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Kesic V, Carcopino X, Preti M, Vieira-Baptista P, Bevilacqua F, Bornstein J, Chargari C, Cruickshank M, Erzeneoglu E, Gallio N, Gultekin M, Heller D, Joura E, Kyrgiou M, Madić T, Planchamp F, Regauer S, Reich O, Esat Temiz B, Woelber L, Zodzika J, Stockdale C. The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) Consensus Statement on the Management of Vaginal Intraepithelial Neoplasia. J Low Genit Tract Dis 2023; 27:131-145. [PMID: 36951985 PMCID: PMC10026974 DOI: 10.1097/lgt.0000000000000732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
ABSTRACT The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vaginal intraepithelial neoplasia (VaIN). The management of VaIN varies according to the grade of the lesion: VaIN 1 (low grade vaginal squamous intraepithelial lesions (SIL)) can be subjected to follow-up, while VaIN 2-3 (high-grade vaginal SIL) should be treated. Treatment needs individualization according to the patient's characteristics, disease extension and previous therapeutic procedures. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Total vaginectomy is used only in highly selected cases of extensive and persistent disease. Carbon dioxide (CO2) laser may be used as both an ablation method and an excisional one. Reported cure rates after laser excision and laser ablation are similar. Topical agents are useful for persistent, multifocal lesions or for patients who cannot undergo surgical treatment. Imiquimod was associated with the lowest recurrence rate, highest human papillomavirus (HPV) clearance, and can be considered the best topical approach. Trichloroacetic acid and 5-fluorouracil are historical options and should be discouraged. For VaIN after hysterectomy for cervical intraepithelial neoplasia (CIN) 3, laser vaporization and topical agents are not the best options, since they cannot reach epithelium buried in the vaginal scar. In these cases surgical options are preferable. Brachytherapy has a high overall success rate but due to late side effects should be reserved for poor surgical candidates, having multifocal disease, and with failed prior treatments. VaIN tends to recur and ensuring patient adherence to close follow-up visits is of the utmost importance. The first evaluation should be performed at 6 months with cytology and an HPV test during 2 years and annually thereafter. The implementation of vaccination against HPV infection is expected to contribute to the prevention of VaIN and thus cancer of the vagina. The effects of treatment can have an impact on quality of life and result in psychological and psychosexual issues which should be addressed. Patients with VaIN need clear and up-to-date information on a range of treatment options including risks and benefits, as well as the need for follow-up and the risk of recurrence.
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Affiliation(s)
- Vesna Kesic
- Medical Faculty, University of Belgrade, Clinic of Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Xavier Carcopino
- Department of Obstetrics and Gynaecology, Hôpital Nord, APHM, Aix-Marseille University (AMU), Univ Avignon, CNRS, IRD, IMBE UMR 7263, 13397, Marseille, France
| | - Mario Preti
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Pedro Vieira-Baptista
- Lower Genital Tract Unit Centro Hospitalar de São João, Porto, Portugal
- Hospital Lusiadas, Porto, Portugal
| | | | - Jacob Bornstein
- Galilee Medical Center and Azrieli Faculty of Medicine, Bar-Ilan, Israel
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Maggie Cruickshank
- Aberdeen Centre for Women’s Health Research, University of Aberdeen, Aberdeen, United Kingdom
| | - Emre Erzeneoglu
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Niccolò Gallio
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Elmar Joura
- Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Maria Kyrgiou
- Surgery and Cancer - West London Gynecological Cancer Center, IRDB, Department of Gut, Metabolism & Reproduction-Surgery & Cancer, Imperial College London, London, United Kingdom
- Imperial Healthcare NHS Trust, Queen Charlotte's & Chelsea Hospital West London Gynaecological Cancer Centre, London, United Kingdom
| | - Tatjana Madić
- Clinic for Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | | | - Sigrid Regauer
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Olaf Reich
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Bilal Esat Temiz
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
| | - Linn Woelber
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
- Dysplasia Center Hamburg; Jerusalem Hospital Hamburg, Hamburg, Germany
| | - Jana Zodzika
- Department of Obstetrics and Gynaecology Rīga Stradiņ,š University, Riga, Latvia
| | - Colleen Stockdale
- Department of Obstetrics & Gynecology, University of Iowa, Iowa City, IA
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Kesic V, Carcopino X, Preti M, Vieira-Baptista P, Bevilacqua F, Bornstein J, Chargari C, Cruickshank M, Erzeneoglu E, Gallio N, Gultekin M, Heller D, Joura E, Kyrgiou M, Madić T, Planchamp F, Regauer S, Reich O, Esat Temiz B, Woelber L, Zodzika J, Stockdale C. The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) consensus statement on the management of vaginal intraepithelial neoplasia. Int J Gynecol Cancer 2023; 33:446-461. [PMID: 36958755 PMCID: PMC10086489 DOI: 10.1136/ijgc-2022-004213] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vaginal intraepithelial neoplasia (VaIN). The management of VaIN varies according to the grade of the lesion: VaIN 1 (low grade vaginal squamous intraepithelial lesions (SIL)) can be subjected to follow-up, while VaIN 2-3 (high-grade vaginal SIL) should be treated. Treatment needs individualization according to the patient's characteristics, disease extension and previous therapeutic procedures. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Total vaginectomy is used only in highly selected cases of extensive and persistent disease. Carbon dioxide (CO2) laser may be used as both an ablation method and an excisional one. Reported cure rates after laser excision and laser ablation are similar. Topical agents are useful for persistent, multifocal lesions or for patients who cannot undergo surgical treatment. Imiquimod was associated with the lowest recurrence rate, highest human papillomavirus (HPV) clearance, and can be considered the best topical approach. Trichloroacetic acid and 5-fluorouracil are historical options and should be discouraged. For VaIN after hysterectomy for cervical intraepithelial neoplasia (CIN) 3, laser vaporization and topical agents are not the best options, since they cannot reach epithelium buried in the vaginal scar. In these cases surgical options are preferable. Brachytherapy has a high overall success rate but due to late side effects should be reserved for poor surgical candidates, having multifocal disease, and with failed prior treatments. VaIN tends to recur and ensuring patient adherence to close follow-up visits is of the utmost importance. The first evaluation should be performed at 6 months with cytology and an HPV test during 2 years and annually thereafter. The implementation of vaccination against HPV infection is expected to contribute to the prevention of VaIN and thus cancer of the vagina. The effects of treatment can have an impact on quality of life and result in psychological and psychosexual issues which should be addressed. Patients with VaIN need clear and up-to-date information on a range of treatment options including risks and benefits, as well as the need for follow-up and the risk of recurrence.
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Affiliation(s)
- Vesna Kesic
- Medical Faculty, University of Belgrade, Clinic of Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Xavier Carcopino
- Department of Obstetrics and Gynaecology, Hôpital Nord, APHM, Aix-Marseille University (AMU), Univ Avignon, CNRS, IRD, IMBE UMR 7263, 13397, Marseille, France
| | - Mario Preti
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Pedro Vieira-Baptista
- Lower Genital Tract Unit Centro Hospitalar de São João, Porto, Portugal
- Hospital Lusiadas, Porto, Portugal
| | | | - Jacob Bornstein
- Galilee Medical Center and Azrieli Faculty of Medicine, Bar-Ilan, Israel
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Maggie Cruickshank
- Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - Emre Erzeneoglu
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Niccolò Gallio
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Debra Heller
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Elmar Joura
- Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Maria Kyrgiou
- Surgery and Cancer - West London Gynecological Cancer Center, IRDB, Department of Gut, Metabolism & Reproduction-Surgery & Cancer, Imperial College London, London, UK
- Imperial Healthcare NHS Trust, Queen Charlotte's & Chelsea Hospital West London Gynaecological Cancer Centre, London, UK
| | - Tatjana Madić
- Clinic for Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
| | | | - Sigrid Regauer
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Olaf Reich
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Bilal Esat Temiz
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynaecological Oncology, Hacettepe University, Ankara, Turkey
| | - Linn Woelber
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
- Dysplasia Center Hamburg; Jerusalem Hospital Hamburg, Hamburg, Germany
| | - Jana Zodzika
- Department of Obstetrics and Gynaecology Rīga Stradiņš University, Riga, Latvia
| | - Colleen Stockdale
- Department of Obstetrics & Gynecology, University of Iowa, Iowa City, Iowa, USA
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Ao M, Zheng D, Wang J, Gu X, Xi M. Risk factors analysis of persistence, progression and recurrence in vaginal intraepithelial neoplasia. Gynecol Oncol 2021; 162:584-589. [PMID: 34226020 DOI: 10.1016/j.ygyno.2021.06.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/19/2021] [Accepted: 06/27/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE to profile patients with vaginal intraepithelial neoplasia (VAIN), to evaluate natural history and to identify risk factors for persistence, progression and recurrence. METHODS At West China Second University Hospital, all patients with histologically confirmed VAIN over a five-year period with minimum follow-up of 6 months were retrospectively identified. Demographics, medical history and clinical information related to the diagnosis and treatment were extracted. Clinical outcomes included normalization, persistence, progression and recurrence. We evaluated risk factors by univariate and multivariate analyses. RESULTS A total of 1478 patients fulfilled the inclusion criteria with a median follow-up of 14 months (range, 6-60 months). In 86.6% of patients, VAIN went into normalization, 6.4% persisted, 3.5% progressed and 3.5% recurred. Besides, 24 (7.1%) VAIN 3 patients and 4 (0.8%) progressed to cancer, accounting for 85.7% and 14.3% of cancer cases, respectively. VAIN 3 patients treated with excision yielded superior outcomes. Risk factors for persistence were HPV 16, 56, 59 and 43 infections, for progression were prior hysterectomy for cervical lesions and HPV 56 infection, for recurrence were HPV 61 infection. CONCLUSION Although VAIN will regress in most patients, there are still risks of persistence, recurrence and progression, even malignancy. Therefore, a long-term follow-up is recommended. Patients with VAIN 3 are at higher risk of progressing to cancer and excision is preferred. HPV 16, 56, 59 and 43 infections might associate with an increased risk of persistence and patients with prior hysterectomy for cervical lesions tend to progress.
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Affiliation(s)
- Mengyin Ao
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Number 20, Third Section of People's South Road, Chengdu 61 0000, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, Sichuan, China
| | - Danxi Zheng
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Number 20, Third Section of People's South Road, Chengdu 61 0000, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, Sichuan, China
| | - Jingwen Wang
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Number 20, Third Section of People's South Road, Chengdu 61 0000, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, Sichuan, China
| | - Xuesai Gu
- Department of Information Management, West China Second University Hospital, Sichuan University, Number 20, Third Section of People's South Road, Chengdu 61 0000, China
| | - Mingrong Xi
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Number 20, Third Section of People's South Road, Chengdu 61 0000, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, Sichuan, China.
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Rountis A, Pergialiotis V, Tsetsa P, Rodolakis A, Haidopoulos D. Management options for vaginal intraepithelial neoplasia. Int J Clin Pract 2020; 74:e13598. [PMID: 32602195 DOI: 10.1111/ijcp.13598] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 06/23/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Vaginal intraepithelial neoplasia (VaIN) is a rare disease of the lower genital tract, strongly associated with HPV infection, which may progress to vaginal carcinoma. PURPOSE The aim of this review is to summarise current treatment options, evaluate their efficacy and make provide recommendations on the optimal management of the disease. MATERIALS AND METHODS A comprehensive search of the literature was performed using the PubMed database for articles referring to the treatment of VaIN. We restricted our search only in articles written in English with publication dates within the last 10 years. RESULTS Surgical approach included local excision, CO2 laser ablation, CO2 laser skinning colpectomy and laparoscopic upper vaginectomy. Medical management was based on intravaginally administered topical agents such as 5% imiquimod cream, 5-fluorouracil cream and topical oestrogens. Intracavitary radiation therapy was reported in two forms: Low-dose rate (LDR) brachytherapy and high-dose rate (HDR) brachytherapy. All treatment options were well tolerated, with satisfactory cure rates and acceptable recurrence rates. CONCLUSION The choice of treatment depends upon many factors. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Topical agents are useful for persistent, multifocal lesions or for women that cannot undergo surgical treatment. Brachytherapy is associated with high morbidity rates and should be reserved for women who have multifocal disease, are poor surgical candidates and/or have failed other treatments. CO2 laser ablation achieves minimal scarring and sexual dysfunction; however, invasive disease should be ruled out with biopsies before the initiation of the treatment.
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Affiliation(s)
- Argirios Rountis
- First department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Pergialiotis
- First department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Tsetsa
- First department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Rodolakis
- First department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Haidopoulos
- First department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Lebreton M, Carton I, Brousse S, Lavoué V, Body G, Levêque J, Nyangoh-Timoh K. Vulvar intraepithelial neoplasia: Classification, epidemiology, diagnosis, and management. J Gynecol Obstet Hum Reprod 2020; 49:101801. [PMID: 32417455 DOI: 10.1016/j.jogoh.2020.101801] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 05/02/2020] [Accepted: 05/04/2020] [Indexed: 11/26/2022]
Abstract
Vulvar intraepithelial neoplasia (VIN) is classified into two entities: differentiated (dVIN) and vulvar high-grade squamous intraepithelial lesions (vH-SIL). dVIN is a premalignant lesion that develops on an existing vulvar lesion such as lichen sclerosus, while vH-SIL is associated with HPV infection. The two entities differ in terms of pathophysiology, background, prognosis, and management. The incidence of VIN in young women is rising and recurrence is common, even after radical surgery, which can cause significant disfigurement. Alternative strategies include topical treatments, ablation, and a watch-and-wait approach. There is currently no consensus on how these lesions should be managed. We review the literature in this field.
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Affiliation(s)
- M Lebreton
- Département de Gynécologie Obstétrique et Reproduction Humaine, CHU Anne de Bretagne, 16 Bd de Bulgarie BP 90347, F-35 203, Rennes Cedex 2, France
| | - I Carton
- Département de Gynécologie Obstétrique et Reproduction Humaine, CHU Anne de Bretagne, 16 Bd de Bulgarie BP 90347, F-35 203, Rennes Cedex 2, France
| | - S Brousse
- Département de Gynécologie Obstétrique et Reproduction Humaine, CHU Anne de Bretagne, 16 Bd de Bulgarie BP 90347, F-35 203, Rennes Cedex 2, France
| | - V Lavoué
- Département de Gynécologie Obstétrique et Reproduction Humaine, CHU Anne de Bretagne, 16 Bd de Bulgarie BP 90347, F-35 203, Rennes Cedex 2, France
| | - G Body
- Service de gynécologie obstétrique et médecine fœtale, université François Rabelais, CHRU de Tours, 2, boulevard Tonnelle, 37044, Tours Cedex 9, France
| | - J Levêque
- Département de Gynécologie Obstétrique et Reproduction Humaine, CHU Anne de Bretagne, 16 Bd de Bulgarie BP 90347, F-35 203, Rennes Cedex 2, France.
| | - K Nyangoh-Timoh
- Département de Gynécologie Obstétrique et Reproduction Humaine, CHU Anne de Bretagne, 16 Bd de Bulgarie BP 90347, F-35 203, Rennes Cedex 2, France
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Zolciak-Siwinska A, Gruszczynska E, Jonska-Gmyrek J, Kulik A, Michalski W. Brachytherapy for vaginal intraepithelial neoplasia. Eur J Obstet Gynecol Reprod Biol 2015; 194:73-7. [DOI: 10.1016/j.ejogrb.2015.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 08/06/2015] [Accepted: 08/13/2015] [Indexed: 10/23/2022]
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Luyten A, Hastor H, Vasileva T, Zander M, Petry KU. Laser-skinning colpectomy for extended vaginal intraepithelial neoplasia and microinvasive cancer. Gynecol Oncol 2014; 135:217-22. [DOI: 10.1016/j.ygyno.2014.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 08/07/2014] [Accepted: 08/13/2014] [Indexed: 11/21/2022]
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Wang Y, Kong WM, Wu YM, Wang JD, Zhang WY. Therapeutic effect of laser vaporization for vaginal intraepithelial neoplasia following hysterectomy due to premalignant and malignant lesions. J Obstet Gynaecol Res 2014; 40:1740-7. [PMID: 24888942 DOI: 10.1111/jog.12383] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 12/13/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Yan Wang
- Department of Gynecological Oncology; Beijing Obstetrics and Gynecology Hospital of Capital Medical University; Beijing China
| | - Wei-Min Kong
- Department of Gynecological Oncology; Beijing Obstetrics and Gynecology Hospital of Capital Medical University; Beijing China
| | - Yu-Mei Wu
- Department of Gynecological Oncology; Beijing Obstetrics and Gynecology Hospital of Capital Medical University; Beijing China
| | - Jian-Dong Wang
- Department of Gynecological Oncology; Beijing Obstetrics and Gynecology Hospital of Capital Medical University; Beijing China
| | - Wei-Yuan Zhang
- Department of Gynecological Oncology; Beijing Obstetrics and Gynecology Hospital of Capital Medical University; Beijing China
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11
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Liao JB, Jean S, Wilkinson-Ryan I, Ford AE, Tanyi JL, Hagemann AR, Lin LL, McGrath CM, Rubin SC. Vaginal intraepithelial neoplasia (VAIN) after radiation therapy for gynecologic malignancies: A clinically recalcitrant entity. Gynecol Oncol 2011; 120:108-12. [DOI: 10.1016/j.ygyno.2010.09.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 08/28/2010] [Accepted: 09/04/2010] [Indexed: 10/19/2022]
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12
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Matsuo K, Chi DS, Walker LD, Rosenshein NB, Im DD. Ultrasonic surgical aspiration for vaginal intraepithelial neoplasia. Int J Gynaecol Obstet 2009; 105:71-3. [DOI: 10.1016/j.ijgo.2008.11.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Revised: 11/23/2008] [Accepted: 11/28/2008] [Indexed: 11/26/2022]
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13
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Abstract
OBJECTIVE To compare pain, adverse effects and recurrence of dysplasia in patients with vaginal intraepithelial neoplasia or vulvar intraepithelial neoplasia prospectively treated by carbon dioxide laser or ultrasonic surgical aspiration. METHODS Patients were randomly assigned to receive treatment by laser or ultrasonic surgical aspiration from 2000-2005. Preoperative biopsy was done to confirm presence of dysplasia. Patients completed a visual analog scale regarding pain and were evaluated at 2-4 weeks to assess scarring, wound healing, and adverse effects. Patients returned every 3 months for 1 year for pelvic examination and cytology to assess recurrence. Follow-up colposcopy and biopsy were used at the discretion of the treating physician. Student t test, chi2, analysis of variance and multiple logistic regression were used for analysis. RESULTS One hundred ten patients were randomly assigned. Ninety-six (87.3%) patients completed 1 year follow-up. Mean age of patients was 48.5 years. Mean visual analog scale score was significantly lower in patients treated by ultrasonic surgical aspiration (20.7 compared with 35.1; P=.032). For patients with vulvar lesions, there was less scarring with ultrasonic surgical aspiration (P<.01). Recurrence overall was 25% and was similar for ultrasonic surgical aspiration compared with laser (relative risk 0.96, 95% confidence interval 0.64-1.50, number needed to treat 95.6). Recurrence was associated with younger age (P<.01). CONCLUSION Patients treated with ultrasonic surgical aspiration for vulvar and vaginal dysplasia reported less postoperative pain. Vulvar scarring was more common in patients treated by the laser. There was no difference in recurrence of dysplasia during a 1-year follow-up period between the two surgical modalities. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT00394758 LEVEL OF EVIDENCE I.
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Affiliation(s)
- Vivian E von Gruenigen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University Hospital Case Medical Center, Case School of Medicine, Cleveland, Ohio, USA.
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Abstract
OBJECTIVE The Home Study Course is intended for the practicing colposcopist or practitioner who is seeking to develop or enhance his or her colposcopic skills. The goal of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions. ACCME ACCREDITATION The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1 hour Category I credit of the Physician's Recognition Award of the American Medical Association. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.
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Affiliation(s)
- Luis A Padilla-Paz
- Professor of Clinical Obstetrics and Gynecology, New York University School of Medicine and North Shore University Hospital, Manhasset, NY Division of Gynecologic Oncology, University of New Mexico, Albuquerque, NM
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15
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Eedarapalli PK, Jain S, McKenna DM. An unusual presentation of basaloid vaginal intraepithelial neoplasia in a young infertile woman. Aust N Z J Obstet Gynaecol 2006; 46:61-3. [PMID: 16441700 DOI: 10.1111/j.1479-828x.2006.00520.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Padma K Eedarapalli
- Department of Obstetrics and Gynaecology, Salisbury District Hospital, Salisbury, UK.
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Lin H, Huang EY, Chang HY, ChangChien CC. Therapeutic Effect of Topical Applications of Trichloroacetic Acid for Vaginal Intraepithelial Neoplasia after Hysterectomy. Jpn J Clin Oncol 2005; 35:651-4. [PMID: 16275678 DOI: 10.1093/jjco/hyi176] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We attempted to evaluate the therapeutic effect of trichloroacetic acid (TCA) for vaginal intraepithelial neoplasia (VaIN) after hysterectomy and to identify factors affecting persistence/recurrence. METHODS Twenty-eight post-hysterectomy patients with various grades of VaIN were enrolled in this study between January 2001 and December 2003. They were managed with intravaginal 50% TCA once weekly for 1-4 weeks, and all patients were followed up every 3 months for at least 1 year. Assessments by Papanicolaou smear and colposcopy were performed, as was biopsy when indicated during the follow-up period. Cox regression analysis was used to identify independent factors predicting persistence/recurrence. RESULTS In 20 of 28 patients (71.4%) VaIN went into remission. Treatment success was observed in all 11 patients with VaIN I, whereas only 9 out of 17 patients (53%) with VaIN II/III went into remission (P = 0.009). Severity of VaIN was the only significant independent predictor of persistence/recurrence (odds ratio = 3.5; 95% confidence interval = 1.1, 11.6; P = 0.038). The treatment was well tolerated with no major side effects. CONCLUSIONS Based on our findings, 50% TCA was a potential agent with minimal side effects for low-grade VaIN. Further prospective controlled study is warranted to verify our statements. However, as for high-grade lesions, further investigation with different TCA concentration is compelling.
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Affiliation(s)
- Hao Lin
- Department of Obstetrics and Gynecology, Chung Gung Memorial Hospital, Kaohsiung, Taiwan.
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Haidopoulos D, Diakomanolis E, Rodolakis A, Voulgaris Z, Vlachos G, Intsaklis A. Can local application of imiquimod cream be an alternative mode of therapy for patients with high-grade intraepithelial lesions of the vagina? Int J Gynecol Cancer 2005; 15:898-902. [PMID: 16174242 DOI: 10.1111/j.1525-1438.2005.00152.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The aim of the present study was to assess the local application of imiquimod cream 5% as an alternative mode of therapy for high-grade vaginal intraepithelial neoplasia (VAIN 2/3). Positive human papillomavirus (HPV) patients with multifocal high-grade VAIN (2/3) not involving the vaginal vault in hysterectomized patients took part in this study. The treatment consisted of vaginal application of the cream under colposcopic guidance. Following management, biopsies were obtained from the previously recorded lesions. p53 expression was recorded prior and after therapy. Seven patients with VAIN 2/3 took part in this study. Six patients (86%) were positive for high-risk HPV type while three (43%) women who were positive for p53 nuclei prior to therapy were found to be negative following treatment. After treatment, 86% of the patients were found to have either HPV infection or low-grade VAIN. During follow-up, two patients (28.5%) were managed by vaginectomy, one for persistent and one for recurrent high-grade VAIN. Currently, from the five patients that are followed, three have simple HPV infection and two, VAIN 1. Imiquimod cream 5% might represent an alternative although not permanent method of management in young, HPV-positive women with multifocal high-grade lesions of the vagina (VAIN 2/3).
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Affiliation(s)
- D Haidopoulos
- Gynecologic Oncology Unit, 1st Department of Obstetrics and Gynecology, Alexandra Hospital, University of Athens, Athens, Greece.
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Wilson H, Rawlings C, Latimer K, Strunk A, Hanley C, Lester VK. Comparison of the Cavitron Ultrasonic Surgical Aspirator and CO2Laser for Lipoma Resection in Budgerigars (Melopsittacus undulatus). J Avian Med Surg 2004. [DOI: 10.1647/02-021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Teruya Y, Sakumoto K, Moromizato H, Toita T, Ogawa K, Murayama S, Kanazawa K. High dose-rate intracavitary brachytherapy for carcinoma in situ of the vagina occurring after hysterectomy: a rational prescription of radiation dose. Am J Obstet Gynecol 2002; 187:360-4. [PMID: 12193925 DOI: 10.1067/mob.2002.123202] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Our purpose was to profile patients who were treated with high dose-rate intracavitary brachytherapy for carcinoma in situ of the vagina that occurred after hysterectomy, with special reference to a rational prescription of radiation dose. STUDY DESIGN We reviewed 13 patients who were treated for posthysterectomy carcinoma in situ of the vagina by the brachytherapy as the sole treatment. The brachytherapy was delivered by a remote-controlled afterloading intracavitary radiation system. RESULTS The mean age of the patients was 62 years. The total dose of absorbed radiation was 36 and 30 Gy that was prescribed at 1.0-cm depth to the vaginal surface in 3 cases and at 40 and 30 Gy that was prescribed at 0.5-cm depth in 10 cases. All patients had vaginal mucosal radiation changes of mild to moderate grade. Three cases that were irradiated to a total dose of 30 Gy at 1.0-cm depth had rectal bleeding and/or macroscopic hematuria. Complaints regarding sexual functioning were not found in this retrospective analysis. All patients remain free of disease after a median follow-up period of 127 months. CONCLUSION High dose-rate brachytherapy with a dose prescription at 0.5-cm depth can yield a promising rate of tumor control, with lower associated morbidity than that with a dose prescription at 1.0-cm depth in the treatment of posthysterectomy carcinoma in situ of the vagina.
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Affiliation(s)
- Yoko Teruya
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan
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Abstract
OBJECTIVE The aim of the study was to investigate the use of the cavitron ultrasonic surgical aspirator (CUSA) for the treatment of vulvar intraepithelial neoplasia (VIN) as it combines the advantage of laser removal of the superficial dermal layers without scars and the advantage of resection with collection of a pathological specimen. METHODS Between 1992 and 1998, 37 patients with VIN were treated using the CUSA. Charts were reviewed retrospectively. RESULTS The median age at diagnosis was 40 years. Eleven patients (30%) had been previously treated for VIN. Diagnosis was made by inspection before and after ascitic acid application, colposcopy, and multiple biopsies revealing VIN II in 8 patients (22%) and VIN III in 29 patients (78%). At least two quadrants of the vulva were involved in 16 cases (43%) and three or four quadrants in 12 cases (33%). Under anesthesia the CUSA was used to remove all lesions with a 1-cm margin. There were no complications except 1 admission for pain control. Healing was complete in 4 to 6 weeks and no patient developed scarring. Final pathology confirmed the preoperative diagnostic grade in 24 cases (65%), while upgrading to a higher dysplasia occurred in 4 patients (11%). A second treatment was necessary in 3 patients with widespread disease. Patients were followed for an average of 33 months. Thirteen recurrences (35%) developed after a median interval of 16 months. Recurrences were significantly (P = 0.004) more frequent if VIN involved hair-bearing tissue, 6 of 7 (86%) cases, in contrast to patients with disease confined to the labia minora and introitus, 7 of 30 (23%) cases. CONCLUSION CUSA is an acceptable treatment alternative for VIN confined to non-hair-bearing vulvar skin.
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Affiliation(s)
- Brigitte E Miller
- Section on Gynecologic Oncology, Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1065, USA.
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Abstract
Vulvar intraepithelial neoplasia and VAIN present unique challenges to the practicing gynecologist. VIN may produce distressing symptoms and undergo malignant conversion. A high index of suspicion and liberal use of biopsy are required to make the diagnosis. The approach to therapy for VIN has been reviewed. Treatment should be tailored to each individual patient and may include a period of expectant observation. Variations and combinations are used whenever necessary to preserve normal function and anatomy. Frequent surveillance is a must because recurrence rates are high, especially with multifocal disease in young women. Although VAIN accounts for less than 0.5% of lower genital tract neoplasia, the frequency of its detection is increasing, especially in younger patients. These lesions are most commonly found in the upper third of the vagina and are often multifocal in nature. The close proximity of the upper vagina to the rectum, bladder, and ureters makes treatment difficult. The occult invasion rate may be as high as 28%, and a wide variety of therapies are available. As is true for VIN, recurrence is not uncommon.
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Affiliation(s)
- R J Cardosi
- Department of Obstetrics and Gynecology, University of South Florida, Tampa 33606, USA.
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Abstract
As is true in neurosurgery and general surgery, the ultrasonic surgical aspirator is a powerful tool for the general gynecologist and gynecologic oncologist in assisting in the treatment and management of benign and malignant diseases. The physical properties of ultrasonic sound waves along with the composition of the tissues in question allow for safe, selective, and precise tissue resection. Although the ultrasonic surgical aspirator has had favorable results to date and future applications seem promising, the ultimate role of this device needs to be established with clinical trials.
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Affiliation(s)
- N S Horowitz
- Department of Obstetrics and Gynecology, Washington University Medical Center, St. Louis, Missouri 63110, USA.
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Dodge JA, Eltabbakh GH, Mount SL, Walker RP, Morgan A. Clinical features and risk of recurrence among patients with vaginal intraepithelial neoplasia. Gynecol Oncol 2001; 83:363-9. [PMID: 11606098 DOI: 10.1006/gyno.2001.6401] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The best treatment modality and factors affecting recurrence among women with vaginal intraepithelial neoplasia (VAIN) are yet to be determined. The aims of the current study were to describe the clinical features, results of treatment, and factors affecting recurrence among patients with VAIN. METHODS We conducted a retrospective review of 121 women with VAIN after confirming the histologic diagnosis. Patient demographics, clinical features, and results of therapy were recorded. Factors affecting recurrence were assessed using the odds ratio and the 95% confidence intervals among patients who were followed up for 7 months or more and had at least one posttreatment Papanicolaou smear. Significant univariate odds ratios were assessed jointly in a multivariate model with a stratified analysis. RESULTS The mean age of the patients was 35.0 (+/-17), 41% of the patients smoked, 39% had a history of human papillomavirus infection, 27% had history of sexually transmitted diseases, 22% had history of surgery for cervical intraepithelial neoplasia (CIN), and 23% had total hysterectomy. The upper third of the vagina was the most common site of VAIN and 61% of the lesions were multifocal. Associated cervical and vulvar intraepithelial neoplasia (VIN) were present in 65 and 10%, respectively. Recurrences of VAIN and progression to invasive vaginal cancer occurred in 33 and 2%, respectively. Recurrences following partial vaginectomy, laser, and 5-fluorouracil were 0, 38, and 59%, respectively (P = 0.0001). Multifocality and method of treatment were significant independent predictors of VAIN recurrences (odds ratio 3.3, 95% CI 1.2, 9.2, P = 0.02, and 22.4, 95% CI 1.3, 393.6, P = 0.001, respectively), with no interaction, based on a stratified analysis. CONCLUSIONS VAIN occurs most often among women with CIN or VIN, commonly involves the upper third of the vagina, and is often multifocal. Partial vaginectomy provides the highest cure rate and multifocality is a risk factor for recurrence.
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Affiliation(s)
- J A Dodge
- Department of Obstetrics and Gynecology, University of Vermont College of Medicine, Burlington, Vermont 05401, USA
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