CO2 laser colposcopic guided surgery for the see and treat management of VHSIL: a preliminary experience.

The purpose of this study is to evaluate the efficiency of CO2 laser colposcopic guided surgery performed in an outpatient see and treat setting in the management of VHSIL. Women with a suspected diagnosis of VHSIL and no vulvoscopic suspicion of vSCC were enrolled. An electronic register of CO2 laser treatment was created where description of performing parameters (excision or ablation) was specified and personal history was recorded. Statistical analysis was performed by Fisher's exact test. Relative risks (RR) of risk factor were calculated and expressed in odds. From September 2014 to September 2018, we enrolled a total of 63 patients who underwent CO2 laser procedure and had a minimum follow-up time of 2 years at Careggi University Hospital in Florence. Forty-eight (76.2%) patients underwent laser excision and 15 (23.8%) patients underwent ablative treatment without histological results. Undertreatment was performed in 3 cases (6.3%) with definitive histology of vSCC. Therapeutical appropriateness of CO2 laser excision was reached in 85.4% of the cases (41/48). No volunteer loss to follow-up was registered; thus, fidelity to treatment was assess at 100%. Recurrence rate within 2 years attested in 8/60 followed patients (13.3%). No personal factor was found to influence the VHSIL course. CO2 laser excision may represent an excellent therapeutic option to VHSIL because it provides adequate oncological purpose with good cosmetic and functional results and high patients' loyalty to treatment. An expert team could allow to undergo patients with VHSIL suspicion to unique diagnostic and therapeutic procedure with significant benefits.

Vulvar melanoma: a 33 years single Italian center experience.

AIM: Vulvar melanoma is a rare disease with a poor prognosis. The purpose of this study was to report our experience on vulvar melanoma. METHODS: This is a retrospective study on patients with primary melanoma of the vulva admitted to our hospital during the last 33 years. Clinical characteristics, surgical therapy and follow-up are reported. Patients were classified following the 2009 edition of the melanoma staging system. RESULTS: The predominant symptom was pain; five patients reported ulceration and one patient presented bleeding from the vulvar lesions. The average age at diagnosis was 61.4 years. Surgical treatment was performed: radical vulvectomy in five cases, emivulvectomy in three cases, large regional excision in one case. Average time to follow-up was 50.2 months. In four cases (44.4%), regional recurrence occurred and the patients died as a result of the tumor; one patient died of other causes; four patients were still alive at the time of the study. CONCLUSION: Current treatment protocols have moved towards less aggressive treatment in view of the current available evidence. Sentinel lymph node biopsy and adjuvant therapy are still under debate. Our study confirms the overall poor prognosis for vulvar melanoma.

Squamous cell carcinoma arising in vulval lichen sclerosus: a longitudinal cohort study.

Histological changes of lichen sclerosus (LS)--a chronic inflammatory disease--are frequently found in association with squamous cell carcinoma (SCC) of the vulva, suggesting that women with this disorder are at increased risk. However, follow-up studies have been less convincing, showing that the vast majority of these patients do not go on to develop cancer. In this study, a series of 211 women affected by histologically demonstrated vulval LS were treated with topical therapy (testosterone, clobetasol) and followed prospectively by repetitive vulval examination. Three patients developed SCC of the vulva (two invasive, one in situ) at the sites affected by LS during an average follow-up period of 1 year and 8 months. Compared with the reference population, the number of cases of invasive SCC detected significantly exceeded the number estimated to occur in a comparable age-matched group. The standardized incidence rate of vulval SCC in the LS cohort was 317 (95% CI 35.7-1146.2). Cumulative risk was 14.8% (0.06% in the general female population), with a relative risk of 246.6. In conclusion, these data support the view that LS is a precursor of SCC, although characterized by slight tendency to evolve to carcinoma. Medical treatment of LS, although useful in the control of severity of disease, did not seem to be able to prevent the evolution to malignancy.

Idiopathic vulvodynia. Clinical evaluation of the pain threshold with acetic acid solutions.

Idiopathic vulvodynia is vulvar discomfort in which a diagnosis has not yet been established. As in other idiopathic pain syndromes, the involvement of primary afferent fibers (PAFs) has been postulated as playing a role in the pathogenesis and maintenance of idiopathic vulvodynia. Capsaicin induces the release of substance P (SP) by PAFs, producing vasodilation and increasing vascular permeability (neurogenic inflammation). Likewise, it has been shown that acid solutions can stimulate PAFs with the release of SP. To evaluate the pain threshold in women with idiopathic vulvodynia, 10 patients with vulvar pain but without significant vulvar physical changes and 10 asymptomatic controls received topically applied acetic acid solutions with increasing hydrogenionic concentrations (pH 3, 2.5, 2, 1.5, 1.2). Results related to pain threshold and pain time monitoring and intensity were analyzed with Fisher's exact and Wilcoxon's tests, respectively. Our data suggest that in idiopathic vulvodynia the pain threshold for acid solutions is decreased, probably in relation to increased sensitivity of PAFs involved in the transduction of painful signals.

Testosterone maintenance therapy. Effects on vulvar lichen sclerosus treated with clobetasol propionate.

OBJECTIVE: To evaluate the possible effects of topical testosterone as maintenance therapy after clobetasol propionate treatment. STUDY DESIGN: Thirty-two patients with biopsy-proven vulvar lichen sclerosus (LS), after 24 weeks of treatment with 0.05% clobetasol propionate cream, were randomly distributed into two groups of 16 each and treated for a further length of time (24 weeks) with testosterone 2% ointment or a cream-based preparation (placebo). The patients were examined before and after treatment for symptoms, gross aspects and histologic features. RESULTS: With clobetasol propionate all patients had a marked improvement (P < .001) in both clinical and histologic parameters. After clobetasol propionate therapy, the 16 testosterone-treated patients had significant worsening of their symptoms (P < .05%) and no evident changes in gross aspects (P = NS). The placebo-treated group had good symptomatic control of their disease, with no significant changes in symptoms or gross aspects (P = NS). CONCLUSION: After the good results obtained with clobetasol propionate, treatment with testosterone appeared to have a negative effect, while a regularly provided emollient cream was useful in symptom control.

[Principles of the clinical evaluation of the vulvar region]. / Principi di valutazione clinica della regione vulvare.

The clinical examination of the vulva, using an articulated method, should form part of the routine gynecological examination thus enabling both the correct diagnosis and treatment of numerous alterations and the prevention and early diagnosis of VIN and invasive neoplasias. A correct evaluation should include basic anamnestic data, a list of symptoms localised in the vulva region, a careful inspection and palpation. The successive aim is to identify the main clinical aspects of the lesion which can be summarized as changes of colour, presence of swellings on surface and loss of substance. The critical evaluation of lesions should allow critical evaluation of lesions should allow the gynecologist to formulate a diagnosis to propose to the pathologist. In this way the collaboration between clinician and pathologist can contribute to progress in the diagnosis and treatment of vulvar diseases.