Vulvar lesions

Question 1

Types of VIN

Answer 1

VIN usual type

• associated with HR HPV
• smoking
• Vulvar HSIL

VIN differentiated type

Question 2

What recommended screening strategies are there for vulvar HSIL?

Answer 2

none

Question 3

When should biopsy be performed?

Answer 3

• when diagnosis cannot be made by clinical grounds
• lesions with presumed diagnosis not responding to typical management
• lesions with atypical vascular patterns
• suspicion of malignancy
• stable lesions that rapidly change in appearance
• post menopausal women with genital warts

Question 4

when should wide local excision be performed?

Answer 4

• suspicion of malignancy

- if patient desires this for treatment

Question 5

when and how should colposcopy be performed?

Answer 5

• when discrete lesion is not visible; or are interested in seeing if multifocal
• 3-5% acetic acid, let sit for several minutes

Question 6

treatment options

Answer 6

• WLE (1 cm margins)
• Laser
• Imiquimod

(last 2 need to be sure there is not occult malignancy)

Question 7

imiquimod - dose, treatment plan

Answer 7

5%
3x/week x 12-20 weeks
colposcopic assessment q4-6 weeks

Question 8

risk of recurrence

Answer 8

9-50%; lower for surgical excision (but 50% for positive margins)
need to follow-up 6 mo, then 12 mo after treatment
then annual exam (consider colposcopy)

Question 9

laser - power, goal/depth, margins

Answer 9

power: 750-1,250 W/cm^2
- hair bearing skin: 3 mm depth, non-hair bearing skin: 2 mm depth
- 0.5-1 cm margin

Question 10

Ddx of vulvar lesions?

Answer 10

• nevus (melanotic vs dysplastic)
• melanoma or lentigo maligna
• VIN or SCC
• Pagets disease
• STDs

Question 11

what is extra-mammary paget’s?
typical appearance?
treatment?
special considerations?

Answer 11

adenocarcinoma, can effect diverse # of sites on body

• often can be without lesions, but there are two types of lesions: erythematous (violaceous hue), eczematous (red skin, thin white coating “cupcake frosting”)
• tx is WLE; can have skin lesions making multiple excisions likely. if invasive adenoCA identified, radical excision with inguinal femoral LAD recommended
• other options include imiquimod (5%, 3-4x/week), CO2 laser, photodynamic therapy
• do full body exam to rule out other sites; consider eval of GI tract/GU if near urethra or peri-anal area