Question

An 88-year-old G2P2 nursing home resident is brought in for evaluation of blood found in her diapers. She has a long-standing history of incontinence. This is the first time that her caregivers have noted blood. They describe it as "quarter size." Her nurses think that she may have been itching, as they frequently find her scratching through the diaper. On review of her medical record, biopsy-documented lichen sclerosus of the vulva was diagnosed fifteen years ago. She has not been on any therapy for this condition for years. Examination of the external genitalia reveals an elevated, firm irregular lesion arising from the left labia. The lesion measures 2.5 cm in greatest dimension. The remainder of the external genitalia shows evidence of excoriation of thin, white skin with a wrinkled parchment appearance. The vagina and cervix are atrophic. No masses are noted on bimanual or rectovaginal exam and a sample of her stool is negative for blood. No nodularity is noted in her groin. Which of the following is the most appropriate next step in the management of this patient?

A. Begin steroids
B. Obtain cultures of the lesion
C. Biopsy the lesion
D. Perform a Pap smear (cytology) of the lesion
E. Complete vulvectomy and lymph node dissection

Answer 1

The most appropriate next step is to biopsy the lesion to confirm the diagnosis and guide further management, considering the risk of vulvar malignancy in a patient with lichen sclerosus.

Step-by-step explanation:

In the clinical scenario described, the elderly patient with a history of lichen sclerosus presented with a new firm and irregular lesion on her external genitalia. Given her previous diagnosis and the appearance of the lesion, there is a concern for malignant transformation, such as squamous cell carcinoma of the vulva. In this context, and considering the lesion's elevated, firm, and irregular characteristics, the most appropriate next step in management is to biopsy the lesion (Option C). This will provide a definitive diagnosis and guide further management, whether it includes local excision, wider surgery, or other therapeutic options. Initiating steroids (Option A) or obtaining cultures (Option B) would not address the primary concern of potential malignancy. A Pap smear (Option D) is not the appropriate modality for diagnosis of a vulvar lesion. A complete vulvectomy and lymph node dissection (Option E) is not indicated without a confirmed diagnosis.