Vulval intraepithelial neoplasia

Vulval intraepithelial neoplasia is the pre-invasive phase of carcinoma of the vulva.

• affects 20-30 per 100,000 women
• approximately 40% of cases occur in women under 41
• aetiological factors include human papilloma virus (HPV) and immunosuppression
  
  
• clinical features
  • pruritus vulvae
  • abnormal skin lesion of vulva
    
    
• investigation - skin biopsy
  
  
• management
  • surgery is often considered the treatment of choice for vulvar intraepithelial neoplasia (1)
    • removes all visible lesions, with the aim of relieving symptoms and preventing vulvar cancer
    • however, there are limitations to surgery
      • percentage of lesions with positive surgical margins ranges from 24 to 68%
      • recurrences are common, because surgery does not eliminate HPV
      • surgery can mutilate the vulva, thereby causing psychosexual distress
  • careful monitoring might be considered by some clinicians - approximately 6% of lesions become malignant
  • topical steroids may have a role in symptomatic treatment
  • if VIN is diagnosed then there is a >10% risk of neoplasia elsewhere, generally cervical. Thus if VIN is diagnosed then an examination of the cervix and breasts should be undertaken

Notes:

• the use of imiquimod 5% cream, a topical immune-response modifier, for treatment of the VIN
  • a study assessed the effectiveness of imiquimod 5% cream in patients with multifocal grade 2 or 3 vulvar intraepithelial neoplasia in a placebo-controlled, double-blind, randomized clinical trial
  • the study revealed that imiquimod 5% cream reduced lesion size in patients with vulvar intrapithelial neoplasia

Reference:

• 1. Van Seters M et al. Treatment of vulvar intraepithelial neoplasia with topical imiquimod. N Engl J Med. 2008 Apr 3;358(14):1465-73.