Vulvar Intraepithelial Neoplasia

This term refers to preinvasive lesions that are warty, basaloid, or differentiated in type. The warty and basaloid types that are often multifocal occur in younger women, and are usually HPV related, while the localized, differentiated type occurs in older women and are usually HPV negative. Natural history studies documenting progression from vulvar intraepithelial neoplasia to invasive vulvar cancer are marred by low numbers, previous treatment, short follow-up times, and lack of stratification based on HPV status. Nevertheless, studies have shown that patients who undergo treatment have a low chance of developing invasive disease. Although it has long been felt that the majority of those with untreated vulvar intra-epithelial neoplasia (VIN) III do not progress to invasion, this is somewhat controversial (8). Patients with immunosuppression are particularly vulnerable and are prone to recurrences, which mirror their immune status.

VIN lesions show a variety of clinical presentations—from a red or pigmented macular lesion to a raised, whitish plaque that can occur anywhere on the vulvar structures. Lesions can appear as hypopigmented in darker-skinned women. Histo-logically, they show increased numbers of undifferentiated cells with nuclear atypia, disorganized epidermal maturation, hyperkeratosis and parakeratosis, and abnormal mitotic figures. Under colposcopic examination, vascular abnormalities can be absent or minimal, especially when hyperkeratosis is present. Therefore, the best diagnostic maneuver is liberal biopsy with either a Keyes punch biopsy or a cervical biopsy instrument under local anesthesia. Often hemostasis can be achieved with silver nitrate sticks or a single absorbable stitch. The application of 5% acetic acid can sometimes help to delineate a lesion for directed biopsy. Treatment is either excision if focal, or laser ablation if widespread or involving the clitoral structures. Since there is a high rate of undetected microinvasive or invasive disease, liberal biopsy at the time of laser ablation is advised.

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