Lectures on vulvar dystrophy and epithelial cancer

2021-03-21 12:00 AM

The prevalence of carcinoma in the vulva is increasing and gradually tends to be detected in young women, especially of childbearing age.

In the ancient literature, there are three clinical pictures used to indicate cancer in the epithelium are described: Bovven's disease, Queyrat erythema and pure carcinoma. This clinical description is based on the outward appearance, but the cytology and clinical attitude are the same. To avoid clinical confusion, the international association of vulvar diseases has grouped these three diseases into a common term, vulva intraepithelial neoplasia (VIN). Diagnosis of vulvar in the epithelium is based mainly on cytology, which is the loss of epithelial structure, the emergence of polynuclear, keratinized, nuclear-multiplying cells, and these cells. individual horns. Based on the spread of abnormal cells over the entire thickness of the epithelium, it is divided into three subgroups:

Mild dysplasia: VIN I.

Moderate dysplasia: VIN II.

Severe dysplasia: VIN III.

Age and disease incidence

The rate of local carcinoma of the vulva is increasing and gradually tends to be detected in young women, especially of the childbearing age. Approximately 75% of the lesions are found in menopausal women. The average age of women with cancer in the vulvar tissue is about 40 years old, with a significant number in the incubation period of 20-39 years.

Epidemiology and related pathological factors

It is believed that the increased incidence of vulvar epithelial cancer in young women is due to the spread of sexually transmitted diseases such as herpes virus, genital warts virus, Chalmydia virus and viruses. other porters.

Vaginal dystrophy

Clinical clinic:

White lesions of the vulva with or without a uterus include different types of vulvar dystrophy.

Lichen fibrosis.

Spiny epithelial hyperplasia.

And other types of skin conditions.

clinically, thin, white or pinkish-pink lichen keratinized lesions: thick hyperplastic dystrophy, white or gray patches; On the cytological side, both of these lesions have inflammatory infiltrations. Lichen cultivates fibrosis layer thin tissue lost wrinkles, dermis layer is currently not uniformly cell. Fibrotic lichen rarely even never turns into a carcinoma. Hyperplastic dystrophy: hyperkeratosis and hyperplasia (deep and thickened pigment cells).

Relationship with vulvar dystrophy - VIN :

It is worth noting that there is a close relationship between vulvar dystrophy and vulvar dysplasia. With chronic dystrophy (white spots in the literature), the risk of developing carcinoma in the epithelium and invasive cancer ranges from 1.4-5% and increases to 10% when the epithelium. pattern with atypical imaging. However, patients with cancer in place, having 50% garlic have obvious vulvar dystrophy.

Treatment of vulvar dystrophy :

Fibrosis Lichen:

Surgery is contraindicated because it can cause bad scarring. Testosterone propionate 2% in white kerosene agar lOOmg applied twice a day for 8 weeks. Throughout life, maintenance therapy is required to ensure stable control of the disease. It is possible during treatment to develop side effects such as increased libido, enlarged clitoris and some other androgen effects. Children and older women do not tolerate the side effects of testosterone and some women do not accept testosterone treatment, for these people should be treated with progesterone 400mg in oil, applied twice a day. , period 4-6 weeks.

Hyperplasia dystrophy:

(1) Topical corticosteroid therapy.

This method is considered the first step of treatment. If the patient has severe itching, add Eurax to the corticoid to increase its anti-itch properties. Fiedrich offered a mixture of 7 parts of valerate methasone cream mixed with three parts eurax applied twice daily for 4 weeks. This treatment should not be prolonged.

(2) Surgical removal of the affected area.

Should not apply. Within 10 years, Haluck Caglar performed vulvectomy but only filtered out the thickness of the skin layer on 3 patients, treated with C02 laser on 2 patients and merely cut the vulva in 1 patient for the reason. topical treatment did not work, discomfort worsens in advanced vaginal dystrophy patients. For 3 patients who were treated with skin-filtering vulvectomy and 2 patients who received laser therapy, they had a relapse. However, the recurrent lesions are not as severe as the initial damage and the condition can be easily controlled by steroid therapy.

Combined dystrophy:

When lichen fibrosis lesions and hyperplastic dystrophy occur concurrently. Fiedrich recommends steroid therapy for 6 weeks until hyperplastic dystrophy subsides, followed by testosterone therapy, followed by alternating steroid and testosterone preparations.

Genital warts virus infection

This virus exists everywhere in nature because of its proliferative properties on the surface of the epithelium and mucous membranes

Potential evil :

Most genital warts viruses cause benign lesions such as skin warts or genital warts. Since the late 1970s, the incidence of genital warts has increased at an alarming rate. Several groups of genital warts viruses cause cancer and there are valuable evidence of this virus on the cervix, vagina, and vulva. Chicken genital warts virus group 6.11 causes vaginal dysplasia, virus groups 16, 18 and 31 cause pre-invasive cancer and vulvar infection.

Treatment :

The active and effective treatment of genital warts is the central issue. Various treatments have been offered, but with limited success, topical medications such as podophyllin, trichloro- acetic acid, bleomycin, 5 fluorouracil, and dinitrochlorobenzene are used. Other methods are offered such as surgery, cryotherapy, heat burning and immunotherapy; treatment with interferon is still in the exploration phase. C02 laser treatment can cure 82% the first time and 96% cure with continued use of laser treatment for relapses.

Lesions to vulvar granulomatosis and other venereal diseases

13% of patients with local vulvar cancer have a history of syphilis. Only a very small number of vulvar cancers in situ are associated with group 2 herpes alone.

History of other urogenital cancer

12% of patients have a history of pre-invasive genital cancer beyond the vulva, 12% have a history of genital and ectopic carcinoma.

Treatment of drugs that cause long-term immunosuppressants such as corticosteroids, anti-cancer chemicals increase the rate of VIN.

Clinical manifestations of cancer in the epithelium

White stain

The most common clinical is white spots (65%). White spot can be a manifestation of vulvar dystrophy, carcinoma in subtypical carcinoma of invasive carcinoma. In the past, some clinicians also considered white stains as a sign of vulvar carcinoma. White spot, however, is only a thickening of the keratinized layer on the epithelium caused by any nonspecific stimulus. The increase in the outer layer of keratinization will mask the blood vessels in the subcutaneous layer. Thick white wounds can be a manifestation of cancer in the epithelium, or even an invasive cancer, but sometimes it is only a sign of an inflammatory response to a skin disease. Cancers in the epithelium can manifest as white raised streaks and sometimes alternate pigmentation.

Itching

Itching is also a common symptom, accounting for up to 50% of cancer patients in the vulvar tissue, lasting from a few months to 10 years. A small number of patients present with pain and secretion of the perineal region without itching.

Diagnosis of vulvar precancerous cancer

Look

Suspected lesions of the vulva may be white, red, or pigmented.

cell study

Of limited value because the abnormal lesions in the epithelium are hidden under the upper keratinized layer, moreover it is difficult for cytology to differentiate between epithelial and invasive cancers. However, using wet cotton to get specimens in the correct position showed that 57% of precancerous lesions and 77% of cancer lesions had severe keratinization.

Apply toluidin green

This substance will cause aluminum in the nucleus of active nucleus cells in areas of vulvar skin ulcers, infections, malignant lesions. The vulvar skin is smeared with 1% toluidine blue, after 2 minutes wiping with 1% acetic acid, areas of abnormal skin will turn blue, normal skin areas will not. Dark green catch skin that shows abnormal organization that requires biopsy. False positive test is due to benign lesions or secondary infection, false negative when the lesions are hyperkeratosis so only a small amount of dye is absorbed.

Magnification of the colposcope

Helps detect small, undetectable lesions with the naked eye. The limitation of magnification is that the vulvar skin vessels cannot be detected with cancer in the epithelium, except in the case of the lesion located in the vulvar mucosa. Some authors believe that cancer in the vulvar epithelium will only pick up weak toluidine, so if the acetic acid is applied within 3 minutes, the cancerous areas in the epithelium often appear white, which the naked eye cannot see and the area. This lesion is more visible if magnified 6 times.

White lesions of the epithelium may be accompanied by a basal dot or not, biopsy is required. Magnification is only valid for non-hyperkeratosis lesions.

Biopsy

White lesions should be biopsied especially in patients with persistent pruritus that do not respond to topical treatment. A biopsy is also a critical diagnostic measure for suspected lesions of the vulva.

Skin biopsy pliers allow for precise positioning, skin needs to be disinfected, then anesthetize subcutaneously with 1% lidocaine, use 4mm biopsy pliers to pinch the affected area and then rotate. If bleeding occurs, use Monsel (iron sulphate) solution within a few minutes. Young women often show cancer in the epithelium in many foci, so it is necessary to have a biopsy on many sites. However, it is not possible to rely on a number of biopsies to rule out latent invasive cancer on extensive sore or ulcerative lesions. With wide compassion, it is necessary to cut wide in place to make sure there is or no intrusion

Examination of the anus and anal canal

The spread of vulvar carcinoma to the anus and anus accounts for about 14-35%.

Treatment of carcinoma of the vulvar epithelium

A spontaneous cure without any treatment has been suggested. However, there is evidence that vulvar cancer in the epithelium in women middle-aged and older is more likely to progress to invasive cancer.

Treatment with 5-fluorouracil and dinitrochlorobenzene