Vulval itch and Pathology

Question 1

Differential diagnosis for Vulval itch

Answer 1

• Lichen sclerosus
• Dermatoses: Lichen simplex chronicus, Lichen planus
• Vulval intraepithelial Neoplasia
• Vulval carcinoma

Question 2

Lichen Sclerosus History

Answer 2

• Most common in postmenopausal women
• severe non resolving itch

Question 3

Lichen sclerosus Examination findings

Answer 3

• Thin, wrinkly skin
• Pearly white appearance
• May be hyperkeratotic if concurrent squamous hyperplasia
• Bilateral and symmetrical
• Localised or figure 8 lesion
• Does not extend into vagina or anus
• Shrinkage of introitus with loss or fusion of labia minora

Question 4

Lichen slerosus investigation

Answer 4

Biopsy: Epidermal atrophy
- hyalinisationof dermis
- underlying lymphocytic infiltrate

Question 5

Lichen sclerosus treatment

Answer 5

• Topical steroids and emollients
• Start with potent or very potents for relief and then change to less potent or decrease frequency of use
• 1% Hydrocort Mild
• Potent: Betamethasone 0.1%
• Very potent: Clobetasol propionate 0,05% or diflucorolone valerate 0,3%

No benefit to topical Oestrogen or testosterone identified
Nil Justification for surgery other than occasional separation of labial adhesions

NB: Longterm follow up every 6-12 months due to 2-5% risk of developing vulval carcinoma (Unsure re pathophys)

Question 6

Lichen simplex chronicus Examination

Answer 6

• dry scaly skin
• non symmetrical
• fissures due to scratching

Question 7

Lichen Simplex Chronicus Treatment

Answer 7

Emollients and low potency steroids
Nigh sedation to avoid scratching

Question 8

Lichen Planus examination

Answer 8

• purple patches which become white
• Wickhams striae which form a lacy white pattern
• Also present on flexor aspects of wrists, gingival margins and oral mucosa
• Can extend into vagina with adhesions and stenosis

Question 9

Lichen planus diagnosis

Answer 9

Clinical diagnosis
Biopsy is non specific

Question 10

Lichen planus treatment

Answer 10

Topical steroids
Systemic steroids and intravaginal steroids may be necessary

Question 11

Psoriasis

Answer 11

Pink with irregular borders with satellite lesions
Rx with topical steroids

Question 12

Vulval intraepithelial Neoplasia

Answer 12

• Squamous premalignant lesion
• Aietiology is oncogenic HPV
• Risk factors; Smoking, immunosuppresion with HIV or medication, lichen sclerosus

Question 13

VIN History

Answer 13

• May occur in young women
• Pruritis
• Pain
• Could be asymptomatic

Question 14

VIN Examination

Answer 14

• Variable appearance
• white lesion if hyperkeratosis
• Red lesion if thin skin
• Brown due to increased Melanin
• Raised papular and rough or macular with indistinct border

Question 15

VIN investigation

Answer 15

1. Histology: Lack of differentiation with disordered maturation
   - hyperchromatic
   - increased mitotic figures
   - increased nucleus to cytoplasm ratio
   occurs in original epithelium rather than metaplastic tissue as in the cervix. Nil TZ
   - Low risk of progression to invasive disease 6%
2. Vulvoscopy : 5% acetic acid to reveal lesions and perform biopsy

Question 16

VIN management

Answer 16

1. Local excision: High recurrence rate. Reserved for florid lesions
2. Topical Imiquimod widely used
3. Laser ablation
4. Long term follow up NB
   Be alert to signs of progression:
   - Ulceration
   - bleeding
   - swelling
   - soreness
   - Irritation
   Most progression will occur within 10 year of dx

Question 17

VIN classification

Answer 17

• Vulval LSIL: Flat condyloma or HPV effect
• Vulval HSIL
• VIN: Differentiated type

Question 18

Vulval Carcinoma History

Answer 18

• Predominantly older women with 80% > 65 years
• rare
• Pruritus of vulva
• History of ulcer or mass
• Bleeding
  Aetiology is that develops from range of skin abormalities
• Lichen sclerosis: 66% of vulval CA occurs with history of Lichen Sclerosis although 2-5% LS develops into Vulval Ca
• Vulval SIL- Secondary to oncogenic HPV
• Pagets disease: Preinvasive lesion for adenoCa of vulva. 4-8% may be associatd with primary adenoCa elsewhere
• Lichen planus: RARE

Question 19

Vulval Ca Examination

Answer 19

• Ulcer
• mass
• labia Majora most common site, then minora, clitoris, posterior forchette, perineum and Bartholins gland
• NB to chec Cervix for co-existing CIN or Cervix CA

Question 20

Vulval Ca examination

Answer 20

• Biopsy of lesion to confirm diagnosis and depth of invasion
• MRI: Check LN involvements

Question 21

Vulval Ca Management:

Answer 21

• mainstay is surgery
  Depends on stage and LN involvement which is large determinant in survival rates

Nil Node involvement survival >90%
If nodes positiveL <60%

Should be managed By Gynae onc led MDT team
- stage 1a: WLE aim for margins >1cm
- Stage 1B- 4a: radical vulvectomy and bilateral groin node dissection via Separate incisions

Consider sentinel node mapping and if FZ negative then nil groin node dissection to reduce wound breakdown, lymphocyst formation and lymphoedema of lower limbs

• Lateral lesions: Modified radical vulvectomy confined to affected side with ipsilateral GN dissection: If nodes clear: Leave other side GN. If positive: Dissect other side as well
• Stage 3: Due to urethral or anal spread: Include incision of distal urethral or anus with Colostomy and GN dissection
• Adj RadioRx if Nodes involved
• May use Chemoradiation to avoid stomas: morbidity includes skin desquamation and pain
• Stage 3 with unilateral nodes: Adj radiation to groin
• Stage 4a: Local extension to pelvic cavity
• Groin node dissection and radical exenterive surgery if nodes clear
• 4a due to pelvic nodes or 4B;
• poor prognosis
• focus on disease control
• may include surgery +/- radiation
• Need to consider psychosecual morbidity