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Xiao J, Chen Z, Xiao Y, Sui L, Wang C, Cong Q. Vulvar squamous intraepithelial neoplasia epithelial thickness in hairy and non-hairy sites: a single center experience from China. Front Oncol 2023; 13:1254820. [PMID: 37854683 PMCID: PMC10579793 DOI: 10.3389/fonc.2023.1254820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/11/2023] [Indexed: 10/20/2023] Open
Abstract
Introduction A large-sample study focusing on VIN lesions of a more precise thickness is needed to help guide clinical treatment. This study aimed to investigate the depth of vulvar intraepithelial neoplasia (VIN) and involved skin appendages to provide evidence for laser surgery. Methods The study retrospectively enrolled and analyzed the clinical characteristics of VIN patients in the obstetrics and gynecology department of a university hospital between January 1, 2019 and December 30, 2021. The study further explored the thickness of epithelium and skin appendages of 285 women with low-grade VIN (VIN1) and 285 women with high-grade VIN (VIN2/3). Results The study included 1,139 (80%) VIN1 and 335 (20%) VIN2/3 cases. The VIN1 and VIN2/3 groups showed a significant difference in human papillomavirus infection (P<0.01) but not in cytology (P = 0.499). Most (89.90%, 1,325) cases occurred in one area of the vulva, whereas 10.11% were multifocal. VIN commonly occurred on the posterior fourchette (76.85%), labia majora (11.61%), and labia minora (9.92%). The VIN2/3 group reported a significantly higher positive rate for concurrent cervical and vaginal intraepithelial neoplasia (160 of 285) than the VIN1 group (321 of 953) (P=0.000). The involved epithelial thicknesses in VIN2/3 and VIN1 were 0.69 ± 0.44 and 0.49 ± 0.23 mm, respectively, both of which were greater than the corresponding noninvolved epithelial thickness (0.31 ± 0.19 and 0.32 ± 0.10 mm, P<0.001 and P<0.001, respectively). In cases of appendage involvement, the VIN thickness was 1.98 ± 0.64 mm. Conclusions VIN thickness was generally ≤1 mm for the superficial lesions in non-hairy areas. However, for lesions extending onto hairy areas, the thickness was approximately 3 mm, leading to the destruction of involved skin appendages.
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Affiliation(s)
- Jingjing Xiao
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Ziren Chen
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Yinping Xiao
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Long Sui
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- Department of Cervical Disease Center, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Chao Wang
- Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Qing Cong
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- Department of Cervical Disease Center, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
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Wang L, Liu X, Zhang J, Li H, Wang X, Fu Y, Liu H, Xu Y, Meng L, Cui B, Zhang Y, Jia L. Comparison of ALA-PDT and CO 2 laser treatment of low-grade vaginal intraepithelial neoplasia with high-risk HPV infection: A non-randomized controlled pilot study. Photodiagnosis Photodyn Ther 2023; 43:103695. [PMID: 37422201 DOI: 10.1016/j.pdpdt.2023.103695] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of 5-aminolevulinic acid-mediated photodynamic therapy (ALA-PDT) and CO2 laser therapy of low-grade vaginal intraepithelial neoplasia (VAIN1) combined with high-risk human papillomavirus (hr-HPV) infection. METHODS A total of 163 patients with VAIN1 and hr-HPV infection were divided into PDT Group (n = 83) and CO2 laser Group (n = 80). The PDT Group received six times of ALA-PDT treatments and the CO2 laser Group received once CO2 laser treatment. HPV types, cytology, colposcopy, and pathological examinations were carried out before and after treatment. The differences in HPV clearance rate, VAIN1 regression rate, and adverse reactions between the two groups were analyzed during 6-month follow-up. RESULTS The overall HPV clearance rate of the PDT Group was significantly higher than that of the CO2 laser Group (65.06% vs 38.75%, P = 0.0008) although similar result was obtained for 16/18-related HPV infection patients (54.55% vs 43.48%, P = 0.4578). The VAIN1 regression rate of the PDT Group was significantly higher than that of the CO2 laser Group (95.18% vs 83.75%, P = 0.0170). In patients ≥ 50 years old, ALA-PDT showed better HPV clearance rate and VAIN1 regression rate than CO2 laser therapy (P < 0.05). The adverse reactions in the PDT Group were significantly lower than that in the CO2 laser Group (P > 0.05). CONCLUSIONS The efficacy of ALA-PDT appears better than CO2 laser for VAIN1 patients. However, the long-term effect of ALA-PDT for VAIN1 still needs to be explored. As a non-invasive treatment, ALA-PDT is a highly effective therapeutic procedure for VAIN1 with hr-HPV infection.
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Affiliation(s)
- Lili Wang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Mailing address: No. 107 West Wenhua Road, Jinan, Shandong 250012, China
| | - Xiaoli Liu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Mailing address: No. 107 West Wenhua Road, Jinan, Shandong 250012, China; Key Laboratory of Gynecologic Oncology of Shandong Province, China
| | - Junhua Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Mailing address: No. 107 West Wenhua Road, Jinan, Shandong 250012, China; Key Laboratory of Gynecologic Oncology of Shandong Province, China
| | - Huamin Li
- Department of Obstetrics and Gynecology, Yicheng District People's Hospital of Zaozhuang Municipality, China
| | - Xia Wang
- Department of Obstetrics and Gynecology, Zibo Municipal Hospital, China
| | - Yuye Fu
- Department of Obstetrics and Gynecology, Lijin County Maternal and Child Health and Family Planning Service Center, China
| | - Hongli Liu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Mailing address: No. 107 West Wenhua Road, Jinan, Shandong 250012, China
| | - Ying Xu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Mailing address: No. 107 West Wenhua Road, Jinan, Shandong 250012, China
| | - Lihua Meng
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Mailing address: No. 107 West Wenhua Road, Jinan, Shandong 250012, China
| | - Baoxia Cui
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Mailing address: No. 107 West Wenhua Road, Jinan, Shandong 250012, China
| | - Youzhong Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Mailing address: No. 107 West Wenhua Road, Jinan, Shandong 250012, China
| | - Lin Jia
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Mailing address: No. 107 West Wenhua Road, Jinan, Shandong 250012, China.
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Fernández-Montolí ME, Heydari F, Lavecchia F, Pavón MÂ, Guerra E, Matias-Guiu X, Marti MD, Tous S. Vulvar High-Grade Squamous Intraepithelial Lesions Treated with Imiquimod: Can Persistence of Human Papillomavirus Predict Recurrence? Cancers (Basel) 2022; 14:cancers14194808. [PMID: 36230731 PMCID: PMC9564312 DOI: 10.3390/cancers14194808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/23/2022] [Accepted: 09/27/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Vulvar high-grade intraepithelial lesion (vulvar HSIL) is a premalignant vulvar condition that requires intervention, usually surgery. It recurs frequently, and its treatment involves repeated disfiguring surgeries. Vulvar HSIL is associated with human papillomavirus. Imiquimod is a medical treatment option currently attracting attention because vulvar high-grade intraepithelial neoplasia is frequent in young women with multiple vulvar lesions. Few studies have evaluated the long-term effects of the response to imiquimod and the association of human papillomavirus with response and recurrence. We describe a retrospective (with cases already treated) study designed to determine the long-term response to imiquimod in patients with vulvar HSIL, and also to analyze the role of human papillomavirus (HPV), and different HPV types, in the persistence or recurrence of vulvar HSIL after imiquimod treatment. Abstract Objectives: Vulvar high-grade squamous intraepithelial lesion (vulvar HSIL) or vulvar intraepithelial neoplasia (VIN) is a premalignant condition that can progress to carcinoma. Imiquimod is a topical drug with high effectiveness and low morbidity. We aimed (1) to assess the long-term response to imiquimod in a cohort of patients with vulvar HSIL and (2) and to analyze the role of HPV determined in pre- and post-imiquimod treatment biopsies in the persistence or recurrence of vulvar HSIL. Design: Retrospective study between 2011 and 2022. Setting: Referrals from the primary care area of Baix Llobregat treated in the gynecology department of a university hospital in Barcelona, Spain. Population: 20 women with vulvar HSIL treated with imiquimod. Methods: The inclusion criteria were vulvar HSIL, vulvar HPV determination by pre- and post-treatment biopsy, acceptance of medical treatment, at least one follow-up and 4 weeks of treatment. Main outcome measures: Histological diagnosis of vulvar HSIL with pre- and post-imiquimod HPV determination. Response to treatment (complete, partial, no response, recurrence). Results: After imiquimod, 10 (50%) and 6 (30%) cases had complete and partial responses, respectively. Another 4 cases (20%) did not respond. Before treatment, 19 (95%) cases were positive for vulvar HPV (16 cases had HPV type 16). After treatment, 10 cases (50%) were positive for HPV (8 cases with HPV type 16): 2 cases (20%) with a complete response, 5 cases (83.3%) with a partial response and 3 cases (75%) with no response. Eight of the 10 HPV-negative cases (80%) post-treatment showed a complete response. HPV type 16 was present in 16 cases (84.2%) pre-treatment and in 8 cases (80%) post-treatment. Ten patients underwent additional treatments following a partial response, no response or recurrence. The 2 HIV and 3 immunosuppressed patients treated with imiquimod showed a partial response and required additional treatment. All these patients were HPV-positive pre- and post-treatment (100%). Response to imiquimod was associated with post-treatment vulvar HPV positivity (p = 0.03). The median time to a complete response in HPV-negative cases was 4.7 months versus 11.5 months in HPV-positive cases post-imiquimod treatment. Recurrence of vulvar HSIL was observed in 7 patients (35%), with a median time to recurrence of 19.7 months (range 3.2–32.7). Recurrence was experienced in 10% of cases with a complete response, in 4/6 (66.6%) cases with a partial response, and in 2/4 (50%) women with no response. Four of the 7 recurrent cases (57%) were infected with HIV or immunosuppressed. Six (85%) of the recurrent cases were HPV-positive post-treatment (all were HPV type 16). Four (30.7%) of the non-recurrent cases were HPV-positive post-treatment with imiquimod (p = 0.05), two of which were HPV type 16 (50%). Conclusions: Imiquimod effectively treats vulvar HSIL. Cases with a complete response showed less HPV positivity post-treatment than partial or non-response cases. Recurrences were more frequent in those with a partial or no response to imiquimod, and in immunosuppressed patients. In recurrent cases, 85% were HPV-positive post-treatment, while 30.7% of non-recurrent cases were HPV-positive. HPV positivity in the post-treatment biopsy suggests the need for stricter follow-up of patients.
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Affiliation(s)
- Maria-Eulalia Fernández-Montolí
- Gynecology Department, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
- Correspondence: ; Tel.: +34-93-2607695; Fax: +34-93-2607639
| | - Fatima Heydari
- Medicine and Translational Research Doctorate Program, Faculty of Medicine and Health Sciences, University of Barcelona, 08036 Barcelona, Spain
| | - Fabrizia Lavecchia
- Gynecology Department, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Miquel-Ângel Pavón
- Infections and Cancer Laboratory, Cancer Epidemiology Research Program, Catalan Institute of Oncology (ICO), Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain
| | - Esther Guerra
- Pathology Department, Hospital Universitari de Bellvitge, IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Xavier Matias-Guiu
- Pathology Department, Hospital Universitari de Bellvitge, IDIBELL, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Maria-Dolores Marti
- Gynecology Department, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Sara Tous
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain
- Cancer Epidemiology Research Program, Catalan Institute of Oncology (ICO), Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
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CO2 laser colposcopic guided surgery for the see and treat management of VHSIL: a preliminary experience. Lasers Med Sci 2021; 37:1635-1641. [PMID: 34580789 PMCID: PMC8971153 DOI: 10.1007/s10103-021-03413-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 09/05/2021] [Indexed: 11/21/2022]
Abstract
The purpose of this study is to evaluate the efficiency of CO2 laser colposcopic guided surgery performed in an outpatient see and treat setting in the management of VHSIL. Women with a suspected diagnosis of VHSIL and no vulvoscopic suspicion of vSCC were enrolled. An electronic register of CO2 laser treatment was created where description of performing parameters (excision or ablation) was specified and personal history was recorded. Statistical analysis was performed by Fisher’s exact test. Relative risks (RR) of risk factor were calculated and expressed in odds. From September 2014 to September 2018, we enrolled a total of 63 patients who underwent CO2 laser procedure and had a minimum follow-up time of 2 years at Careggi University Hospital in Florence. Forty-eight (76.2%) patients underwent laser excision and 15 (23.8%) patients underwent ablative treatment without histological results. Undertreatment was performed in 3 cases (6.3%) with definitive histology of vSCC. Therapeutical appropriateness of CO2 laser excision was reached in 85.4% of the cases (41/48). No volunteer loss to follow-up was registered; thus, fidelity to treatment was assess at 100%. Recurrence rate within 2 years attested in 8/60 followed patients (13.3%). No personal factor was found to influence the VHSIL course. CO2 laser excision may represent an excellent therapeutic option to VHSIL because it provides adequate oncological purpose with good cosmetic and functional results and high patients’ loyalty to treatment. An expert team could allow to undergo patients with VHSIL suspicion to unique diagnostic and therapeutic procedure with significant benefits.
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Rountis A, Pergialiotis V, Tsetsa P, Rodolakis A, Haidopoulos D. Management options for vaginal intraepithelial neoplasia. Int J Clin Pract 2020; 74:e13598. [PMID: 32602195 DOI: 10.1111/ijcp.13598] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 06/23/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Vaginal intraepithelial neoplasia (VaIN) is a rare disease of the lower genital tract, strongly associated with HPV infection, which may progress to vaginal carcinoma. PURPOSE The aim of this review is to summarise current treatment options, evaluate their efficacy and make provide recommendations on the optimal management of the disease. MATERIALS AND METHODS A comprehensive search of the literature was performed using the PubMed database for articles referring to the treatment of VaIN. We restricted our search only in articles written in English with publication dates within the last 10 years. RESULTS Surgical approach included local excision, CO2 laser ablation, CO2 laser skinning colpectomy and laparoscopic upper vaginectomy. Medical management was based on intravaginally administered topical agents such as 5% imiquimod cream, 5-fluorouracil cream and topical oestrogens. Intracavitary radiation therapy was reported in two forms: Low-dose rate (LDR) brachytherapy and high-dose rate (HDR) brachytherapy. All treatment options were well tolerated, with satisfactory cure rates and acceptable recurrence rates. CONCLUSION The choice of treatment depends upon many factors. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Topical agents are useful for persistent, multifocal lesions or for women that cannot undergo surgical treatment. Brachytherapy is associated with high morbidity rates and should be reserved for women who have multifocal disease, are poor surgical candidates and/or have failed other treatments. CO2 laser ablation achieves minimal scarring and sexual dysfunction; however, invasive disease should be ruled out with biopsies before the initiation of the treatment.
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Affiliation(s)
- Argirios Rountis
- First department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Pergialiotis
- First department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Tsetsa
- First department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Rodolakis
- First department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Haidopoulos
- First department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Iavazzo C, Gkegkes I. Local versus definitive management of vaginal high-grade squamous intraepithelial lesions. Eur J Obstet Gynecol Reprod Biol 2020; 251:279. [PMID: 32522385 DOI: 10.1016/j.ejogrb.2020.05.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/27/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Christos Iavazzo
- Gynaecological Oncology Department, Metaxa Cancer Hospital, Piraeus, Greece.
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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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Proximal Partial Vaginectomy for Vaginal Intraepithelial Neoplasia. J Obstet Gynaecol India 2018; 69:160-164. [PMID: 31686750 DOI: 10.1007/s13224-018-1158-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022] Open
Abstract
Objective The purpose of this study was to evaluate the use of proximal partial vaginectomy for the treatment of VaIN. Study design Descriptive. Methods Between May 2009 and December 2017, 20 patients were identified who underwent partial vaginectomy for VaIN. The electronic medical records were reviewed and information collated. Operative technique A circular incision in mid-vagina, was taken for all these patients and the upper vagina was closed over a gauze pack. The proximal vagina was then excised with the gauze inside. Results None of the patients had previously been treated for VaIN. The diagnosis was made on cytology/biopsy. Twelve of the 13 patients who were tested, were positive for high-risk HPV DNA, while one was negative. Thirteen (65%) had previous gynaecological surgery for cervical neoplasia (invasive cancer 6 and CIN 7) and the remaining 7 for apparent benign disease. There was one patient who went on to have a cone biopsy, and one had a modified radical hysterectomy at the same sitting. None of the patients had post-operative complications. Median hospital stay was 3 days (range 2-9). Follow-up (median 7 months, range 0-60) was available in 19 patients out of whom five had abnormal cytology, five were HPV DNA positive, and three had recurrent VaIN on follow-up biopsy and had re-excision for recurrence. One patient had vulvar intraepithelial neoplasia (VIN 3) and underwent excision. Another had CIN 3 and underwent excision of cervical stump. Conclusions Vaginectomy appears to be a safe and efficacious procedure for treatment of VaIN. Patients have to be followed up with cytology, HPV testing, and biopsy to exclude vagina recurrence and HPV-related lesion at another site.
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Saito T, Tabata T, Ikushima H, Yanai H, Tashiro H, Niikura H, Minaguchi T, Muramatsu T, Baba T, Yamagami W, Ariyoshi K, Ushijima K, Mikami M, Nagase S, Kaneuchi M, Yaegashi N, Udagawa Y, Katabuchi H. Japan Society of Gynecologic Oncology guidelines 2015 for the treatment of vulvar cancer and vaginal cancer. Int J Clin Oncol 2018; 23:201-234. [PMID: 29159773 PMCID: PMC5882649 DOI: 10.1007/s10147-017-1193-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/05/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Vulvar cancer and vaginal cancer are relatively rare tumors, and there had been no established treatment principles or guidelines to treat these rare tumors in Japan. The first version of the Japan Society of Gynecologic Oncology (JSGO) guidelines for the treatment of vulvar cancer and vaginal cancer was published in 2015 in Japanese. OBJECTIVE The JSGO committee decided to publish the English version of the JSGO guidelines worldwide, and hope it will be a useful guide to physicians in a similar situation as in Japan. METHODS The guideline was created according to the basic principles in creating the guidelines of JSGO. RESULTS The guidelines consist of five chapters and five algorithms. Prior to the first chapter, basic items are described including staging classification and history, classification of histology, and definition of the methods of surgery, radiation, and chemotherapy to give the reader a better understanding of the contents of the guidelines for these rare tumors. The first chapter gives an overview of the guidelines, including the basic policy of the guidelines. The second chapter discusses vulvar cancer, the third chapter discusses vaginal cancer, and the fourth chapter discusses vulvar Paget's disease and malignant melanoma. Each chapter includes clinical questions, recommendations, backgrounds, objectives, explanations, and references. The fifth chapter provides supplemental data for the drugs that are mentioned in the explanation of clinical questions. CONCLUSION Overall, the objective of these guidelines is to clearly delineate the standard of care for vulvar and vaginal cancer with the goal of ensuring a high standard of care for all women diagnosed with these rare diseases.
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Affiliation(s)
- Toshiaki Saito
- Gynecology Service, National Kyushu Cancer Center, Fukuoka, Japan
| | - Tsutomu Tabata
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Mie University, Mie, Japan
| | - Hitoshi Ikushima
- Department of Therapeutic Radiology, Tokushima University, Tokushima, Japan
| | - Hiroyuki Yanai
- Department of Diagnostic Pathology, Okayama University Hospital, Okayama, Japan
| | - Hironori Tashiro
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hitoshi Niikura
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takeo Minaguchi
- Department of Obstetrics and Gynecology, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Toshinari Muramatsu
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Kanagawa, Japan
| | - Tsukasa Baba
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Wataru Yamagami
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Kazuya Ariyoshi
- Gynecology Service, National Kyushu Cancer Center, Fukuoka, Japan
| | - Kimio Ushijima
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Mikio Mikami
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Kanagawa, Japan
| | - Satoru Nagase
- Department of Obstetrics and Gynecology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Masanori Kaneuchi
- Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Medicine, Nagasaki, Japan
| | - Nobuo Yaegashi
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Udagawa
- Department of Obstetrics and Gynecology, Fujita Health University School of Medicine, Aichi, Japan
| | - Hidetaka Katabuchi
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan.
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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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Mahjabeen S, Hatipoglu MK, Chandra V, Benbrook DM, Garcia-Contreras L. Optimization of a Vaginal Suppository Formulation to Deliver SHetA2 as a Novel Treatment for Cervical Dysplasia. J Pharm Sci 2017; 107:638-646. [PMID: 28989018 DOI: 10.1016/j.xphs.2017.09.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/14/2017] [Accepted: 09/18/2017] [Indexed: 12/11/2022]
Abstract
Cervical dysplasia induced by the human papilloma virus unpredictably progresses to cervical cancer. Therapeutic options are invasive and affect the patient's quality of life. SHetA2 has demonstrated therapeutic efficacy against human and murine human papilloma virus-induced tumors, but its oral bioavailability is <1%. An optimized vaginal suppository formulation can deliver SHetA2 in sufficient doses to prevent cervical dysplasia. The quality by design approach was employed to optimize the suppository formulation consisting of cocoa butter as base with 5% Kolliphor and 40% SHetA2. The suppository had a content uniformity of 105.44 ± 0.42%, melted in <8 min, and had a complete release of SHetA2 in water. Administration of the suppository to mice-achieved cervix concentrations that were significantly higher than the SHetA2 therapeutic concentration, with the maximum concentration (Cmax-cervix = 336.78 μg/g) being more than 100-fold the therapeutic SHetA2 concentration. Furthermore, the levels of cyclin D1 protein decreased 9-fold indicating a correlation of drug concentrations with the pharmacodynamic endpoint. These proof-of-concept studies suggest that the SHetA2 optimized vaginal suppository formulation may have a potential use in the prevention of cervical dysplasia, but detailed efficacy studies are required to confirm this assumption.
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Affiliation(s)
- Sanjida Mahjabeen
- Department of Pharmaceutical Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104
| | - Manolya K Hatipoglu
- Department of Pharmaceutical Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104
| | - Vishal Chandra
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104
| | - Doris M Benbrook
- Department of Pharmaceutical Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104; Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104
| | - Lucila Garcia-Contreras
- Department of Pharmaceutical Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 73104.
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Jones SEF, Hibbitts S, Hurt CN, Bryant D, Fiander AN, Powell N, Tristram AJ. Human Papillomavirus DNA Methylation Predicts Response to Treatment Using Cidofovir and Imiquimod in Vulval Intraepithelial Neoplasia 3. Clin Cancer Res 2017; 23:5460-5468. [PMID: 28600473 DOI: 10.1158/1078-0432.ccr-17-0040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/28/2017] [Accepted: 06/05/2017] [Indexed: 11/16/2022]
Abstract
Purpose: Response rates to treatment of vulval intraepithelial neoplasia (VIN) with imiquimod and cidofovir are approximately 57% and 61%, respectively. Treatment is associated with significant side effects and, if ineffective, risk of malignant progression. Treatment response is not predicted by clinical factors. Identification of a biomarker that could predict response is an attractive prospect. This work investigated HPV DNA methylation as a potential predictive biomarker in this setting.Experimental Design: DNA from 167 cases of VIN 3 from the RT3 VIN clinical trial was assessed. HPV-positive cases were identified using Greiner PapilloCheck and HPV 16 type-specific PCR. HPV DNA methylation status was assessed in three viral regions: E2, L1/L2, and the promoter, using pyrosequencing.Results: Methylation of the HPV E2 region was associated with response to treatment. For cidofovir (n = 30), median E2 methylation was significantly higher in patients who responded (P ≤ 0.0001); E2 methylation >4% predicted response with 88.2% sensitivity and 84.6% specificity. For imiquimod (n = 33), median E2 methylation was lower in patients who responded to treatment (P = 0.03; not significant after Bonferroni correction); E2 methylation <4% predicted response with 70.6% sensitivity and 62.5% specificity.Conclusions: These data indicate that cidofovir and imiquimod may be effective in two biologically defined groups. HPV E2 DNA methylation demonstrated potential as a predictive biomarker for the treatment of VIN with cidofovir and may warrant investigation in a biomarker-guided clinical trial. Clin Cancer Res; 23(18); 5460-8. ©2017 AACR.
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Affiliation(s)
- Sadie E F Jones
- School of Medicine, Cardiff University, Cardiff, United Kingdom.
| | | | - Christopher N Hurt
- Wales Cancer Trials Unit (WCTU), School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Dean Bryant
- University of Southampton, Southampton, United Kingdom
| | | | - Ned Powell
- School of Medicine, Cardiff University, Cardiff, United Kingdom
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Topical Therapy With Imiquimod for Vaginal Intraepithelial Neoplasia: A Case Series. J Low Genit Tract Dis 2016; 20:e34-6. [DOI: 10.1097/lgt.0000000000000214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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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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Paternotte J, Hebert T, Ouldamer L, Marret H, Body G. [Treatment of vulvar intra-epithelial neoplasias with Imiquimod]. ACTA ACUST UNITED AC 2015; 43:528-32. [PMID: 26047969 DOI: 10.1016/j.gyobfe.2015.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 04/14/2015] [Indexed: 11/25/2022]
Abstract
The incidence of vulvar intra-epithelial neoplasia (VIN) is increasing in the developed countries especially in young women. There is little consensus regarding the optimal management. Surgery used to be the gold standard. Alternatives to surgery are now needed for the treatment of VIN. Many studies investigated the effectiveness of Imiquimod 5% cream in this pathology. We present a literature review of the results published on the subject.
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Affiliation(s)
- J Paternotte
- Service de gynécologie-obstétrique et médecine fœtale, université François-Rabelais, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France.
| | - T Hebert
- Service de gynécologie-obstétrique et médecine fœtale, université François-Rabelais, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
| | - L Ouldamer
- Service de gynécologie-obstétrique et médecine fœtale, UMR Inserm U 1069, université François-Rabelais, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
| | - H Marret
- Service de gynécologie-obstétrique et médecine fœtale, UMR Inserm U 930, université François-Rabelais, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
| | - G Body
- Service de gynécologie-obstétrique et médecine fœtale, université François-Rabelais, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
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Patel J, Salit IE, Berry MJ, de Pokomandy A, Nathan M, Fishman F, Palefsky J, Tinmouth J. Environmental scan of anal cancer screening practices: worldwide survey results. Cancer Med 2014; 3:1052-61. [PMID: 24740973 PMCID: PMC4303174 DOI: 10.1002/cam4.250] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 03/05/2014] [Accepted: 03/16/2014] [Indexed: 12/15/2022] Open
Abstract
Anal squamous cell carcinoma is rare in the general population but certain populations, such as persons with HIV, are at increased risk. High-risk populations can be screened for anal cancer using strategies similar to those used for cervical cancer. However, little is known about the use of such screening practices across jurisdictions. Data were collected using an online survey. Health care professionals currently providing anal cancer screening services were invited to complete the survey via email and/or fax. Information was collected on populations screened, services and treatments offered, and personnel. Over 300 invitations were sent; 82 providers from 80 clinics around the world completed the survey. Fourteen clinics have each examined more than 1000 patients. Over a third of clinics do not restrict access to screening; in the rest, eligibility is most commonly based on HIV status and abnormal anal cytology results. Fifty-three percent of clinics require abnormal anal cytology prior to performing high-resolution anoscopy (HRA) in asymptomatic patients. Almost all clinics offer both anal cytology and HRA. Internal high-grade anal intraepithelial neoplasia (AIN) is most often treated with infrared coagulation (61%), whereas external high-grade AIN is most commonly treated with imiquimod (49%). Most procedures are performed by physicians, followed by nurse practitioners. Our study is the first description of global anal cancer screening practices. Our findings may be used to inform practice and health policy in jurisdictions considering anal cancer screening.
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Treatment of Vulvar Intraepithelial Neoplasia With CO2 Laser Vaporization and Excision Surgery. J Low Genit Tract Dis 2013; 17:446-51. [DOI: 10.1097/lgt.0b013e318284c1ed] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Clinical Characteristics Associated With Development of Recurrence and Progression in Usual-Type Vulvar Intraepithelial Neoplasia. Int J Gynecol Cancer 2013; 23:1476-83. [DOI: 10.1097/igc.0b013e3182a57fd6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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20
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Toll-like receptors as therapeutic targets for cancer. Drug Discov Today 2013; 19:379-82. [PMID: 24012797 DOI: 10.1016/j.drudis.2013.08.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 08/21/2013] [Accepted: 08/23/2013] [Indexed: 12/28/2022]
Abstract
Stimulation of Toll-like receptors (TLRs) to activate the innate immune system has been a legitimate therapeutic strategy for some years. TLRs 3, 4, 7, 8 and 9 are all validated targets for cancer and a number of companies are developing agonists and vaccine adjuvants. TLR7 in particular has established proof-of-concept as a target in the topical treatment of bladder and skin cancers. However, the development of systemic treatments targeting TLR7 for most other cancers has proved difficult owing to cardiotoxicity or myelosuppression. Tantalisingly, recent animal data have demonstrated that a new class of modified TLR7 agonists can be administered systemically with a good toxicology profile, opening up this target in therapeutic interventions for systemic cancers.
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Lin CT, Qiu JT, Wang CJ, Chang SD, Tang YH, Wu PJ, Jung SM, Huang CC, Chou HH, Jao MS, Lai CH. Topical imiquimod treatment for human papillomavirus infection in patients with and without cervical/vaginal intraepithelial neoplasia. Taiwan J Obstet Gynecol 2013; 51:533-8. [PMID: 23276555 DOI: 10.1016/j.tjog.2012.09.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2012] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy and toxicity of topical imiquimod for the treatment of persistent human papillomavirus (HPV) infection in patients with or without cervical/vaginal intraepithelial neoplasia (CIN/VAIN). METHODS Patients with persistent HPV infection (≥ 1 year) after a history of treatment for cervical or vaginal neoplasm but normal histology and cytology, abnormal Papanicolaou (Pap) smears without abnormal histology, and untreated histology-documented CIN/VAIN Grade 1/2/3 with HPV-positive testing were recruited. Patients were instructed to apply 250 mg of 5% imiquimod cream intravaginally on consecutive days or at least twice weekly on an outpatient basis for a minimum of 12 doses. A group of age- and previous diagnosis-matched, imiquimod-untreated historical controls (n = 20) were selected. The main outcome measures included HPV DNA detection, cytology, and colposcopy/histology at 6 months after treatment. RESULTS A total of 72 patients were eligible for analysis. At a median follow-up of 33.6 months, 37 patients (51.4%) had cytological/histological regression and tested HPV-negative. Six patients (8.3%) had progressive cytology/histology with persistent HPV infections. Of the 72 treated patients, 26 patients who had a normal Pap test but were persistently HPV-positive for at least 1 year had a complete regression rate of 65.4%, which was significantly different from the rate (30%) observed in the untreated historical control (p = 0.036). Six patients with histologically proven CIN2/3 or VAIN2/3 had a complete regression rate of 66.6% (4/6). CONCLUSIONS The tolerability of intravaginal self-administered imiquimod is confirmed. Its efficacy in the treatment of women with persistent HPV infection and normal cytology warrants further randomized, controlled trials to determine appropriate dosages and scheduling.
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Affiliation(s)
- Cheng-Tao Lin
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
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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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Gurumurthy M, Cruickshank ME. Management of Vaginal Intraepithelial Neoplasia. J Low Genit Tract Dis 2012; 16:306-12. [DOI: 10.1097/lgt.0b013e31823da7fb] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Randomized clinical trial of imiquimod: an adjunct to treating cervical dysplasia. Am J Obstet Gynecol 2012; 206:42.e1-7. [PMID: 21907959 DOI: 10.1016/j.ajog.2011.06.105] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 05/24/2011] [Accepted: 07/28/2011] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Human papillomavirus (HPV) infection is a major risk factor for cervical cancer. Imiquimod is a topical medication that enhances the immune response to HPV-induced genital warts. This study evaluated cervical application of imiquimod as an adjunct to standard treatment for cervical dysplasia. STUDY DESIGN Fifty-six patients were randomized to standard excisional/ablative treatment vs applications of imiquimod followed by standard treatment. The primary endpoint was dysplasia recurrence within 2 years. RESULTS There were no differences in dysplasia recurrence between the 2 groups. Treatment was well tolerated, with side effects being mild but significantly worse in women receiving imiquimod for, chills, fatigue, fever, headache, myalgias, and vaginal discharge. CONCLUSION This trial does not support the hypothesis that imiquimod, as used in this trial, has an impact on recurrence of cervical dysplasia, but the adequacy of findings are limited by sample size. The trial does support the feasibility and acceptability of the use of imiquimod on the cervix.
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Screening and follow up of vulval skin disorders. Best Pract Res Clin Obstet Gynaecol 2011; 26:175-88. [PMID: 22189088 DOI: 10.1016/j.bpobgyn.2011.11.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Accepted: 11/03/2011] [Indexed: 02/06/2023]
Abstract
Vulval squamous cell carcinoma is relatively rare; however, up to 20% of women have significant vulval symptoms during their lifetime. Formal screening programmes for vulval disease have not been established. The evidence for the use of vulval cytology and vulvoscopy is reviewed. No randomised-controlled trials have compared follow-up regimens, and although a few consensus documents have been published, formal guidelines are lacking in Grade A evidence. With increasing pressure on healthcare resources, the possibility of identifying high-risk groups to optimise the use of follow up in specialist clinics is explored. Vulval disease is uncommon and there is no evidence that screening would decrease incidence. If high-risk groups can be identified, follow up should take place in specialised vulval clinics with experienced clinicians who are trained in vulval disease. Women with uncomplicated vulval conditions should be discharged to patient-initiated follow up or primary care. Central to the reduction of mortality and morbidity is increased awareness of vulval conditions among women and improved education of healthcare professionals, with particular understanding of the importance of physical examination.
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Smyth EC, Flavin M, Pulitzer MP, Gardner GJ, Costantino PD, Chi DS, Bogatch K, Chapman PB, Wolchok JD, Schwartz GK, Carvajal RD. Treatment of locally recurrent mucosal melanoma with topical imiquimod. J Clin Oncol 2011; 29:e809-11. [PMID: 22010009 DOI: 10.1200/jco.2011.36.8829] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Terlou A, Kleinjan A, Beckmann I, Heijmans-Antonissen C, van Seters M, Santegoets LAM, van Beurden M, Helmerhorst TJM, Blok LJ. Nonsteroidal anti-inflammatory drugs do not interfere with imiquimod treatment for usual type vulvar intraepithelial neoplasia. Int J Cancer 2011; 128:2463-9. [PMID: 20658529 DOI: 10.1002/ijc.25573] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Imiquimod has been shown to be an effective treatment for usual type vulvar intraepithelial neoplasia (uVIN). Since local inflammation and burning are common side effects, patients often use nonsteroidal anti-inflammatory drugs (NSAIDs). Our study investigated whether NSAID-use, which has been documented to inhibit the cell-mediated immune response, interferes with the outcome of imiquimod treatment. Monocyte-derived dendritic cells (moDCs) and Langerhans cells (moLCs) were cultured in the presence of NSAIDs. The expression of relevant surface markers (CD80, CD86, CD40, HLA-DR, CCR6 and CCR7), stimulatory function, and cytokine production were evaluated. Furthermore, we analyzed in uVIN patients whether frequent NSAID-use had an effect on the clinical response and on immunocompetent cell counts before and after imiquimod treatment. Although an effect was observed on the expression of moDC and moLC maturation markers, NSAIDs did not affect the ability of moDCs and moLCs to stimulate allogeneic T-cell proliferation, or the production of cytokines in an allogeneic T-cell stimulation assay. In agreement with this, in uVIN patients treated with imiquimod, no interference of frequent NSAID-use with clinical outcome was observed. However, we did notice that high CD1a(+) and CD207(+) cell counts in frequent NSAID-users before treatment seemed to predict a favourable response to imiquimod treatment. Our data indicate that NSAID-use does not seem to interfere with moDC and moLC function and does not interfere with immunomodulatory properties of imiquimod in uVIN patients. Therefore, NSAIDs can safely be used to reduce imiquimod side effects in uVIN patients during treatment.
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Affiliation(s)
- Annelinde Terlou
- Department of Obstetrics and Gynaecology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Quist SR, Gollnick HP. Imiquimod 3.75% cream (Zyclara) for the treatment of actinic keratoses. Expert Opin Pharmacother 2011; 12:451-61. [PMID: 21254950 DOI: 10.1517/14656566.2011.549128] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION actinic keratosis is a premalignant disease with a high incidence and is a strong predictor for the development of squamous cell carcinoma. Various treatment options have been established over recent years, including topical treatment with imiquimod, 5-fluorouracil, diclofenac or photodynamic therapy, cryotherapy and surgical procedures. AREAS COVERED this review covers basic and clinical experiences with imiquimod 3.75% for topical treatment of actinic keratosis of the face and balding scalp and its comparators with special focus on imiquimod 5%. It also covers pharmacology of imiquimod 3.5% and its contribution to the current treatment options of actinic keratoses. EXPERT OPINION imiquimod 3.75% is an interesting, safe and well-tolerated treatment option for actinic keratoses of the face or balding scalp especially in respect of compliance, as it is indicated for daily use for a shorter time period (2 times, 2-week cycles) and approved for use on larger areas compared with imiquimod 5%. Data from current trials indicate lower efficacy compared with imiquimod 5% cream when applied three times a week for 16 weeks or for two 4-week cycles with a 4-week no-treatment interval, but indicate similar efficacy when compared with a twice-weekly schedule for 16 weeks. An additive effect was observed when combining cryosurgery followed by imiquimod 3.75%.
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Affiliation(s)
- Sven R Quist
- Otto-von-Guericke University Magdeburg, Department of Dermatology and Venereology, Magdeburg, Germany
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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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Terlou A, van Seters M, Ewing PC, Aaronson NK, Gundy CM, Heijmans-Antonissen C, Quint WGV, Blok LJ, van Beurden M, Helmerhorst TJM. Treatment of vulvar intraepithelial neoplasia with topical imiquimod: seven years median follow-up of a randomized clinical trial. Gynecol Oncol 2011; 121:157-62. [PMID: 21239049 DOI: 10.1016/j.ygyno.2010.12.340] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Revised: 12/15/2010] [Accepted: 12/16/2010] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Recently we reported on the efficacy of imiquimod for treating vulvar intraepithelial neoplasia (VIN) in a placebo-controlled, double-blinded randomized clinical trial (RCT). Four weeks after treatment, a complete response was observed in 35% of patients and a partial response in 46%. All complete responders remained disease-free at 12 months follow-up. In the current investigations, we assessed long-term follow-up at least 5 years after the initial RCT. METHODS Twenty-four of 26 imiquimod-treated patients who had participated in the initial RCT were seen for follow-up. Primary endpoint was durability of clinical response to imiquimod assessed by naked eye vulvar examination and histology. Long-term clinical response was correlated to lesion size before start of the initial RCT. Secondary endpoints were mental health, global quality of life, body image and sexual function in relation with long-term clinical response. RESULTS Median follow-up period was 7.2 years (range 5.6-8.3 years). VIN recurred in one of nine complete responders. Of the initial partial responders, two became disease-free after additional imiquimod treatment. In the other partial responders, VIN recurred at least once after the initial RCT. In long-term complete responders, lesion size at study entry was smaller and these patients had a significantly better global quality of life at follow-up than patients with residual disease and/or recurrence after imiquimod treatment. CONCLUSIONS In case of a complete response, imiquimod is effective in the long-term. Furthermore, patients with a long-term complete response had a significantly better global quality of life than patients who recurred after imiquimod treatment.
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Affiliation(s)
- Annelinde Terlou
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.
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Lai KW, Mercurio MG. Medical and surgical approaches to vulvar intraepithelial neoplasia. Dermatol Ther 2010; 23:477-84. [DOI: 10.1111/j.1529-8019.2010.01351.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mahto M, Nathan M, O'Mahony C. More than a decade on: review of the use of imiquimod in lower anogenital intraepithelial neoplasia. Int J STD AIDS 2010; 21:8-16. [PMID: 20029061 DOI: 10.1258/ijsa.2009.009309] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
To assess the effectiveness of 5% imiquimod cream (IQ) in the treatment of vulvar, penile and anal intraepithelial neoplasias (VIN, PIN and AIN), we searched Medline, Embase, PubMed and Cochrane Library databases. With regard to VIN there were two randomized controlled trials (RCTs), eight uncontrolled/cohort studies, nine case reports and one review article. Use of IQ in PIN and AIN were only supported by cohort studies (two each for PIN and AIN) and case reports (15 for PIN and 3 for AIN). On pooled analysis of RCTs, uncontrolled and cohort studies, the mean complete response (CR) rate for VIN, PIN and AIN were 51%, 70% and 48%, respectively. The mean partial response (PR) rate for VIN, PIN and AIN were 25%, 30% and 34% respectively. The recurrence (RR) rate for VIN, PIN and AIN were 16%, 0% and 36%, respectively. The follow-up period for VIN, PIN and AIN ranged from 2 to 32 months, 10 to 12 months and 11 to 39 months, respectively. Although the results for PIN look the best, the strongest evidence regarding efficacy of IQ in anogenital intraepithelial neoplasia is for VIN supported by RCTs. Evidence for use of IQ in AIN was essentially limited to HIV-positive men who have sex with men. IQ was reasonably well tolerated with side-effects being managed with reduction in frequency of drug usage and/or rest periods. Based on these results, IQ seems to be a safe mode of treatment and is possibly an alternative to currently available methods of treatment. However, there are no comparative studies assessing its efficacy against traditional modes of treatment.
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Affiliation(s)
- M Mahto
- Department of Genitourinary Medicine, Cheshire East Community Health (Central and Eastern Cheshire PCT), Assura Health and Wellness Centre, Sunderland Street, Macclesfield SK11 6JL.
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New Approaches to External Genital Warts and Vulvar Intraepithelial Neoplasia. Clin Obstet Gynecol 2008; 51:518-26. [DOI: 10.1097/grf.0b013e31818092a3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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