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Vulvar intraepithelial neoplasia

Key sources
The following summarized guidelines for the evaluation and management of vulvar intraepithelial neoplasia are prepared by our editorial team based on guidelines from the British Gynaecological Cancer Society (BGCS 2020), the British Photodermatology Group (BPG/BAD 2019), and the American College of Obstetricians and Gynecologists (ACOG 2016).
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Guidelines

1.Screening and diagnosis

Indications for screening: insufficient evidence to recommend screening for vulvar high-grade squamous intraepithelial lesions (VIN usual type) for the prevention of vulvar cancer.
I
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2.Diagnostic investigations

Clinical assessment: obtain a visual assessment for detection followed by histopathology for confirmation when needed.
E

3.Diagnostic procedures

Vulvar biopsy
Perform biopsy for visible vulvar lesions in the following situations:
definitive diagnosis cannot be made clinically
possible malignancy
presumed clinical diagnosis not responding to usual therapy
atypical vascular patterns
stable lesions rapidly changing in color, border, or size
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Perform a biopsy in postmenopausal patients with apparent genital warts and in female patients of all ages with suspected condyloma if topical therapies have failed.
E

4.Medical management

Indications for treatment: offer treatment in all patients with vulvar high-grade squamous intraepithelial lesions (VIN usual type).
E

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5.Therapeutic procedures

Laser ablation: consider offering laser ablation as a treatment option in patients with vulvar high-grade squamous intraepithelial lesions (VIN usual type) if an occult invasion is not a concern.
E

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6.Surgical interventions

Surgical excision: as per BGCS 2020 guidelines, perform surgical excision as a treatment option in patients with high-grade VIN, recognizing that it has a ~50% response/recurrence rate by 12 months after treatment.
A

7.Preventative measures

Smoking cessation: advise smoking cessation as it is strongly associated with vulvar high-grade squamous intraepithelial lesions (VIN usual type).
E

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8.Follow-up and surveillance

Follow-up
As per BGCS 2020 guidelines:
Obtain follow-up with careful clinical inspection with or without vulvoscopy in patients with high-grade VIN usual type.
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Consider discharging patients with no recurrence of VIN usual type with access to rapid re-referral after 5 years.
C