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04. Suárez C (215-220) Neoplasia intraepitelial vulvar - Carmen Suárez y col. 215 ARTÍCULO ORIGINAL Rev Venez Oncol 2003;15(4):215-220 NEOPLASIA INTRAEPITELIAL VULVAR. EXPERIENCIA EN EL HOSPITAL ONCOLÓGICO PADRE MACHADO CARMEN SUÁREZ, ALIRIO MIJARES, JOSEPMILLY PEÑA, SHEILA MEDINA, JOSEFA MARÍA BRICEÑO, IGOR MATA. SERVICIO DE GINECOLOGÍA, HOSPITAL ONCOLÓGICO PADRE MACHADO, CARACAS, VENEZUELA RESUMEN SUMMARY OBJETIVOS: Presentar los resultados obtenidos en el OBJECTIVES: To present the results attained during the manejo de las neoplasias intraepiteliales vulvares, en el management of vulvar intraepithelial neoplasia, at the Hospital Oncológico Padre Machado. MÉTODOS: Hospital Oncológico Padre Machado. METHODS: We Presentamos la revisión retrospectiva de 43 historias present a retrospective review of 43 medical records of clínicas de pacientes con diagnóstico de neoplasia patients with a diagnosis of vulvar intraepithelial neoplasia intraepitelial vulvar desde 1990 a el 2000, en el Servicio between the years 1990 and 2000 at the Gynaecologic de Ginecología del Hospital Oncológico Padre Machado. Oncology service of the Hospital Oncológico Padre Evaluamos los aspectos clínicos, clasificación, manejo y Machado. Clinical aspects, histologic classification, recurrencia. RESULTADOS: Todas las pacientes tenían management and outcome were registered. RESULTS: edades comprendidas entre 17 y 74 años y diagnóstico de All the patients had ages understood between 17 and 74 neoplasias intraepiteliales vulvares por estudio years old. The histologic type diagnosed more frequently histológico. El tipo más frecuente fue neoplasias was vulvar intraepithelial neoplasia III (44.18 %). Genital intraepiteliales vulvares III representando 44,18 % de los human papilloma virus infection was present in all cases. casos. En todos los casos hubo infección por virus Most of the patients to the moment of the diagnosis were papiloma humano genital asociado. La mayoría de las asymptomatic. At the physical exam, 48.3 % of cases had pacientes al momento del diagnóstico eran asintomáticas. verrucous lesions located mainly at the labia majora. Al examen físico el 48,3 % de las pacientes tenían lesiones 86 % were treated surgically with dermovulvectomy and tipo verrugosa, localizadas principalmente en los labios immediate reconstruction with local flaps. CONCLU- mayores. El 86 % de las pacientes fueron tratadas SIONS: The neoplasia intraepitelial vulvar is a not very quirúrgicamente con dermovulvectomía y reconstruidas frequent pathology in the gynecological consultation. de forma inmediata con colgajos locales. CONCLU- Diagnosis is histopathological, patients are generally SIONES: La neoplasia intraepitelial vulvar es una asymptomatic and the most frequent clinical presentation patología poco frecuente en la consulta ginecológica. El is a verrucous lesion. Surgery is the treatment of choice. diagnóstico es histológico, son generalmente asintomá- Dermovul-vectomy is recommended for vulvar ticas presentándose como una lesión verrugosa. El intraepithelial neoplasia III in order to rule out invasive tratamiento de elección es quirúrgico, recomendándose la lesions. dermovulvectomía en casos de neoplasias intraepiteliales vulvares III para así descartar lesiones invasoras. KEY WORDS: Intraepithelial vulvar neoplasia, diagnosis, dermovulvectomy, treatment, surgery. PALABRAS CLAVE: Neoplasia intraepitelial vulvar, diagnóstico, dermovulvectomías, tratamiento, cirugía. INTRODUCCIÓN Recibido: 12/08/2002 Revisado: 16/09/2002 Aceptado para publicación: 18/6/2003 Correspondencia: Dra. Carmen María Suárez os trastornos epiteliales de la piel Coordinación Docente, Piso 4, Hospital Oncológico y la mucosa vulvar no se ven con Padre Machado frecuencia en la práctica clínica, Av. Alejandro Calvo Lairet, El Cementerio, L siendo la mayoría de las veces no Caracas, 1070, Venezuela. Teléfono: (0414)3312678 Rev Venez Oncol 215 216 Neoplasia intraepitelial vulvar - Carmen Suárez y col. diagnosticados de manera precoz por la falta de RESULTADOS atención en el examen de la región vulvar. Durante las dos últimas décadas se han La edad media de presentación de la enfer- producido grandes cambios en la terminología medad fue 42,46 años (rango: 17 a 74 años). Se de las alteraciones vulvares, generando diagnosticó VIN I en 15 casos (34,88 %), VIN desacuerdos entre los ginecólogos oncólogos, II en 9 casos (20,93 %) y VIN III en 19 casos dermatólogos y patólogos que evalúan y tratan (44,18 %). La mayoría de las pacientes para el estas lesiones. Por ser nuestro hospital un momento del diagnóstico estaban asintomáticas centro de referencia nacional se han reunido un (41,86 %). Entre las que presentaban número significativo de casos a través del sintomatología, lo más frecuente fue el prurito tiempo. Es de hacer notar que la incidencia ha (27,90 %) seguido de la presencia de una lesión aumentado en los últimos años, relacionándose verrugosa en la vulva en 9 pacientes (20,93 %). esto con el aumento de la infección del virus del Cuando se analizaron las enfermedades papiloma humano (VPH) a nivel genital en asociadas se verificó que 100 % de las pacientes nuestras pacientes y, con un examen físico más tenían diagnóstico de VPH genital. Trece cuidadoso en la población de riesgo, que se pacientes (30,23 %) tenían diagnóstico de traduce en diagnósticos más frecuentes y neoplasia intraepitelial cervical (NIC), 7 de las precisos. El objetivo de este trabajo es analizar pacientes (16,27 %) tenían antecedentes de la casuística de la neoplasia intraepitelial vulvar carcinoma de cuello uterino tratado con (VIN) en el Hospital Oncológico Padre radioterapia y una paciente tenía diagnóstico de Machado, evaluando aspectos diagnósticos y linfoma tipo Hodking (2,32 %). Al examen de tratamiento y, realizar una revisión de la físico de las pacientes se apreciaron lesiones literatura. verrugosas en 21 (48,83 %), 2 lesiones hiperpigmentadas (4,65 %), 2 úlceras (4,65 %) MÉTODOS y una leucoplasia (2,32 %). En 17 pacientes sólo se apreció la lesión mediante vulvoscopia, Se analizaron retrospectivamente las histo- que evidenció la presencia de zonas de epitelio rias clínicas de 43 pacientes con diagnóstico de blanco al acético (39,53 %). La mayoría de las neoplasia intraepitelial vulvar (VIN) en el lesiones se encontraron ubicadas a nivel de los Servicio de Ginecología del Hospital labios mayores (46,51 %) y la horquilla vulvar Oncológico Padre Machado en un período de 10 (41,86 %) encontrándose localizadas en labios años, desde el año 1990 hasta el año 2000, menores en 4 casos y en el clítoris en un caso. registrándose la edad de las pacientes, modo de Se realizó biopsia incisional en el 79,06 % de presentación, antecedentes, enfermedades los casos y escisional en 9 pacientes (20,93 %). asociadas, tipo histológico, tratamiento, El tratamiento utilizado con mayor frecuencia recurrencia y tiempo de seguimiento. Se fue la dermovulvectomía (41,86 % de los casos). tabularon los datos utilizando Access 2000 para Todas las pacientes tratadas con dermo- Windows (Microsoft Corp., EE.UU). Las vulvectomía se reconstruyeron inmediatamente variables se expresaron en forma de promedio y con colgajos locales. No se registraron compli- porcentaje, realizándose un análisis descriptivo caciones inherentes al tratamiento quirúrgico. de las mismas. Las biopsias posoperatorias se correspon- Para el análisis del tratamiento de las dieron en 34 casos con el diagnóstico pacientes se excluyeron 6 que no fueron preoperatorio; sólo en 2 pacientes se evidenció manejadas en nuestro centro. la presencia de una lesión invasora asociada. Vol. 15, Nº 4, diciembre 2003 Neoplasia intraepitelial vulvar - Carmen Suárez y col. 217 Los márgenes de las piezas operatorias fueron pacientes) la mayoría se presentó de forma libres en 30 pacientes. En 6 pacientes con asintomática, el promedio de edad fue de 42,26 diagnóstico histológico de VIN III se años, estuvieron asociadas con NIC y VPH, en evidenciaron márgenes de resección con lesión: la mayoría se apreció al examen físico un epitelio un solo caso fue reintervenido realizándose blanco al acético a nivel de la horquilla vulvar ampliación de márgenes y, reportando la biopsia y el tratamiento más frecuente fue la posoperatoria la presencia de VIN I. En el dermovulvectomía en 14 casos (73,57 %). grupo de pacientes con diagnóstico de VIN I se evidenciaron márgenes tomados en la pieza DISCUSIÓN operatoria en un solo caso. Dicha paciente fue controlada periódicamente, no necesitando reintervención. El término de neoplasia intraepitelial vulvar fue introducido en 1980 para designar las atipias El promedio de seguimiento fue de 19 meses. epiteliales escamosas severas y el carcinoma de Recidivaron 2 pacientes: la primera paciente células escamosas in situ de la vulva. La con diagnóstico histopatológico de carcinoma terminología del VIN fue adoptada por la invasor resecado con márgenes negativos y, Sociedad Internacional de Estudios de las libre de enfermedad hasta el quinto año de Enfermedades Vulvares en 1986 (1). El seguimiento, cuando se diagnosticó un VIN I diagnóstico es histopatológico y, se caracteriza tratado con dermovulvectomía; la segunda por la pérdida de la arquitectura epitelial paciente, con diagnóstico de VIN II, presentó al asociada a hipercromatismo y pleomorfismo tercer año de seguimiento un VIN I focal, que nuclear, presencia de atipias, mitosis anormales, fue tratado con la biopsia diagnóstica. disqueratosis, paraqueratosis e hipercromatismo Analizando los casos según la clasificación (2,3). Estas lesiones se catalogan
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