Ever notice that some weeks have a certain theme to them? I managed to squeeze in some fun last Friday night and went to a play called "The Vagina Monologues." It was great! Funny, sad, and poignant. My girlfriends and I had a great time laughing and reveled in the fact we loved being women. Little did I know that this part of the body would be the theme for me this week at work.
As you may know, I am now working in a large cancer institute. I am seeing things I have never seen or treated before, which I love because this means I am learning and growing more as an oncology nurse practitioner. This past week I saw several patients with some form of vulvar carcinoma, and I learned so much that I thought I would share what I have discovered so far.
Many of the women were 40 to 60 years of age. And interestingly, some of the younger patients had the same subtle symptom: itching on the labium majus area. One woman, in her early 40s, had this itching go on for more than a year. She often scratched herself while she slept, and the area on her skin became inflamed. She went to her primary care doctor, who referred her to a dermatologist who provided a cream. The cream didn't help. The itching continued.
There was no lump, no swelling, and no visible lesion. The itching was so intense and constant that she went to her GYN. The GYN doctor decided to monitor it. They changed creams a couple of times, but this woman had little relief. It was not until recently that a lump formed right under the area that had been itching for some time. A biopsy was performed, and a diagnosis for vulvar dysplasia was finally determined.
The woman underwent a vulvectomy, and it was on her return visit that I met this woman. The surgery was a success. She no longer suffered from the itching, and the site was healing quite well. Purple stitches were still in place just a week after this procedure, and this woman was doing a great job of following all the post-op instructions. However, she was upset at this return visit. She had been experiencing itching for well over a year and believed her GYN should have biopsied sooner. Being her oncology gynecologist team, we explained that there had to be a visible abnormal area (superficial or beneath) in order to identify where and what to biopsy. She felt better to some degree, but I believe I would have been just as frustrated as well. A year is a long time to endure something you know is not normal for your body.
Vulvar dysplasia can lead to vulvar intraeptithelial neoplasia (VaIN or VIN), and this condition tends to occur in younger women. The incidence of VIN has doubled since the 1970s. And guess what condition has had a role in this increase? You probably guessed it: human papillomavirus (HPV). Over 80 to 90 percent of VIN lesions are identified with the HPV-16 strain or other HPV strain. The medical community, at large, believes the HPV vaccination could prevent about two-thirds of VIN lesions.
The Vulvar Oncology Subcommittee of the International Society for the Study of Vulvar Diseases (ISSVD) developed the current classification system in 2004 for VIN. There are two main groups classified:
- VIN, usual type, which encompasses the former subcategories of VIN, warty type; VIN, basaloid type; and VIN, mixed (warty, basaloid) type
- VIN, differentiated type, which encompasses the former category simplex type
Rare cases that do not fit into these categories are termed "unclassified type."
I also found that there were no NCCN (National Comprehensive Cancer Network) guidelines for this type of condition. However, depending on the stage of the lesion, many treatment options may include:
- Stage I lesions: Radical local excision alone (simple vulvectomy) or combined with inguinofemoral lymphadenectomy if depth of invasion exceeds 1mm
- Stage II lesions: Modified radical vulvectomy and inguinofemoral lymphadenectomy
- Locally extensive cancers can be managed with synchronous preoperative chemotherapy and radiation (chemoradiation), followed by conservative excision of residual disease, or by radical chemoradiation alone
- Elective radiation or chemoradiation may be an alternative to surgical treatment of inguinofemoral nodes in selected patients with clinically and radiographically negative groin nodes
I learned many of the women we saw this week with this malignancy had a history of either smoking or HPV. It was an interesting week, to say the least, focused around a malignancy that no one really talks about, for obvious reasons.
Have you seen many VIN cases at your cancer center? If so, is there anything you have learned that you would like to share here with community members?
- Abeloff, M. (2008): Abeloff's Clinical Oncology, 4th ed. Elsevier. Retrieved from https://www.mdconsult.com+page.do?eid=4-u1.0-B978-0-443-06694-8..50095-6--cesec41&isbn=978-0-443-06694-8&uniqId=366167390-2#4-u1.0-B978-0-443-06694-8..50095-6--cesec41
- DeVita, V., Lawrence, T., & Rosenberg, S. (2011). Cancer. 8th edition. Lippincott Williams & Wilkins. Retrieved from https:// www.r2library.com+1451105452