GYN

CMECNE

Vulvar Intraepithelial Neoplasia (VIN): Diagnosis and Treatment

Learning Objectives and CME/Disclosure Information

Original Launch Date: 11/07/2016

Expiration Date: 11/07/2018

ACCME PARS: 3224

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Apply the criteria for vulvar biopsy of a visible lesion
2. Identify risk factors for VIN

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Financial Relationship

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics.

Planners and Managers: PIM Planners have nothing to disclose

Method of Participation and Request for Credit

Participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

VIN is an increasingly common problem, particularly for women in their 40s, and should be considered a premalignant condition. A low threshold for consideration, biopsy and follow up should be maintained.

CLINICAL ACTIONS:

Detection is limited to visual assessment with biopsy confirmation when needed
Biopsy any visible lesion on the vulva that meets the following criteria
- Diagnosis cannot be made on clinical grounds
- Possible malignancy
- Lesion not responding to usual therapy
- Lesion with atypical vascular pattern
- Lesion with rapid change in size/color/border
- Presumed condyloma not responding to topical treatment
Perform colposcopy several minutes after the application of 3 to 5% acetic acid if lesions not clearly visualized or in women with persistent focal symptoms of pruritis/pain despite treatment for vulvo-vaginitis
Treatment is recommended for all with vulvar HSIL (see classification below)
Preferred treatment is wide local excision with gross margins of 0.5 to 1 cm
- Laser ablation is acceptable if cancer is not suspected
- Topical imiquimod 5% applied three times/week for 12 to 20 weeks with colposcopy every 4 to 6 weeks is effective though not FDA approved
Women with VIN are at risk of recurrent disease and vulvar cancer throughout their lives.
- Surveillance is 6 and 12 months after treatment, then annual visual inspection of the vulva

SYNOPSIS:

In 2015 terminology for VIN was changed by the International Society for the Study of VulvoVaginal Disease (ISSVD) to unify nomenclature for HPV associated lesions of the cervix, vagina and vulva. In the new classification, low-grade squamous intraepithelial lesion of the vulva (vulvar LSIL) corresponds to ‘condyloma’, or ‘HPV effect’. High-grade squamous intraepithelial lesion of the vulva (vulvar HSIL) includes ‘usual type VIN’ (warty, basaloid type or mixed). Differentiated type VIN is unchanged from the 2004 classification. Of these three types, differentiated VIN is usually not HPV associated, being more often associated with a vulvar dermatologic condition such as lichen sclerosis, and with squamous cell carcinoma of the vulva.

KEY POINTS:

Risk factors for VIN include HPV infection and cigarette smoking
Prevention should include vaccination in women under the age of 26, and smoking cessation
As differentiated VIN is associated with vulvar dermatoses, treatment of these disorders, especially lichen sclerosis, reduces the risk of cancer of the vulva

Learn More – Primary Sources:

ACOG ASCCP Committee Opinion No. 675: Management of vulvar intraepithelial neoplasia

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