The risk of urinary incontinence after partial urethral resection in patients with anterior vulvar cancer.

OBJECTIVE: The number of women with vulvar carcinoma located in the anterior fourchette in immediate proximity to the urethral opening has increased. A retrospective analysis was performed in order to evaluate the risk of urinary incontinence after tumor-resection, standard inguinal lymphadenectomy and additional partial urethral resection. STUDY DESIGN: Between 2002 and 2007, 19 women with vulvar carcinomas located close to the urethral opening and consequently treated by additional partial urethral resection of up to 1.5 cm, were evaluated for urinary loss postoperatively by standard incontinence questionnaire. All patients complaining about some kind of urinary loss underwent urodynamic measurement. Results were compared with 21 controls (women with anterior vulvar cancer treated without urethral resection). RESULTS: Five of 19 women (26%) of the study group complained about urinary disturbances and received urodynamic evaluation. Ninety-five percent of the patients (18/19 women) were continent by urodynamic criteria; in one woman the measurement was unreliable. One patient in the control group (1/21 women) complained of an increase of urge symptoms that had been present preoperatively. CONCLUSIONS: Twenty-six percent of our patients after partial urethral resection reported incontinence symptoms, though this was not always confirmed by urodynamics. We conclude that the risk of urinary stress incontinence after partial urethral resection in anterior vulvar carcinoma is acceptable.

Single large inguinal lymph node metastasis in human papillomavirus-induced early invasive vulvar cancer of the anterior fourchette in two young women.

The incidence of human papillomavirus (HPV)-induced vulvar cancer in young women is increasing and often presents as microinvasive or early invasive tumors in a grade 3 vulvar intraepithelial neoplasia. So far, the risk of lymph node metastases in early invasive vulvar carcinoma (depth of invasion 1.1-2.0 mm) is reported to be less than 8%. We present 2 cases of young women with early invasive vulvar cancers (depth of invasion 1.5 and 2.0 mm) induced by HPV 16 and 42. In both cases, the cancers are located between the clitoris and urethra and are each accompanied by one groin macro-metastatic lymph node. This case report highlights the necessity for complete inguinofemoral lymphadenectomy and/or adequate radiation therapy of the groin in early invasive tumors in young women to prevent cancer recurrence in the groin. Additionally, the indication for a sentinel node procedure in these specific cases requires particular caution.

Comprehensive analysis of 130 multicentric intraepithelial female lower genital tract lesions by HPV typing and p16 expression profile.

PURPOSE: HPV associated cervical transformation is characterized by well-defined steps, including persistent HPV infection and deregulated oncogene expression. Recent studies have suggested that a number of lower genital tract lesions are clonally related to cervical lesions. In the current study, HPV infections and oncogene expression were assessed in a large series of patients with multicentric lower genital tract disease to analyze the transformation steps in extracervical disease. METHODS: One hundred and thirty biopsies of 52 women treated for multicentric synchronous or metachronous lower genital tract intraepithelial neoplasias were collected. Up to seven multicentric specimens taken from one patient were studied with a maximum follow up of 20 years. HPV typing and p16(ink4a) immunostaining was performed. RESULTS: HPV DNA was present in 121 of 130 specimens (93%). HPV16 was frequently found in VIN, VaIN and AIN (73, 60 and 77%, respectively), whereas only 37% of CIN were HPV16 positive. Infections with identical HPV types in multicentric lesions were diagnosed in 46% of the HPV positive patients. p16INK4a expression was negative in the nine HPV negative lesions whereas about 90% of the high grade lesions showed diffuse p16 staining. CONCLUSION: Our findings indicate that multicentric lower genital tract disease evolves through different pathways. Some cases were related to a high susceptibility towards HPV infections, while others exhibited features of clonal propagation of transformed cervical cell clones. The clinical management of the latter group is particularly challenging, because malignant cell clones can persist over a long time course.

Effect of human papillomavirus vaccines on vulvar, vaginal, and anal intraepithelial lesions and vulvar cancer.

OBJECTIVE: Human papillomavirus (HPV) is a necessary cause for cervical cancer, and it has been associated with vulvar and vaginal cancer and vulvar (VIN) and vaginal (VaIN) and anal (AIN) intraepithelial neoplasia. We assessed the prevalence of HPV (and the types) to estimate the possible effect of a HPV vaccine on lower genital tract disease prevention. METHODS: Two hundred fifty-eight samples of VIN, VaIN, AIN, and vulvar cancer from 241 women were included in the study. The diagnosis of surgical samples was made using published histomorphologic criteria. The DNA was extracted for HPV detection and typed using polymerase chain reaction and sequencing. RESULTS: The analyses were performed on 210 intraepithelial neoplasia samples (VIN2/3, VaIN2/3, AIN2/3) and 48 vulvar carcinoma samples. Human papillomavirus DNA was detected in 92%, 91%, 89%, and 60% of the VIN, VaIN, AIN, and vulvar carcinoma samples, respectively. High-risk HPV types 16 or 18 were detected in 76%, 64%, 81%, and 42% of the VIN2/3, VaIN2/3, AIN, and vulvar carcinoma samples. Women with HPV-positive samples were younger than those with HPV-negative samples (46 years compared with 55 years and 51 years compared with 61 years, for the VIN2/3 and vulvar carcinoma samples, respectively). Human papillomavirus-positive vulvar carcinoma was more frequent in women aged younger than 56 years (77%), than in those aged 56 years or older (41%). CONCLUSION: Based on the data obtained in this study, widely-implemented prophylactic HPV vaccination could make an important contribution to the reduction of the risk for cervical cancer and could also prevent about half the vulvar carcinomas in younger women and about two thirds of the intraepithelial lesions in the lower genital tract. LEVEL OF EVIDENCE: II-3.

A case of a pT3, HPV 52-positive vulvar carcinoma in an 18-year-old woman.

BACKGROUND: Vulvar carcinoma in young women is rare; so far, no case of an 18-year-old woman has been described. Here, we report a case with a T3 HPV 52-induced tumor 3 years after primary HPV contamination. CASE: An 18-year-old woman without risk factors complaining of dysuria and vulvar pain was treated several months for fungal infection before referred and diagnosed with a vulvar carcinoma located between clitoris and urethra. She underwent operation with partial urethral resection and external radiation. The tumor tested positive for HPV type 52, the time between primary sexual contact and tumor development was less than 3 years. CONCLUSION: Also in very young women, an ulcer and vulvar pain have to be biopsied to exclude malignancy despite an unusual short time interval between possible HPV contamination and symptoms.