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Zhou M, Su Y, Tong Y, Zhang C, Yuan S, Zhang M, Dai K, Wang Y, Cao L, Zhang M, Zhang T. Comparative study of topical 5-aminolevulinic acid photodynamic therapy and surgery for the treatment of vulvar squamous intraepithelial lesion. Photodiagnosis Photodyn Ther 2023; 44:103868. [PMID: 37898260 DOI: 10.1016/j.pdpdt.2023.103868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/25/2023] [Accepted: 10/25/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND Vulvar squamous intraepithelial lesion (SIL) is a precursor lesion of vulvar squamous cell carcinoma. The current clinical treatments for vulvar SIL cause damage to the vulvar structure, chronic pain and psychological distress. Topical 5-aminolevulinic acid photodynamic therapy (ALA-PDT) is a novel, non-invasive therapy for intraepithelial lesions. The objective of this study was to compare the clinical efficacy and safety of ALA-PDT with local surgical resection for vulvar SIL. METHODS A total of 56 patients with vulvar SIL were enrolled in this retrospective study. Among them, 16 patients received local resection and 40 patients received ALA-PDT. HPV genotyping and ThinPrep cytologic test (TCT) were used to evaluate treatment efficacy. In addition, colposcopy-directed biopsy was performed in all patients at 3-month follow-up and in patients with positive high-risk human papillomavirus (HR-HPV) and/or abnormal TCT results during the follow-up. RESULTS At 3-month follow-up and in HSIL group the complete remission (CR) rate of the ALA-PDT group and surgery group was 90.6% (29/32) and 87.5% (14/16) (P = 1.000), respectively. The HPV clearance rate of the ALA-PDT group and surgery group was 45.2% (14/31) and 43.8% (7/16) (P = 0.927), respectively. The average numbers of ALA-PDT treatments were 5.34 for HSIL patients and 4.88 for LSIL patients, respectively. The CR rate of HSIL patients and LSIL patients was 90.6% (29/32) and 75.0% (6/8) (P = 0.550), respectively. The HPV clearance rate of HSIL patients and LSIL patients was 45.2% (14/31) and 37.5% (3/8) (P = 1.000), respectively. The ALA-PDT group showed similar clinical efficacy and milder adverse effects compared with the surgical group. CONCLUSION ALA-PDT showed similar clinical efficacy as surgery in the treatment of vulvar SIL, but with milder adverse effects and maintaining the integrity of the vulvar structure.
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Affiliation(s)
- Mengjiao Zhou
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuehui Su
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yutong Tong
- Xinxiang Medical University, Xinxiang, China; Zhengzhou Central Hospital, Zhengzhou, China
| | - Chunyan Zhang
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shuyu Yuan
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mengzhuo Zhang
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kaili Dai
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yimeng Wang
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lili Cao
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mengzhen Zhang
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Ting Zhang
- Department of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Bhattacharya D, Mukhopadhyay M, Shivam K, Tripathy S, Patra R, Pramanik A. Recent developments in photodynamic therapy and its application against multidrug resistant cancers. Biomed Mater 2023; 18:062005. [PMID: 37827172 DOI: 10.1088/1748-605x/ad02d4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/12/2023] [Indexed: 10/14/2023]
Abstract
Recently, photodynamic therapy (PDT) has received a lot of attention for its potential use in cancer treatment. It enables the therapy of a multifocal disease with the least amount of tissue damage. The most widely used prodrug is 5-aminolevulinic acid, which undergoes heme pathway conversion to protoporphyrin IX, which acts as a photosensitizer (PS). Additionally, hematoporphyrin, bacteriochlorin, and phthalocyanine are also studied for their therapeutic potential in cancer. Unfortunately, not every patient who receives PDT experiences a full recovery. Resistance to different anticancer treatments is commonly observed. A few of the resistance mechanisms by which cancer cells escape therapeutics are genetic factors, drug-drug interactions, impaired DNA repair pathways, mutations related to inhibition of apoptosis, epigenetic pathways, etc. Recently, much research has been conducted to develop a new generation of PS based on nanomaterials that could be used to overcome cancer cells' multidrug resistance (MDR). Various metal-based, polymeric, lipidic nanoparticles (NPs), dendrimers, etc, have been utilized in the PDT application against cancer. This article discusses the detailed mechanism by which cancer cells evolve towards MDR as well as recent advances in PDT-based NPs for use against multidrug-resistant cancers.
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Affiliation(s)
- Debalina Bhattacharya
- Department of Microbiology, Maulana Azad College, Kolkata, West Bengal 700013, India
| | - Mainak Mukhopadhyay
- Department of Biotechnology, JIS University, Kolkata, West Bengal 700109, India
| | - Kumar Shivam
- Amity Institute of Click Chemistry Research & Studies, Amity University, Noida 201301, India
| | - Satyajit Tripathy
- Department of Pharmacology, University of Free State, Bloemfontein, Free State, 9301, South Africa
- Amity Institute of Allied Health Science, Amity University, Noida 201301, India
| | - Ranjan Patra
- Amity Institute of Click Chemistry Research & Studies, Amity University, Noida 201301, India
- Department of Chemistry, Pohang University of Science and Technology, Pohang 37673, Republic of Korea
| | - Arindam Pramanik
- School of Medicine, University of Leeds, Leeds, LS9 7TF, United Kingdom
- Amity Institute of Biotechnology, Amity University, Noida 201301, India
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Jamieson A, Tse SS, Proctor L, Sadownik LA. A Scoping Review of Treatment Outcome Measures for Vulvar Intraepithelial Neoplasia. J Low Genit Tract Dis 2022; 26:328-338. [PMID: 36074136 DOI: 10.1097/lgt.0000000000000698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The goal of this study is to identify a list of clinician-reported outcome measures (CROMs) and patient-reported outcome measures (PROMs) through a review of published studies reporting on any therapeutic interventions for vulvar intraepithelial neoplasia (VIN). MATERIALS AND METHODS A systematic search of published studies reporting on any therapeutic interventions for VIN was performed on MEDLINE, Embase, Cochrane Database, PsychInfo, and CINAHL from inception to September 20, 2021, based on predetermined study selection criteria. Data were extracted and analyzed by 2 authors independently using Covidence software. RESULTS Thirty two of 2386 studies identified met study selection criteria. None of the 32 studies provided an explicit definition of VIN treatment "success." The most common CROM was "clinical response to treatment." The most common scale used to measure this outcome was "complete response/partial response/no response"; however, 17 of 23 studies (73.9%) did not define these values. Laboratory CROMs were reported in 12/32 (37.5%) studies. Patient-reported outcome measures were reported in only 10 of 32 studies(31.3%) -the most common PROM was "symptoms." Only 2 of 32 studies measured PROMs related to "quality of life" domains. Adverse events/treatment-related adverse effects were reported in 24 of 32 studies (75%), although 71% of studies provided no details on how these data were collected. CONCLUSIONS There is a large variation in outcome measures, instruments, and scales used for any clinician-reported treatment outcome such as "clinical response." Most studies do not include patient-reported outcome measures assessing quality of life domains. A Core Outcome Set for the treatment of VIN is needed to improve the quality of VIN research.
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Zhang T, Zhang Y, Tang Y, Qin L, Shen Y, Wang B, Zhang L, Cao L, Zhou Y, Su Y, Wang L, Zhang M. The effect of high-risk HPV E6/E7 mRNA on the efficacy of topical photodynamic therapy with 5-aminolevulinic acid for cervical high-grade squamous intraepithelial lesions. Photodiagnosis Photodyn Ther 2022; 39:102974. [PMID: 35724936 DOI: 10.1016/j.pdpdt.2022.102974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND E6 and E7 high-risk human papillomavirus (HR-HPV) oncoproteins are closely associated with the initiation and progression of cervical cancer (CC) and pre-cancerous lesions. Cervical high-grade squamous intraepithelial lesions (HSIL), as pre-cancerous lesions, have a 5% chance of progressing to invasive cancer. Topical 5-aminolevulinic acid photodynamic therapy (ALA-PDT) is a novel non-invasive targeted therapy for intraepithelial lesions. Herein, we analyzed the effect of HR-HPV E6/E7 mRNA on ALA-PDT for cervical HSIL. METHODS A retrospective analysis of 148 HR-HPV-positive patients diagnosed with cervical HSIL and receiving ALA-PDT was carried out. ALA-PDT was performed with 20% ALA thermosensitive gel, and irradiation at wavelength of 635 nm and density of 80-100 J/cm2 for 20-30 min. The therapeutic instruments of LED and semiconductor laser were applied for cervical lesions and lesions in endocervical canal, respectively. All patients were tested for HPV E6/E7 mRNA before and after PDT, and then followed up at 3, 6, and 12 months after treatment, and every six months thereafter. RESULTS At the 6-month follow up, the complete remission (CR) rate of patients' lesions was 86.5% (128/148), whereas the total HPV clearance rate was 72.3% (107/148). It was evident that positive E6/E7 mRNA before treatment had a significant effect on HPV clearance rate (66.3% VS 81.4%, P=0.045) and CR rate (80.9% VS 94.9%, P=0.015). The E6/E7 mRNA associated with HPV16/18 and HPV16/18 combined with other HR-HPV (HPV16/18 and other HR-HPV) affected HPV clearance (P=0.035) and lesions CR (P=0.039), respectively. Moreover, persistently positive E6/E7 mRNA after treatment was closely associated with poor efficacy (HPV clearance rate: P=0.000, CR rate: P=0.000). Throughout the follow up period, two cases recurred but none of the patients progressed. CONCLUSIONS This study has shown that ALA-PDT is an effective, safe, and alternative treatment for cervical HSIL, especially for the patients of childbearing age. However, its efficacy is relatively poor in patients with persistently positive E6/E7 mRNA before and after treatment, who are insensitive to ALA-PDT.
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Affiliation(s)
- Ting Zhang
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yingcui Zhang
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yujie Tang
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lihong Qin
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan Shen
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bingjie Wang
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Luoman Zhang
- Department of Clinical Medicine, Zhengzhou University, Zhengzhou, China
| | - Lili Cao
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yingying Zhou
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuehui Su
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Liping Wang
- Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Mengzhen Zhang
- Department of Gynecology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Mechanisms of Resistance to Photodynamic Therapy (PDT) in Vulvar Cancer. Int J Mol Sci 2022; 23:ijms23084117. [PMID: 35456936 PMCID: PMC9028356 DOI: 10.3390/ijms23084117] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 02/06/2023] Open
Abstract
Photodynamic therapy (PDT) is a valuable treatment method for vulvar intraepithelial neoplasia (VIN). It allows for the treatment of a multifocal disease with minimal tissue destruction. 5-Aminolevulinic acid (5-ALA) is the most commonly used prodrug, which is converted in the heme pathway to protoporphyrin IX (PpIX), an actual photosensitizer (PS). Unfortunately, not all patients treated with PDT undergo complete remission. The main cause of their failure is resistance to anticancer therapy. In many cancers, resistance to various anticancer treatments is correlated with increased activity of the DNA repair protein apurinic/apyrimidinic endonuclease 1 (APE1). Enhanced activity of drug pumps may also affect the effectiveness of therapy. To investigate whether multidrug resistance mechanisms underlie PDT resistance in VIN, porphyrins were isolated from sensitive and resistant vulvar cancer cells and their culture media. APE1 activity was measured, and survival assay after PDT combined with APE1 inhibitor was performed. Our results revealed that resistant cells accumulated and effluxed less porphyrins than sensitive cells, and in response to PDT, resistant cells increased APE1 activity. Moreover, PDT combined with inhibition of APE1 significantly decreased the survival of PDT-resistant cells. This means that resistance to PDT in vulvar cancer may be the result of alterations in the heme synthesis pathway. Moreover, increased APE1 activity may be essential for the repair of PDT-mediated DNA damage, and inhibition of APE1 activity may increase the efficacy of PDT.
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Lebreton M, Carton I, Brousse S, Lavoué V, Body G, Levêque J, Nyangoh-Timoh K. Vulvar intraepithelial neoplasia: Classification, epidemiology, diagnosis, and management. J Gynecol Obstet Hum Reprod 2020; 49:101801. [PMID: 32417455 DOI: 10.1016/j.jogoh.2020.101801] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 05/02/2020] [Accepted: 05/04/2020] [Indexed: 11/26/2022]
Abstract
Vulvar intraepithelial neoplasia (VIN) is classified into two entities: differentiated (dVIN) and vulvar high-grade squamous intraepithelial lesions (vH-SIL). dVIN is a premalignant lesion that develops on an existing vulvar lesion such as lichen sclerosus, while vH-SIL is associated with HPV infection. The two entities differ in terms of pathophysiology, background, prognosis, and management. The incidence of VIN in young women is rising and recurrence is common, even after radical surgery, which can cause significant disfigurement. Alternative strategies include topical treatments, ablation, and a watch-and-wait approach. There is currently no consensus on how these lesions should be managed. We review the literature in this field.
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Affiliation(s)
- M Lebreton
- Département de Gynécologie Obstétrique et Reproduction Humaine, CHU Anne de Bretagne, 16 Bd de Bulgarie BP 90347, F-35 203, Rennes Cedex 2, France
| | - I Carton
- Département de Gynécologie Obstétrique et Reproduction Humaine, CHU Anne de Bretagne, 16 Bd de Bulgarie BP 90347, F-35 203, Rennes Cedex 2, France
| | - S Brousse
- Département de Gynécologie Obstétrique et Reproduction Humaine, CHU Anne de Bretagne, 16 Bd de Bulgarie BP 90347, F-35 203, Rennes Cedex 2, France
| | - V Lavoué
- Département de Gynécologie Obstétrique et Reproduction Humaine, CHU Anne de Bretagne, 16 Bd de Bulgarie BP 90347, F-35 203, Rennes Cedex 2, France
| | - G Body
- Service de gynécologie obstétrique et médecine fœtale, université François Rabelais, CHRU de Tours, 2, boulevard Tonnelle, 37044, Tours Cedex 9, France
| | - J Levêque
- Département de Gynécologie Obstétrique et Reproduction Humaine, CHU Anne de Bretagne, 16 Bd de Bulgarie BP 90347, F-35 203, Rennes Cedex 2, France.
| | - K Nyangoh-Timoh
- Département de Gynécologie Obstétrique et Reproduction Humaine, CHU Anne de Bretagne, 16 Bd de Bulgarie BP 90347, F-35 203, Rennes Cedex 2, France
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Zhang R, Wang L. Photodynamic therapy for treatment of usual-type vulvar intraepithelial neoplasia: a case report and literature review. J Int Med Res 2019; 47:4019-4026. [PMID: 31364444 PMCID: PMC6726813 DOI: 10.1177/0300060519862940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/20/2019] [Indexed: 01/10/2023] Open
Abstract
Vulvar intraepithelial neoplasia (VIN) is a pre-malignant condition of the vulvar skin that is found in 50% to 70% of patients with vulvar squamous cell cancer and is regarded as a precursor of vulvar tumors. Thus far, treatment remains lesion- and patient-specific. Here, we describe a VIN patient who presented with a 15-month history of large lesions in the bilateral labium, associated with human papillomavirus infection. The lesions were inappropriate for surgical excision and laser ablation because of their size; therefore, they were treated with photodynamic therapy and concurrent topical 5-aminolevulinic acid hydrochloride. The patient showed no recurrence throughout 2 years of post-treatment follow-up, and reported only slight pain during treatment. Moreover, no significant side effects or scarring were detected. Thus, we conclude that photodynamic therapy can be a useful alternative treatment for large VIN in the bilateral labium that cannot be excised or ablated.
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Affiliation(s)
- Ruina Zhang
- Department of Dermatology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Li Wang
- Department of Dermatology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Ayakannu T, Murugesu S, Taylor AH, Sokhal P, Ratnasekera L, Wilhelm-Benartzi CSM, Lyons D, Chatterjee J. The Impact of Focality and Centricity on Vulvar Intraepithelial Neoplasia on Disease Progression in HIV+ Patients: A 10-Year Retrospective Study. Dermatology 2019; 235:327-333. [PMID: 31256169 DOI: 10.1159/000500469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 04/15/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The impact of lesion focality and centricity in relation to patient outcome and disease recurrence of vulvar intraepithelial neoplasia (VIN) is an understudied area of research, especially in immunocompromised women. The prevalence and incidence of VIN have increased steadily since the 1980s because of the co-existence of human papillomavirus (HPV) and human immunodeficiency virus (HIV). In this study, we retrospectively examined the records of VIN patients to determine the effect of lesion focality and centricity with respect to the interval to disease recurrence. MATERIALS AND METHODS All women diagnosed with VIN and managed between January 2002 and December 2011 were included (n = 90) and followed up until December 2017. Symptoms at the time of presentation, including HIV positivity (n = 75), were collated, including the influences of multifocality and multicentricity on time to disease recurrence. RESULTS Multicentricity caused a more rapid recurrence of disease than unicentricity (p = 0.006), whereas multifocality increased the risk of recurrence more than unifocality (p < 0.0001). Viral load in the HIV+ patients was not associated with time to disease recurrence, but the reduced number of CD4+ lymphocytes present in HIV+ patients was. Treatment modalities had no effect on disease recurrence. CONCLUSION Both focality and centricity have effects on interval to recurrence and final patient outcome, with multifocal disease having a poorer prognosis. Centricity and focality should be recorded at the time of diagnosis and act as a warning for disease recurrence. HIV+ VIN patients with multifocal disease and/or known immunosuppression (low CD4+ lymphocyte counts) should be regarded as "high-risk" patients and treated accordingly.
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Affiliation(s)
- Thangesweran Ayakannu
- Department of Gynaecology Oncology, Royal Surrey County Hospital, NHS Foundation Trust, Guildford, United Kingdom.,Department of Gynaecology Oncology, Liverpool Women's Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Sughashini Murugesu
- Department of Obstetrics and Gynaecology, Hillingdon Hospital, Uxbridge, United Kingdom
| | - Anthony H Taylor
- Department of Molecular and Cellular Biology, University of Leicester, Leicester, United Kingdom
| | - Priya Sokhal
- Department of Cancer and Surgery, Imperial College London, Institute of Reproductive and Development Biology, London, United Kingdom
| | - Limandhee Ratnasekera
- Department of Cancer and Surgery, Imperial College London, Institute of Reproductive and Development Biology, London, United Kingdom
| | - Charlotte S M Wilhelm-Benartzi
- Department of Cancer and Surgery, Imperial College London, Institute of Reproductive and Development Biology, London, United Kingdom
| | - Deirdre Lyons
- Department of Obstetrics and Gynaecology, St. Mary's Hospital, London, United Kingdom
| | - Jayanta Chatterjee
- Department of Gynaecology Oncology, Royal Surrey County Hospital, NHS Foundation Trust, Guildford, United Kingdom, .,Department of Gynaecology Oncology, Liverpool Women's Hospital NHS Foundation Trust, Liverpool, United Kingdom, .,Department of Cancer and Surgery, Imperial College London, Institute of Reproductive and Development Biology, London, United Kingdom,
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Sharova A, Farrakhova D, Slovokhodov E, Arakelov S, Zykov A, Sarantsev A, Linkov K, Loschenov V. Evaluation of vulvar leukoplakia photodynamic therapy efficiency by fluorescent diagnostics method with local «Alasens®» photosensitizer application. Photodiagnosis Photodyn Ther 2019; 27:105-110. [PMID: 31116997 DOI: 10.1016/j.pdpdt.2019.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/19/2019] [Accepted: 05/17/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE Using continuous-pulse irradiation mode application for performing photodynamic therapy sessions to introduce a new method, and conclude results of clinical research focused on vulvar leukoplakia photodynamic therapy efficiency in combination with topical aqueous «Alasens®» solution administration. METHOD Seventy patients (average age of 61 years) diagnosed with vulvar leukoplakia disease (2018 ICD-10-CM Diagnosis Code N90.4) were examined. The following values represent doses of combined mode photodynamic therapy session: 12 J/cm2 pulse radiation dose; 3.5 J/cm2 continuous radiation dose. Non-invasive spectroscopic and visual control of drug accumulation in real time was carried out by fluorescence diagnostic method before and after each therapy session. RESULTS Single-therapy session efficiency was estimated by a fluorescent signal reduction in the pathological region after irradiation, and the direct correlation between photosensitizer photobleaching and disease regression was registered. Photodynamic therapy course included three procedures, with each session applied in 24 -h intervals, and when necessary, an additional course of therapy was applied 60 days afterward. Significant post-treatment results took effect after 2-3 courses with symptom presence reduced or fully regressed depending on the initial severity of the disease. Additionally, side effects and sequelae remained absent in all cases. CONCLUSION The result of methods applied during the clinical research period indicate strong potential in utilizing such promising technology to contribute to the possible prevention of malignant transformation and the treatment of vulvar leukoplakia.
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Affiliation(s)
- Alina Sharova
- Prokhorov General Physics Institute of the Russian Academy of Sciences, Vavilova str.38, 119991, Moscow, Russia.
| | - Dina Farrakhova
- Prokhorov General Physics Institute of the Russian Academy of Sciences, Vavilova str.38, 119991, Moscow, Russia; National Research Nuclear University «MEPh», Kashirskoe shosse 31, 115409, Moscow, Russia.
| | - Egor Slovokhodov
- City Clinical Hospital № 40, Kasatkina str.7, 129301, Moscow, Russia.
| | - Sergey Arakelov
- City Clinical Hospital № 40, Kasatkina str.7, 129301, Moscow, Russia.
| | - Arkady Zykov
- City Clinical Hospital № 40, Kasatkina str.7, 129301, Moscow, Russia.
| | - Andrey Sarantsev
- City Clinical Hospital № 40, Kasatkina str.7, 129301, Moscow, Russia.
| | - Kirill Linkov
- Prokhorov General Physics Institute of the Russian Academy of Sciences, Vavilova str.38, 119991, Moscow, Russia.
| | - Victor Loschenov
- Prokhorov General Physics Institute of the Russian Academy of Sciences, Vavilova str.38, 119991, Moscow, Russia; National Research Nuclear University «MEPh», Kashirskoe shosse 31, 115409, Moscow, Russia.
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Abstract
The aim of study is to evaluate the tolerability and effectiveness of photodynamic therapy as an organ‑preserving treatment in patients with vulvar leukoplakia. 50 patients with a verifed diagnosis of «vulvar leukoplakia» were included in the study. The age varied from 27 to 74 years. The method of treatment assumed the use of the photosensitizer рhotolon (RUE «Belmedpreparaty», Belarus) administered intravenously in doses of 1.8–2.5 mg/kg. Photoirradiation of pathological foci was carried out 2.5–3 hours after intravenous injection of photolon® using a semiconductor laser «UPL PDT» (LEMT, Belarus, λ=661 nm) at exposure doses from 30 to 100 J/cm2 with a power density of 100–170 mW/cm2. The treatment was performed under medical anesthesia. The results of treatment were evaluated using clinical data. Adverse reactions and complications after the introduction of the photosensitizer and photoirradiation have not been observed. Complete clinical regression of the treated pathological foci was noted in 100% of cases with a follow‑up observation 1 month after the treatment. At follow‑up after 3 months, local recurrences of the disease were detected in 4 cases, which were successfully treated with repeated photo‑dynamic therapy sessions. The percentage of complete regressions was 92%, partial – 8%. The obtained results allow judging on the possibility of using photodynamic therapy in the treatment of patients with vulvar leukoplakia, which allows to preserve the organ and obtain a satisfactory functional and cosmetic result.
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Tosti G, Iacobone AD, Preti EP, Vaccari S, Barisani A, Pennacchioli E, Cantisani C. The Role of Photodynamic Therapy in the Treatment of Vulvar Intraepithelial Neoplasia. Biomedicines 2018; 6:biomedicines6010013. [PMID: 29393881 PMCID: PMC5874670 DOI: 10.3390/biomedicines6010013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 01/25/2018] [Accepted: 01/30/2018] [Indexed: 01/30/2023] Open
Abstract
Background: vulvar intraepithelial neoplasia is a non-invasive precursor lesion found in 50–70% of patients affected by vulvar squamous cell carcinoma. In the past, radical surgery was the standard treatment for vulvar intraepithelial neoplasia, however, considering the psychological and physical morbidities related to extensive surgery, several less aggressive treatment modalities have been proposed since the late 1970s. Photodynamic therapy is an effective and safe treatment for cutaneous non-melanoma skin cancer, with favorable cosmetic outcomes. Methods: in the present paper, the results of selected studies on photodynamic therapy in the treatment of vulvar intraepithelial neoplasia are reported and discussed. Results: Overall, complete histological response rates ranged between 20% and 67% and symptom response rates ranged between 52% and 89% according to different studies and case series. Conclusions: the real benefit of photodynamic therapy in the setting of vulvar intraepithelial neoplasia lies in its ability to treat multi-focal disease with minimal tissue destruction, preservation of vulvar anatomy and excellent cosmetic outcomes. These properties explain why photodynamic therapy is an attractive option for vulvar intraepithelial neoplasia treatment.
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Affiliation(s)
- Giulio Tosti
- Division of Melanoma, Soft Tissue Sarcomas and Rare Tumors, Istituto Europeo di Oncologia, Via G. Ripamonti 437, 20141 Milano, Italy.
| | | | | | - Sabina Vaccari
- Unit of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, Policlinico Sant'Orsola-Malpighi, 40138 Bologna, Italy.
| | - Alessia Barisani
- Unit of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, Policlinico Sant'Orsola-Malpighi, 40138 Bologna, Italy.
| | - Elisabetta Pennacchioli
- Division of Melanoma, Soft Tissue Sarcomas and Rare Tumors, Istituto Europeo di Oncologia, Via G. Ripamonti 437, 20141 Milano, Italy.
| | - Carmen Cantisani
- Department of Dermatology, Policlinico Umberto I, Sapienza University of Rome, 00185 Rome, Italy.
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12
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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] [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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13
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Moghissi K, Dixon K, Gibbins S. A Surgical View of Photodynamic Therapy in Oncology: A Review. Surg J (N Y) 2015; 1:e1-e15. [PMID: 28824964 PMCID: PMC5530619 DOI: 10.1055/s-0035-1565246] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 08/25/2015] [Indexed: 12/18/2022] Open
Abstract
Clinical photodynamic therapy (PDT) has existed for over 30 years, and its scientific basis has been known and investigated for well over 100 years. The scientific foundation of PDT is solid and its application to cancer treatment for many common neoplastic lesions has been the subject of a huge number of clinical trials and observational studies. Yet its acceptance by many clinicians has suffered from its absence from the undergraduate and/or postgraduate education curricula of surgeons, physicians, and oncologists. Surgeons in a variety of specialties many with years of experience who are familiar with PDT bear witness in many thousands of publications to its safety and efficacy as well as to the unique role that it can play in the treatment of cancer with its targeting precision, its lack of collateral damage to healthy structures surrounding the treated lesions, and its usage within minimal access therapy. PDT is closely related to the fluorescence phenomenon used in photodiagnosis. This review aspires both to inform and to present the clinical aspect of PDT as seen by a surgeon.
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Affiliation(s)
- K. Moghissi
- The Yorkshire Laser Centre, Goole and District Hospital, Goole, East Yorkshire, United Kingdom
| | - Kate Dixon
- The Yorkshire Laser Centre, Goole and District Hospital, Goole, East Yorkshire, United Kingdom
| | - Sally Gibbins
- The Yorkshire Laser Centre, Goole and District Hospital, Goole, East Yorkshire, United Kingdom
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14
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Helgesen ALO, Warloe T, Pripp AH, Kirschner R, Peng Q, Tanbo T, Gjersvik P. Vulvovaginal photodynamic therapy vs. topical corticosteroids in genital erosive lichen planus: a randomized controlled trial. Br J Dermatol 2015; 173:1156-62. [PMID: 26189484 DOI: 10.1111/bjd.14033] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Genital erosive lichen planus (GELP) in women is a chronic inflammatory disease characterized by painful vulval and vaginal erosions. Topical photodynamic therapy (PDT) is increasingly used in premalignant and malignant diseases and may have an effect in inflammatory diseases. OBJECTIVES To assess the feasibility, efficacy and safety of hexyl 5-aminolevulinate-hydrocloride (HAL)-PDT in GELP. METHODS Forty women, diagnosed with GELP at a specialized vulva clinic, were randomized to one session HAL-PDT in vulva and/or vagina (n = 20) or daily applications of clobetasol propionate 0·05% ointment in vulva and optional hydrocortisone acetate 1·0% foam in vagina for 6 weeks (n = 20). After 6 weeks, all patients were allowed to use topical corticosteroids as needed. Clinical examinations were performed at weeks 0, 6 and 24, using a clinical score developed for the study. All patients wrote a weekly log on pain, topical corticosteroid use and adverse events. RESULTS Three patients, all in the corticosteroid group, withdrew from the study after 1-3 weeks. The mean reduction in clinical scores was similar in the PDT group and the corticosteroid group; 25% vs. 22% after 6 weeks (P = 0·787) and 35% vs. 38% after 24 weeks (P = 0·801). The mean reduction in pain visual analogue scale scores was 38% vs. 55% after 6 weeks (P = 0·286) and 39% vs. 12% after 24 weeks (P = 0·452). Patients in the PDT group reported significantly less topical corticosteroid use during weeks 7-24 than those in the corticosteroid group. No major adverse events were reported. CONCLUSIONS Vulvovaginal HAL-PDT seems to be an effective and safe treatment for GELP.
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Affiliation(s)
- A L O Helgesen
- Norwegian National Advisory Unit on Women's Health, Oslo University Hospital, N-0424, Oslo, Norway.,Department of Dermatology, Oslo University Hospital, N-0424, Oslo, Norway.,Institute of Clinical Medicine, Oslo University Hospital, N-0424, Oslo, Norway
| | - T Warloe
- Department of Internal Medicine, Oslo University Hospital, N-0424, Oslo, Norway
| | - A H Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, N-0424, Oslo, Norway
| | - R Kirschner
- Department of Gynaecology, Oslo University Hospital, N-0424, Oslo, Norway
| | - Q Peng
- Department of Pathology, Oslo University Hospital, N-0424, Oslo, Norway
| | - T Tanbo
- Institute of Clinical Medicine, Oslo University Hospital, N-0424, Oslo, Norway.,Department of Gynaecology, Oslo University Hospital, N-0424, Oslo, Norway
| | - P Gjersvik
- Department of Dermatology, Oslo University Hospital, N-0424, Oslo, Norway.,Institute of Clinical Medicine, Oslo University Hospital, N-0424, Oslo, Norway
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15
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Pepas L, Kaushik S, Nordin A, Bryant A, Lawrie TA. Medical interventions for high-grade vulval intraepithelial neoplasia. Cochrane Database Syst Rev 2015; 2015:CD007924. [PMID: 26284429 PMCID: PMC6457779 DOI: 10.1002/14651858.cd007924.pub3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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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16
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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: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [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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17
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Preti M, Igidbashian S, Costa S, Cristoforoni P, Mariani L, Origoni M, Sandri MT, Boveri S, Spolti N, Spinaci L, Sanvito F, Preti EP, Falasca A, Radici G, Micheletti L. VIN usual type-from the past to the future. Ecancermedicalscience 2015; 9:531. [PMID: 25987900 PMCID: PMC4431399 DOI: 10.3332/ecancer.2015.531] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Indexed: 12/27/2022] Open
Abstract
Usual vulvar intraepithelial neoplasia (uVIN) is the most common VIN type, generally related to a human papillomavirus (HPV) infection, predominantly type 16. The incidence of uVIN has been increasing over the last decades, and a bimodal peak is observed at the age of 40–44 and over 55 years. Almost 40% of patients with uVIN have a past, concomitant or future HPV-associated lesion of the lower genital tract. HPV-related malignancies are associated with a persistent HPV infection. The host immune response is of crucial importance in determining clearance or persistence of both HPV infections and HPV-related VIN. About 60% of the patients present with symptoms. Clinical features of uVIN vary in site, number, size, shape, colour, and thickness of lesions. Multicentric disease is often present. Most uVIN lesions are positive at immunohistochemistry to p16ink4a and p14arf, but negative to p53. Irrespective of surgical treatment used, uVIN recurrence rates are high. Positive margins do not predict the development of invasive disease and the need to re-excide the tissue around the scare remains to be demonstrated. Therefore, considering the low progression rate of uVIN and psycosexual sequelae, treatments should be as conservative as possible. Medical treatments available are mainly based on immunotherapy to induce normalisation of immune cell count in uVIN. None are approved by the food and drug administration (FDA) for the treatment of uVIN. If medical treatment is performed, adequate biopsies are required to reduce the risk of unrecognised invasive disease. Some studies suggest that failure to respond to immunotherapy might be related to a local immunosuppressive microenvironment, but knowledge of the uVIN microenvironment is limited. Moreover, our knowledge of the potential mechanisms involved in the escape of HPV-induced lesions from the immune system has many gaps. HPV vaccines have been demonstrated to be effective in preventing uVIN, with 94.9% efficacy in the HPV-naive population, while studies on therapeutic vaccines are limited. The low incidence of VIN requires large multicentre studies to determine the best way to manage affected patients and to investigate the immunological characteristics of the ‘vulvar microenviroment’ which leads to the persistence of HPV.
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Affiliation(s)
- Mario Preti
- Preventive Gynecology Unit, European Institute of Oncology, Milano 20100, Italy ; The Italian HPV Study Group (IHSG)
| | - Sarah Igidbashian
- Preventive Gynecology Unit, European Institute of Oncology, Milano 20100, Italy
| | - Silvano Costa
- M.F. Toniolo Hospital, Bologna 40100, Italy ; The Italian HPV Study Group (IHSG)
| | - Paolo Cristoforoni
- Villa Montallegro, Genova 16100, Italy ; The Italian HPV Study Group (IHSG)
| | - Luciano Mariani
- HPV-Unit Gynecologic Oncology, Regina Elena National Cancer Institute of Rome, Rome 00100, Italy ; The Italian HPV Study Group (IHSG)
| | - Massimo Origoni
- Department of Obstetrics and Gynecology, Vita Salute San Raffaele University School of Medicine, Milano 20100, Italy ; The Italian HPV Study Group (IHSG)
| | - Maria T Sandri
- Division of Laboratory Medicine, European Institute of Oncology, Milano 20100, Italy ; The Italian HPV Study Group (IHSG)
| | - Sara Boveri
- Preventive Gynecology Unit, European Institute of Oncology, Milano 20100, Italy
| | - Noemi Spolti
- Preventive Gynecology Unit, European Institute of Oncology, Milano 20100, Italy
| | - Laura Spinaci
- Preventive Gynecology Unit, European Institute of Oncology, Milano 20100, Italy
| | - Francesca Sanvito
- Preventive Gynecology Unit, European Institute of Oncology, Milano 20100, Italy
| | - Eleonora P Preti
- Preventive Gynecology Unit, European Institute of Oncology, Milano 20100, Italy
| | - Adriana Falasca
- Preventive Gynecology Unit, European Institute of Oncology, Milano 20100, Italy
| | - Gianluigi Radici
- Preventive Gynecology Unit, European Institute of Oncology, Milano 20100, Italy
| | - Leonardo Micheletti
- Department of Obstetrics and Gynecology, University of Torino, Torino 10100, Italy
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18
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Kim JM, Lee HJ, Kim SH, Kim HS, Ko HC, Kim BS, Kim MB, Song M. Efficacy of 5% imiquimod cream on vulvar intraepithelial neoplasia in Korea: pilot study. Ann Dermatol 2015; 27:66-70. [PMID: 25673934 PMCID: PMC4323605 DOI: 10.5021/ad.2015.27.1.66] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 10/13/2014] [Accepted: 11/19/2014] [Indexed: 11/30/2022] Open
Abstract
Background Various therapeutic options, including surgery, electrocautery, cryotherapy, 5-fluorouracil treatment, laser therapy, radiotherapy, photodynamic therapy, and interferon-α/γ injection, have been employed to treat vulvar intraepithelial neoplasia (VIN) with varying degrees of success. To truly cure VIN, human papillomavirus elimination is considered important. Objective To investigate the efficacy of 5% imiquimod cream used to treat VIN in Korean patients Methods We performed a prospective, uncontrolled, observational study. Nine patients with histologically confirmed VIN applied 5% imiquimod cream to their vulvar lesions three to five times a week until a clinical response was apparent. All lesions were photo-documented, and therapeutic efficacy was assessed in terms of local adverse effects lesion number, size, and hyperpigmentation. Results The mean treatment duration was 30.2 months, and the median follow-up period after therapy completion was 30 months. Of the nine patients recruited, six (66.6%) experienced complete responses (CR) or partial responses (PR). Hyperpigmented patches in the VIN lesions were evident in five subjects (55.6%), and all experienced either CR or PR. Only three patients (33.3%) suffered from local adverse effects, which were relieved after temporary suspension of therapy, and better outcomes were attained ultimately. Conclusion The imiquimod cream was more efficacious when used to treat VIN of the hyperpigmented type compared with lesions lacking pigmentation. The unifocal nature of a lesion and the development of local adverse effects are useful factors when imiquimod cream is prescribed. However, although the cream is convenient and effective, regional resistance may develop, and close follow-up is essential because VIN may become malignant.
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Affiliation(s)
- Jeong-Min Kim
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea
| | - Hyun-Joo Lee
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea
| | - Su-Han Kim
- Goun Laser and Cosmetic Clinic, Busan, Korea
| | - Hoon-Soo Kim
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea. ; Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Hyun-Chang Ko
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea. ; Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Byung-Soo Kim
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea. ; Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Moon-Bum Kim
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea. ; Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Margaret Song
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea. ; Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Vulvar intraepithelial neoplasia. Best Pract Res Clin Obstet Gynaecol 2014; 28:1051-62. [DOI: 10.1016/j.bpobgyn.2014.07.010] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 07/11/2014] [Indexed: 11/22/2022]
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20
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Lu YG, Wang YY, Yang YD, Zhang XC, Gao Y, Yang Y, Zhang JB, Li GL. Efficacy of topical ALA-PDT combined with excision in the treatment of skin malignant tumor. Photodiagnosis Photodyn Ther 2014; 11:122-6. [DOI: 10.1016/j.pdpdt.2014.02.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 12/29/2013] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
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Kaushik S, Pepas L, Nordin A, Bryant A, Dickinson HO, Lawrie TA. Surgical interventions for high-grade vulval intraepithelial neoplasia. Cochrane Database Syst Rev 2014; 2014:CD007928. [PMID: 24596022 PMCID: PMC6457760 DOI: 10.1002/14651858.cd007928.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND This is an updated version of an original Cochrane review published in The Cochrane Library, 2011, Issue 1.Vulval intraepithelial neoplasia (VIN) is a pre-malignant condition of the vulval skin. This uncommon chronic skin condition of the vulva is associated with a high risk of recurrence and the potential to progress to vulval cancer. The condition is complicated by its multicentric and multifocal nature. The incidence of this condition appears to be rising, particularly in the younger age group. There is a lack of consensus on the optimal surgical treatment method. However, the rationale for the surgical treatment of VIN has been to treat the symptoms and exclude any underlying malignancy, with the continued aim of preserving the vulval anatomy and function. Repeated treatments affect local cosmesis and cause psychosexual morbidity, thus impacting he individual's quality of life. OBJECTIVES To evaluate the effectiveness and safety of surgical interventions in women with high-grade VIN. SEARCH METHODS We searched the Cochrane Gynaecological Cancer Group Trials Register and the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 11,2013 and MEDLINE and EMBASE up to December 2013. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies, and contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared surgical interventions in adult women diagnosed with high-grade VIN. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data and assessed risk of bias. MAIN RESULTS We identified one RCT, including 30 women, that met our inclusion criteria; this trial reported data on carbon dioxide (CO2) laser surgery versus cavitational ultrasonic surgical aspiration (CUSA). There were no statistically significant differences in the risks of disease recurrence after one year of follow-up, pain, scarring, dysuria or burning, adhesions, infection, abnormal discharge or eschar between women who underwent CO2 laser surgery and those who received CUSA. The trial lacked statistical power due to the small number of women in each group and the low number of observed events, but was at low risk of bias. AUTHORS' CONCLUSIONS The included trial lacked statistical power due to the small number of women in each group and the low number of observed events. The absence of reliable evidence regarding the effectiveness and safety of the two surgical techniques for the management of VIN therefore precludes any definitive guidance or recommendations for clinical practice.
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Affiliation(s)
- 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
| | - 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
| | - Heather O Dickinson
- 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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Kushnir CL, Fleury AC, Hill MC, Silver DF, Spirtos NM. The use of argon beam coagulation in treating vulvar intraepithelial neoplasia III: a retrospective review. Gynecol Oncol 2013; 131:386-8. [PMID: 23887037 DOI: 10.1016/j.ygyno.2013.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 06/03/2013] [Accepted: 06/06/2013] [Indexed: 11/18/2022]
Abstract
UNLABELLED Argon beam coagulation (ABC) has unique properties which make it suitable for the local treatment of superficial epithelial disorders such as vulvar intraepithelial neoplasia (VIN III). OBJECTIVE To evaluate argon beam coagulation in treating multifocal VIN III. METHODS Argon beam coagulation was used in twenty-nine patients. ABC was set at 80 W, 7 L/min. All patients were given 1% silvadene cream to apply to vulva. Patients had follow-up appointments two weeks and six weeks postoperatively. Patients were followed every three to six months for the subsequent year. RESULTS 2 of 29 (6.8%) experienced moderate pain within the first two weeks postoperatively requiring prescriptions for perocet. 2 of 29 (6.8%) had yeast infection requiring diflucan. Mean follow-up time was 34.9 months (11.7-37.4). 15 of 29 (51.7%) had no recurrence within the follow-up period. 14 of 29 (48.3%) recurred within the follow-up period. The mean time to recurrence is 23.2 months. CONCLUSION This small retrospective review is the first to evaluate argon beam coagulation in treating multifocal VIN III. This review indicates that ABC is comparable to other vulva organ conserving therapies. ABC retains cosmesis, and form of the vulva. This is a major advantage over surgery. Repeat treatments are also possible, which is important in a condition such as VIN, which tends to be multifocal and recurrent.
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Affiliation(s)
- Christina L Kushnir
- Department of Obstetrics and Gynecology, Johns Hopkins Medical Institutions, Kelly Gynecologic Oncology Service, 600 North Wolfe Street, Phipps 281, Baltimore, MD 21287, USA
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van Esch EMG, Welters MJP, Jordanova ES, Trimbos JBMZ, van der Burg SH, van Poelgeest MIE. Treatment failure in patients with HPV 16-induced vulvar intraepithelial neoplasia: understanding different clinical responses to immunotherapy. Expert Rev Vaccines 2012; 11:821-40. [PMID: 22913259 DOI: 10.1586/erv.12.56] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Failure of the immune system to launch a strong and effective immune response to high-risk HPV is related to viral persistence and the development of anogenital (pre)malignant lesions such as vulvar intraepithelial neoplasia (VIN). Different forms of immunotherapy, aimed at overcoming the inertia of the immune system, have been developed and met with clinical success. Unfortunately these, in principal successful, therapeutic approaches also fail to induce clinical responses in a substantial number of cases. In this review, the authors summarize the traits of the immune response to HPV in healthy individuals and in patients with HPV-induced neoplasia. The potential mechanisms involved in the escape of HPV-induced lesions from the immune system indicate gaps in our knowledge. Finally, the interaction between the immune system and VIN is discussed with a special focus on the different forms of immunotherapy applied to treat VIN and the potential causes of therapy failure. The authors conclude that there are a number of pre-existing conditions that determine the patients' responsiveness to immunotherapy. An immunotherapeutic strategy in which different aspects of immune failure are attacked by complementary approaches, will improve the clinical response rate.
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Affiliation(s)
- Edith M G van Esch
- Department of Gynecology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
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Fallani MG, Fambrini M, Lozza V, Bianchi C, Pieralli A. CO2 laser total superficial vulvectomy: an outpatient treatment for wide multifocal vulvar intraepithelial neoplasia grade 3. J Minim Invasive Gynecol 2012; 19:758-61. [PMID: 23084682 DOI: 10.1016/j.jmig.2012.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 07/27/2012] [Accepted: 08/02/2012] [Indexed: 11/29/2022]
Abstract
The ideal treatment of large multifocal vulvar intraepithelial neoplasia grade 3 (VIN 3) in young patients is still debated. The goal is to prevent development of invasive vulvar cancer while preserving normal vulvar anatomy and function. The authors describe the case of a 37-year-old woman affected by a biopsy-proven VIN 3 involving the entire external genitalia. A total superficial vulvectomy was carried out in 2 closer sessions by CO(2) laser used in an excisional way. Both procedures were performed in an outpatient setting with the patient under local anesthesia and without suturing stitches or skin flaps. Definitive pathologic analysis confirmed VIN 3 with free margins. No intraoperative and postoperative complications were documented. Functional and anatomic outcomes were optimal, and no relapse occurred after 12 months of follow-up. Use of CO(2) laser total superficial vulvectomy shows promise of a safe and adequate treatment in selected young patients with VIN 3 involving the entire external genitalia.
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Affiliation(s)
- Maria Grazia Fallani
- Department of Science for Woman and Child Health, University of Florence, Florence, Italy
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Shishkova N, Kuznetsova O, Berezov T. Photodynamic therapy for gynecological diseases and breast cancer. Cancer Biol Med 2012; 9:9-17. [PMID: 23691448 PMCID: PMC3643637 DOI: 10.3969/j.issn.2095-3941.2012.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 01/12/2012] [Indexed: 12/19/2022] Open
Abstract
Photodynamic therapy (PDT) is a minimally invasive and promising new method in cancer treatment. Cytotoxic reactive oxygen species (ROS) are generated by the tissue-localized non-toxic sensitizer upon illumination and in the presence of oxygen. Thus, selective destruction of a targeted tumor may be achieved. Compared with traditional cancer treatment, PDI has advantages including higher selectivity and lower rate of toxicity. The high degree of selectivity of the proposed method was applied to cancer diagnosis using fluorescence. This article reviews previous studies done on PDT treatment and photodetection of cervical intraepithelial neoplasia, vulvar intraepithelial neoplasia, ovarian and breast cancer, and PDT application in treating non-cancer lesions. The article also highlights the clinical responses to PDT, and discusses the possibility of enhancing treatment efficacy by combination with immunotherapy and targeted therapy.
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Affiliation(s)
- Natashis Shishkova
- Department of Biochemistry, School of Medicine, People's Friendship University of Russia, Moscow 117198, Russia
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Pepas L, Kaushik S, Bryant A, Nordin A, Dickinson HO. Medical interventions for high grade vulval intraepithelial neoplasia. Cochrane Database Syst Rev 2011:CD007924. [PMID: 21491403 PMCID: PMC4170998 DOI: 10.1002/14651858.cd007924.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Vulval intraepithelial neoplasia (VIN) is a pre-malignant condition of the vulval skin; its incidence is increasing in women under 50 years. VIN is graded histologically as low grade or high grade. High grade VIN is associated with infection with human papilloma virus (HPV) infection and may progress to invasive disease. There is no consensus on the optimal management of high grade VIN. The high morbidity and high relapse rate associated with surgical interventions call for a formal appraisal of the evidence available for less invasive but effective interventions for high grade VIN. OBJECTIVES To evaluate the effectiveness and safety of medical interventions for high grade VIN. SEARCH STRATEGY We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3), MEDLINE and EMBASE (up to September 2010). 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 interventions, in adult women diagnosed with high grade VIN. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data and assessed risk of bias. Where possible the data were synthesised in a meta-analysis. MAIN RESULTS Four trials met our inclusion criteria: three assessed the effectiveness of topical imiquimod versus placebo in women with high grade VIN; one examined low versus high dose indole-3-carbinol in similar women. Meta-analysis of three trials found that the proportion of women who responded to treatment at 5 to 6 months was much higher in the group who received topical imiquimod than in the group who received placebo (relative risk (RR) = 11.95, 95% confidence interval (CI) 3.21 to 44.51). A single trial showed similar results at 12 months in (RR = 9.10, 95% CI 2.38 to 34.77). Only one trial reported adverse events, which were more common in the imiquimod group. One trial found no significant differences in quality of life (QoL) or body image between the imiquimod and placebo groups. AUTHORS' CONCLUSIONS Imiquimod appears to be effective, but its safety needs further examination. Its use is associated with side effects which are tolerable, but more extensive data on adverse effects are required. Long term follow-up should be mandatory in view of the known progression of high grade VIN to invasive disease. Alternative medical interventions, such as cidofovir, should be explored.
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Affiliation(s)
- Litha Pepas
- Centre of Reproductive Medicine, Barts Health NHS Trust, London, UK
| | - Sonali Kaushik
- Division of Gynaecological Oncology, Cheltenham General Hospital, Cheltenham, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Andy Nordin
- East Kent Gynaecological Oncology Centre, Queen Elizabeth The Queen Mother Hospital, Kent, UK
| | - Heather O Dickinson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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St Denis TG, Aziz K, Waheed AA, Huang YY, Sharma SK, Mroz P, Hamblin MR. Combination approaches to potentiate immune response after photodynamic therapy for cancer. Photochem Photobiol Sci 2011; 10:792-801. [PMID: 21479313 DOI: 10.1039/c0pp00326c] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Photodynamic therapy (PDT) has been used as a cancer therapy for forty years but has not advanced to a mainstream cancer treatment. Although it has been shown to be an efficient way to destroy local tumors by a combination of non-toxic dyes and harmless visible light, it is its additional effects in mediating the stimulation of the host immune system that gives PDT great potential to become more widely used. Although the stimulation of tumor-specific cytotoxic T-cells that can destroy distant tumor deposits after PDT has been reported in some animal models, it remains the exception rather than the rule. This realization has prompted several investigators to test various combination approaches that could potentiate the immune recognition of tumor antigens that have been released after PDT. This review will cover these combination approaches using immunostimulants including various microbial preparations that activate Toll-like receptors and other receptors for pathogen-associated molecular patterns, cytokines growth factors, and approaches that target regulatory T-cells. We believe that by understanding the methods employed by tumors to evade immune response and neutralizing them, more precise ways of potentiating PDT-induced immunity can be devised.
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Affiliation(s)
- Tyler G St Denis
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02114, USA
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Ballester I, Belinchón I, Guijarro J, Oltra F, Toledo F, Cuesta L. Photodynamic therapy of vulvar intraepithelial neoplasia using methyl aminolevulinate. J DERMATOL TREAT 2011; 23:156-8. [DOI: 10.3109/09546634.2010.509640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kaushik S, Pepas L, Nordin A, Bryant A, Dickinson HO. Surgical interventions for high grade vulval intraepithelial neoplasia. Cochrane Database Syst Rev 2011:CD007928. [PMID: 21249698 PMCID: PMC4170992 DOI: 10.1002/14651858.cd007928.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Vulval intraepithelial neoplasia (VIN) is a pre-malignant condition of the vulval skin. This uncommon chronic skin condition of the vulva is associated with a high risk of recurrence and the potential to progress to vulval cancer. The condition is complicated by its' multicentric and multifocal nature. The incidence of this condition appears to be rising particularly in the younger age group.There is a lack of consensus on the optimal surgical treatment method. However, the rationale for surgical treatment of VIN has been to treat symptoms and exclude underlying malignancy with the continued aim of preservation of vulval anatomy and function. Repeated treatments affect local cosmesis and cause psychosexual morbidity thus impacting on the patients' quality of life. OBJECTIVES To evaluate the effectiveness and safety of surgical interventions for high grade VIN. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 3, 2010, Cochrane Gynaecological Cancer Group Trials Register, MEDLINE and EMBASE up to September 2010. 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 compared surgical interventions, in adult women diagnosed with high grade vulval intraepithelial neoplasia. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data and assessed risk of bias. MAIN RESULTS We found only one RCT which included 30 women that met our inclusion criteria and this trial reported data on carbon dioxide laser (CO(2) laser) versus ultrasonic surgical aspiration (USA).There was no statistically significant difference in the risk of disease recurrence after one year follow-up, pain, presence of scarring, dysuria or burning, adhesions, infection, abnormal discharge and eschar between women who received CO(2) laser and those who received USA. The trial lacked statistical power due to the small number of women in each group and the low number of observed events, but was at low risk of bias. AUTHORS' CONCLUSIONS The included trial lacked statistical power due to the small number of women in each group and the low number of observed events. Therefore in the absence of reliable evidence regarding the effectiveness and safety of the two surgical techniques for the management of vulval intraepithelial neoplasia precludes any definitive guidance or recommendations for clinical practice.
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Affiliation(s)
- Sonali Kaushik
- Obstetrics and Gynaecology, Queen Elizabeth The Queen Mother Hospital, Kent, UK
| | - Litha Pepas
- Obstetrics and Gynaecology, Queen Elizabeth The Queen Mother Hospital, Kent, UK
| | - Andy Nordin
- East Kent Gynaecological Oncology Centre, Queen Elizabeth The Queen Mother Hospital, Kent, UK
| | - Andrew Bryant
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Heather O Dickinson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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Abstract
Approximately one of every 10 women has a pigmented vulvar lesion. Given the risk of melanomas and pigmented vulvar intraepithelial neoplasia (squamous cell carcinoma in situ), proper evaluation of vulvar pigmented lesions is critical. Most vulvar lesions are benign; however, vulvar lesions grossly, dermoscopically, and histologically can appear atypical compared with pigmented lesions on the rest of the body. Thus, it is imperative to use not only a keen eye but also a low threshold for biopsy.
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Daayana S, Winters U, Stern PL, Kitchener HC. Clinical and immunological response to photodynamic therapy in the treatment of vulval intraepithelial neoplasia. Photochem Photobiol Sci 2011; 10:802-9. [DOI: 10.1039/c0pp00344a] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Soergel P, Hillemanns P. Photodynamic therapy for intraepithelial neoplasia of the lower genital tract. Photodiagnosis Photodyn Ther 2010; 7:10-4. [PMID: 20230987 DOI: 10.1016/j.pdpdt.2009.12.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 12/19/2009] [Accepted: 12/21/2009] [Indexed: 11/15/2022]
Abstract
Photodynamic Diagnosis (PDD) and Therapy (PDT) are modern methods which are evaluated in different fields in gynaecology. PDT has been successfully evaluated in human papillomavirus-related (HPV) genital dysplasia like CIN and VIN. The aim of this review is to give an overview about current applications.
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Affiliation(s)
- Philipp Soergel
- University Women's Hospital, Hanover Medical School, Carl-Neuberg-Strasse 1, 30625 Hanover, Germany.
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McFadden KM, Sharp L, Cruickshank ME. The prospective management of women with newly diagnosed vulval intraepithelial neoplasia: clinical outcome and quality of life. J OBSTET GYNAECOL 2010; 29:749-53. [PMID: 19821671 DOI: 10.3109/01443610903191285] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Vulval intraepithelial neoplasia (VIN) is a premalignant skin condition with significant morbidities from standard surgical treatment. This two-year prospective study recruited women with newly diagnosed VIN for careful observation rather than primary surgical excision. Surgery was performed to exclude progression or for uncontrollable symptoms. Participants were seen six-monthly for clinical review and completion of questionnaires assessing depression and anxiety, quality of life, sexual functioning, and partner relationships. Eight women were recruited. Six women required immediate treatment and two women were observed carefully. By study completion, seven participants had undergone surgical treatment, often for symptom control. Women scored poorly on quality of life and sexual functioning scores; this did not appear to be due to depression or anxiety. In conclusion, careful observation does not appear a feasible option for most women with VIN since the majority require surgical treatment. VIN has an adverse impact on quality of life and sexual functioning.
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Clinical and immunohistochemical assessment of vulval intraepithelial neoplasia following photodynamic therapy using a novel bioadhesive patch-type system loaded with 5-aminolevulinic acid. Photodiagnosis Photodyn Ther 2009; 6:28-40. [PMID: 19447369 DOI: 10.1016/j.pdpdt.2009.03.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Revised: 03/27/2009] [Accepted: 03/30/2009] [Indexed: 11/21/2022]
Abstract
BACKGROUND The work in this study appraised photodynamic treatment (PDT) as a treatment method for vulval intraepithelial neoplasia (VIN) using a novel bioadhesive patch to deliver aminolevulinic acid. An analysis of changes in expression of apoptotic and cell cycle proteins (p53, p21, Mdm2, Blc-2, Bax, Ki-67) in response to PDT was evaluated. METHODS PDT was performed using non-laser light, either as a one or two-cycle treatment, with clinical and pathological assessment following after 6 weeks. Twenty-three patients with 25 VIN lesions underwent 49 cycles of PDT. Patches were designed to conform to uneven vulval skin and contained 38 mg cm(-2) aminolevulinic acid. Assessment was carried out at 6 weeks post-treatment. Patient-based treatment assessment, along with clinical and pathological changes, were monitored. Immunohistochemical staining was used to elucidate a possible biomolecular basis for induced cellular changes. RESULTS Most patients (52%) reported a symptomatic response, with normal pathology restored in 38% of lesions. The patch was easy to apply and remove, causing minimal discomfort. Fluorescence inspection confirmed protoporphyrin accumulation. Pain during implementation of PDT was problematic, necessitating some form of local analgesia. Changes in expression of cell cycle and apoptotic-related proteins suggested involvement of apoptotic pathways. Down regulation of p21 and inverse changes in Bcl-2 and Bax were key findings. CONCLUSION Treatment of VIN lesions using a novel bioadhesive patch induced changes in cell cycle and apoptotic proteins in response to PDT with possible utilisation of apoptotic pathways. The efficacy of PDT in treating VIN could be improved by a better understanding of these apoptotic mechanisms, the influence of factors, such as HPV status, and of the need for effective pain management.
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Hillemanns P, Soergel P, Löning M. Fluorescence diagnosis and photodynamic therapy for lower genital tract diseases – A review. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.mla.2008.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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van de Nieuwenhof H, van der Avoort I, de Hullu J. Review of squamous premalignant vulvar lesions. Crit Rev Oncol Hematol 2008; 68:131-56. [DOI: 10.1016/j.critrevonc.2008.02.012] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2007] [Revised: 02/15/2008] [Accepted: 02/26/2008] [Indexed: 01/31/2023] Open
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Winters U, Daayana S, Lear JT, Tomlinson AE, Elkord E, Stern PL, Kitchener HC. Clinical and immunologic results of a phase II trial of sequential imiquimod and photodynamic therapy for vulval intraepithelial neoplasia. Clin Cancer Res 2008; 14:5292-9. [PMID: 18698049 DOI: 10.1158/1078-0432.ccr-07-4760] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE High-risk human papillomavirus (HPV)-associated vulval intraepithelial neoplasia (VIN) is difficult to treat by excision or ablation because of high recurrence rates. Small studies of photodynamic therapy (PDT) and imiquimod treatments have shown some success and function at least in part through stimulation of local immune responses. Indeed, there is evidence that immunosuppressed individuals have higher rates of VIN, suggesting immune control is relevant. EXPERIMENTAL DESIGN In the study, 20 women with high-grade VIN were treated with topical imiquimod and the PDT sequentially. Vulval biopsy and blood were taken pretreatment and, after imiquimod and PDT, with follow up for 1 year. Clinical response was assessed by measuring lesion size. Biopsies were analyzed for HPV DNA and tumor-infiltrating lymphocytes including T regulatory cells. RESULTS The treatment was well-tolerated. There was an overall response rate of 55% by intention treat and 64% per protocol. The 52-week symptom response was 65% asymptomatic, compared with 5% at baseline. The nonresponders showed a significantly higher level of T regulatory cells in the lesions after imiquimod treatment. CONCLUSIONS The response rates are clinically relevant, and the treatment regimen was feasible for the majority. Initial nonresponders to imiquimod seem to be relatively refractory, and this may derive from their unfavorable local immune environment, in particular, the increased proportions of T regulatory cells, possibly the limiting action and/or development of any HPV T-cell immunity. The potential benefit of this treatment is its ability to treat multifocal disease.
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Affiliation(s)
- Ursula Winters
- School of Cancer and Imaging, University of Manchester, St. Mary's Hospital, Immunology Group, Paterson Institute for Cancer Research, University of Manchester, Manchester, United Kingdom
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McCarron PA, Donnelly RF, Woolfson AD. Autoradiographic and Scintillation Analysis of 5-Aminolevulinic Acid Permeation Through Epithelialised Tissue: Implications for Topical Photodynamic Therapy of Superficial Gynaecological Neoplasias. Pharm Res 2007; 25:812-26. [PMID: 17657596 DOI: 10.1007/s11095-007-9352-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Accepted: 05/17/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE Aminolevulinic acid (5-ALA) diffusion through both keratinised and non-keratinised tissue, used as a model tissue substrates, was evaluated, together with the depth of permeation and the concentration achieved following delivery from bioadhesive patch and proprietary cream formulations. MATERIALS AND METHODS Moisture-activated, bioadhesive patches loaded with 5-ALA at concentrations of 19.0, 38.0 and 50.0 mg cm(-2) and an o/w cream (20% w/w 5-ALA) were radiolabelled with C14 5-ALA and applied to excised human vaginal tissue and porcine skin. After 1, 2 and 4 h, tissue was sectioned in two orientations and the 5-ALA concentration at specific depths determined using autoradiography and liquid scintillation counting (LSC). RESULTS The stratum corneum was a significant barrier to 5-ALA permeation, with concentrations in tissue dependent on application time and drug loading. 5-ALA was detected at 6 mm using autoradiography after 2 h, with LSC showing phototoxic concentrations at 2.375 mm after 4 h of application. Inclusion of oleic acid and dimethyl sulphoxide in bioadhesive patches increased 5-ALA significantly in neonate porcine tissue, but only for patches cast from blends containing 5% w/w oleic acid. CONCLUSIONS The bioadhesive patch described delivered 5-ALA to depths of at least 2.5 mm in tissue types indicative of vulval skin, suggesting that photodynamic therapy of deep vulval intraepithelial neoplasia is feasible using this means of bioadhesive 5-ALA delivery.
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Affiliation(s)
- Paul A McCarron
- School of Pharmacy, Queens University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK.
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Hillemanns P. Invited comments. Photodiagnosis Photodyn Ther 2007; 4:94. [PMID: 25047340 DOI: 10.1016/j.pdpdt.2007.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2007] [Accepted: 02/27/2007] [Indexed: 11/16/2022]
Affiliation(s)
- Peter Hillemanns
- Department of Obstetrics and Gynecology, Medical University Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
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Donnelly RF, McCarron PA, Woolfson AD. Drug Delivery of Aminolevulinic Acid from Topical Formulations Intended for Photodynamic Therapy¶. Photochem Photobiol 2007. [DOI: 10.1111/j.1751-1097.2005.tb01439.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Mainstream uses for photodynamic therapy (PDT) in dermatology include nonmelanoma skin cancer and its precursors, acne vulgaris, photorejuvenation, and hidradenitis suppurativa. Many other dermatologic entities have been treated with PDT, including psoriasis, lichen planus, lichen sclerosus, scleroderma, cutaneous T cell lymphoma, alopecia areata, verruca vulgaris, Darier's disease and tinea infections. Nondermatologic applications include anal and vulva carcinoma, palliation of metastatic breast cancer to skin, Barrett's esophagus, and macular degeneration of the retina. PDT also has found to be useful in immunologic and inflammatory disorders, neoplasias other than skin cancer, and infections. The ability of this treatment to hone in on dysplastic epithelial and endothelial cells while retaining viability of surrounding tissue is its key feature because this leads to specific tumor destruction with cosmesis and function of the target organ intact.
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Affiliation(s)
- Amy Forman Taub
- Department of Dermatology, Northwestern University Medical School, 676 St. Clair Street, Chicago, IL 60611, USA.
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Wang XL, Wang HW, Guo MX, Huang Z. Combination of immunotherapy and photodynamic therapy in the treatment of Bowenoid papulosis. Photodiagnosis Photodyn Ther 2007; 4:88-93. [PMID: 25047339 DOI: 10.1016/j.pdpdt.2007.01.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2006] [Revised: 12/30/2006] [Accepted: 01/02/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the feasibility and efficacy of combination of imiquimod and 5-aminolevulinic acid-mediated photodynamic therapy (ALA-PDT) for the treatment of genital Bowenoid papulosis (BP). MATERIALS AND METHODS A total of 27 BP patients were randomized into two groups. Fifteen (12 male and 3 female, age 22-56 years old) were treated with topical application of 5% imiquimod cream (three times a week) and ALA-PDT (100J/cm(2) at 100mW/cm(2), once a week) for 1-4 times. For comparison, other 12 (6 male and 6 female, age 29-58 years old) were treated with CO2 laser vaporization as a control. Patients were followed up for 3-12 months. Biopsies were taken from BP lesions prior to treatment and tested for HPV-16 and HPV-18 DNA. RESULTS In combined therapy group, 60% (9/15) patients showed complete remission and only one recurred (11.1%) during follow up. Local side effects included mild erythema, edema, erosion and burning and/or stinging sensation. No systemic side effect was found. In CO2 laser vaporization group, 83.3% (10/12) patients showed complete remission. However, recurrence occurred in six patients (60.0%). Local side effects included mild to moderate edema, erosion, ulceration, delayed healing, prolonged pain and scarring. The difference of recurrence rate between two groups was statistically significant (P<0.05). CONCLUSION Topical application of imiquimod cream and ALA-PDT is safe, effective and associated with low recurrence and less side effect.
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Affiliation(s)
- Xiu-Li Wang
- Shanghai Skin Diseases and STD Hospital, Shanghai 200050, PR China
| | - Hong-Wei Wang
- Shanghai Skin Diseases and STD Hospital, Shanghai 200050, PR China
| | - Ming-Xia Guo
- Shanghai Skin Diseases and STD Hospital, Shanghai 200050, PR China
| | - Zheng Huang
- University of Colorado at Denver and Health Sciences Center, Aurora, CO, USA
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Booth S, Poole D, Moghissi K. Initial experience of the use of photodynamic therapy (PDT) in recurrent malignant and pre-malignant lesions of the vulva. Photodiagnosis Photodyn Ther 2006; 3:156-61. [PMID: 25049149 DOI: 10.1016/j.pdpdt.2006.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2006] [Revised: 06/12/2006] [Accepted: 06/14/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To assess the suitability and effectiveness of photodynamic therapy (PDT) in the treatment and symptom relief of vulval intraepithelial neoplasia (VIN), other pre-malignant and early neoplastic conditions of the vulva in an out patient setting. METHODS Patients were selected from the vulvoscopy clinic whilst being investigated or under long-term follow-up. PDT was offered to patients in whom other treatments had failed or were unsuitable. 5-Aminoleuvinic acid (5-ALA) was used as a topical pro-drug, inducing the photosensitiser protoporphyrin IX. This was applied 4-6h before treatment. Laser light (630nm) generated by a Diode laser and Light Emitting Diode (LED) non-laser light of 630nm wavelength was also used. Initially, PDT was carried out with no analgesia, followed by oral analgesia, inhaled nitrous oxide and oral anxiolytic. Patients were seen and examined 2-3 weeks following treatment to assess clinical and symptomatic improvement. Further review was arranged as required. RESULTS All those who had been symptomatic described improvement of their symptoms and all improved clinically. However, pain was a significant side effect during treatment and for 24h post treatment in most cases. CONCLUSION The use of PDT for pre-malignant and early malignant vulval conditions, particularly VIN appears to be effective in the control of symptoms and can be carried out in an outpatient setting. However, a further long-term study, combined with biopsy, is needed to assess the pathological response. Pain is a significant side effect.
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Affiliation(s)
- Susanne Booth
- Department of MRI, Hull Royal Infirmary, Anlaby Road, Hull, East Yorkshire HU3 2JZ, United Kingdom
| | - David Poole
- Department of Gynaecology, Castle Hill Hospital, Cottingham, Hull, East Yorkshire HU16 5JQ, United Kingdom
| | - Keyvan Moghissi
- Yorkshire Laser Centre, Goole and District Hospital, Woodland Avenue, Goole, East Yorkshire DN14 6RX, United Kingdom
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Hillemanns P, Wang X. Integration of HPV-16 and HPV-18 DNA in vulvar intraepithelial neoplasia. Gynecol Oncol 2006; 100:276-82. [PMID: 16300821 DOI: 10.1016/j.ygyno.2005.10.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Revised: 09/27/2005] [Accepted: 10/03/2005] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Vulvar intraepithelial neoplasia (VIN) is a premalignant disease of the lower genital tract. The increased occurrence of high-risk human papillomavirus (HPV) infection seems to be associated with the increasing frequency of VIN. Integration of HPV DNA into host chromosome has been hypothesized to be a critical step in the carcinogenesis of cervical neoplasia resulting in altered expression of two viral transforming genes E6 and E7. METHOD We analyzed HPV-16 and HPV-18 DNA, and integrated transcripts of HPV-16 and HPV-18 genomes in 30 VIN cases with 53 lesions using a PCR-based protocol for the amplification of papillomavirus oncogene transcripts (APOT). RESULT 24 of 30 VIN lesions (80%) harbored HPV-16 (in 23 cases) and HPV-18 DNA. Integration of HPV-16 and HPV-18 genome was observed in eight (38.1%) of 21 HPV-16/18 positive VIN III cases. All eight VIN were multifocal and had multicentric disease (CIN/VAIN) including one case that progressed to vulvar carcinoma. Five of eight lesions were found to have E7 specific viral-cellular fusion transcripts only, two of eight showed E7-E4 viral-cellular fusion transcripts, and one of eight had both episomally derived and E7-E4 viral-cellular fusion transcripts. In 10 (83.3%) of 12 multifocal VIN III patients, all specimens derived from the same patient harbored the same HPV type and HPV transcript pattern suggesting monoclonality. CONCLUSION HPV-16 is the most prevalent type among VIN II/III. HPV-16 and HPV-18 DNA integration into host cell genome seems to be related to the progression stage of vulvar dysplasia and, therefore, may be necessary for development of HPV-associated invasive vulvar carcinoma.
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Affiliation(s)
- Peter Hillemanns
- Department of Obstetrics and Gynecology of the University of Munich-Grosshadern, Germany.
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Donnelly RF, Morrow DIJ, McCarron PA, Juzenas P, Woolfson AD. Pharmaceutical analysis of 5-aminolevulinic acid in solution and in tissues. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY B-BIOLOGY 2006; 82:59-71. [PMID: 16242952 DOI: 10.1016/j.jphotobiol.2005.08.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2005] [Revised: 08/10/2005] [Accepted: 08/26/2005] [Indexed: 11/28/2022]
Abstract
Quantification of 5-aminolevulinic acid (ALA) in solution, and methods used to achieve this, have been extensively reported in the literature. However, validated methods have only rarely been presented and never have methods been compared. Due to a necessity in drug delivery research for optimised and validated methods for determination of ALA in solution, this paper compares, for the first time, two such methods validated to International Conference on Harmonisation (ICH) standards. Of major importance, derivatisation of ALA with acetyl acetone and formaldehyde was found to be more suitable for routine fluorimetric HPLC analysis of ALA than derivatisation with o-phthaldialdehyde and 2-mercaptoethanol. This former method was successfully utilised in the comparison of in vitro drug release from a proprietary ALA cream and a novel bioadhesive patch-based system. In addition, determination of ALA in tissue is necessary to compare different topical formulations, in terms of their ability to deliver the drug successfully, and different tissue types, to assess their barrier properties to penetration of the drug. Consequently, this paper also describes the use of liquid scintillation spectroscopy as an analytical tool for rapid, convenient and routine quantification of ALA in tissue and determination of penetration depth following topical application of creams and patches.
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Affiliation(s)
- Ryan F Donnelly
- School of Pharmacy, Queens University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, UK.
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Abstract
ALA-PDT is a safe, well-tolerated, and effective treatment for many dermatologic conditions. Current data most strongly support its use in the treatment of actinic damage, but further investigation into alternative uses continues. Current efficacy is limited primarily by the depth of penetration of the photosensitizing agent and the activating light source. Even with this limitation, the potential applications of PDT are numerous. As new technology is developed to overcome current restraints, the future of PDT is wide open.
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Affiliation(s)
- Mario Preti
- Department of Obstetrics and Gynaecology, University of Torino, Torino, Italy.
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Hillemanns P, Wang X, Staehle S, Michels W, Dannecker C. Evaluation of different treatment modalities for vulvar intraepithelial neoplasia (VIN): CO(2) laser vaporization, photodynamic therapy, excision and vulvectomy. Gynecol Oncol 2005; 100:271-5. [PMID: 16169064 DOI: 10.1016/j.ygyno.2005.08.012] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Revised: 08/07/2005] [Accepted: 08/16/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To evaluate various treatment modalities for vulvar intraepithelial neoplasia (VIN) in relation to possible risk factors for recurrence. METHODS Retrospective review of 93 patients with VIN treated by CO(2) laser vaporization, photodynamic therapy with aminolevulinic acid (PDT), excision or vulvectomy. RESULTS 40.4% of the 47 patients with laser vaporization, 48.1% of 27 patients with PDT, 42% of 12 patients with local excision and none of the 7 patients treated by vulvectomy experienced a relapse within a mean follow-up of 53.7 months. The risk for recurrence significantly increased with VIN grade (P = 0.02), multifocal VIN disease (P = 0.01), multicentric intraepithelial neoplasia (P = 0.05) and high-risk HPV infection (P < 0.001). In multivariate analysis, only HPV status remained significant (P = 0.012) and, if HPV testing is not available, multifocality (P = 0.03). The lowest rate of postoperative side effects was noted in patients after PDT. There was one (1%) case of progression to vulvar cancer. CONCLUSIONS Vulva preserving treatment methods for VIN have high recurrence rates, especially in patients with HPV infection and multifocal disease. Therefore, careful long-term surveillance is mandatory.
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Affiliation(s)
- Peter Hillemanns
- Department of Obstetrics and Gynecology, Klinikum Grosshadern, Ludwig-Maximilians-University, Munich, Germany.
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Therapeutic effects of 5-ALA-induced photodynamic therapy in vulvar lichen sclerosus. Photodiagnosis Photodyn Ther 2005; 2:157-60. [PMID: 25048675 DOI: 10.1016/s1572-1000(05)00062-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2005] [Revised: 06/08/2005] [Accepted: 06/09/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND Lichen sclerosus (LS) is a rarely diagnosed, chronic inflammatory skin and mucosal condition. Its therapy is difficult and frequently not satisfactory. The data on photodynamic therapy (PDT) of vulva are promising but scanty. The aim of our study was to evaluate the therapeutic efficacy of photodynamic therapy in genital LS in women. METHODS Twenty-four patients with clinical and histopathological diagnosis of lichen sclerosus accompanied with chronic vulvar itching, lasting between 3 months and 11 years, with human papillomavirus (HPV), bacterial and mycotic infections excluded, received three to six PDT cycles (180J, 700mW/cm(2)) in 14 days long intervals. Simultaneously they received no topical corticosteroids. Photodynamic diagnosis (PDD) was conducted prior to therapy and 4 weeks after its completion. RESULTS In 17 patients, the itching ceased completely, in 6 women it decreased, in 1 patient the itching continued, none of the patients presented exacerbation of itching. PDD after completion of therapy revealed in 10 patients normal, green fluorescence of vulva and in 14 women pathological, red fluorescence, usually fainter than before PDT. CONCLUSION PDT is an effective therapeutic modality for chronic itching in lichen sclerosus.
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