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ESSENTIALS OF DIAGNOSIS

  • History of genital warts.

  • History of prolonged vulvar irritation, with pruritus, local discomfort, or slight bloody discharge.

  • Early lesions may suggest or include non-neoplastic epithelial disorders.

  • Late lesions appear as a mass, an exophytic growth, or a firm, ulcerated area in the vulva (eFigure 18–8).

  • Biopsy is necessary for diagnosis.

eFigure 18–8.

Diffuse, hypertrophic carcinoma in situ of the vulva and perianal skin. A skinning vulvectomy was performed. (Reproduced, with permission, from DeCherney AH, Pernoll ML [editors]. Current Obstetrics & Gynecology Diagnosis & Treatment, 8th ed. Originally published by Appleton & Lange. Copyright © 1994 by The McGraw-Hill Companies, Inc.)

GENERAL CONSIDERATIONS

The majority of cancers of the vulva are squamous lesions that classically have occurred in women over 50 years of age. Several subtypes (particularly 16, 18, and 31) of HPV have been identified in some but not all vulvar cancers. About 70–90% of vulvar intraepithelial neoplasia (VIN) and 40–60% of vulvar cancers are HPV associated. As with squamous cell lesions of the cervix, a grading system of VIN from mild dysplasia to carcinoma in situ is used.

DIFFERENTIAL DIAGNOSIS

Benign vulvar disorders that must be excluded in the diagnosis of carcinoma of the vulva include chronic granulomatous lesions (eg, lymphogranuloma venereum, syphilis), condylomas, hidradenoma, or neurofibroma (eFigure 18–9). Lichen sclerosus and other associated leukoplakic changes in the skin should be biopsied. The likelihood that a superimposed vulvar cancer will develop in a woman with a non-neoplastic epithelial disorder (vulvar dystrophy) is 1–5%.

eFigure 18–9.

Lymphogranuloma venereum. Note involvement of perineum and spread over buttocks. (Reproduced, with permission, from DeCherney AH, Pernoll ML [editors]. Current Obstetrics & Gynecology Diagnosis & Treatment, 8th ed. Originally published by Appleton & Lange. Copyright © 1994 by The McGraw-Hill Companies, Inc.)

DIAGNOSIS

Biopsy is essential for the diagnosis of VIN and vulvar cancer and should be performed with any localized atypical vulvar lesion, including white patches. Multiple skin-punch specimens can be taken in the office under local anesthesia, with care to include tissue from the edges of each lesion sampled. Colposcopy of vulva, vagina, and cervix can help in identifying areas for biopsy and in planning further treatment.

STAGING

Vulvar cancer generally spreads by direct extension into the vagina, urethra, perineum, and anus, with discontinuous spread into the inguinal and femoral lymph nodes. CT or MRI of the pelvis or abdomen is generally not required except in advanced cases for planning therapeutic options.

TREATMENT

A. General Measures

Early diagnosis and treatment of irritative or other predisposing causes, such as lichen sclerosis and VIN, should ...

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