Management of Vulvar Intraepithelial Neoplasia

Question 1

Immunization with the quadrivalent or 9-valent human papillomavirus (HPV) vaccine, which is effective against HPV genotypes 6, 11, 16, and 18, and 6, 11, 16, 18, 31, 33, 45, 52, and 58, respectively, has been shown to decrease the risk of vulvar high-grade squamous intraepithelial lesions (HSIL) (also known as vulvar intraepithelial neoplasia [VIN usual type]) and should be recommended for girls aged 11–12 years with catch-up through age 26 years if not vaccinated in the target age.

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Question 2

Detection is limited to visual assessment with confirmation by histopathology when needed.

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Question 3

Biopsy is indicated for visible lesions for which definitive diagnosis cannot be made on clinical grounds, possible malignancy, visible lesions with presumed clinical diagnosis that is not responding to usual therapy, lesions with atypical vascular patterns, or stable lesions that rapidly change in color, border, or size.

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Question 4

Biopsy should be performed in postmenopausal women with apparent genital warts and in women of all ages with suspected condyloma in whom topical therapies have failed.

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Question 5

Treatment is recommended for all women with vulvar HSIL (VIN usual type). Because of the potential for occult invasion, wide local excision should be performed if cancer is suspected, even if biopsies show vulvar HSIL.

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Question 6

When occult invasion is not a concern, vulvar HSIL (VIN usual type) can be treated with excision, laser ablation, or topical imiquimod (off-label use).

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Question 7

Women with a complete response to therapy and no new lesions at follow-up visits scheduled 6 months and 12 months after initial treatment should be monitored by visual inspection of the vulva annually thereafter.

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Question 8

The appearance of vulvar HSIL (VIN usual type) can vary. Most women have visible lesions that are elevated, but flat lesions occur. Color can vary from white to gray or from red to brown to black. Biopsy is indicated for visible lesions for which definitive diagnosis cannot be made on clinical grounds, possible malignancy, visible lesions with presumed clinical diagnosis that is not responding to usual therapy, lesions with atypical vascular patterns, or stable lesions that rapidly change in color, border, or size. Expert opinion is divided regarding the need for biopsy of all warty lesions, but biopsy should be performed in postmenopausal women with apparent genital warts and in women of all ages with suspected condyloma in whom topical therapies have failed.

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Question 9

topical imiquimod 5% is effective for the treatment of vulvar HSIL (VIN usual type) (17, 18), although it is not approved by the U.S. Food and Drug Administration for this purpose.

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Question 10

The value of vulvar self-examination and serial office visits in the detection of recurrence has not been proved, but both appear prudent. Given the relatively slow rate of progression, women with a complete response to therapy and no new lesions at follow-up visits scheduled 6 months and 12 months after initial treatment should be monitored by visual inspection of the vulva annually thereafter.

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Question 11

Wide local excision is the preferred initial intervention to obtain a specimen for pathologic analysis for women in whom invasive cancer cannot be adequately ruled out from their clinical or pathologic findings, despite a biopsy diagnosis of only vulvar HSIL (VIN usual type). The

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