GYNECOLOGIC

ONCOLOGY

44,

191-194

(1992)

CASE REPORT An Unusual Presentation of Vulvar Carcinoma in a HIV Patient G. GIORDA, M.D.,*

E. VACCHER, M.D.,? AND

*Department

of Gynecologic

Oncology,

tDepartment

R. VOLPE, M.D.,3 G. DEPIERO, M.D.,* C. SCARABELLI, M.D.*

of Medical Oncology, Aviano I-33081, Received

April

and $Department Italy

of Pathology,

U. TIRELLI, Centro

Riferimento

M.D.,? Oncologico,

3, 1991

tibodies).

The patient presented with a rapid growth of

A report of a caseof rapidly growing vulvar cancerassociated with vulvar condylomasin a patient with HIV infection is given. preexistent vulvar condylomas in the last few months, This aggressivetumor resembles thoseepithelial tumorsobserved associated with vulvar burn and discomfort that were the in womenwith iatrognic immunosuppression and lymphoid neo- actual reason for her being referred to our institution. Physical examination revealed thrush, hepatomegalia, plasiacurrently observedin HIV patients. o PWZ Academic pr=, I,,~. INTRODUCTION

The link between HPV infection and vulvar intraepithelial neoplasia or invasive cancer of the vulva is well established. A high incidence of HPV infection in women with iatrogenic immunosuppression, such as after renal transplantation [ 1,2], has also been demonstrated. Moreover, men and women with HIV infection antibodies have an increased chance of developing anogenital HPV infection, sometimes associated with either intraepithelial or invasive cervical [3,4] and anogenital neoplasm [5-71. Until now, however, an invasive vulvar cancer associated with an overt clinical HPV infection in a patient with HIV infection has never, to our knowledge, been reported. CASE REPORT

A 27-year-old woman, gravida 0, and a current intravenous drug abuser, was referred to the AIDS Unit of Centro Riferimento Oncologico, Aviano, Italy, with a complaint of vulvar discomfort related to a vulvar mass of 13 cm in diameter involving the left side of the vulva (Fig. 1). Her past history revealed a long history of drug addiction, multiple sexual partners, sexually transmitted diseases such as vulvar condylomas and syphilis, and HIV infection that dated back to 1985 (positive for HIV an-

and bilateral enlargement of axillary and inguinal nodes. Laboratory investigation revealed a white cell count within the normal range, a decreased hemoglobin concentration (9.3 g/dl), a decreased helper T4 limphocytes count (302/pm3), and a positive serology for syphilis. She was assigned to group IV C2 of HIV infection according to CDC. After a preliminary vulvar biopsy revealing an invasive squamous cell carcinoma, the patient was considered a candidate for a radical surgery, and a radical vulvectomy with bilateral inguinal limphoadenectomy was performed. Pathology evaluation of the surgical specimen demonstrated a moderately differentiated keratinized invasive squamous cell carcinoma, within a giant condyloma (Figs. 2 and 3) and a lymph node metastasis in one left inguinal node. The postoperatory period was characterized by incomplete and prolonged wound healing and intractable painful symptomatology in the lower back and perineal region. At discharge, 1 month later, the surgical wound was almost completely healed, and an adjuvant radiotherapy course after complete healing was planned. Twenty-five days later, the patient developed a vulvar relapse 9 cm in diameter, so that high-energy external radiotherapy was undertaken. Concomitantly, 500 mg zydovudine was given daily. A course of 50 Gy was performed, and the tumoral mass decreased to an extent greater than 50% of the initial bulk. After discharge, with planned follow-up as an outpatient, the woman was lost to follow-up and died 9 months later.

191 0090~8258/92 $1.50 Copyright 0 1992 by Academic Press, Inc. All rights of reproduction in any form reserved.

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ET AL.

FIG. 1. Vulvar carcinoma of 13 cm in diameter involving the left side of the vulva.

DISCUSSION Invasive vulvar cancer usually develops in the sixth to seventh decade of a woman’s life, with a mean age of 61 years and a well-established relationship with previous HPV infection [8]. In other instances a sharp decrease of mean age incidence of this tumor in immunosuppressed women after renal transplantation has been observed, and

in fact the mean age of women developing invasive anogenital cancer in this setting was 42 years [9]. Moreover in immunosuppressed women a high incidence of vulvar intraepithelial neoplasia, frequently multifocal, associated with HPV infection, also involving other sites of the lower genital tract has been found, so that the concept of a “field effect” has been elicited [2,9]. However, the development of intraepithelial neoplasia

FIG. 2. Histologic section of atypical condyloma. Koilocytes with enlarged nuclei and vacuolated cytoplasm can be seen throughout epithelium (hematoxylin and eosin, X 160).

the

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CASE REPORT

FIG. 3. Obvious squamous cell carcinoma infiltrating at the edge of condyloma (hematoxylin and eosin,

does not seem to be related to immunosuppression per se, as it has been demonstrated that in immunosuppressed women there is a strong association between developing abnormal cytopathology and having more than two sexual partners [ 11. There are numerous papers reporting a wide correlation between HIV infection and increased incidence of either intraepithelial or invasive lower genital tract neoplasia [4, 10-121. A correlation of neoplastic changes with clinical or subclinical HPV infection in homosexual HIV-seropositive men [6] has also been shown, with a significant association with a decreased helper-suppressor T lymphocyte ratio [7]. However, until now, an invasive vulvar carcinoma in a HIV-seropositive woman has never been reported and, moreover, our case report presents other interesting matters of discussion. First, the age of onset is quite unusually low, suggesting that the promoting effect of HPV has probably added to a field of acquired, noniatrogenic immunosuppression. Second, this tumor behaved in a very aggressive manner, resembling the tumultuous dissemination of non-Hodgkin’s lymphomas in patients with HIV infection [13]. This case report can be compared to that of Rellihan et al. [14], who presented a stage IIb cervical carcinoma in a 32-year-old HIV-positive woman, treated with external radiotherapy. After an initial improvement, when no further disease was detectable, there was, 2 months later, a widespread dissemination of metastasis to vulva and inguinal, paraortic, and mediastinal nodes and subsequent death from disseminated cancer. Our observation, although not substantiated bv nost-

x

160).

mortem evaluation, may therefore suggest that this unfavorable and rapid course, quite unusual in the natural history of vulvar carcinoma, is strongly related to AIDS infection, as it was in the case reported above. REFERENCES 1. Halpert, R., Fruchter, R. G., Sedhs, A., Butt, K., Boyce, J. G., and Sillman, F. Human papillomavirus and lower genital neoplasia in renal transplant patients, Obstet. Gynecol. 68, 251-258 (1986). 2. Sillman, F., Stanek, A., Sedlis, A., Rosenthal, J., Lanks, K. W., Buchhagen, D., Nicastri, A., and Boyce, J. The relationship between human papillomavirus and lower genital intraepithelial neoplasia in immunosuppressed women, Am. J. Obstet. Gynecol. 150, 300-308 (1984). 3. Miyazaki, K., Yamaguchi, K., Takatsuki, K., Fujiasaki, S., and Okamura, H. Letter to the editor, Gynecol. Oncol. 37, 306 (1990). 4. Spurret, B., Shelley, Jones, D., and Steward, G. Cervical dysplasia and HIV infection, Lancer i, 237-238 (1988). 5. Byrne, M. A., Taylor-Robinson, D., Munday, P. E., and Harris, J. R. W. The common occurence of human papillomavirus infection and intraepithelial neoplasia in women infected by HIV, AIDS 3, 379-382 (1989). Palefsky, J. M., Gonzales, J., Greenblatt, R. M., Ahn, D. K., and 6. Hopander, H. Anal intrepithelial neoplasia and anal papillomavirus infection among homosexual males with group IV HIV disease, JAMA 263, 2911-2916 (1990). 7. Frazer, H. I., Medley, G., Crapper, R. M., and Brown, T. C. Association between anorectal dysplasia, human papillomavirus, and human immunodeficiency virus infection in homosexual men, Lnncet

ii, 657-660

(1986).

8. Hoskins, W. J., Perez, C., and Young, R. Gynecologic tumors, in Cancer: Principle and practice of oncology (R. Devita, Ed.), Lippincott, Philadelphia, 3rd ed., pp. 1099-1118 (1988).

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9. Penn, I. Cancer of the anogenital region in renal transplant recipients, Cancer 58, 611-616 (1986). 10. Maiman, M., Fruchter, R. G., Serur, E., and Boyce, J. G. Prevalence of human immunodeficiency virus in a colposcopy clinic, JAMA 260, 2214-2215 (1988). 11. Provencher, D., Valme, B., Averette, H. E., Ganjei, P., Donato, D., Penalver, M., and Sevin, B. U. HIV status and positive Papanicolau screening: Identification of a high-risk population, Gynecol. Oncol. 31. 184-190 (1988).

ET AL. 12. Bradbeer, C. Is infection with HIV a risk factor for cervical intraepithelial neoplasia? Lancer Ii, 1277-1278 (1987). 13. Knowles, D. M., and Raphael, B. G. Acquired immunodeficiency syndrome-associated non-Hodgkins’ lymphoma, Semin. Oncol. 17, 361-372 (1990). 14. Rellihan, M. A., Dooley, D. P., Burke, T. W., Berkland, M. E., and Longfield, R. N. Rapidly progressing cervical cancer in patient with human immunodeticiency virus infection, Gynecol. Oncol. 36, 435-438 (1990).

An unusual presentation of vulvar carcinoma in a HIV patient.

A report of a case of rapidly growing vulvar cancer associated with vulvar condylomas in a patient with HIV infection is given. This aggressive tumor ...
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