Monika Hampl

Heinrich-Heine-Universität Düsseldorf, Düsseldorf, North Rhine-Westphalia, Germany

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Publications (49)94.65 Total impact

  • M. Hampl
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    ABSTRACT: Background and etiology Severe vulvar intraepithelial neoplasia (VIN 2–3) represents a precancerous condition for the formation of invasive vulvar cancer. The VINs are subdivided into the undifferentiated usual type (uVIN), which is induced by human papillomavirus (HPV), occurs particularly in young women and is the most common form (80–90 % of cases). Differentiated VIN (dVIN) is much less common and is formed on the floor of a chronic skin disease, such as lichen sclerosus. When untreated, dVIN can transform into keratinized squamous cell carcinoma of the vulva, which is moren aggressive than non-keratinized carcinoma based on HPV-induced VIN. Treatment is carried out by resection or laser therapy after biopsy. Epidemiological development The incidence of vulvar cancer has increased 3–4 fold in recent decades mainly due to the increasing number of young women presenting with these tumors, often due to persistent infection with high risk HPV (30–60 %). Approximately 40 % of the tumors are located in the region between the clitoris and urethra. Conclusion Standard treatment is tumor resection with sufficient margins or (partial) vulvectomy and complete inguinofemoral lymphadenectomy. Due to the high morbidity of complete lymphadenectomy and only low risk of metastases in early stage disease, alternative therapy options are resection of the sentinel nodes only, which is not a standard therapy and should be restricted to centers experienced in performing this technique and only under certain conditions.
    No preview · Article · Jun 2015 · Der Gynäkologe
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    ABSTRACT: The accuracy of colposcopy as the gold standard to manage abnormal screening tests depends on qualification and well defined standards. A recent survey of the European Federation for Colposcopy (EFC) found strong heterogeneity in the practice of colposcopy across Europe. EFC defined four quality indicators (QIs) to enable quality assessment in colposcopy as one tool to harmonize colposcopy standards. We undertook a pilot project to estimate the utility of these QIs for an independent external quality assessment in daily routine colposcopy. Participating colposcopy clinics used newly developed software for data collection. Data were automatically anonymized, encrypted and stored in a secure relational database located within the clinics' network and allowed for an independent external benchmarking comparing the performance of participating clinics according to EFC QIs. 10,869 patients referred for routine colposcopy were included. On average none of the four EFC QIs was fulfilled. One target was almost met with 83.3% instead of 85% excisional treatments/conizations containing CIN2+ and for another QI the difference of 94.4% instead of 100% cases having a colposcopic examination prior to treatment for abnormal cervical cytology was mainly explained by wrong documentation. For a third QI, visibility of the squamocolumnar junction (SCJ) was only reported in 90.9% instead of 100% but reporting improved to 94.7% after a consensus meeting. The last QI, >80% clear margins in excised lesions/conizations were not considered as useful by some clinics and therefore not documented. At least 3 out of 4 QIs seemed to be useful for quality assessment in colposcopy but will need rewording and readjustment. All tools for an independent electronic quality assessment with the use of EFC-QI are available and could be used to achieve a high quality standard in colposcopy across Europe. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
    No preview · Article · May 2015 · European journal of obstetrics, gynecology, and reproductive biology
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    Full-text · Article · Nov 2014 · DMW - Deutsche Medizinische Wochenschrift
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    ABSTRACT: Carcinogenesis of squamous cell carcinomas (SCCs) in the anogenital tract and head and neck region is heterogeneous. A substantial proportion of SCC in the vulva, anus, and head and neck follows a human papillomavirus (HPV)-induced carcinogenic pathway. However, the molecular pathways of carcinogenesis in the HPV-independent lesions are not completely understood. We hypothesized that oncogenic Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations might represent a carcinogenic mechanism in a proportion of those HPV-negative cancers. Considering the repeated observation of KRAS-associated p16(INK4a) overexpression in human tumors, it was assumed that KRAS mutations might be particularly present in the group of HPV-negative, p16(INK4a)-positive cancers. To test this hypothesis, we analyzed 66 anal, vulvar, and head and neck SCC with known immunohistochemical p16(INK4a) and HPV DNA status for KRAS mutations in exon 2 (codons 12, 13, and 15). We enriched the tumor collection with HPV DNA-negative, p16(INK4a)-positive cancers. A subset of 37 cancers was also analyzed for mutations in the B-Raf proto-oncogene, serine/threonine kinase (BRAF) gene. None of the 66 tumors harbored mutations in KRAS exon 2, thus excluding KRAS mutations as a common event in SCC of the anogenital and head and neck region and as a cause of p16(INK4a) expression in these tumors. In addition, no BRAF mutations were detected in the 37 analyzed tumors. Further studies are required to determine the molecular events underlying HPV-negative anal, vulvar, and head and neck carcinogenesis. Considering HPV-independent p16(INK4a) overexpression in some of these tumors, particular focus should be placed on alternative upstream activators and potential downstream disruption of the p16(INK4a) pathway.
    No preview · Article · Nov 2014 · Human Pathlogy
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    ABSTRACT: Objective: To compare the distribution of International Federation for Cervical Pathology and Colposcopy (IFCPC) transformation zone (TZ) types among women in different age groups referred to 8 colposcopy clinics. Materials and methods: Between February 2012 and February 2013, we prospectively collected individual patient data from 8 clinics within the German Colposcopy Network (G-CONE). Data were analyzed using ODSdysplasie, software designed to allow continuous quality assessment in colposcopy clinics. The distribution of IFCPC-classified TZ was compared between different centers for the following age groups: younger than 30 years, between 30 and 50 years, and older than 50 years. Results: Of 3,761 patients included in the analysis, 2,153 (57%) were classified as having type 2 TZ, 906 (24%) as type 1 TZ, and 702 (19%) as type 3 TZ. Type 3 TZ was the most commonly reported type in women older than 50 years (70%). We found that the relative distribution of type 3 TZ between age groups was similar in the participating colposcopy clinics. However, there was evidence of heterogeneous distribution of types 1 and 2 TZ between age groups in different clinics, ranging from 7.8% to 66.4% for type 1 TZ in women younger than 30 years and 28.9% to 78.1% for type 2 TZ in women 30 to 50 years old. Conclusions: Although IFCPC type 3 TZ seems to be a reproducible finding, the distribution of types 1 and 2 TZ showed significant heterogeneity. A more precise anatomic distinction between types 1 and 2 TZ in the IFCPC terminology could improve reporting of colposcopy findings.
    Full-text · Article · Aug 2014 · Journal of Lower Genital Tract Disease
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    ABSTRACT: Carcinogenesis of squamous cell carcinomas (SCC) in the anogenital tract and head and neck region is heterogeneous. A substantial proportion of SCC in the vulva, anus and head and neck follows an HPV-induced carcinogenic pathway. However, the molecular pathways of carcinogenesis in the HPV-independent lesions are not completely understood. We hypothesized that oncogenic KRAS mutations might represent a carcinogenic mechanism in a proportion of those HPV-negative cancers. Considering the repeated observation of KRAS-associated p16INK4a overexpression in human tumors, it was assumed that KRAS mutations might be particularly present in the group of HPV-negative, p16INK4a-positive cancers. To test this hypothesis, we analyzed 66 anal, vulvar and head and neck SCC with known immunohistochemical p16INK4a and HPV DNA status for KRAS mutations in exon 2 (codons 12, 13 and 15). We enriched the tumor collection with HPV DNA-negative, p16INK4a-positive cancers. A subset of 37 cancers was also analyzed for mutations in the BRAF gene. None of the 66 tumors harbored mutations in KRAS exon 2, thus excluding KRAS mutations as a common event in SCC of the anogenital and head and neck region and as a cause of p16INK4a expression in these tumors. In addition, no BRAF mutations were detected in the 37 analyzed tumors. Further studies are required to determine the molecular events underlying HPV-negative anal, vulvar and head and neck carcinogenesis. Considering HPV-independent p16INK4a overexpression in some of these tumors, particular focus should be placed on alternative upstream activators and potential downstream disruption of the p16INK4a pathway.
    No preview · Article · Jan 2014 · Human pathology
  • M. Hampl · R. Kürzl
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    ABSTRACT: Die Inzidenz des Vulvakarzinoms hat in den letzten Jahren deutlich zugenommen. Während früher diese Tumorentität bevorzugt bei älteren Frauen diagnostiziert wurde, werden heutzutage zunehmend jüngere Frauen mit Vulvakarzinomen operiert.Literaturrecherche und Auswertung eigener Daten.Bei den jungen Patientinnen ist in 30–50 % eine Infektion mit humanen Papillomviren (HPV) Auslöser für die Tumorentstehung. Prädilektionsstelle der Tumoren ist die Region zwischen Klitoris und Urethra (> 50 % aller Tumoren, eigene Daten).Die Behandlung ist die Resektion in sano oder (partielle) Vulvektomie und eine inguinofemorale Lymphknotenentfernung ein- oder beidseitig, ggf. Sentinellymphonodektomie in ausgewählten Zentren. Die Deckung des Vulvadefekts mit lokoregionären Lappen zur Verbesserung des ästhetisch-funktionellen Ergebnisses ist eine Therapieoption, die v. a. jungen, sexuell aktiven Frauen angeboten werden sollte. Beispiele werden dargestellt.
    No preview · Article · Jan 2014 · Der Onkologe
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    ABSTRACT: Human papillomavirus (HPV) contribution in vulvar intraepithelial lesions (VIN) and invasive vulvar cancer (IVC) is not clearly established. This study provides novel data on HPV markers in a large series of VIN and IVC lesions. Histologically confirmed VIN and IVC from 39 countries were assembled at the Catalan Institute of Oncology (ICO). HPV-DNA detection was done by polymerase chain reaction using SPF-10 broad-spectrum primers and genotyping by reverse hybridisation line probe assay (LiPA25) (version 1). IVC cases were tested for p16(INK4a) by immunohistochemistry (CINtec histology kit, ROCHE). An IVC was considered HPV driven if both HPV-DNA and p16(INK4a) overexpression were observed simultaneously. Data analyses included algorithms allocating multiple infections to calculate type-specific contribution and logistic regression models to estimate adjusted prevalence (AP) and its 95% confidence intervals (CI). Of 2296 cases, 587 were VIN and 1709 IVC. HPV-DNA was detected in 86.7% and 28.6% of the cases respectively. Amongst IVC cases, 25.1% were both HPV-DNA and p16(INK4a) positive. IVC cases were largely keratinising squamous cell carcinoma (KSCC) (N=1234). Overall prevalence of HPV related IVC cases was highest in younger women for any histological subtype. SCC with warty or basaloid features (SCC_WB) (N=326) were more likely to be HPV and p16(INK4a) positive (AP=69.5%, CI=63.6-74.8) versus KSCC (AP=11.5%, CI=9.7-13.5). HPV 16 was the commonest type (72.5%) followed by HPV 33 (6.5%) and HPV 18 (4.6%). Enrichment from VIN to IVC was significantly high for HPV 45 (8.5-fold). Combined data from HPV-DNA and p16(INK4a) testing are likely to represent a closer estimate of the real fraction of IVC induced by HPV. Our results indicate that HPV contribution in invasive vulvar cancer has probably been overestimated. HPV 16 remains the major player worldwide.
    Full-text · Article · Jul 2013 · European journal of cancer (Oxford, England: 1990)
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    ABSTRACT: Objective. The incidence of vulvar squamous cell carcinomas located between the clitoris and urethra in young women is rising in distinct geographic regions, but characteristics of the tumors indicating certain carcinogenic mechanisms are unknown. The present study aimed at characterizing these vulvar cancers for their human papillomavirus (HPV), p16(INK4a), and p53 status, revealing potential pathways of carcinogenesis. Materials and Methods. Squamous cell vulvar cancers of the anterior fourchette were retrospectively collected from 8 German hospitals, with additional squamous cell cancers located at other sites of the vulva from 2 of the hospitals. All tumors were analyzed for HPV DNA by polymerase chain reaction and for p16(INK4a) and p53 expression by immunohistochemistry. Results. Potentially HPV-associated tumors (HPV and p16(INK4a) positive, 21.4% [27/126] of the anterior fourchette and 27.7% [13/47] from other locations), p53 overexpressing tumors (35.7% [45/126] and 29.8% [14/47]), and a third group (HPV/p16 negative/p53 not overexpressed, 42.9% [54/126] and 42.6% [20/47]) were observed among tumors from the anterior fourchette as well as among vulvar cancers from other locations. Women with vulvar cancers of the anterior fourchette were of young age irrespective of the HPV/p16(INK4a)/p53 status. Conclusions. Different types of vulvar cancers can be found in squamous cell tumors of the anterior fourchette, similar to the finding in vulvar cancers from other locations and to what has previously been reported for vulvar squamous cell carcinomas in general.
    No preview · Article · Jul 2013 · Journal of Lower Genital Tract Disease
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    ABSTRACT: Objective: The incidence of vulvar squamous cell carcinomas located between the clitoris and urethra in young women is rising in distinct geographic regions, but characteristics of the tumors indicating certain carcinogenic mechanisms are unknown. The present study aimed at characterizing these vulvar cancers for their human papillomavirus (HPV), p16(INK4a), and p53 status, revealing potential pathways of carcinogenesis. Materials and methods: Squamous cell vulvar cancers of the anterior fourchette were retrospectively collected from 8 German hospitals, with additional squamous cell cancers located at other sites of the vulva from 2 of the hospitals. All tumors were analyzed for HPV DNA by polymerase chain reaction and for p16(INK4a) and p53 expression by immunohistochemistry. Results: Potentially HPV-associated tumors (HPV and p16(INK4a) positive, 21.4% [27/126] of the anterior fourchette and 27.7% [13/47] from other locations), p53-overexpressing tumors (35.7% [45/126] and 29.8% [14/47]), and a third group (HPV/p16(INK4a) negative/p53 not overexpressed, 42.9% [54/126] and 42.6% [20/47]) were observed among tumors from the anterior fourchette as well as among vulvar cancers from other locations. Women with vulvar cancers of the anterior fourchette were of young age irrespective of the HPV/p16(INK4a)/p53 status. Conclusions: Different types of vulvar cancers can be found in squamous cell tumors of the anterior fourchette, similar to the finding in vulvar cancers from other locations and to what has previously been reported for vulvar squamous cell carcinomas in general.
    No preview · Article · May 2013 · Journal of Lower Genital Tract Disease
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    Alexander Kreuter · Ulrike Wieland · Monika Hampl
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    ABSTRACT: Chronic idiopathic CD4+ T lymphocytopaenia is a rare syndrome characterized by pronounced CD4+ T-cell depletion in the absence of HIV infection. Based on the Centers for Disease Control and Prevention diagnostic criteria, patients present decreased circulating T lymphocytes (< 300 μ/l or < 20% of peripheral lymphocytes) on at least 2 occasions, a low CD4/CD8 ratio, absence of HIV infection, and no history of other immunodeficiencies or immunosuppressive drugs (1). Patients with chronic idiopathic CD4+ T lymphocytopaenia may exhibit a broad spectrum of opportunistic and unusual fungal, bacterial, protozoal, and viral infections (2). We report here 2 women with chronic idiopathic CD4+ T lymphocytopaenia diagnosed following longstanding and recurrent human papillomavirus (HPV)- induced high-grade anogenital dysplasia.
    Full-text · Article · Apr 2013 · Acta Dermato-Venereologica
  • M. Hampl · W. Janni
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    ABSTRACT: Whereas decades ago, vulvar cancer was a tumor primarily diagnosed in elder women, nowadays, this tumor is increasingly seen in younger women. The rising incidence is mainly due to the increasing number of young women presenting with these tumors. Depending on the age of the women persistent infection with high risk human papillomavirus is responsible for the development of these lesions in 30-60% of the cases. More than 50% (own data) of the tumors are located between clitoris and urethra. Standard treatment is tumor resection with sufficient margin or (partial) vulvectomy and complete inguinofemoral lymphadenectomy or sentinel node biopsy in specialized centers. New therapy options are reconstruction of the vulva with local skin flaps to improve asthetic and functional outcome especially in young, sexually active women.
    No preview · Article · Mar 2013
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    ABSTRACT: OBJECTIVE: The aim of the study was to describe the (a) symptom experience of women with vulvar intraepithelial neoplasia and vulvar cancer (vulvar neoplasia) during the first week after hospital discharge, and (b) associations between age, type of disease, stage of disease, the extent of surgical treatment and symptom experience. METHODS: This cross-sectional study was conducted in eight hospitals in Germany and Switzerland (Clinical Trial ID: NCT01300663). Symptom experience after surgical treatment in women with vulvar neoplasia was measured with our newly developed WOMAN-PRO instrument. Outpatients (n=65) rated 31 items. We used descriptive statistics and regression analysis. RESULTS: The average number of symptoms reported per patient was 20.2 (SD 5.77) with a range of 5 to 31 symptoms. The three most prevalent wound-related symptoms were 'swelling' (n=56), 'drainage' (n=54) and 'pain' (n=52). The three most prevalent difficulties in daily life were 'sitting' (n=63), 'wearing clothes' (n=56) and 'carrying out my daily activities' (n=51). 'Tiredness' (n=62), 'insecurity' (n=54) and 'feeling that my body has changed' (n=50) were the three most prevalent psychosocial symptoms/issues. The most distressing symptoms were 'sitting' (Mean 2.03, SD 0.88), 'open spot (e.g. opening of skin or suture)' (Mean 1.91, SD 0.93), and 'carrying out my daily activities' (Mean 1.86, SD 0.87), which were on average reported as 'quite a bit' distressing. Negative associations were found between psychosocial symptom experience and age. CONCLUSIONS: WOMAN-PRO data showed a high symptom prevalence and distress, call for a comprehensive symptom assessment, and may allow identification of relevant areas in symptom management.
    No preview · Article · Jan 2013 · Gynecologic Oncology
  • M. Hampl · W. Janni
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    ABSTRACT: Die Inzidenz des Vulvakarzinoms hat in den letzten Jahren deutlich zugenommen. Während diese Tumorentität früher vor allem bei älteren Frauen diagnostiziert wurde, werden inzwischen viele junge Vulvakarzinompatientinnen operiert, bei denen in 30–50% eine Infektion mit humanen Papillomviren (HPV) die Tumorentstehung auslöst. Prädilektionsstelle ist die Region zwischen Klitoris und Urethra (>50% aller Tumoren, eigene Daten). Die Behandlung ist die Resektion in sano oder eine (partielle) Vulvektomie und eine inguinofemorale Lymphknotenentfernung ein- oder beidseitig, ggf. Sentinel-Lymphonodektomie in ausgewählten Zentren. Die Deckung des Vulvadefektes mit lokoregionären Lappen zur Verbesserung des ästhetisch/funktionellen Ergebnisses ist eine Therapieoptionen, die vor allem jungen, sexuell aktiven Frauen angeboten werden sollte; im Beitrag werden Beispiele dargestellt.
    No preview · Article · Nov 2012 · Der Gynäkologe
  • M. Hampl · G. Bauerschmitz
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    ABSTRACT: Eine 35-jährige gesunde 0G/0P stellt sich mit seit neun Monaten bestehendem, therapieresistentem Brennen und Jucken in der Region der vorderen Vulva vor. Kolposkopisch lässt sich eine kleine erosive Läsion in der Region zwischen Klitoris und Urethra darstellen, die auf Essigapplikation zart weiß reagiert. Die Exzision ergibt ein invasives Vulvakarzinom (pT1b), die Sentinel LK waren negativ. Diskutiert wird das zunehmend häufige Auftreten dieser „neuartigen“ tumorösen Läsionen in Deutschland. Abstract A 35-yearold healthy nulliparous woman presents in our clinic for further evaluation of burning and itching in the anterior vulvar region persisting for 9 months and resistant to external treatment. On colposcopy, a small reddish erosive lesion between the clitoris and urethra was diagnosed, turning its color to light white after acetic acid application. The excision led to the diagnosis of a small, but invasive vulvar cancer (pT1b); the sentinel nodes removed from both groins were tumor free. The increasing incidence of this “new tumor entity” in Germany is discussed.
    No preview · Article · Apr 2012 · Der Gynäkologe
  • M. Hampl · G. Bauerschmitz · W. Janni
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    ABSTRACT: Das Vulvakarzinom ist nicht mehr ein Alterskarzinom: Die Zunahme dieser Tumorentität um 300–400% in der letzten Dekade ist vor allem durch das gehäufte Auftreten dieser Tumoren bei jungen Frauen bedingt. Abhängig vom Alter der Patientin ist an diesen Tumoren in 30–60% eine Infektion mit humanen Papillomviren (HPV) ursächlich beteiligt. Die Prädilektionsstelle ist die Region zwischen Klitoris und Urethra (etwa 40%). Die Behandlung ist die Resektion in sano oder (partielle) Vulvektomie und eine inguinofemorale Lymphknotenentfernung. Als neue Therapieoptionen ist die Sentinel-Lymphonodektomie und die Deckung des Defektes mit lokoregionären Lappen zur Verbesserung des ästhetischen wie des funktionellen Ergebnisses zu sehen.
    No preview · Article · Sep 2011 · Der Gynäkologe
  • M. Hampl · G. Bauerschmitz · W. Janni
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    ABSTRACT: Die HPV-induzierte klassische vulväre intraepitheliale Neoplasie (VIN) ist die häufigste Präkanzerose der Vulva (90%). Die Inzidenz der Erkrankung hat zugenommen und liegt derzeit bei 5–7/100.000 Frauen/Jahr, der Altersmedian liegt bei 46 Jahren. Die Erkrankung kann multifokal auftreten und multizentrisch. Die nicht HPV-assoziierte differenzierte VIN ist selten und tritt v. a. bei älteren Frauen auf. Die Beschwerden sind unspezifisch mit Juckreiz, Brennen oder tastbarer Veränderung. Die Diagnose erfolgt kolposkopisch mittels Stanzbiopsie. Die Standardtherapie ist die chirurgische Entfernung im Gesunden (Exzision oder Lasertherapie). Das Immunmodulans Immiquimod zeigt gute Heilungsraten, ist aber für die Erkrankung nicht zugelassen und deshalb nur im ,,Off-Label-Use“ einsetzbar. Die zweithäufigste prämaligne Läsion ist der M. Paget. Die kolposkopische Verdachtsdiagnose wird über eine Biopsie gesichert. Auch hier besteht die Therapie in der weiten/tiefen Exzision oder Laservaporisation. Die Rezidivrate ist hoch.
    No preview · Article · Apr 2011 · Der Gynäkologe
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    ABSTRACT: Human papillomavirus is responsible for a variety of diseases including grade 2 and 3 vulvar and vaginal intraepithelial neoplasia. The aim of this study was to assess parts of the burden of the last diseases including treatment costs. The direct medical resource use and cost of surgery associated with neoplasia and related diagnostic procedures (statutory health insurance perspective) were estimated, as were the indirect costs (productivity losses) associated with surgical treatment and related gynaecology visits for diagnostic purposes. Data from 1991-2008 were retrospectively collected from patient records of the outpatient unit of the Gynaecological Dysplasia Clinic, Heinrich Heine University, Dusseldorf, Germany. Two subgroups of patients were analysed descriptively: women undergoing one surgical procedure related to a diagnosis of vulvar and/or vaginal intraepithelial neoplasia, and women undergoing two or more surgical procedures. Target measures were per-capita medical resource consumption, direct medical cost and indirect cost. Of the 94 women analysed, 52 underwent one surgical intervention and 42 two or more interventions (mean of 3.0 interventions during the total period of analysis). Patients undergoing one surgical intervention accrued €881 in direct costs and €682 in indirect costs; patients undergoing more than one intervention accrued €2,605 in direct costs and €2,432 in indirect costs. The economic burden on German statutory health insurance funds and society induced by surgical interventions and related diagnostic procedures for grade 2/3 vulvar and vaginal neoplasia should not be underrated. The cost burden is one part of the overall burden attributable to human papillomavirus infections.
    Full-text · Article · Mar 2011 · BMC Infectious Diseases
  • M Hampl · C Nestle-Krämling · W Janni

    No preview · Article · Nov 2010 · Geburtshilfe und Frauenheilkunde
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    ABSTRACT: Hailey-Hailey disease (HHD) is a rare, autosomal dominant intraepidermal blistering disorder characterized by recurrent vesicles and erosions affecting mostly the intertriginous areas. We report a case of HHD affecting exclusively the vulva from which an invasive squamous cell carcinoma developed after tacrolimus therapy.
    No preview · Article · Sep 2010 · American journal of obstetrics and gynecology

Publication Stats

587 Citations
94.65 Total Impact Points

Institutions

  • 2006-2015
    • Heinrich-Heine-Universität Düsseldorf
      • • Frauenklinik
      • • Faculty of Medicine
      • • Institute of Neuropathology
      Düsseldorf, North Rhine-Westphalia, Germany
  • 2006-2009
    • Universitätsklinikum Düsseldorf
      Düsseldorf, North Rhine-Westphalia, Germany
  • 2002
    • National Institutes of Health
      • Branch of Neuro-Oncology
      Maryland, United States
  • 2001
    • National Cancer Institute (USA)
      • Neuro-Oncology Branch
      베서스다, Maryland, United States