Fabrizio Bogliatto

The 2015 International Society for the Study of Vulvovaginal Disease (ISSVD) Terminology of Vulvar Squamous Intraepithelial Lesions

OBJECTIVES: The impact of terminology for vulvar intraepithelial lesions has been significant over the years, because it has affected diagnosis, treatment, and research. The introduction of the Lower Anogenital Squamous Terminology (LAST) in 2012 raised 2 concerns in relation to vulvar lesions: firstly, the absence of reference to “differentiated vulvar intraepithelial neoplasia” (differentiated VIN) could lead to its being overlooked by health care providers, despite its malignant potential. Secondly, including the term “low-grade squamous intraepithelial lesion” (LSIL) in LAST recreated the potential for overdiagnosis and overtreatment for benign, self-limiting lesions. MATERIALS AND METHODS: The International Society for the Study of Vulvovaginal Disease (ISSVD) assigned the terminology committee the task of developing a terminology to take these issues into consideration. The committee reviewed the development of terminology for vulvar SILs with the previous 2 concerns in mind and reviewed several new terminology options. RESULTS: The final version accepted by the ISSVD contains the following: 1) Low-grade SIL of the vulva or vulvar LSIL, encompassing flat condyloma or human papillomavirus effect. 2) High-grade SIL or vulvar HSIL (which was termed “vulvar intraepithelial neoplasia usual type” in the 2004 ISSVD terminology). 3) Vulvar intraepithelial neoplasia, differentiated type. CONCLUSION: The advantage of the new terminology is that it includes all types of vulvar SILs, it provides a solution to the concerns in relation to the application of LAST to vulvar lesion, and it is in accordance with the World Health Organization classification as well as the LAST, creating unity among clinicians and pathologists.

Groin lymphadenectomy with Preservation of Femoral Fascia: Total Inguinofemoral Node Dissection for Treatment of Vulvar Carcinoma

This article describes a new technique for groin lymphadenectomy with preservation of the femoral fascia based on correct embryologic and anatomic knowledge of inguinofemoral lymph node disposition and their exact relation with the fascial structures of Scarpa’s triangle. Scarpa’s triangle dissection follows a three-step procedure: development of the side starting from the inguinal ligament; development of the angles proceeding from the apex where the saphenous vein is resected; and dissection of the fossa ovalis by grasping and elevating the entire block of adipose tissue containing the superficial inguinofemoral nodes and the stump of the great saphenous vein. This surgical step allows us to expose and remove en bloc the deep femoral nodes lying medial to the portion of the femoral vein located within the fossa ovalis. The total number of inguinofemoral nodes removed from a series of 156 patients operated on during 1981–2002 ranged from 8 to 35 (mean 20) bilaterally and from 4 to 18 (mean 10) unilaterally. The 5-year survivals by stage were, respectively, 86.2% for stage Ib, 69.2% for stage II, 49.3% for stage III, and 13.3% for stage IVa; these figures are comparable to the survival rates reported by those performing the classic groin lymphadenectomy. Groin lymphadenectomy with preservation of the femoral fascia is thus an oncologically sound conservative procedure that can replace the classic Way’s technique, which involves femoral vessel skeletonization, and can be useful for treating malignant diseases requiring groin dissection.

The 2015 International Society for the Study of Vulvovaginal Disease (ISSVD) Terminology of Vulvar Squamous Intraepithelial Lesions.

Objectives The impact of terminology for vulvar intraepithelial lesions has been significant over the years, because it has affected diagnosis, treatment, and research. The introduction of the Lower Anogenital Squamous Terminology (LAST) in 2012 raised 2 concerns in relation to vulvar lesions: firstly, the absence of reference to “differentiated vulvar intraepithelial neoplasia” (differentiated VIN) could lead to its being overlooked by health care providers, despite its malignant potential. Secondly, including the term “low-grade squamous intraepithelial lesion” (LSIL) in LAST recreated the potential for overdiagnosis and overtreatment for benign, self-limiting lesions. Materials and Methods The International Society for the Study of Vulvovaginal Disease (ISSVD) assigned the terminology committee the task of developing a terminology to take these issues into consideration. The committee reviewed the development of terminology for vulvar SILs with the previous 2 concerns in mind and reviewed several new terminology options. Results The final version accepted by the ISSVD contains the following: •Low-grade SIL of the vulva or vulvar LSIL, encompassing flat condyloma or human papillomavirus effect. •High-grade SIL or vulvar HSIL (which was termed “vulvar intraepithelial neoplasia usual type” in the 2004 ISSVD terminology). •Vulvar intraepithelial neoplasia, differentiated type. Conclusions The advantage of the new terminology is that it includes all types of vulvar SILs, it provides a solution to the concerns in relation to the application of LAST to vulvar lesion, and it is in accordance with the World Health Organization classification as well as the LAST, creating unity among clinicians and pathologists.

Relationships between Gastric Development and Anatomic Bases of Radical Surgery for Cancer

Abstract The aim of this study was to determine with all possible accuracy the processes of embryologic development of the stomach and its lymphatics in order to confirm their supposed link with the modern anatomic bases of gastric cancer surgery. The knowledge of the anatomic behavior of the peritoneal folds and of the lymphatic drainage of the stomach is, in fact, considered the essential basis for the comprehension of the oncologic dissection of the stomach. The study was based on reconstruction of serial histologic sections of 9 human embryos and 8 human fetuses regarding the mesogastric area, as well as anatomic microdissection of 2 9-month fetuses. The proximal part of the stomach is not involved in the rotation mechanism of the other portions; the lesser sac development follows cranial migration of the spleen; the cardiac (pars cardiaca gastris) area is in continuity with the zone of paraaortic lymph node development; lateral and posterior lymph nodes of the hepatoduodenal ligament do not take origin in the dorsal mesogastrium: they develop together with the common bile duct and the ventral pancreas inside the mesoduodenum; the fusion of the dorsal mesogastrium and the gastric fundus with the posterior abdominal wall appears late in development. The embryologic study of the mesogastric area clarifies the real mechanism of development of the stomach and its lymphatic pathways with some differences from classic reports; these results agree with the more recent modification of the lymph nodes classification used in the radical treatment of gastric cancer.

LAST terminology applied to the vulva: the challenge of VIN continues.

cancer programs, including myself, must make decisions about optimizing quality of care today, not at some unspecified point in the future. Visual inspection with acetic acid–based strategies are becoming widespread and improving access to screening. We believe that these programs should be supported and strengthened by incorporating QA activities. Our manuscript illustrates the potential benefit of one such QA approach.

Speaking the Same Language: Using Standardized Terminology.

T erms are words and compound words or multiword expressions that in specific contexts are given specific meanings. Within the clinical sciences, we use terms to describe findings, diagnoses, diseases, and treatments. Terminology is the discipline of designating termswithin a particular field. A standardized terminology provides an established comprehensive set of recommended terms. Within the clinical sciences, standardized terminologies are generally established by consensus agreement to the judgment reached by a group as a whole. The system of choosing or revising names of terms is nomenclature. Nomenclature is the naming of terms (from the Latin nomen [name] + calator [caller]). Although sometimes used as a synonym for terminology, we understand nomenclature to be the system for devising or choosing names, which are the body of named terms that belong to a specific terminology. A classification is the systematic grouping and organization of the terms of a specific terminology into classes or categories, based on characteristics in common. A clinical practice guideline is a comprehensive, consensus, or evidence-based aid for clinicians managing patients with abnormal findings, cytology, histopathology, or clinical diagnosis. Often, clinical practice guidelines use a precise nomenclature and may seek to establish a standardized terminology for a specific field of clinical science. There are many standardized terminologies within the field of anourogenital diseases. These are continuously evolving and typically updated every few years as understanding increases. Although intended to provide comprehensive and unambiguous classification, some of the terminologies overlap and may differ from one another in measuring magnitude of change from normal to abnormal. As a consequence, some clinical research was conducted at the time of 1 terminology and published after a newer standardized terminology has taken hold. Expert colleagues belonging to different specialties and cultures may not agree on the standardized terminology during a given period. Readers of journals may be confused by competing terms for similar or related conditions. As examples, the terms “Pap smear” and “Pap test” may be replaced by “cervical cytology” and the term “dysplasia” has been replaced by “intraepithelial lesion.”As 1 example, the Lower Anogenital Squamous Terminology (LAST) recommendations standardized biologically relevant histopathologic terminology for human papillomavirus– associated squamous intraepithelial lesions and superficially invasive squamous carcinomas across all lower anogenital tract sites detailed the appropriate use of specific biomarkers to clarify histologic interpretations and enhance diagnostic accuracy. A standardized terminologywill facilitate the ability of 2 or more clinicians, sites of care, healthcare systems, or countries to exchange and apply health research and information in a meaningful way for their patients. The importance of a standardized terminology is highlighted by these following aspects:

Vulvar Intraepithelial Neoplasia (VIN) and Condylomata.

Human papillomavirus (HPV) infection of the lower genital tract is common and its effects are variable. The majority of infections are transient and the related pathology is self-resolving. Condyloma accuminatum is caused predominantly by HPV 6, 11 and can be managed with medical or surgical therapy. Vulvar intraepithelial neoplasia is a treatable precursor to vulvar cancer with 2 main forms: one related to HPV and the other to chronic vulvar inflammatory conditions. It may be treated medically, surgically, or potentially via the use of therapeutic HPV vaccines. Preventive utilization of a quadrivalent HPV vaccine has the potential to decrease HPV-related lower genital disease burden substantially.

Vulvodynia: When a Paradigm Challenges the Management

I n many disciplines of science, new advances and theory are slowly adopted. Once accepted, they become a paradigm, a collective set of beliefs and theories of the existing scientific leaders. The adoption of new principles and concepts that form the basis of a paradigm help the clinicians successfully navigate through states of health and disease. One disease may have multiple causes, and one initiating factor may cause multiple diseases. Following a paradigm facilitates the diagnosis and treatment of a condition. Nevertheless, this model of action may induce a simplification and generalization of the management in cases of complex disease. Vulvar pain is a disease process characterized by complex high order dysfunction. Understanding the underlying mechanisms causing pain is a challenge for the physicians dealing with this symptom. Over time, medical research in this field supported a deeper explanation of pain process, and this has led to proposed terminologies and classifications to categorize vulvar pain into a single nomenclature, understandable and easy to use. The past attempts included vestibulitis, dysesthesia, and vulvodynia. Vulvodynia is the best term to identify vulvar pain without a clear identifiable cause (idiopathic). The term vulvodynia fits the role of a medical paradigm. Many clinicians, not trained in vulvar diseases and belonging to different medical specialties, have adopted this term with a reductionistic approach. Consequently, vulvar pain is not treated with a dynamic functional and individualized model, based on an intricate understanding of the nature of the interaction of the potential factors. Vulvodynia, in this limiting paradigmatic adaptation, encompasses all the different causes of pain affecting vulvar area. Under this basic general framework, the management of vulvar pain may be limited to narrow actions, according to single specialist perspective, without a broad multidisciplinary approach. The paradigm of vulvodynia becomes meaningless in the light of the understanding of the basic mechanisms of dysfunction of the entire human body. The success of the therapy rests not on making a descriptive diagnosis but upon a proper assessment of the etiologic factors (and they are often multiple). Several causes have been proposed for vulvodynia: recurrent Candida infections, hormonal factors, genetic factors, altered immunoinflammatory response, allergic reaction, chronic inflammation, increased urinary oxalates, neuropathic changes, persistent afferent C-fiber activation, embryological abnormalities, psychosomatic disorders, and pelvic floor overactivity. Often, more than one cause contributes to pain origin.

Ambulatory Surgery Center Experience: Perioperative Complications After Cervical High-Grade Squamous Intraepithelial Lesion Excision.

M ost cervical high-grade squamous intraepithelial lesions (HSILs) are now treated in the outpatient setting, and large loop excision of the transformation zone (LLETZ) procedure has become the key intervention. Generally, LLETZ is considered to have low surgical morbidity; however, little is known about perioperative complications after this procedure in an ambulatory surgery center (ASC) setting. Ambulatory surgery provides all the safeguards that are standard in a general hospital operating rooms, while ensuring rapid postoperative recovery, safe discharge, maintenance of clinical records, and costs reduction. The present series was undertaken to review the advantages of LLETZ performed according to ASC quality assessment.