Case Number : Case 2251 - 29 January 2019 Posted By: Uma Sundram

dVIN (Differentiated Vulvar intraepithelial neoplasia).

VIN, differentiated type.

All of these lesion are considered high grade

why not lichen planus?

Dyskeratosis with satellitosis in stromalepithelial interfacce are more in keeping with autoimmune T-cell mediated reaction, so agree with dermpath1’s question: Why not LP?  

It´s a valid question and probably you are rigth. My first impression was dysplastic changes but now i´m not sure.

Lichen planus seems to be more reasonable.

Waiting for more comments.

My question is: Why not LP?  But I’m not sure about the answer... there are clues to LP, but also to dVIN: sharp margin with adiacent epidermis and some market unicellular eosinophilic appearance up in epithelium and some light atypia in basal layer .Hypergranulosis instead is a clue to LP.  Waiting for other comments too. 

Perhaps it should be convenient a follow up because dVIN is an high grade lesion. 

Found this article:https://dx.doi.org/10.1007%2Fs00428-018-2436-8.

Important clues to dVIN could be, according to these authors, MACRONUCLEOLI, ANGULATED NUCLEI, AND COBBLESTONE APPEARANCE IN BOTTOM HALF. I don't see these features, but may be it's a subjective status! What do you guys think about?

LP

Thought of lichen planus too. P53 and ki67 could help Article

I have an advantage over you guys as I happen to know that this patient had a high grade invasive SCC on the left vulva and this lesion, thought to be dVIN clinically, on the right vulva. Hypertrophic LP and hypertrophic LS are both good thoughts here. What catches my eye, outside of the usual LP features, is the level of extreme hyperkeratosis and the presence of diffuse cytologic atypia extending all the way to the granular layer.  A hyperchromatic basal layer is also a distinctive feature, not usually seen in typical lesions of LP, even hypertrophic ones. There is low power basaloid nuclear hyperchromasia, disorganization of the epithelial layers, and skipping of adnexal structures. These latter features, coupled with the clinical impression, favors dVIN over hypertrophic LP. If unsure, one can ask for the clinical picture, an outside expert opinion, or err on the side of atypicality with greater follow up and lower threshold for re biopsy. A lesion like this may eventually lead to anastomosing of rete pegs, which would be unusual in any LP lesion but can be seen with some frequency in dVIN.This is an extremely difficult case which is why I posted it.  I have not found stains to be particularly helpful, but GATA 3 appears to show some promise (Goyal A et al., Mod Pathol. 2018 Jul;31(7):1131-1140)

Excellent case and discussion Dr. Uma. Very difficult indeed.

I´ve learned a lot form all your comments. Thank you.