Vulvar intraepithelial neoplasia (VIN)
- Half of patients are asymptomatic, but others have local discomfort including itching, burning, and pain.
- Twenty percent have a coexistent invasive vulvar cancer.
- Risk factors. Patients infected with HIV or other immunodeficient medical conditions tend to be most susceptible. Smokers are also at higher risk.
- Diagnosis. Careful inspection of the vulva during routine gynecologic examinations is the most effective diagnostic “technique.” VIN has multiple possible appearances. It can resemble a wart, a mole, or condylomas, or be practically invisible. Application of acetic acid using soaked cotton balls for at least 5 minutes is necessary before many lesions are colposcopically apparent. Keyes dermatologic punch biopsies should be performed liberally under local anesthesia for any abnormality. Premenopausal women are more likely to have human papillomavirus (HPV)-related, multifocal lesions.
- Surgical treatment. Wide local excision (simple partial vulvectomy) is usually the treatment of choice for a small, solitary lesion. It provides tissue to rule out invasive disease, but can disrupt the anatomy for larger lesions. Carbon dioxide (CO2) laser ablation is particularly useful for scattered, multifocal lesions, as is Cavitron ultrasonic aspiration (CUSA). “Skinning” vulvectomy is indicated for large, confluent lesions, but rarely required.
- Medical treatment. Imiquimod (Aldara) locally stimulates the immune system to attack HPV-affected areas. 5-Fluorouracil (5-FU) is another topical chemotherapeutic agent, but it results in considerable local irritation and is not consistently successful – most likely related to poor patient compliance.
Vulvar cancer
Epidemiology and risk factors
- Incidence (annual). The USA: 4,500 new cases and 950 deaths; the UK: 1,000 new cases and 350 deaths – accounts for 5% of all gynecologic cancers.
- Median age. Sixty-five years.
- Risk factors.
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