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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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Qiu L, Li J, Chen F, Wang Y, Wang Y, Wang X, Lv Q, Li C, Li M, Yang Q, Wu D, Zhang Y, Zhang Y, Zhang M, Zhang Y, Qie M, Zhou H, Zhou J, Zhao W, Xia B, Liang X, Cai Y, Teng Y, Huang Z, Sui L, Wei L, Di W. Chinese Expert Consensus on the Clinical Applications of Aminolevulinic Acid-Based Photodynamic Therapy in Female Lower Genital Tract Diseases (2022). Photodiagnosis Photodyn Ther 2022; 39:102993. [PMID: 35781093 DOI: 10.1016/j.pdpdt.2022.102993] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION With the younger onset age of female lower genital tract diseases, there are increasing demands for protecting organ and tissue structures to preserve fertility and, therefore, effective fertility-sparing treatments that cause minimal normal tissue damage and less adverse reactions are urgently needed. OBJECTIVE This study is aimed at reviewing information and achieving consensus on recommendations on the clinical applications of aminolevulinic acid-based photodynamic therapy (ALA-PDT) in female lower genital tract diseases. METHODS Members of the expert panel held online and in-person meetings to discuss and revise drafts created by the steering committee based on the literature review and the clinical experiences of the expert panel. Opinions of the experts were transcribed and discussed in detail to ensure that the consensus statement best reflects the current advances in the field and the experts' view. RESULTS After numerous rounds of meetings, experts unanimously agreed on the importance of ALA-PDT in the treatment of cervical squamous intraepithelial lesions (SIL), vaginal SIL, vulvar SIL, vulvar lichen sclerosus (VLS), and condyloma acuminatumon (CA). Experts also reached consensus on the recommended treatment regimen and treatment methods. CONCLUSION This consensus aimed to provide practical basis and guidance for the clinical applications of ALA-PDT in female lower genital tract diseases in China. Of note, this is the only expert consensus prepared by board-certified specialists in gynecology and obstetrics in China. More evidence-based clinical studies should be made to update and expand the current recommendations.
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Affiliation(s)
- Lihua Qiu
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jingran Li
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Fei Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
| | - Yifeng Wang
- Department of Obstetrics and Gynecology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yue Wang
- Department of Obstetrics and Gynecology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Xinyu Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qiubo Lv
- Department of Obstetrics and Gynecology, Beijing Hospital, Beijing, China
| | - Changzhong Li
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Mingzhu Li
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Qiuyun Yang
- Department of Obstetrics and Gynecology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Dan Wu
- Department of Obstetrics and Gynecology, International Peace Maternity & Child Health Hospital of China Welfare Institute, Shanghai, China
| | - Youzhong Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Yuquan Zhang
- Department of Obstetrics and Gynecology, Affiliated Hospital, Nantong University, Nantong, China
| | - Mengzhen Zhang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Yu Zhang
- Department of Obstetrics and Gynecology, Xiangya Hospital, Central South University, Changsha, China
| | - Mingrong Qie
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Huaijun Zhou
- Department of Obstetrics and Gynecology, Naijing Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Jiade Zhou
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Anhui Medical University, Hefei, China
| | - Weidong Zhao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Anhui Medical University, Hefei, China
| | - Bairong Xia
- Department of Obstetrics and Gynecology, Anhui Provincial Cancer Hospital, Hefei, China
| | - Xuefang Liang
- Department of Obstetrics and Gynecology, Guangdong Province Traditional Chinese Medical Hospital, Guangzhou, China
| | - Yunlang Cai
- Department of Obstetrics and Gynecology, Zhongda Hospital, Southeast University, Nanjing, China
| | - Yincheng Teng
- Department of Obstetrics and Gynecology, Shanghai Sixth People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Zheng Huang
- MOE Key Laboratory of OptoElectronic Science and Technology for Medicine, Fujian Provincial Key Laboratory of Photonics Technology, Fujian Normal University, Fuzhou, China.
| | - Long Sui
- Department of Obstetrics and Gynecology, Obstetrics & Gynecology Hospital, Fundan University Shanghai, China.
| | - Lihui Wei
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China.
| | - Wen Di
- Department of Obstetrics and Gynecology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
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Monfrecola G, Megna M, Rovati C, Arisi M, Rossi M, Calzavara-Pinton I, Fabbrocini G, Calzavara-Pinton P. A Critical Reappraisal of Off-Label Use of Photodynamic Therapy for the Treatment of Non-Neoplastic Skin Conditions. Dermatology 2020; 237:262-276. [PMID: 32554971 DOI: 10.1159/000507926] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/16/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In the past 30 years, topical photodynamic therapy (PDT) has been investigated for the treatment of a broad spectrum of cosmetic, inflammatory, and infectious skin conditions with variable, and often contrasting, results. However, the non-expert clinician may be in difficulty evaluating these results because different sensitizers, concentrations, formulations, light sources, and irradiation protocols have been used. In addition, many of these studies have poor quality design being case reports and uncontrolled studies of few cases. SUMMARY With the aim to clarify the potential usefulness of PDT for the treatment of infectious and inflammatory skin diseases as well as selected cosmetic indications, we searched for randomized controlled clinical trials, non-randomized comparative studies, retrospective studies, and case series studies with a number of at least 10 patients, published since 1990. Later, we reappraised the results in order to give a simple critical overview. Key Messages: Evidence from the literature seems to strongly support the use of ALA- and MAL-PDT for the treatment of common skin diseases such as acne, warts, condylomata, and Leishmania skin infection and for photorejuvenation, i.e., the correction of selected cosmetic changes of aging and photoaging. For other disorders, the level of evidence and strength of recommendation are lower, and controlled randomized studies with prolonged follow-ups are necessary in order to assess the clinical usefulness and other potential advantages over current treatment options.
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Affiliation(s)
- Giuseppe Monfrecola
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Matteo Megna
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Chiara Rovati
- Dermatology Department, University of Brescia, Brescia, Italy
| | | | | | | | - Gabriella Fabbrocini
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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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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Turksoy A, Yildiz D, Akkaya EU. Photosensitization and controlled photosensitization with BODIPY dyes. Coord Chem Rev 2019. [DOI: 10.1016/j.ccr.2017.09.029] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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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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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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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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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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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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Abstract
Photodynamic therapy (PDT) is a light-based intervention with a long and successful clinical track record for both oncology and non-malignancies. In cancer patients, a photosensitizing agent is intravenously, orally or topically applied and allowed time to preferentially accumulate in the tumor region. Light of the appropriate wavelength and intensity to activate the particular photosensitizer employed is then introduced to the tumor bed. The light energy will activate the photosensitizer, which in the presence of oxygen should allow for creation of the toxic photodynamic reaction generating reactive oxygen species. The photodynamic reaction creates a cascading series of events including initiation of apoptotic and necrotic pathways both in tumor and neovasculature, leading to permanent lesion destruction often with upregulation of the immune system. Cutaneous phototoxicity from unintentional sunlight exposure remains the most common morbidity from PDT. This paper will highlight current research and outcomes from the basic science and clinical applications of oncologic PDT and interpret how these findings may lead to enhanced and refined future PDT.
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Affiliation(s)
- Ron R Allison
- 21st Century Oncology, 801 WH Smith Boulevard, Greenville, NC 27834, USA.
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13
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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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Ruthenium oligonucleotides, targeting HPV16 E6 oncogene, inhibit the growth of cervical cancer cells under illumination by a mechanism involving p53. Gene Ther 2012; 20:435-43. [PMID: 22809997 DOI: 10.1038/gt.2012.54] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
High-risk Human Papillomaviruses (HPV) has been found to be associated with carcinomas of the cervix, penis, vulva/vagina, anus, mouth and oro-pharynx. As the main tumorigenic effects of the HPV have been attributed to the expression of E6 and E7 genes, different gene therapy approaches have been directed to block their expression such as antisense oligonucleotides (ASO), ribozymes and small interfering RNAs. In order to develop a gene-specific therapy for HPV-related cancers, we investigated a potential therapeutic strategy of gene silencing activated under illumination. Our aim according to this antisense therapy consisted in regulating the HPV16 E6 oncogene by using an E6-ASO derivatized with a polyazaaromatic ruthenium (Ru(II)) complex (E6-Ru-ASO) able, under visible illumination, to crosslink irreversibly the targeted sequence. We examined the effects of E6-Ru-ASO on the expression of E6 and on the cell growth of cervical cancer cells. We demonstrated using HPV16(+) SiHa cervical cancer cells that E6-Ru-ASO induces after illumination, a reactivation of p53, the most important target of E6, as well as the inhibition of cell proliferation with a selective repression of E6 at the protein level. These results suggest that E6-Ru ASOs, activated under illumination and specifically targeting E6, are capable of inhibiting HPV16(+) cervical cancer cell proliferation.
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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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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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Szeimies RM, Radny P, Sebastian M, Borrosch F, Dirschka T, Krähn-Senftleben G, Reich K, Pabst G, Voss D, Foguet M, Gahlmann R, Lübbert H, Reinhold U. Photodynamic therapy with BF-200 ALA for the treatment of actinic keratosis: results of a prospective, randomized, double-blind, placebo-controlled phase III study. Br J Dermatol 2010; 163:386-94. [PMID: 20518784 DOI: 10.1111/j.1365-2133.2010.09873.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Photodynamic therapy (PDT) with 5-aminolaevulinic acid (ALA) provides a therapeutic option for the treatment of actinic keratosis (AK). Different strategies are applied to overcome the chemical instability of ALA in solution and to improve skin penetration. A new stable nanoemulsion-based ALA formulation, BF-200 ALA, is currently in clinical development for PDT of AK. OBJECTIVES To evaluate the efficacy and safety of PDT of AK with BF-200 ALA. METHODS The study was performed as a randomized, multicentre, double-blind, placebo-controlled, interindividual, two-armed trial with BF-200 ALA and placebo. A total of 122 patients with four to eight mild to moderate AK lesions on the face and/or the bald scalp were included in eight German study centres. The efficacy of BF-200 ALA after one and two PDT treatments was evaluated. BF-200 ALA was used in combination with two different light sources under illumination conditions defined by European competent authorities. RESULTS PDT with BF-200 ALA was superior to placebo PDT with respect to patient complete clearance rate (per-protocol group: 64% vs. 11%; P < 0.0001) and lesion complete clearance rate (per-protocol group: 81% vs. 22%) after the last PDT treatment. Statistically significant differences in the patient and lesion complete clearance rates and adverse effect profiles were observed for the two light sources, Aktilite CL128 and PhotoDyn 750, at both time points of assessment. The patient and lesion complete clearance rates after illumination with the Aktilite CL128 were 96% and 99%, respectively. CONCLUSIONS BF-200 ALA is a very effective new formulation for the treatment of AK with PDT. Marked differences between the efficacies and adverse effects were observed for the different light sources used. Thus, PDT efficacy is dependent both on the drug and on the characteristics of the light source and the illumination conditions used.
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Affiliation(s)
- R-M Szeimies
- Department of Dermatology, Regensburg University Hospital, Regensburg, Germany
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Daayana S, Elkord E, Winters U, Pawlita M, Roden R, Stern PL, Kitchener HC. Phase II trial of imiquimod and HPV therapeutic vaccination in patients with vulval intraepithelial neoplasia. Br J Cancer 2010; 102:1129-36. [PMID: 20234368 PMCID: PMC2853099 DOI: 10.1038/sj.bjc.6605611] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Vulval intraepithelial neoplasia (VIN) is a premalignant condition, which is frequently associated with type HPV16 infection, and multifocal disease has high rates of surgical treatment failure. METHODS We report a phase II clinical trial of the topical immunomodulator, imiquimod, for 8 weeks, followed by 3 doses (weeks 10, 14 and 18) of therapeutic human papillomavirus (HPV) vaccination (TA-CIN, fusion protein HPV16 E6E7L2) in 19 women with VIN grades 2 and 3. Histology and HPV testing of biopsies were performed at weeks 0, 10, 20 and 52. Intralesional infiltration of T-cell subsets and lymphocyte proliferation for HPV systemic immune responses were also assessed. RESULTS Lesion response (complete regression of VIN on histology) was observed in 32% (6 out of 19) of women at week 10, increasing to 58% (11 out of 19) at week 20 and 63% (12 out of 19) at week 52. At this time, 36% (5 out of 14) of lesions showed HPV16 clearance and 79% (15 out of 19) of women were symptom free. At week 20, after treatment with imiquimod and vaccination, there was significantly increased local infiltration of CD8 and CD4 T cells in lesion responders; in contrast, non-responders (persistent VIN by histology) showed an increased density of T regulatory cells. After vaccination, only lesion responders had significantly increased lympho-proliferation to the HPV vaccine antigens. CONCLUSION The therapeutic effect of treatment depends on the differential immune response of responders and non-responders with affect locally and systemically.
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Affiliation(s)
- S Daayana
- Academic Unit of Obstetrics and Gynaecology, University of Manchester, St Mary's Hospital, Whitworth Park, Manchester M13 0JH, UK
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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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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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Kagan KO, Abele H, Wallwiener D, Schauf B. Laser application in obstetrics and gynecology – A short introduction to therapeutic options. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.mla.2008.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Donnelly RF, McCarron PA, Morrow DIJ, Sibani SA, Woolfson AD. Photosensitiser delivery for photodynamic therapy. Part 1: Topical carrier platforms. Expert Opin Drug Deliv 2008; 5:757-66. [PMID: 18590460 DOI: 10.1517/17425247.5.7.757] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Photodynamic therapy (PDT) is a medical treatment in which a combination of a photosensitising drug and visible light causes destruction of selected cells. Due to the lack of true selectivity of preformed photosensitisers for neoplastic tissue and their high molecular weights, PDT of superficial skin lesions has traditionally been mediated by topical application of the porphyrin precursor 5-aminolevulinic acid (ALA). OBJECTIVE This article aims to review the traditional formulation-based approaches taken to topical delivery of ALA and discusses the more innovative strategies investigated for enhancement of PDT mediated by topical application of ALA and preformed photosensitisers. METHODS All of the available published print and online literature in this area was reviewed. As drug delivery of agents used in PDT is still something of an emerging field, it was not necessary to go beyond literature from the last 30 years. RESULTS/CONCLUSION PDT of neoplastic skin lesions is currently based almost exclusively on topical application of simple semisolid dosage forms containing ALA or its methyl ester. Until expiry of patents on the current market-leading products, there is unlikely to be a great incentive to engage in design and evaluation of innovative formulations for topical PDT, especially those containing the more difficult-to-deliver preformed photosensitisers.
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Affiliation(s)
- Ryan F Donnelly
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, Belfast, UK.
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Abstract
Multicentre randomized controlled studies now demonstrate high efficacy of topical photodynamic therapy (PDT) for actinic keratoses, Bowen's disease (BD) and superficial basal cell carcinoma (BCC), and efficacy in thin nodular BCC, while confirming the superiority of cosmetic outcome over standard therapies. Long-term follow-up studies are also now available, indicating that PDT has recurrence rates equivalent to other standard therapies in BD and superficial BCC, but with lower sustained efficacy than surgery in nodular BCC. In contrast, current evidence does not support the use of topical PDT for squamous cell carcinoma. PDT can reduce the number of new lesions developing in patients at high risk of skin cancer and may have a role as a preventive therapy. Case reports and small series attest to the potential of PDT in a wide range of inflammatory/infective dermatoses, although recent studies indicate insufficient evidence to support its use in psoriasis. There is an accumulating evidence base for the use of PDT in acne, while detailed study of an optimized protocol is still required. In addition to high-quality treatment site cosmesis, several studies observe improvements in aspects of photoageing. Management of treatment-related pain/discomfort is a challenge in a minority of patients, and the modality is otherwise well tolerated. Long-term studies provide reassurance over the safety of repeated use of PDT.
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Affiliation(s)
- C A Morton
- Department of Dermatology, Stirling Royal Infirmary, Stirling FK2 8AU, UK.
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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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Donnelly RF, McCarron PA, Woolfson DA. Derivatives of 5-Aminolevulinic Acid for Photodynamic Therapy. PERSPECTIVES IN MEDICINAL CHEMISTRY 2007. [DOI: 10.1177/1177391x0700100005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Photodynamic therapy (PDT) is a clinical treatment that combines the effects of visible light irradiation with subsequent biochemical events that arise from the presence of a photosensitising drug (possessing no dark toxicity) to cause destruction of selected cells. Today, the most common agent used in dermatological PDT is 5-aminolevulinic acid (ALA). As a result of its hydrophilic character, ALA penetrates skin lesions poorly when applied topically. Its systemic bioavailability is limited and it is known to cause significant side effects when given orally or intravenously. Numerous chemical derivatives of ALA have been synthesised with the aims of either improving topical penetration or enhancing systemic bioavailability, while reducing side effects. In vitro cell culture experiments with ALA derivatives have yielded promising results. However, if ALA derivatives are to demonstrate meaningful clinical benefits, a rational approach to topical formulation design is required, along with a systematic study aimed at uncovering the true potential of ALA derivatives in photodynamic therapy. With respect to systemic ALA delivery, more study is required in the developing area of ALA-containing dendrons and dendrimers.
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Affiliation(s)
- Ryan F. Donnelly
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, U.K
| | - Paul A. McCarron
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, U.K
| | - David A. Woolfson
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, U.K
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Ascencio M, Collinet P, Cosson M, Vinatier D, Mordon S. Intérêt et place de la thérapie photodynamique en gynécologie. ACTA ACUST UNITED AC 2007; 35:1155-65. [DOI: 10.1016/j.gyobfe.2007.07.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Accepted: 07/10/2007] [Indexed: 11/26/2022]
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Juzeniene A, Peng Q, Moan J. Milestones in the development of photodynamic therapy and fluorescence diagnosis. Photochem Photobiol Sci 2007; 6:1234-45. [PMID: 18046478 DOI: 10.1039/b705461k] [Citation(s) in RCA: 207] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Many reviews on PDT have been published. This field is now so large, and embraces so many sub-specialties, from laser technology and optical penetration through diffusing media to a number of medical fields including dermatology, gastroenterology, ophthalmology, blood sterilization and treatment of microbial-viral diseases, that it is impossible to cover all aspects in a single review. Here, we will concentrate on a few basic aspects, all important for the route of development leading PDT to its present state: early work on hematoporphyrin and hematoporphyrin derivative, second and third generation photosensitizers, 5-aminolevulinic acid and its derivatives, oxygen and singlet oxygen, PDT effects on cell organelles, mutagenic potential, the basis for tumour selectivity, cell cooperativity, photochemical internalization, light penetration into tissue and the significance of oxygen depletion, photobleaching of photosensitizers, optimal light sources, effects on the immune system, and, finally, future trends.
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Affiliation(s)
- Asta Juzeniene
- Department of Radiation Biology, Institute for Cancer Research, Rikshospitalet-Radiumhospitalet Medical Center, The Norwegian Radium Hospital, Montebello, N-0310, Oslo, Norway.
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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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Sauthier P, Petignat P. [Diagnosis and management of vulvar intraepithelial neoplasias and invasive vulvar cancers]. ACTA ACUST UNITED AC 2007; 47:88-93. [PMID: 17440270 DOI: 10.1159/000100338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Accepted: 05/05/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Update on the diagnosis and management of vulvar intraepithelial neoplasia (VIN) and vulvar carcinoma. METHOD Review of the literature. RESULTS The classification of VIN is leaning towards the development of two distinct anatomoclinical models. VIN of the usual type and of a differentiated type. New forms of treatment of preinvasive lesions that are less traumatic and as efficient will have to be evaluated in the future such as immunomodulators and photodynamic therapy. The invasive carcinoma is generally rapidly symptomatic and visible; however, more than one third of patients are still diagnosed at an advanced stage. New therapeutic alternatives are being examined such as the sentinel lymph node in early stages and the preoperative radiochemotherapy in advanced stages. CONCLUSIONS VIN and vulvar cancer need specialized treatment which may be mutilating, despite the fact that therapeutic options are well defined today and tend towards less aggressive surgery.
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Affiliation(s)
- Philippe Sauthier
- Service de gynécologie oncologique, Département d'obstétrique et gynécologie, Centre hospitalier de l'Université de Montréal, Montréal, Canada.
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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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Naik R, Nixon S, Lopes A, Godfrey K, Hatem MH, Monaghan JM. A randomized phase II trial of indole-3-carbinol in the treatment of vulvar intraepithelial neoplasia. Int J Gynecol Cancer 2006; 16:786-90. [PMID: 16681761 DOI: 10.1111/j.1525-1438.2006.00386.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The aim of this study was to determine the potential therapeutic benefits of indole-3-carbinol (I3C) in the management of vulvar intraepithelial neoplasia (VIN). Women with histologically confirmed high-grade VIN were randomized to receive 200 and 400 mg/day of I3C. Symptomatology by visual analog scale and vulvoscopic appearance were assessed at recruitment, 6 weeks, 3 months, and 6 months. Tissue biopsy to determine histologic response was obtained at completion of the study period. Urine samples were obtained at each visit to determine 2-hydroxyestrone to 16-alpha-hydroxyestrone ratios. Data from 12 women were suitable for analysis. There was a significant improvement in symptomatology with the introduction of I3C (itch, P= 0.018; pain, P= 0.028). Lesion size and severity were also significantly reduced (size, P= 0.005; appearance, P= 0.046). In addition, there was a significant increase in 2-hydroxyestrone to 16-alpha-hydroxyestrone ratio following commencement of I3C, P= 0.05. However, tissue biopsy from the worst-affected vulval areas revealed no improvement in grade of VIN during the 6-month period, P= 0.317. There were no significant differences in results between those women taking 200 mg/day of I3C and those on 400 mg/day. This study has shown significant clinical improvement in symptomatology and vulvoscopic appearance of VIN with I3C therapy. Further clinical and scientific investigations are required to support these preliminary findings.
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Affiliation(s)
- R Naik
- Northern Gynaecological Oncology Centre; and Department of Haematology, Queen Elizabeth Hospital, Sheriff Hill, Gateshead, United Kingdom
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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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Epidemiología, diagnóstico y tratamiento de la neoplasia vulvar intraepitelial (VIN). CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2006. [DOI: 10.1016/s0210-573x(06)74082-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Al-Waili NS, Butler GJ. Phototherapy and malignancy: Possible enhancement by iron administration and hyperbaric oxygen. Med Hypotheses 2006; 67:1148-58. [PMID: 16860490 DOI: 10.1016/j.mehy.2005.12.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Revised: 11/28/2005] [Accepted: 12/01/2005] [Indexed: 12/27/2022]
Abstract
Photodynamic therapy (PDT) is a new therapeutic approach for the treatment of malignant tumors. Hyperbaric oxygen (HBO(2)) shows beneficial effects in various modalities of cancer interventions. Tumor cells tend to accumulate large amount of iron. There is interaction between tissue content of oxygen, iron, free radical production and tissue damage. Accumulation of intracellular iron is necessary for the production of oxygen radicals. HBO(2) increases tissue oxygen and hydrogen peroxide production in the cells. Malignant cells require iron, and exhibit more transferrin receptors. The photodynamic sensitization of human leukemic cells is achieved with accumulation of porphyrins stimulated by 5-aminolaevulanic acid (ALA) plus hemin. Further, a significant improvement in tumor response is obtained when PDT is delivered during hyperoxygenation. When PDT is combined with hyperoxygenation, the hypoxic condition is improved and the cell killing rate at various time points after PDT is significantly enhanced. Photosensitization with use of porphyrins is used with HBO(2) and PDT for treatment of certain tumors. PDT with ALA is used for treatment of actinic keratosis (AK). The combination of iron administration (by injection or oral rout), hemin, or transferrin, as a source for iron, HBO(2) as a source of oxygen under pressure and PDT as a source of generating free-radical tissue damage may be useful in the treatment of tumors. The possibility of combining HBO(2), iron, light and local photosensitizers to overcome skin tumors deserve extensive laboratory and clinical research work. Conclusively, iron, HBO(2), and PDT may have synergistic effect to hamper tumor cells.
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Affiliation(s)
- Noori S Al-Waili
- Life Support Technologies, Inc. - NEWTechnologies, Inc., The Chronic Wound Management and Hyperbaric Medicine Center, The Mount Vernon Hospital, Sound Shore Health System, Mount Vernon, 7th Avenue, North 12, New York 10550, USA
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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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Knopp S, Bjørge T, Nesland JM, Tropé C, Holm R. Cyclins D1, D3, E, and A in vulvar carcinoma patients. Gynecol Oncol 2005; 97:733-9. [PMID: 15894358 DOI: 10.1016/j.ygyno.2005.03.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2004] [Revised: 02/10/2005] [Accepted: 03/13/2005] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The treatment of vulvar squamous cell carcinoma patients is often mutilating. Effort is being made to individualize treatment in order to reduce negative side effects for patients with good prognosis. Molecular markers have been able to predict patient outcome in several tumors. The aim of this study was to characterize the expression of cyclins D1, D3, E, and A in a comparatively large series of patients with vulvar squamous cell carcinoma and look for prognostic impact. METHODS A total of 224 vulvar squamous cell carcinomas were immunohistochemically investigated for expression of cyclins D1, D3, E, and A using the biotin-streptavidin-peroxidase method and the OptiMax Plus automated cell staining system. RESULTS High protein levels of cyclin D1 (any positive nuclei) were found in 58 (26%) cases, cyclin D3 (> or =50% positive nuclei) in 61 (27%) cases, cyclin E (> or =50% positive nuclei) in 41 (18%) cases, and cyclin A (> or =5% positive nuclei) in 156 (70%) cases. No prognostic impact was found for the cyclins D1, D3, E, or A. CONCLUSIONS The high number of cases showing increased levels of cyclin A suggests that this protein may be important in the pathogenesis of vulvar squamous cell carcinoma. No prognostic impact was found for the cyclins D1, D3, E, or A.
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Affiliation(s)
- Synne Knopp
- Department of Pathology, The Norwegian Radium Hospital, University of Oslo, Montebello, 0310 Oslo, Norway.
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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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Allison R, Cuenca R, Downie G, Randall M, Bagnato V, Sibata C. PD/PDT for gynecological disease: A clinical review. Photodiagnosis Photodyn Ther 2005; 2:51-63. [DOI: 10.1016/s1572-1000(05)00033-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2005] [Revised: 04/05/2005] [Accepted: 04/06/2005] [Indexed: 10/25/2022]
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Wang XL, Wang HW, Wang HS, Xu SZ, Liao KH, Hillemanns P. Topical 5-aminolaevulinic acid-photodynamic therapy for the treatment of urethral condylomata acuminata. Br J Dermatol 2005; 151:880-5. [PMID: 15491431 DOI: 10.1111/j.1365-2133.2004.06189.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Electrocoagulation and laser evaporation for urethral condylomata acuminata have high recurrence rates and can be associated with urethral malformations. OBJECTIVES To investigate the effect of photodynamic therapy (PDT) with topical 5-aminolaevulinic acid (ALA) on urethral condylomata acuminata and to examine the histological changes in lesions of condylomata acuminata after ALA-PDT. METHODS Patients with urethral condylomata (n = 164) were given topical ALA followed by intraurethral PDT through a cylindrical fibre. Patients included 11 individuals with 16 penile or vulval condylomatous lesions which were biopsied before or after treatment; the histological changes were then evaluated by light microscopy and electron microscopy. RESULTS The complete response rate was 95% and the recurrence rate was 5% after 6-24 months of follow-up. Light microscopy revealed keratinocytes in the middle and upper layers of the epidermis showing marked vacuolation and some necrocytosis 1 and 3 h after PDT. Necrosis in all layers of the epidermis was noted 5 h after PDT. Electron microscopy of keratinocytes revealed distinct ultrastructural abnormalities of mitochondria and the endoplasmic reticulum, and membrane damage. Apoptotic bodies were detected 3 h after PDT and a large number of keratinocytes exhibited necrosis 5 h after PDT. CONCLUSIONS Results suggest that, compared with conventional therapies, topical ALA-PDT is a simple, effective, safe and well-tolerated treatment for urethral condylomata acuminata that is associated with a low recurrence rate. The mechanism might be the triggering of both apoptosis and necrosis by ALA-PDT in human papillomavirus-infected keratinocytes.
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Affiliation(s)
- X L Wang
- Department of Dermatology and Venereology, Shanghai Dermatosis and STD Hospital, Wuyi Road, Shanghai 200050, China.
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Donnelly RF, McCarron PA, Woolfson AD. Drug Delivery of Aminolevulinic Acid from Topical Formulations Intended for Photodynamic Therapy¶. Photochem Photobiol 2005. [DOI: 10.1562/2004-08-23-ir-283r1.1] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
It is more than 25 years since photodynamic therapy (PDT) was proposed as a useful tool in oncology, but the approach is only now being used more widely in the clinic. The understanding of the biology of PDT has advanced, and efficient, convenient, and inexpensive systems of light delivery are now available. Results from well-controlled, randomised phase III trials are also becoming available, especially for treatment of non-melanoma skin cancer and Barrett's oesophagus, and improved photosensitising drugs are in development. PDT has several potential advantages over surgery and radiotherapy: it is comparatively non-invasive, it can be targeted accurately, repeated doses can be given without the total-dose limitations associated with radiotherapy, and the healing process results in little or no scarring. PDT can usually be done in an outpatient or day-case setting, is convenient for the patient, and has no side-effects. Two photosensitising drugs, porfirmer sodium and temoporfin, have now been approved for systemic administration, and aminolevulinic acid and methyl aminolevulinate have been approved for topical use. Here, we review current use of PDT in oncology and look at its future potential as more selective photosensitising drugs become available.
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Affiliation(s)
- Stanley B Brown
- Centre for Photobiology and Photodynamic Therapy, School of Biochemistry and Microbiology, University of Leeds, UK.
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Frei KA, Bonel HM, Frick H, Walt H, Steiner RA. Photodynamic detection of diseased axillary sentinel lymph node after oral application of aminolevulinic acid in patients with breast cancer. Br J Cancer 2004; 90:805-9. [PMID: 14970857 PMCID: PMC2410184 DOI: 10.1038/sj.bjc.6601615] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Benign as well as malignant tumour tissues of the breast demonstrate higher fluorescence intensity (FI) than normal breast tissue after application of a photosensitiser. As a follow-up study, we evaluated the FI of metastatic sentinel lymph nodes and metastatic axillary lymph nodes compared to nonmetastatic sentinel and axillary lymph nodes in patients with breast cancer. In all, 11 patients received 30 mg 5-aminolevulinic acid (ALA) kg(-1) bodyweight orally 3 h prior to surgery. The sentinel lymph node was marked with Nanocoll preoperatively and with a blue dye intraoperatively. Tumour excision, excision of the sentinel lymph node and an axillary lymph node dissection were performed during the same surgical session. The operation site was illuminated with blue light (400 nm) to obtain macroscopic tissue characterisation of fluorescence. Tissue samples were stored protected from light, and analysed using a fluorescence microscope. Results were correlated with histopathology. In all, 14 sentinel lymph nodes, seven axillary lymph nodes and seven primary tumours were analysed. Metastatic sentinel lymph nodes demonstrated a statistically significant higher FI than nonmetastatic sentinel lymph nodes (2630 vs 526, P<0.0001). The FI of metastatic sentinel lymph nodes, of metastatic axillary lymph nodes and of the primary tumour were comparably high, and were statistically significantly higher compared to the normal mammary tissue. Intraoperatively, only in a few cases, it was possible to recognise the metastatic sentinel lymph node macroscopically with blue light. Our study indicates that photodynamic diagnosis with ALA has a potential in the diagnosis and detection of the sentinel lymph node in patients with breast cancer, and is worth to be further investigated and developed for intraoperative photodynamic diagnosis and possibly therapy.
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Affiliation(s)
- K A Frei
- Department of Obstetrics and Gynaecology, University Hospital Bern, Inselspital, Effingerstrasse 102, Bern CH-3010, Switzerland.
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