VULVAR INTRAEPITHELIAL NEOPLASIA (2004 terminology)

Terminology Age, frequency Appearance of skin Risk factors Symptoms & Exam
VIN 1: no longer considered pre-cancerous (usually HPV 6 and 11)
VIN, USUAL TYPE (encompasses VIN 2 and 3)
Former VIN warty type
Former VIN baseloid type
Former VIN mixed (warty and baseloid) type		 Younger, pre-menopausal women75% of VIN cases are in young women
  1. Often multi-focal, multicentric (different ebryologically similar areas)
  2. Colors: red, pink, grey, brown, white
  3. Textures: slightly raised or flat or verrucous
  4. Warty type: condylomatous appearance
  5. Baseloid type: thick epithelium with flat, smooth surface
  1. HPV infection (often 16, 18, 31) (may be associated with CIN or VAIN)
  2. Cigarette smoking
  3. Immunodeficiency (HIV)
  4. Immunosuppression
  1. 50% asymptomatic
  2. Pruritus, palpable or visible lesion, perineal pain or burning, dysuria
  3. EXAM: Must check entire vulva and groin; use colposcope or magnifying glass; use acetic acid; BIOPSY suspicious lesions.
VIN, DIFFERENTIATED TYPE (encompasses VIN 2 and 3)
Former simplex type		 <5% of VIN cases are differentiated type and are usually in postmenopausal women
  1. Often unifocal, unicentric
  2. Epithelium is thickened and parakeratotic (with thick scale formation, cracking and fissuring and underlying raw, red surface)
  1. History of lichen sclerosus (or lichen planus)
  1. 50% asymptomatic
  2. Pruritus, palpable or visible lesion, perineal pain or burning, dysuria
  3. EXAM: Must check entire vulva and groin; use colposcope or magnifying glass; use acetic acid; BIOPSY suspicious lesions.
VIN, UNCLASSIFIED TYPE(rare) BIOPSY suspicious lesions.

 

 TREATMENT OF VULVAR INTRAEPITHELIAL NEOPLASIA (2004 terminology)
See Atlas Topic or UpToDate for more information.

Treatment action Topical/behavioral Type of lesion Procedure Advantage/disadvantage/Notes
Comfort measures, general care Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants or tight clothing, application of cool gel packs When VIN, VAIN, CIN, or AIN are found, the patient needs to have a complete colposcopic evaluation of the vulva, vagina, cervix, and anus, including anoscopy. Treatment goal: Prevention of development of invasive cancer, relief of symptoms, preservation of normal anatomy and function. If untreated, VIN may persist, progress, or resolve. Recurrence is common: 1/3 of women utilizing any treatment.
Wide local excision VIN, most commonly differentiated type: unifocal Wide local excision (knife, electrosurgery, CO2 laser) with a 1 cm margin and removal of the epidermis and a small section of dermis. Allows for histopathological examination of the sample.
Laser ablation VIN, most commonly usual type: multifocal or extensive Laser vaporization treats the whole area, with depth to 1 mm (in hair-free areas) to 3 mm (in hair-bearing areas). Must evaluate with colposcope and biopsy for cancer prior to ablative treatment;Superficial laser treatment is comestically more satisfactory than skinning vulvectomy.

Deep laser may cause scarring.
Simple vulvectomy VIN, most commonly usual type: multifocal or extensive Removal of the entire vulva usually including some subcutaneous tissue. Tissue available for pathological evaluation.
Skinning vulvectomy VIN, usually usual type: multifocal or large and confluent Removal of the vulvar skin along an avascular plane beneath the epidermis, leaving the subcutaneous tissue. Rarely used unless other treatments have failed. May need skin graft.
Topical medical treatment VIN, usually usual type Application of Imiquimod cream (Aldara) to individual lesions:
1 x a week x 2 weeks, then
2 x a week x 2 weeks, then
3 x a week till lesions are gone or up to 16 weeks		 Must evaluate with colposcope and biopsy for cancer prior to topical treatment. Response rate varies.

Updated 7/11/14 Link to VIN in Atlas