Neoplasia 3: Case Report and Literature Review
Abstract
Vulvar intraepithelial neoplasia is a premalignant lesion of the vulva. Women with vulvar cervical intraepithelial neoplasia 3 are at high risk of recurrence and vulvar carcinoma. They warrant a
surgical management for the same reason. It may be either ablative or excisional, sometimes can be a combination of both. The decision for wide local excision or simple vulvectomy depends on clinical factors. Case: We present a case of a 67-year-old lady who presented with vulvar itching and a large black vulvar lesion involving the fourchette area, with HPV 16 positive. Initially, there was a doubt of melanoma, but vulval biopsy was suggestive of high-grade squamous intraepithelial lesion (HSIL) (vulval intraepithelial neoplasia 3 [VIN 3]). As it was a single large lesion, the initial plan was wide local excision but as the lesion was large and occupying almost half of the vulva, the decision of simple vulvectomy was taken. A wide local excision would have resulted in vulvar
asymmetry and since there was a big lesion, chances of satellite lesions over the vulva were there decision was made for simple vulvectomy. In this case report, we will review the literature on the surgical management of VIN 3. Conclusion: Treatment is recommended for all vulvar HSIL because of the potential for invasion. Simple vulvectomy is an easy procedure, with less hospital stay, less blood loss, and least recurrence rates. It is a suitable treatment option for multifocal and large lesions
of the vulva.
Keywords: Itching, simple vulvectomy, Vulval Intraepithelial Neoplasia 3
Nilanchali Singh,
Sivalakshmi Ramu,
Ruchi Rathore1,
Divya Sehra,
Jyoti Meena
Department of Obstetrics and
Gynecology, Division of Gynae
Oncology, All India Institute of Medical Sciences, Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
Introduction
Vulval Intraepithelial Neoplasia (VIN) can be vulvar low-grade squamous intraepithelial lesion, vulvar high-grade squamous intraepithelial lesion (HSIL), and differentiated types. Differentiated VIN may be associated with vulvar dermatoses
such as lichen sclerosis. Unlike cervical intraepithelial neoplasia (CIN), there are no screening strategy and management protocols for vulvar intraepithelial neoplasia. There is no robust management quoted in the literature regarding the effective surgical option for patients with vulvar HSIL. The outcome of the various surgical interventions on the risk of recurrence and progression to vulval cancer remains unexplored. It all depends on the operating surgeon’s decision to tailor the treatment plan according to individual patient characteristics.
with complaints of vulvar itching for 2 years. There was no history of cancer in the family. She was a type 2 diabetic for the past 21 years on oral hypoglycemic agents and was started on insulin therapy recently in view of deranged blood sugar levels. She had no other comorbidities.
On clinical examination, she had Eastern Co-operative Oncology Group PS 1, no pallor, and her vitals were stable with a blood pressure – 120/86 mm Hg and pulse rate – 88 beats/min. Her breast and thyroid examination was normal with
no palpable lymph nodes. On abdominal examination, no organomegaly was noted. Local examination revealed a blackish pigmentation of the vulva involving the fourchette area [Figure 1a]. On speculum and vaginal examination, the cervix and vagina were healthy, and rectal mucosa was free on palpation. All baseline investigations were done which were normal except for her blood sugar values which were deranged with fasting and postprandial values of 128 and 206 mg/dl,
respectively. Hemoglobin A1C was 8.24%.
Received: 21-Feb-2024
Revised: 07-MayAccepted: 24-Apr-2024
Published: ***
Address for correspondence:
Dr. Nilanchali Singh, Department of Obstetrics and Gynecology, Division of Gynae Oncology, All India Institute of Medical Sciences, New Delhi, India.
E‑mail: nilanchalisingh@gmail. com
Case Report
Our patient was a 67-year-old nulliparous lady, from an upper middle class family,
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How to cite this article: Singh N, Ramu S, Rathore R, Sehra D, Meena J. Wide local excision versus simple vulvectomy in vulval intraepithelial neoplasia 3: Case report and literature review. J Colposcopy Low Genit Tract Pathol 2024;XX:XX-XX.
Figure 1: (a) Preoperative figure showing a blackish pigmentation of the vulva involving the fourchette area (b) immediate post‑operative image (c) image showing healing of the surgical site
Chest X-ray was normal, and electrocardiogram was in normal sinus rhythm. Biopsy of the vulvar lesion revealed a full-thickness dysplasia in the epidermis, suggestive of VIN-3 with immunohistochemistry stain P-16 positive dysplastic areas. After pre-operative evaluation, she was
planned for a simple vulvectomy since the lesion was large and occupied half of the vulva. Initially, the outline of the lesion was made, and incision was given above the labial folds on mons pubis and it was extended down the lateral folds of labia majora and across the posterior
fourchette. The entire circumference of the tissue was dissected out with care given near 3’o clock and 9’o clock positions to avoid injury to pudendal vessels. The entire vulval tissue was dissected out leaving behind the vagina and urethral orifices following which the subcutaneous tissue was closed. The skin was closed by interrupted
sutures [Figure 1b]. She had no complications in the postoperative period [Figure 1c].
Outcome and follow‑up
After 6 weeks of follow–up, she was asymptomatic without any complications. We had planned for six monthly, then 12 months followed by an annual follow-up thereafter.
Discussion
American college of obstetricians and gynecologists (ACOG) recommends that treatment is recommended for all women with vulvar HSIL (VIN usual type). Because of the potential risk 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,treatment can also be adjusted to the patient’s specific needs, with the possibility of calibrating the depth of
the vaporized and removed tissues. Excisional treatment is the preferred method because it permits histologic evaluation of the excised tissue and detection of possible occult early invasion.[5]
Due to the disfiguring nature of excisional procedures and the younger population of women being treated, less invasive modalities were also developed. Photodynamic therapy is a relatively new technique with unique properties that make it attractive for the local treatment of superficial epithelial disorders.[6] Imiquimod cream was well tolerated and resulted in the regression in a majority of high-grade VIN lesions. The recurrence rate appeared to be comparable to primary surgical ablation.[7] Topical treatment with cidofovir may have a place in the therapeutic armamentarium of high-grade VIN.[8]
There are also studies on the adjuvant modalities of treatment for vulvar HSIL. The study conducted by Gentile et al. found that surgery remains the principal approach for VIN with regard to relapse and complete response since the treatment with imiquimod associated with surgery did
not show a lower recurrence rate. Although the surgical
treatments remain the best therapeutic option for VIN
with regard to recurrence and overall complete response, combined therapy seems to be an interesting modality, but further studies are needed.[9]
A significant number of women diagnosed initially with VIN III on a vulvar biopsy harbored occult vulvar cancer. Recurrences were almost threefold higher when margins were positive for residual VIN III. It was concluded that surgical resection is an appropriate method of treatment of VIN III for both diagnostic and therapeutic purposes.[10] It was also studied that The quadrivalent HPV vaccine, administered after surgical treatment for vulvar HSIL, may be useful in preventing the recurrence of the disease.[11] High rates of recurrence were noted and found to be associated with smoking, larger lesion size, and positive margins. While higher rates of recurrence were found among those treated with laser ablation, it was not inferior with respect to relapse-free survival when used alone, but the use of a laser with excision was associated with decreased relapse‑free survival. Our findings provide hypothesis-generating material for further research in the
management of VIN2/3.[12] A systematic review by van Seters et al. showed that the progression rate from VIN 3 to invasive SCC, after various clinical treatments was 3.3%.[13]
Conclusion
Careful examination with targeted biopsy is warranted for all suspicious lesions of the vulva, and the management depends on the decision of the surgeon with individual patient needs. The diagnosis and management of vulvar
vulvar HSIL (VIN usual type) can be treated with excision, laser ablation, or topical imiquimod (off-label use). Depending on the extent of the lesion, surgery involves either a local excision, a hemi-vulvectomy, or a simple
vulvectomy. However, full vulvectomy is rarely indicated. A skinning vulvectomy which removes the vulvar skin may be needed in cases of multifocal lesions, which can occur in women who are immunocompromised. There are no cases in the literature where simple vulvectomy is performed in a case of vulvar HSIL. The recurrence rates after simple vulvectomy in vulvar HSIL are also yet to be studied.
Medical management using topical imiquimod is effective in vulval HSIL. The topical treatment with imiquimod 5% was shown to be very efficient. Local side effects were a common feature but tolerable after dose reduction.[1] Published regimens include three times weekly application to affected areas for 12–20 weeks, with colposcopic assessment at 4–6 week intervals during treatment. Residual lesions require surgical treatment. Erythema and vulvar pain may limit use. A study by Frega
et al. [2] aimed at establishing the recurrence rate and the risk factors for relapse among patients with VIN 2/3 treated with imiquimod or surgical excision. It was concluded that although the advent of new medical options can decrease the morbidity associated with invasive surgical procedures, surgical treatments remain the best treatment modality for
VIN with regard to relapse and overall complete response.
Laser ablation is acceptable for the treatment of vulvar HSIL (VIN usual type) when cancer is not suspected. It can be used for single, multifocal, or confluent lesions, although the risk of recurrence may be higher than
with excision. In addition, CO2 laser excision allows evaluation of the operative specimen and detection of occult early invasion with good preservation of vulvar morphology; laser vaporization, while retaining good
cosmetic results, is less effective in VIN treatment and does not allow evaluation of the surgical specimen.[4] CO2 laser surgery permits the treatment of VIN in an outpatient or day surgery setting under local anesthesia with excellent cosmetic and functional results. The lesions should be based on a good clinicodermoscopic correlation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship Nil.
Conflicts of interest
There are no conflicts of interest
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