Management of Vaginal Intraepithelial Neoplasia

Department of Gynecology, Aberdeen Royal Infirmary, Aberdeen, United Kingdom.
Journal of Lower Genital Tract Disease (Impact Factor: 1.99). 03/2012; 16(3):306-12. DOI: 10.1097/LGT.0b013e31823da7fb
Source: PubMed


Vaginal intraepithelial neoplasia (VaIN) accounts for 0.4% of the lower genital tract intraepithelial disease. Various treatments have been reported often as small case series or reports.
An electronic search of the Ovid MEDLINE (from 1948 to present) and PubMed was performed, and only articles written in English were reviewed. All articles ranging from case reports to randomized controlled trials were included. This review critically appraises the published evidence for different treatment modalities and gives an overview of these options.
The 3 main modalities reported were surgery, brachytherapy, and medical management. Surgery included local excision, laser ablation, vaginectomy, and cavitational ultrasonic ablation. Medical management included topical 5% imiquimod, 5-fluorouracil, and tricholoroacetic acid. All treatments had good success rates for disease clearance with low rates of progression to cancer. Prerequisites for ablative treatments are the lesion is fully visible and adequately examined by biopsy to exclude invasion. Where invasion is suspected or cannot be excluded (e.g., at the vault suture line), surgical excision is essential. Brachytherapy and vaginectomy, although effective, have a limited place because of their related morbidity. Treatment choice may depend on the availability of equipment and expertise.
Conservative options in the form of laser ablation and topical agents are useful as first-line treatment methods especially in young women and for multifocal disease. Radical options like brachytherapy and vaginectomy should be reserved for highly selected cases. Evidence from a randomized controlled trial of first-line treatment with surgical and medical therapies is needed to compare treatment success and impact on quality of life.

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    • "Furthermore, although laser-skinning colpectomy may be a treatment option for patients with microinvasive cancer up to a depth of invasion of less than 3 mm with free margins, our dataset is not sufficiently robust to allow definitive conclusions to be made for this subgroup. Management of patients with VaIN requires an individualized treatment plan [13] and a conservative approach is appropriate for VaIN1 and most VaIN2 lesions, while laser vaporization is usually the most effective treatment for small VaIN2/3 lesions. However, we have no data to suggest that laser-skinning colpectomy can entirely replace conventional, radical colpectomy or if cases with deep involvement of the hysterectomy scar may finally benefit from a more radical approach. "
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    ABSTRACT: Objective To analyze the efficacy of colposcopic-guided laser-skinning colpectomy to treat extended high-grade vaginal intraepithelial neoplasia (VaIN). Methods Retrospective review of 33 heavily pretreated patients with high-grade VaIN extending over 20–100% of the vaginal surface treated between 2003 and 2013 with colposcopic-guided laser-skinning colpectomy. The vaginal epithelium including all VaIN lesions was excised in one piece with a depth of 2–3 mm. Results Vaginal cancer was diagnosed in 10 patients (nine microinvasive squamous cell carcinoma and one vaginal carcinoma). No serious adverse events related to laser-skinning colpectomy were observed. Of 33 patients, 23 were followed up with cytology and colposcopy for at least 12 months at our institution (median follow 26.5 months; range 12–104 months), while five had a shorter follow-up, four an external follow-up and one patient was lost. Of 23 patients with follow-up ≥ 12 months, 20 were disease free after a single laser-skinning colpectomy (overall cure rate 87.0%). Moderate shortening of the vagina was observed in two patients and another two required reconstruction of vaginal strictures during long-term follow-up. Conclusion Laser-skinning colpectomy appears to be a feasible treatment for extended high-risk VaIN3. The procedure avoids the mutilation associated with colpectomy and allows early diagnosis and staging of invasive disease.
    Full-text · Article · Nov 2014 · Gynecologic Oncology
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    • "Although the best treatment option for VAIN is uncertain, there are various choices, including partial or total colpectomy, laser ablation, cavitational ultrasonic surgical application, vaginectomy, topical application of 5-fluorouracil, and brachytherapy [3]. Several previous studies have described the effectiveness of brachytherapy in VAIN [6-11]. "
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    ABSTRACT: Vaginal intraepithelial neoplasia (VAIN), a rare premalignant condition, is difficult to eradicate. We assess the effectiveness of high-dose rate intracavitary brachytherapy (HDR-ICR) in patients with VAIN or carcinoma in situ (CIS) of the vagina after hysterectomy. We reviewed 34 patients treated for posthysterectomy VAIN or CIS of the vagina by brachytherapy as the sole treatment. All patients underwent a coloposcopic-directed punch biopsy or had abnormal cytology, at least 3 consecutive times. All patients were treated with a vaginal cylinder applicator. The total radiation dose was mainly 40 Gy in 8 fractions during the periods of 4 weeks at a prescription point of the median 0.2 cm (range, 0 to 0.5 cm) depth from the surface of the vaginal mucosa. Acute toxicity was minimal. Seven patients had grade 1/2 acute urinary and rectal complications. There were 15 cases of late toxicity, predominantly vaginal mucosal reaction in 12 patients. Of these patients, two patients suffered from grade 3 vaginal stricture and dyspareunia continuously. After a median follow-up time of 48 months (range, 4 to 122 months), there were 2 recurrences and 2 persistent diseases, in which a second-line therapy was needed. The success rate was 88.2%. The average prescription point in failure patients was 1.1 mm from the surface of the vagina compared to an average of 2.6 mm in non-recurrent patients (p=0.097). HDR-ICR is an effective treatment method in VAIN patients. In spite of high cure rates, we should consider issues regarding vaginal toxicity and radiation techniques to reduce the occurrence of failure and toxicity.
    Full-text · Article · Jan 2014 · Cancer Research and Treatment
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    ABSTRACT: Human papilloma virus is associated with a multitude of lower genital tract diseases in women in addition to cervical cancer, including genital warts, vulvar intraepithelial neoplasia, vaginal intraepithelial neoplasia, and some vulvar, vaginal, and anal cancers that are associated with oncogenic subtypes. The degree to which HPV manifests pathology depends on viral type, host immune response, and local environmental factors. This article reviews the evaluation and management of the following vulvar and vaginal human papilloma virus diseases: condyloma, vulvar intraepithelial neoplasia, and vaginal intraepithelial neoplasia. Included is a brief discussion of the association with vulvar and vaginal cancer.
    No preview · Article · Jun 2013 · Obstetrics and Gynecology Clinics of North America
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