Perineal reconstruction with biologic graft vulvoplasty for verrucous carcinoma treated by repeated vulvar excisions: a case report

Vulvar neoplasia represents 5% of malignancies in female genital tract and 0.6% of all cancers in women. Although it is known to be a rare type of cancer, which occurs especially in elderly women, its incidence is increasing in young females because of its association with the human papillomavirus (HPV). In this paper, we report the case of a 46-year-old woman, gravidity 4, parity 3, with a medical history of multiple vulvar excisions for recurrent ulcerative vulvar lesions during a period of 11 years. The first lesion appeared in 2003, it was excised and the histopathological result showed squamous cell carcinoma with undifferentiated areas and chronic ulcerative inflammation. The patient underwent radiation therapy remaining at the end of it a small-ulcerated lesion at the superior vulvar commissure, which was biopsied in 2004 showing chronic ulcerative inflammation with reparatory areas of squamous immature benign metaplasia In April 2014, a dermatological consult described vulvar scleroatrophic lichen confirmed by a biopsy. In November 2014, the patient presented to our clinic when a vicious vulvar scar was detected, with a transformed tegument with aspect of atrophic lichen. A perineal reconstruction including anal sphincter plasty was performed. Due to the important remaining skin defect, a Surgisis graft vulvoplasty was performed. The histopathological result of the excised suspect areas was vulvar intraepithelial high-grade neoplasia (VIN III). A retrospective histopathological review of the case established that is more accurate to consider that the vulvar lesions were, all along, a very well differentiated squamous cell carcinoma (verrucous carcinoma), which lacks cytopathic effect of HPV infection, has a low p53 expression but a high Ki67. Case evolution was favorable with the acceptance and integration of the biologic grafts at two months after surgery and normal healing.