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GYNECOLOGY
Vinluan, Joseph David
Dr. Trinidad
Wong, Deo Adiel 3rd Year
–D
Yague, Glenn Sept. 5,
2007
Yang, Caprice
Case #15
73 year old G2P2 (2002) complained of vulvar pruritus for 3 years.
PMH: (+) DM, HPN on medication. She consulted a private
physician and was prescribed with Fluconazole, which afforded no
relief. PPE: (+) 3x2 cm hyperpigmented patch with excoriation on
the left mid portion of the vulva extending up to the left labia
majora. Spec. exam: vagina- pale; cervix: flushed to the vaginal
wall; uterus: small, movable; and (-) mass (-) tenderness
In parallel with this, since dermatoses occur anywhere in the body, ask
for other similar pruritic lesions in other parts of the body that accompanied
or came before/after the vulvar lesion. It is also very helpful to ask if there are
accompanying symptoms like redness, dryness, scaling, small red bumps,
swelling, skin plaques, blisters/ulcers and/or oozing/crusting. These are
helpful when ruling in/out primary inflammatory conditions but not
exclusively as malignancy may as well present with some of these.
In the history, the patient presented with chronic vulvar pruritus for a
period of 3 years; and on PE, a hyperpigmented patch on the vulva was
noted. She was previously prescribed with fluconazole, an antifungal agent,
but afforded no relief. From this data, we can set aside fungal infection from
our considerations. Considering her age, 73 years old, which is in the
postmenopausal period, this is most likely a neoplastic process, probably
malignant.
Neoplasms of the vulvar area are often slow growing and can cause
low-grade
Pruritus which includes squamous intraepithelial neoplasia and nonsquamous
intraepithelial neoplasia. Under squamous intraepithelial neoplasia is VIN. VIN
can be grouped into two: those associated with HPV infection and those that
are associated with squamous cell hyperplasia and lichen sclerosus (leading
directly to carcinoma). As was discussed above, the latter group is not
probable because of certain factors in the history of our patient.
Management
Clinical staging
The International Federation of Gynecology and Obstetrics (FIGO) has
adopted a surgical staging system for vulvar cancer. The stage of cancer is
determined after surgery. The previous clinical staging system for vulvar
cancer is no longer used. Vulvar cancer is categorized into five stages (0, I, II,
III, and IV) which may be further subdivided (A and B) based on the depth or
spread of cancerous tissue. The FIGO stages for vulvar cancer are:
Treatment Options
Treatment for vulvar cancer will depend on its stage and the patient's
general state of health. Surgery is the mainstay of treatment for most cases
of vulvar cancer. However for our patient who is in Stage II vulvar carcinoma,
surgery is the best possible treatment (wide excision); in addition, Mohs
surgery has provided good results. Radiotherapy and Chemotherapy may also
be indicated especially in advanced stages.
SURGERY. The primary treatment for stage I and stage II vulvar cancer
is surgery to remove the cancerous lesion and possibly the inguinofemoral
lymph nodes. Removal of the lesion may be done by laser, to burn off a
minimal amount of tissue, or by scalpel (local excision), to remove more of
the tissue. The choice will depend on the severity of the cancer. If a large
area of the vulva is removed, it is called a vulvectomy. Radical vulvectomy
removes the entire vulva. A vulvectomy may require skin grafts from other
areas of the body to cover the wound and make an artificial vulva. Because of
the significant morbidity and the psychosexual consequences of radical
vulvectomy, there is a trend toward minimizing the extent of cancer excision.
The specific inguinofemoral lymph node that would receive lymph fluid from
the cancerous lesion, known as the sentinel node, may be exposed for
examination (lymph node dissection) or removed (lymphadenectomy),
especially in cases in which the cancerous lesion has invaded to a depth of
more than 1 mm. Surgery may also be followed by chemotherapy and/or
radiation therapy to kill additional cancer cells.
RADIATION THERAPY. Radiation therapy uses high-energy radiation
from x rays and gamma rays to kill the cancer cells. The skin in the treated
area may become red and dry and may take as long as a year to return to
normal. Fatigue, upset stomach, diarrhea, and nausea are also common
complaints of women having radiation therapy. Radiation therapy in the
pelvic area may cause the vagina to become narrow as scar tissue forms.
This phenomenon, known as vaginal stenosis, makes intercourse painful.
Alternative treatment
Although alternative and complementary therapies are used by many
cancer patients, very few controlled studies on the effectiveness of such
therapies exist. Mind-body techniques such as prayer, biofeedback,
visualization, meditation, and yoga have not shown any effect in reducing
cancer but can reduce stress and lessen some of the side effects of cancer
treatments. Clinical studies of hydrazine sulfate found that it had no effect on
cancer and even worsened the health and well-being of the study subjects.
One clinical study of the drug amygdalin (Laetrile) found that it had no effect
on cancer. Laetrile can be toxic and has caused death. Shark cartilage,
although highly touted as an effective cancer treatment, is an improbable
therapy that has not been the subject of clinical study.
The American Cancer Society has found that the "metabolic diets"
pose serious risk to the patient. The effectiveness of the macrobiotic, Gerson,
and Kelley diets and the Manner metabolic therapy has not been scientifically
proven. The FDA was unable to substantiate the anticancer claims made
about the popular Cancell treatment.
REFERENCES:
• Berek & Novak’s Gynecology, 14th Edition.
• Andrew’s Clinical Dermatology, 10th Edition.
• Robbins & Cotran’s Pathologic Basis of Disease, 7th Edition.
• Nonneoplastic Epithelial Disorders of the Vulva
http://www.emedicine.com/med/topic3294.htm
• Malignant Vulvar Lesions
http://www.emedicine.com/med/topic3296.htm
• Vulvar pruritus: Differential diagnostic in medical practice
http://www.tellmed.ch/include_php/previewdoc.php?file_id=956
• Postgraduate Medicine Online: “Vulvar problems in elderly women”
http://www.postgradmed.com/issues/1997/09_97/barhan.htm
• American Cancer Society: “What is Vulvar cancer?”
http://www.cancer.org/docroot/cri/content/cri_2_4_1x_what_is_vulvar_cancer_
45.asp