Vulvar Region Research Articles

Pre‐pubertal isolated plexiform neurofibroma of labium majus without clitoral involvement

Sir, Neurofibromas are tumors of neural crest origin with protean manifestations which can affect virtually every organ and system. Isolated involvement of the female genital organs by this disease is rare and clitoral hypertrophy is the most common presentation. Genital neurofibromas usually enlarge in size and become symptomatic during puberty and pregnancy; however, we report an isolated plexiform neurofibroma in one labium majus without clitoral involvement and with documented rapid growth in a pre-pubertal girl. A 9-year-old girl presented with a swelling in the vulval region present since birth and with progressive painless enlargement for the last two years. The mass remained completely asymptomatic till the age of six years when it started to increase in size, causing discomfort during walking. The girl was 112 cm tall, breasts were Tanner's stage I and pubic and axillary hair absent. Multiple (more than six) café-au-lait spots measuring >15 mm were present over the abdomen, back and buttocks (Figure 1). A 7.2 × 5.4-cm sized irregular growth was noted in the left labium majus leading to disfigurement. The clitoris was unremarkable. The growth was firm, not tender, irreducible, with ill-defined margins and without vaginal extension. Ultrasound showed a predominantly hypo-echoic lesion with septae without any pelvic organ abnormality. Fine needle aspiration cytology suggested a benign spindle cell tumor. The mass was excised and histopathology revealed plexiform neurofibromatosis (Figure 1). Multiple café-au-lait spots and histopathological slide showing a well circumscribed lesion composed of spindle cells in a loose fibrillary matrix in isolated vulvar plexiform neurofibroma in a pre-pubertal girl. Neurofibromatosis-1 (NF1) is an autosomal dominant neuro-cutaneous syndrome with a reported incidence of 1 in 3000 live births. It is a multisystem disorder which may affect virtually every structure of the body; however, involvement of the external genitalia is extremely unusual (1) and most commonly affects the clitoris. Non clitoral involvement, as in this case, is exceptionally rare. Labial neurofibromas grow in size during puberty and pregnancy (2), due to elevated sex steroids, growth hormone and/or other growth factors (3). To the best of our knowledge only five cases of isolated labial neurofibroma without clitoral involvement have been reported in the English literature, but all became symptomatic during or after pubertal transition. In our case no pubertal changes were present, suggesting causative factors other than steroids or growth hormone. The diagnosis of a labial neurofibroma should prompt a search for other stigmata of the disease. The mainstay of treatment for a symptomatic isolated neurofibroma is local resection with preservation of genital anatomy. Complete removal can be difficult because of size, encroachment into surrounding tissues and indistinct margins (4).

Vulvar Skin Atrophy Induced by Topical Glucocorticoids

Steroid-induced skin atrophy is the most frequent and perhaps most important cutaneous side effect of topical glucocorticoid therapy. To date, it has not been described in vulvar skin. A patient presented with significant vulvar skin atrophy following prolonged steroid application to treat vulvar dermatitis. The extensive atrophy in the perineum resulted in secondary "webbing" and partial obstruction of the genital hiatus and superimposed dyspareunia. Prolonged use of topical steroids may result in atrophic changes in vulvar skin. Further research in clinical correlates of steroid-induced atrophy in the vulvar region is warranted.

Photodynamic therapy of vulvar lichen sclerosus et atrophicus in a woman with hypothyreosis – Case report

Lichen sclerosus et atrophicus (LSA) is disease of skin and mucosa, its pathogenesis remains unknown. Itching, pain and burning sensations and atrophy of vulva impair quality of life. Treatment is symptomatic. We report case of 30-year old woman with lesions in vulva in which series of topical PDT were carried out. We applied Levulan®Kerastick® for 4h and after that lesions were illuminated with red light. Along with above treatment patient started receiving Euthyrox®, because of recently diagnosed hypothyreosis. Significant relief from subjective symptoms was achieved and lesions in vulvar region disappeared. Combination of topical PDT with hormonal therapy allowed controlling course of disease and minimizing symptoms, and thus improved quality of life.

Acquired lymphangioma circumscriptum of the vulva

A lymphangioma is a rare proliferation of the lymphatic system. The condition is unpleasant but benign. There are 3 types of lymphangioma: circumscriptum, cavernous, and cystic. Lymphangioma circumscriptum is considered primary if it is present at birth or it develops in early childhood, or secondary or acquired if it is caused by impaired lymph flow. Involvement of the vulva is rare [1,2]. The differential diagnosis of lymphangioma circumscriptum of the vulva includes genital warts, molluscum contagiosum, tuberculosis verrucosa cutis, lymphogranuloma venereum, and filariasis [3]. Lymphangioma circumscriptum can be caused by infections (filariasis, sexually transmitted infections, tuberculosis, erysipelas, lymphogranuloma venereum); Crohn's disease; surgical or radiotherapy procedures (radical hysterectomy, pelvic lymphadenectomy, radiation for cervical cancer); trauma; keloids; scleroderma; dermopathy from penicillamine or corticosteroids; and lymphatic obstruction associated with neoplasia [1,4]. A 44-year-old woman presented with vesicles in the vulvar region, watery discharge, and itching. The patient reported occasional foul-smelling white vaginal discharge and no history of sexual contact. Clinical examination revealed well-defined, multiple, grouped, dome-shaped papulovesicular lesions over the labia majora and mons pubis. The lesions were not tender and showed diffuse induration. Inguinal lymph nodes were absent. The perianal region was without lesions (Fig. 1). Speculum examination revealed copious foul-smelling white discharge around the cervix. Other general examination was unremarkable. Histologic examination of the lesions revealed acanthosis and prominent elongation of epidermal rete ridges. The spaces between the rete pegs were distended by dilated spaces lined by endothelium and contained pale secretory material. Adjacent dermis showed infiltration by lymphocytes. The diagnosis of lymphangioma circumscriptum was proposed. Pap smear ruled out intraepithelial malignancy.

A dosimetric evaluation of dose escalation for the radical treatment of locally advanced vulvar cancer by intensity-modulated radiation therapy

The purpose of this planning study was to determine whether intensity-modulated radiation therapy (IMRT) reduces the radiation dose to organs at risk (OAR) when compared with 3D conventional radiation therapy (3D-CRT) in patients with vulvar cancer treated by irradiation. This study also investigated the use of sequential IMRT boost (seq-IMRT) and simultaneous integrated boost (SIB-IMRT) for dose escalation in the treatment of locally advanced vulvar cancer. Five vulvar cancer patients treated in the postoperative setting and 5 patients treated with definitive intent (def-group) were evaluated. For the postoperative group, 3D-CRT and IMRT plans to a total dose (TD) of 45 Gy were generated. For the def-group, 4 plans were generated: a 3D-CRT and an IMRT plan to a TD of 56.4 Gy, a SIB-IMRT plan to a TD of 56 Gy, and a SIB-IMRT with dose escalation (SIB-IMRT-esc): TD of 67.2 Gy. Mean dose and dose-volume histograms were compared using Student's t-test. IMRT significantly (all p < 0.05) reduced the Dmean, V30, and V40 for all OAR in the adjuvant setting. The V45 was also significantly reduced for all OAR except the bladder. For patients treated in the def-group, all IMRT techniques significantly reduced the Dmean, V40, and V45 for all OAR. The mean femur doses with SIB-IMRT and SIB-IMRT-esc were 47% and 49% lower compared with 3D-CRT. SIB-IMRT-esc reduced the doses to the OAR compared with seq-3D-CRT but increased the Dmax. for the small bowel, rectum, and bladder. IMRT reduces the dose to the OAR compared with 3D-CRT in patients with vulvar cancer receiving irradiation to a volume covering the vulvar region and nodal areas without compromising the dosimetric coverage of the target volume. IMRT for vulvar cancer is feasible and an attractive option for dose escalation studies.

Vesicobullous disorders of female genitalia.

Blistering over the vulval region can be due to multiple causes, each having nearly a similar presentation. Thus, a thorough understanding of the various etiologies is necessary to make a correct diagnosis. Clinically, there always remains some ambiguity as to the precise diagnosis, thus investigations, such as biopsy, play a very essential role in clinching the correct diagnosis. Most of these disorders are amenable to treatment and thus an early intervention is a must to prevent morbidity associated with these diseases.

Vulvar pathology: Selected topics

Skin of the vulva differs from the other sites from the different bacterial and friction features. Dermatologic diseases of vulvar skin and mucosa can be divided in two groups. The first includes dermatoses similar extravulvar sites, and second includes dermatoses affected predominantly vulvar region. Specific dermatoses of vulva are contact dermatitis, seborrhoic dermatitis, lichen planus, lichen sclerosus. Infectios deseases of vulva can be transmited by direct contact. Recognition of typical microscopic findings can helped for dignosis of scabies, herpes virus, molluscum contagiosum diseases of vulva. Human papilloma viruses (HPV) are epithelitrophic viruses and cause premalgnant and malignant transformation of epithelial cells.According criteria like viral associated changes,clinical paramethars, microscopic features there are two pathways in carcinogenesissquamous cell carcinoma HPVrelated pathway associated with Vulvar intraepithelial neoplasia/VIN of the classic type, and the non- HPV related with VIN of the differentiated (simlex) type frequently associated with lichen sclerosus and/or vulvar hyperplasia. Invasive squamous carcinoma is the most common carcinoma of vulva. Prognostic factors like stage, extracapsular nodal spread,infiltrative margins, vascular invasion, degree of differentiation, status of adjacent skin, stromal response, p53 overexpression are necessary for report. High tumor grade, capillary lymphatics invasion, biger tumor size and depth invasion deserve imunohistochemical analysis lymph nodes for metastatic cells of carcinoma. Extramammary Pagets desease is rare neoplasm. Paget desease can be primary cutaneus vulvar disease,or associated with noncutaneous carcinoma gastrointenstinal origin or bladder carcinoma. Immunohistochemical analysis is very helpful to determine primary origin.

Hidroadenoma papilífero vulvar. Presentación de un caso

Hidroadenoma papilliferum (HP) is a rare benign tumor of the vulva that grows mainly in the skin of the anogenital region of adult women. The differential diagnosis between this neoplasm and Bartholin cysts and abscesses, lipoma and some premalignant and malignant vulvar lesions can be difficult. HP may arise from mammary-like glands located in the vulvar and perineal region of women.We report a case of HP that was removed in a 32-year-old woman who had undergone a cesarean delivery 5 months previously.

Olmsted syndrome in a baby girl and her mother

A 2-month-old baby girl developed universal keratotic plaques soon after birth. Physical examination revealed well-defined, dark erythematous, keratotic plaques with thick scales and mild infiltration at the periorbital, perioral, perianal and vulvar regions, as well as deep fissures of both hands and feet covered with thick yellowish crusts. Another case was a 24-year-old female, the mother of the baby, who presented with hyperkeratotic plaques at perioral and perianal regions, congenital alopecia universalis, mutilation of fingers and toes with massive thick keratotic yellow crusts and scales. Histopathology of skin lesions from the gluteal region of the baby showed psoriasiform hyperplasia of the epidermis, slight inflammatory infiltration of dermal papillae and superficial dermal perivascular regions. Immunohistochemistry demonstrated the positive staining for acidic keratin (AE1) in the prickle cell layer and granular layer and for CK10 in the upper prickle cell layer and granular layer. Electron microscopy showed increased cell space and decreased tonofilament. Both the baby girl and her mother were diagnosed with Olmsted syndrome. Key words: Keratoderma, palmoplantar; Olmsted syndrome; Case reports [Publication type]

Risk factors for high‐risk human papillomavirus infection in unscreened Malian women

To investigate the epidemiology of human papillomavirus (HPV) infection in Malian women, for whom cervical cancer is the most common cancer and the second most common cause of cancer-related mortality. Pilot study of 202 women aged 15-65 to determine the prevalence rate of high-risk HPV infection among unscreened Malian women. Information on risk factors was collected through a standardized, structured interview and clinical examination. High-risk (HR) HPV DNA was detected using signal amplification methods (hybrid capture II). High-risk HPV DNA was detected in 12% of unscreened women, while visual inspection after application of acetic acid and Lugol's iodine (VIA/VILI) identified suspicious abnormalities in 2.5% of unscreened women. Histopathological evaluation of VIA/VILI-positive biopsies revealed no evidence of cervical intraepithelial neoplasia or cervical cancer. The majority of infections occurred among women in the 15-24 year old range. Compared to women who were married or widowed, single women were 3.5 times more likely to be infected with HR HPV. The prevalence of infection with cancer causing types of HPV in this study was 12%. These prevalence estimates are consistent with what has been reported previously for other West African countries.

Establishment of a Caenorhabditis elegans infection model for Vibrio alginolyticus

Vibrio alginolyticus, a common bacterium in the marine environment, is a threat to marine animals and humans by causing serious infections. The present study reveals the establishment of a Caenorhabditis elegans infection model for Vibrio alginolyticus. The infection and colonization was localized in the animal by tagging V. alginolyticus with GFP and using Confocal Laser Scanning Microscopy. Chemotactic response of C. elegans to V. alginolyticus, pharyngeal distention and blockage of vulval region leading to internal hatching were analyzed. The time required for causing infection, and the bacterial loads in the intestine of C. elegans were determined. Regulation of innate immune related genes, lys-7, clec-60 and clec-87, were also analyzed using real time PCR. The pathogen infected animals appeared to ward-off infection by up-regulating the candidate antimicrobial gene(s) for few hours, before succumbing to the pathogen. For the first time, the pathogenicity of V. alginolyticus at both physiological and molecular level has been studied in detail using the model organism C. elegans.

MRI of vulvar Crohn disease

Crohn disease is a chronic granulomatous inflammatory disorder that most commonly affects the gastrointestinal tract, particularly the distal small bowel and colon. While certain extraintestinal manifestations of Crohn disease are relatively common and well-known, others, such as metastatic cutaneous involvement, are quite rare and may be difficult to recognize, particularly in the pediatric population. This case report illustrates the magnetic resonance imaging (MRI) appearance of vulvar region cutaneous Crohn disease in an 11-year-old girl.

Human Papillomavirus Vaccine Intentions Among Men Participating in a Human Papillomavirus Natural History Study Versus a Comparison Sample

Human papillomavirus (HPV), the most common sexually transmitted virus in the United States, remains a considerable public health problem. HPV has been associated with anogenital warts and cancers in males and females, affecting the cervix, penis, anus, vulvar, and vaginal regions; and more recently, has been associated with oropharyngeal cancers. In 2006, the Food and Drug Administration (FDA) approved a prophylactic quadrivalent HPV vaccine for females (9-26 years); in 2009, this approval extended to males of this same age group. However, limited research has examined attitudes and other factors related to males' intention to receive the vaccine. Factors associated with HPV vaccination intentions/willingness were examined among: (1) males (N=296) participating in a HPV natural history study with repeated exposure to HPV information; and (2) male University students (N=198) "unexposed" to intense HPV messages and testing. About 94% of HPV study participants and 62% of University males reported intentions/willingness toward vaccination, respectively. In multivariate analyses, among HPV study males, concerns about getting an appointment (odds ratio [OR], 0.06; confidence interval [CI], 0.01- 0.68), getting time off (OR, 0.14; CI, 0.03- 0.63), and "other" barriers (OR, 0.04; CI, 0.01- 0.17) were negatively associated with vaccine intentions. Among University males, vaccine awareness (OR, 0.06; CI, 0.02- 0.17), low risk perceptions (OR, 0.11; CI, 0.04-0.33), and unimportance of provider recommendations (OR, 9.66; CI, 2.69 -34.68) were negatively associated with willingness to vaccinate. Repeated exposure to HPV information and provider recommendations may be critical for male vaccine promotion. Future research is needed to increase understanding of factors that may prevent men from receiving HPV vaccination.

Pequi is a Host for Pratylenchus zeae in the Brazilian Cerrado Region.

The Brazilian Cerrado Region has many natural resources that have high social economic interest. Pequi (Caryocar brasiliense Camb.), a native species from that area, has an edible fruit, which is highly appreciated by the local population, and also a high-quality wood. In January 2010, pequi root samples were collected near the municipality of Rio Verde, Goiás State, Brazil (17°49'25.76″S, 51°02'10.06″W). Roots were washed with tapwater, dried on absorbent paper, cut in 1-cm2 pieces, and processed for nematode extraction by the blender centrifugal flotation method (2). The specimens were identified by morphological and morphometrical characteristics of six adult females mounted in formaldehyde temporary slides (1). Morphological characters used for identification included female body, stylet, pharyngeal overlapping, pharynges, postvulval uterine sac, tail lengths, stylet knobs, number of labial rings, vulva position in relation to body length, body diameters (high body, vulval, and anus region), and the de Man's ratios (a, b, b', c, and c'). Characters measured were consistent with those described for Pratylenchus zeae Graham, 1951 (1); the labial region showed three annuli, stylet was 14.83 (±0.93) μm long, with broad, anteriorly flattened basal knobs. Vulva position was 71.66% (±0.98) of body length and spermatheca was round, small, and without sperm (males were not found). Postvulval uterine sac was short (31.3 ± 4.03 μm) and tail (26.6 ± 3.61 μm) was conoid, pointed, and unstriated. Pharyngeal overlapping length was 30.5 (±6.5) μm; pharynges were 150.83 (± 28.16) μm long. The de Man's ratios obtained were: a = 24.26 ± 2.31; b = 3.89 ± 0.69; b' = 3.08 ± 0.48; c = 17.17 ± 1.47; and c' = 2.25 ± 0.19. To our knowledge, this is the first report of P. zeae infecting pequi. It is difficult to determine the economic importance of this nematode parasite to pequi production since pequi is not yet a commercial crop in Brazil. This finding, however, has long term importance because researchers have been developing improved cultivars by combining favorable agronomic characteristics with high oilseed content for biofuel production. If these are commercialized, P. zeae could become an important pathogen in pequi plantings.

Vaginal cavernous hemangioma with cystic ovaries and cystic endometrial hyperplasia in a dog

A 10-year-old intact female German shepherd dog was presented with a chief compliant of vaginal bleeding that had become progressively heavier over a 2-week period. On clinical examination, the abdominal cavity was distended, and no wounds or masses were observed in vulva and caudal vaginal regions. Digital vaginal examination and vaginoscopy had no specific findings. Abdominal ultrasonography and radiography revealed a giant soft tissue mass in caudal part of the abdomen that extended in to the pelvic cavity. A midline exploratory laparotomy was performed. On gross examination, a very huge tumor was noticed in the caudal part of the abdomen, which extended to the pelvic cavity, right behind the cervix. On the other hand, uterine vessels were engorged obviously, and both ovaries had a multicystic appearance. Surgical excision of the mass, cystic ovaries, and uterus was performed. Histopathological studies revealed the complex of vaginal hemangioma with luteal ovarian cysts and cystic endometrial hyperplasia (CEH). Vaginal hemangioma is extremely rare in dogs, and to the authors' knowledge, this is the first reported case of a synchronous vaginal hemangioma with ovarian cyst and CEH in dogs.

Vulvar syringomas presenting with a polypoid mass or pruritus: Report of two cases

Syringoma is a benign eccrine sweat gland tumor and it presents more frequently in women at puberty as multiple, tiny, firm, skin-colored papules at the upper cheek and eyelid. We report here on two cases with an unusual location of syringomas on the vulva. The first case presented with multiple erythematous papules on the labia majora in a 30-year-old woman who presented with pruritus, which waxed and waned according to her menstrual cycle. The second case occurred as a polypoid mass on the prepuce in a 46-year-old woman who had been suffering from groin pruritus. Microscopically, both cases showed aggregates of ducts lined by two-layers of epithelial cells embedded in a dense fibrous stroma. Some of these ducts showed comma-like tails that gave them a tadpole shape. Albeit uncommon in vulvar region, syringoma should be included in the differential diagnosis of a pruritic vulvar lesion, and even a polypoid mass.

Angiomyofibroblastoma of the Vulva

Journal of Ultrasound in MedicineVolume 28, Issue 10 p. 1417-1420 Case Report Angiomyofibroblastoma of the Vulva Sonographic and Computed Tomographic Findings With Pathologic Correlation Sang Won Kim MD, Corresponding Author Sang Won Kim MD [email protected] Department of Radiology, Soonchunhyang University, Cheonan Hospital, Cheonan, KoreaAddress correspondence to Sang Won Kim, MD, Department of Radiology, Cheonan Hospital, Soonchunhyang University School of Medicine, 23-20 Bongmyeong-dong, Cheonan-Si, Choongnam 330-720, Korea.,Search for more papers by this authorJi-Hye Lee MD, Ji-Hye Lee MD Department of Pathology, Soonchunhyang University, Cheonan Hospital, Cheonan, KoreaSearch for more papers by this authorJong Kyu Han MD, Jong Kyu Han MD Department of Radiology, Soonchunhyang University, Cheonan Hospital, Cheonan, KoreaSearch for more papers by this authorSeob Jeon MD, Seob Jeon MD Department of Obstetrics and Gynecology, Soonchunhyang University, Cheonan Hospital, Cheonan, KoreaSearch for more papers by this author Sang Won Kim MD, Corresponding Author Sang Won Kim MD [email protected] Department of Radiology, Soonchunhyang University, Cheonan Hospital, Cheonan, KoreaAddress correspondence to Sang Won Kim, MD, Department of Radiology, Cheonan Hospital, Soonchunhyang University School of Medicine, 23-20 Bongmyeong-dong, Cheonan-Si, Choongnam 330-720, Korea.,Search for more papers by this authorJi-Hye Lee MD, Ji-Hye Lee MD Department of Pathology, Soonchunhyang University, Cheonan Hospital, Cheonan, KoreaSearch for more papers by this authorJong Kyu Han MD, Jong Kyu Han MD Department of Radiology, Soonchunhyang University, Cheonan Hospital, Cheonan, KoreaSearch for more papers by this authorSeob Jeon MD, Seob Jeon MD Department of Obstetrics and Gynecology, Soonchunhyang University, Cheonan Hospital, Cheonan, KoreaSearch for more papers by this author First published: 01 October 2009 https://doi.org/10.7863/jum.2009.28.10.1417Citations: 14Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume28, Issue10October 2009Pages 1417-1420 RelatedInformation

Perineal leiomyoma mimicking complex Bartholin mass

Leiomyomas of the external genitalia are uncommon soft tissue tumors. We report the case of a 47-year-old woman with perineal leiomyomas mimicking Bartholin's gland mass according to the preoperative magnetic resonance imaging (MRI) findings. Leiomyomas in the vulvar region should be differentiated from complicated Bartholin's gland cysts and preoperative MRI findings may be misleading. The complete surgical excision should be the choice of treatment.

Clinicopathological study of deep angiomyxoma

Objective To study the clinicopathologic features and differential diagnosis of deep angiomyxoma(DAM). Methods Seven cases of DAM were collected from 2000 to 2008. All the patients were examined by microscopy and immunohistochemistry. Results 6 patients with DAM were females and 1 was male, with median age of 48.5 years. Median maximum dimension was 5.9cm, with invasive growth pattern. The tumor cells of DAM were infantile, spindle or stellate,diffuse and nodular arrangement. A distinctive histologic feature of DAM was its vascularity. Non-arborizing, thin-wall, ectastic capillaries or more commonly, small thick-wall vessels were dispersed throughout the tumor. Mast cells and extravasated red blood cells were frequently found in the stroma, immunohistochemical study showed that 7 cases were positive for vimentin, desmin, ER and PR, 5 for CD34 and SMA, and negative for S-100 and CK. Conclusion DAM is a rare soft tumor that occurs principally in the vulval and vagina region of woman. Misdiagnosis has happened frequently. Immunohistochemical staining are helpful to diagnosis for DAM, but no significance to distinguish it. Key words: Myxoma; Neoplasms invasiveness; Pathology, clinical

Angiomyofibroblastoma: a rare vulvar tumor

Angiomyofibroblastoma is a rare, benign mesenchymal tumor that occurs mainly in the vulval region of middle age (35-45years) women. We describe a 41-year-old woman, presenting with a 10-cm right vulvar mass and persistent perineal pain lasting 1month. A surgical excision of the lesion was performed and a large mass with an intact capsule was sent for pathological examination. The results indicated angiomyofibroblastoma. The differential diagnosis between angiomyofibroblastoma (AMF) and aggressive angiomyxoma (AAM) is very important because prognoses are not the same. AMF is a well-circumscribed lesion, with a weak risk of local non-destructive recurrence. AAM is a locally aggressive and infiltrative neoplasm, with a high risk of local aggressive recurrence. Wide excision with a rim of normal tissue is recommended in all cases of vulvar tumors.