VULVAR INTRAEPITHELIAL NEOPLASIA (VIN)

SYMPTOMS

Symptoms of vulvar intraepithelial neoplasia can vary depending on the extent and location of the lesions but may include:

• Vulvar itching (pruritus): Itching or discomfort in the vulvar area may be a common symptom of VIN, particularly in cases of extensive or multifocal lesions.
• Pain or burning sensation: Some individuals with VIN may experience pain, burning, or discomfort in the vulvar region, especially during intercourse or urination.
• Bleeding: Vulvar bleeding or spotting may occur, particularly if VIN lesions are traumatized or ulcerated.
• Changes in vulvar skin appearance: VIN lesions may appear as raised, red, white, or pigmented patches or plaques on the vulvar skin, which may be flat, slightly elevated, or verrucous (wart-like) in appearance.
• Dyspareunia: Pain or discomfort during sexual intercourse (dyspareunia) may occur in individuals with VIN, particularly if lesions involve the vaginal introitus or vestibule.
• Asymptomatic: In some cases, vulvar intraepithelial neoplasia may be asymptomatic and detected incidentally during routine gynecological examination or screening for cervical cancer.

DIAGNOSIS

Diagnosing vulvar intraepithelial neoplasia typically involves a combination of clinical evaluation, colposcopic examination, vulvar biopsy, and histopathological analysis of tissue samples. Diagnostic steps may include:

• Clinical examination: A thorough clinical examination of the vulvar area is performed to assess for the presence of abnormal lesions, changes in skin texture or color, and any associated symptoms such as itching or pain.
• Colposcopy: Colposcopic examination of the vulva allows for magnified visualization of abnormal lesions and assessment of their size, extent, and vascular pattern. Acetic acid (vinegar) or Lugol’s iodine solution may be applied to enhance visualization of dysplastic areas.
• Vulvar biopsy: If suspicious lesions are identified, a biopsy is performed to obtain tissue samples for histopathological analysis. Punch biopsy or excisional biopsy may be used to obtain representative tissue samples for accurate diagnosis and grading of VIN.
• Histopathological analysis: Microscopic examination of vulvar biopsy specimens allows for confirmation of VIN, assessment of lesion grade (e.g., low-grade or high-grade), and differentiation from other vulvar conditions such as lichen sclerosus or squamous cell carcinoma.

TREATMENT

Treatment of vulvar intraepithelial neoplasia aims to remove or destroy abnormal tissue to prevent progression to invasive vulvar cancer and reduce the risk of recurrence. Treatment options may include:

• Topical therapies: Topical agents such as imiquimod cream or 5-fluorouracil (5-FU) cream may be applied directly to vulvar lesions to induce local immune-mediated or cytotoxic effects and promote regression of VIN.
• Surgical excision: Surgical excision or removal of VIN lesions may be performed using techniques such as wide local excision, laser ablation, or electrocautery. Surgical excision allows for complete removal of dysplastic tissue and histological examination to exclude invasive carcinoma.
• Laser therapy: Carbon dioxide (CO2) laser therapy or erbium:YAG laser therapy may be used to ablate or vaporize VIN lesions, particularly for multifocal or extensive disease involving the vulvar epithelium.
• Cryotherapy: Cryotherapy or freezing of vulvar lesions with liquid nitrogen may be considered as an alternative to surgical excision for small, superficial VIN lesions.
• Photodynamic therapy: Photodynamic therapy (PDT) involves the application of a photosensitizing agent followed by exposure to light of a specific wavelength to selectively destroy abnormal cells in the vulvar epithelium.
• Immunotherapy: Intralesional injection of interferon or administration of immune checkpoint inhibitors (e.g., pembrolizumab) may be considered for individuals with refractory or recurrent VIN lesions, particularly in cases associated with high-risk HPV infection.