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3/10/2024

Management of Vulvar Dysplasia

Vulvar cancer is predominantly squamous in origin and may develop slowly from vulvar intraepithelial neoplasia (VIN). Two forms of VIN exist including vulvar HSIL (VHSIL) and differentiated VIN (DVIN). Vulvar HSIL refers to lesions strongly associated with human papillomavirus infection (HPV), while DVIN refers to lesions that are related instead to chronic inflammatory dermatoses, such as lichen sclerosus and lichen simplex chronicus. While vulvar cancer comprises less than 5% of gynecologic cancers, the incidence of vulvar HSIL has risen sharply over the past few decades in the United States due to the rising prevalence of HPV infection.

One should maintain a low threshold for collecting biopsies of vulvar lesions. Lesions that are persistent, rapidly changing, or display atypical vascular patterns, colors, or borders should be biopsied. Suspected genital warts in postmenopausal patients and lesions that have not responded to topical therapies in patients of all ages should also be biopsied. 

Treatment is recommended for vulvar HSIL. Size, location, and number of lesions should drive decision-making between medical and surgical approaches to treatment. Medical treatment using topical imiquimod 5% can be used off-label for the treatment of vulvar HSIL and can be considered for patients with diffuse or numerous lesions when cancer is not suspected. Patient compliance is paramount when choosing this treatment strategy as multiple office visits will be needed for completion: treatment may require a frequency of three times weekly for 12-20 weeks with monthly vulvoscopic assessments. Lesions that fail to respond require surgical excision. Vulvar irritation or pain may disrupt or prematurely terminate treatment. Nonetheless, topical therapy may be an ideal approach for patients unable to tolerate conditions required for surgical treatments such as ablation or excision.

Laser ablation is acceptable treatment for vulvar HSIL when cancer is not suspected.  Laser ablation can be used for single, multifocal, or confluent lesions. Vulvoscopy facilitates delineation of lesion margins. A Laser treatment of vulvar HSIL requires the destruction of cells through the entire epithelium, roughly two millimeters for non-hair-bearing areas. Vulvar HSIL identified in hair-bearing areas of the vulva may contain dysplasia within hair follicles deeper in the subcutaneous tissue. Surgical excision is, therefore, preferred for large lesions in hair-bearing regions.

When occult cancer is suspected, wide local excision is preferred, with attention made to avoid injury to surrounding structures including the clitoris, urethra, and anus. Negative margins reduce, but do not eliminate, the risk of recurrence. Skinning vulvectomy is rarely needed.

Patients with vulvar HSIL remain at risk for HSIL recurrence and progression to vulvar cancer for the remainder of their lives. Positive margins following wide local excision and cigarette smoking are associated with higher recurrence rates. Following successful treatment of HSIL, 6- and 12-month vulvar exams are recommended with annual exams thereafter.

Further Reading:

Committee Opinion No. 675 Summary: Management of Vulvar Intraepithelial Neoplasia. Obstet Gynecol. 2016 Oct;128(4):937-938. doi: 10.1097/AOG.0000000000001704. PMID: 27661648.

Hoffman BL, Schorge JO, Halvorson LM, Hamid CA, et al. Preinvasive Lesions of the Lower Anogenital Tract. Williams Gynecology, 4e. McGraw Hill; 2020. Accessed October 08, 2022. https://accessmedicine.mhmedical.com/content.aspx?bookid=2658&sectionid=241012254

Xavier J, Figueiredo R, Vieira-Baptista P. Vulvar High-Grade Squamous Intraepithelial Lesion and the Risk of Recurrence and Progression to Cancer. J Low Genit Tract Dis. 2023 Apr 1;27(2):125-130. doi: 10.1097/LGT.0000000000000726. Epub 2023 Feb 16. PMID: 36794761.

Thuijs NB, van Beurden M, Duin S, Heideman DA, Berkhof J, et al. High‐grade vulvar intraepithelial neoplasia: comprehensive characterization and long‐term vulvar carcinoma risk. Histopathology. 2023 Sep 19.

Initial Publication March 2024

 

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