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Background: Prognostic factors such as surgery and pathology in vulvar squamous cell carcinoma are studied., Patients and Methods: 47 patients with vulva squamous cell carcinoma treated at the Gynecology Department of the University of Padua, have been retrospectively studied., Results: At the univariate relapse-free survival analysis, a significant association was found for histological grade, stage of disease and type of surgery. All patients presented vulvar squamous cell carcinoma: G(1) in 25 (53%), G(2) in 14 (30%), and G(3) in 8 (17%) patients. The distribution of stages was as following: stage 1 in 6 (13%), stage 2 in 20 (43%), stage 3 in 11 (23%), and stage 4 in 10 patients (21%). Radiotherapy was performed in 13 patients. Among the 47 patients evaluable: 26 (55.3%) developed local recurrence, 12 of these patients developed a second local relapse, 3 of these also had distant metastases (lung in 1 patient, lomboaortic and mediastinic lymph nodes in the other 2 patients). Stromal invasions were 9 mm in 30 patients with 27 relapses (univariated analysis p=0 0066). Five episodes (10,6%) of thrombosis were observed., Conclusion: After multivariate analysis, surgery, stage and stromal invasion over 9 mm (hazard ratio=3.1; 95% confidence interval: 1.3-7.7) proved to be the most dominant predictor for relapse-free survival. Histological grades 1 and 2 were predictive of better disease-free survival (p=0.0012).

Objectives: To investigate the effects of transdermal estrogen replacement therapy (ERT) on plasma homocysteine levels in postmenopausal women who underwent total hysterectomy with bilateral oophorectomy., Methods: In two-phase open longitudinal prospective study we compared 28 premenopausal women and 35 healthy postmenopausal patients to evaluate the effect of transdermal estrogen treatment (TTS 50 twice-weekly) on plasma homocysteine levels after 6 and 12 months of therapy., Results: The study showed statistically relevant differences (P<0.05) in baseline plasma homocysteine concentration between the patients in premenopausal and in postmenopausal status. No difference in the plasma homocysteine levels was observed after 6 and 12 months of ERT on postmenopausal patients., Conclusions: Surgically postmenopausal women have higher plasma homocysteine concentrations than premenopausal women, but transdermal estrogen treatment for 12 months in postmenopausal women does not modify homocysteine levels.

The Authors studied 37 women affected by vulvar condylomatosis. Thirty-four presented features of florid or microflorid condylomatosis, three were affected by flat condylomatosis, Papillomavirus (HPV) infection of the cervico-vaginal tract was present in 25 women. No vulvar cellular atypia was found in the 37 cases with HPV lesions, while in 6 cases there were also cervical dysplasia (CIN 1-CIN 2). Nineteen out of 23 patients with disseminated revealed a vaginal flogosis mostly by yeats, detected by microbiological examinations. The evidence of disseminated florid or microflorid lesions associated with the virus infection, both located at the cervico-vaginal tract, support the ipothesis of virus types with higher virulence, a greater ubiquitary trophysm and a greater oncogenic risk, as supported also by other Authors.

The presence of second neoplasia in association with vulvar neoplasia is significant. We confirm the usefulness of including a screening procedure for vulvar neoplasia in the follow-up of patients with gynecological cancer, especially those with carcinoma of the portio. Patients with a first gynecological neoplasia who present vulvar viral infection, or dystrophies, or who have undergone radiotherapy or immunosuppressive treatment are considered at high risk.

187 patients with atrophic, hypertrophic and mixed vulvar dystrophy were treated with 2% testosterone propionate ointment from 18 months to 7 years. Symptoms, macroscopic, and histologic picture were evaluated before and during treatment. About 75% of the patients achieved good and excellent symptom relief. Treatment efficacy differentiates according to the type of dystrophy, and in relation to the lesion's extension and the duration of symptoms, which consist mostly of pruritus. Side effects from therapy were negligible.

An adequate and unified classification of vulvar pathology has been difficult and continues to be a problem hard to solve, due to the difficulties in including different clinical aspects in various pathological classes. The causes of this uncertainty, as rather a multiplicity of view points, may be ascribed in particular to the extreme polymorphic nature of vulvar pathology. Our classification, in attempting to overcome arbitrary and absolute distinctions in such a polymorphic and variable field, adopts an etiological and anatomo-histological criterium which distinguishes vulvar pathology in: primary disorders, secondary disorders. It is evidently important to know and distinguish possible vulvar infections, in order to be able to identify those disorders which assume an oncogenous risk, while trying to overcome the problems of differential diagnosis.

Plain films of the abdomen taken during pregnancy at term from 1971 to 1981 at the Radiology Service of the Obstetric and Gynecological Clinic of the University of Padua are summarized and analysed. The average frequency of X-ray investigation is 0.5%, ranging from 0.06% (in 1980) to 2.11% (in 1977), compared to Carmichael's data which range from 11 to 30%. Indications have remained fairly constant over the years, in view of the very low incidence of this examination. The most significant finding is the greater incidence of fetal malformation in recent years, and is explained by a more efficacious program of pregnancy screening. X-ray examination may be still employed in some cases to obtain superior information regarding the best definition of gestational age, some fetal malformation, and in rare cases, hemolytic disease.

Six patients with basal cell carcinoma of the vulva underwent differentiated surgical therapy, and their courses were evaluated. No apparent differences in survival time and absence of recurrences and metastases were observed inthe patients treated with radical vulvectomy (1 case), simple vulvectomy (3 cases) and local excision (2 cases). Conservative surgical therapy is therefore considered most indicated.

Since 1982 we have been associating the study of hormonal receptors with the histological examination of the vulvar lesions in an attempt to interpret the action mechanism of steroids on the vulva, to find possible correlations between histological pictures and receptorial order and to find a possible predictive "marker" toward therapeutic and prognostic ends. In our Laboratory assays for androgen, estrogen and progesterone receptors were performed with the Dextran-Charcoal technique in 41 patients with vulvar dystrophy; 20 of whom had atrophic dystrophy and 21 with hypertrophic dystrophy. Another 24 patients with vulvar carcinoma were studied; 23 with epidermoid carcinoma of various differentiation grades and only one case of Paget's Disease. None of the three receptors assayed could be considered a predictive or prognostic marker in the approach to neoplastic forms. The levels of the progesterone receptor appears increased in the case of dystrophies. This justifies the hypothesis of a hormonal involvement in the pathogenesis of the lesion, as has already been documented by the beneficial effects of therapy with topical steroids.

The authors report the case of a young nun who came to their attention because of the simultaneous development of mammary and pelvic lymphoblastic lymphoma and acute leukemia showing aspects typical of nonendemic Burkitt's lymphoma. The rapid tumoral growth and the equally rapid spontaneous cell lysis led to severe renal insufficiency and metabolic acidosis which were ultimately the cause of death. Given the rareness of the clinical situation and the diagnostic problems involved, the authors examined the literature dealing with this subject.

The increased incidence of multiple primary tumors of genital-breast district has been evaluated, with the possibility of early diagnosis which consent greater survival in cancer patients. We found a particular high incidence of second neoplasia associated with vulval tumors (7.4%). With regard to pathogenetic factors, the oncogenic role of certain treatments is undoubtedly important, especially if they are protracted in time. It is necessary that these patients undergo complete gynecological screening for a time period that is much longer than that held sufficient to consider a patient cured.

On the basis of our clinical experience and a careful revision of the literature, we have attempted to identify the natural history of vulvar carcinoma by verifying the real evolutive possibility of these lesions, their possible genesis, the latent period between pre-invasive and invasive forms, and some events which seem to play a significant role in the onset of the invasive form in this period. These considerations indicate a new clinical and study approach to carcinoma in situ, which would thus become a pathology characterized by a more precise pathogenetic and evolutive individuality.

The Authors have studied the topical use of progesterone gel in the treatment of vulvar dystrophies. The results compared with those obtained previously with testosterone propionate pointed out the positive effects even of the progesterone, which has to be the first therapeutical approach for all the types of vulvar dystrophies, reserving to serious and resistants cases the treatment with testosterone propionate.

In pre-terminal and terminal gynaecological patients with persistent cancer pain, now it is possible to carry out some anthalgic methods associated or not to parenteral administration of non-narcotic or narcotic analgesic, i.e. intrathecal neurolytic injections and epidural narcotic administration. Many favourable results have been obtained by means of single or repeated 7% phenol in glycerine injections to patients with advanced but not terminal cancer affected by somatic and segmental pain or by perineal pain. In order to control more extensive pains, epidural injections of morphine in saline have been employed in preterminal patients. This method appears to be the best answer to many problems complained by the patients: pain, depression, malaise. As a matter of fact, low doses of epidural morphine induce both complete pain relief and sedation or slight drowsiness.

In the vulvar pathology surgery unit we have come across 3 patients with Sjögren's syndrome. Two of them also now show the presence of vulvar carcinoma, and one of them shows the presence of vulvar dystrophy with dysplasia. This has induced us to consider the possible connections between the 2 pathologies. All 3 of the patients, at different times and in different periods have been treated with steroids for the original disorder. The connections between the 2 affections are presumably to be found in the possible autoimmunitary genesis of the original disease and in the concomitant use of steroids.

In confronting the problem of prevention and early diagnosis of vulvar lesions at risk, the diagnostic methodology for their recognition and the therapeutic measures best taken are discussed. Through the use of routine, ambulatory screening tests, it is possible to detect and recognize those pathological situations which may evolve towards neoplasia. Among these, the vulvar dystrophies, some viral infections and sexually-transmitted diseases are particularly at risk. Patients with oncologic precedents are also at risk as well as patients receiving immunosuppressive therapy.

Hormone receptor assays for testosterone, estrogens and androgens were performed on 53 biopsy specimens of vulva from 40 patients, consisting of 6 with normal tissue, 14 with atrophic type dystrophy, 13 with hypertrophic type dystrophy, and 20 with malignancy. Atrophic and hypertrophic forms showed a different receptor pattern; hypertrophic forms were characterized by consistently higher levels of progesterone receptors not correlated with estrogen receptors. Neoplastic tissue showed no significant changes in values compared to normal or dystrophic forms, but range of variability was high. The bond between neoplastic forms and hormone activity seems without doubt less important than in the corresponding endometrial and mammary forms. The study of dystrophic forms, instead, should be further explored with a larger number of cases.

Assays have been developed for the quantitation of androgen, estrogen and progesterone receptors in the cytosol of 45 vulvar dystrophic tissues. In 27 patients we assayed only cytoplasmatic receptors, while in 18 patients both cytoplasmatic and nuclear receptors. The workers verified the possibility to assay these carriers, finding significant correlations neither with patient's age nor between atrophic and hypertrophic dystrophies. The research concerning the cytoplasmatic depletion and nuclear accumulation allowed us to understand the action mechanism of the androgen in vulvar tissues in patients in menopause.

Two cases of Paget's disease of the vulva are presented and the complex problem of diagnosis of this neoplasia is evaluated: all the diagnosis tests used in vulvar disease (vulvar citology, toluidine blue test) are insufficient in the presence of on eventual underlying carcinoma. In view of these considerations, the therapeutic approach is total vulvectomy.