A CASE OF A POSTMENOPAUSAL WOMEN WITH DIFFERENTIATED VULVAR INTRAEPITHELIAL NEOPLASIA (dVIN) – HPV INDEPENDANT

Abstract

Introduction: Human papillomavirus (HPV) independent vulvar intraepithelial neoplasia is the precursor lesion of HPV independent vulvar squamous cell carcinoma (SCC). Differentiated vulvar intraepithelial neoplasia (dVIN) is an aggressive lesion with higher potential to become invasive than HPV associated VIN (usual type). It is most common in older women ~60-80 years of age, who have a history of chronic inflammatory dermatoses, lichen sclerosus, lichen simplex chronicus. Case report: A 67 years old woman was referred to the Specialized hospital for gynecology and obstetrics “Mother Teresa” due to the presence of a dark red change of the vulva and itching. On inspection, there was fusion of the anterior commissure and an effaced clitoris. With acetic acid, a vinegar-positive sector was observed at the junction of the commissures with dimensions of 2-3 cm. An indication for a biopsy was established. A pathohistological analysis of a biopsy fragment with a diameter of 0.5 cm was performed. It was partially lined with keratotic stratified squamous epithelium and partially with squamous epithelium showing dyskeratosis and parakeratosis, and the epithelial cells contained prominent nucleoli and showed pathological mitoses in the basal layers. A lympho-plasmacytic inflammatory infiltrate was found subepidermally. Immunohistochemically, the cells showed negative staining for p16 protein and positive for p53 protein. The proliferative marker Ki-67 showed nuclear positivity in the distal two-thirds of the epithelium. The morphological and immunohistochemical characteristics corresponded to a differentiated type of vulvar intraepithelial neoplasia that was HPV independent. The patient was referred to a tertiary healthcare facility where an indication for vulvectomy was established due to the size and location of the change. Conclusion: We like to emphasize the need of performing biopsy of any suspicious lesion of the vulva, especially in older women, because inflammatory changes can be precursors to intraepithelial neoplasia, which can further develop into invasive SCC.