[Comparative study of diagnostic hysteroscopy and transvaginal ultrasonography in patients with abnormal uterine hemorrhage during the peri- and post-menopausal period]. / Studio comparativo tra isteroscopia diagnostica ed ecografia transvaginale in pazienti con sanguinamento uterino anomalo in epoca peri- e postmenopausale.

BACKGROUND: The aim of this study was to determine the diagnostic value of hysteroscopy and transvaginal ultrasonography in patients with abnormal uterine bleeding (AUB) in the peri and postmenopausal period. METHODS: 302 patients with AUB, underwent hysteroscopy and in 86 cases, also a transvaginal ultrasonography before hysteroscopy was performed. Results were compared with the histological diagnosis. RESULTS: The diagnostic accuracy of hysteroscopy was very high in the cases of endometrial carcinoma (sensibility 100%, specificity 99%), and lower in the cases of endometrial hyperplasia (sensibility 69%, specificity 72%) and endometrial atrophy (sensibility 29% and specificity 97%). Sonography proved to be less reliable in the diagnosis of endometrial pathology (carcinoma: sensibility 57%, specificity 100%, hyperplasia: sensibility 62.5% specificity 63%). The results of this study show that sonography may be used as a first choice diagnostic test in the investigation of women with AUB. CONCLUSIONS: Hysteroscopy represent a second diagnostic step for achieving a proper histologic diagnosis.

[Role of radiotherapy in the combined treatment of invasive cancer of the vulva]. / Ruolo della radioterapia nel trattamento integrato del carcinoma invasivo della vulva.

The authors review the literature on the different combinations of radiotherapy with chemotherapy and surgery with the aim of giving a state of art on the role of combined multimodality treatment of invasive vulvar carcinoma. From the data of the recent literature it appears that radiation integrated with surgery and chemotherapy can play an important role in reducing the risk of postoperative locoregional failure in patients with advanced primary or nodal disease and avoiding exenteration in patients with disease involving the anus or proximal urethra. This integrated multimodality therapy is a promising approach in the treatment of invasive vulvar carcinoma but further exploration in a larger number of patients is needed before giving consolidated data applicable in routine oncological clinical practice.

[Terminology and classification problems in relation to vulvar pathology]. / Problematiche classificativo-terminologiche relative alla patologia vulvare.

The aim of this paper is to update the physicians (gynecologists, dermatologists and pathologists) on the evolution of vulvar disease terminologies. In doing that the authors illustrate briefly the fundamental steps which led to present classifications of the International Society for the Study of Vulvar Disease (ISSVD). The classification of "non neoplastic epithelial disorders" together with that of "intraepithelial alterations" are illustrated and compared with the terminologies previously employed. The last ISSVD definition of "superficially invasive carcinoma" of the vulva is also presented and discussed. The authors concluded that even if all these ISSVD classifications represent an important effort for reaching a common language for a better international exchange of different experiences, nevertheless an improvement of these terminologies is still requested.

Membranous hypertrophy of the posterior fourchette as a cause of dyspareunia and vulvodynia.

Twenty-one women were treated surgically for entry dyspareunia and vulvodynia. The ages of the patients ranged from 18 to 39 years (mean, 24.5). Physical examination showed the presence of membranous hypertrophy of the posterior fourchette with consequent stricture of the vaginal introitus in all the patients. Eighty percent of the patients had erythema and tenderness of the vestibule, particularly in the posterior part. The histologic findings were somewhat enigmatic and quite unimpressive, frequently suggestive of chronic nonspecific inflammation; in only two cases were histologic changes suggestive of human papillomavirus infection observed. All the patients underwent excision of the posterior part of the vestibule with vaginal advancement under general anesthesia. Follow-up showed elimination of the symptoms in 19 patients and an improvement in the symptoms in the remaining 2.

Psychological distress in women with nonneoplastic epithelial disorders of the vulva.

The aim of this study was to evaluate psychological distress in 44 women with vulvar squamous cell hyperplasia and 21 with vulvar lichen sclerosus in order to examine the presence of psychological factors in these dermatologic disorders. Two psychometric tests were used to evaluate depressive status and various aspects of anger. No significant depressive status was diagnosed with the former test either in patients with vulvar squamous cell hyperplasia or in patients with vulvar lichen sclerosus. Patients with squamous cell hyperplasia had two components of anger (state and internal anger) that were significantly higher and three components (trait anger, exteriorization and control of anger) significantly lower than did the controls. In patients with lichen sclerosus all the components of anger were within the normal range. These findings suggest that psychological factors may be associated with vulvar conditions, such as squamous cell hyperplasia, and may have some therapeutic implications in cases resistant to standard treatment.

[Current knowledge about the natural history of intraepithelial neoplasms of the vagina]. / Attuali conoscenze sulla storia naturale delle neoplasie intraepiteliali della vagina.

The data on the natural history of vaginal intraepithelial neoplasia (VaIN) available in the literature are scarce and incomplete. As a matter of fact the majority of the Authors report series with a small number of cases, which are predominantly represented by VaIN III and usually already treated. Nevertheless from the review of the literature it seems that VaIN, particularly those of low grade (I-II), tend to show a high rate of spontaneous regression. The lesions are frequently multifocal, associated with papilloma virus (HPV) infection and arising in young women. On the contrary, the VaIN showing a more aggressive behaviour are usually represented by single lesions, arising in older women. Those patients are also frequently immunosuppressed, with a history of preceding genital neoplasia and a previous exposure to radiation and/or chemotherapy.

Biologic behavior of vulvar intraepithelial neoplasia. Histologic and clinical parameters.

The aim of this study was to evaluate the role by which different factors, such as human papillomavirus (HPV) infection, age, dystrophic alterations, focal nature and size of the lesion, influence the biologic behavior of vulvar intraepithelial neoplasia (VIN). Sixty-nine cases of VIN were investigated (28 VIN 1, 9 VIN 2, 32 VIN 3). Follow-up was possible in 58 cases, with a mean of 31 months; no treatment was given to 3 patients, while 55 were treated either medically or surgically. Eighty-four percent of the patients were cured, recurrences were found in 11%, and 5% of the patients showed progression of the disease to carcinoma. The ratio between medical and surgical treatment was the same among the cured, recurred and progressed groups of patients. No differences with regard to focal nature of the lesion, presence of HPV infection or dystrophic alterations were observed between the three groups of patients. Only the mean age was higher in patients who showed progression of the lesion to carcinoma.

Histologic parameters of vulvar invasive carcinoma and lymph node metastases.

We evaluated seven histologic parameters (tumor diameter, histologic grading, depth of stromal invasion, vascular invasion, pattern of invasion, lymphoplasmocytic infiltration and amount of necrosis) of 50 cases of vulvar invasive carcinoma to assess their correlation with groin lymph node metastases. Of 50 patients, 25 had groin lymph node metastases. No lymph node metastasis was found in four cases with depth of invasion < or = 2.0 mm. Among the 31 patients with vascular invasion, 23 (74%) had positive nodes, whereas lymph nodes were metastatic only in two of the 19 patients (10%) without vascular invasion. At univariate analysis, performed with Fisher's exact method, all the parameters considered, except pattern of invasion and amount of necrosis, were significantly associated (P < .05) with lymph node metastases. However, after adjustment by multiple logistic regression for the variables statistically significant at univariate level, only the presence of vascular invasion was significantly associated with nodal involvement and tumor diameter was borderline, whereas the effect of the other variables was almost completely explained by confounding.

[Intra-lesion administration of beta-interferon in the treatment of CIN associated with HPV infection]. / Il beta-interferone intralesionale nel trattamento delle CIN associate ad infezione da HPV.

Thirty-two women with histologically confirmed cervical intraepithelial neoplasia (CIN) associated with human papillomavirus (HPV) infection were treated with intralesional beta-interferon. At 12 months from the end of the treatment, 60% of the patients showed complete regression, histologically assessed, of CIN. Considering separately the different CIN grades, the regression for CIN I was 71%, 64% for CIN II and 45% for CIN III. Side-effects were rather frequent (84%) but they did not require discontinuation of the treatment. On the basis of these data the Authors believe that intralesional beta-interferon, in selected cases, can play a role, as a conservative modality, among the different techniques of CIN therapy.

Deep femoral lymphadenectomy with preservation of the fascia lata. Preliminary report on 42 invasive vulvar carcinomas.

Forty-two patients with primary invasive vulvar carcinoma were treated with radical vulvectomy and deep femoral lymphadenectomy with preservation of the fascia lata and cribriform fascia. The rationale for using this technique was based on anatomic knowledge of the topographic distribution of groin lymph nodes, which was confirmed by the study of 50 cadavers. The preliminary data show that the number of superficial and deep femoral lymph nodes removed from the 42 patients (mean number of nodes, 20; range, 8-32) was similar to the number reported in anatomy books. In addition, the five-year actuarial survival rate, 70%, was comparable to that in the literature. These preliminary results suggest that the surgical technique used in this study is as radical an oncologic procedure as Way's classic groin lymphadenectomy, which consists of removing the fascia lata and cribriform fascia.

Vulvar intraepithelial neoplasia. A clinicopathologic study of 60 cases.

Sixty cases of vulvar intraepithelial neoplasia (VIN) were analyzed clinicopathologically (24 VIN I, 9 VIN II, 27 VIN III). The ages of the patients ranged from 21 to 83 years (mean, 53.7). Colposcopic examinations showed the presence of white areas in 29 cases, red areas in 9, acetowhite areas in 6 and other alterations in 13. One-third of the lesions were multifocal. Pruritus and burning were present in 65% of the cases. Fifty-one percent of the cases showed histologic changes suggestive of human papillomavirus (HPV) infection; the mean age of those patients was significantly lower than that of patients without HPV infection. In 15 cases of VIN, HPV DNA testing was performed with Southern blot hybridization; in three (20%) of those specimens HPV 16 episomal DNA was identified. Epithelial alterations surrounding the areas of VIN were found in 24 cases (40%)-23 squamous cellular hyperplasias and 1 lichen sclerosus. Different types of treatment were performed according to the different grades of VIN: medical therapy, diathermocoagulation, local excision, hemivulvectomy and total vulvectomy. Follow-up was possible in 52 cases, with a mean of 33 months (range, 3-98). Two cases of VIN I showed progression of disease over 12-24 months.