Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Management of Vulvar Intraepithelial Neoplasia

Obstet Gynecol; ePub 2016 Oct; ACOG & ASCCP

The American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice and the American Society for Colposcopy and Cervical Pathology (ASCCP) have issued a committee opinion on the management of vulvar intraepithelial neoplasia (VIN), an increasingly common problem, particularly among women in their 40s. Although spontaneous regression has been reported, VIN should be considered a premalignant condition. ACOG and ASCCP offer the following recommendations and conclusions:

  • Immunization with the quadrivalent or 9-valent human papillomavirus (HPV) vaccine, which is effective against HPV genotypes 6, 11, 16, and 18, and 6, 11, 16, 18, 31, 33, 45, 52, and 58, respectively, has been shown to decrease the risk of vulvar high-grade squamous intraepithelial lesions (HSIL) (also known as vulvar intraepithelial neoplasia [VIN usual type]) and should be recommended for girls aged 11 to 12 years with catch-up through age 26 years if not vaccinated in the target age.
  • Cigarette smoking is strongly associated with vulvar HSIL (VIN usual type), and cessation should be encouraged.
  • There are no screening strategies for the prevention of vulvar cancer through early detection of vulvar HSIL (VIN usual type).
  • Detection is limited to visual assessment with confirmation by histopathology when needed.
  • Biopsy is indicated for visible lesions for which definitive diagnosis cannot be made on clinical grounds, possible malignancy, visible lesions with presumed clinical diagnosis that is not responding to usual therapy, lesions with atypical vascular patterns, or stable lesions that rapidly change in color, border, or size.
  • Biopsy should be performed in postmenopausal women with apparent genital warts and in women of all ages with suspected condyloma in whom topical therapies have failed.
  • Treatment is recommended for all women with vulvar HSIL (VIN usual type). Because of the potential for occult invasion, wide local excision should be performed if cancer is suspected, even if biopsies show vulvar HSIL.
  • When occult invasion is not a concern, vulvar HSIL (VIN usual type) can be treated with excision, laser ablation, or topical imiquimod (off-label use).
  • Women with vulvar HSIL (VIN usual type) are at risk of recurrent disease and vulvar cancer throughout their lifetimes.
  • Women with a complete response to therapy and no new lesions at follow-up visits scheduled 6 months and 12 months after initial treatment should be monitored by visual inspection of the vulva annually thereafter.

Citation:

Management of vulvar intraepithelial neoplasia. Committee Opinion No. 675. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2016;128:e178–82.