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In the current classification, squamous vulvar intraepithelial neoplasia (VIN) is categorized as VIN 1, 2 and 3 according to the degree of abnormality. There is neither evidence that the VIN 1-3 morphologic spectrum reflects a biologic continuum nor that VIN 1 is a cancer precursor. The VIN 2 and 3 category includes 2 types of lesion, which differ in morphology, biology and clinical features. VIN, usual type (warty, basaloid and mixed), is HPV related in most cases. Invasive squamous carcinomas of warty or basaloid type is associated with VIN, usual type. VIN, differentiated type, is seen particularly in older women with lichen sclerosus and/or squamous cell hyperplasia in some cases. Neither VIN, differentiated type, nor associated keratinizing squamous cell carcinoma is HPV related. The term VIN should apply only to histologically high grade squamous lesions (former terms, VIN 2 and VIN 3 and differentiated VIN 3). The term VIN 1 will no longer be used. Two categories should describe squamous VIN: VIN, usual type (encompassing former VIN 2 and 3 of warty, basaloid and mixed types) and VIN, differentiated type (VIN 3, differentiated type).

Objective: To underline the usefulness of a new multidisciplinary subspecialty devoted entirely to vulvar diseases, to be termed vulvology., Study Design: Disorders of the vulva present a wide spectrum of clinical appearance, rendering clinical diagnosis difficult, if not impossible. The three types of physicians usually involved in treating the vulva (generalists, dermatologists and gynecologists) receive little training in and have little experience with vulvar problems. The end result is that women today are receiving far less than optimal care for vulvar disorders., Results: This situation can be much improved through the establishment of vulvology as a new multidisciplinary subspecialty. Vulvology can become a neutral field for research and debate and can provide a point of consolidation for all clinical care (infectious, metabolic, oncologic, neurologic, psychological, etc.) of vulvar disorders. The interdisciplinary nature of this new subspecialty will also facilitate the standardization and systematization of the currently confusing terminology and classification applicable to vulvar disorders., Conclusion: Vulvology, as a new, well-defined, multidisciplinary subspecialty, will improve the care of women with vulvar problems through the delineation of vulvologists as physicians with special expertise in this area, the establishment of clinics devoted specifically to the care of vulvar problems and the provision of education for physicians, other health care providers and the public.

The aim of this study was to evaluate psychological distress in 44 women with vulvar squamous cell hyperplasia and 21 with vulvar lichen sclerosus in order to examine the presence of psychological factors in these dermatologic disorders. Two psychometric tests were used to evaluate depressive status and various aspects of anger. No significant depressive status was diagnosed with the former test either in patients with vulvar squamous cell hyperplasia or in patients with vulvar lichen sclerosus. Patients with squamous cell hyperplasia had two components of anger (state and internal anger) that were significantly higher and three components (trait anger, exteriorization and control of anger) significantly lower than did the controls. In patients with lichen sclerosus all the components of anger were within the normal range. These findings suggest that psychological factors may be associated with vulvar conditions, such as squamous cell hyperplasia, and may have some therapeutic implications in cases resistant to standard treatment.

Twenty-one women were treated surgically for entry dyspareunia and vulvodynia. The ages of the patients ranged from 18 to 39 years (mean, 24.5). Physical examination showed the presence of membranous hypertrophy of the posterior fourchette with consequent stricture of the vaginal introitus in all the patients. Eighty percent of the patients had erythema and tenderness of the vestibule, particularly in the posterior part. The histologic findings were somewhat enigmatic and quite unimpressive, frequently suggestive of chronic nonspecific inflammation; in only two cases were histologic changes suggestive of human papillomavirus infection observed. All the patients underwent excision of the posterior part of the vestibule with vaginal advancement under general anesthesia. Follow-up showed elimination of the symptoms in 19 patients and an improvement in the symptoms in the remaining 2.

The aim of this study was to evaluate the role by which different factors, such as human papillomavirus (HPV) infection, age, dystrophic alterations, focal nature and size of the lesion, influence the biologic behavior of vulvar intraepithelial neoplasia (VIN). Sixty-nine cases of VIN were investigated (28 VIN 1, 9 VIN 2, 32 VIN 3). Follow-up was possible in 58 cases, with a mean of 31 months; no treatment was given to 3 patients, while 55 were treated either medically or surgically. Eighty-four percent of the patients were cured, recurrences were found in 11%, and 5% of the patients showed progression of the disease to carcinoma. The ratio between medical and surgical treatment was the same among the cured, recurred and progressed groups of patients. No differences with regard to focal nature of the lesion, presence of HPV infection or dystrophic alterations were observed between the three groups of patients. Only the mean age was higher in patients who showed progression of the lesion to carcinoma.

We evaluated seven histologic parameters (tumor diameter, histologic grading, depth of stromal invasion, vascular invasion, pattern of invasion, lymphoplasmocytic infiltration and amount of necrosis) of 50 cases of vulvar invasive carcinoma to assess their correlation with groin lymph node metastases. Of 50 patients, 25 had groin lymph node metastases. No lymph node metastasis was found in four cases with depth of invasion < or = 2.0 mm. Among the 31 patients with vascular invasion, 23 (74%) had positive nodes, whereas lymph nodes were metastatic only in two of the 19 patients (10%) without vascular invasion. At univariate analysis, performed with Fisher's exact method, all the parameters considered, except pattern of invasion and amount of necrosis, were significantly associated (P < .05) with lymph node metastases. However, after adjustment by multiple logistic regression for the variables statistically significant at univariate level, only the presence of vascular invasion was significantly associated with nodal involvement and tumor diameter was borderline, whereas the effect of the other variables was almost completely explained by confounding.

Forty-two patients with primary invasive vulvar carcinoma were treated with radical vulvectomy and deep femoral lymphadenectomy with preservation of the fascia lata and cribriform fascia. The rationale for using this technique was based on anatomic knowledge of the topographic distribution of groin lymph nodes, which was confirmed by the study of 50 cadavers. The preliminary data show that the number of superficial and deep femoral lymph nodes removed from the 42 patients (mean number of nodes, 20; range, 8-32) was similar to the number reported in anatomy books. In addition, the five-year actuarial survival rate, 70%, was comparable to that in the literature. These preliminary results suggest that the surgical technique used in this study is as radical an oncologic procedure as Way's classic groin lymphadenectomy, which consists of removing the fascia lata and cribriform fascia.

There is a discrepancy between anatomy textbooks' description of groin node position and Way's technique of lymphadenectomy. On the one hand, anatomic studies have demonstrated that the deep femoral nodes are on the medial side of the femoral vein, lying on the deep portion of the fascia lata, and can be seen easily through the opening of the fossa ovalis. On the other hand, the standard technique of deep femoral lymphadenectomy consists of removing the fat lying lateral to the femoral artery through the incision and detachment of the fascia lata from the sartorius to adductor longus muscle. With the aim of demonstrating that a correct deep femoral lymphadenectomy does not require removal of the fascia lata, we dissected Scarpa's triangles in 50 female cadavers. The examination of 100 specimens demonstrated that the deep femoral nodes are always situated within the opening of the fossa ovalis, and no lymph nodes are distal to the lower margin of the fossa ovalis, under the fascia cribrosa. These findings suggest that deep femoral lymphadenectomy can be performed without removing the fascia lata.

Sixty cases of vulvar intraepithelial neoplasia (VIN) were analyzed clinicopathologically (24 VIN I, 9 VIN II, 27 VIN III). The ages of the patients ranged from 21 to 83 years (mean, 53.7). Colposcopic examinations showed the presence of white areas in 29 cases, red areas in 9, acetowhite areas in 6 and other alterations in 13. One-third of the lesions were multifocal. Pruritus and burning were present in 65% of the cases. Fifty-one percent of the cases showed histologic changes suggestive of human papillomavirus (HPV) infection; the mean age of those patients was significantly lower than that of patients without HPV infection. In 15 cases of VIN, HPV DNA testing was performed with Southern blot hybridization; in three (20%) of those specimens HPV 16 episomal DNA was identified. Epithelial alterations surrounding the areas of VIN were found in 24 cases (40%)-23 squamous cellular hyperplasias and 1 lichen sclerosus. Different types of treatment were performed according to the different grades of VIN: medical therapy, diathermocoagulation, local excision, hemivulvectomy and total vulvectomy. Follow-up was possible in 52 cases, with a mean of 33 months (range, 3-98). Two cases of VIN I showed progression of disease over 12-24 months.

We studied the frequency and distribution of cellular atypia in 448 cases of vulvar dystrophy. The total frequency was 9.4%. Atypia was found almost exclusively in hyperplastic areas. Epithelial changes suggestive of human papillomavirus infection were found in 14.2% of the atypical dystrophies. During the follow-up of 78 patients with typical dystrophy, mild atypia developed in three cases, but with the continuation of medical treatment it disappeared in two cases. Eleven cases of atypical dystrophy were followed for 3-48 months; three patients with severe atypia underwent surgical treatment, and eight with mild atypia underwent medical treatment. Among the last patients, six showed regression and two, progression of the atypia.

Eighty-six cases of vulvar dystrophy in young and premenopausal women (age range, 6-53 years) were studied clinically and histopathologically. The most frequent symptom was pruritus associated with burning. Clinical examination showed the presence of white areas in 73% of the patients, red areas in 9% and other signs (such as melanosis) in 18%. Hyperplastic dystrophy was the most frequent type of dystrophy in these patients and was observed in 63% of cases. Cellular atypia was observed in 9.8% of the cases and was found almost exclusively in hyperplastic dystrophy. Epithelial changes suggestive of human papillomavirus infection were found in 4 of the 86 cases of dystrophy, and they were observed only in atypical dystrophies.

Material from 111 invasive primary vulvar carcinomas was reviewed in order to study the histopathologic changes adjacent to the neoplasia. The histopathologic characteristics of the adjacent tissue were divided into categories. Dystrophic lesions were adjacent to invasive cancer in 57.6% of the cases, carcinoma in situ (CIS) in 21.6% and epithelial changes suggestive of human papillomavirus infection in 18.9%. A spectrum of epithelial changes, ranging from hyperplastic dystrophy without atypia to CIS, was found adjacent to nine cases of invasive carcinoma (8.1%). In 40.5% of the vulvar carcinomas there were no specific alterations surrounding the neoplasia. These data show that dystrophies and CIS were adjacent to invasive carcinomas in nearly 60% and 20% of cases, respectively.