-related adverse effects were reported in 24 of 32 studies (75%), although 71% of studies provided no details on how these data were collected. CONCLUSIONS There is a large variation in outcome measures, instruments, and scales used for any clinician-reported treatment outcome such as "clinical response." Most studies do not include patient-reported outcome measures assessing quality of life domains. A Core Outcome Set for the treatment of VIN is needed to improve the quality of VIN research.
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Eva L, Sadler L, Thompson JM, Sahota S, Fong KL, Jones RW, Bigby SM. HPV-independent and HPV-associated vulvar squamous cell carcinoma: two different cancers. Int J Gynecol Cancer 2022; 32:ijgc-2022-003616. [PMID: 35914776 DOI: 10.1136/ijgc-2022-003616] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES We report the disease-specific survival of patients with human papillomavirus (HPV)-associated and HPV-independent vulvar squamous cell carcinomas and determine whether differences exist and are independent of stage and age at diagnosis. METHODS This was a retrospective cohort study with case note and pathology slide review of 265 consecutive women with vulvar squamous cell carcinoma. These patients were treated over a 15 year period (2001-2016) at a centralized cancer center covering half the population of New Zealand. The women's cancers were categorized dependent on their adjacent pathology, immunohistochemistry and HPV status following expert slide review. Disease-specific survival was calculated using Kaplan-Meier univariable and Cox proportional hazard (adjusting for stage, age, and HPV dependence) multivariable methods. RESULTS The survival analysis included 236 women with follow-up to 96 months; 124 of them were HPV-associated, 95 HPV-independent, and 17 were unclassifiable. Of the 236 women, 146 were stage 1 (92 HPV-associated, 49 HPV-independent, 5 unclassifiable), 13 stage II (7 HPV-associated, 6 HPV-independent), 62 stage III (20 HPV-associated, 34 HPV-independent, 8 unclassifiable) and 15 stage IV (5 HPV-associated, 6 HPV-independent, 4 unclassifiable). HPV-independent vulvar squamous cell carcinomas had significantly worse survival than HPV-associated vulvar squamous cell carcinomas independent of stage and age at diagnosis (HR 3.6 (95% confidence interval (CI): 1.6 to 8.2)). Tumors that were unclassifiable by HPV type also had significantly worse survival than HPV-associated tumors independent of stage and age at diagnosis (HR 6.2 (95% CI: 2.4 to 16.0)). CONCLUSIONS HPV-independent vulvar squamous cell carcinomas present more frequently in older women than HPV-associated tumors. However, the poorer prognosis is independent of age and stage, with worse outcomes even in early stage disease.
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Affiliation(s)
- Lois Eva
- Gynaecological Oncology, National Women's Health, Auckland City Hospital, Auckland, New Zealand
- Gynaecological Oncology, University of Auckland, Auckland, New Zealand
| | - Lynn Sadler
- University of Auckland, Auckland, New Zealand
| | | | - Sukwinder Sahota
- Gynaecological Oncology, National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Kah Leng Fong
- Gynaecological Oncology, National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Ronald W Jones
- Gynaecological Oncology, National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Susan M Bigby
- Histopathology, Middlemore Hospital, Auckland, New Zealand
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Kim E, Chung M, Jeong HS, Baek CH, Cho J. Histological features of differentiated dysplasia in the oral mucosa: A review of oral invasive squamous cell carcinoma cases diagnosed with benign or low-grade dysplasia on previous biopsies. Hum Pathol 2022; 126:45-54. [PMID: 35597368 DOI: 10.1016/j.humpath.2022.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/08/2022] [Accepted: 05/12/2022] [Indexed: 11/04/2022]
Abstract
The diagnosis of oral squamous cell carcinoma is sometimes delayed. Recently, the concept of differentiated dysplasia in the oral mucosa was proposed, and we attempted to elucidate the histologic features of differentiated dysplasia in the oral mucosa. Two pathologists reviewed 38 small biopsy cases of patients diagnosed with benign to low grade dysplasia in the first biopsy, but were diagnosed with invasive carcinoma after excisional biopsy within 2 years. Of these, 29 cases were suspected of having differentiated dysplasia, which histologically showed "abnormal variation in nuclear size and shape", "increased number and size of nucleoli", and "loss of polarity of basal cells". In addition to the features observed in classic dysplasia, "premature keratinization in single cells" and "loss of epithelial cell cohesion" were characteristically observed. These two findings were often observed only in the lower half of the epithelium, but not in the full layer of the epithelium. Histological findings of oral differentiated dysplasia were very similar to those of differentiated vulvar intraepithelial neoplasia. "Premature keratinization in single cells" and "loss of epithelial cell cohesion" are specific pathological findings of oral differentiated dysplasia. Oral differentiated dysplasia is considered as a part of the broad spectrum of oral dysplasia that exhibits morphological characteristics different from classic dysplasia rather than being a separate entity. The diagnosis of oral differentiated dysplasia is expected to reduce the delayed diagnosis and improve the prognosis and post-treatment quality of life of oral cavity cancer patients.
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Affiliation(s)
- Eojin Kim
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81, Irwon-ro, Gangnam-Gu, Seoul 06351, Korea
| | - Manki Chung
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81, Irwon-ro, Gangnam-Gu, Seoul 06351, Korea
| | - Han-Sin Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81, Irwon-ro, Gangnam-Gu, Seoul 06351, Korea
| | - Chung-Hwan Baek
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81, Irwon-ro, Gangnam-Gu, Seoul 06351, Korea
| | - Junhun Cho
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81, Irwon-ro, Gangnam-Gu, Seoul 06351, Korea.
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Jamieson A, Tse SS, Brar H, Sadownik LA, Proctor L. A Systematic Review of Risk Factors for Development, Recurrence, and Progression of Vulvar Intraepithelial Neoplasia. J Low Genit Tract Dis 2022; 26:140-146. [PMID: 35249976 DOI: 10.1097/lgt.0000000000000662] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Vulvar intraepithelial neoplasia (VIN) is a premalignant condition with high recurrence rates despite treatment. Vulvar intraepithelial neoplasia develops through separate etiologic pathways relative to the presence or absence of human papillomavirus (HPV) and TP53 mutations. This systematic review was conducted (1) to identify historical risk factors for the development, recurrence, and progression of VIN and (2) to critique these risk factors in the context of advances made in the stratification of VIN based on HPV or TP53 status. MATERIALS AND METHODS A systematic search was performed on MEDLINE, Embase, Cochrane Database, PsychInfo, and CINAHL from inception to July 5, 2021. Three gynecologic oncologists independently evaluated the eligibility of studies based on predetermined inclusion and exclusion criteria, abstracted data, and then analyzed the relevant data. RESULTS A total of 1,969 studies (involving 6,983 patients) were identified. Twenty-nine studies met inclusion criteria. The quality of evidence was low; primarily level 2b (Oxford Centre for Evidence-Based Medicine). Risk factors associated with the development of VIN include: smoking and coexisting vulvar dermatoses. Risk factors associated with recurrence include: smoking, multifocal disease, and positive surgical margins. Recent studies identified the presence of differentiated VIN/TP53 mutation as the most significant risk factor for both VIN recurrence and malignant progression. CONCLUSIONS The current body of evidence consists primarily of small retrospective observational studies. Well-designed retrospective case-control series and/or prospective observational studies are urgently needed. Ideally, future studies will collect standardized data regarding associated risk factors and stratify women with VIN based on HPV and TP53 status.
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Affiliation(s)
| | - Samantha S Tse
- British Columbia Centre for Vulvar Health, Vancouver, Canada
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9
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Abstract
Vulvar cancer is an uncommon gynecological malignancy primarily affecting postmenopausal women. There is no specific screening and the most effective strategy to reduce vulvar cancer incidence is the opportune treatment of predisposing and preneoplastic lesions associated with its development. While vulvar cancer may be asymptomatic, most women present with vulvar pruritus or pain, or have noticed a lump or ulcer. Therefore, any suspicious vulvar lesion should be biopsied to exclude invasion. Once established, the most common subtype is squamous cell carcinoma. Treatment of vulvar cancer depends primarily on histology and surgical staging. Treatment is predominantly surgical, particularly for squamous cell carcinoma, although concurrent chemoradiation is an effective alternative, particularly for advanced tumors. Management should be individualized and carried out by a multidisciplinary team in a cancer center experienced in the treatment of these tumors. A useful update for trainees and specialists regarding the diagnosis, staging, treatment, and some controversies in the management of vulvar neoplasms.
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Affiliation(s)
- Alexander B Olawaiye
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mauricio A Cuello
- Department of Gynecology, Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Linda J Rogers
- Division of Gynecological Oncology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,South African Medical Research Council University of Cape Town Gynecological Cancer Research Centre (SA MRC UCT GCRC, Cape Town, South Africa
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10
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Leis M, Singh A, Li C, Ahluwalia R, Fleming P, Lynde CW. Risk of Vulvar Squamous Cell Carcinoma in Lichen Sclerosus and Lichen Planus: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:182-192. [PMID: 34678521 DOI: 10.1016/j.jogc.2021.09.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objectives of this study were to determine: 1) the prevalence of lichen sclerosus (LS) and lichen planus (LP) present in association with vulvar squamous cell carcinoma (VSCC), and 2) the incidence and absolute risk of developing VSCC in LS and LP. METHODS A search was performed of MEDLINE, EMBASE and CINAHL databases. Three independent reviewers screened articles published before September 1, 2020, first on title/abstract and then on the full text. Women with a history of VSCC, human papillomavirus, smoking, or autoimmune disease were excluded. Newcastle-Ottawa observational study scales were used to assess the risk of bias and methodological quality of the included studies. Of the 3132 studies assessed, 31 were selected for analysis. Due to study heterogeneity, a qualitative synthesis was conducted. RESULTS The prevalence of LS and LP in association with VSCC ranged from 0% (95% CI 0-5) to 83% (95% CI 36-100) and 1% (95% CI 0-7) to 33% (95% CI 4-78), respectively. The incidence of VSCC ranged from 1.16 (95% CI 0.03-6.44) to 13.67 (95% CI 5.50-28.17) per 1000 person-years for LS. The absolute risk of developing VSCC in patients ranged from 0.0% (95% CI 0.0-5.52) to 21.88% (95% CI 9.28-39.97) with LS and was 1.16% (95% CI 0.1-4.1) with LP. Incidence was not calculable for LP owing to study characteristics. CONCLUSIONS This review provides evidence that there is an increased risk of developing VSCC in women with LS, while associations with LP are less clear. Early identification, treatment, and long-term follow-up are essential to prevent potential malignant progression of these vulvar dermatoses.
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Affiliation(s)
- Maria Leis
- Faculty of Medicine, University of Toronto, ON.
| | | | - Calandra Li
- Faculty of Medicine, University of Toronto, ON
| | - Renita Ahluwalia
- Women's College Hospital, Toronto, ON; Division of Dermatology, University of Toronto, ON
| | - Patrick Fleming
- Division of Dermatology, University of Toronto, ON; Lynde Institute of Dermatology, Markham, ON
| | - Charles W Lynde
- Division of Dermatology, University of Toronto, ON; Lynde Institute of Dermatology, Markham, ON
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11
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Management of Vulvar Cancer Precursors: A Survey of the International Society for the Study of Vulvovaginal Disease. J Low Genit Tract Dis 2021; 24:387-391. [PMID: 32986387 DOI: 10.1097/lgt.0000000000000559] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to determine how experts treat vulvar high-grade squamous intraepithelial neoplasia (VHSIL) and differentiated vulvar intraepithelial neoplasia (dVIN). METHOD A 26-question survey was designed through a literature review, reviewed by the Survey Committee of the International Society for the Study of Vulvovaginal Disease (ISSVD), and distributed to all ISSVD members via e-mail in January 2019. RESULTS Overall, 90 of 441 physician members consented to participate and 78 of 90 were eligible to complete the survey. Most respondents were gynecologists (77%), followed by dermatologists (12%). Forty-five percent responded that their pathology was being reported using the 2015 ISSVD terminology of vulvar squamous intraepithelial lesions. The most common first-line treatments were as follows: unifocal VHSIL-excision (65%), multifocal VHSIL-imiquimod 5% (45%), VHSIL in a hair-bearing area-excision (69%), and clitoral disease-imiquimod 5% (47%). In the recurrent VHSIL, excision was favored (28%), followed by imiquimod 5% (26%) and laser (19%). Differentiated vulvar intraepithelial neoplasia was most often first treated with excision (82%), and more patients were referred to gynecologic oncology. Most patients were seen in follow-up at 3 months (range: 1 week-6 months). Sixty-seven respondents provided 26 different ways to follow treated patients, which were most commonly every 6 months for 2 years and then yearly (25%), followed by every 6 months indefinitely (18%). CONCLUSIONS Treatment of VHSIL and dVIN varies among vulvar experts with excision being the most common treatment, except in multifocal VHSIL where imiquimod is commonly used. There is wide variation in how patients are followed after treatment.
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12
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Superficially Invasive Vulvar Squamous Cell Carcinoma: A 37-Year-Long Experience of a Tertiary Referral Center. Cancers (Basel) 2021; 13:cancers13153859. [PMID: 34359760 PMCID: PMC8345506 DOI: 10.3390/cancers13153859] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 12/23/2022] Open
Abstract
Superficially, invasive vulvar squamous cell carcinoma (SISCCA) (FIGO stage IA) is a rare subset of vulvar cancer defined as a single lesion measuring ≤2 cm with a depth of invasion of ≤1.0 mm. This is a retrospective study performed on 48 patients with SISCCA, surgically treated between 1981 and 2018 at the S. Anna Hospital, University of Turin, to evaluate pathological characteristics and prognosis of these tumors. Ten patients (21%) recurred: seven (14%) as SISCCA and three (7%) as deeply invasive carcinoma. One case with perineural invasion and groin node metastasis at recurrence. No patient had groin lymph node metastases at initial diagnosis. Site of SISCCA, type of surgery, status of surgical margins, and histopathological features did not differ between recurrent and non-recurrent patients. We observed a non-significant trend towards an increase of recurrences in younger women (median age: 63 years vs. 70 years, p = 0.09), while, surprisingly, smaller tumors (<12 mm) were significantly related to tumor relapse (p = 0.03). Overall, SISCCA has a good long-term prognosis, regardless of the pathological characteristics and the type of surgical treatment. We recommend close follow-up, especially for younger patients and for small tumors, due to the possibility of recurrence or re-occurrence even after years.
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13
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Heller DS, Day T, Allbritton JI, Scurry J, Radici G, Welch K, Preti M. Diagnostic Criteria for Differentiated Vulvar Intraepithelial Neoplasia and Vulvar Aberrant Maturation. J Low Genit Tract Dis 2021; 25:57-70. [PMID: 33105449 PMCID: PMC7748053 DOI: 10.1097/lgt.0000000000000572] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of the study was to describe the features required for diagnosis of differentiated vulvar intraepithelial neoplasia (dVIN) and vulvar aberrant maturation (VAM). MATERIALS AND METHODS The International Society of the Study of Vulvovaginal Diseases tasked the difficult pathologic diagnoses committee to develop consensus recommendations for clinicopathologic diagnosis of vulvar lichen planus, lichen sclerosus, and dVIN. The dVIN subgroup reviewed the literature and formulated diagnostic criteria that were reviewed by the committee and then approved by the International Society of the Study of Vulvovaginal Diseases membership. RESULTS Differentiated vulvar intraepithelial neoplasia is the immediate precursor of human papillomavirus (HPV)-independent vulvar squamous cell carcinoma and shows a spectrum of clinical and microscopic appearances, some overlapping with HPV-related neoplasia. The histopathologic definition of dVIN is basal atypia combined with negative or nonblock-positive p16 and basal overexpressed, aberrant negative, or wild-type p53. The most common pattern of dVIN is keratinizing with acanthosis, aberrant rete ridge pattern, and premature maturation. The morphologic spectrum of keratinizing dVIN includes hypertrophic, atrophic, acantholytic, and subtle forms. A few dVIN cases are nonkeratinizing, with basaloid cells replacing more than 60% of epithelium. Vulvar aberrant maturation is an umbrella term for lesions with aberrant maturation that arise out of lichenoid dermatitis and lack the basal atypia required for dVIN. CONCLUSIONS Evaluation of women at risk for dVIN and VAM requires a collaborative approach by clinicians and pathologists experienced in vulvar disorders. Close surveillance of women with lichen sclerosus and use of these recommendations may assist in prevention of HPV-independent squamous cell carcinoma through detection and treatment of dVIN and VAM.
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Affiliation(s)
| | - Tania Day
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | | | - James Scurry
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
- NSW Health Pathology, Hunter New England, Newcastle, New South Wales, Australia
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14
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Pouwer AFW, VAN DEN Einden LCG, VAN DER Linden M, Hehir-Kwa JY, Yu J, Hendriks KM, Kamping EJ, Eijkelenboom A, Massuger LFAG, Bulten J, VAN Tilborg AAG, DE Hullu JA, Kuiper RP. Clonal Relationship Between Lichen Sclerosus, Differentiated Vulvar Intra-epithelial Neoplasia and Non HPV-related Vulvar Squamous Cell Carcinoma. Cancer Genomics Proteomics 2020; 17:151-160. [PMID: 32108037 DOI: 10.21873/cgp.20175] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/19/2019] [Accepted: 01/10/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND/AIM Differentiated vulvar intraepithelial neoplasia (dVIN) and lichen sclerosus (LS) can give rise to vulvar squamous cell carcinoma (VSCC), but genetic evidence is currently still limited. We aimed to determine genetic abnormalities in VSCC and backtrack these abnormalities in the dVIN and LS lesions. MATERIALS AND METHODS DNA from VSCC and patient-matched dVIN and LS samples of twelve patients was collected. High-resolution genome-wide copy number analysis was performed and subsequently, we sequenced TP53. RESULTS Copy number alterations were identified in all VSCC samples. One dVIN lesion presented with three copy number alterations that were preserved in the paired VSCC sample. Targeted sequencing of TP53 identified mutations in five VSCCs. All five mutations were traced back in the dVIN (n=5) or the LS (n=1) with frequencies ranging from 3-19%. CONCLUSION Our data provide genetic evidence for a clonal relationship between VSCC and dVIN or LS.
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Affiliation(s)
- Anne-Floor W Pouwer
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Loes C G VAN DEN Einden
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michelle VAN DER Linden
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jayne Y Hehir-Kwa
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Jiangyan Yu
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Koen M Hendriks
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eveline J Kamping
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Astrid Eijkelenboom
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Leon F A G Massuger
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Johan Bulten
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Joanne A DE Hullu
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Roland P Kuiper
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
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15
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Somatic Mutation Profiling in Premalignant Lesions of Vulvar Squamous Cell Carcinoma. Int J Mol Sci 2020; 21:ijms21144880. [PMID: 32664330 PMCID: PMC7402303 DOI: 10.3390/ijms21144880] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/29/2020] [Accepted: 07/08/2020] [Indexed: 12/12/2022] Open
Abstract
Vulvar squamous cell carcinoma (VSCC) originates from the progression of either a high-grade squamous intraepithelial lesion (HSIL) or differentiated-type vulvar intraepithelial neoplasia (dVIN), often in a background of lichen sclerosus (LS). The mechanisms leading to the progression of these premalignant lesions to VSCC are elusive. This study aims to identify pathogenic mutations implicated in VSCC development. Using next-generation sequencing, 38 HSIL, 19 dVIN, 20 LS, of which 10 were solitary lesions and 10 with adjacent VSCC, and 10 VSCC adjacent to LS, were screened for hotspot mutations in 50 genes covered by the Ion AmpliSeq Cancer Hotspot Panel v2 Kit (Thermo Fisher Scientific). Pathogenic mutations of TP53 were the most common genetic alterations identified in 53% and 24% of dVIN and HSIL cases, respectively, followed by CDKN2A (p16) mutated in 42% and 0% of dVIN and HSIL, respectively. Seven (70%) and three (30%) of 10 cases of VSCC associated with LS carried TP53 and CDKN2A mutations, respectively, whereas neither solitary LS nor LS associated with VSCC cases harbored mutations in these genes. It appears that TP53 mutations are early events during VSCC carcinogenesis, being present in both HSIL and dVIN lesions. Our preliminary data do not support a genetic background for the notion of LS as the VSCC premalignant lesion.
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16
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Morrison J, Baldwin P, Buckley L, Cogswell L, Edey K, Faruqi A, Ganesan R, Hall M, Hillaby K, Reed N, Rolland P, Fotopoulou C. British Gynaecological Cancer Society (BGCS) vulval cancer guidelines: Recommendations for practice. Eur J Obstet Gynecol Reprod Biol 2020; 252:502-525. [PMID: 32620514 DOI: 10.1016/j.ejogrb.2020.05.054] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/15/2020] [Accepted: 05/26/2020] [Indexed: 12/20/2022]
Abstract
The purpose of this guideline is to collate evidence and propose evidence-based guidelines for the diagnosis and management of adult patients with vulva carcinoma treated in the UK. Malignant melanoma may present via similar routes and will be discussed. The reader is referred to the Ano-uro-genital Mucosal Melanoma Full Guideline [1] for more detailed recommendations. The management of vulval sarcoma is outside of the scope of this guideline. For further information, including details of guideline development and GRADE of recommendations, please see BGCS website for details (https://www.bgcs.org.uk/professionals/guidelines-for-recent-publications/).
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Affiliation(s)
- Jo Morrison
- Department of Gynaecological Oncology, GRACE Centre, Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton, TA1 5DA, UK.
| | - Peter Baldwin
- Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Lynn Buckley
- Department of Gynae-Oncology, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, East Yorkshire, HU16 5JQ, UK
| | - Lucy Cogswell
- Consultant Plastic & Reconstructive Surgeon, Department of Plastic &Reconstructive Surgery, Oxford University Hospitals NHS Trust, Headington, Oxford, OX3 9DU, UK
| | - Katharine Edey
- Centre for Women's Health Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW, UK
| | - Asma Faruqi
- Department of Cellular Pathology, The Royal London Hospital, Barts Health NHS Trust, London, E1 2ES, UK
| | - Raji Ganesan
- Department of Cellular Pathology, Birmingham Women's Hospital, Birmingham, B15 2TG, UK
| | - Marcia Hall
- Dept Medical Oncology, Mount Vernon Cancer Centre, Rickmansworth Road, Northwood, Middx HA6 2RN, UK
| | - Kathryn Hillaby
- Department Gynaecological Oncology, Cheltenham General Hospital, Gloucestershire, Hospitals NHS Foundation Trust, GL53 7AN, UK
| | - Nick Reed
- Beatson Oncology Centre, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, Scotland, UK
| | - Phil Rolland
- Department Gynaecological Oncology, Cheltenham General Hospital, Gloucestershire Hospitals NHS Foundation Trust, GL53 7AN, UK
| | - Christina Fotopoulou
- Gynaecologic Oncology, Imperial College London Faculty of Medicine, London, SW7 2DD, UK
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17
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Mancini S, Bucchi L, Baldacchini F, Giuliani O, Ravaioli A, Vattiato R, Preti M, Tumino R, Ferretti S, Biggeri A, Brustolin A, Boschetti L, Caiazzo AL, Caldarella A, Cesaraccio R, Cirilli C, Citarella A, Filiberti RA, Fusco M, Galasso R, Gatti L, Lotti FL, Magoni M, Mangone L, Masanotti G, Mazzoleni G, Mazzucco W, Melcarne A, Michiara M, Pesce P, Piffer S, Pinto A, Rognoni M, Rosso S, Rugge M, Sampietro G, Scalzi S, Scuderi T, Tagliabue G, Tisano F, Toffolutti F, Vitarelli S, Falcini F. Incidence trends of vulvar squamous cell carcinoma in Italy from 1990 to 2015. Gynecol Oncol 2020; 157:656-663. [PMID: 32273199 DOI: 10.1016/j.ygyno.2020.03.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/08/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The incidence of vulvar squamous cell carcinoma has increased for decades in most Western countries - a trend virtually restricted to women aged <50 or 60 years. In southern Europe, conversely, the trends have been insufficiently studied. This article reports a study from Italy. METHOD Thirty-eight local cancer registries, currently covering 15,274,070 women, equivalent to 49.2% of the Italian national female population, participated. Invasive cancers registered between 1990 and 2015 with an International Classification of Diseases for Oncology, 3rd revision, topography code C51 and morphology codes compatible with vulvar squamous cell carcinoma (n = 6294) were eligible. Incidence trends were analysed using joinpoint regression models, with calculation of the estimated annual percent change (EAPC), and age-period-cohort models. RESULTS Total incidence showed a regular and significant decreasing trend (EAPC, -0.96; 95% confidence interval (CI), -1.43 to -0.48). This was entirely accounted for by women aged ≥60 years (EAPC, -1.34; 95% CI, -1.86 to -0.81). For younger women, the EAPC between 1990 and 2012 was 1.20 (95% CI, 0.34 to 2.06) with a non-significant acceleration thereafter. This pattern did not vary substantially in a sensitivity analysis for the effect of geographic area and duration of the registry. The age-period-cohort analysis revealed a risk decrease in cohorts born between 1905 and 1940 and a new increase in cohorts born since 1945. CONCLUSIONS The decreasing trend observed among older women and the resulting decrease in total rate are at variance with reports from most Western countries. Age-period-cohort analysis confirmed a decreasing trend for earliest birth cohorts and an opposite one for recent ones.
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Affiliation(s)
- Silvia Mancini
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Forlì, Italy
| | - Lauro Bucchi
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Forlì, Italy
| | - Flavia Baldacchini
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Forlì, Italy
| | - Orietta Giuliani
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Forlì, Italy
| | - Alessandra Ravaioli
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Forlì, Italy.
| | - Rosa Vattiato
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Forlì, Italy
| | - Mario Preti
- Department of Obstetrics and Gynaecology, University of Torino, Torino, Italy
| | - Rosario Tumino
- Cancer Registry and Histopathology Department, Provincial Health Authority (ASP), Ragusa, Italy
| | | | - Annibale Biggeri
- Department of Statistics, Computer Science, Applications G. Parenti, University of Florence, Florence, Italy
| | - Angelita Brustolin
- Unit of Epidemiology and Cancer Registry, Local Health Authority, Viterbo, Italy
| | | | - Anna L Caiazzo
- Cancer Registry of Local Health Authority Salerno, Salerno, Italy
| | - Adele Caldarella
- Tuscany Cancer Registry, Clinical and Descriptive Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy
| | - Rosaria Cesaraccio
- Sassari Cancer Registry, Azienda Regionale per la Tutela della Salute - ATS, Sassari, Italy
| | - Claudia Cirilli
- Modena Cancer Registry, Public Health Department, Local Health Authority, Modena, Italy
| | - Annarita Citarella
- Cancer Registry, Department of Prevention, Unit of Epidemiology, Local Health Authority, Benevento, Italy
| | - Rosa A Filiberti
- Liguria Cancer Registry, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Rocco Galasso
- Unit of Regional Cancer Registry, Clinical Epidemiology and Biostatistics, IRCCS-CROB, Basilicata, Rionero in Vulture, Italy
| | - Luciana Gatti
- Mantova Cancer Registry, Epidemiology Unit, Agenzia di Tutela della Salute (ATS) della Val Padana, Mantova, Italy
| | - Fernanda L Lotti
- Brindisi Cancer Registry, Local Health Authority, Brindisi, Italy
| | - Michele Magoni
- Cancer Registry of Brescia Province, Epidemiology Unit, Brescia Health Protection Agency, Brescia, Italy
| | - Lucia Mangone
- Epidemiology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Giuseppe Masanotti
- Section of Public Health and RTUP Register, Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | | | - Walter Mazzucco
- Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | | | - Maria Michiara
- Parma Cancer Registry, Medical Oncology Unit, University Hospital of Parma, Parma, Italy
| | - Paola Pesce
- Catania, Messina, and Enna Cancer Registry, Catania, Italy
| | - Silvano Piffer
- Trento Province Cancer Registry, Unit of Clinical Epidemiology, Trento, Italy
| | - Angela Pinto
- Barletta, Andria, Trani Cancer Registry, BAT Province, Barletta, Italy
| | - Magda Rognoni
- Epidemiology Unit, Cancer Registry of ATS Brianza, Health Protection Agency, Monza, Italy
| | - Stefano Rosso
- Piedmont Cancer Registry, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Massimo Rugge
- Veneto Tumour Registry, Azienda Zero, University of Padova-DIMED, Padova, Italy
| | | | | | | | - Giovanna Tagliabue
- Lombardy Cancer Registry-Varese Province, Cancer Registry Unit, Department of Research, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | | | - Federica Toffolutti
- Cancer Epidemiology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Susanna Vitarelli
- Macerata Province Cancer Registry, University of Camerino, Camerino, Italy
| | - Fabio Falcini
- Romagna Cancer Registry, Romagna Cancer Institute, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Forlì, Italy; Cancer Prevention Unit, Local Health Authority, Forlì, Italy
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Eva LJ, Sadler L, Fong KL, Sahota S, Jones RW, Bigby SM. Trends in HPV-dependent and HPV-independent vulvar cancers: The changing face of vulvar squamous cell carcinoma. Gynecol Oncol 2020; 157:450-455. [PMID: 32037194 DOI: 10.1016/j.ygyno.2020.01.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 12/31/2019] [Accepted: 01/19/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate the incidence and survival of Vulvar Squamous Cell Carcinoma (VSCC) by etiology over a 27 year period. METHOD Retrospective case-note and pathology slide review of 390 consecutive VSCC, treated at a Centralized Cancer Centre covering half New Zealand's population, 1990-2016. Incidence was calculated in 5-6 year cohorts and correlated with precursor of the VSCC, age and stage. RESULTS Age-standardized incidence of all VSCC did not change significantly, however age standardized incidence of HPV-dependent VSCC increased significantly, from 0.55/100,000 (95% CI 0.38-0.72) in 1991-2000 to 0.83/100,000 (95% CI 0.68-0.97) in 2001-2016, with a significant decrease in the incidence of HPV-independent VSCC, from 0.76/100,000 (95% CI 0.58-0.95) to 0.54/100,000 (95%CI 0.43-0.65). HPV-dependent VSCC in women ≥50 years increased significantly from 0.75/100,000 (95% CI 0.45-1.17) to 1.43/100,000 (95% CI 1.14-1.77), with no significant change seen in younger women. HPV-independent VSCC in women ≥50 years has decreased significantly from 2.53/100,000 (95% CI 1.95-3.23) to 1.62/100,000 (95% CI 1.31-1.98) with no change in younger women. The proportion of HPV-dependent VSCC has increased from 25% to 50%. Age standardized death rate from VSCC has not changed significantly from 0.22/100,000 (95% CI 0.10-0.34) in 2001-5 to 0.27/100,000 (95% CI 0.15-0.40) in 2011-16. Five year survival for HPV-dependent VSCC was 93% and 68% for HPV-independent VSCC (p < .0001). CONCLUSIONS HPV-dependent VSCC incidence has increased significantly and now accounts for half of VSCC, with a significant rise in women over 50. HPV-dependent and independent VSCC have different prognoses and should be registered and investigated separately.
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Affiliation(s)
- Lois J Eva
- Department of Gynecological Oncology, National Women's Health at Auckland City Hospital, Auckland, New Zealand; Department of Obstetrics and Gynecology, University of Auckland, New Zealand.
| | - Lynn Sadler
- Department of Obstetrics and Gynecology, University of Auckland, New Zealand
| | - Kah Leng Fong
- Department of Gynecological Oncology, National Women's Health at Auckland City Hospital, Auckland, New Zealand
| | - Sukhwinder Sahota
- Department of Gynecological Oncology, National Women's Health at Auckland City Hospital, Auckland, New Zealand
| | - Ronald W Jones
- Department of Gynecological Oncology, National Women's Health at Auckland City Hospital, Auckland, New Zealand
| | - Susan M Bigby
- Department of Histopathology, Middlemore Hospital, Auckland, New Zealand
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19
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Associated Lichen Sclerosis Increases the Risk of Lymph Node Metastases of Vulvar Cancer. J Clin Med 2020; 9:jcm9010250. [PMID: 31963481 PMCID: PMC7019519 DOI: 10.3390/jcm9010250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/13/2020] [Accepted: 01/15/2020] [Indexed: 01/24/2023] Open
Abstract
The most important prognostic factor in vulvar cancer is inguinal lymph node status at the time of diagnosis, even in locally advanced vulvar tumors. The aim of our study was to identify the risk factors of lymph node involvement in these women, especially the impact of lichen sclerosis (LS). We conducted a retrospective population-based cross-sectional study in two French referral gynecologic oncology institutions. We included all women diagnosed with a primary invasive vulvar cancer. Epithelial alteration adjacent to the invasive carcinoma was found in 96.8% (n = 395). The most frequently associated was LS in 27.7% (n = 113). In univariate analysis, LS (p = 0.009); usual type VIN (p = 0.04); tumor size >2 cm and/or local extension to vagina, urethra or anus (p < 0.01), positive margins (p < 0.01), thickness (p < 0.01) and lymphovascular space invasion (LVSI) (p < 0.01) were significantly associated with lymph node involvement. In multivariate analysis, only LS (OR 2.3, 95% CI [1.2-4.3]) and LVSI (OR 5.6, 95% CI [1.7-18.6]) remained significantly associated with positive lymph node. LS was significantly associated with older patients (p = 0.005), anterior localization (p = 0.017) and local extension (tumor size > 2 cm: p = 0.001). LS surrounding vulvar cancer is an independent factor of lymph node involvement, with local extension and LVSI.
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20
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Dasgupta S, Ewing-Graham PC, Swagemakers SMA, van der Spek PJ, van Doorn HC, Noordhoek Hegt V, Koljenović S, van Kemenade FJ. Precursor lesions of vulvar squamous cell carcinoma - histology and biomarkers: A systematic review. Crit Rev Oncol Hematol 2020; 147:102866. [PMID: 32058913 DOI: 10.1016/j.critrevonc.2020.102866] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/21/2019] [Accepted: 01/13/2020] [Indexed: 12/01/2022] Open
Abstract
The precursor lesion of vulvar squamous cell carcinoma (VSCC), namely vulvar intraepithelial neoplasia (VIN), is classified as: human papillomavirus (HPV)-related high grade squamous intraepithelial lesion (HSIL), and HPV-independent differentiated VIN (dVIN). Traditionally, histology and immunohistochemistry (IHC) have been the basis of diagnosis and classification of VIN. HSIL shows conspicuous histological atypia, and positivity on p16-IHC, whereas dVIN shows less obvious histological atypia, and overexpression or null-pattern on p53-IHC. For both types of VIN, other diagnostic immunohistochemical markers have also been evaluated. Molecular characterization of VIN has been attempted in few recent studies, and novel genotypic subtypes of HPV-independent VSCC and VIN have been identified. This systematic review appraises the VSCC precursors identified so far, focusing on histology and biomarkers (immunohistochemical and molecular). To gain further insights into the carcinogenesis and to identify additional potential biomarkers, gene expression omnibus (GEO) datasets on VSCC were analyzed; the results are presented.
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Affiliation(s)
- Shatavisha Dasgupta
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, the Netherlands.
| | | | - Sigrid M A Swagemakers
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, the Netherlands; Department of Bioinformatics, Erasmus MC, University Medical Centre Rotterdam, the Netherlands.
| | - Peter J van der Spek
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, the Netherlands; Department of Bioinformatics, Erasmus MC, University Medical Centre Rotterdam, the Netherlands.
| | - Helena C van Doorn
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - Vincent Noordhoek Hegt
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, the Netherlands.
| | - Senada Koljenović
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, the Netherlands.
| | - Folkert J van Kemenade
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, the Netherlands.
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21
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Abstract
PURPOSE OF REVIEW The aim of this article is to provide clinicians and pathologists with an understanding of the aetiopathology, pathogenesis and classification of vulval neoplasia and their molecular correlates. RECENT FINDINGS There is an increased understanding of subcellular changes in vulvar malignancies. These provide the direction for further research and aid personalised treatment for patients. The article explores concepts of the aetiology of vulvar cancer and updates the reader with the equivalence of terminology of preneoplastic vulval disease. The differential diagnosis of squamous neoplasia and their clinicopathological correlation is detailed. The salient findings from recent literature into the understanding of the disease of squamous cell neoplasia and rare vulvar malignancies are summarised.
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Affiliation(s)
- Anthony Williams
- Birmingham Women's and Children's NHS Foundation Trust, 1st Floor Labs, Mindelsohn Way, Birmingham, B15 2TG, UK
| | - Sheeba Syed
- Pathology Department, Queen Elizabeth University Hospital Glasgow, 1345 Govan Road, Laboratory Medicine and Facility Building, Glasgow, G51 4TF, UK
| | - Shireen Velangi
- University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TG, UK
| | - Raji Ganesan
- Birmingham Women's and Children's NHS Foundation Trust, 1st Floor Labs, Mindelsohn Way, Birmingham, B15 2TG, UK.
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22
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Differentiated Vulvar Intraepithelial Neoplasia-like and Lichen Sclerosus-like Lesions in HPV-associated Squamous Cell Carcinomas of the Vulva. Am J Surg Pathol 2019; 42:828-835. [PMID: 29505429 DOI: 10.1097/pas.0000000000001047] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Most human papillomavirus (HPV)-associated vulvar squamous cell carcinomas (VSCCs) originate from high-grade squamous intraepithelial lesions, also named usual type vulvar intraepithelial neoplasia. However, growing evidence suggests that morphologic studies have limitations in predicting HPV status in vulvar lesions. We aimed to evaluate adjacent intraepithelial lesions in a series of DNA HPV-positive VSCCs, focusing on unusual histologic patterns mimicking differentiated vulvar intraepithelial neoplasia (dVIN) or lichen sclerosus (LS). We identified 326 DNA HPV-positive VSCC with at least 1 cm of skin adjacent to the invasive tumor and analyzed HPV typing, HPV E6*I mRNA, and p16 immunohistochemistry in all cases. A careful histologic evaluation was conducted. A conclusive association with HPV was based on a positive p16 or HPV E6*I mRNA result or both in addition to the HPV DNA, whereas cases negative for both markers were classified as nonconclusively associated with HPV. One hundred twenty-one tumors (37.1%) had normal adjacent skin, 191 (58.6%) had only high-grade squamous intraepithelial lesions, also named usual type vulvar intraepithelial neoplasia, and unusual intraepithelial lesions were identified in 14 (4.3%) tumors. Seven cases showed dVIN-like features, 5 showed adjacent LS-like lesion, and in 2 cases dVIN-like and LS-like lesions were identified simultaneously. Six of them were conclusively associated with HPV (3 dVIN-like, 2 LS-like, 1 with combined dVIN/LS-like features). All 6 tumors were associated with HPV16 and were positive for both p16 and HPV mRNA, and p16 was also positive in the dVIN-like and LS-like lesions. In summary, a small subset of VSCCs conclusively associated with HPV may arise on intraepithelial lesions, mimicking precursors of HPV-independent VSCC.
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23
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Abstract
The pathogenesis of vulvar squamous neoplasia has 2 pathways: human papillomavirus (HPV)-dependent and HPV-independent. The HPV-dependent pathway in the vulva follows the same progression as HPV-dependent lesions elsewhere in the gynecologic tract-HPV infection results in high-grade squamous intraepithelial lesion with subsequent progression to basaloid squamous cell carcinoma. The HPV-independent pathway is more complex, with a variety of precursor lesions and molecular alterations. Although the most recognized form of HPV-independent vulvar lesion is differentiated vulvar intraepithelial neoplasia, recent explorations have elucidated new precursors. This review provides an update on HPV-independent risk factors and precursor lesions for squamous cell carcinoma of the vulva.
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Affiliation(s)
- Jaclyn C Watkins
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, MCN C-3306A, 1161 21st Avenue South, Nashville, TN 37232-2582, USA.
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24
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Watkins JC, Yang E, Crum CP, Herfs M, Gheit T, Tommasino M, Nucci MR. Classic Vulvar Intraepithelial Neoplasia With Superimposed Lichen Simplex Chronicus: A Unique Variant Mimicking Differentiated Vulvar Intraepithelial Neoplasia. Int J Gynecol Pathol 2019; 38:175-182. [PMID: 29750709 DOI: 10.1097/pgp.0000000000000509] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
High-grade vulvar intraepithelial neoplasia, a precursor lesion to vulvar squamous cell carcinoma, is subdivided into 2 types, classic or usual vulvar intraepithelial neoplasia (CVIN) and differentiated vulvar intraepithelial neoplasia (DVIN). CVIN, which is a human papilloma virus (HPV)-dependent lesion, is typically distinguished from DVIN, a p53 mutation-dependent process, by its distinct histomorphologic and immunohistochemical characteristics. However, distinguishing between the 2 entities becomes challenging in cases of CVIN with superimposed inflammatory changes, especially lichen simplex chronicus (LSC). Twelve cases of DVIN, 9 cases of LSC, and 9 cases of CVIN with superimposed LSC were assessed for a number of morphologic features, including hyperkeratosis, hypergranulosis, acanthosis, hypercellularity, abnormal maturation (i.e. abnormal keratinization close to the base and/or dyskeratosis), hyperchromasia, and basal atypia. Immunohistochemistry for p53, p16, and MIB-1 was performed for all cases. When sufficient tissue was available, HPV genotyping was performed for cases of CVIN with superimposed LSC. DVIN uniformly demonstrated abnormal maturation, and atypia involving the basal cell layer; they were all p16 negative and demonstrated p53 positivity of moderate to strong intensity in a basal and parabasal distribution. CVIN with superimposed LSC frequently displayed hyperchromasia involving the basal 3 to 4 cell layers, basal to full-thickness atypia, and apoptosis. CVIN with superimposed LSC demonstrated intense p16 positivity extending from the basal cells to the mid-epithelium and a reduction or loss of staining in maturing keratinocytes. P53 staining revealed a unique pattern of parabasal and mid-epithelial weak to moderate staining with sparing of the basal layer. Cases of LSC demonstrated heterogenous p53 positivity and were negative for p16. MIB-1 staining showed a similar range of positivity for all diagnoses. HPV genotyping revealed HPV 16 in all 5 cases of CVIN with LSC that underwent testing. We conclude that, although CVIN with superimposed LSC can closely resemble DVIN, morphologic features such as nuclear hyperchromasia uniformly involving the basal 3 to 4 cell layers, apoptosis, and absent or less pronounced cytoplasmic maturation are more suggestive of CVIN with superimposed LSC. In cases where the morphology remains ambiguous, immunohistochemistry for both p16 and p53 can be helpful. In particular, p53 parabasal and mid-epithelial staining without involvement of the basal layer appears to be a characteristic finding in CVIN with superimposed LSC. MIB-1 staining is of little utility in distinguishing between these entities and should not be routinely performed.
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Affiliation(s)
- Jaclyn C Watkins
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (J.C.W., C.P.C., M.R.N.) Stanford University Hospital, Palo Alto, California (E.Y.) Laboratory of Experimental Pathology, GIGA-Cancer, University of Liege, Liege, Belgium (M.H.) Infections and Cancer Biology Group, International Agency for Research on Cancer, Lyon, France (T.G., M.T.)
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25
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Cohen PA, Anderson L, Eva L, Scurry J. Clinical and molecular classification of vulvar squamous pre-cancers. Int J Gynecol Cancer 2019; 29:821-828. [PMID: 30737358 DOI: 10.1136/ijgc-2018-000135] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 12/25/2022] Open
Abstract
Vulvar intraepithelial neoplasia (VIN) is a precursor to vulvar squamous cell carcinoma and is defined histopathologically by the presence of atypia. VIN has been classified into two types: usual vulvar intraepithelial neoplasia (uVIN), which is also referred to as a vulvar high-grade squamous intra-epithelial lesion (HSIL), and differentiated VIN (dVIN). The former is associated with chronic infection by sub-types of the human papilloma virus (HPV), whereas dVIN is HPV-independent and frequently associated with lichen sclerosus. The distinction is important because dVIN has a greater risk of, and more rapid transit to, vulvar squamous cell carcinoma. Furthermore, dVIN-associated vulvar cancers have an increased risk of recurrence and higher mortality than those arising from HSIL. Molecular characterization of vulvar squamous cell carcinoma precursors using next-generation sequencing is a relatively novel, but rapidly advancing field. This review appraises recent studies that have investigated the risks of progression to vulvar malignancy associated with HSIL and dVIN, the prognosis of HPV-dependent and HPV-independent vulvar squamous cell carcinomas, and conducted next generation sequencing mutation analyses to elucidate the genomic profiles underlying VIN. These studies suggest that HSIL and dVIN are characterized by different underlying molecular alterations that may have important implications for treatment and follow-up of women diagnosed with vulvar squamous cell cancer.
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Affiliation(s)
- Paul A Cohen
- Department of Gynaecological Oncology, St John of God Hospital Bendat Family Comprehensive Cancer Centre, Perth, Western Australia, Australia .,Division of Obstetrics and Gynaecology, Faculty of Health and Medical Sciences, University of Western Australia, Crawley, Western Australia, Australia
| | - Lyndal Anderson
- Anatomical Pathology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,School of Medicine, Western Sydney University, Penrith South, New South Wales, Australia
| | - Lois Eva
- Department of Gynaecological Oncology, National Women's Health, Auckland City Hospital, Auckland, New Zealand.,Department of Gynaecological Oncology, University of Auckland, Auckland, New Zealand
| | - James Scurry
- Pathology North, New Lambton Heights, New South Wales, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
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26
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Jin C, Liang S. Differentiated Vulvar Intraepithelial Neoplasia: A Brief Review of Clinicopathologic Features. Arch Pathol Lab Med 2018; 143:768-771. [DOI: 10.5858/arpa.2018-0019-rs] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Differentiated-type vulvar intraepithelial neoplasia (dVIN) is a non–human papilloma virus (HPV)-related precursor lesion to vulvar squamous carcinoma. The terminology has only become recognized clinically and histopathologically in recent years despite being described more than 50 years ago. As opposed to the HPV-related VIN (uVIN), dVIN has different features of histomorphology, risk of progression, and molecular pathogenesis. Notably, dVIN commonly develops in a background of chronic inflammatory dermatoses such as lichen sclerosis and lichen simplex chronicus. The recognition of dVIN remains a challenge owing to lack of accurate and reproducible diagnostic criteria. Morphologically, basal layer atypia, dyskeratosis, and elongation and anastomosis of the rete ridges are regarded as very useful diagnostic features. Ancillary tests can be very helpful to establish a definitive diagnosis in some ambiguous cases. In contrast to uVIN, dVIN is more likely to progress to vulvar squamous carcinoma in a shorter period. The goal of this review is to elaborate on the clinicopathologic characteristics and underline the key histologic features that best facilitate the diagnosis of dVIN.
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Affiliation(s)
- Cao Jin
- From the Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York
| | - Sharon Liang
- From the Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York
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27
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Abstract
Vulvar cancer is an uncommon gynecological malignancy primarily affecting postmenopausal women. There is no specific screening and the most effective strategy to reduce vulvar cancer incidence is the opportune treatment of predisposing and preneoplastic lesions associated with its development. While vulvar cancer may be asymptomatic, most women present with vulvar pruritus or pain, or have noticed a lump or ulcer. Therefore, any suspicious vulvar lesion should be biopsied to exclude invasion. Once established, the most common subtype is squamous cell carcinoma. Treatment of vulvar cancer depends primarily on histology and surgical staging. Treatment is predominantly surgical, particularly for squamous cell carcinoma, although concurrent chemoradiation is an effective alternative, particularly for advanced tumors. Management should be individualized, and carried out by a multidisciplinary team in a cancer center experienced in the treatment of these tumors.
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Affiliation(s)
- Linda J Rogers
- Division of Gynecological Oncology, Groote Schuur Hospital/University of Cape Town, Cape Town, South Africa.,South African Medical Research Council/University of Cape Town Gynaecological Cancer Research Centre (SA MRC/UCT GCRC), Cape Town, South Africa
| | - Mauricio A Cuello
- Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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28
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Dasgupta S, Ewing-Graham PC, van Kemenade FJ, van Doorn HC, Noordhoek Hegt V, Koljenović S. Differentiated vulvar intraepithelial neoplasia (dVIN): the most helpful histological features and the utility of cytokeratins 13 and 17. Virchows Arch 2018; 473:739-747. [PMID: 30187167 PMCID: PMC6267258 DOI: 10.1007/s00428-018-2436-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/24/2018] [Accepted: 08/13/2018] [Indexed: 11/06/2022]
Abstract
Differentiated vulvar intraepithelial neoplasia (dVIN) is the precursor lesion of HPV-negative vulvar squamous cell carcinoma (VSCC). The histopathological diagnosis of dVIN can be challenging, as it often resembles vulvar non-neoplastic epithelial disorders (NNED), especially lichen sclerosus (LS). We aimed to establish the most specific and reproducible histological features of dVIN and assessed cytokeratin 13 (CK13) and cytokeratin 17 (CK17) immunohistochemistry as a diagnostic aid. Consecutive cases of dVIN (n = 180) and LS (n = 105) from the period 2010 to 2013 were reviewed using a checklist of histological features. Each feature was recorded as ‘present’ or ‘absent’ and statistical comparison (dVIN vs LS) was made. Interobserver agreement between two pairs of pathologists was assessed for a subset of cases of dVIN (n = 31) and LS and other NNED (n = 23). Immunohistochemistry with CK13, CK17, MIB1 and p53 was performed on dVIN, LS, and other NNED cases. Macronucleoli, features of disturbed maturation and angulated nuclei were significantly more common in dVIN than LS (p < 0.001). We found ‘substantial agreement’ for the diagnosis of dVIN (κ = 0.71). Macronucleoli and deep keratinisation had the highest agreement. In dVIN, the mean percentage of cells staining with CK13 was 15 and with CK17, this was 74. For LS, the mean percentage of cells staining with CK13 was 31, and with CK17, this was 41. By plotting receiver operating characteristic curves (ROC), an area under the curve (AUC) of 0.52 was obtained for CK13, and an AUC of 0.87 was obtained for CK17. The most helpful histological features for diagnosing dVIN were macronucleoli, features of disturbed maturation, and angulated nuclei. Increased CK17 expression may have promise for supporting dVIN diagnosis.
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Affiliation(s)
- Shatavisha Dasgupta
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Patricia C Ewing-Graham
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
| | - Folkert J van Kemenade
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Helena C van Doorn
- Department of Gynaecologic Oncology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Vincent Noordhoek Hegt
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Senada Koljenović
- Department of Pathology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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29
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Nitecki R, Feltmate CM. Human papillomavirus and nonhuman papillomavirus pathways to vulvar squamous cell carcinoma: A review. Curr Probl Cancer 2018; 42:476-485. [PMID: 30093165 DOI: 10.1016/j.currproblcancer.2018.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 06/05/2018] [Indexed: 11/16/2022]
Abstract
Vulvar squamous cell carcinoma (VSCC) is a rare tumor of the female genital tract. While previously considered a disease of older women, the epidemiologic landscape is changing with more young women diagnosed with VSCC and its precursor lesions. This may be secondary to the global increase in human papillomavirus (HPV) infection of the lower genital tract. While VSCC precursor lesions have been described for many years, the terminology, and thus the understanding and reproducibility of these lesions have been debated. In the most recent publication from the International Society of the Study of Vulvovaginal Disease (ISSVD), there is a distinction between high-risk vulvar lesions associated with HPV infection (vulvar HSIL) and high-risk vulvar lesions that are not thought to be associated with HPV infection (differentiated VIN or dVIN). These precursors have different risk factors and thus affect different populations, leading to two separate pathways for developing VSCC. The HPV-related VSCC is likely to have a better prognosis than the non-HPV-related VSCC, as seen in other disease sites. Early-stage VSCC may be surgically treated with margin and node status affecting whether adjuvant radiation is recommended. Advanced stage VSCC may be unresectable, requiring neoadjuvant chemoradiation. Although VSCC is a rare disease, ongoing studies investigating the different pathways leading to carcinogenesis may increase the understanding of VSCC and improve therapeutic options for patients.
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Affiliation(s)
- Roni Nitecki
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Colleen M Feltmate
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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30
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Lewin MR, Hick RW, Selim MA. Lichenoid Dermatitis of the Vulva: Diagnosis and Differential Diagnosis for the Gynecologic Pathologist. Adv Anat Pathol 2017; 24:278-293. [PMID: 28654444 DOI: 10.1097/pap.0000000000000160] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Inflammatory processes affecting the vulva may present a unique challenge due to location specific changes. Different factors are behind the intricacy in the presentation of vulvar dermatoses. First, the vulva is lined by different epithelia (hair-bearing keratinized epithelium, modified mucosa, and mucosa). Furthermore, among other factors, this organ is exposed to friction, occlusion, and trauma. Lastly, as there is a tendency to look for health care advice at an advanced stage of the disease, the lesion may be modified by secondary changes due to self-treatment. This article describes the clinical presentation and pathologic features of vulvar dermatoses with a lichenoid pattern and highlights practical points for their diagnoses.
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31
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Reutter JC. High-Yield Vulvar Histopathology for the Clinician. Obstet Gynecol Clin North Am 2017; 44:329-338. [PMID: 28778634 DOI: 10.1016/j.ogc.2017.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Certain adjustable factors may influence how helpful a pathology report is to the clinician. Different biopsy techniques may be preferable based on the type of lesion being biopsied and the background epithelial surface. Key observations from the history and physical examination, possibly with a clinical photograph, are helpful to the pathologist. When reading the pathology report, realize the difficulties arising from definitively classifying some diseases and how treatment can affect the tissue. Finally, avoid miscommunication with the pathologist by understanding current nomenclature of vulvar disease.
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Affiliation(s)
- Jason C Reutter
- Piedmont Pathology Associates, 1899 Tate Boulevard Southeast, Suite 1105, Hickory, NC 28601, USA.
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32
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McAlpine JN, Leung SCY, Cheng A, Miller D, Talhouk A, Gilks CB, Karnezis AN. Human papillomavirus (HPV)-independent vulvar squamous cell carcinoma has a worse prognosis than HPV-associated disease: a retrospective cohort study. Histopathology 2017; 71:238-246. [PMID: 28257152 DOI: 10.1111/his.13205] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 02/27/2017] [Indexed: 11/30/2022]
Abstract
AIMS Vulvar squamous cell carcinoma (VSCC) can be subdivided by human papillomavirus (HPV) status into two clinicopathological entities. Studies on the prognostic significance of HPV in VSCC are discordant. METHODS AND RESULTS We performed a retrospective analysis of overall survival (OS), disease-specific survival (DSS) and progression-free survival (PFS) in 217 patients with VSCC. Cases were extracted from an era of more aggressive en-bloc radical dissections (1985-95) and more localized radical surgery through separate vulvar and groin excisions (1996-2005). p16 immunohistochemistry was used as a surrogate for HPV status. HPV status could be determined in 197 tumours, 118 HPV-independent and 79 HPV-associated tumours. Patients with HPV-associated tumours were younger (mean 58.8 versus 71.6 years for HPV-independent tumours, P < 0.0001) and more likely to have prior abnormal cervical cytology (41.1 versus 5.6% for HPV-independent tumours, P < 0.0001). In univariable analysis, patients with HPV-associated tumours had superior PFS [hazard ratio (HR): 0.37, 95% confidence interval (CI): 0.18-0.70], DSS (HR: 0.19, 95% CI: 0.08-0.41) and OS (HR: 0.35, 95% CI: 0.21-0.59). This was driven by worse outcomes (PFS, DSS and OS) for patients with HPV-independent tumours compared with HPV-associated tumours who underwent surgery after 1995. After adjusting for age and stage in multivariable analysis, patients with HPV-associated tumours showed superior PFS (HR: 0.25, 95% CI: 0.07-0.77) and DSS (HR: 0.21, 95% CI: 0.04-0.78). CONCLUSIONS VSCC can be stratified into two prognostically different diseases based on p16 immunostaining. HPV status was associated only with prognosis in the cohort that underwent surgery after 1995, suggesting that more conservative surgery may have led to worse outcomes for patients with HPV-independent tumours.
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Affiliation(s)
- Jessica N McAlpine
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, University of British Columbia, Vancouver, BC, Canada
| | - Samuel C Y Leung
- Department of Pathology and Laboratory Medicine, Genetic Pathology Evaluation Centre, University of British Columbia, Vancouver, BC, Canada
| | - Angela Cheng
- Department of Pathology and Laboratory Medicine, University of British Columbia and BC Cancer Agency, Vancouver, BC, Canada
| | - Dianne Miller
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, University of British Columbia, Vancouver, BC, Canada
| | - Aline Talhouk
- Department of Pathology and Laboratory Medicine, University of British Columbia and BC Cancer Agency, Vancouver, BC, Canada
| | - C Blake Gilks
- Department of Pathology and Laboratory Medicine, University of British Columbia and Vancouver General Hospital, Vancouver, BC, Canada
| | - Anthony N Karnezis
- Department of Pathology and Laboratory Medicine, University of British Columbia and BC Cancer Agency, Vancouver, BC, Canada
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Differentiated Vulvar Intraepithelial Neoplasia: What Criteria Do We Use in Practice? J Low Genit Tract Dis 2017; 20:261-6. [PMID: 27105329 DOI: 10.1097/lgt.0000000000000211] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We sought to recognize the working diagnostic criteria for differentiated vulvar intraepithelial neoplasia (dVIN) among expert pathologists in the field. We also sought the frequency of definitive diagnosis, terminology of equivocal lesions, and views on dVIN's biological significance. METHODS Respondents ranked 26 histological and 8 ancillary studies and 5 clinical findings as "essential," "nonessential but strongly supports diagnosis," "possibly supports diagnosis," "weighs against diagnosis" or "uncertain significance or noncontributory." Consensus was defined as 75% agreement. They were asked about diagnosing dVIN on partially sampled lesions, terminology for uncertain lesions, frequency of diagnosis of dVIN relative to uncertain lesions, and if dVIN a is a precursor to an invasion. RESULTS Twenty-three completed the survey. Only "basal layer atypia" met consensus (86%) as essential. Consensus criteria for being at least strongly supportive of dVIN were "basal layer hyperchromasia," "presence of basal layer mitoses," and "large keratinocytes with abundant eosinophilic cytoplasm." Only "block-like positivity with p16" or positive HPV specific studies weighed against the diagnosis by consensus. Approximately 87% diagnosed dVIN on partially sampled lesions. Squamous cell hyperplasia with atypia was the most frequent terminology used for uncertain lesions; 87% felt dVIN is a precursor to invasion. CONCLUSIONS Only basal layer atypia was considered diagnostically essential by consensus. Additional criteria that strongly support the diagnosis include changes affecting the basal layer and abundant eosinophilic keratinocytic cytoplasm. There was no consensus on ancillary study findings to confirm dVIN. Most would diagnose dVIN on a partial sample. Most consider dVIN a precursor to invasion.
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Yap JKW, O'Neill D, Nagenthiran S, Dawson CW, Luesley DM. Current insights into the aetiology, pathobiology, and management of local disease recurrence in squamous cell carcinoma of the vulva. BJOG 2017; 124:946-954. [PMID: 28081287 DOI: 10.1111/1471-0528.14560] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2016] [Indexed: 01/04/2023]
Affiliation(s)
- JKW Yap
- Institute of Cancer and Genomic Sciences; College of Dental and Medical School; University of Birmingham; Edgbaston UK
- Department of Obstetrics and Gynaecology; Birmingham City Hospital; Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
| | - D O'Neill
- Department of Obstetrics and Gynaecology; Birmingham City Hospital; Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
| | - S Nagenthiran
- Department of Obstetrics and Gynaecology; Birmingham City Hospital; Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
| | - CW Dawson
- Institute of Cancer and Genomic Sciences; College of Dental and Medical School; University of Birmingham; Edgbaston UK
| | - DM Luesley
- Institute of Cancer and Genomic Sciences; College of Dental and Medical School; University of Birmingham; Edgbaston UK
- Department of Obstetrics and Gynaecology; Birmingham City Hospital; Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
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The 2015 International Society for the Study of Vulvovaginal Disease (ISSVD) Terminology of Vulvar Squamous Intraepithelial Lesions. Obstet Gynecol 2016; 127:264-8. [PMID: 26942352 DOI: 10.1097/aog.0000000000001285] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The impact of terminology for vulvar intraepithelial lesions has been significant over the years, because it has affected diagnosis, treatment, and research. The introduction of the Lower Anogenital Squamous Terminology (LAST) in 2012 raised 2 concerns in relation to vulvar lesions: firstly, the absence of reference to "differentiated vulvar intraepithelial neoplasia" (differentiated VIN) could lead to its being overlooked by health care providers, despite its malignant potential. Secondly, including the term "low-grade squamous intraepithelial lesion" (LSIL) in LAST recreated the potential for overdiagnosis and overtreatment for benign, self-limiting lesions. MATERIALS AND METHODS The International Society for the Study of Vulvovaginal Disease (ISSVD) assigned the terminology committee the task of developing a terminology to take these issues into consideration. The committee reviewed the development of terminology for vulvar SILs with the previous 2 concerns in mind and reviewed several new terminology options. RESULTS The final version accepted by the ISSVD contains the following: 1) Low-grade SIL of the vulva or vulvar LSIL, encompassing flat condyloma or human papillomavirus effect. 2) High-grade SIL or vulvar HSIL (which was termed "vulvar intraepithelial neoplasia usual type" in the 2004 ISSVD terminology). 3) Vulvar intraepithelial neoplasia, differentiated type. CONCLUSION The advantage of the new terminology is that it includes all types of vulvar SILs, it provides a solution to the concerns in relation to the application of LAST to vulvar lesion, and it is in accordance with the World Health Organization classification as well as the LAST, creating unity among clinicians and pathologists.
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Hoang LN, Park KJ, Soslow RA, Murali R. Squamous precursor lesions of the vulva: current classification and diagnostic challenges. Pathology 2016; 48:291-302. [PMID: 27113549 PMCID: PMC5518939 DOI: 10.1016/j.pathol.2016.02.015] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 02/08/2016] [Accepted: 02/12/2016] [Indexed: 01/11/2023]
Abstract
Growing evidence has established two major types of vulvar intraepithelial neoplasia (VIN), which correspond to two distinct oncogenic pathways to vulvar squamous cell carcinoma (VSCC). While the incidence of VSCC has remained relatively stable over the last three decades, the incidence of VIN has increased. VIN of usual type (uVIN) is human papillomavirus (HPV)-driven, affects younger women and is a multicentric disease. In contrast, VIN of differentiated type (dVIN) occurs in post-menopausal women and develops independent of HPV infection. dVIN often arises in a background of lichen sclerosus and chronic inflammatory dermatoses. Although isolated dVIN is significantly less common than uVIN, dVIN bears a greater risk for malignant transformation to VSCC and progresses over a shorter time interval. On histological examination, uVIN displays conspicuous architectural and cytological abnormalities, while the morphological features that characterise dVIN are much more subtle and raise a wide differential diagnosis. On the molecular level, dVIN is characterised by a higher number of somatic mutations, particularly in TP53. Here we review the classification, epidemiology, clinical features, histomorphology, ancillary markers and molecular genetics of both types of VIN, and discuss the morphological challenges faced by pathologists in interpreting these lesions.
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Affiliation(s)
- Lien N Hoang
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kay J Park
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert A Soslow
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rajmohan Murali
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Marie-Josee and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Bradbury M, Cabrera S, García-Jiménez A, Franco-Camps S, Sánchez-Iglesias JL, Díaz-Feijoo B, Pérez-Benavente A, Gil-Moreno A, Centeno-Mediavilla C. Vulvar intraepithelial neoplasia: clinical presentation, management and outcomes in women infected with HIV. AIDS 2016; 30:859-68. [PMID: 26959352 DOI: 10.1097/qad.0000000000000984] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Immunocompromised patients are at increased risk of developing preinvasive lesions of the lower genital tract. There are a limited number of studies on vulvar intraepithelial neoplasia (VIN) in HIV-positive women. We aimed to review the clinical presentation of VIN, management and survival outcomes in this group of patients. DESIGN Observational cohort study. METHODS Data was collected from women diagnosed with VIN at the Hospital Vall d'Hebron between September 1994 and October 2011. The main outcome measures were recurrence-free survival (RFS) and progression-free survival (PFS). Risk factors for recurrence and progression were assessed using univariate and multivariate analyses. RESULTS Thirty-seven out of 107 women were HIV positive (34.6%). The median follow-up time was 32 (range 12-179) months. Compared with the HIV-negative group, HIV-positive women were younger (median age 37 vs. 44 years, P = 0.003) and presented with multifocal and multicentric disease more frequently (63.6 vs. 22.2% and 84.8 vs. 43.3%, respectively, P < 0.0001). RFS and PFS were lower in the HIV-positive group (42.4 vs. 71.4% P = 0.043 and 69.7 vs. 95.2% P = 0.006, respectively). RFS was significantly associated to multicentric and multifocal disease on multivariate analysis. PFS was associated to HIV infection on univariate analysis. CONCLUSION HIV-positive women are at increased risk of developing VIN and frequently present at a younger age with multifocal and multicentric disease. They have shorter RFS and PFS compared with HIV-negative women. Close surveillance of the lower genital tract is mandatory to enable early recognition and treatment of any suspicious lesions. Close follow-up after treatment of VIN is essential to exclude early recurrence or progression.
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The 2015 International Society for the Study of Vulvovaginal Disease (ISSVD) Terminology of Vulvar Squamous Intraepithelial Lesions. J Low Genit Tract Dis 2016; 20:11-4. [DOI: 10.1097/lgt.0000000000000169] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Toby M, Conway K, Sethi G, Lewis F. Usual vulval intraepithelial neoplasia in HIV-positive women - a case series. Int J STD AIDS 2015; 27:1253-1256. [PMID: 26472432 DOI: 10.1177/0956462415611513] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 09/21/2015] [Indexed: 11/16/2022]
Abstract
Usual or undifferentiated type vulval intraepithelial neoplasia (VIN) is more common in young women and is usually associated with high-risk human papillomavirus infection. It is associated with the development of basaloid or warty squamous cell carcinoma. Studies have shown that HIV-positive women have an increased risk of VIN and invasive vulval carcinoma, but there is a paucity of data about this cohort of women. The objective of this study was to describe the clinical features and treatment responses of HIV-positive women diagnosed with VIN in a specialist vulval dermatology clinic. HIV-positive women diagnosed with VIN from 2007 to 2013 were retrospectively identified. Data were collected on demographics, clinical features, treatments and outcomes. Seven cases were retrospectively identified. The median CD4 cell count at presentation was 500 cells/mm3 (range 59-761). Five had multifocal VIN. Five were treated with imiquimod alone, one had surgical excision and one patient was treated with imiquimod and surgery. Five of the seven had complete resolution of disease. HIV-positive patients with VIN had good responses to treatment with imiquimod. They were likely to be stable on combination antiretroviral therapy at presentation, have multifocal disease and concurrent vaginal, anal or cervical intraepithelial neoplasia.
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Affiliation(s)
- M Toby
- Department of Genito-Urinary Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - K Conway
- Department of Genito-Urinary Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - G Sethi
- Department of Genito-Urinary Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - F Lewis
- St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust, London, UK
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Moyal-Barracco M, Wendling J. Vulvar dermatosis. Best Pract Res Clin Obstet Gynaecol 2014; 28:946-58. [PMID: 25132276 DOI: 10.1016/j.bpobgyn.2014.07.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 07/10/2014] [Indexed: 01/09/2023]
Abstract
Vulvar dermatoses are inflammatory conditions responsible for chronic or recurrent itching and soreness. The lesions are either circumscribed to the vulva or associated with extragenital localizations which may help to assess the diagnosis. They should be differentiated from infectious or neoplastic diseases which may have clinical similarities. As opposed to the majority of all dermatoses that have a benign and regular course, lichen sclerosus or lichen planus could exceptionally foster the occurrence of an epithelial cancer precursor which may evolve to squamous cell carcinoma. Topical corticosteroids are the mainstay treatment of vulvar dermatosis. We do not know if the treatment of vulvar lichen sclerosus and vulvar lichen planus prevents squamous cell carcinoma.
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Affiliation(s)
| | - Jeanne Wendling
- Department of Dermatology, Hôpital Tarnier Cochin, 89 rue d'Assas, 75006 Paris, France
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Kaushik S, Pepas L, Nordin A, Bryant A, Dickinson HO, Lawrie TA. Surgical interventions for high-grade vulval intraepithelial neoplasia. Cochrane Database Syst Rev 2014; 2014:CD007928. [PMID: 24596022 PMCID: PMC6457760 DOI: 10.1002/14651858.cd007928.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND This is an updated version of an original Cochrane review published in The Cochrane Library, 2011, Issue 1.Vulval intraepithelial neoplasia (VIN) is a pre-malignant condition of the vulval skin. This uncommon chronic skin condition of the vulva is associated with a high risk of recurrence and the potential to progress to vulval cancer. The condition is complicated by its multicentric and multifocal nature. The incidence of this condition appears to be rising, particularly in the younger age group. There is a lack of consensus on the optimal surgical treatment method. However, the rationale for the surgical treatment of VIN has been to treat the symptoms and exclude any underlying malignancy, with the continued aim of preserving the vulval anatomy and function. Repeated treatments affect local cosmesis and cause psychosexual morbidity, thus impacting he individual's quality of life. OBJECTIVES To evaluate the effectiveness and safety of surgical interventions in women with high-grade VIN. SEARCH METHODS We searched the Cochrane Gynaecological Cancer Group Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 11,2013 and MEDLINE and EMBASE up to December 2013. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies, and contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared surgical interventions in adult women diagnosed with high-grade VIN. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data and assessed risk of bias. MAIN RESULTS We identified one RCT, including 30 women, that met our inclusion criteria; this trial reported data on carbon dioxide (CO2) laser surgery versus cavitational ultrasonic surgical aspiration (CUSA). There were no statistically significant differences in the risks of disease recurrence after one year of follow-up, pain, scarring, dysuria or burning, adhesions, infection, abnormal discharge or eschar between women who underwent CO2 laser surgery and those who received CUSA. The trial lacked statistical power due to the small number of women in each group and the low number of observed events, but was at low risk of bias. AUTHORS' CONCLUSIONS The included trial lacked statistical power due to the small number of women in each group and the low number of observed events. The absence of reliable evidence regarding the effectiveness and safety of the two surgical techniques for the management of VIN therefore precludes any definitive guidance or recommendations for clinical practice.
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Affiliation(s)
- Sonali Kaushik
- Royal Sussex County HospitalDivision of Gynaecological OncologyBrightonUKBN2 5BE
| | - Litha Pepas
- St Bartholomew's HospitalCentre of Reproductive Medicine2nd Floor Kenton and Lucas WingLondonUKEC1A 7BE
| | - Andy Nordin
- Queen Elizabeth The Queen Mother HospitalEast Kent Gynaecological Oncology CentreSt Peters RoadMargateKentUKCT9 4AN
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Heather O Dickinson
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Theresa A Lawrie
- Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupEducation CentreBathUKBA1 3NG
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Reyes MC, Cooper K. An update on vulvar intraepithelial neoplasia: terminology and a practical approach to diagnosis. J Clin Pathol 2014; 67:290-4. [PMID: 24399036 DOI: 10.1136/jclinpath-2013-202117] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
There are two distinct types of vulvar intraepithelial neoplasia (VIN), which differ in their clinical presentation, aetiology, pathogenesis and histological/immunophenotypical features. One form driven by high-risk human papilloma virus infection usually occurs in young women and has been termed classic or usual VIN (uVIN). The other, not related to viral infection, occurs in postmenopausal women with chronic skin conditions such as lichen sclerosus and lichen simplex chronicus and is termed differentiated or simplex-type VIN. The latter is the precursor lesion of the most common type of squamous cell carcinoma (SCC) in the vulva, namely keratinizing SCC (representing 60% of cases). In contrast, uVIN usually gives rise to basaloid or warty SCC (40% of cases). The histological features of uVIN are similar to those of high grade lesions encountered in other lower anogenital tract sites (hyperchomatic nuclei with high nuclear to cytoplasmic ratios and increased mitotic activity). However, differentiated VIN has very subtle histopathological changes and often escapes diagnosis. Since uVIN is driven by high-risk human papilloma virus infections, p16 immunohistochemistry is diffusely positive in these lesions and is characterized with a high Ki-67 proliferation index. In contrast, differentiated or simplex-type VIN is consistently negative for p16 and the majority of the cases harbour TP53 mutations, correlating with p53 positivity by immunohistochemistry.
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Affiliation(s)
- M Carolina Reyes
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, , Philadelphia, Pennsylvania, USA
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Schuurman M, van den Einden L, Massuger L, Kiemeney L, van der Aa M, de Hullu J. Trends in incidence and survival of Dutch women with vulvar squamous cell carcinoma. Eur J Cancer 2013; 49:3872-80. [DOI: 10.1016/j.ejca.2013.08.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 07/10/2013] [Accepted: 08/01/2013] [Indexed: 01/20/2023]
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van den Einden LCG, de Hullu JA, Massuger LFAG, Grefte JMM, Bult P, Wiersma A, van Engen-van Grunsven ACH, Sturm B, Bosch SL, Hollema H, Bulten J. Interobserver variability and the effect of education in the histopathological diagnosis of differentiated vulvar intraepithelial neoplasia. Mod Pathol 2013; 26:874-80. [PMID: 23370772 DOI: 10.1038/modpathol.2012.235] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
No published data concerning intraobserver and interobserver variability in the histopathological diagnosis of differentiated vulvar intraepithelial neoplasia (DVIN) are available, although it is widely accepted to be a subtle and difficult histopathological diagnosis. In this study, the reproducibility of the histopathological diagnosis of DVIN is evaluated. Furthermore, we investigated the possible improvement of the reproducibility after providing guidelines with histological characteristics and tried to identify histological characteristics that are most important in the recognition of DVIN. A total number of 34 hematoxylin and eosin-stained slides were included in this study and were analyzed by six pathologists each with a different level of education. Slides were reviewed before and after studying a guideline with histological characteristics of DVIN. Kappa statistics were used to compare the interobserver variability. Pathologists with a substantial agreement were asked to rank items by usefulness in the recognition of DVIN. The interobserver agreement during the first session varied between 0.08 and 0.54, which slightly increased during the second session toward an agreement between -0.01 and 0.75. Pathologists specialized in gynecopathology reached a substantial agreement (kappa 0.75). The top five of criteria indicated to be the most useful in the diagnosis of DVIN included: atypical mitosis in the basal layer, basal cellular atypia, dyskeratosis, prominent nucleoli and elongation and anastomosis of rete ridges. In conclusion, the histopathological diagnosis of DVIN is difficult, which is expressed by low interobserver agreement. Only in experienced pathologists with training in gynecopathology, kappa values reached a substantial agreement after providing strict guidelines. Therefore, it should be considered that specimens with an unclear diagnosis and/or clinical suspicion for DVIN should be revised by a pathologist specialized in gynecopathology. When adhering to suggested criteria the diagnosis of DVIN can be made easier.
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Affiliation(s)
- Loes C G van den Einden
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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del Pino M, Rodriguez-Carunchio L, Ordi J. Pathways of vulvar intraepithelial neoplasia and squamous cell carcinoma. Histopathology 2012. [DOI: 10.1111/his.12034] [Citation(s) in RCA: 175] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Marta del Pino
- Faculty of Medicine; Institute Clinic of Gynaecology, Obstetrics and Neonatology; Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona; Barcelona; Spain
| | - Leonardo Rodriguez-Carunchio
- Department of Pathology; Faculty of Medicine; CRESIB (Centre de Recerca en Salut Internacional de Barcelona); Hospital Clinic; University of Barcelona; Barcelona; Spain
| | - Jaume Ordi
- Department of Pathology; Faculty of Medicine; CRESIB (Centre de Recerca en Salut Internacional de Barcelona); Hospital Clinic; University of Barcelona; Barcelona; Spain
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Denny L. International perspective on the global advances in gynecologic oncology. Am Soc Clin Oncol Educ Book 2012:330-4. [PMID: 24451758 DOI: 10.14694/edbook_am.2012.32.58] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The treatment of gynecologic cancer has evolved over the years, with greater emphasis on tailored surgery and reducing morbidity and mortality related to surgery, particularly in the management of vulvar and cervical cancer. The addition of concurrent chemotherapy to radiation regimens has improved survival of patients with cervical cancer in developed countries; however, most women with cancer in developing countries have advanced, untreatable disease and minimal access to anticancer therapies. In the past 15 years there has been intense research into alternatives to cervical cytologic testing, particularly in low resourced regions but also in an attempt to improve on cytologic testing in developed countries. Surgical staging in endometrial cancer has enabled the use of adjuvant radiation to be individualized to the patient's particular risk factors for recurrence. The management of ovarian cancer, long stagnant since the introduction of platinum and paclitaxel as chemotherapeutic agents, is set to change with the onset of molecular and genetic profiling and the introduction of novel therapies.
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Affiliation(s)
- Lynette Denny
- From the Department of Obstetrics & Gynaecology, University of Cape Town/Groote Schuur Hospital, Cape Town, South Africa
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Screening and follow up of vulval skin disorders. Best Pract Res Clin Obstet Gynaecol 2011; 26:175-88. [PMID: 22189088 DOI: 10.1016/j.bpobgyn.2011.11.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Accepted: 11/03/2011] [Indexed: 02/06/2023]
Abstract
Vulval squamous cell carcinoma is relatively rare; however, up to 20% of women have significant vulval symptoms during their lifetime. Formal screening programmes for vulval disease have not been established. The evidence for the use of vulval cytology and vulvoscopy is reviewed. No randomised-controlled trials have compared follow-up regimens, and although a few consensus documents have been published, formal guidelines are lacking in Grade A evidence. With increasing pressure on healthcare resources, the possibility of identifying high-risk groups to optimise the use of follow up in specialist clinics is explored. Vulval disease is uncommon and there is no evidence that screening would decrease incidence. If high-risk groups can be identified, follow up should take place in specialised vulval clinics with experienced clinicians who are trained in vulval disease. Women with uncomplicated vulval conditions should be discharged to patient-initiated follow up or primary care. Central to the reduction of mortality and morbidity is increased awareness of vulval conditions among women and improved education of healthcare professionals, with particular understanding of the importance of physical examination.
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Abstract
OBJECTIVE Taking a biopsy is a standard procedure to make the correct diagnosis in patients with suspicious premalignant vulvar lesions. The use of a less invasive diagnostic tool as triage instrument to determine whether biopsy is necessary may improve patient comfort especially in patients with chronic vulvar disorders that may warrant consecutive biopsies. This study was conducted to investigate whether vulvar brush cytology is feasible and may be used to detect (pre)malignant vulvar lesions. METHODS A pilot study was performed with patients having clinically normal vulvar skin, lichen sclerosus (LS), usual or differentiated vulvar intraepithelial neoplasia or squamous cell carcinoma. A total of 65 smears were taken with the use of a vulvar brush and biopsies were performed for histopathological analysis. RESULTS Out of 65 smears, 17 (26%) were discarded because of poor cellularity. A total of 28 of 29 (97%) smears with a histological proven (pre)malignancy had a smear classified as 'suspicious' or 'uncertain'. Cytology classified 11 smears as 'non-suspicious', of which 10 (91%) were indeed normal skin or LS. The accuracy, based on the presence of a lesion, for (pre)malignant lesions with the use of the brush showed a sensitivity of 97% and a negative predictive value of 88%. CONCLUSION Vulvar brush cytology is feasible and may be a first step in the development of a triage instrument to determine whether subsequent biopsy of a clinically (pre)malignant lesion is necessary.
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50
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Abstract
Carcinoma of the vulva is an uncommon malignant neoplasm (approximately one-fifth as frequent as cervical cancer) and represents 4% of all genital cancers in women. Approximately two-thirds of cases occur in women older than 60 years, and squamous cell carcinoma is the most common histologic type. Several different subtypes of squamous cell carcinoma have been described in the vulva; however, in terms of etiology, pathogenesis, and histologic features, most carcinomas belong to one of two categories: keratinizing squamous cell carcinomas associated with chronic inflammatory skin disorders, and basaloid or warty carcinomas related to infection with high oncogenic risk human papillomaviruses. Glandular neoplasms of the vulva arise from the vulvar apocrine sweat glands (papillary hidradenoma and Paget disease) or the Bartholin gland and their cause is not known.
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Affiliation(s)
- Edyta C Pirog
- Department of Pathology, Weill Medical College of Cornell University, 525 East 68th Street, ST-1041, New York, NY 10065, USA.
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