We are excited to see so many of you join our FMEP courses. Several of you have requested we continue to post more practice SAMPs, so here you go!

SAMP

Eloise Milan, a 72-year-old woman, presents to your family practice with a 6-month history of persistent vulvar itching and discomfort. She had been advised to try an over-the-counter antifungal cream by her friend, who has similar symptoms. Eloise reports occasional spotting on her underwear and increasing localized pain. She has a history of smoking. On examination, she appears well. You note a white, thickened plaque with areas of erythema on the vulva, along with a small, irregular nodular lesion with superficial ulceration. (8 points)

1. What is the most appropriate next step in management? (1 point)

   Answer:
   Urgent referral to gynecology
   Biopsy of the lesion to rule out malignancy

2. List two clinical features that should prompt concern for vulvar malignancy and further evaluation. (2 points)

   Answer:
   Persistent vulvar pruritus not responding to standard therapy
   Vulvar pain or soreness
   Thickened or indurated plaques
   Irregular, pigmented, or erythematous nodular lesions
   Vulvar bleeding or ulceration
   Visible structural change of vulvar skin

3. Which of the following is the most common histologic type of vulvar cancer? (1 point)
   1. Adenocarcinoma
   2. Basal cell carcinoma
   3. Squamous cell carcinoma
   4. Melanoma
   5. Sarcoma

   Answer: C

4. Which of the following statements about vulvar intraepithelial neoplasia (VIN) is most accurate? (1 point)
   1. All VIN is caused by HPV
   2. Differentiated VIN has a lower cancer risk than usual VIN
   3. Usual VIN is associated with high-risk HPV
   4. VIN does not progress to cancer
   5. VIN only occurs in young patients

   Answer: C

5. Which of the following is a red flag symptom for vulvar cancer? (1 point)
   1. Mild transient itching
   2. Vaginal discharge only
   3. Persistent vulvar itching with lesion changes
   4. Dysmenorrhea
   5. Urinary frequency

   Answer: C

6. True or false: Lichen sclerosus is associated with an increased risk of vulvar squamous cell carcinoma. (1 point)

   Answer: True

7. True or false: HPV vaccination has no role in preventing vulvar cancer. (1 point)

   Answer: False

Helpful CMAJ Resource:
https://www.cmaj.ca/content/198/7/E264