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Imiquimod for vaginal intraepithelial neoplasia 2-3: A systematic review and meta-analysis. Gynecol Oncol 2020; 160:140-147. [PMID: 33010966 DOI: 10.1016/j.ygyno.2020.09.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 09/15/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The treatment strategy for vaginal intraepithelial neoplasia (VaIN) 2-3 has not been established. This study aimed to investigate the efficacy of imiquimod in VaIN 2-3. METHODS Electronic databases (PubMed, EMBASE, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials) were searched from their inception until October 2019 and articles reporting imiquimod treatment for VaIN 2-3 were extracted. Additionally, the clinical records of women with VaIN 2-3 who had been treated with imiquimod in Shizuoka General Hospital from January 2016 to May 2020 were investigated. The data from the systematic search and the data from our hospital were analyzed, and a pooled complete response (CR) rate and response rate of imiquimod treatment for VaIN 2-3 were estimated. As a subgroup analysis, the CR rates and response rates were compared between women with and without a history of hysterectomy, and the rate ratio was calculated. RESULTS Five articles described 28 women with VaIN 2-3 who underwent imiquimod treatment, and nine women with VaIN 2-3 were treated with imiquimod in our hospital. The discontinuation of the treatment was required in only one patient of the reported cases. The pooled CR rate and response rate of imiquimod, regardless of a history of hysterectomy, was 0.76 (95% CI, 0.59-0.87) and 0.89 (95% CI, 0.71-0.97), respectively. In the subgroup analysis, the CR rate in patients with hysterectomy was 0.98 (95% CI, 0.11-1.0) and in those without hysterectomy was 0.60 (95% CI, 0.30-0.84), and the rate ratio was 0.83 (95% CI, 0.48-1.19). The pooled response rates with and without a history of hysterectomy were not estimated, and the rate ratio was 0.83 (95% CI, 0.54-1.09). CONCLUSION Imiquimod can be an effective treatment for vaginal intraepithelial neoplasia 2-3.
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Sasagasako N, Kosaka K, Sagae Y, Itoh K, Aratake J, Yamada K, Inayama Y, Gou R, Kawamura A, Yamanishi M, Yamanishi Y, Suzuki M, Arai K. Recurrent vaginal intraepithelial neoplasia successfully treated with topical imiquimod: A case report. Mol Clin Oncol 2020; 13:19. [PMID: 32754333 DOI: 10.3892/mco.2020.2089] [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: 12/09/2019] [Accepted: 05/22/2020] [Indexed: 11/06/2022] Open
Abstract
Vaginal intraepithelial neoplasia (VAIN) is a rare disease associated with human papillomavirus infection. High-grade VAIN is typically treated with either excisional or ablative therapy. However, recurrent VAIN lesions are common and these treatments cause vaginal scarring. Recent studies have indicated that 5% imiquimod is an effective treatment for VAIN. The present report describes a case of a woman diagnosed with recurrent VAIN 3 who was treated with a 5% topical imiquimod cream and achieved a complete response after excision and CO2 laser vaporization. A 53-year-old, gravida 5, para 2 postmenopausal woman who was diagnosed with papillary squamous cell carcinoma by biopsy underwent conization, total abdominal hysterectomy and bilateral salpingo-oophorectomy. A histological examination revealed grade 3 cervical intraepithelial neoplasia with free surgical margins. At 3 years after the hysterectomy, the vaginal smear revealed atypical squamous cells, leading to a pathological diagnosis of VAIN 3. Partial vaginectomy was performed, and VAIN 3 was detected in the lesion with positive margins. At 4 months into follow-up, the vaginal smear revealed a high-grade squamous intraepithelial lesion (HSIL), and subsequent biopsy during colposcopy revealed a pathological diagnosis of VAIN 3. At 3 months after CO2 laser vaporization, the vaginal smear revealed HSIL with suspected recurrence and imiquimod treatment was initiated. One sachet of 5% imiquimod cream (0.25 g) was placed in the entire vagina three times per week for 14 weeks with no apparent complications. At 3 years after the treatment, there has been no recurrence. This case demonstrated that topical imiquimod with careful follow-up is an effective treatment for VAIN and is well-tolerated. Further clinical evidence of the effectiveness and safety of imiquimod in patients diagnosed with VAIN is required.
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Affiliation(s)
- Nanayo Sasagasako
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
| | - Kenzo Kosaka
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
| | - Yusuke Sagae
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
| | - Kunitoshi Itoh
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
| | - Junichi Aratake
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
| | - Kaori Yamada
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
| | - Yoshihide Inayama
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
| | - Rei Gou
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
| | - Atsuko Kawamura
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
| | - Megumi Yamanishi
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
| | - Yukio Yamanishi
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
| | - Makoto Suzuki
- Department of Pathology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
| | - Kazumori Arai
- Department of Pathology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
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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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de Witte CJ, van de Sande AJM, van Beekhuizen HJ, Koeneman MM, Kruse AJ, Gerestein CG. Imiquimod in cervical, vaginal and vulvar intraepithelial neoplasia: a review. Gynecol Oncol 2015; 139:377-84. [PMID: 26335596 DOI: 10.1016/j.ygyno.2015.08.018] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 08/17/2015] [Accepted: 08/24/2015] [Indexed: 01/22/2023]
Abstract
Human papillomavirus (HPV) infection is in the vast majority of patients accountable for the development of vulvar, cervical and vaginal intraepithelial neoplasia (VIN, CIN, VAIN); precursors of vulvar, cervical and vaginal cancers. The currently preferred treatment modality for high grade VIN, CIN and VAIN is surgical excision. Nevertheless surgical treatment is associated with adverse pregnancy outcomes and recurrence is not uncommon. The aim of this review is to present evidence on the efficacy, safety and tolerability of imiquimod (an immune response modifier) in HPV-related VIN, CIN and VAIN. A search for papers on the use of imiquimod in VIN, CIN and VAIN was performed in the MEDLINE, EMBASE and Cochrane library databases. Data was extracted and reviewed. Twenty-one articles met the inclusion criteria and were analyzed; 16 on VIN, 3 on CIN and 2 on VAIN. Complete response rates in VIN ranged from 5 to 88%. Although minor adverse effects were frequently reported, treatment with imiquimod was well tolerated in most patients. Studies on imiquimod treatment of CIN and VAIN are limited and lack uniformly defined endpoints. The available evidence however, shows encouraging effect. Complete response rates for CIN 2-3 and VAIN 1-3 ranged from 67 to 75% and 57 to 86% respectively. More randomized controlled trials on the use of imiquimod in CIN, VAIN and VIN with extended follow-up are necessary to determine the attributive therapeutic value in these patients.
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Affiliation(s)
- C J de Witte
- Universal Medical Center Utrecht, The Netherlands
| | - A J M van de Sande
- Erasmus MC Cancer Institute, Department of Gynaecology, Rotterdam, The Netherlands
| | - H J van Beekhuizen
- Erasmus MC Cancer Institute, Department of Gynaecology, Rotterdam, The Netherlands
| | - M M Koeneman
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A J Kruse
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands
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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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Randomized clinical trial of imiquimod: an adjunct to treating cervical dysplasia. Am J Obstet Gynecol 2012; 206:42.e1-7. [PMID: 21907959 DOI: 10.1016/j.ajog.2011.06.105] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 05/24/2011] [Accepted: 07/28/2011] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Human papillomavirus (HPV) infection is a major risk factor for cervical cancer. Imiquimod is a topical medication that enhances the immune response to HPV-induced genital warts. This study evaluated cervical application of imiquimod as an adjunct to standard treatment for cervical dysplasia. STUDY DESIGN Fifty-six patients were randomized to standard excisional/ablative treatment vs applications of imiquimod followed by standard treatment. The primary endpoint was dysplasia recurrence within 2 years. RESULTS There were no differences in dysplasia recurrence between the 2 groups. Treatment was well tolerated, with side effects being mild but significantly worse in women receiving imiquimod for, chills, fatigue, fever, headache, myalgias, and vaginal discharge. CONCLUSION This trial does not support the hypothesis that imiquimod, as used in this trial, has an impact on recurrence of cervical dysplasia, but the adequacy of findings are limited by sample size. The trial does support the feasibility and acceptability of the use of imiquimod on the cervix.
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