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Voss FO, Groenewegen KL, Vermaat H, Bleeker MCG, van Beurden M. Prevalence of prescribing topical corticosteroids to patients with lichen sclerosus following surgery for vulvar cancer: a survey among gynaecologic oncologists in The Netherlands. J OBSTET GYNAECOL 2024; 44:2294330. [PMID: 38156715 DOI: 10.1080/01443615.2023.2294330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 12/09/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Vulvar lichen sclerosus (LS) is a chronic inflammatory dermatosis which can progress to precursor lesion differentiated vulvar intraepithelial neoplasia (dVIN) and vulvar squamous cell carcinoma (VSCC). The risk of developing recurrent vulvar cancer following LS-associated VSCC is high. Evidence suggests that treatment of LS with topical corticosteroids (TCS) can prevent progression to dVIN, VSCC and recurrences. However, current guidelines do not give any recommendation on the management of LS following surgery for VSCC. The aim of this study was to conduct a survey among all registered gynaecologic oncologists (GOs) in the Netherlands to evaluate the current management of LS patients without a history of VSCC (LSnoVSCC) and patients with LS following surgery for VSCC (LSVSCC). METHODS An online survey was distributed to all registered GOs in the Netherlands. Primary outcome measures were the frequency, type and duration of TCS treatment prescribed for LSnoVSCC and LSVSCC patients, separately. As a secondary outcome measure, reasons for treating or not treating patients with LSnoVSCC and LSVSCC with TCS were analysed. RESULTS Forty-four GOs completed the survey, resulting in a response rate of 75%. TCS were prescribed more often to patients with LSnoVSCC as compared to patients with LSVSCC (86% versus 52%, respectively, p < 0.001). If treatment was initiated, ultra-potent (class IV) TCS were most commonly prescribed for an indefinite period of time for both patient groups. The most reported reason for treating patients in both groups with TCS was symptoms, followed by clinical aspects of the lesion and prevention of progression to dVIN and VSCC. CONCLUSION The majority of GOs who participated in our study endorse the utilisation of long-term ultra-potent TCS therapy in both patients with LSnoVSCC and LSVSCC. Nevertheless, Dutch GOs are currently prescribing TCS more frequently to patients with LSnoVSCC than to patients with LSVSCC.
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Affiliation(s)
- Féline O Voss
- Department of Pathology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Karelina L Groenewegen
- Department of Gynaecology, Netherlands Cancer Institute/Antoni Van Leeuwenhoek hospital, Amsterdam, The Netherlands
| | - Hester Vermaat
- Department of Dermatology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Maaike C G Bleeker
- Department of Pathology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Centre Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - Marc van Beurden
- Department of Gynaecology, Netherlands Cancer Institute/Antoni Van Leeuwenhoek hospital, Amsterdam, The Netherlands
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Rees S, Arnold S, Kherlopian A, Fischer G. Attitudes Toward Proactive Topical Corticosteroid Use Among Women With Vulval Lichen Sclerosus. J Low Genit Tract Dis 2024; 28:183-188. [PMID: 38518216 DOI: 10.1097/lgt.0000000000000791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
OBJECTIVES Some practitioners are adopting proactive topical corticosteroid (TCS) therapy for vulval lichen sclerosus (VLS). We sought to understand patient attitudes toward proactive TCS therapy for VLS in a context in which proactive therapy is adopted. METHODS Four online focus group discussions with 12 participants. Data analysis was informed by social constructionist grounded theory. RESULTS All participants had accepted a proactive regimen. Three themes were developed from the analysis: "Coming to accept proactive therapy," "Motivators to maintaining a proactive regimen," and "The importance of a routine that fits me." Within each theme are subthemes illustrating different dimensions of the theme. CONCLUSIONS Accepting proactive TCS therapy for VLS requires incorporating regular TCS use into a patient's identity, unlearning previous understandings regarding the safety of long-term TCS use, and adopting a regimen that fits within patients' lives and minimizes the loss of autonomy.
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Affiliation(s)
- Sophie Rees
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Susanne Arnold
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | | | - Gayle Fischer
- Sydney Medical School, University of Sydney, Sydney, Australia
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Day T, Selim MA, Allbritton JI, Scurry J. Nonsclerotic Lichen Sclerosus: Definition of a Concept and Pathologic Description. J Low Genit Tract Dis 2023; 27:358-364. [PMID: 37467474 PMCID: PMC10545066 DOI: 10.1097/lgt.0000000000000760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Nonsclerotic lichen sclerosus (NSLS) refers to the clinicopathologic situation of examination findings consistent with lichen sclerosus (LS) but without dermal sclerosis on microscopy. This review aims to describe the features of NSLS and provide a classification framework. METHODS The International Society of the Study of Vulvovaginal Diseases tasked the Difficult Pathologic Diagnoses Committee with development of consensus documents for conditions with problematic histopathology. The Difficult Pathologic Diagnoses Committee reviewed the literature on NSLS and formulated descriptions and diagnostic criteria, then approved by the International Society of the Study of Vulvovaginal Diseases membership. RESULTS Nonsclerotic LS may be categorized into 4 histopathologic subtypes: lichenoid dermatitis, hypertrophic lichenoid dermatitis, dermal fibrosis without acanthosis, and dermal fibrosis with acanthosis. Each has a pathologic differential diagnosis of 1 or more entities, so clinical correlation is required for final diagnosis of LS. There is no evidence to support a reliable association between absent sclerosis and clinical appearance, duration, or oncogenic potential of LS. CONCLUSIONS Pathologists and clinicians should be familiar with the concept of NSLS and its implications for patient management. Use of the term "early LS" to indicate a lack of sclerosis in presumed LS should be abandoned. Clinical correlation is required to confirm LS from among the differential diagnoses.
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Affiliation(s)
- Tania Day
- University of Newcastle, Newcastle, New South Wales, Australia
- John Hunter Hospital, Newcastle, New South Wales, Australia
| | | | | | - James Scurry
- University of Newcastle, Newcastle, New South Wales, Australia
- New South Wales Health Pathology, Hunter New England, Newcastle, New South Wales, Australia
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Preti M, Borella F, Ferretti S, Caldarella A, Corazza M, Micheletti L, De Magnis A, Borghi A, Salvini C, Gallio N, Pasquero G, Vieira-Baptista P, Selk A, Benedetto C, Rosso S. Genital and extragenital oncological risk in women with vulvar lichen sclerosus: A multi-center Italian study. Maturitas 2023; 175:107767. [PMID: 37302181 DOI: 10.1016/j.maturitas.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/04/2023] [Accepted: 04/18/2023] [Indexed: 06/13/2023]
Abstract
Vulvar lichen sclerosus is a chronic inflammatory disease involving vulvar skin. The risk of developing invasive vulvar cancer for women with LS is reported in the literature, but the risk of extra-vulvar tumors has been under-investigated. This multicentric study aims to estimate the risk of developing cancers in a cohort of women with a diagnosis of vulvar lichen sclerosus. METHODS A cohort of women diagnosed with and treated for vulvar lichen sclerosus in three Italian gynecological and dermatological clinics (Turin, Florence, and Ferrara) was retrospectively reviewed. Patient data were linked to cancer registries of the respective regions. The risk of subsequent cancer was estimated by dividing the number of observed and expected cases by the standardized incidence ratio. RESULTS Among 3414 women with a diagnosis of vulvar lichen sclerosus corresponding to 38,210 person-years of follow-up (mean 11.2 years) we identified 229 cancers (excluding skin cancers and tumors present at the time of diagnosis). We found an increased risk of vulvar cancer (standardized incidence ratio = 17.4; 95 % CL 13.4-22.7), vaginal cancer (standardized incidence ratio = 2.7; 95 % CL 0.32-9.771), and oropharyngeal cancer (standardized incidence ratio = 2.5; 95 % CL 1.1-5.0), and a reduced risk of other gynecological tumors (cervical, endometrial, ovarian) and breast cancer. CONCLUSIONS Patients with vulvar lichen sclerosus should undergo annual gynecological check-up with careful evaluation of the vulva and vagina. The increased risk of oropharyngeal cancer also suggests the need to investigate oropharyngeal cavity symptoms and lesions in patients with vulvar lichen sclerosus.
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Affiliation(s)
- Mario Preti
- Division of Gynecology and Obstetrics 1, Department of Surgical Sciences, "City of Health and Science University Hospital", University of Turin, 10126 Turin, Italy
| | - Fulvio Borella
- Division of Gynecology and Obstetrics 1, Department of Surgical Sciences, "City of Health and Science University Hospital", University of Turin, 10126 Turin, Italy.
| | - Stefano Ferretti
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, and Local Health Authority, 44121 Ferrara, Italy
| | - Adele Caldarella
- Tuscany Cancer Registry, Clinical, and Descriptive Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy
| | - Monica Corazza
- Section of Dermatology and Infectious Diseases, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Leonardo Micheletti
- Division of Gynecology and Obstetrics 1, Department of Surgical Sciences, "City of Health and Science University Hospital", University of Turin, 10126 Turin, Italy
| | - Angelina De Magnis
- Department of Gynecology and Obstetrics, University of Florence, Florence, Italy
| | - Alessandro Borghi
- Section of Dermatology and Infectious Diseases, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Camilla Salvini
- Dermatology Unit, Department of Health Sciences, University of Florence, Florence, Italy
| | - Niccolò Gallio
- Division of Gynecology and Obstetrics 1, Department of Surgical Sciences, "City of Health and Science University Hospital", University of Turin, 10126 Turin, Italy
| | - Giorgia Pasquero
- Division of Gynecology and Obstetrics 1, Department of Surgical Sciences, "City of Health and Science University Hospital", University of Turin, 10126 Turin, Italy
| | - Pedro Vieira-Baptista
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Lower Genital Tract Unit, Centro Hospitalar de São João, Porto, Portugal
| | - Amanda Selk
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Chiara Benedetto
- Division of Gynecology and Obstetrics 1, Department of Surgical Sciences, "City of Health and Science University Hospital", University of Turin, 10126 Turin, Italy
| | - Stefano Rosso
- Piedmont Cancer Registry, A.O.U, City of Health and Science University Hospital, Turin, Italy
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De Luca DA, Papara C, Vorobyev A, Staiger H, Bieber K, Thaçi D, Ludwig RJ. Lichen sclerosus: The 2023 update. Front Med (Lausanne) 2023; 10:1106318. [PMID: 36873861 PMCID: PMC9978401 DOI: 10.3389/fmed.2023.1106318] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/18/2023] [Indexed: 02/18/2023] Open
Abstract
Lichen sclerosus (LS) is an underdiagnosed inflammatory mucocutaneous condition affecting the anogenital areas. Postmenopausal women are predominantly affected and, to a lesser extent, men, prepubertal children, and adolescents. The etiology of LS is still unknown. Hormonal status, frequent trauma and autoimmune diseases are well-known associations for LS, yet infections do not seem to be clear risk factors. LS pathogenesis involves factors such as a genetic predisposition and an immune-mediated Th1-specific IFNγ-induced phenotype. Furthermore, there is a distinct expression of tissue remodeling associated genes as well as microRNAs. Oxidative stress with lipid and DNA peroxidation provides an enabling microenvironment to autoimmunity and carcinogenesis. Circulating IgG autoantibodies against the extracellular matrix protein 1 and hemidesmosome may contribute to the progression of LS or simply represent an epiphenomenon. The typical clinical picture includes chronic whitish atrophic patches along with itching and soreness in the vulvar, perianal and penile regions. In addition to genital scarring, and sexual and urinary dysfunction, LS may also lead to squamous cell carcinoma. Disseminated extragenital LS and oral LS are also reported. The diagnosis is usually clinical; however, a skin biopsy should be performed in case of an unclear clinical picture, treatment failure or suspicion of a neoplasm. The gold-standard therapy is the long-term application of ultrapotent or potent topical corticosteroids and, alternatively, topical calcineurin inhibitors such as pimecrolimus or tacrolimus. Collectively, LS is a common dermatological disease with a so far incompletely understood pathogenesis and only limited treatment options. To foster translational research in LS, we provide here an update on its clinical features, pathogenesis, diagnosis and (emerging) treatment options.
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Affiliation(s)
- David A De Luca
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Cristian Papara
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Department of Dermatology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Artem Vorobyev
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Department of Dermatology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Hernán Staiger
- Department of Dermatology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Katja Bieber
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Diamant Thaçi
- Institute and Comprehensive Center Inflammation Medicine, University of Lübeck, Lübeck, Germany
| | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Department of Dermatology, University Medical Center Schleswig-Holstein, Lübeck, Germany
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Manuelpillai N, Saunders H, Veysey E. Management of severe vulval lichen sclerosus with adalimumab. Australas J Dermatol 2022; 63:248-250. [PMID: 35262179 DOI: 10.1111/ajd.13814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 02/10/2022] [Accepted: 02/13/2022] [Indexed: 11/30/2022]
Abstract
Vulval Lichen Sclerosus (VLS) is a chronic inflammatory dermatosis that significantly impacts the quality of life. We report 2 cases of severe treatment-resistant VLS treated with subcutaneous adalimumab. One patient showed modest clinical improvement with no significant improvement in quality-of-life measures. The second patient showed a significant improvement in both clinical and quality-of-life measures. Both patients achieved optimal control with a maintenance dosing of 40 mg subcutaneously weekly. Adalimumab may be a treatment option for recalcitrant VLS; however, clinical trials are required to confirm efficacy for this indication.
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Affiliation(s)
| | - Helen Saunders
- Department of Dermatology, St Vincent's Hospital, Melbourne, Australia.,Vulvar Clinic, The Royal Women's Hospital, Melbourne, Australia
| | - Emma Veysey
- Department of Dermatology, St Vincent's Hospital, Melbourne, Australia.,Vulvar Clinic, The Royal Women's Hospital, Melbourne, Australia
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