WIDE EXCISION FOR MULTIPLE SQUAMOUS PAPILLOMA OF THE VULVA WITH V-Y

ADVANCEMENT FLAP : A CASE REPORT

Diah Adiyani Kartikaratri*, Yahya Irwanto**, Hendy Setyo Yudhanto***
* Obstetrics and Gynaecology Department, Brawijaya University / Saiful Anwar Hospital, Malang
** Oncogynecology Division, Obstetrics and Gynaecology Department, Brawijaya University / Saiful Anwar Hospital, Malang
*** Anatomic Pathology Department Brawijaya University / Saiful Anwar Hospital, Malang

ABSTRACT
Multiple squamous papilloma tumor of the vulva is a rare gynecologic tumor, occur at about 1%
of reproductive women.7 We present a woman aged 48 years with chief complaint a lump in
vulvar area. On physical examination of the external genitalia area around anterior fourchet
found a mass about 7x7 cm. We performed wide excision with V-Y advancement flap. Histology
examination found a multiple squamous papilloma. Seven weeks after surgery, surgical wound
attached perfectly, and patient had no further complaints so far.

INTRODUCTION
Multiple squamous papilloma tumor of the vulva is a rare gynecologic tumor, occur at
about 1% of reproductive women.7 A literature search using keyword vulvar squamous
papilloma tumors revealed six reports in gynecologic journal and one report in dermatologic
journal.8 Various molecular biology techniques have been used to clarify the origin of vulvar
squamous papilloma, but the results have not been clear.7 Various types of advancement flaps
have been described in some gynecologic oncology literatures for the therapy of vulvar tumor,
but to date, this surgical techniques is still rarely used.6

CASE PRESENTATION
A woman aged 48 years presented at Saiful Anwar Hospital, Malang, Indonesia in March
2016 with chief complaint a lump in vulvar area since about 18 years ago, initially resemble the
size of a small marbles and increasingly enlarged, not painful, but sometimes itchy especially at
night. Patient had been performed previous operation of lump in vulvar area for a quite similar
lesion as the latter, two times, in 1986 and 1996. Physical examination of the external genitalia
area around anterior fourchet found a mass about 7x7 cm with solid consistency and
cauliflower-like appearance, intact, mobile, without tenderness.
On March 2016, the patient was diagnosed as tumor of the vulva and planned for
surgical treatment vulvectomy. The FNAB result suggested that a representative preparation
can not be obtained. On May 20, 2016, we performed wide excision with V-Y advancement flap.
Patient discharged at day 5, at the time surgical wound seemingly attached without exudate.
Histology examination on anatomical pathology department found benign tumors that
may conclude a multiple squamous papilloma. Macroscopically seen on a 6x5x3,5 cm skin
tissue, a cauliflower-like tumor found on the surface of the skin, 9,5x5x3,5 cm sized, grayish-
white, solid, smooth surface. Tumor tissue composed by papillomatous, multiple, with lining of
squamous epithelium complex. Stroma seem widely spread with chronic fibrotic inflamation.
Seen increased thickness of spinosum cells lining (acanthosis). Seem several koilosit cells,
looked as cells with an enlarged nucleus, multinuclear, irregular nuclear membrane or grape-
like, seen hyperchromatic, with perinuklear halo. No malignant cells found in this preparation.
Basal layer of the epidermis seem intact, not seen any infiltrating cells penetrate the basal layer
of the epidermis to the stroma.

A B

C D

Picture 1. Macroscopic and microscopic fingdings. A. macroscopic view; B,C,D.

microscopic view on hematoxilin-eosin
On June 2016 at days 10 post surgery, non-absorbable surgical sutures of the skin was
partly removed and treated with antibiotics and bioplacenton, urinary catheter was kept up to 3
weeks, wound care continued every two days. On July 2016, 8 weeks after surgery, non-
absorbable surgical sutures of the skin was completely removed, surgical wound attached
perfectly, and patient had no further complaints so far.
 Before day 0

day 3 day11

day 21 day 56

Picture 2. Timelapse picture of patient;s surgical wound.

DISCUSSION
Multiple squamous papilloma tumor of vulva presents as benign papillary tumor with
squamous epithelium without atypia or koilocytosis with fibrovascular stalk line.8 It usually
appears as a solitary verrucous exophytic growth in the vestibule of the vulva and often
regarded as a variant of normal skin by several authors. Although vulvar squamous papilloma
usually asymptomatic, it is sometimes accompanied by pruritus and burning sensation.7 Its
origin and cause remains a controversy. It is apparently not transmitted sexually.8 Vulvar
squamous papilloma tumors possibly presented with symptoms associated with HPV infection.
It is revealed in patients with visible koilosit cells on histological examination that suggest the
existence of HPV infection.
 The ideal method for reconstruction after wide resection of the vulva should provide
immediate restoration of anatomy and faster recovery. The skin donor of “new” vulva must have
a lot of anatomical characteristics of vulva as similar as possible. Various types of advancement
flap of have been described in the literature of gynecologic oncology, but the flap is not
commonly used. Occasionally, VY flap can be used, especially in geriatric patients.6 Surgical
wound healing can only be achieved when the surgical wound edges are well vascularised and
approachable without tension. Wound healing complications can arise from abnormalities in one
of the basic components of the remodelling process.5
This patients underwent a wide excision with V-Y advancement flap in vulvar squamous
papilloma tumor due to the large tumor mass. Vulvar tissue excised approximately 2 cm from
the edge of the mass, then three V-Y flaps were done. Postoperative care was given on the
ward for about one week, with antibiotic therapy injection, catheters, wound care, an vulvar
hygiene. Patients was given education to consume high protein and enough vitamins. At 7
weeks after surgery, surgical wound appeared perfectly attached.

CONCLUSSION
This report represents a rare case of vulvar squamous papilloma tumor treated with wide
excision surgery with V-Y advancement flap, handled in an integrated manner, and achieve a
good and satisfactory outcome.

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