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Diagnosis & Management Of VAIN/VIN
Richard Hutson
Gynaecological Oncologist
St. James’s University Hospital
Definition
• A condition where neoplastic cells are within the boundaries of surface epithelium
• Excludes:-
• Paget’s disease of the Vulva
• Melanoma-in-situ
• Maturation disorders
Classification
• VIN/VAIN I :- mild dysplasia; lower 1/3
• VIN/VAIN II :- mod. dysplasia; lower 2/3
• VIN/VAIN III :- severe dysplasia; > 2/3
Symptoms
• Pruritus (38-73 %)
• Vulval pain / soreness
• A lump / lesion
• Asymptomatic
Physical Signs
• Papular & rough surfaced (warts)
• Macular with indistinct/irregular borders
• Micropapillary/granular associated with acanthosis
• Pigmentation (brown/black)
• White lesions (hyperkeratosis)
Diagnosis
• Histologically; biopsy always required
• Biopsy under LA; use of EMLA
• Punch / scalpel
Normal Epithelium with L.S.
VIN II-III
VIN II with Koilocytosis
Paget’s Disease of the Vulva
Aetiology
• Strong association with STD’s
• HPV (43-79 %)
• Younger women condyloma and koilocytes
• Older women no koilocytosis
• Smoking
• Immunosuppressed
Natural History of VIN / VAIN
• No established rates of progression or regression
• Risk of invasion is small
• Risk of invasion more likely women > 45; immunosuppressed; SLE; multifocal disease
Management in Young Women
• Risk of invasion is small
• Recurrence rate up to 84 %
• > 20 % recurrent disease after simple vulvectomy
• Regresses after pregnancy
Who to Treat ?
• Post menopausal presentation
• Immunosuppressed / immunodeficient
• Histologically progressive lesions on serial biopsy
• Excessively hyperkeratotic lesions
Treatment Techniques
• W.L.E. (8mm margin)
• Skinning Vulvectomy; skin graft, 27% rec.
• Vulvectomy; rarely employed
• Topical 5 FU; failure rate = 38-100 %
• Dinitrochlorobenzene; topical immunotherapy
• CO2 laser; to upper reticular dermis
Summary
• HPV and multifocal disease commoner in young women
• Unifocal and HPV neg. lesions in post-men. Women
• CIN found in 33% of women with VIN• VIN assoc. with 25-33% vulval cancers• 50% vulval cancers assoc. with non-
neoplastic disorders