Vulvar dysplasia and vulvar cancer: Clinical sciences

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. 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.

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. Patients typically report vulvar lesions, with possible pruritus or chronic irritation. Risk factors include tobacco use, immunocompromised status, and prior HPV exposure.

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. The HPV vaccine is recommended for all patients ages 9 to 26 and up to age 45 in certain populations after shared decision-making.

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. Biopsies are also indicated in any postmenopausal patient with grossly visual genital warts.

Here’s another clinical pearl! The one exception where you can start management without colposcopy is if your exam findings are consistent with condyloma acuminate. 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.

Time for a high-yield fact! Bartholin gland cancer is a rare form of vulvar malignancy. Normally, if you see a Bartholin cyst abscess, you manage it with incision and drainage with a Word catheter, or marsupialization.

However, if the abscess is recurring, there are solid masses, or you suspect malignancy, you should go with an excision of the gland. 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. On physical exam, you might see condylomata acuminata, which is the most common form of LSIL. On colposcopy, you typically find leukoplakia or hyperpigmentation. Biopsy results will show an exophytic papillary lesion, consistent with a condyloma acuminatum, displaying atypical koilocytes in the upper layers of the epithelium. With these results, diagnose LSIL. There is little evidence that LSIL is a cancer precursor and most LSIL is due to HPV. Topical treatment options include imiquimod; 5-fluorouracil, or 5-FU; and trichloroacetic acid, or TCA.

Here’s a high-yield fact! 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. 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. 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.

On that note, let’s discuss HSIL. On physical exam, these lesions are typically localized and well isolated with a raised slightly rough texture. 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. 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. With these results, diagnose HSIL. HSIL are high-grade, HPV-related lesions. 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. Lesions that raise suspicion for cancer include those that are raised, ulcerative, or have irregular borders, irrespective of the results from colposcopy and biopsy. 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.