Chapter 14 Vulvar Biopsy and Excision of Vulvar Lesions. Operative Techniques

 Chapter 14 Vulvar Biopsy and Excision of Vulvar Lesions

GENERAL PRINCIPLES

Definition

■ Vulvar lesions represent a wide spectrum of disorders found in the vulvar and perianal regions.1,2 The correct diagnosis is based on clinical history, physical examination, and sometimes laboratory tests. The greatest challenge is to differentiate what is normal, or a normal variant, from the abnormal and also to identify potentially serious disease or infection.3 The most concerning vulvar lesions are intraepithelial neoplasia (VIN) and cancer. The most bothersome are the lichen diseases that are characterized by intense pain and pruritus.

Differential Diagnosis

■ Vulvar dermatoses: These are inflamed, scaling skin diseases of the vulvar and fall into two morphologic groups: papulosquamous disease and eczematous disease. Papulosquamous diseases are well demarcated and usually show little evidence of rubbing and scratching while eczematous disease has poorly demarcated borders, and characterized by excoriations or thickening of skin from rubbing.

■ Infectious vulvar lesions may result from candida or herpes simplex virus (HSV) infection. Acquisition of human papilloma virus (HPV) and syphilis may manifest as condyloma accuminata and condyloma lata, respectively. In turn, these lesions are treated with antifungal, antiviral, and antibiotics.

■ Other benign vulvar lesions include lichen planus, lichen sclerosus, lichen simplex chronicus. Lesions may also develop from chronic irritation secondary to contact/allergic irritants.

■ Vulvar ulcers: Ulcers are deep with the defect extending into the dermis. They could be infectious or noninfectious. Examples of noninfectious ulcers include Behcet’s disease, apthous ulcers, complex aphthosis, and Crohn’s disease. Vulvar ulcers are often treated with steroids and immunotherapy such as tacrolimus.

■ Premalignant or malignant vulvar lesions include vulvar intraepithelial neoplasia (VIN), melanoma, basal cell carcinoma, and squamous cell carcinoma. At the very minimum, these lesions require biopsy and excision.Nonoperative Management

■ There are no special considerations prior to performing a vulvar biopsy, but patients undergoing excisional biopsy may need to be optimized. Controlling blood sugar in diabetics improves wound healing, anticoagulated and chronically immunosuppressed patient needs a multidisciplinary approach for optimization prior to surgery. If a patient is anti-coagulated and the international normalized ratio is within the therapeutic window, the procedure can be performed, but physician must have electrical or chemical cautery available for hemostasis.

IMAGING AND OTHER DIAGNOSTICS

■ Diagnosis should be made prior to initiating treatment. It is imperative for the clinician to ascertain if the etiology is infectious in nature. This may lead to ancillary blood tests, vulvar and vaginal swabs for culture, polymerase chain reaction (PCR), and biopsies. For example, a patient with vulvar ulcer should be screened for syphilis and HSV using serology. The ulcer should be swabbed and sent for HSV culture or PCR, and dark-field microscopy. Ulcer should be biopsied and sent to pathology.

■ Vulvar colposcopy: High-grade intraepithelial lesions of the vulvar (HSIL) or VIN are usually multifocal and located on the nonhairy part of the vulvar. Lesions may be raised and variegated with hues of white, red, pink, brown, or grey. Thorough vulvar colposcopy identifies additional lesions and assists in biopsy planning.

■ Perform colposcopy by covering the area with gauze soaked in 3% to 5% acetic acid for 3 to 5 minutes. Abnormal areas may appear white (acetowhite) and should be biopsied.4 Other areas may present with irregular borders and uneven pigmentation. VIN usually presents as sharply marginated flat-topped papules and plaques (see Pearls and Pitfalls section).

■ Vulvar biopsy should also be performed on lesions with the following: asymmetry, color variation, irregular borders, rapid change in size or appearance, and bleeding or nonhealing ulcers.

■ Recalcitrant, nonimproving lesions must be biopsied. A common scenario is an elderly woman who was adequately treated for candida infection but continues to experience persistent itching. On examination, her vulva remains erythematous, with or without fissures and excoriations. Such a patient may have contact or allergic dermatitis, lichen sclerosus, or a premalignant lesion.

■ Diagnostic vulvar biopsies are office procedures, whereas wide local excisions are performed in the operating room to ensure all affected tissues are excised down to the subcutaneous tissue level.

■ Prior to procedure, discuss the indication and steps of the procedure withthe patient. Counsel her on the risk of pain, bleeding, infection, scarring, and the possibility of a nondiagnostic sample. Finally, obtain the patient’s written consent.

■ Ensure all equipment and supplies are arranged and available (Table 14.1).

Table 14.1 Biopsy Box Supplies

■ Depending on the biopsy area, we recommend applying topical anesthetic to increase patient comfort.

■ If the site involves keratinized skin, apply topical anesthesia (lidocaine cream) for at least 30 to 60 minutes. If the site is confined to the mucous membrane, 20 minutes of topical anesthesia is sufficient. Application of 2% lidocaine gel or 2.5% prilocaine cream desensitizes the skin and allows painless injection of 1% to 2% lidocaine into the site. Lidocaine with or without epinephrine can be used, lidocaine solution with epinephrine mayreduce bleeding, but do not use epinephrine around the clitoral area.

■ Position the patient on an examination table with lower extremity stirrups and prep the area of interest with chlorhexidine, povidone–iodine, or baby soap solution (depending on patient’s allergy profile) (Fig. 14.1).

Figure 14.1. Positioning of patient and preparation of biopsy site.

■ Inject 1 to 3 mL of 1% to 2% lidocaine (local anesthetic) using a small needle (27- to 30-gauge needle) into the dermis to form a bleb or wheal under the lesion and beyond its edges (Fig. 14.2). Wheal formed should be wider in diameter than the biopsy instrument used. Test for appropriate anesthesia using a forceps prior to biopsy; in general, adequate anesthesia is achieved about 2 minutes post lidocaine injection.

Figure 14.2. Injecting anesthetic solution under the lesion to create a wheal or bleb.Procedures and Techniques Vulvar sampling can be performed using these different instruments and techniques: punch biopsy (Keyes punch biopsy), cervical biopsy forceps, suture and scissors technique, or wide local excision. Table 14.1 highlights the basic supplies needed.

A punch biopsy

This is a disposable instrument which removes a core-shaped piece of tissue.5 Use this instrument when all skin layers are needed to make a diagnosis. It is available in different sizes and most commonly used diameters are 3 to 6 mm. Select the appropriate size of punch biopsy based on the lesion.

Using sterile gloves and technique test the patient’s analgesia. Once it is confirmed to be adequate, position your nondominant hand to stretch the skin perpendicular to the lines of least skin tension. Then place the biopsy instrument perpendicular to the skin and firmly press down on it while simultaneously twisting the instrument 360 degrees until the tissue yields, indicating it has reached the subcutaneous fat and a full-thickness biopsy has been obtained. Stabilize the tissue with forceps and excise the tissue from its base with Metzenbaum or Iris scissors (Tech Fig. 14.1).

Apply moderate pressure and possibly a hemostatic agent (silver nitrate or Monsel’s solution) to achieve hemostasis. Electrocautery may be used to stop bleeding if needed. Re-approximate larger biopsies (>4 mm) with suture to prevent scarring (Tech Fig. 14.2A,B).

If decision is made to re-approximate the defect, most patients will need a single stitch to close the defect; make sure to evert the skin edges, the underlying dermis from both edges should touch. This compensates for future contracture of the wound and produces a flat scar.

For large defects, start suturing in the middle of the wound and work toward the edges to prevent “dog ears” of the wound. If tension is noticed during the repair, undermine the edges of the wound by 2 to 3 mm to prevent tension.

Tech Figure 14.1. 4-mm Keyes punch biopsy technique.

Tech Figure 14.2. A and B: Suturing of a defect >4 mm.

A Tischler biopsy forceps

■ The same used for cervical biopsy may also be used for vulvar lesion biopsies.

■ Simply grasp the lesion within the open jaws of the biopsy forceps and squeeze the handles together to excise the specimen.

The suture and scissors technique

■ For fragile tissue, place a 3-0 or 4-0 absorbable suture in the lesion and apply gentle traction to elevate the tissue. Then excise the lesion from its base using a small scissors (Tech Fig. 14.3A,B). Take care to excise under the suture to avoid cutting the suture itself.

■ Regardless of the biopsy method, achieve hemostasis with any combination of firm pressure, suture, and a chemical hemostatic agent such as Monsel’s solution or silver nitrate or electrical coagulation.

Tech Figure 14.3. A and B: The suture and scissors method of vulvar biopsy.

Excisional biopsy

This technique is ideal for lesions that need complete removal for diagnostic or therapeutic purposes. It requires the greatest amount of time and expertise. It is usually performed under general or regional anesthesia. Position the patient with lower-extremity stirrups. Prep the patient in a standard surgical fashion. Using a marking pen, draw an ellipse around the lesion and include a 2 to 5 mm circumferential margin of normal/healthy skin.4 Apply a sharp stimulus to test the patient’s level of analgesia. Using a no. 15 scalpel, begin at one apex and place firm, consistent, downward pressure on the scalpel perpendicular to the skin. Takethe incision down to the subcutaneous adipose tissue and continue along the ellipse. Once the excisional biopsy is removed, this adipose tissue will be exposed. Take care to excise a uniform depth from apex to apex and avoid decreasing excisional depth at the apices. Lift the edge of the excised tissue with forceps and undermine the sample at the level of subcutaneous fat with a scalpel or scissors. Use a microfine needle tip to apply electrical coagulation sparingly to obtain hemostasis and to minimize thermal destruction of the tissue (Tech Fig. 14.4). Using a 4-0 absorbable suture, close from the middle of the defect to the edges to prevent “dog ear.” Depending on the depth of the wound, defect may need to be closed in two layers with the subcutaneous space closed first with interrupted stitches before the skin is everted and closed.

Tech Figure 14.4. Illustration of excisional biopsy.

PEARLS AND PITFALLS

More than one punch biopsy may be required to get an accurate pathologic diagnosis of a lesion/ulcer.

Avoid biopsy of the clitoris, urethra, and anal opening unless it is absolutely necessary.

Biopsy the thickest area of a lesion and include ulcerated edge.

Avoid biopsy of areas with a blood vessel to avoid a hematoma.

Obtain a biopsy that contains both a section of healthy normal skin adjacent to the suspicious ulcer.

If the punch biopsy blade does not completely transect the dermis in a circular fashion, the specimen may be of inadequate depth. If this occurs, replace the circular blade in the exact same location and extend the biopsy depth.

A circular defect is difficult to re-approximate, whereas an oval-shaped defect has less tension along the suture line and provides better cosmesis. Therefore, do not forget to stretch the skin prior to punch biopsy to create an elliptical incision from the circular blade.

POSTOPERATIVE CARE

Apply 2% lidocaine for topical pain management along with over-the-counter oral nonsteroidal analgesia. Most patients are able to resume work and activities the same day after vulvar biopsy.

Patients are instructed to keep the site clean and dry. Sitz baths two times a day are recommended followed with an application of a thin film of plain petroleum jelly until the area is healed. Patients do not need antibiotic pre- or postprocedure. Avoid taking a bath in a tub until the site is healed. Patient may take showers.

OUTCOMES

■ If the biopsy is nondiagnostic, a repeat biopsy or excision may be required.

COMPLICATIONS

■ Infection

■ Pain

■ Bleeding, hematoma, ecchymosis

■ Scarring of biopsy site

■ Irritation and change in pigmentation of skin from Monsel.

■ Controlling complications:

■ Bleeding can be controlled by applying pressure for 5 minutes and orsuture ligation of bleeding vessels. The risk of hematoma can be reduced with pressure dressing and use of ice to affected area, which may also decrease pain. If bleeding remains uncontrolled, remove the suture, find and tie off the bleeding vessel, and then resuture.

■ Patient should notify physician office if severe pain and swelling, erythema, or purulent malodorous discharge.

■ If an infection of operative site is diagnosed, most patients would benefit from oral antibiotics covering staphylococcus and streptococcus. Patients with history of methicillin-resistant Staphylococcus aureus (MRSA) should be treated with anti-MRSA agent like trimethoprim/sulfamethoxazole and antibiotics tailored based on culture results if applicable