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Abstract & Commentary
Synopsis: Invasive vulvar carcinoma associated with lichen sclerosis or squamous hyperplasia has a poorer prognosis than that associated with HPV infection.
Source: Rouzier R, et al. Gyencol Oncol. 2001;81:
Recently, invasive squamous cell carcinoma of the vulva has been subdivided into 2 entities: that associated with vulvar dermatoses such as lichen sclerosus and squamous hyperplasia, and that associated with human papillomavirus (HPV) infection. The HPV-associated type occurs in women who are younger in age.
In order to determine whether the 2 groups of vulvar carcinoma have different survivals, Rouzier and colleagues evaluated 108 patients with invasive squamous cell carcinoma. Most of these patients were treated with wide resection with a 1 cm margin of normal skin at the resection lines. The pathology of each case was reviewed, and all cases were assigned to 2 different categories. In the first, the invasive squamous cancer was associated with some type of vulvar dermatosis. In the second group the cancer was associated with "undifferentiated high grade vulvar intraepithelial neoplasia." This second type is associated with HPV infection. Rouzier et al did not perform HPV DNA probes on the study material.
Of the patients, 77 of 108 had some type of epithelial abnormality adjacent to the invasive cancer. In 36 cases it was squamous hyperplasia, HPV-associated vulvar carcinoma in situ (VIN III) in 25 cases, and lichen sclerosus in 16 cases. The group of patients that were associated with vulvar dermatoses were statistically significantly older than those associated with HPV. Kaplan-Meier survival analyses showed that survival was poorer for the group of patients associated with a vulvar dermatosis.
Rouzier et al suggest that it is not necessary to perform HPV DNA analysis to separate invasive cancer into subgroups. Those associated with HPV infection exhibit an "undifferentiated VIN" pattern compared to a "differentiated VIN" pattern which is associated with vulvar dermatoses.
Comment by Kenneth L. Noller, MD
For some time now it has become clear that not all invasive squamous cancers of the vulva are the same. Those individuals who develop the disease at a younger age seem to do much better than those who develop it at a later age when compared stage for stage. When HPV DNA probes have been used to study these cancers, HPV-positive cases tend to be those that occur in younger women who have a better survival. However, even in younger HPV-positive women there is a significant risk of death.
Rouzier et al introduce terminology that is not commonly used in the United States at the present time: undifferentiated VIN and differentiated VIN. This terminology has recently been accepted by the International Society for the Study of Vulvar Diseases, but has been slow to catch on among pathologists. Whether this terminology will gain favor in the United States or not is yet to be seen. Certainly more studies need to be done to determine whether the undifferentiated type of VIN is truly associated with HVP infection more frequently than the differentiated type.
The current study would have been better had Rouzier et al performed HPV DNA tests on the specimens. While their conclusions probably would not have changed, they would be more believable if supported by HPV DNA evidence. Nonetheless, the results certainly suggest that invasive vulvar cancer is worse if it occurs in a background of lichen sclerosus or squamous cell hyperplasia.