Vulvar & Vaginal disease & neoplasia (from Dr. K's book)

Question 1

what is lichen sclerosus

Answer 1

lymphocytic infiltration of upper dermis & epidermal basal layer. Familial, immune disorder.

Question 2

sx’s of lichen sclerosus

Answer 2

vulvar pruritis, thin, whitish epithelium (“onion skin” or “cigarette paper”), may have areas of cracked skin, c/=> dyspareunia

Question 3

how to dx lichen sclerosis

Answer 3

bx, histo’c dx

Question 4

what are the histo’c findings of lichen sclerosis

Answer 4

“hyalinized” or “glassy” appearing dermis

Question 5

tx of lichen sclerosis. What kind of f/u needed?

Answer 5

corticosteroid cream (clobetasol)
f/u with re-bx b/c tx-resistant form is ass'd w/SCC

Question 6

prognosis of lichen sclerosis

Answer 6

unlikely to completely resolve. May need intermittent tx indefinitely

Question 7

what is lichen simplex chronicus?

Answer 7

“an itch that rashes” 2/2 irritant dermatitis. Scratching => epidermal thickening, inflam

Question 8

tx of lichen simplex chronicus

Answer 8

benadryl, hydroxyzine hydrochloride (anti-itch). Remove irritant. Topical steroid. If relief does not occur in 3 mos, bx.

Question 9

what is lichen planus?

Answer 9

desquamation of vulva

Question 10

sx’s of lichen planus

Answer 10

vulvar burning, pruritis, insertional dyspareunia, profuse discharge containing lots of inflam cells but few bacteria

Question 11

tx for lichen planus

Answer 11

topical steroid, maybe intravaginal hydrocortisone douche

Question 12

etiology of vulvar psoriasis

Answer 12

AD inheritance (component of a generalized dermatologic disorder)

Question 13

when is vulvar psoriasis likely to occur

Answer 13

during menarche, pregnancy, menopause

Question 14

tx of vulvar psoriasis

Answer 14

derm consult

corticosteroids (topical or intralesional injection)

Question 15

2 categories of vulvar dermatitis

Answer 15

eczema, seborrheic dermatitis

Question 16

2 categories of eczema

Answer 16

exogenous & endogenous

Question 17

what is exogenous eczema:

Answer 17

irritant or allergic contact dermatitis

Question 18

what is endogenous eczema:

Answer 18

atopic dermatitis

Question 19

tx of vulvar dermatitis

Answer 19

remove irritant, perineal hygeine, aluminum acetate solution + air-dry
betamethasone valerate (penetrates skin well)
antipruritic agents to help with nighttime scratching

Question 20

vulvar vestibulitis

Answer 20

acute & chronic inflam of vestibular glands (near hymenal ring)

Question 21

sx’s of vestibulitis

Answer 21

new-onset insertional dyspareunia, usually progressive worsening over 3-4 mos, pain w/tampon insertion or bathing

Question 22

tx of vestibulitis

Answer 22

variable, individualized. Topical lidocaine, cortisone ointment, abstinence, surgical excision of vestibular glands, low dose TCA, calcium citrate to remove urine oxalic acid crystals

Question 23

how is vulvar intraepithelial neoplasia classified

Answer 23

VIN 1, 2, 3.
VIN1 = mild dysplasia
VIN 2 = moderate dysplasia
VIN 3 = severe dysplasia, carcinoma in situ

Question 24

cause of VIN 1

Answer 24

HPV, or reactive atypia. Usually not neoplastic. (ISSVD got rid of this term since its not precancerous)

Question 25

what is "VIN, usual type"

Answer 25

ISSVD grouping of both VIN 2 and 3. Is true neoplasia, high likelihood of progressing to cancer

Question 26

what causes VIN, usual type?

Answer 26

HPV

Question 27

what % of women w/VIN 3 or VAIN 3 will also have CIN?

Answer 27

60

Question 28

sx's of VIN

Answer 28

vulvar pruritis, irritation, raised mass lesions

Question 29

what are the 3 subtypes of VIN usual type

Answer 29

warty basaloid mixed

Question 30

tx of VIN usual type

Answer 30

wide local excision or laser ablation

Question 31

what is VIN differentiated type

Answer 31

a hyperkeratotic, warty papule, or ulcer most often seen in older women. Not HPV-related. Ass'd w/SCC or lichen sclerosus. Progresses rapidly to invasive cancer

Question 32

tx of VIN differentiated type

Answer 32

excision

Question 33

what is Paget disease of vulva

Answer 33

"fiery red background mottled w/whitish hyperkeratotic areas"

Question 34

pts w/Paget disease have increased risk of what?

Answer 34

underlying internal malignancy (esp breast and lung)

Question 35

tx of Paget dis

Answer 35

wide local excision or vulvectomy

Question 36

what is most common vulvar carcinoma

Answer 36

squamous cell carcinoma (90%0, then melanoma. Adenoca is not common.

Question 37

what age does vulvar ca occur?

Answer 37

postmenopausal, mostly 70-80, some (about 20%) dx'd younger than 50. Esp smokers

Question 38

sx of vulvar ca

Answer 38

pruritis, may notice an ulcerative exophytic lesion

Question 39

nat hist of vulvar ca

Answer 39

remains localized for a long time | then spreads to LNs

Question 40

how is vulvar ca staged?

Answer 40

surgically. Remove the tumor, assess regional LN involvement

Question 41

tx of vulvar ca

Answer 41

surgery - trying to do less radical procedures

Question 42

what is an irritated pigmented vulvar lesion concerning for, and what to do about it?

Answer 42

melanoma, bx it

Question 43

vaginal neoplasias usually occur 2/2 what?

Answer 43

local spread of cervical or vaginal cancers

Question 44

what is a gartner duct cyst?

Answer 44

a vaginal cyst that forms from vestigial remnants of wolffian or mesonephric duct

Question 45

what is an inclusion cyst?

Answer 45

a cyst on post lower vagina 2/2 imperfect approximation of childbirth lacs or episiotomy

Question 46

what is VAIN

Answer 46

vaginal intraepithelial neoplasia

Question 47

VAIN classifications

Answer 47

VAIN 1 = involves basal epith layers VAIN 2 = involves up to 2/3 of vaginal epith VAIN 3 = involves most of vag epith (CIS)

Question 48

where is VAIN most commonly found?

Answer 48

upper 1/3 of vagina, due to its ass'n w/cervical ca spread

Question 49

mgt of VAIN I and II =

Answer 49

monitor, usually no tx needed. Topical ES for atrophy.

Question 50

mgt of VAIN III =

Answer 50

laser ablation or local excision, or 5-FU cream

Question 51

what % of pts who undergo hysterectomy for CIN III will dvp VAIN III?

Answer 51

1-2%

Question 52

sx's of VAIN III

Answer 52

ulcerated, hyperkeratotic lesion but asx'c

Question 53

VAIN III can progress to what?

Answer 53

invasive vaginal carcinoma

Question 54

what is the most common type of vaginal cancer?

Answer 54

squamous cell

Question 55

what are the 2nd and 3rd most common vaginal cancers?

Answer 55

adenoca, melanoma

Question 56

how is vaginal cancer staged?

Answer 56

clinical, by degree of invasion to adjacent structures (same as cervical ca.)

Question 57

tx for SCC of vagina

Answer 57

radiation, surgery for some. Pelvic exenteration & radical vulvectomy if lower vaginal lesions and vulvar involvement.