The risk of squamous cell carcinoma in persistent vulvar ulcers

Objective: The standard evaluation for vulvar ulcers includes an office biopsy. There are limited data regarding the false-negative rate of a punch biopsy in detecting squamous cell carcinoma of the vulva. This study reports on pathologic discrepancies between office biopsy and subsequent wide local excision for nonhealing vulvar ulcers. Methods: A retrospective review of the surgical records of 118 consecutive vulvar procedures was performed. Eleven women with persistent vulvar ulcers in the absence of a mass or pigmented lesion were identified. Patient demographics, physical examination, office evaluation, and surgical and pathology reports for these 11 women were reviewed. Results: A persistent vulvar ulcer was the presenting complaint in 11 (13.8%) of 80 women with squamous cell disease. Most women were postmenopausal, with a median age of 72 years. Nine of the 11 women had an office biopsy performed before consultation with a gynecologic oncologist. Five (55%) of these specimens had benign findings on office biopsy but revealed invasive squamous cell carcinoma after subsequent excision. Three of four women with prior diagnosis of lichen sclerosis had ulcers harboring invasive carcinoma. Conclusions: Vulvar ulceration may be the only presenting symptom in women with vulvar squamous cell carcinoma especially in postmenopausal women. Prompt office biopsy should remain part of the standard diagnostic evaluation; however, cancer should be suspected even with a negative biopsy result if ulcerations persist. More extensive tissue sampling in the operating room should be considered for these women.