A 52-year-old postmenopausal woman comes to the office for evaluation of vulvar irritation. The patient wears sanitary napkins due to stress urinary incontinence and occasionally notices streaks of blood on the napkin. She is sexually active and has had some pain with sexual intercourse. The patient underwent a hysterectomy and bilateral salpingo-oophorectomy at age 48 for adenomyosis. She has had abnormal Pap tests previously but normal colposcopy results. The patient currently uses a nicotine patch for smoking cessation. Vital signs are normal. Pelvic examination shows multiple vulvar excoriations with surrounding erythema. There is a unifocal, erythematous, highly friable plaque on the left labium majus. On speculum examination, the vagina has no lesions or abnormal discharge. Which of the following is the most likely diagnosis in this patient?
Vulvar cancer | |
Etiology |
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Risk factors |
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Clinical features |
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Diagnosis |
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HPV = human papillomavirus. | |
This patient's erythematous, friable plaque on the labium majus is concerning for vulvar squamous cell carcinoma. A risk factor for the development of vulvar cancer is persistent human papillomavirus (HPV) infection, particularly with types 16 and 18, which are also associated with cervical cancer (as seen in this patient's prior abnormal Pap tests). While most HPV infections are transient, patients with either chronic tobacco use or immunodeficiency (eg, HIV) are less likely to clear the infection, resulting in dysplastic changes.
Constant dysplastic changes over the vulvar squamous cells can result in a unifocal, friable plaque or ulcer, typically on the labia majora, that produces persistent vulvar irritation (eg, vulvar excoriations, erythema) and/or pain. Patients may also have intermittent bleeding and dyspareunia (as seen in this patient) or an asymptomatic lesion found on routine examination. Diagnosis is with vulvar biopsy, which evaluates for depth of invasion and determines management options.
(Choice A) Patients with condylomata acuminata are typically asymptomatic or have mild vulvar pruritus. In contrast to this patient, condylomata acuminata typically present with multiple lesions that are fungated or dome-shaped.
(Choice B) Contact dermatitis may occur secondary to constant irritation from sanitary napkins; however, it typically does not cause a discrete, friable plaque.
(Choice C) Vulvar lichen planus typically presents with pruritic, purple-hued plaques that are sometimes associated with thin, white striae around the labia and vulva (ie, Wickham striae). A unifocal, highly friable mass in the setting of vulvar irritation, dyspareunia, and abnormal Pap tests is more consistent with vulvar squamous cell carcinoma.
(Choice D) Vulvar lichen sclerosus lesions are typically multiple white papules that converge into plaques. A single lesion is uncommon.
(Choice F) Women with vulvovaginal atrophy typically have thinning of the skin and fusion of the labia majora, rather than a distinct, friable vulvar plaque.
Educational objective:
Vulvar squamous cell carcinoma often occurs secondary to persistent human papillomavirus infection, which is associated with chronic tobacco use. Patients with vulvar cancer often have vulvar irritation, intermittent bleeding, and a unifocal, friable mass commonly located on the labia majora.