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Diagnostik und Therapie von Dysplasien und malignen Tumoren der Vulva

Vulvar cancer compromises about five percent of malignancies of the female genital tract. It is predominantly a cancer of the postmenopausal woman (mean age at diagnosis 65 years) although rising numbers in the age group under 50 were observed over the past years. Risk factors for vulvar cancer and intraepithelial neoplasia, ist potential precursor lesion, include vulvar dystrophy (e.g. lichen sclerosus), cigarette smoking, human papillomavirus (HPV) infection and immunodeficiency syndromes.

Over 90% of vulvar cancers are squamous cell carcinomas. As the intraepithelial lesions they can be subdivided in HPV associated lesion and HPV independent lesion. HPV associated lesions are mostly seen in younger women and tend to be multifocal (basaloid type) whereas HPV independent lesions are often unifocal, combined with vulvar dystrophy and affect mainly postmenopausal women (simplex type). Other histologic types of vulvar cancer include melanoma, Bartholin gland adenocarcinoma, sarcoma, Paget's disease or basal cell carcinoma.

Diagnosis of vulvar intraepithelial neoplasia and cancer is based on clinical examination, thorough colposcopy of vulva, cervix and vagina and biopsy of the suspect lesion. Additional radiographic and endoscopic studies can be considered for women with large tumors or suspect metastasis.

Treatment of the disease is depending on ist stage and histological findings. For carcinoma first and foremost surgery (to varying extent) is performed, a lymphadenectomy (ipsilateral or bilateral) is added for all stages of invasive disease except stage 1a. As the inguinofemoral lymph node status is of capital importance for the prognosis, sentinel node biopsy to avoid complete groin dissection is still under investigation and not yet the standard clinical option. Adju vant radiotherapy of the groin and pelvis will be necessary if at least two inguinofemoral lymph nodes are positive. Primary radiotherapy or (radio)chemotherapy can be an option for inoperable disease.

Given the rising numbers of younger women affected by vulvar cancer this disease should mainly be treated and followed in specialized centres to avoid a loss of life quality due to improper treatment.

Jörg Schwarz, Linn Wölber

Reviewer: Marcus Schmidt, Mainz
und Roberto Kurzeja, Berlin

CME Prakt Fortbild Gynakol Geburtsmed Gynakol Endokrinol 2007;3(2):64-75