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Malagón T, Franco EL, Tejada R, Vaccarella S. Epidemiology of HPV-associated cancers past, present and future: towards prevention and elimination. Nat Rev Clin Oncol 2024:10.1038/s41571-024-00904-z. [PMID: 38760499 DOI: 10.1038/s41571-024-00904-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/19/2024]
Abstract
Cervical cancer is the first cancer deemed amenable to elimination through prevention, and thus lessons from the epidemiology and prevention of this cancer type can provide information on strategies to manage other cancers. Infection with the human papillomavirus (HPV) causes virtually all cervical cancers, and an important proportion of oropharyngeal, anal and genital cancers. Whereas 20th century prevention efforts were dominated by cytology-based screening, the present and future of HPV-associated cancer prevention relies mostly on HPV vaccination and molecular screening tests. In this Review, we provide an overview of the epidemiology of HPV-associated cancers, their disease burden, how past and contemporary preventive interventions have shaped their incidence and mortality, and the potential for elimination. We particularly focus on the cofactors that could have the greatest effect on prevention efforts, such as parity and human immunodeficiency virus infection, as well as on social determinants of health. Given that the incidence of and mortality from HPV-associated cancers remain strongly associated with the socioeconomic status of individuals and the human development index of countries, elimination efforts are unlikely to succeed unless prevention efforts focus on health equity, with a commitment to both primary and secondary prevention.
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Affiliation(s)
- Talía Malagón
- Department of Oncology, McGill University, Montréal, Quebec, Canada.
- St Mary's Research Centre, Montréal West Island CIUSSS, Montréal, Quebec, Canada.
- Department of Epidemiology Biostatistics, and Occupational Health, McGill University, Montréal, Quebec, Canada.
| | - Eduardo L Franco
- Department of Oncology, McGill University, Montréal, Quebec, Canada
- Department of Epidemiology Biostatistics, and Occupational Health, McGill University, Montréal, Quebec, Canada
| | - Romina Tejada
- Department of Oncology, McGill University, Montréal, Quebec, Canada
- Department of Epidemiology Biostatistics, and Occupational Health, McGill University, Montréal, Quebec, Canada
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Gupta S, Ahuja S, Kalwaniya DS, Shamsunder S, Solanki S. Vulval premalignant lesions: a review article. Obstet Gynecol Sci 2024; 67:169-185. [PMID: 38262367 PMCID: PMC10948211 DOI: 10.5468/ogs.23274] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/20/2023] [Revised: 12/27/2023] [Accepted: 01/05/2024] [Indexed: 01/25/2024] Open
Abstract
Vulvar intraepithelial neoplasia (VIN) is a noninvasive squamous lesion that is a precursor of vulvar squamous cell cancer. Currently, no screening tests are available for detecting VIN, and a biopsy is performed to confirm the clinical diagnosis. Despite sharing many risk factors with cervical intraepithelial neoplasia, the diagnosis of VIN is poses challenges, contributing to its increasing prevalence. This study aimed to analyze the underlying risk factors that contribute to the development of VIN, identify specific populations at risk, and define appropriate treatment approaches. Differentiated VIN (dVIN) and usual VIN (uVIN) are the classifications of VIN. While dVIN is associated with other vulvar inflammatory disorders, such as lichen sclerosis, the more prevalent uVIN is associated with an underlying human papillomavirus infection. Patients with differentiated VIN have an increased risk of developing invasive malignancies. Few effective surveillance or management techniques exist for vulvar intraepithelial neoplasia, a preinvasive neoplasm of the vulva. For suspicious lesions, a thorough examination and focused biopsy are necessary. Depending on the specific needs of each patient, a combination of surgical and medical approaches can be used.
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Affiliation(s)
- Sumedha Gupta
- Department of Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi,
India
| | - Sana Ahuja
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi,
India
| | - Dheer Singh Kalwaniya
- Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi,
India
| | - Saritha Shamsunder
- Department of Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi,
India
| | - Shalu Solanki
- Department of Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi,
India
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Boonlikit S, Tangterdchanakit P. Multicentricity and the Risk of Recurrence/Persistence After Laser Vaporization for High-Grade Vulvar and Vaginal Intraepithelial Neoplasia. World J Oncol 2024; 15:90-99. [PMID: 38274717 PMCID: PMC10807919 DOI: 10.14740/wjon1743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/13/2023] [Indexed: 01/27/2024] Open
Abstract
Background The aim of the study was to assess the effect of multicentricity on the recurrence/persistence of high-grade vulvar intraepithelial neoplasia (VIN) and vaginal intraepithelial neoplasia (VAIN) after laser vaporization. Methods A retrospective cohort study was conducted on patients diagnosed with high-grade VIN/VAIN, who had undergone laser vaporization between 1997 and 2014. Recurrence/persistence rates and factors affecting recurrence/persistence were analyzed, and a life table analysis of recurrence-free intervals was conducted. Results Among the 65 patients, the recurrence/persistence rate following laser vaporization was 22.3 per 100 person-years, with a median time to recurrence/persistence of 31.2 months (95% confidence interval (CI): 0.0 - 71.9 months). Patients with multicentricity and unicentricity had a recurrence/persistence rate of 49.1 per 100 person-years, with a median time to recurrence/persistence of 11.4 months, and 7.4 per 100 person-years, with a median time to recurrence/persistence of 96.5 months, respectively (P = 0.0002). The difference in recurrence-free survival between the multicentricity and unicentricity groups was significant (P = 0.00035). Patients with multicentricity had a 4.7-fold higher risk of recurrence/persistence (hazard ratio (HR): 4.71, 95% CI: 1.87 - 11.88, P = 0.001). Multivariate analysis showed that multicentricity was an independent risk factor for recurrence/persistence (odds ratio (OR): 4.16, 95% CI: 1.56 - 11.06, P = 0.004). Conclusions Treatment of multicentric, high-grade VIN/VAIN with laser vaporization is strongly associated with treatment failure, with approximately half of patients experiencing recurrence/persistence.
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Affiliation(s)
- Sathone Boonlikit
- Department of Obstetrics and Gynecology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Punyacha Tangterdchanakit
- Department of Obstetrics and Gynecology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
- Department of Obstetrics and Gynecology, Pakkred Hospital, Nonthaburi, Thailand
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Xavier J, Figueiredo R, Vieira-Baptista P. Vulvar High-Grade Squamous Intraepithelial Lesion and the Risk of Recurrence and Progression to Cancer. J Low Genit Tract Dis 2023; 27:125-130. [PMID: 36794761 DOI: 10.1097/lgt.0000000000000726] [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: 02/17/2023]
Abstract
OBJECTIVE This study aimed to analyze which clinical characteristics are associated with recurrence and progression of vulvar high-grade squamous intraepithelial lesion (vHSIL). MATERIALS AND METHODS This was a retrospective cohort study, including all women with vHSIL followed in 1 center between 2009 and 2021. Women with a concomitant diagnosis of invasive vulvar cancer were excluded. Medical records were reviewed for demographic factors, clinical data, treatment type, histopathologic results, and follow-up information. RESULTS A total of 30 women were diagnosed with vHSIL. The median follow-up time was 4 years (range = 1-12 years). More than half of the women (56.7% [17/30]) underwent excisional treatment, whereas 26.7% (8/30) underwent combined (excisional plus medical) treatment, and 16.7% (5/30) only had medical treatment (imiquimod). Six women had recurrence of vHSIL (20% [6/30]), with a mean time to recurrence of 4.7 ± 2.88 years. The progression rate to invasive vulvar cancer was 13.3% (4/30), with a mean time to progression of 1.8 ± 0.96 years. Multifocal disease was associated with progression to vulvar cancer ( p = .035). We did not identify other variables associated with progression; no differences were found between women with and without recurrences. CONCLUSIONS Multifocality of the lesions was the only variable associated with progression to vulvar cancer. This reinforces the idea that these lesions are a challenge in both treatment and surveillance, involving a more difficult therapeutic decision with greater associated morbidity.
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Affiliation(s)
- Joana Xavier
- Department of Gynaecology, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Rita Figueiredo
- Department of Gynaecology, Centro Hospitalar Universitário São João, Porto, Portugal
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Preti M, Joura E, Vieira-Baptista P, Van Beurden M, Bevilacqua F, Bleeker MCG, Bornstein J, Carcopino X, Chargari C, Cruickshank ME, Erzeneoglu BE, Gallio N, Heller D, Kesic V, Reich O, Stockdale CK, Esat Temiz B, Woelber L, Planchamp F, Zodzika J, Querleu D, Gultekin M. 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 statements on pre-invasive vulvar lesions. Int J Gynecol Cancer 2022; 32:830-845. [PMID: 35728950 PMCID: PMC9279839 DOI: 10.1136/ijgc-2021-003262] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/16/2022] 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 vulvar squamous intraepithelial neoplasia, vulvar Paget disease in situ, and melanoma in situ. For differentiated vulvar intraepithelial neoplasia (dVIN), an excisional procedure must always be adopted. For vulvar high-grade squamous intraepithelial lesion (VHSIL), both excisional procedures and ablative ones can be used. The latter can be considered for anatomy and function preservation and must be preceded by several representative biopsies to exclude malignancy. Medical treatment (imiquimod or cidofovir) can be considered for VHSIL. Recent studies favor an approach of using imiquimod in vulvar Paget's disease. Surgery must take into consideration that the extension of the disease is usually wider than what is evident in the skin. A 2 cm margin is usually considered necessary. A wide local excision with 1 cm free surgical margins is recommended for melanoma in situ. Following treatment of pre-invasive vulvar lesions, women should be seen on a regular basis for careful clinical assessment, including biopsy of any suspicious area. Follow-up should be modulated according to the risk of recurrence (type of lesion, patient age and immunological conditions, other associated lower genital tract lesions).
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Affiliation(s)
- Mario Preti
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Elmar Joura
- Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Pedro Vieira-Baptista
- Hospital Lusiadas Porto, Porto, Portugal
- Lower Genital Tract Unit, Centro Hospitalar de São João, Porto, Portugal
| | - Marc Van Beurden
- Centre for Gynecological Oncology Amsterdam, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Maaike C G Bleeker
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Jacob Bornstein
- Galilee Medical Center and Azrieli Faculty of Medicine, Bar-Ilan, Israel
| | - Xavier Carcopino
- Department of Obstetrics and Gynaecology, Hôpital Nord, APHM, Aix-Marseille University (AMU), Univ Avignon, CNRS, IRD, IMBE UMR 7263, 13397, Marseille, France
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Paris, France
| | | | - Bilal 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
| | - Debra Heller
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Vesna Kesic
- Department of Obstetrics and Gynecology, University of Belgrade, Belgrade, Serbia
| | - Olaf Reich
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Colleen K Stockdale
- Department of Obstetrics & Gynecology, University of Iowa, Iowa City, Iowa, USA
| | - 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, Germany
| | | | - Jana Zodzika
- Department of Obstetrics and Gynaecology Rīga Stradiņš university, Riga, Latvia
| | - Denis Querleu
- Department of Obstetrics and Gynecologic Oncology, University Hospital, Strasbourg, France
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Preti M, Joura E, Vieira-Baptista P, Van Beurden M, Bevilacqua F, Bleeker MCG, Bornstein J, Carcopino X, Chargari C, Cruickshank ME, Erzeneoglu BE, Gallio N, Heller D, Kesic V, Reich O, Stockdale CK, Temiz BE, Woelber L, Planchamp F, Zodzika J, Querleu D, Gultekin M. 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 Statements on Pre-invasive Vulvar Lesions. J Low Genit Tract Dis 2022; 26:229-244. [PMID: 35763611 PMCID: PMC9232287 DOI: 10.1097/lgt.0000000000000683] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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 vulvar squamous intraepithelial neoplasia, vulvar Paget disease in situ, and melanoma in situ. For differentiated vulvar intraepithelial neoplasia (dVIN), an excisional procedure must always be adopted. For vulvar high-grade squamous intraepithelial lesion (VHSIL), both excisional procedures and ablative ones can be used. The latter can be considered for anatomy and function preservation and must be preceded by several representative biopsies to exclude malignancy. Medical treatment (imiquimod or cidofovir) can be considered for VHSIL. Recent studies favor an approach of using imiquimod in vulvar Paget's disease. Surgery must take into consideration that the extension of the disease is usually wider than what is evident in the skin. A 2 cm margin is usually considered necessary. A wide local excision with 1 cm free surgical margins is recommended for melanoma in situ. Following treatment of pre-invasive vulvar lesions, women should be seen on a regular basis for careful clinical assessment, including biopsy of any suspicious area. Follow-up should be modulated according to the risk of recurrence (type of lesion, patient age and immunological conditions, other associated lower genital tract lesions).
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Affiliation(s)
- Mario Preti
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Elmar Joura
- Department of Gynecology and Gynecologic Oncology, Comprehensive Cancer; Center, Medical University of Vienna, Vienna, Austria
| | - Pedro Vieira-Baptista
- Hospital Lusiadas Porto, Porto, Portugal; Lower Genital Tract Unit, Centro Hospitalar de São João, Porto, Portugal
| | - Marc Van Beurden
- Centre for Gynecological Oncology Amsterdam, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Maaike C. G. Bleeker
- Department of Pathology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jacob Bornstein
- Galilee Medical Center and Azrieli Faculty of Medicine, Bar-Ilan, Israel
| | - Xavier Carcopino
- Department of Obstetrics and Gynaecology, Hôpital Nord, APHM, Aix-Marseille University (AMU), Univ Avignon, CNRS, IRD, IMBE UMR 7263, 13397, Marseille, France
| | - Cyrus Chargari
- Radiation Therapy, Gustave Roussy Cancer Campus, Paris, France
| | - Margaret E. Cruickshank
- Aberdeen Centre for Women’s Health Research, University of Aberdeen, Aberdeen, United Kingdom
| | - Bilal 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
| | | | - Vesna Kesic
- Department of Obstetrics and Gynecology, University of Belgrade, Belgrade, Serbia
| | - 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, Dysplasia Center Hamburg, Jerusalem Hospital, Hamburg, Germany
| | | | - Jana Zodzika
- Department of Obstetrics and Gynaecology Rīga Stradiņš university, Riga, Latvia
| | - Denis Querleu
- Department of Obstetrics and Gynecologic Oncology, University Hospital, Strasbourg, France; Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Murat Gultekin
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Jamieson A, Tse SS, Brar H, Sadownik LA, Proctor L. A Systematic Review of Risk Factors for Development, Recurrence, and Progression of Vulvar Intraepithelial Neoplasia. J Low Genit Tract Dis 2022; 26:140-146. [PMID: 35249976 DOI: 10.1097/lgt.0000000000000662] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 11/25/2022]
Abstract
OBJECTIVE Vulvar intraepithelial neoplasia (VIN) is a premalignant condition with high recurrence rates despite treatment. Vulvar intraepithelial neoplasia develops through separate etiologic pathways relative to the presence or absence of human papillomavirus (HPV) and TP53 mutations. This systematic review was conducted (1) to identify historical risk factors for the development, recurrence, and progression of VIN and (2) to critique these risk factors in the context of advances made in the stratification of VIN based on HPV or TP53 status. MATERIALS AND METHODS A systematic search was performed on MEDLINE, Embase, Cochrane Database, PsychInfo, and CINAHL from inception to July 5, 2021. Three gynecologic oncologists independently evaluated the eligibility of studies based on predetermined inclusion and exclusion criteria, abstracted data, and then analyzed the relevant data. RESULTS A total of 1,969 studies (involving 6,983 patients) were identified. Twenty-nine studies met inclusion criteria. The quality of evidence was low; primarily level 2b (Oxford Centre for Evidence-Based Medicine). Risk factors associated with the development of VIN include: smoking and coexisting vulvar dermatoses. Risk factors associated with recurrence include: smoking, multifocal disease, and positive surgical margins. Recent studies identified the presence of differentiated VIN/TP53 mutation as the most significant risk factor for both VIN recurrence and malignant progression. CONCLUSIONS The current body of evidence consists primarily of small retrospective observational studies. Well-designed retrospective case-control series and/or prospective observational studies are urgently needed. Ideally, future studies will collect standardized data regarding associated risk factors and stratify women with VIN based on HPV and TP53 status.
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Affiliation(s)
| | - Samantha S Tse
- British Columbia Centre for Vulvar Health, Vancouver, Canada
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Hurt CN, Nedjai B, Alvarez-Mendoza C, Powell N, Tristram A, Jones S. Combined HPV 16 E2 and L1 methylation predict response to treatment with cidofovir and imiquimod in patients with vulval intraepithelial neoplasia. Cancer Biomark 2022; 35:143-153. [PMID: 35912731 PMCID: PMC9661315 DOI: 10.3233/cbm-210448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 06/24/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Topical cidofovir and imiquimod can effectively treat approximately 55% of patients with vulval intraepithelial neoplasia (VIN), thus avoiding the need for surgery. Human papillomavirus (HPV) E2 gene methylation predicts response to treatment but a methylation measurement is only obtainable in approximately 50% of patients. OBJECTIVE This work aimed to determine if the applicability and predictive power of the E2 methylation assay could be improved by combining it with the components of a host and viral DNA methylation panel (S5) that has been found to predict disease progression in patients with cervical intraepithelial neoplasia. METHODS HPV E2 methylation and S5 classifier score were measured in fresh tissue samples collected pre-treatment from 132 patients with biopsy-proven VIN grade 3 who participated in a multicentre clinical trial and were randomised to treatment with cidofovir or imiquimod. RESULTS Combining HPV16 E2 and HPV16 L1 methylation provides a biomarker that is both predictive of response to topical treatment and that can produce a clinically applicable result for all patients. Patients with HPV 16 L1^high and HPV 16 E2^high (36/132 (27.3%)) were more likely to respond to treatment with cidofovir (12/15 (80.0%)) than imiquimod (9/21 (42.9%)) (p= 0.026). Patients with HPV 16 L1^low or HPV 16 E2^low (including those with no HPV/unassessable methylation) were more likely to respond to imiquimod: 23/50 (46.0%) vs 31/46 (67.4%) (p= 0.035). CONCLUSIONS Combined HPV E2 and L1 methylation is a potential predictive marker in treatment for all patients with VIN. These findings justify validation in a prospective trial.
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Affiliation(s)
| | - Belinda Nedjai
- Centre for Trials Research, Cardiff University, Cardiff, UK
- Wolfson Institute of Preventive Medicine, Centre for Cancer Prevention, Queen Mary University of London, London, UK
| | | | - Ned Powell
- Centre for Medical Education, Cardiff University, Cardiff, UK
| | | | - Sadie Jones
- School of Medicine, Cardiff University, Cardiff, UK
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Voss FO, Thuijs NB, Vermeulen RFM, Wilthagen EA, van Beurden M, Bleeker MCG. The Vulvar Cancer Risk in Differentiated Vulvar Intraepithelial Neoplasia: A Systematic Review. Cancers (Basel) 2021; 13:6170. [PMID: 34944788 PMCID: PMC8699429 DOI: 10.3390/cancers13246170] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/02/2021] [Accepted: 12/04/2021] [Indexed: 01/04/2023] Open
Abstract
Differentiated vulvar intraepithelial neoplasia (dVIN) is the precursor of human papillomavirus (HPV)-independent vulvar squamous cell carcinoma (VSCC). Given the rare incidence of dVIN, limited information on the exact cancer risk is available. We systematically reviewed the primary and recurrent VSCC risk in patients with dVIN, as well as the time to cancer development. A systematic search was performed up to July 2021 according to the PRISMA guidelines. Five reviewers independently screened articles on title, abstract and full text, followed by critical appraisal of selected articles using the Quality in Prognostic Studies (QUIPS) tool. Of the 455 screened articles, 7 were included for analysis. The absolute risk for primary VSCC in dVIN varied between 33 and 86%, with a median time to progression to VSCC of 9–23 months. The risk of developing recurrent VSCC in dVIN associated VSCC was 32–94%, with a median time to recurrence of 13–32 months. In conclusion, patients with dVIN have a high risk of developing primary and recurrent VSCC with a short time to cancer progression. Increased awareness, timely recognition, aggressive treatment and close follow-up of HPV-independent vulvar conditions including dVIN is therefore strongly recommended.
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Green N, Adedipe T, Dmytryshyn J, Preti M, Selk A. Management of Vulvar Cancer Precursors: A Survey of the International Society for the Study of Vulvovaginal Disease. J Low Genit Tract Dis 2020; 24:387-91. [PMID: 32986387 DOI: 10.1097/LGT.0000000000000559] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to determine how experts treat vulvar high-grade squamous intraepithelial neoplasia (VHSIL) and differentiated vulvar intraepithelial neoplasia (dVIN). METHOD A 26-question survey was designed through a literature review, reviewed by the Survey Committee of the International Society for the Study of Vulvovaginal Disease (ISSVD), and distributed to all ISSVD members via e-mail in January 2019. RESULTS Overall, 90 of 441 physician members consented to participate and 78 of 90 were eligible to complete the survey. Most respondents were gynecologists (77%), followed by dermatologists (12%). Forty-five percent responded that their pathology was being reported using the 2015 ISSVD terminology of vulvar squamous intraepithelial lesions. The most common first-line treatments were as follows: unifocal VHSIL-excision (65%), multifocal VHSIL-imiquimod 5% (45%), VHSIL in a hair-bearing area-excision (69%), and clitoral disease-imiquimod 5% (47%). In the recurrent VHSIL, excision was favored (28%), followed by imiquimod 5% (26%) and laser (19%). Differentiated vulvar intraepithelial neoplasia was most often first treated with excision (82%), and more patients were referred to gynecologic oncology. Most patients were seen in follow-up at 3 months (range: 1 week-6 months). Sixty-seven respondents provided 26 different ways to follow treated patients, which were most commonly every 6 months for 2 years and then yearly (25%), followed by every 6 months indefinitely (18%). CONCLUSIONS Treatment of VHSIL and dVIN varies among vulvar experts with excision being the most common treatment, except in multifocal VHSIL where imiquimod is commonly used. There is wide variation in how patients are followed after treatment.
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Bakker NAM, Rotman J, van Beurden M, Zijlmans HJM, van Ruiten M, Samuels S, Nuijen B, Beijnen J, De Visser K, Haanen J, Schumacher T, de Gruijl TD, Jordanova ES, Kenter GG, van den Berg JH, van Trommel NE. HPV-16 E6/E7 DNA tattoo vaccination using genetically optimized vaccines elicit clinical and immunological responses in patients with usual vulvar intraepithelial neoplasia (uVIN): a phase I/II clinical trial. J Immunother Cancer 2021; 9:jitc-2021-002547. [PMID: 34341131 PMCID: PMC8330588 DOI: 10.1136/jitc-2021-002547] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 11/23/2022] Open
Abstract
Background Usual vulvar intraepithelial neoplasia (uVIN) is a premalignancy caused by persistent infection with high-risk types of human papillomavirus (HPV), mainly type 16. Even though different treatment modalities are available (eg, surgical excision, laser evaporation or topical application of imiquimod), these treatments can be mutilating, patients often have recurrences and 2%–8% of patients develop vulvar carcinoma. Therefore, immunotherapeutic strategies targeting the pivotal oncogenic HPV proteins E6 and E7 are being explored to repress carcinogenesis. Method In this phase I/II clinical trial, 14 patients with HPV16+ uVIN were treated with a genetically enhanced DNA vaccine targeting E6 and E7. Safety, clinical responses and immunogenicity were assessed. Patients received four intradermal HPV-16 E6/E7 DNA tattoo vaccinations, with a 2-week interval, alternating between both upper legs. Biopsies of the uVIN lesions were taken at screening and +3 months after last vaccination. Digital photography of the vulva was performed at every check-up until 12 months of follow-up for measurement of the lesions. HPV16-specific T-cell responses were measured in blood over time in ex vivo reactivity assays. Results Vaccinations were well tolerated, although one grade 3 suspected unexpected serious adverse reaction was observed. Clinical responses were observed in 6/14 (43%) patients, with 2 complete responses and 4 partial responses (PR). 5/14 patients showed HPV-specific T-cell responses in blood, measured in ex vivo reactivity assays. Notably, all five patients with HPV-specific T-cell responses had a clinical response. Conclusions Our results indicate that HPV-16 E6/E7 DNA tattoo vaccination is a biologically active and safe treatment strategy in patients with uVIN, and suggest that T-cell reactivity against the HPV oncogenes is associated with clinical benefit. Trial registration number NTR4607.
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Affiliation(s)
- Noor Alida Maria Bakker
- Division of Molecular Oncology & Immunology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Division of Tumor Biology and Immunology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Oncode Institute, Utrecht, The Netherlands
| | - Jossie Rotman
- Center for Gynecologic Oncology Amsterdam (CGOA), The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Center for Gynecological Oncology Amsterdam (CGOA), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marc van Beurden
- Center for Gynecologic Oncology Amsterdam (CGOA), The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Henry J Maa Zijlmans
- Center for Gynecologic Oncology Amsterdam (CGOA), The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Maartje van Ruiten
- Center for Gynecologic Oncology Amsterdam (CGOA), The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Sanne Samuels
- Center for Gynecologic Oncology Amsterdam (CGOA), The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Center for Gynecological Oncology Amsterdam (CGOA), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bastiaan Nuijen
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Jos Beijnen
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Karin De Visser
- Division of Tumor Biology and Immunology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Oncode Institute, Utrecht, The Netherlands
| | - John Haanen
- Division of Molecular Oncology & Immunology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Ton Schumacher
- Division of Molecular Oncology & Immunology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Oncode Institute, Utrecht, The Netherlands
| | - Tanja D de Gruijl
- Department of Medical Oncology, -Cancer Center Amsterdam, Amsterdam UMC-Vrije Universiteit, Amsterdam, The Netherlands
| | - Ekaterina S Jordanova
- Center for Gynecological Oncology Amsterdam (CGOA), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gemma G Kenter
- Center for Gynecologic Oncology Amsterdam (CGOA), The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Center for Gynecological Oncology Amsterdam (CGOA), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Joost H van den Berg
- Division of Molecular Oncology & Immunology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Nienke E van Trommel
- Center for Gynecologic Oncology Amsterdam (CGOA), The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
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12
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Yap J, Slade D, Goddard H, Dawson C, Ganesan R, Velangi S, Sahu B, Kaur B, Hughes A, Luesley D. Sinecatechins ointment as a potential novel treatment for usual type vulval intraepithelial neoplasia: a single-centre double-blind randomised control study. BJOG 2021; 128:1047-1055. [PMID: 33075197 DOI: 10.1111/1471-0528.16574] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To compare the safety and efficacy of 10% sinecatechins (Veregen® ) ointment against placebo in the treatment of usual type vulvar intraepithelial neoplasia (uVIN). DESIGN A Phase II double-blind randomised control trial. SETTING A tertiary gynaecological oncology referral centre. POPULATION All women diagnosed with primary and recurrent uVIN. METHODS Eligible patients were randomised 1:1 to receive either sinecatechins or placebo ointment (applied three times daily for 16 weeks) and were followed up at 2, 4, 8, 16, 32 and 52 weeks. MAIN OUTCOME MEASURES The primary outcome measure, recorded at 16 and 32 weeks, was histological response (HR). Secondary outcome measures included clinical (CR) response, toxicity, quality of life and pain scores. RESULTS There was no observed difference in HR between the two arms. However, of the 26 patients who were randomised, all 13 patients who received sinecatechins showed either complete (n = 5) or partial (n = 8) CR, when best CR was evaluated. In placebo group, three patients had complete CR, two had partial CR, six had stable disease and two were lost to follow up. Patients in the sinecatechins group showed a statistically significant improvement in best observed CR as compared with the placebo group (P = 0.002). There was no difference in toxicity reported in either group. CONCLUSION Although we did not observe a difference in HR between the two treatment arms, we found that 10% sinecatechins application is safe and shows promise in inducing clinical resolution of uVIN lesions and symptom improvement, thus warranting further investigation in a larger multicentre study. TWEETABLE ABSTRACT A randomised control study indicating that sinecatechins ointment may be a novel treatment for uVIN.
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Affiliation(s)
- J Yap
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Pan Birmingham Gynaecological Cancer Centre, City Hospital, Birmingham, UK
| | - D Slade
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - H Goddard
- Pan Birmingham Gynaecological Cancer Centre, City Hospital, Birmingham, UK
| | - C Dawson
- Department of Microbiology & Infection, Warwick Medical School, University of Warwick, Coventry, UK
| | - R Ganesan
- Department of Histopathology, Birmingham Women's NHS Foundation Trust, Birmingham, UK
| | - S Velangi
- Department of Dermatology, Queen Elizabeth Hospital, Birmingham, UK
| | - B Sahu
- Department of Obstetrics and Gynaecology, The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - B Kaur
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - A Hughes
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - D Luesley
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Pan Birmingham Gynaecological Cancer Centre, City Hospital, Birmingham, UK
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13
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Yap JKW, Kehoe ST, Woodman CBJ, Dawson CW. The Major Constituent of Green Tea, Epigallocatechin-3-Gallate (EGCG), Inhibits the Growth of HPV18-Infected Keratinocytes by Stimulating Proteasomal Turnover of the E6 and E7 Oncoproteins. Pathogens 2021; 10:459. [PMID: 33920477 DOI: 10.3390/pathogens10040459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/19/2021] [Accepted: 04/02/2021] [Indexed: 11/17/2022] Open
Abstract
Epigallocatechin-3-gallate (EGCG), the primary bioactive polyphenol in green tea, has been shown to inhibit the growth of human papilloma virus (HPV)-transformed keratinocytes. Here, we set out to examine the consequences of EGCG treatment on the growth of HPV18-immortalised foreskin keratinocytes (HFK-HPV18) and an authentic HPV18-positive vulvar intraepithelial neoplasia (VIN) clone, focusing on its ability to influence cell proliferation and differentiation and to impact on viral oncogene expression and virus replication. EGCG treatment was associated with degradation of the E6 and E7 oncoproteins and an upregulation of their associated tumour suppressor genes; consequently, keratinocyte proliferation was inhibited in both monolayer and organotypic raft culture. While EGCG exerted a profound effect on cell proliferation, it had little impact on keratinocyte differentiation. Expression of the late viral protein E4 was suppressed in the presence of EGCG, suggesting that EGCG was able to block productive viral replication in differentiating keratinocytes. Although EGCG did not alter the levels of E6 and E7 mRNA, it enhanced the turnover of the E6 and E7 proteins. The addition of MG132, a proteasome inhibitor, to EGCG-treated keratinocytes led to the accumulation of the E6/E7 proteins, showing that EGCG acts as an anti-viral, targeting the E6 and E7 proteins for proteasome-mediated degradation.
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14
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Thuijs NB, van Beurden M, Bruggink AH, Steenbergen RDM, Berkhof J, Bleeker MCG. Vulvar intraepithelial neoplasia: Incidence and long-term risk of vulvar squamous cell carcinoma. Int J Cancer 2020; 148:90-98. [PMID: 32638382 PMCID: PMC7689827 DOI: 10.1002/ijc.33198] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/15/2020] [Accepted: 06/25/2020] [Indexed: 12/17/2022]
Abstract
The risk of vulvar squamous cell carcinoma (VSCC) in patients with high-grade vulvar intraepithelial neoplasia (VIN) is considered lower in high-grade squamous intraepithelial lesion (HSIL) compared to differentiated VIN (dVIN), but studies are limited. Our study investigated both the incidence of high-grade VIN and the cumulative incidence of VSCC in patients with HSIL and dVIN separately. A database of women diagnosed with high-grade VIN between 1991 and 2011 was constructed with data from the Dutch Pathology Registry (PALGA). The European standardized incidence rate (ESR) and VSCC risk were calculated, stratified for HSIL and dVIN. The effects of type of VIN (HSIL vs dVIN), age and lichen sclerosis (LS) were estimated by Cox regression. In total, 1148 patients were diagnosed with high-grade VIN between 1991 and 2011. Between 1991-1995 and 2006-2011, the ESR of HSIL increased from 2.39 (per 100 000 woman-years) to 3.26 and the ESR of dVIN increased from 0.02 to 0.08. The 10-year cumulative VSCC risk was 10.3%; 9.7% for HSIL and 50.0% for dVIN (log rank P < .001). Type of VIN, age and presence of LS were independent risk factors for progression to VSCC, with hazard ratios of 3.0 (95% confidence interval [CI] 1.3-7.1), 2.3 (95% CI 1.5-3.4) and 3.1 (95% CI 1.8-5.3), respectively. The incidence of high-grade VIN is rising. Because of the high cancer risk in patients with dVIN, better identification and timely recognition are urgently needed.
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Affiliation(s)
- Nikki B Thuijs
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Pathology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marc van Beurden
- Antoni van Leeuwenhoek hospital, Department of Gynaecology, Amsterdam, The Netherlands
| | | | - Renske D M Steenbergen
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Pathology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Johannes Berkhof
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Maaike C G Bleeker
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Pathology, Cancer Center Amsterdam, Amsterdam, The Netherlands
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15
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Nugent EK, Nugent AK, Nugent R, Nugent C, Nugent K. The Management of Women's Health Care by Internists With a Focus on the Utility of Ultrasound. Am J Med Sci 2020; 360:435-446. [PMID: 32586640 DOI: 10.1016/j.amjms.2020.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 01/06/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 11/18/2022]
Abstract
Adult women require routine care for the acute and chronic health problems found in both sexes, and they require specialized care for women's health problems, including disease prevention, disease screening, and disease management. Internists should direct primary care and participate in specialized care and to the extent possible follow guidelines published by various professional organizations. They should understand the use of ultrasound in breast cancer screening, the management of pregnancy, and other gynecologic problems, including vaginal bleeding, pelvic pain, and investigation for pelvic malignancy. Finally, all management decisions need discussions on the potential benefit or harm in each step of a woman's care with an emphasis on personal preferences.
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Affiliation(s)
| | - Anne K Nugent
- University of Kansas Medical Center, Kansas City, Kansas
| | | | - Connie Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas.
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16
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Ahmed AA, Adam Essa ME. Epigenetic alterations in female urogenital organs cancer: Premise, properties, and perspectives. Scientific African 2020. [DOI: 10.1016/j.sciaf.2020.e00318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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17
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Zhao S, Liu D, Shi W, Kang Y, Li Q, Liu Q, Chen M, Li F, Su J, Zhang Y, Wu L. Efficacy of a New Therapeutic Option for Vulvar Intraepithelial Neoplasia: Superficial Shaving Combined With Photodynamic Therapy. Lasers Surg Med 2019; 52:488-495. [DOI: 10.1002/lsm.23185] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2019] [Indexed: 01/10/2023]
Affiliation(s)
- Shuang Zhao
- Department of Dermatology, Xiangya HospitalCentral South University 87 Xiangya Road Changsha 410008 Hunan China
- Hunan Key Laboratory of Skin Cancer and Psoriasis Changsha 410008 Hunan China
| | - Dihui Liu
- Department of Dermatology, Xiangya HospitalCentral South University 87 Xiangya Road Changsha 410008 Hunan China
| | - Wei Shi
- Department of Dermatology, Xiangya HospitalCentral South University 87 Xiangya Road Changsha 410008 Hunan China
| | - Yanan Kang
- Department of Obstetrics and Gynecology, Xiangya HospitalCentral South University 87 Xiangya Road Changsha 410008 Hunan China
| | - Qingling Li
- Department of Pathology, Xiangya HospitalCentral South University 87 Xiangya Road Changsha 410008 Hunan China
| | - Queping Liu
- Department of Pathology, Xiangya HospitalCentral South University 87 Xiangya Road Changsha 410008 Hunan China
| | - Mingliang Chen
- Department of Dermatology, Xiangya HospitalCentral South University 87 Xiangya Road Changsha 410008 Hunan China
| | - Fangfang Li
- Department of Dermatology, Xiangya HospitalCentral South University 87 Xiangya Road Changsha 410008 Hunan China
- Hunan Key Laboratory of Skin Cancer and Psoriasis Changsha 410008 Hunan China
| | - Juan Su
- Department of Dermatology, Xiangya HospitalCentral South University 87 Xiangya Road Changsha 410008 Hunan China
- Hunan Key Laboratory of Skin Cancer and Psoriasis Changsha 410008 Hunan China
| | - Yu Zhang
- Department of Obstetrics and Gynecology, Xiangya HospitalCentral South University 87 Xiangya Road Changsha 410008 Hunan China
- Gynecological Oncology Research and Engineering Center of Hunan ProvinceChangsha 410008 Hunan China
| | - Lisha Wu
- Department of Dermatology, Xiangya HospitalCentral South University 87 Xiangya Road Changsha 410008 Hunan China
- Hunan Key Laboratory of Skin Cancer and Psoriasis Changsha 410008 Hunan China
- National Clinical Research Center for Geriatric Disorders, Xiangya HospitalCentral South University Changsha 410008 Hunan China
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18
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Rogers AC, Brophy M, Walsh TA, Hanson RP, Brannigan AE. Modified Turnbull-Cutait anastomosis with fasciocutaneous flap reconstruction for radical excision of vulvar and anal intraepithelial neoplasia. Tech Coloproctol 2019; 23:493-496. [PMID: 31197521 DOI: 10.1007/s10151-019-02009-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 05/13/2019] [Indexed: 11/29/2022]
Affiliation(s)
- A C Rogers
- Department of General and Colorectal Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
| | - M Brophy
- Department of General and Colorectal Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
| | - T A Walsh
- Department of General and Colorectal Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
| | - R P Hanson
- Department of General and Colorectal Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
| | - A E Brannigan
- Department of General and Colorectal Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
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19
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Stankiewicz Karita HC, Hauge K, Magaret A, Mao C, Schouten J, Grieco V, Xi LF, Galloway DA, Madeleine MM, Wald A. Effect of Human Papillomavirus Vaccine to Interrupt Recurrence of Vulvar and Anal Neoplasia (VIVA): A Trial Protocol. JAMA Netw Open 2019; 2:e190819. [PMID: 30977845 PMCID: PMC6481452 DOI: 10.1001/jamanetworkopen.2019.0819] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
IMPORTANCE Human papillomavirus (HPV), particularly HPV type 16, causes most anal and vulvar high-grade squamous intraepithelial lesions (HSIL), which are precursors to cancer. After initial treatment of HSIL, more than 30% of patients will have disease recurrence, with even higher recurrence among HIV-positive individuals and men who have sex with men. Recurrences can be debilitating and lead to significant morbidity and medical expense. Observational studies suggest a possible therapeutic benefit of the licensed HPV vaccines in reducing recurrent lesions in previously infected persons. OBJECTIVE To test whether the licensed prophylactic HPV vaccine (Gardasil-9) can reduce the risk of HSIL recurrence by 50% in previously unvaccinated individuals recently treated for anal or vulvar HSIL. DESIGN, SETTING, AND PARTICIPANTS This is a trial protocol for a randomized, double-blind, placebo-controlled, proof-of-concept clinical trial. Eligible participants are aged 27 to 69 at study start and have not received prior HPV vaccination, have had anal or vulvar HSIL diagnosed on or after January 1, 2014, and have no evidence of HSIL recurrence at screening. Persons infected with HIV are eligible for the study provided they are receiving antiretroviral therapy. Target enrollment is 345 individuals. The primary outcome is time to histopathologically confirmed recurrence of HSIL. Differences in the risk for recurrence of HSIL will be evaluated using Cox proportional hazard models. Additional analyses include (1) frequency of HSIL recurrence; (2) role of HPV antibodies in deterring recurrence; (3) role of HPV persistence in recurrence, as measured by HPV genotype or HPV-16 variant lineage determined using swab samples collected at months 0, 18, and 36; and (4) incidence of adverse events. The study will be conducted at the University of Washington Virology Research Clinic from 2017 through 2022. Participants will be followed up for up to 36 months in the clinic, and up to 42 months by telephone. DISCUSSION Management of persistent or rapidly recurring anogenital HSIL remains challenging. Results from this study will provide evidence on whether incorporating the nonavalent HPV vaccine into routine care can decrease recurrence of anal and vulvar HSIL. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03051516.
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Affiliation(s)
| | - Kirsten Hauge
- Department of Medicine, University of Washington, Seattle
| | - Amalia Magaret
- Department of Biostatistics, University of Washington, Seattle
- Division of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Laboratory Medicine, University of Washington, Seattle
| | - Constance Mao
- Department of Obstetrics and Gynecology, University of Washington, Seattle
| | - Jeffrey Schouten
- Department of Medicine, University of Washington, Seattle
- Division of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Surgery, University of Washington, Seattle
| | - Verena Grieco
- Department of Pathology, University of Washington, Seattle
| | - Long Fu Xi
- Department of Epidemiology, University of Washington, Seattle
| | - Denise A Galloway
- Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Margaret M Madeleine
- Department of Epidemiology, University of Washington, Seattle
- Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Anna Wald
- Department of Medicine, University of Washington, Seattle
- Division of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Laboratory Medicine, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
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20
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Hurt CN, Jones SEF, Madden T, Fiander A, Nordin AJ, Naik R, Powell N, Carucci M, Tristram A. Recurrence of vulval intraepithelial neoplasia following treatment with cidofovir or imiquimod: results from a multicentre, randomised, phase II trial (RT3VIN). BJOG 2018; 125:1171-1177. [PMID: 29336101 PMCID: PMC6055842 DOI: 10.1111/1471-0528.15124] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the recurrence rates after complete response to topical treatment with either cidofovir or imiquimod for vulval intraepithelial neoplasia (VIN) 3. DESIGN A prospective, open, randomised multicentre trial. SETTING 32 general hospitals located in Wales and England. POPULATION OR SAMPLE 180 patients were randomised consecutively between 21 October 2009 and 11 January 2013, 89 to cidofoovir (of whom 41 completely responded to treatment) and 91 to imiquimod (of whom 42 completely responded to treatment). METHODS After 24 weeks of treatment, complete responders were followed up at 6-monthly intervals for 24 months. At each visit, the Common Terminology Criteria for Adverse Events (CTCAE) v3.0 was assessed and any new lesions were biopsied for histology. MAIN OUTCOME MEASURES Time to histologically confirmed disease recurrence (any grade of VIN). RESULTS The median length of follow up was 18.4 months. At 18 months, more participants were VIN-free in the cidofovir arm: 94% (95% CI 78.2-98.5) versus 71.6% (95% CI 52.0-84.3) [univariable hazard ratio (HR) 3.46, 95% CI 0.95-12.60, P = 0.059; multivariable HR 3.53, 95% CI 0.96-12.98, P = 0.057). The number of grade 2+ events was similar between treatment arms (imiquimod: 24/42 (57%) versus cidofovir: 27/41 (66%), χ2 = 0.665, P = 0.415), with no grade 4+. CONCLUSIONS Long-term data indicates a trend towards response being maintained for longer following treatment with cidofovir than with imiquimod, with similar low rates of adverse events for each drug. Adverse event rates indicated acceptable safety of both drugs TWEETABLE ABSTRACT: Long-term follow up in the RT3VIN trial suggests cidofovir may maintain response for longer than imiquimod.
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Affiliation(s)
- CN Hurt
- Centre for Trials ResearchCardiff UniversityCardiffUK
| | - SEF Jones
- School of MedicineCardiff UniversityCardiffUK
| | - T‐A Madden
- Centre for Trials ResearchCardiff UniversityCardiffUK
| | - A Fiander
- Centre for Women's Global HealthRoyal College of Obstetricians & GynaecologistsLondonUK
| | - AJ Nordin
- East Kent Gynaecological Oncology CentreQueen Elizabeth the Queen Mother HospitalMargateUK
| | - R Naik
- Northern Gynaecological Oncology CentreQueen Elizabeth HospitalGatesheadUK
| | - N Powell
- School of MedicineCardiff UniversityCardiffUK
| | - M Carucci
- Centre for Trials ResearchCardiff UniversityCardiffUK
| | - A Tristram
- School of MedicineCardiff UniversityCardiffUK
- Wellington Regional HospitalWellingtonNew Zealand
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21
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Satmary W, Holschneider CH, Brunette LL, Natarajan S. Vulvar intraepithelial neoplasia: Risk factors for recurrence. Gynecol Oncol 2017; 148:126-131. [PMID: 29126556 DOI: 10.1016/j.ygyno.2017.10.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [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: 08/26/2017] [Revised: 10/23/2017] [Accepted: 10/24/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We studied a large population of women with high-grade vulvar intraepithelial neoplasia (VIN) in order to identify patient and treatment-related risk factors for recurrence and progression to cancer. METHODS For this retrospective cohort study of women with a histologic diagnosis of VIN within Southern California Permanente Medical Group between 1995 and 2007 medical records were reviewed; clinical, demographic and pathologic data were collected. Statistical analyses included Chi-squared and Student's t-tests, univariate and multivariate logistic regression, and cumulative incidence analysis. RESULTS 914 patients with high-grade VIN were identified; 784 met inclusion criteria. We found 26.3% recurrences among treated women, with 2.2% progression to cancer (8.2% among those with recurrence). Risk factors for recurrence on multivariate analysis were: age >50years (OR, 1.44; 95%CI 1.01-2.07), immunosuppression (OR 2.08; 95%CI 1.42-3.06), metasynchronous VAIN or CIN (OR 1.76; 95%CI 1.08-2.88) in addition to margin status (OR 8.17; 95%CI 4.60-14.51) and adjacent LSA (OR 9.91; 95%CI 1.53-31.32) or HPV (OR 2.15; 95%CI 1.13-3.37) with excisional treatment. Recurrence rates did not differ significantly by smoking status and treatment modalities. Median time to recurrence was 16.9months; 25% had late recurrences (44-196months). Cumulative incidence analyses of time to recurrence shows a significantly higher risk among patients over age 50 (log-rank p=0.0031). CONCLUSION We identified independent risk factors for recurrence including age >50years, immunosuppression, metasynchronous vaginal or intraepithelial neoplasia, positive excision margins, and adjacent lichen sclerosus or human papilloma-virus. Regardless of treatment modality, 25% of recurrences occurred late, highlighting the need for long-term surveillance in women treated for VIN.
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Affiliation(s)
- W Satmary
- Department of Obstetrics & Gynecology, Kaiser Permanente Medical Center, Panorama City, CA 91402, United States.
| | - C H Holschneider
- Department of Obstetrics & Gynecology, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States; David Geffen School of Medicine, UCLA, Los Angeles, CA 90095, United States
| | - L L Brunette
- LAC+USC Medical Center, Keck School of Medicine, University of Southern California, 90033, United States
| | - S Natarajan
- Department of Pathology, Kaiser Permanente Medical Center, Los Angeles, CA 90027, United States
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Abstract
Human papillomavirus (HPV) is involved in one of the at least 2 pathways leading to vulvar squamous cell carcinoma (VSCC). Inactivation of p53 and retinoblastoma by the viral products E6 and E7 is involved in malignant transformation. The percentage of HPV-positive VSCCs ranges from 18% to 75%, depending on the geographical area. HPV-associated tumors affect relatively young women and arise from high-grade intraepithelial lesions, identical to other HPV-associated premalignant lesions of the anogenital tract. HPV-independent tumors tend to affect older women and usually arise in a background of inflammatory skin disorders and a subtle variant of in situ lesion called differentiated vulvar intraepithelial neoplasia. HPV-positive tumors tend to be of basaloid or warty types, whereas HPV-independent tumors tend to be of keratinizing type, but there is frequent overlap between histologic types. There is no conclusive evidence yet on the best strategy in terms of determining HPV attribution. HPV DNA detection is generally considered the gold standard although there is some concern about misclassification when using this technique alone. p16 immunostaining has shown to be an excellent surrogate marker of HPV infection. Positive results for both techniques are considered the best evidence for HPV-association. The prognostic role of HPV in VSCC is still contradictory, but increasing evidence suggests that HPV-associated tumors are less aggressive. Currently, there are no differences in treatment between HPV-associated and HPV-independent VSCC, but novel immunological strategies based on anti-HPV antigens are being evaluated in clinical trials.
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Madeleine MM, Johnson LG, Doody DR, Tipton ER, Carter JJ, Galloway DA. Natural Antibodies to Human Papillomavirus 16 and Recurrence of Vulvar High-Grade Intraepithelial Neoplasia (VIN3). J Low Genit Tract Dis 2016; 20:257-60. [PMID: 27224532 DOI: 10.1097/LGT.0000000000000227] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recurrence of high-grade intraepithelial neoplasia of the vulva (VIN3) was less frequent among women with detectable human papillomavirus 16 antibodies. Objectives Approximately 30% of women treated for squamous high-grade intraepithelial neoplasia (VIN3), often associated with human papillomavirus (HPV), have recurrent disease. In this study, we assess predictors of recurrence that may provide targets for early prevention or treatment. Materials and Methods Women with VIN3 who participated in a previous population-based case-control study with blood and tumor samples completed a follow-up telephone interview an average of 5 years after initial diagnosis. The risk of recurrence was determined by proportional hazards modeling. Results Women with VIN3 in the follow-up study (n = 65) were similar to women with VIN3 in the parent study (n = 215) with regard to age at primary diagnosis, level of current cigarette smoking (>60%), and lifetime number of partners. We found that 22 (33.8%) of 65 participants had a vulvar recurrence and that 73.4% recurred within 3 years of treatment. Recurrences occurred more often among women with common warts in the decade before diagnosis (hazard ratio [HR] = 2.5, 95% CI = 1.1–5.8) and among those with a previous anogenital cancer (HR = 2.7, 95% CI = 1.2–6.3). Interestingly, recurrence was less frequent among women who mounted a natural antibody response to HPV16 (HR = 0.4, 95% CI = 0.2–0.9). Conclusions These data provide strong preliminary evidence that VIN3 recurrence was less frequent among those with HPV16 antibodies. Vaccination with the currently licensed HPV vaccine as part of adjunctive therapy for VIN3 would increase antibody response and may decrease risk of recurrence. Randomized controlled trials are needed to determine whether HPV vaccination is effective against VIN3 recurrence.
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Bradbury M, Cabrera S, García-Jiménez A, Franco-Camps S, Sánchez-Iglesias JL, Díaz-Feijoo B, Pérez-Benavente A, Gil-Moreno A, Centeno-Mediavilla C. Vulvar intraepithelial neoplasia: clinical presentation, management and outcomes in women infected with HIV. AIDS 2016; 30:859-68. [PMID: 26959352 DOI: 10.1097/qad.0000000000000984] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Immunocompromised patients are at increased risk of developing preinvasive lesions of the lower genital tract. There are a limited number of studies on vulvar intraepithelial neoplasia (VIN) in HIV-positive women. We aimed to review the clinical presentation of VIN, management and survival outcomes in this group of patients. DESIGN Observational cohort study. METHODS Data was collected from women diagnosed with VIN at the Hospital Vall d'Hebron between September 1994 and October 2011. The main outcome measures were recurrence-free survival (RFS) and progression-free survival (PFS). Risk factors for recurrence and progression were assessed using univariate and multivariate analyses. RESULTS Thirty-seven out of 107 women were HIV positive (34.6%). The median follow-up time was 32 (range 12-179) months. Compared with the HIV-negative group, HIV-positive women were younger (median age 37 vs. 44 years, P = 0.003) and presented with multifocal and multicentric disease more frequently (63.6 vs. 22.2% and 84.8 vs. 43.3%, respectively, P < 0.0001). RFS and PFS were lower in the HIV-positive group (42.4 vs. 71.4% P = 0.043 and 69.7 vs. 95.2% P = 0.006, respectively). RFS was significantly associated to multicentric and multifocal disease on multivariate analysis. PFS was associated to HIV infection on univariate analysis. CONCLUSION HIV-positive women are at increased risk of developing VIN and frequently present at a younger age with multifocal and multicentric disease. They have shorter RFS and PFS compared with HIV-negative women. Close surveillance of the lower genital tract is mandatory to enable early recognition and treatment of any suspicious lesions. Close follow-up after treatment of VIN is essential to exclude early recurrence or progression.
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Lawrie TA, Nordin A, Chakrabarti M, Bryant A, Kaushik S, Pepas L. Medical and surgical interventions for the treatment of usual-type vulval intraepithelial neoplasia. Cochrane Database Syst Rev 2016; 2016:CD011837. [PMID: 26728940 PMCID: PMC6457805 DOI: 10.1002/14651858.cd011837.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Usual-type vulval intraepithelial neoplasia (uVIN) is a pre-cancerous condition of the vulval skin. Also known as high-grade VIN, VIN 2/3 or high-grade vulval squamous intraepithelial lesion (HSIL), uVIN is associated with high-risk subtype human papilloma virus (HPV) infection. The condition causes distressing vulval symptoms in the majority of affected women and may progress to vulval cancer, therefore is usually actively managed. There is no consensus on the optimal management of uVIN. High morbidity and recurrence rates associated with surgical treatments make less invasive treatments highly desirable. OBJECTIVES To determine which interventions are the most effective, safe and tolerable for treating women with uVIN. SEARCH METHODS We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 8 2015, MEDLINE and EMBASE (up to 1 September 2015). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) that assessed medical and surgical interventions in women with uVIN. If no RCTs were available, we included non-randomised studies (NRSs) with concurrent comparison groups that controlled for baseline case mix in multivariate analysis. DATA COLLECTION AND ANALYSIS We used Cochrane methodology with two review authors independently extracting data and assessing risk of bias. Where possible, we synthesised data in meta-analyses using random-effects methods. Network meta-analysis was not possible due to insufficient data. MAIN RESULTS We included six RCTs involving 327 women and five NRSs involving 648 women. The condition was variously named by investigators as uVIN, VIN2/3 or high-grade VIN. Five RCTs evaluated medical treatments (imiquimod, cidofovir, indole-3 carbinol), and six studies (one RCT and five NRSs) evaluated surgical treatments or photodynamic therapy. We judged two RCTs and four NRSs to be at a high or unclear risk of bias; we considered the others at relatively low risk of bias. Types of outcome measures reported in NRSs varied and we were unable to pool NRS data. Medical interventions: Topical imiquimod was more effective than placebo in achieving a response (complete or partial) to treatment at five to six months post-randomisation (three RCTs, 104 women; risk ratio (RR) 11.95, 95% confidence interval (CI) 3.21 to 44.51; high-quality evidence). At five to six months, a complete response occurred in 36/62 (58%) and 0/42 (0%) women in the imiquimod and placebo groups, respectively (RR 14.40, 95% CI 2.97 to 69.80). Moderate-quality evidence suggested that the complete response was sustained at one year (one RCT, nine complete responses out of 52 women (38%)) and beyond, particularly in women with smaller VIN lesions. Histologically confirmed complete response rates with imiquimod versus cidofovir at six months were 45% (41/91) and 46% (41/89), respectively (one RCT, 180 women; RR 1.00, 95% CI 0.73 to 1.37; moderate-quality evidence). Twelve-month data from this trial are awaited; however, interim findings suggested that complete responses were sustained at 12 months. Only one trial reported vulval cancer at one year (1/24 and 2/23 in imiquimod and placebo groups, respectively). Adverse events were more common with imiquimod than placebo and dose reductions occurred more frequently in the imiquimod group than in the placebo group (two RCTs, 83 women; RR 7.77, 95% CI 1.61 to 37.36; high-quality evidence). Headache, fatigue and discontinuation were slightly more common with imiquimod than cidofovir (moderate-quality evidence). Quality of life scores reported in one trial (52 women) were not significantly different for imiquimod and placebo. The evidence of effectiveness of topical treatments in immunosuppressed women was scant. There was insufficient evidence on other medical interventions. Surgical and other interventions: Low-quality evidence from the best included NRS indicated, when data were adjusted for confounders, that there was little difference in the risk of VIN recurrence between surgical excision and laser vaporisation. Recurrence occurred in 51% (37/70) of women overall, at a median of 14 months, and was more common in multifocal than unifocal lesions (66% versus 34%). Vulval cancer occurred in 11 women (15.1%) overall at a median of 71.5 months (9 to 259 months). The risk of vulval cancer did not differ significantly between excision and laser vaporisation in any of the NRSs; however, events were too few for robust findings. Alternative surgical procedures that might be as effective include Cavitron ultrasonic surgical aspiration (CUSA) and loop electrosurgical excision (LEEP) procedures, based on low- to very low-quality evidence, respectively. Very low-quality evidence also suggested that photodynamic therapy may be a useful treatment option.We found one ongoing RCT of medical treatment (imiquimod) compared with surgical treatment. AUTHORS' CONCLUSIONS Topical treatment (imiquimod or cidofovir) may effectively treat about half of uVIN cases after a 16-week course of treatment, but the evidence on whether this effect is sustained is limited. Factors predicting response to treatment are not clear, but small lesions may be more likely to respond. The relative risk of progression to vulval cancer is uncertain. However, imiquimod and cidofovir appear to be relatively well tolerated and may be favoured by some women over primary surgical treatment.There is currently no evidence on how medical treatment compares with surgical treatment. Women who undergo surgical treatment for uVIN have about a 50% chance of the condition recurring one year later, irrespective of whether treatment is by surgical excision or laser vaporisation. Multifocal uVIN lesions are at a higher risk of recurrence and progression, and pose greater therapeutic dilemmas than unifocal lesions. If occult cancer is suspected despite a biopsy diagnosis of uVIN, surgical excision remains the treatment of choice. If occult cancer is not a concern, treatment needs to be individualised to take into account the site and extent of disease, and a woman's preferences. Combined modalities may hold the key to optimal treatment of this complex disease.
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Affiliation(s)
- Theresa A Lawrie
- Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupEducation CentreBathUKBA1 3NG
| | - Andy Nordin
- Queen Elizabeth The Queen Mother HospitalEast Kent Gynaecological Oncology CentreSt Peters RoadMargateKentUKCT9 4AN
| | - Manas Chakrabarti
- Apollo Gleneagles Cancer HospitalConsultant Gynaecological Oncologist58 Canal Circular RoadKolkataKolkataIndia700054
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Sonali Kaushik
- Royal Sussex County HospitalDivision of Gynaecological OncologyBrightonUKBN2 5BE
| | - Litha Pepas
- St Bartholomew's HospitalCentre of Reproductive Medicine2nd Floor Kenton and Lucas WingLondonUKEC1A 7BE
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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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Abstract
BACKGROUND This is an updated version of a review first published in theCochrane Database of Systematic Reviews, Issue 4, in 2011. Vulval intraepithelial neoplasia (VIN) is a pre-cancerous condition of the vulval skin and its incidence is increasing in women under 50 years. High-grade VIN (also called usual-type VIN (uVIN) or VIN 2/3 or high-grade vulval intraepithelial lesion) is associated with human papilloma virus (HPV) infection and may progress to vulval cancer, therefore is usually actively managed. There is no consensus on the optimal management of high-grade VIN; and the high morbidity and relapse rates associated with surgical interventions make less invasive interventions highly desirable. OBJECTIVES To evaluate the effectiveness and safety of medical (non-surgical) interventions for high-grade VIN. SEARCH METHODS We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 3), MEDLINE and EMBASE (up to 30 March 2015). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) that assessed non-surgical interventions in women diagnosed with high-grade VIN. DATA COLLECTION AND ANALYSIS We used Cochrane methodology with two review authors independently abstracting data and assessing risk of bias. Where possible, we synthesised data in meta-analyses using random effects methods. MAIN RESULTS Five trials involving 297 women with high-grade VIN (defined by trial investigators as VIN 2/3 or VIN 3 or 'high-grade' lesions) met our inclusion criteria: three trials assessed the effectiveness of topical imiquimod versus placebo; one assessed topical cidofovir versus topical imiquimod; and one assessed low- versus high-dose indole-3-carbinol in similar types of participants. Three trials were at a moderate to low risk of bias, two were at a potentially high risk of bias.Meta-analysis of the three trials comparing topical imiquimod 5% cream to placebo found that women in the active treatment group were more likely to show an overall response (complete and partial response) to treatment at five to six months compared with the placebo group (Risk Ratio (RR) 11.95, 95% confidence interval (CI) 3.21 to 44.51; participants = 104; studies = 3; I(2) = 0%; high-quality evidence). A complete response at five to six months occurred in 36/62 (58%) and 0/42 (0%) participants in the active and placebo groups, respectively (RR 14.40, 95% CI 2.97 to 69.80; participants = 104; studies = 3; I(2) = 0%). A single trial reported 12-month follow-up, which revealed a sustained effect in overall response in favour of the active treatment arm at 12 months (RR 9.10, 95% CI 2.38 to 34.77; moderate-quality evidence), with 9/24 (38%) and 0/23 (0%) complete responses recorded in the active and placebo groups respectively. Progression to vulval cancer was also documented in this trial (one versus two participants in the active and placebo groups, respectively) and we assessed this evidence as low-quality. Only one trial reported adverse events, including erythema, erosion, pain and pruritis at the site of the lesion, which were more common in the imiquimod group. Dose reductions occurred more frequently in the active treatment group compared with the placebo group (19/47 versus 1/36 participants; RR 7.77, 95% CI 1.61 to 37.36; participants = 83; studies = 2; I(2) = 0%; high-quality evidence). Only one trial reported quality of life (QoL) and there were no significant differences between the imiquimod and placebo groups.For the imiquimod versus cidofovir trial, 180 women contributed data. The overall response at six months was similar for the imiquimod and cidofovir treatment groups with 52/91 (57%) versus 55/89 (62%) participants responding, respectively (RR 0.92, 95% CI 0.73 to 1.18). A complete response occurred in 41 women in each group (45% and 46%, respectively; RR 1.00, 95% CI 0.73 to 1.37). Although not statistically different, total adverse events were slightly more common in the imiquimod group of this trial with slightly more discontinuations occurring in this group. Longer term response data from this trial are expected.The small trial comparing two doses of indole-3-carbinol contributed limited data. We identified five ongoing randomised trials of various interventions for VIN. AUTHORS' CONCLUSIONS Topical imiquimod appears to be a safe and effective treatment for high-grade VIN (uVIN), even though local side-effects may necessitate dose reductions. However, longer term follow-up data are needed to corroborate the limited evidence that response to treatment is sustained, and to assess any effect on progression to vulval cancer. Available evidence suggests that topical cidofovir may be a good alternative to imiquimod; however, more evidence is needed, particularly regarding the relative effectiveness on longer term response and progression. We await the longer-term response data and the results of the five ongoing trials.
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Affiliation(s)
- Litha Pepas
- St Bartholomew's HospitalCentre of Reproductive Medicine2nd Floor Kenton and Lucas WingLondonUKEC1A 7BE
| | - Sonali Kaushik
- Royal Sussex County HospitalDivision of Gynaecological OncologyBrightonUKBN2 5BE
| | - Andy Nordin
- Queen Elizabeth The Queen Mother HospitalEast Kent Gynaecological Oncology CentreSt Peters RoadMargateKentUKCT9 4AN
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Theresa A Lawrie
- Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupEducation CentreBathUKBA1 3NG
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Jentschke M, Hoffmeister V, Soergel P, Hillemanns P. Clinical presentation, treatment and outcome of vaginal intraepithelial neoplasia. Arch Gynecol Obstet 2016; 293:415-9. [DOI: 10.1007/s00404-015-3835-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/27/2015] [Indexed: 11/27/2022]
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Choi MC, Kim MS, Lee GH, Jung SG, Park H, Joo WD, Lee C, Lee JH, Hwang YY, Kim SJ. Photodynamic therapy for premalignant lesions of the vulva and vagina: A long-term follow-up study. Lasers Surg Med 2015; 47:566-570. [PMID: 26174756 DOI: 10.1002/lsm.22384] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVE We aimed to evaluate responses to photodynamic therapy (PDT) and its long-term efficacy in preserving normal anatomy and function in women with premalignant lesions of the lower genital tract. STUDY DESIGN/MATERIALS AND METHODS Fifteen patients received PDT for vulvar intraepithelial neoplasia (VIN), vaginal intraepithelial neoplasia (VAIN), or vulvar Paget's disease between January 2003 and December 2013. Patients underwent colposcopy and/or vulvoscopy for assessment of lesions. Surface photoillumination with a 630-nm red laser light was applied to the lesions 48 hours after intravenous injection of 2 mg/kg photosensitizer (PSZ; Photogem®). The light dose to the lesions was 150 J/cm2 . RESULTS The median age of the 15 patients (VIN II: 3, VIN III: 4, VAIN II: 2, VAIN III: 3, Paget's disease: 3) was 42.3 years. The complete response (CR) rate was 80% (12/15) at the 3-month follow-up and 71.4% (10/14) at the 1-year follow-up. There were two cases of persistent disease at the 3-month follow-up. One patient with persistent disease underwent partial vulvectomy three times for repetitive recurrence, and the other received secondary PDT with topical 5-aminolevulinic acid (5-ALA) and subsequently showed no evidence of disease (NED). Another patient achieved 90% remission through a combination of additional alternative treatments after showing partial response (PR). In two cases of CR, recurrence was observed at the 1-year follow-up. Regarding adverse events, photosensitivity reactions such as facial edema and urticaria occurred in 13.3% (2/15) and perineal pain occurred in one patient. CONCLUSIONS PDT may be an effective alternative treatment for premalignant lesions of the female lower genital tract to preserve normal anatomy and sexual function without therapeutic impairment. Lasers Surg. Med. 47:566-570, 2015. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Min Chul Choi
- Comprehensive Gynecologic Cancer Center, Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Korea
| | - Mi Sun Kim
- Comprehensive Gynecologic Cancer Center, Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Korea
| | - Gee Hoon Lee
- Comprehensive Gynecologic Cancer Center, Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Korea
| | - Sang Geun Jung
- Comprehensive Gynecologic Cancer Center, Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Korea
| | - Hyun Park
- Comprehensive Gynecologic Cancer Center, Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Korea
| | - Won Duk Joo
- Comprehensive Gynecologic Cancer Center, Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Korea
| | - Chan Lee
- Comprehensive Gynecologic Cancer Center, Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Korea
| | - Je Ho Lee
- Comprehensive Gynecologic Cancer Center, Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Korea
| | - Yoon Young Hwang
- Comprehensive Gynecologic Cancer Center, Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Korea
| | - Seung Jo Kim
- Comprehensive Gynecologic Cancer Center, Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, Seongnam-si, Gyeonggi-do, Korea
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Tristram A, Hurt CN, Madden T, Powell N, Man S, Hibbitts S, Dutton P, Jones S, Nordin AJ, Naik R, Fiander A, Griffiths G. Activity, safety, and feasibility of cidofovir and imiquimod for treatment of vulval intraepithelial neoplasia (RT³VIN): a multicentre, open-label, randomised, phase 2 trial. Lancet Oncol 2014; 15:1361-8. [PMID: 25304851 DOI: 10.1016/s1470-2045(14)70456-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Vulval intraepithelial neoplasia is a skin disorder affecting the vulva that, if left untreated, can become cancerous. Currently, the standard treatment for patients with vulval intraepithelial neoplasia is surgery, but this approach does not guarantee cure and can be disfiguring, causing physical and psychological problems, particularly in women of reproductive age. We aimed to assess the activity, safety, and feasibility of two topical treatments--cidofovir and imiquimod--as an alternative to surgery in female patients with vulval intraepithelial neoplasia. METHODS We recruited female patients (age 16 years or older) from 32 centres to an open-label, randomised, phase 2 trial. Eligibility criteria were biopsy-proven vulval intraepithelial neoplasia grade 3 and at least one lesion that could be measured accurately. We randomly allocated patients to topical treatment with either 1% cidofovir (supplied as a gel in a 10 g tube, to last 6 weeks) or 5% imiquimod (one 250 mg sachet for every application), to be self-applied three times a week for a maximum of 24 weeks. Randomisation (1:1) was done by stratified minimisation via a central computerised system, with stratification by hospital, disease focality, and presentation stage. The primary endpoint was a histologically confirmed complete response at the post-treatment assessment visit 6 weeks after the end of treatment (a maximum of 30 weeks after treatment started). Analysis of the primary endpoint was by intention to treat. Secondary outcomes were toxic effects (to assess safety) and adherence to treatment (to assess feasibility). We present results after all patients had reached the primary endpoint assessment point at 6 weeks; 2-year follow-up of complete responders continues. This trial is registered with Current Controlled Trials, ISRCTN 34420460. FINDINGS Between Oct 21, 2009, and Jan 11, 2013, 180 participants were enrolled to the study; 89 patients were randomly allocated cidofovir and 91 were assigned imiquimod. At the post-treatment assessment visit, a complete response had been achieved by 41 (46%; 90% CI 37·0-55·3) patients allocated cidofovir and by 42 (46%; 37·2-55·3) patients assigned imiquimod. After 6 weeks of treatment, 156 (87%) patients (78 in each group) had adhered to the treatment regimen. Five patients in the cidofovir group and seven in the imiquimod group either withdrew or were lost to follow-up before the first 6-week safety assessment. Adverse events of grade 3 or higher were reported in 31 (37%) of 84 patients allocated cidofovir and 39 (46%) of 84 patients assigned imiquimod; the most frequent grade 3 and 4 events were pain in the vulva, pruritus, fatigue, and headache. INTERPRETATION Cidofovir and imiquimod were active, safe, and feasible for treatment of vulval intraepithelial neoplasia and warrant further investigation in a phase 3 setting. Both drugs are effective alternatives to surgery for female patients with vulval intraepithelial neoplasia after exclusion of occult invasive disease. FUNDING Cancer Research UK.
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Affiliation(s)
- Amanda Tristram
- HPV Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Christopher N Hurt
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK.
| | - Tracie Madden
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Ned Powell
- HPV Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Stephen Man
- Institute of Cancer & Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | - Sam Hibbitts
- HPV Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Peter Dutton
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Sadie Jones
- HPV Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Andrew J Nordin
- East Kent Gynaecological Oncology Centre, Queen Elizabeth the Queen Mother Hospital, Margate, UK
| | - Raj Naik
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, UK
| | - Alison Fiander
- HPV Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Gareth Griffiths
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK; University of Southampton Clinical Trials Unit, Faculty of Medicine, Southampton General Hospital, Southampton UK
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