Management of vulvar intraepithelial neoplasia

Vulvar intraepithelial neoplasia (VIN) is an increasingly common problem, particularly among women in their 40s. Although spontaneous regression has been reported, VIN should be considered a premalignant condition. Immunization with the quadrivalent or 9-valent human papillomavirus vaccine, which is effective against human papillomavirus genotypes 6, 11, 16, and 18, and 6, 11, 16, 18, 31, 33, 45, 52, and 58, respectively, has been shown to decrease the risk of vulvar high-grade squamous intraepithelial lesion (HSIL) (VIN usual type) and should be recommended for girls aged 11–12 years with catch-up through age 26 years if not vaccinated in the target age. There are no screening strategies for the prevention of vulvar cancer through early detection of vulvar HSIL (VIN usual type). Detection is limited to visual assessment with confirmation by histopathology when needed. Treatment is recommended for all women with vulvar HSIL (VIN usual type). Because of the potential for occult invasion, wide local excision should be performed if cancer is suspected, even if biopsies show vulvar HSIL. When occult invasion is not a concern, vulvar HSIL (VIN usual type) can be treated with excision, laser ablation, or topical imiquimod (off-label use). Given the relatively slow rate of progression, women with a complete response to therapy and no new lesions at follow-up visits scheduled 6 months and 12 months after initial treatment should be monitored by visual inspection of the vulva annually thereafter. Recommendations and Conclusions The American College of Obstetricians and Gynecologists (the College) and the American Society for Colposcopy and Cervical Pathology make the following recommendations and conclusions: • Immunization with the quadrivalent or 9-valent human papillomavirus (HPV) vaccine, which is effective against HPV genotypes 6, 11, 16, and 18, and 6, 11, 16, 18, 31, 33, 45, 52, and 58, respectively, has been shown to decrease the risk of vulvar highgrade squamous intraepithelial lesions (HSIL) (also known as vulvar intraepithelial neoplasia [VIN usual type]) and should be recommended for girls aged 11–12 years with catch-up through age 26 years if not vaccinated in the target age. • Cigarette smoking is strongly associated with vulvar HSIL (VIN usual type), and cessation should be encouraged. • There are no screening strategies for the prevention of vulvar cancer through early detection of vulvar HSIL (VIN usual type). • Detection is limited to visual assessment with confirmation by histopathology when needed. • Biopsy is indicated for visible lesions for which definitive diagnosis cannot be made on clinical grounds, possible malignancy, visible lesions with presumed clinical diagnosis that is not responding to usual therapy, lesions with atypical vascular patterns, or stable lesions that rapidly change in color, border, or size. COMMITTEE OPINION Number 675 • October 2016 (Replaces Committee Opinion Number 509, November 2011)