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Malignant melanoma of the vagina is an uncommon genital tumor. When the lesion arises in the distal vagina, radical surgery has been the only treatment to produce long-term survivors. A total vaginectomy, vulvectomy, and bilateral groin node dissection is recommended to assure adequate margins. Sexual function is lost unless reconstruction is performed. The bilateral myocutaneous gracilis flap neovagina has been a successful plastic procedure after exenterative procedures that result in loss of bladder and/or rectum. The authors present a technique in which bladder function was preserved after creation of a gracilis flap neovagina in a patient with Stage I melanoma of the distal vagina. Placement of the distal urethra through the reconstructed gracilis flap neovagina resulted in preservation of urinary function and continence, primary closure of the vulvar defect, and satisfactory sexual function. Two and one-half years after surgery the patient has good bladder and vaginal function without significant sequele.

Cutaneous metastases from squamous cell carcinoma of the vulva are extremely uncommon. A 72-year old woman had undergone vulvectomy with bilateral inguinal lymphadenectomy. The operative specimen showed tumor infiltration in the resection borders to a considerable depth. Thereafter she received radiotherapy. Seven months after the primary operation, multiple non-tender tumor metastases appeared on the lower abdomen. These metastases result from cross-section and obstruction of lymphatic channels.

Within the past 5 years, two opposing points of view have been expressed regarding the extent of lymphadenectomy required for treatment of vulvar cancer. Krupp and Bohm suggested that optimum therapy required bilateral pelvic lymphadenectomy in addition to extended vulvectomy and bilateral inguinal lymphadenectomy [1]. On the other hand, Morris [2] advocated omitting the pelvic lymphadenectomy and the contralateral inguinal lymphadenectomy, provided that the primary tumour was unilateral and the ipsilateral inguinal-femoral nodes were negative.

A case of primary malignant melanoma of the vagina is discussed. The lesion consisted of a nodule in the middle third of the vagina that was histologically suspected of being an unpigmented malignant melanoma. The melanocytic origin of the lesion was confirmed by the pattern of reactivity to a battery of human melanoma associated antigens and to class 1 and 2 histocompatibility antigens. No secondary lesions or alternative primary sites were found. The patient underwent radical hysterectomy with bilateral salpingo-oophorectomy, total vaginectomy and vulvectomy, radical inguinal, pelvic and para-aortic lymphadenectomy. The pathology report showed the presence of multiple neoplastic foci in the vagina. Although the removed lymph nodes were histologically free of metastases, microscopic foci of neoplastic cells were detected by immunohistochemistry in three lymph nodes. There is no evidence of recurrence at the twelfth postoperative month. Our results show that immunohistochemical techniques may usefully complement diagnostic histopathology in the diagnosis of female genital tract melanoma.

A skin and fascia flap from the medial thigh is proposed for vaginal and perineal reconstruction. Dissection, vascular injection, and radiographs of 20 fresh cadaver limbs uniformly demonstrated the presence of a communicating suprafascial vascular plexus in the medial thigh. Three to four nonaxial vessels were consistently found to enter the proximal plexus from within 5 cm of the perineum. Preservation of these vessels permitted reliable elevation of a 9 X 20 cm fasciocutaneous flap without using the gracilis muscle as a vascular carrier. Fifteen flaps in 13 patients were used for vaginal replacement and coverage of vulvectomy, groin, and ischial defects. Depending on the magnitude of the defect, simultaneous and independent elevation of the gracilis muscle provided additional vascularized coverage as needed. Our experience indicates that the medial thigh fasciocutaneous flap is a durable, less bulky, and potentially sensate alternative to the gracilis musculocutaneous flap for vaginal and perineal reconstruction.

A survey of post-vulvectomy patients revealed that compared with post-hysterectomy patients, they are more likely to be depressed, to harbor feelings of sexual guilt, and to have encapsulated deficits in reality testing. Some of these problems may be prevented. The patient undergoing vulvectomy should receive detailed information before and after the surgery, and psychosexual counseling should be offered to her and her sexual partner on a long-term basis.

1. 1. Theories of histogenesis of basal cell and basal-squamous cell carcinomas of the vulva are discussed. 2. 2. Approximately 80 cases of basal cell carcinoma of the vulva have been reported to date. The incidence of the pure basal cell type is calculated to be 2.7 per cent of all vulvar malignancies; the incidence of the basal-squamous cell type is 2.5 per cent. 3. 3. Clinical features and histologic characteristics are presented. 4. 4. One basal cell and three basal-squamous cell carcinormas of the vulva are herein reported. 5. 5. The importance of careful serial examination of suspected basal cell lesions to rule out a squamous component is stressed. 6. 6. Wide complete vulvectomy is recommended for basal cell carcinoma, a lesion with a predilection for local recurrence as well as a potential for multicentric origin and for transformation to basal-squamous cell carcinoma. A basal-squamous cell carcinoma must be treated by radical vulvectomy and bilateral regional node dissection.

The results of various forms of primary treatment of cancer of the vulva during the decade 1958-1968 in the Radium Centre, Arhus Municipal Hospital, University of Arhus, are submitted. The series consists of 67 patients classified by the T-N-M system (U.I.C.C. 1967). Comparison of 29 patients treated by vulvectomy and node dissection with 26 patients treated by less extensive surgery without node dissection showed a 19% higher corrected 4 year survival and a 14% lower nodal recurrence rate in the former group although according to the T-N-M classification it must be presumed to have contained rather more advanced cancers. There was quite a marked difference between the clinical assessment of the regional lymph nodes and the histological findings at dissection. This applied to the histologically positive as well as negative lymph nodes. A review of the literature shows that the present results are in keeping with previous publications which have shown that the treatment of choice in cancer of the vulva is ...

1. 1. Chronic vulval dystrophy is a term used to cover any chronic skin change of uncertain etiology which affects the vulva. It includes not only white lesions sometimes called leukoplakia, kraurosis, and lichen sclerosus, but also red lesions. 2. 2. Multiple vulval biopsy is indicated at the outset of the management of all women with a chronic vulval dystrophy. It aims to detect the presence of cancer or of atypical epithelial hyperplasia which may threaten cancer. 3. 3. The findings in a consecutive series of 294 patients, all of whom had had vulval discomfort for at least one year and who also showed naked-eye vulval skin changes are presented. 4. 4. In 8 cases cancer of some type was found to be present when the patient was first seen. Sixteen women proved to suffer from previously unsuspected diabetes and 9 had well-recognized skin diseases (mostly psoriasis) not specific to the vulva. The last 25 cases were excluded from further consideration. 5. 5. In 82 cases the lesion was essentially red in color, in 109 white, and in 78 partly red and partly white. 6. 6. Cancer was found in 5 red lesions, 2 white ones, and one in which the color was red and white. In one case, carcinoma in situ was found at the age of 23 years and may have been present since the age of 14 years. 7. 7. All patients were investigated for possible etiologic factors which included achlorhydria, deficiency states, monilial vulvitis, fungus infections in other parts of the body (notably the hands and feet), glycosuria, and allergy. 8. 8. Treatment was designed to oppose any possible etiologic factor discovered and, when none was found, fungicides and antihistamines were employed empirically. 9. 9. Partial or total vulvectomy was carried out in only 28 cases, and the dystrophy recurred in more than 50 per cent of these cases. Cancer developed later in one case. 10. 10. Treatment, mostly conservative, was attended by results better than expected. Of 216 women subsequently observed for periods up to 27 years, 82 were cured, 40 cured for intervals between relapses, and 50 improved. 11. 11. Carcinoma of the vulva supervened in only 4 women in this series and that at 7 months, 3 years, 4½ years, and 10 years after the patient was first seen. A fifth case of cancer, developing in a patient not included in this series but previously seen on account of vulval symptoms is mentioned. 12. 12. The likely development of carcinoma is usually foreshadowed by a finding of atypical epithelial activity on biopsy. Such a finding is an indication for vulvectomy although the operation does not necessarily protect the woman from cancer. Otherwise vulvectomy is not recommended as an empirical treatment except occasionally for small clearly circumscribed lesions, when it may be the best form of biopsy. 13. 13. The chance of cancer supervening on a vulval dystrophy within 3 to 25 years is small, not more than 4 to 5 per cent. But even this small risk means that women whose vulval complaint is not completely cured should be kept under observation and subjected to vulval biopsy at intervals if necessary. This is true even if the vulval dystrophy is treated by vulvectomy.

Establishment of a vulvar disease clinic on our service has dramatically increased the diagnostic acumen of the resident staff. In addition during the last 5 years 34 per cent of vulvar cancers diagnosed have been in the intraepithelial stage. More intensive and frequent use of biopsy of the vulva is advocated. Extensive vulvectomy is sufficient for the therapy of intraepithelial cancer. Lymphadenectomy is not necessary for the cure of noninvasive cancer. Eponyms have no place in predicating therapy, as all types of intraepithelial cancer have invasive potential.

Summary A series of 8 cases of superficial vulvectomy with primary free skin grafting is reported. With careful attention to technique almost 100 per cent take has been achieved. The cosmetic and functional results justify early excision of any chronic lesion of the vulvar epithelium; if more premalignant lesions were treated thus, the incidence of vulvar carcinoma might well be reduced.

A case of metastatic melanoma of the vagina and cervix is presented, with four-year survival to date, treated by an abdominoperineal resection. This combined approach allowed a radical hysterectomy, vaginectomy, and vulvectomy to be done in continuity.

1. One case of carcinoma of the vulva, occurring in a woman 37 years of age, for which wide vulvectomy, bilateral inguinal and pelvic lymphadenectomy and right lumbar lymphadenectomy and humbar sympathectomy were performed, is described. 2. The reasons for performing lumbar lymphadenectomy and lumbar sympathectomy as a prophylactie measure and its method of performance are presented and discussed. 3. Similarly, the reasons and a method for extending lymphadenectomy in carcinoma of the vulva to include the lumbar glands are given.

1.1. The etiology, symptomatology and treatment of leukoplakia and carcinoma of the vulva have been discussed. 2.2. A method of closure of the vulvectomy defect is described using primary skin graft of split thickness. Its value is (a) more extensive excision is possible with less chance of recurrence; (b) shorter hospital stay because of the fewer postoperative complications and better healing; (c) minimal scar tissue formation so that sexual function can be maintained. 3.3. We believe that this procedure shows the value of the cooperation between two specialty departments in a large general hospital working together as a team and giving the best treatment available for this condition at the present time.

A series of 127 patients presenting at two London hospitals with carcinoma of the vulva during the period 1948-70 is reviewed. Patients with intraepithelial carcinoma or rodent ulcer are excluded, but the series includes two cases of malignant melanoma, one of adenocarcinoma of Bartholin's gland, and two of basal cell carcinoma. In the remainder the pathological diagnosis was squamous cell carcinoma.Leucoplakia was present in only 30 cases (24%) and it is therefore concluded that this condition is probably not so dangerous as a precursor of cancer as has been stated in the past, though an association with cancer of the vulva is undeniable.In only three cases was no form of treatment practicable. Of the remaining 124, two were treated by radiotherapy, 37 by simple vulvectomy, 12 by vulvectomy followed by separate inguinal lymphadenectomy, and 73 by radical vulvectomy combined with bilateral lymphadenectomy en bloc, pelvic lymphadenectomy being included whenever the superficial lymph nodes appeared to be involved or when Cloquet's node was shown by frozen-section examination to be invaded. Excellent results, with an absolute five-year survival rate of 66%, were obtained with this last procedure, especially when primary skin cover was provided by the delayed technique (five-year survival 73%). The results of simple vulvectomy were also surprisingly good, with an absolute five-year survival rate of 65%, and this operation may be a wise choice for the very old or infirm patient.

The immunohistochemical (IHC) detection of MMR proteins is an accurate and rapid method to predict the presence of defective DNA MMR genes. MMR protein expression could also serve as a prognostic indicator of human cancers. The results of many studies demonstrate the usefulness of IHC tests with monoclonal antibodies MSH2 and MLH1 in screening the microsatellite sequence instability within both spontaneous and hereditary malignant neoplasms. The aim of our study was to perform an IHC estimation of the hMLH1 and hMSH2 expression in a subset of vulvar carcinomas according to HPV 16/18 status. The level of MMR proteins was further analyzed in relation to histoclinical features of the disease in either HPV-positive or -negative cancers. We identified archival diagnostic phase tissue specimens from 46 cases of vulvar cancer. From the same paraffin blocks containing material from the margin of surgical section during vulvectomy, normal epithelial tissue fragments were collected and designated as the control group. The characteristic of the lesion was examined in comparison with the presence of HPV DNA. Identification of the HPV 16/18 types was performed using PCR. IgG1 monoclonal antibodies detecting those epitopes characteristic for hMLH1 and hMSH2 were used in the study. In the analyzed cases of vulvar cancer, we have observed increased expression of proteins of both hMSH2 and hMLH1 genes compared to the control group. A comparison of the hMLH1 and hMSH2 protein expression levels showed that hMSH2 expression was higher than that of hMLH1 in the case of vulvar carcinomas. The performed analysis of correlation between individual parameters did not reveal statistically significant relationship with both the gradient and status of HPV 16/18. hMSH2 and hMLH1 were definitely interrelated.

An increasing number of women are now presenting for maternity care in the UK who have undergone FGM in their countries of origin and their daughters are also at risk. Yana Richens urges the judiciary, government and midwives to strengthen their stand.

This case report describes the use of a simple appliance for the control of the urinary stream in four patients who experienced difficulty voiding after radical vulvar surgical procedures.

SummaryLaser vulvectomy was performed in five patients with pruritus in association with chronic vulval dystrophy. Relief of pruritus was obtained in all the cases, and the appearance of the vulva was improved following the procedure. The main problem was postoperative pain.

Of 108 women treated for vulvar intraepithelial neoplasia between 1977 and 1984 at the Irvine Medical Center, University of California, and the Memorial Medical Center of Long Beach, Women's Hospital, 48 with multifocal and/or widespread lesions underwent skinning vulvectomy and split thickness skin graft reconstruction. Six women in the skinning vulvectomy sample had early stromal invasion in the vulvectomy specimen. Recurrences at intervals of four to 87 months occurred in 13 patients undergoing this procedure. The risk of recurrence did not appear to be related to the status of the surgical margins because seven of 22 patients with involved margins experienced recurrence compared with six of 26 with uninvolved margins.

When examined histologically, clinical leukoplakia of the vulva in the postmenopausal female exhibits features of lichen sclerosus et atrophicus (LSA) in most cases. Leukoplakia of the vulva has long been regarded as premalignant and in a number of previous series of invasive squamous carcinoma of the vulva, LSA was reported to be seen in association with the carcinoma in only 10–50% of cases. During the 12-yr period 1966–77, we have examined 924 tissue specimens of the vulva. Of these, 157 were malignant lesions, 106 being invasive squamous carcinoma and 36 being carcinoma in situ . A review of the pathological material taken from vulvectomy specimens of all the invasive squamous carcinoma in postmenopausal females disclosed that when 5–10 tissue blocks of the tumour and the vulval skin were examined, the association with LSA was 20–30%. However, when 15–30 blocks were examined, the association was 60–70%, many showing multifocal microinvasive carcinoma arising in areas of LSA while others showed adjacent LSA with dysplastic epithelium. Therefore, to assess reliably the distribution, incidence and premalignant potential of vulval LSA with squamous carcinoma, adequate tissue sampling of the primary tumour and the adjacent skin has to be done.

A case of primary melanoma of the vagina is reported in detail. An apparent cure of the disease has been obtained eighteen months after treatment by excision, vulvectomy, and radical dissection of both groins. A group of 17 previously recorded cases is also reviewed, and an account of the development and course of the disease is briefly given.

Vulvar involvement was found in ten (18%) of 53 females with von Recklinghausen's disease. Vulvectomy was necessary in only two of these ten patients. In distinguishing elephantiasis nervorum of the vulva from an intersex problem, the presence of cafe au lait spots and a familial history of neurofibromatosis are helpful clues.

The purpose of this paper is twofold: (1) to substantiate a preliminary report 1 concerning the treatment of pruritus vulvae by alcohol injection and (2) to report the results of four years' experience with the method, in forty-nine cases. Candidates for alcohol injection were selected only after every effort to determine the cause of the pruritus had failed. The majority of the patients had run the gamut of conservative therapy, including the use of antipruritic ointments, powders and lotions. Several had received ultraviolet irradiation and roentgen treatments, and one had undergone complete vulvectomy. None of these procedures had elicited more than temporary relief from the itching, which in many cases was becoming intolerable. The duration of pruritus varied from two months to thirty-five years, the average for the series being eight and seven-tenths years. The majority of the women at the time of injection were over 45, while the average

Nine years ago, I presented in theArchivesa review of my experiences with leukoplakic and malignant lesions of the vulval skin. Since that time I have had considerable additional experience and an opportunity to check up on the final outcome—the five year results—in these cases, so that it seems well to present a brief outline of the conclusions of these investigations. Forty cases of leukoplakia and 76 cases of cancer of the vulva seen since 1906 are the basis of this study. The material has been available in part through the cooperation of my fellow gynecologists and through the reference of cases by Drs. M. F. Engman, W. H. Mook and Richard S. Weiss. In a large majority of these 116 cases, material was obtained for histologic study through a partial or complete vulvectomy or through biopsy excisions. LEUKOPLAKIC VULVITIS First, in regard to the so-called "precancerous" lesions known

The purpose of this paper is to form some estimate of the efficacy of neurectomy of sensory nerves in the treatment of certain irritative lesions of the female external genitalia. The intolerable itching which may be associated with such conditions as kraurosis, leukoplakic vulvitis and pruritus of the vulva with or without lichenification is often particularly resistant to local medication, whether this consists in the application of drugs or in exposure of the region to roentgen or actinic rays. This distressing symptom not only leads to excoriation of the parts, but also reduces the physical and moral stamina of the patient by depriving her of sleep. Two surgical procedures are available for the treatment of these conditions: vulvectomy and section of the sensory nerves to the parts. The choice of operation may be simplified by the occasional appearance of malignant lesions in the course of one of these diseases, a

Kraurosis vulvae is a rare disease occurring about the time of the menopause or later. It is characterized by intense itching of the vulva and various stages of inflammation and leukoplakia of the labia minora, clitoris and vaginal orifice. The diseased tissue is brittle and consequently fissures readily. These fissures are tender and painful. The subsequent course of kraurosis vulvae is that of atrophy, leukokeratosis and eventually epitheliomatosis. Kraurosis vulvae is chronic, is unresponsive to topical treatment and leads to serious complications. Cole stated the belief that kraurosis vulvae always eventuates in cancer if it continues sufficiently long. To date surgical intervention has been considered the best form of therapy. However, to be effective vulvectomy must be extensive, with subsequent loss of (sexual) function and disfigurement. Although injections of alcohol or sclerosing fluids may produce good results, the relief is temporary, and there is always the danger of sloughing. Roentgen