Vulval intraepithelial neoplasia

Question 1

Definition of VIN

Answer 1

This is a vulval skin condition which may become
cancerous if left untreated. It is confirmed by histological diagnosis and can be defined as low grade or high grade.
Low-grade change is usually associated with human papillomavirus (HPV) and may resolve. The commonest aetiological agent is HPV that is known as usual type and is mainly associated with HPV 16. A second type, generally not HPV related, occurs in conjunction
with LS or lichen planus (known as differentiated
type). The risk of progression to SCC is much greater
with the differentiated type of VIN and needs specialised
management. VIN is commoner in immunocompromised
women. Smoking is also a risk factor.

Question 2

Symptoms of VIN

Answer 2

. Lumps
. Erosions
. Burning and itch/irritation
. Asymptomatic
. Pain

Question 3

Signs of VIN

Answer 3

. Clinical appearance is very variable.
. Raised white, erythematous or pigmented lesions
occur and these may be warty, moist or eroded (pigmented lesions were previously known as Bowenoid
papulosis).
. Multifocal lesions are common

Question 4

Complications of VIN

Answer 4

. Development of SCC has been reported in between
9% and 18.5% of women.
. Recurrence is common and progression to cancer
can occur following previous treatment.
. Psychosexual consequences have also been described
(especially following surgical treatment).

Question 5

Diagnosis of VIN

Answer 5

. Biopsy – histopathology shows loss of organisation of
squamous epithelium with a variable degree of cytological atypia which is graded as undifferentiated or differentiated and by depth. Multiple biopsies may be
required as there is a risk of missing invasive disease

Question 6

Investigations of VIN

Answer 6

. Ensure that cervical cytology remains up-to-date –
there is an association with cervical intraepithelial neoplasia (CIN) (this is probably only applicable
to those due to HPV).
. All patients with VIN should be referred for up-todate
colposcopy to exclude CIN and VIN. If there
are any perianal lesions, referral for anoscopy is recommended

Question 7

Treatment of VIN

Answer 7

. Local excision – this is the treatment of choice for
small well-circumscribed lesions as it has the lowest
rate of recurrence on follow-up.
. Imiquimod cream 5% – partial and complete clinical
and histological regression has been shown but treatment limited by side effects. Only short-term follow-up data are available.
. Vulvectomy – this has been effective but recurrence
may occur and function and cosmesis will be
impaired