Efficacy of Poly-Gamma-Glutamic Acid in Women with High-Risk Human Papillomavirus-Positive Vaginal Intraepithelial Neoplasia: an Observational Pilot Study

Non-Excisional Therapeutic Modalities In Vaginal Intraepithelial Neoplasia

Vaginal intraepithelial neoplasia is an uncommon Human Papilloma Virus-related premalignant lesion of the lower genital tract. There is still no consensus regarding its management. Therapeutic modalities include observation, laser ablation, topical agents, radiation and surgical approach. Due to the current increasing adherence to minimally invasive therapies the aim of this study is to identify and characterize non-excisional treatment modalities. Expectant management is the first therapeutical option in low-grade lesions management. Up to 81% of lesions through an expectant approach regressed spontaneously and most of them were low-grade lesions. In contrast, high-grade lesions, due to its higher potential to invasion progression and low regression rate, require treatment, which should be selected depending on its characteristics and the patient's preference. Laser ablation is suitable for multifocal lesions in sexually active young women with a cure rate up to 90% and recurrence rate up to 6.3%. Brachytherapy can be 71.4%-90% efficient with a maximum of 5.8% and 20% of persistence rate and recurrence rate, respectively. However, due to its toxicity, it should be reserved for selected cases only. Topical modalities for multifocal lesions, such as Imiquimod 5% and 5-Flouorouracil, have a good therapeutic effect, low pharmacological morbidity, and 25%-98% cure rate, 11.1%-75% persistence rate and 5.6%-94.4% recurrence rate.

Short-term clinical and immunologic effects of poly-gamma-glutamic acid (γ-PGA) in women with cervical intraepithelial neoplasia 1 (CIN 1): A multicenter, randomized, double blind, phase II trial

OBJECTIVE

The aim of this study was to investigate the short-term efficacy and safety of Poly-gamma-glutamic acid (γ-PGA) and the immunologic changes in patients with CIN 1.

METHODS

Participants were randomly assigned to one of two groups and orally treated with placebo or 1,500 mg of γ-PGA for 4 weeks. The primary endpoint of the study was histologic regression rate of CIN 1 at 12 weeks between γ-PGA and control groups. The secondary endpoints were HPV clearance and change in immune responses.

RESULT

From April 2013 to December 2015, 195 patients participated in the study. In the intention-to-treat analysis, 42 (42.4%) of the women who received γ-PGA experienced histologic remission versus 26 (27.1%) in the control group, with a statistically significant difference (p = 0.018). In the γ-PGA group, HPV clearance was found in 37 (43.5%) of 85 patients infected with high-risk HPV, showing a significant difference compared to the control group, in which 20 (26.7%) of 75 patients exhibited HPV clearance (p = 0.026). However, there was no significant difference between the two groups in the change of NK cell activity, major histocompatibility complex (MHC) class II CD8 count, and CD56 count.

CONCLUSION

γ-PGA showed a short-term therapeutic effect on CIN 1 and high-risk HPV infection. It is a non-invasive, promising oral medication for women with these conditions.

TRIAL REGISTRATION

Clinical Trials NCT01826045.

High-dose-rate brachytherapy for high-grade vaginal intraepithelial neoplasia: a dosimetric analysis

Purpose

Due to the rarity of vaginal intraepithelial neoplasia (VAIN), it is impossible to define the best treatment approach or to assess vaginal morbidity. However, brachytherapy (BT) could be a valuable choice for VAIN grade 3 (VAIN3). The aim of this paper was to report a single-institution study of the application of high-dose-rate BT and to evaluate clinical outcomes as well as to investigate the dose-effect relationship for vaginal stenosis.

Material and methods

We retrospectively collected hospital records and treatment plans of 14 consecutive women treated in our department from August 2010 to August 2016, with HDR-BT delivered using iridium-192 by a remote after-loading system. Doses in 3D-planned treatment based on computed tomography (CT) were prescribed in high-risk clinical target volume (HR-CTV) at the vaginal wall. Vaginal stenosis was defined as vaginal shortening/narrowing according to CTCAE4.1. The International Commission on Radiation Units & Measurements (ICRU) bladder and rectal points were used for dose report analysis. The posterior-inferior border of the symphysis points was used to derive reference points. The median age of the enrolled women was 60 years, and the median total radiation dose delivered was 35 Gy.

Results

During a median period of 15 days, the treatment was well tolerated, and no interruption was necessary. Acute toxicity was minimal, whereas late toxicity appeared in 4 patients as G2 and in 3 patients as G3 vaginal stenosis. Patients with stenosis G ≥ 2 received a higher median dose to the rectal point and were mainly over 60 years old.

Conclusions

Patients with VAIN3 seemed to benefit from BT. It is generally assumed that the vagina is radio-resistant, and no constraints have yet been set, but sexual dysfunction after BT is an important cause of long-term distress. Finding applicable dose limits to the vagina could improve patients’ quality of life.