Vulvar dysplasia and vulvar cancer: Clinical sciences
Introduction0:00–0:27
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Vulvar dysplasia and vulvar cancer are a group of conditions that include benign lesions associated with human papillomavirus, or HPV; premalignant lesions; and overt vulvar cancer.
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Vulvar cancers make up only a small percentage of gynecologic cancers, with squamous cell cancer as the most common type; and vulvar melanomas being less common.
Vulvar dysplasia0:27–3:11
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When evaluating a patient with a chief concern suggesting vulvar dysplasia or cancer, your first step is to obtain a focused history and physical examination.
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Patients typically report vulvar lesions, with possible pruritus or chronic irritation. Risk factors include tobacco use, immunocompromised status, and prior HPV exposure.
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Here’s a clinical pearl! HPV exposure and infection is generally thought of as a risk of cervical cancer; however, it also increases the risk of vaginal, vulvar, anal, penile, and oropharyngeal cancer.
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The HPV vaccine is recommended for all patients ages 9 to 26 and up to age 45 in certain populations after shared decision-making.
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On physical examination, you might see elevated or flat lesions with variable coloration from white to reddened, which should get you to suspect vulvar dysplasia.Vulvar colposcopy with biopsies is the next step in management if: you are unable to make the diagnosis on clinical findings alone; malignancy is possible; the lesion is not responding to usual treatment; the lesion has an atypical vascular pattern; or a stable lesion has rapidly changed in color, border, or size.
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Biopsies are also indicated in any postmenopausal patient with grossly visual genital warts. Here’s another clinical pearl!
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The one exception where you can start management without colposcopy is if your exam findings are consistent with condyloma acuminate.
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In this case, you may first attempt treatment with topical medications. However, if the lesions do not respond, a biopsy is needed to confirm the diagnosis.
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Time for a high-yield fact! Bartholin gland cancer is a rare form of vulvar malignancy.
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Normally, if you see a Bartholin cyst abscess, you manage it with incision and drainage with a Word catheter, or marsupialization.
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However, if the abscess is recurring, there are solid masses, or you suspect malignancy, you should go with an excision of the gland.
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Additionally, if your patient with Bartholin cyst abscess is at least 40 years old, get a wall biopsy to rule out cancer.Okay, let's review the colposcopy and biopsy findings starting with low-grade squamous intraepithelial lesions, or LSIL.
Low-grade squamous intraepithelial lesion3:11–5:00
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On physical exam, you might see condylomata acuminata, which is the most common form of LSIL. On colposcopy, you typically find leukoplakia or hyperpigmentation.
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Biopsy results will show an exophytic papillary lesion, consistent with a condyloma acuminatum, displaying atypical koilocytes in the upper layers of the epithelium.
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With these results, diagnose LSIL. There is little evidence that LSIL is a cancer precursor and most LSIL is due to HPV.
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Topical treatment options include imiquimod; 5-fluorouracil, or 5-FU; and trichloroacetic acid, or TCA.Here’s a high-yield fact!
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Like many conditions in medicine, the terminology for vulvar dysplasia has changed. LSIL, which is currently in use, was formerly known as vulvar intraepithelial neoplasia 1, or VIN 1.
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High-grade squamous intraepithelial lesion, or HSIL, has also been renamed. It was formerly known as vulvar intraepithelial neoplasia, usual type, or VIN usual type.
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The usual type here refers to its association with HPV infection. In contrast, VIN, a differentiated type, is associated with vulvar dermatoses like lichen sclerosus.
High-grade squamous intraepithelial lesion5:00–7:06
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On that note, let’s discuss HSIL. On physical exam, these lesions are typically localized and well isolated with a raised slightly rough texture.
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They are generally found on the posterior, hairless area of the vulva and perineal body, but can occur anywhere. Colposcopy findings can include leukoplakia or hyperpigmentation, along with an atypical vascular pattern.
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Be sure to biopsy in multiple sites to thoroughly investigate HSIL and exclude cancer. Biopsy results will show cytologic atypia from two-thirds to full thickness of the epithelium, without invasion.
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With these results, diagnose HSIL. HSIL are high-grade, HPV-related lesions.
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If left untreated, they have a high rate of progression to severe intraepithelial lesions and eventually cancer. Treatment is based on suspicion for underlying cancer.
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Lesions that raise suspicion for cancer include those that are raised, ulcerative, or have irregular borders, irrespective of the results from colposcopy and biopsy.
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Additionally, cancer should be suspected in patients with a lesion and risk factors for invasion, like previous vulvar HSIL, differentiated VIN, or vulvar carcinoma; immunosuppression; or lichen sclerosus.
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If cancer is suspected, then a wide local excision is indicated. If cancer is not suspected, treatment options include excision, laser ablation, or topical imiquimod.
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Due to the risk of recurrence of HSIL long-term follow-up is needed. Here’s another clinical pearl!
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Keep in mind that if your patient is diagnosed with vulvar HSIL, they also have a high chance of coexisting cervical HSIL lesions.
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Next up let’s discuss VIN, differentiated type. These lesions are not HPV related and biopsy is mandatory for diagnosis.
Vulvar intraepithelial neoplasia, differentiated type7:06–8:09
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VIN differentiated type is associated with lichen sclerosus and squamous cell cancer. Unfortunately, this type of lesion is thought to be underdiagnosed as there is a short interval from the intraepithelial phase before progressing to cancer.
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Physical examination findings can include a hyperkeratotic plaque, warty papule, or ulcer. Colposcopy findings can include focal discoloration, ill-defined plaques, and red, hyperkeratotic lesions.
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Biopsy results reveal cytologic atypia in the basal and parabasal layers of the epithelium. With these findings, diagnose VIN, differentiated type.
Squamous cell vulvar cancer8:09–9:57
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Squamous cell cancers of the vulva are more common for patients 70 to 90 years old but can occur in younger patients too.
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Lesions are most commonly found on the posterior two-thirds of either labia majora. Colposcopic findings might include leukoplakia, hyperpigmentation or erythema, atypical vascular patterns with friability, and ulcerative or warty lesions.
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Biopsy results reveal cytologic atypia through the full thickness of the epithelium and invading into the dermis. With these findings, diagnose squamous cell vulvar cancer.
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Keep in mind that vulvar squamous cell cancers typically remain localized for long periods of time and then spread predictably to regional lymph nodes, in the inguinal and femoral chains.
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The larger and deeper the lesion, the more likely a patient is to have metastasis to the lymph nodes. Squamous cell vulvar cancer is staged surgically using the classification by the International Federation of Gynecology and Obstetrics, or FIGO.
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Treatment is via surgical excision with increasingly more conservative approaches to reduce the amount of radical surgery being performed.
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Radiation and chemotherapy are dependent on stage and grade. The 5-year survival rate for stages 1 and 2 is 60-80%.
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For stage 3, it is 45%, while for stage 4, 5–year survival rate is 15%.Okay, we’ve covered a lot but let’s not forget about vulvar melanoma, which is a rare form of vulvar cancer.
Vulvar melanoma9:57–11:45
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Similarly to vulvar dysplasia, patients typically present with vulvar pruritus and irritation. On examination, the key finding is a pigmented lesion, often with the ABCDEs of atypical moles; which represents asymmetry, border, color, diameter, and evolving.
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Typically melanomas are asymmetric, have irregular, ragged, or notched borders, consist of shades of brown or black and sometimes patches of pink, red, white, or blue; have a diameter greater than 6 millimeters, and are changing in size, shape, or color.
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The most common areas to find vulvar melanomas are the labia minora or clitoris. The next step in management is a vulvar biopsy with a full-thickness technique such as elliptical or punch excision including the most abnormal or atypical part of the lesion.
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The result will reveal infiltration by atypical melanocytes and positive staining for melanoma-specific antigen.Treatment includes a wide local excision to confirm diagnosis and for adequate staging.
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If the melanoma is confined to the intrapapillary ridges, the survival rate is near 100 percent. However, survival decreases rapidly as the papillary dermis, reticular dermis, and subcutaneous tissue are involved.
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Radiation and chemotherapy are dependent on the stage and grade of the vulvar melanoma. Alright, as a quick recap… Vulvar dysplasia and vulvar cancers are a group of conditions that include LSIL, HSIL, VIN differentiated type, squamous cell vulvar cancer, and vulvar melanoma.
- "ACOG committee opinion no 675. Management of vulvar intraepithelial neoplasia" Obstet Gynecol (2016)
- "Beckmann and Ling’s Obstetrics and Gynecology" Wolters Kluwer (2023)
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