Vulvar Cancer: The Daily PANCE Blueprint
A 64-year-old woman comes to the gynecology clinic with complaints of persistent vulvar itching. The itching started over a year ago and has worsened in recent months. She has tried using topical steroids but experienced no relief. She denies being sexually active. Her medical history includes a diagnosis of lichen sclerosus. On examination, there is a small ulcerated nodule on the right labia and thin, white, atrophic skin around the vulvar and perianal areas. What is the most likely diagnosis?
A. Vulvar squamous cell carcinoma
B. Vulvar candidiasis
C. Herpes simplex virus infection
D. Lichen planus
E. Psoriasis
Answer and topic summary
The answer is A. Vulvar squamous cell carcinoma.
This patient has a history of lichen sclerosus, a chronic inflammatory condition of the vulvar area that increases the risk of vulvar squamous cell carcinoma. The presence of a non-healing ulcerated nodule along with worsening pruritus despite the use of steroids is concerning for malignancy. Squamous cell carcinoma is the most common type of vulvar cancer, and it often develops in the setting of chronic vulvar irritation or inflammation, such as lichen sclerosus. A biopsy is required for definitive diagnosis.
Incorrect Answers:
- B. Vulvar candidiasis: Vulvar candidiasis typically presents with itching, redness, and thick, white discharge, but it is not associated with ulcerated nodules or chronic lesions.
- C. Herpes simplex virus infection: Herpes simplex usually presents with painful, clustered vesicles or ulcers, but this patient has a chronic lesion without associated pain or vesicles, making this diagnosis unlikely.
- D. Lichen planus: Lichen planus can cause pruritic, violaceous lesions but is less likely to present with ulcerated nodules and is not typically linked to an increased risk of squamous cell carcinoma.
- E. Psoriasis: Psoriasis usually presents with erythematous plaques with silvery scaling and is not associated with ulceration or an increased risk of vulvar squamous cell carcinoma.
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