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Prognosis
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With early diagnosis and treatment, the overall 5-year survival is 80 85% With stage I disease, the depth of myometrial invasion is the strongest predictor of survival, with a 98% 5year survival with less than 66% depth of invasion and 78% survival with 66% or greater invasion
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When to Refer
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All patients with endometrial carcinoma should be referred to a gynecologist
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Amant F et al Endometrial cancer Lancet 2005 Aug 6 12; 366(9484):491 505 [PMID: 16084259] American College of Obstetricians and Gynecologists ACOG Practice Bulletin, Clinical Management Guidelines for Obstetrician-Gynecologists, No 65, August 2005: Management of endometrial cancer Obstet Gynecol 2005 Aug;106(2):413 25 [PMID: 16055605]
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CARCINOMA OF THE VULVA
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ESSENTIALS OF DIAGNOSIS
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History of genital warts History of prolonged vulvar irritation, with pruritus, local discomfort, or slight bloody discharge
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Gynecology
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Early lesions may suggest or include nonneoplastic epithelial disorders Late lesions appear as a mass, an exophytic growth, or a firm, ulcerated area in the vulva Biopsy is necessary to make the diagnosis
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CMDT 2008
less than 1 mm Patients with more advanced disease may receive preoperative radiation, chemotherapy, or both
Prognosis
Basal cell carcinomas very seldom metastasize, and carcinoma in situ by definition has not metastasized With adequate excision, the prognosis for both lesions is excellent Patients with invasive vulvar squamous cell carcinoma 2 cm in diameter or less, without inguinal lymph node metastases, have an 85 90% chance of a 5-year survival If the lesion is greater than 2 cm and lymph node involvement is present, the likelihood of 5-year survival is approximately 40%
General Considerations
The majority of cancers of the vulva are squamous lesions that classically have occurred in women over 50 years of age Several subtypes (particularly 16, 18, and 31) of HPV have been identified in some but not all vulvar cancers As with squamous cell lesions of the cervix, a grading system of vulvar intraepithelial neoplasia (VIN) from mild dysplasia to carcinoma in situ has been established
When to Refer
All patients with invasive vulvar carcinoma should be referred to a gynecologic oncologist
Maclean AB Vulvar Cancer: prevention and screening Best Pract Res Clin Obstet Gynaecol 2006 Apr;20(2):379 95 [PMID: 16543120] Preti M et al Superficially invasive carcinoma of the vulva: diagnosis and treatment Clin Obstet Gynecol 2005 Dec;48 (4):862 8 [PMID: 16286832]
Differential Diagnosis
Biopsy is essential for the diagnosis of VIN and vulvar cancer and should be performed with any localized atypical vulvar lesion, including white patches Multiple skin-punch specimens can be taken in the office under local anesthesia, with care to include tissue from the edges of each lesion sampled Benign vulvar disorders that must be excluded in the diagnosis of carcinoma of the vulva include chronic granulomatous lesions (eg, lymphogranuloma venereum, syphilis), condylomas, hidradenoma, or neurofibroma Lichen sclerosus and other associated leukoplakic changes in the skin should be biopsied The likelihood that a superimposed vulvar cancer will develop in a woman with a nonneoplastic epithelial disorder (vulvar dystrophy) ranges from 1% to 5%
ENDOMETRIOSIS
ESSENTIALS OF DIAGNOSIS
Pelvic pain related to menstrual cycle Dysmenorrhea Dyspareunia Increased frequency among infertile women
Treatment
A General Measures
Early diagnosis and treatment of irritative or other predisposing causes, such as lichen sclerosis and VIN, should be pursued A 7:3 combination of betamethasone and crotamiton is particularly effective for itching After an initial response, fluorinated steroids should be replaced with hydrocortisone because of their skin atrophying effect For lichen sclerosus, recommended treatment is clobetasol propionate cream 005% twice daily for 2 3 weeks, then once daily until symptoms resolve Application one to three times a week can be used for long-term maintenance therapy
General Considerations
Endometriosis is an aberrant growth of endometrium outside the uterus, particularly in the dependent parts of the pelvis and in the ovaries and is the most common cause of secondary dysmenorrhea While retrograde menstruation is the most widely accepted cause, its pathogenesis and natural course are not fully understood The overall prevalence in the United States is 6 10% and is fourfold to fivefold greater among infertile women
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