ASCCP - Practice Recommendations - Practice Management Materials

PRACTICE RECOMMENDATIONS: Practice Management Materials

• Vulva • Vagina • Cervix • Anus

VULVA: HUMAN PAPILLOMAVIRUS INFECTIONS & VULVAR INTRAEPITHELIAL NEOPLASIA

HPV:	• Introduction	• Definition	• Diagnosis	• Treatment	• References
VIN:	• Introduction	• Definition	• Diagnosis	• Treatment	• References
	• Cases/Examples

VIN TREATMENT
Three therapies are now the principal ones used to manage VIN: local excision, local destruction, and, in select cases, partial or total superficial vulvectomy with or without split-thickness skin grafts. Good results have been reported using a combination of surgical excision and laser vaporization. Attention to adequate surgical margins (1-1.5 cm around the lesion) is important. (Julian et al.)

Hairy and non-hairy areas. Approximately 75-85% of VIN lesions are found in non-hair bearing areas. In non-hair bearing areas of the vulva laser ablation should extend to a depth of only 1 mm (Wright, 1990). Eradication of lesions in hair bearing areas should go down at most 3 mm (Reid, 1985; Shatz, 1989).

Recent reports on the use of imiquimod to treat VIN 2 and VIN 3 have been noted.

Special Circumstances Associated with VIN
Immunocompromised or immunosuppressed patients have a rate of VIN and HPV infections more than 16 times that of the general population (Halpert, 1986; Sillman 1984). The immunocompromised patient who is no longer immunocompromised may undergo spontaneous resolution of VIN: the pregnant patient, the patient coming off steroids, or someone who stops smoking (Wilkinson, 1988).

For the multi-focal and immunocompromised patient multiple recurrence of VIN is common, occurring in at least one-third of cases (Julian et al.).

Association of VIN with Cancer
There is a substantial risk that untreated VIN 3 will progress to invasive cancer. However, reasonable periods of observation may be used to treat the patient with HPV related VIN 3 if she is pregnant, coming off steroids or attempting to quit smoking. These states may be followed by regression of lesions. Persistent lesions following the correction of such immunocompromised states require therapy.

Lifetime follow-up of patients with VIN 3 is required. Office visits range from every 3 months to yearly.

Anal Disease
Approximately 20% of women with vulvar intraepithelial neoplasia have involvement of the anal canal with anal intraepithelial neoplasia (AIN). Intra-anal VIN is generally warty and white but may be gray or more pigmented. At the anal verge near the rectum, these lesions are often associated with frond-like epithelial papillations with each frond containing a single-looped capillary. In all cases, when gross evidence of VIN extends down on to the perineum and approaches the anal verge it is wise to examine the anus with an anoscope. Anal tags, sometimes erroneously thought to be hemorrhoids, may have anal intraepithelial neoplasia. Since the anal skin junction is a muco-cutaneous junction, it is prone to the development of invasive squamous cell carcinoma.

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