Vulvar dystrophies: A long-term Brisbane study of 155 cases

Objective: To review the long-term outcomes for 155 women with a vulvar dystrophy (VD) who attended the Royal Brisbane Hospital Vulvar Clinic between 1976 and 1988. Methods: VD data from Vulvar Diseases Clinic were reviewed and analysed using the computer software Statistical package for the Social Sciences (SPSS) 11.0. Results: Of 155 patients 94 had Lichen Sclerosus (LS), 41 Lichen Simplex Chronicus (LSC) and 20 Mixed Dystrophy (MD). Three patients developed squamous cell carcinomas of the vulva between 10 and 26 years after presentation with a VD. To date only one of these three patients remains alive following treatment. Conclusion: The need for long term follow up is stressed and any of the three types of VD may become malignant. Time from diagnosis to malignant change is not predictive. VD treatments seem to go through phases with the application of potent steroid creams having stood the test of time.

Vulvar basal cell carcinoma: A retrospective study of 29 cases from Queensland

Objective: Review the clinical features, diagnosis, management and outcomes for 29 cases of Basal Cell Carcinoma (BCC) of the Vulva referred to Queensland Centre for Gynaecological Cancer (QCGC) between 1986 and 2010. Methods: Vulvar BCC cases from QCGC were reviewed and analysed using the computer software Statistical Package for the Social Sciences (SPSS) 11.0. Results: BCC of the vulva is uncommon with an incidence from the QCGC vulvar cancer registry of 3.2%. Of the 29 patients one died of their BCC and seven died of unrelated causes. The mean age at diagnosis was 69.5 years (range 40 to 91). All cases were Caucasian. Time from onset of symptoms to diagnosis averaged 22.6 months (range 0 - 120 months). Not until a biopsy was performed was the diagnosis made. The most common presenting complaints were pruritis and a lump. Initial treatment was surgical. Conclusions: The prognosis for vulvar BCC is excellent. Histological diagnosis and long term follow-up are important management issues. The status of disease at the margins of surgical specimens does not reliably equate to patient long term outcomes. Follow up should be supervised via a gynecological oncology register to reduce the risk of patient loss to follow up.

Bartholin’s Gland Carcinomas: A 20 plus-year experience from Queensland

Objective: To review the records of cases of Bartholin’s Gland Carcinoma referred to the Queensland Centre for Gynaecological Cancer (QCGC) between mid 1993 and mid 2012. Methods: Bartholin’s Gland Carcinoma case data from QCGC were reviewed and analysed using the computer software Statistical Package for the Social Sciences 11.0. Results: Of the 12 cases four died of their disease, seven are still alive and disease free and one is alive with recurrent disease. The mean age at diagnosis was 52.8 years. Time from onset of symptoms to diagnosis averaged 5.8 months. All diagnoses were confirmed histologically. Presenting symptoms included a lump and pain. The most common presenting complaint was a lump. Treatment included surgical excision, occasional biopsy followed by radiotherapy with or without chemotherapy. In some cases radiation and chemotherapy was followed by vulvectomy of various extent. Conclusions: Bartholin’s Gland Carcinoma is a rare condition with outcome dependent on duration of symptoms, including delay in diagnosis, cell-type, cellular differentiation and the International Federation of Gynecology and Obstetrics (FIGO) classification. A Bartholin’s gland mass in a woman aged 40 years or more should be considered malignant until a biopsy proves otherwise.The incidence of Bartholin’s Gland Carcinoma in Queensland is less than that reported elsewhere but a higher proportion of squamous cell carcinomas was found in this small series.

Vulvar sarcomas: A 25 plus-year experience from Queensland

Objective: To review the characteristics of cases of vulvar sarcomas (VS) referred to the Queensland Centre for Gynaecological Cancer (QCGC) between mid 1984 and mid 2012. Methods: VS case data from QCGC were reviewed and analysed using the computer software Statistical Package for the Social Sciences (SPSS) 11.0. Results: Of the nine cases three died of their disease, one died of ovarian cancer and five are still alive and disease free. The mean age at diagnosis was 54.8 years. Time from onset of symptoms to diagnosis averaged one month. All diagnoses were confirmed histologically. The most common presenting complaint was a lump. Treatment in all but one case involved surgical excision, one case had chemotherapy alone and two cases had surgery followed by radiotherapy. Conclusions: To talk of five year survival for patients with such a rare cancer, so many histological types with variable cell differentiation plus the unknown of when sarcomatous cells metastasize from even early FIGO staged lesions is in our opinion taking generalisation to far. A multidisciplinary approach to management achieves the best results for each individual and pooling multicentre data will improve our understanding of this rare disease and benefit future patients.

Influences on the study of Vulvar Anatomy and Disease

The study of Gynaecology over the years has been influenced by the culture and social attitudes of society to the body as a whole and to the genital organs in particular. Variations in these attitudes between different cultures and at different times have influenced the subsequent rate of progress in the study of the vulva and its diseases.

A review of conditions altering the permanent appearance of the vulva

This article is aimed at providing information on variations in the clinical appearance of the vulva. The appearance of the vulva can be altered by reversible or permanent conditions both of which may result in minor or major changes. Reversible conditions include those associated with infections or acute trauma which results in distortion of the vulva. Some permanent changes are caused by life threatening conditions which are present at birth whereas others develop more slowly or as the result of a deliberate act either traditional female surgery or surgery performed by a registered medical practitioner. To the inexperienced practitioner changes from the normal vulvar appearance can be confusing. The aim of this article is to highlight and categorise changes that can affect the appearance of the vulva. Whatever the presentation the importance of obtaining a detailed history and performing an appropriate, sensitive and thorough examination can not be over emphasised.

Melanoma of the vulva: A retrospective study of 46 cases from Queensland

Objective: To review the records of cases of vulvar melanoma referred to the Queensland Centre for Gynaecological Cancer (QCGC) between 1986 and 2009 recognising the high incidence of cutaneous melanoma in Queensland. Methods: Vulvar melanoma case data from QCGC were reviewed and analysed using the computer software Statistical Package for the Social Sciences (SPSS) 11.0. Results: Of the 46 cases 22 died of their disease, nine died of other diseases, ten are still alive and five lost to follow up. The mean age at diagnosis was 65.5 years for nodular melanoma and 69 years for superficial spreading melanoma. All cases were Caucasian. Time from on-set of symptoms to diagnosis averaged 3.2 months. In all 46 cases diagnosis was confirmed histologically. Presenting symptoms included lumps, itch, stinging, bleeding and pain. The most common presenting complaint was a lump. The initial treatment was surgical without a trend to a less radical approach to management. Conclusions: Vulvar melanoma prognosis remains guarded. Increased tumor size, depth of invasion, mitotic rate, groin lymph node positivity and status of disease at the margins of surgical specimens reliably equate to long term outcome. The incidence of vulvar melanoma was not increased in Queensland.

Non-obstetric vaginal trauma

Objective: To describe the mechanism, injury pattern and management of women who present to the Emergency Department with non-obstetric vaginal trauma. Methods: A retrospective, single institution case series was carried out. Data was sourced from medical records of women who presented to the Emergency Department and Royal Brisbane and Women’s Hospital between 2007 and 2011. Records of possible injuries to the vagina were assessed to determine incidence, age, site, type of injury, mechanism of injury and whether urinary retention required treatment. Results: Vaginal non-obstetric trauma was found in 11 of 519 cases resulting in lacerations or tears. Injuries were due to consensual coitus, other forms of sexual activity and self harm. Acute urinary retention did not occur in any case but two cases required resuscitation. Site of injury was most common high in the vagina. Conclusion: Non-obstetric vaginal injuries are uncommon (incidence 2.1%). All cases require assessment for vulvar, vaginal, urethral, anal and bony pelvis injuries. This may require examination under anaesthesia. Social worker and psychological support is important to reduce the incidence of long-term psychological problems.

Melanosis of the vulva: A long-term follow-up from Brisbane, Australia

Object: To determine if vulvar melanosis progressed to melanoma over a period of 20 years or more. Methods: In 2010 the hospital records from the Royal Brisbane Hospital Vulvar Clinic between 1976 and 1988 were reviewed and cross checked with the state wide Queensland Centre for Gynaecological Cancer (QCGC) data base to determine if any patient had been lost to follow up and subsequently developed a vulvar melanoma. Data collected were stored and analysed using the computer software Statistical Package for the Social Sciences (SPSS) 11.0. Results: None of the 12 patients developed vulval melanoma in the years up to 2010. Conclusion: In this small group, followed for more than 20 years, melanosis was not a precursor of melanoma. One patient, who attended the Vulvar Clinic but was not included in this melanosis study, was found to have co-existing melanosis well away from her melanoma in situ and malignant melanoma at presentation. It was not possible to determine if these findings represented a progression of the benign to malignant. Biopsy of abnormal hyper pigmented vulvar skin is recommended. Current knowledge suggests that vulvar melanosis is a benign condition but to be on the safe side follow up of all hyper pigmented vulval lesions to detect early malignant change is recommended.