Carcinoma of the vulva.

Carcinoma of the vulva often presents as a large ulcerating or fungating tumor with considerable destruction of the vulva and surrounding tissues. The area usually is very painful and foul smelling. Most such tumors are of the squamous-cell variety. Despite the degree of histologic differentiation, the lymph nodes are involved in more than 50% of the cases. The best therapeutic results are obtained with radical vulvectomy and groin node dissection "en bloc." Occasionally treatment should be modified in the geriatric patient because of associated medical problems. Various techniques are discussed. Since the disease is rare, best results are achieved by referral to a specialized treatment center.

Understanding the colposcope. Optics, light path, magnification, and field of view.

The colposcope, basically binoculars on a stand, is used for the evaluation of the genital tract. Its optics, although complicated in theory, are easy to use in practice. Certain adjustments are necessary for stereoscopic viewing. Other adjustments adapt the optics for high viewing and either adapt the optics for high magnification study of disease features or low magnification for seeing the entire surgical field during treatment.

Colposcopy of intraepithelial neoplasia of the vulva and adjacent sites.

The colposcopic appearances of VIN III differ on the vulva and adjacent sites according to the anatomic sites. Lesions on the hairy skin appear more well defined than lesions on nonhairy areas. VIN III histologically can extend into underlying adnexal structures. Most frequently, it is the hair follicles in which it may extend deeply. This involvement is not identified by colposcopic methods. A variety of colposcopic mimics or "look-alike" lesions occur on the vulvar skin. Therefore the performance of a biopsy is required to establish the diagnosis.

Colposcopy of adenocarcinoma in situ and invasive adenocarcinoma of the cervix.

Colposcopy is most useful in evaluating squamous lesions of the lower genital tract. Its usefulness in evaluating glandular abnormalities of the uterine cervix now are limited. There are abnormal features in invasive adenocarcinoma of the cervix that allow the colposcopist to make that diagnosis with directed punch biopsies. The biopsy specimens should be large enough to allow the pathologist to make the diagnosis of invasion. At the present time, the colposcopic features of adenocarcinoma in situ are not well recognized. It must be stressed that where adenocarcinoma in situ is suspected colposcopically or by cytology, the definitive diagnostic procedure remains cone biopsy.

Cyto-histological correlates in a colposcopic clinic: a 1-year prospective study.

As part of the Quality Assurance Program, all surgical pathology reports of cervical colposcopic biopsies, cone biopsies, and hysterectomy specimens of 772 consecutive patients were correlated with cytology results for a period of 1 yr. The abnormality in cytology or histology ranged from HPV effect to invasive carcinoma. Cytohistological correlation within one grade of severity was obtained in 662 (86%) cases. On formal review of the remaining 110 (14%) cases, sampling error occurred in 75 cytology smears and in 21 colposcopic biopsies. Screening and interpretation error occurred in 10 smears and four biopsies. In this study the sensitivity of cervical cytology in detecting epithelial abnormalities was 90%, with a positive predictive value of 99.7%. The false-negative rate of cytology was 11% and the false-positive rate 0.26%. The majority (90%) of false negatives were due to sampling error; the rest were due to laboratory error. The sensitivity of colposcopic biopsy was 97% with a positive predictive value of 99.4%. The false-negative rate of biopsy was 2.7% and the false-positive rate 0.5%. Endocervical cells were seen in 48% (370) of smears and absent in 52% (402). However, in both instances the detection rate of squamous abnormality was 90%. Also 43% (33) of smears that showed endocervical cells failed to contain the abnormal cells. Endocervical curettage or cone biopsy in 16 of these 33 cases clearly showed a small CIN-III lesion high in the endocervical canal. We believe that the value of endocervical cells as an indicator of adequacy is questionable.(ABSTRACT TRUNCATED AT 250 WORDS)

Atypical squamous cells of undetermined significance: A cytohistological study in a colposcopy clinic.

Cytohistologic correlation was performed by 3 observers on 100 atypical squamous cells of undetermined significance (ASCUS) cases from a colposcopy clinic. Our objectives were to: 1) subclassify ASCUS cases and determine their clinical significance; 2) assess the independent predictive value of different cytologic parameters for biopsy-proven dysplasia (BPD); and 3) calculate interobserver variability. The prevalence of BPD was 73% in the ASCUS favor dysplasia (AFD) group, and 27% in the ASCUS favor reactive (AFR) group (P 0.001). The sensitivity of cervical cytology (AFD) for detecting BPD was 88.5%. Using multiple logistic regression, only nuclear membrane irregularity was found to be independently predictive of BPD (P 0.0001). The interobserver agreement (kappa) was 0.41. Colposcopic smears were inferior to referring smears in detecting dysplasia, with 67% of patients having a referring diagnosis of dysplasia. In a colposcopy clinic population there is a high prevalence (73%) of BPD in the AFD group. Attention should be paid to nuclear membrane irregularity in the risk stratification of ASCUS cases. Diagn. Cytopathol. 1999;21:211-216.

When to suspect squamous cancer at colposcopy.

Advanced practice nurses are increasingly using colposcopy to investigate abnormal cervical cytology. Specific colposcopic features can lead the clinician to suspect squamous cancer. This article discusses vascular pattern study, examination evaluation, lesion grading, and correlating colposcopy with histology and cytology to aid in identifying squamous cancer.

Cervical intraepithelial neoplasia: new developments in diagnosis and treatment.

Cervical dysplasia appears to be a precursor of frank invasive cancer; the same epidemiological factors probably apply in cervical intraepithelial neoplasia. This article describes the tissue at risk and how it can be evaluated, treated and followed up using the colposcope.

Carcinoma in situ of the cervix.

Carcinoma in situ is not always cured (even though it could be) because of errors in morphological diagnosis and inadequate operative techniques. In the past we have been conditioned to accept the tissue biopsy diagnosis in preference to the cytological diagnosis. In many cases positive exfoliative cytology has not been explained by tissue biopsy, mainly because the technique of tissue sampling has been inadequate. Insufficient operative techniques have failed to remove sufficient vaginal vault adjacent to the cervix. Failure to recognize that these early lesions may spread to the vaginal vault has resulted in a recurrence to the vaginal apex, either as a carcinoma in situ or an early invasive carcinoma. Because of the multicentricity of carcinoma in situ, cancerization of the entire female genital tract may occur. It is therefore mandatory that all patients be followed up with cytology after any method of management.

Carbon dioxide laser surgery for cervical intraepithelial neoplasia.

During 1977-1983, 787 consecutive referred cases of CIN were treated by vaporization of a dome-shaped defect, by excision of a cylindrical specimen, or a combination of procedures where 48% were CIN III. Vaporization was used for 72% of CIN I, 76% of CIN II, and 64% of CIN III cases. Less than 15% of vaporization and all excision cases were done in hospital under anesthesia; 11% had delayed bleeding requiring attention (admission was required in 2%); 100% of CIN I, 96% of CIN II, and 96% of CIN III cases were cured. Persistent disease was diagnosed at the first (96%) or second (4%) visit. Subsequent treatment included laser and less than 1% hysterectomy. Overall cure for laser surgery was 99.5%. Sixty-eight patients subsequently became pregnant; outcomes were normally distributed. Treatment success is related to adequate volume of tissue removed.

Laser surgery: using the carbon dioxide laser.

In 1917 Einstein theorized tha through an atomic process a unique kind of electromagnetic radiation could be produced by stimulated emission. When such radiation is in the optical or infrared spectrum it is termed laser (light amplification by stimulated emission of radiation) light. A laser, a high-intensity light source, emits a nearly parallel electromagnetic beam of energy at a given wavelength that can be captured by a lens and concentrated in the focal spot. The wavelength determines how the laser will be used. The carbon dioxide laser is now successfully employed for some surgical procedures in gynecology, otorhinolaryngology, neurosurgery, and plastic and general surgery. The CO2 laser beam is directed through the viewing system of an operating microscope or through a hand-held laser component. Its basic action in tissue is thermal vaporization; it causes minimal damage to adjacent tissues. Surgeons require special training in the basic methods and techniques of laser surgery, as well as in the safety standards that must be observed.

Colposcopy of adenocarcinoma in situ and adenocarcinoma of the uterine cervix: differentiation from other cervical lesions.

Colposcopic features of cervical adenocarcinoma in situ (AIS) and adenocarcinoma exist, and colposcopists can learn to recognize them. This ability will increase the colposcopic discovery rate for these lesions and can lead to appropriate management in early stages. An excisional biopsy with negative margins is required to differentiate between in situ and invasive disease. The general categories of revealing features are surface patterns and blood vessels. Surface patterns indicative of AIS and adenocarcinoma are (1) lesions overlying columnar epithelium not contiguous with the squamocolumnar border; (2) lesions with large "gland"/cleft openings; (3) papillary lesions; (4) lesion exhibiting epithelial budding; and (5) variegated red and white lesions. Blood vessels indicative of AIS or adenocarcinoma are (1) waste-thread-like vessels; (2) tendril-like vessels; (3) rootlike vessels; (4) character-writing-like vessels; and (5) single and multiple dotlike formations in tips of papillary excrescences. Some of these characteristics also are apparent when other disease processes are present, but an observant colposcopist can differentiate lesions using inclusionary and exclusionary criteria.

Evaluating the cervix.

The colposcope is a stereoscopic microscope mounted on a tripod and is capable of magnifying the cervix ten to 45 times. Differential diagnosis of a diseased cervix is easily obtained through using the colposcope. A diagnosis of epidermization, ectopy, atypical epithelial changes and their extent can be established immediately. Use of colposcopy should diminish the use of tissue biopsy for benign cervical lesions and will modify the treatment of cervical dysplasia and carcinoma in situ by preserving the uterus in many cases.

Evaluating abnormal pap smears.

The colposcope is a low-powered microscope with built-in illumination which can be used for a close examination of the cervix and vagina, enlarging the area 10-20 times. With this instrument, cervical areas of dysplasia, carcinoma in situ and early invasive cancer are usually visible. As a result the colposcope can be used to direct the actual site for cervical biopsy with great accuracy. The colposcope is also useful in visualizing the vaginal vault to study the possibility of neoplastic changes both before and after surgical treatment for carcinoma of the cervix.

Human papilloma virus infections.

Genital warts are believed to be caused by human papilloma viruses and to be sexually transmitted. The viruses are classified by DNA types, which appear to cause different types of disease. The choice of treatment, and usually its success rate, vary according to the type of disease and its location.