GYN
CMECNE

Vulvar Intraepithelial Neoplasia (VIN): Diagnosis and Treatment 

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Learning Objectives and CME/Disclosure Information

VIN is an increasingly common problem, particularly for women in their 40s, and should be considered a premalignant condition. A low threshold for consideration, biopsy and follow up should be maintained.

CLINICAL ACTIONS:

  • Detection is limited to visual assessment with biopsy confirmation when needed
  • Biopsy any visible lesion on the vulva that meets the following criteria:
    • Diagnosis cannot be made on clinical grounds
    • Possible malignancy
    • Lesion not responding to usual therapy
    • Lesion with atypical vascular pattern
    • Lesion with rapid change in size/color/border
    • Presumed condyloma not responding to topical treatment
  • Perform colposcopy several minutes after the application of 3-5% acetic acid if lesions not clearly visualized or in women with persistent focal symptoms of pruritis/pain despite treatment for vulvo-vaginitis
  • Treatment is recommended for all with vulvar HSIL (see classification below)
  • Preferred treatment is wide local excision with gross margins of 0.5-1 cm
    • Laser ablation is acceptable if cancer is not suspected
    • Topical imiquimod 5% applied three times/week for 12-20 weeks with colposcopy every 4-6 weeks is effective though not FDA approved
  • Women with VIN are at risk of recurrent disease and vulvar cancer throughout their lives.
    • Surveillance is 6 and 12 months after treatment, then annual visual inspection of the vulva

SYNOPSIS:

In 2015 terminology for VIN was changed by the International Society for the Study of VulvoVaginal Disease (ISSVD) to unify nomenclature for HPV associated lesions of the cervix, vagina and vulva. In the new classification Low-grade squamous intraepithelial lesion of the vulva (vulvar LSIL) corresponds to “condyloma”, or “HPV effect”.  High-grade squamous intraepithelial lesion of the vulva (vulvar HSIL) includes “usual type VIN” (warty, basaloid type or mixed). Differentiated type VIN is unchanged from the 2004 classification. Of these three types, differentiated VIN is usually not HPV associated, being more often associated with a vulvar dermatologic condition such as lichen sclerosis, and with squamous cell carcinoma of the vulva.

KEY POINTS:

  • Risk factors for VIN include HPV infection and cigarette smoking
  • Prevention should include vaccination in women under the age of 26, and smoking cessation
  • As differentiated VIN is associated with vulvar dermatoses, treatment of these disorders, especially lichen sclerosis, reduces the risk of cancer of the vulva

Learn More – Primary Sources:

ACOG ASCCP Committee Opinion No. 675: Management of vulvar intraepithelial neoplasia 

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