Laser Ablation of Surgical Margins After Excisional Partial Vulvectomy for VIN

Abstract

This paper presents the results of a retrospective review of all patients of a single gynecologist (n = 33) who underwent surgical treatment for vulvar intraepithelial neoplasia (VIN) 2 or 3 from 1994 through 2002. Four different surgical techniques were used. The size, location, and extent of the lesion influenced the choice of surgical technique. Sixteen patients (48.5%) underwent a laser and excisional partial vulvectomy in which all gross disease was excised, and the surgical margins were ablated an additional 4 mm laterally with a colposcopically directed CO2 laser. The excision was then closed with interrupted 2.0 polyglactin 910 sutures. Ten (30.3%) patients had a laser partial vulvectomy, which involved laser ablation of colposcopically visible disease to the basement membrane. An excisional partial vulvectomy used a traditional scalpel to excise all disease with 0.5- to 1.0-cm margins (n = 6). One additional patient was treated with a cavitational ultrasonic surgical aspirator. The median age of patients was 46 years (range, 31–80 years). Twenty-one women were smokers, 2 were using immunosuppressive medications, 12 had a history of infection with human papilloma virus, and 4 had previous nonvulvar intraepithelial neoplasia. None were positive for human immunodeficiency virus. Nine patients had undergone previous surgical treatment for VIN. The preoperative biopsy was VIN 3 in 30 of the 33 patients. Fourteen patients had multifocal lesions. The lesions were located on the posterior fourchette (n = 19), the right or left labium majus (n = 13 each), and the right or left labium minus (n = 11 and 9, respectively). With an average follow up of 20 months, 12 (36.4%) of the 33 patients had recurrent disease, including 7 of 10 women who had laser partial vulvectomy, 3 of 6 who had excisional partial vulvectomy, and the one patient treated with a cavitational ultrasonic surgical aspirator. Only one of the 16 patients who underwent laser/excisional partial vulvectomy had a recurrence of disease (P = .0016). Seven of the 14 patients with multifocal disease and 6 of the 21 who smoked recurred. Of the 6 patients who had excisional partial vulvectomy, 4 had positive surgical margins, one had negative, and one was unknown. The 3 patients in this group who recurred included one each with positive, negative, and unknown margins. Seven years 9 months after treatment, an invasive squamous cell carcinoma on the skin over the coccyx was diagnosed in a patient who was taking immunosuppressive medications after a combined kidney and liver transplant.