View source for Differentiated vulvar intraepithelial neoplasia

{{ Infobox diagnosis
| Name       = {{PAGENAME}}
| Image      = Differentiated_vulvar_intraepithelial_neoplasia_-_intermed_mag.jpg
| Width      =
| Caption    = Differentiated vulvar intraepithelial neoplasia. [[H&E stain]].
| Synonyms   =
| Micro      = thickening of the stratum spinosum ([[acanthosis]]), elongation of rete ridges with bridging/anastomoses between rete ridges, nuclear atypia - esp. basal layer, nuclei in stratum corneum (parakeratosis), +/-atypical mitoses
| Subtypes   =
| LMDDx      = [[vulvar squamous cell carcinoma]], [[lichen sclerosus]], [[classic vulvar intraepithelial neoplasia]]
| Stains     =
| IHC        = p53 +ve, p16 -ve
| EM         =
| Molecular  =
| IF         =
| Gross      =
| Grossing   =
| Site       = [[vulva]]
| Assdx      = [[lichen sclerosus]], [[vulvar squamous cell carcinoma]]
| Syndromes  =
| Clinicalhx =
| Signs      =
| Symptoms   =
| Prevalence = uncommon
| Bloodwork  =
| Rads       =
| Endoscopy  =
| Prognosis  =
| Other      =
| ClinDDx    =
| Tx         =
}}
'''Differentiated vulvar intraepithelial neoplasia''', abbreviated '''dVIN''', is a pre-neoplastic pathology of the [[vulva]] typically arising in the context of [[lichen sclerosus]].

It is also known as '''VIN simplex'''.<ref name=pmid15910611>{{Cite journal  | last1 = Ruhul Quddus | first1 = M. | last2 = Xu | first2 = C. | last3 = Steinhoff | first3 = MM. | last4 = Zhang | first4 = C. | last5 = Lawrence | first5 = WD. | last6 = Sung | first6 = CJ. | title = Simplex (differentiated) type VIN: absence of p16INK4 supports its weak association with HPV and its probable precursor role in non-HPV related vulvar squamous cancers. | journal = Histopathology | volume = 46 | issue = 6 | pages = 718-20 | month = Jun | year = 2005 | doi = 10.1111/j.1365-2559.2005.02036.x | PMID = 15910611 }}</ref>

==General==
Epidemiology:
*Associated with [[lichen sclerosus]].
*Seen in older women - typically 50s-70s.<ref name=pmid19730361>{{Cite journal  | last1 = Ordi | first1 = J. | last2 = Alejo | first2 = M. | last3 = Fusté | first3 = V. | last4 = Lloveras | first4 = B. | last5 = Del Pino | first5 = M. | last6 = Alonso | first6 = I. | last7 = Torné | first7 = A. | title = HPV-negative vulvar intraepithelial neoplasia (VIN) with basaloid histologic pattern: an unrecognized variant of simplex (differentiated) VIN. | journal = Am J Surg Pathol | volume = 33 | issue = 11 | pages = 1659-65 | month = Nov | year = 2009 | doi = 10.1097/PAS.0b013e3181b40081 | PMID = 19730361 }}</ref>
*More common than ''[[classic VIN]]'' caused by HPV.<ref name=pmid21946295>{{Cite journal  | last1 = Kokka | first1 = F. | last2 = Singh | first2 = N. | last3 = Faruqi | first3 = A. | last4 = Gibbon | first4 = K. | last5 = Rosenthal | first5 = AN. | title = Is differentiated vulval intraepithelial neoplasia the precursor lesion of human papillomavirus-negative vulval squamous cell carcinoma? | journal = Int J Gynecol Cancer | volume = 21 | issue = 7 | pages = 1297-305 | month = Oct | year = 2011 | doi = 10.1097/IGC.0b013e31822dbe26 | PMID = 21946295 }}</ref>

Note:
*'''Not''' associated with [[HPV]].<ref name=pmid10716158>{{Cite journal  | last1 = Yang | first1 = B. | last2 = Hart | first2 = WR. | title = Vulvar intraepithelial neoplasia of the simplex (differentiated) type: a clinicopathologic study including analysis of HPV and p53 expression. | journal = Am J Surg Pathol | volume = 24 | issue = 3 | pages = 429-41 | month = Mar | year = 2000 | doi =  | PMID = 10716158 }}</ref>

==Microscopic==
Features:<ref name=pmid21057461>{{Cite journal  | last1 = van de Nieuwenhof | first1 = HP. | last2 = Bulten | first2 = J. | last3 = Hollema | first3 = H. | last4 = Dommerholt | first4 = RG. | last5 = Massuger | first5 = LF. | last6 = van der Zee | first6 = AG. | last7 = de Hullu | first7 = JA. | last8 = van Kempen | first8 = LC. | title = Differentiated vulvar intraepithelial neoplasia is often found in lesions, previously diagnosed as lichen sclerosus, which have progressed to vulvar squamous cell carcinoma. | journal = Mod Pathol | volume = 24 | issue = 2 | pages = 297-305 | month = Feb | year = 2011 | doi = 10.1038/modpathol.2010.192 | PMID = 21057461 }}</ref>
*Thickening of the stratum spinosum ([[acanthosis]]). 
*Elongation of rete ridges with bridging/anastomoses between rete ridges.
*Nuclear atypia - esp. basal layer.
*Nuclei in stratum corneum (parakeratosis).
*+/-Atypical mitoses.

Notes:
*'''Not''' graded like [[classic VIN]] - considered high-grade by definition.{{fact}}
*Mnemonic ''BAD LAP'': '''b'''asal cell atypia, '''a'''nastomosing rete ridges (bridging), '''d'''VIN, '''l'''ichen sclerosus, '''a'''canthosis, '''p'''arakeratosis.

DDx:
*[[Lichen sclerosus]].
*[[Lichen simplex chronicus]] (squamous hyperplasia).
*[[Vulvar squamous cell carcinoma]].
*[[Classic vulvar intraepithelial neoplasia]].

===Images===
<gallery>
Image:Differentiated_vulvar_intraepithelial_neoplasia_-_low_mag.jpg | Differentiated VIN - low mag. (WC)
Image:Differentiated_vulvar_intraepithelial_neoplasia_-_intermed_mag.jpg | Differentiated VIN - intermed. mag. (WC)
Image: Differentiated vulvar intraepithelial neoplasia - superficial - high mag.jpg | Differentiated VIN - superficial - high mag. (WC)
Image:Differentiated_vulvar_intraepithelial_neoplasia_-_deep_-_high_mag.jpg | Differentiated VIN - deep - high mag. (WC)
</gallery>
www:
*[http://www.nature.com/modpathol/journal/v24/n2/fig_tab/modpathol2010192f3.html#figure-title Differentiated VIN (nature.com)].<ref name=pmid21057461>{{Cite journal  | last1 = van de Nieuwenhof | first1 = HP. | last2 = Bulten | first2 = J. | last3 = Hollema | first3 = H. | last4 = Dommerholt | first4 = RG. | last5 = Massuger | first5 = LF. | last6 = van der Zee | first6 = AG. | last7 = de Hullu | first7 = JA. | last8 = van Kempen | first8 = LC. | title = Differentiated vulvar intraepithelial neoplasia is often found in lesions, previously diagnosed as lichen sclerosus, which have progressed to vulvar squamous cell carcinoma. | journal = Mod Pathol | volume = 24 | issue = 2 | pages = 297-305 | month = Feb | year = 2011 | doi = 10.1038/modpathol.2010.192 | PMID = 21057461 }}</ref>
*[http://www.nature.com/modpathol/journal/v23/n3/fig_tab/modpathol2009179f1.html Differentiated VIN with bridging rete ridges (nature.com)].<ref name=pmid20062014>{{Cite journal  | last1 = Pinto | first1 = AP. | last2 = Miron | first2 = A. | last3 = Yassin | first3 = Y. | last4 = Monte | first4 = N. | last5 = Woo | first5 = TY. | last6 = Mehra | first6 = KK. | last7 = Medeiros | first7 = F. | last8 = Crum | first8 = CP. | title = Differentiated vulvar intraepithelial neoplasia contains Tp53 mutations and is genetically linked to vulvar squamous cell carcinoma. | journal = Mod Pathol | volume = 23 | issue = 3 | pages = 404-12 | month = Mar | year = 2010 | doi = 10.1038/modpathol.2009.179 | PMID = 20062014 }}</ref>

==IHC==
*Differentiated VIN: p16 -ve, p53 +ve.<ref name=pmid20062014/>
*Classic VIN: p16 +ve, p53 -ve.

Note: 
*p16 can be thought of as a poor man's [[HPV]] test.

==Sign out==
<pre>
LABIA MINUS, RIGHT, PUNCH BIOPSY:
- DIFFERENTIATED VULVAR INTRAEPITHELIAL NEOPLASIA.
- LICHEN SCLEROSUS.
</pre>

==See also==
*[[Vulva]].
*[[Classic vulvar intraepithelial neoplasia]].

==References==
{{Reflist|2}}

[[Category:Vulva]]
[[Category:Diagnosis]]