Four international medical societies have collaborated on consensus statements for physicians, published in the Journal of Lower Genital Tract Diseases, how to treat pre-invasive lesions of the vulva. The journal is part of Wolters Kluwer’s Lippincott portfolio.
A pre-invasive vulvar lesion is an area of skin or mucosa that has not yet progressed to invasive malignancy (cancer), but has the potential to do so. “Pre-invasive vulvar lesions deserve special attention because, in addition to oncological risk, they affect not only functionality and body image, but also psychosexual factors,” according to the guidelines’ lead author, Mario Preti, MD. from the University of Turin, Italy, and its co-authors.
Lesions on a woman’s vulva can cause symptoms such as burning and itching that make intercourse painful, but they can be asymptomatic, the authors note, emphasizing the need for a proper vulvar examination.
The consensus statements were compiled after a systematic review of the medical literature and were voted on by experts chosen by the four scientific societies. The document advises doctors on the four main types of preinvasive lesions that can develop on the vulva.
1) High-grade vulvar squamous intraepithelial lesions (VHSIL) are more common in women under 65 and can develop into invasive cancer. “About 60% of patients report itching and/or irritation, pain or bleeding as well as visible vulvar lesions,” explain Dr. Preti and colleagues. “In others, the lesions are diagnosed [by chance]during a routine gynecological examination. The lesions differ widely from woman to woman in number, size, shape, color and thickness.
The authors suggest several options for treating VHSIL: surgical removal, ablation (laser or radiofrequency ablation), or topical medications. If ablation or drugs are used, the patient should undergo several biopsies beforehand to ensure that no invasive cancer is present.
2) Differentiated vulvar intraepithelial neoplasia (dVIN) is much rarer than VHSIL, as it is usually seen in older women. “Neoplasia” is the growth of abnormal cells or abnormal amounts of cells, which may start out as benign but become cancerous. dVIN is more likely than VHSIL to turn into invasive cancer, sometimes quickly. It should always be completely surgically removed, according to the new consensus.
3) Vulvar Paget’s disease on the spot is a glandular skin cancer of the vulva that can give rise to invasive cancer. Traditionally it was always treated surgically, but the consensus now is that imiquimod skin cream is effective and has minimal adverse effects. Radiation therapy may be used in some cases.
4) Vulvar melanoma on the spot-;Melanoma is the most serious form of skin cancer, but vulvar melanoma in situ represents a non-invasive type (stage Ia). The recommended treatment is surgery which removes the lesion and an area of skin around it.
“After treatment of preinvasive vulvar lesions, women should be seen regularly for careful clinical evaluation, including biopsy of any suspicious areas,” advise the authors of the consensus statements. The frequency of follow-up visits will depend on the type of lesion, the age of the patient, and whether the patient has an infection, immunologic disease, or other lesions in the lower genital tract.
The medical societies that published the guidelines are the European Society for Gynecological Oncology, the International Society for the Study of Vulvovaginal Diseases, the European College for the Study of Vulvar Diseases, and the European Colposcopy Federation.