Vulvar Neoplasm Vulvar Intraepithelial Neoplasia

Surgical treatment for frankly invasive vulvar carcinoma is indicated clearly; however, no commonly accepted treatment for VIN exists. The goal of treatment is to minimize symptoms and halt progression to invasive cancer, while attempting to preserve anatomy and sexual function. Options include topical agents, wide local excision, laser therapy, and skinning vulvectomy. Management is individualized based upon biopsy, extent of disease, and symptoms. Table 3 summarizes vulvar neoplasm treatments supported by nonRCTs.

Table 3 Nonrandomized Trial-Supported Treatment for Vulvar Neoplasm

Stage

Primary treatment

Additional therapies

VIN

Local excision (137), skinning

Promising topicals: imiquimod

vulvectomy (139), laser (138),

(21,137), 5-FU (139), IFN-a

LEEP (138)

(143), PDT (144)

Stage I

If <1 mm: Local excision with wide

Laser/LEEP (138)

or radical margins (140)

If >1 mm: Add lymphadenectomy

(141)

Stage II

3-Incision conservative or radical

Laser/LEEP (138)

vulvectomy with bilateral

inguinofemoral

lymphadenectomy (141)

Stage III

3-Incision radical vulvectomy with

Primary chemoradiation therapy

bilateral inguinofemoral

(145), preoperative

lymphadenectomy (141)

chemoradiation (146),

If > 1 node positive, add

preoperative radiation (147)

postoperative groin and pelvic

irradiation (142)

Stage IV

Radical or en bloc vulvectomy and

Primary chemoradiation therapy

lympadenectomy, remove

(145), preoperative

metastases (141)

chemoradiation (146),

If > 1 positive node, add

preoperative radiation (147)

postoperative groin and pelvic

irradiation (142)

Abbreviations: VIN, vulvar intraepithelial neoplasia; 5-FU, 5-fluorouracil; IFN-a, interferon-a; LEEP, loop electrosurgical excision procedures; PDT, photodynamic therapy.

Abbreviations: VIN, vulvar intraepithelial neoplasia; 5-FU, 5-fluorouracil; IFN-a, interferon-a; LEEP, loop electrosurgical excision procedures; PDT, photodynamic therapy.

Lower grade VIN may be managed best with a conservative, nonsurgical treatments that preserve vulvar anatomy. Several chemotherapeutic agents appear promising, but are yet to be proven by RCTs.

Imiquimod is currently FDA approved for treatment of genital warts is being used currently to treat human papillomavirus-associated VIN. In a few small noncontrolled studies, topical 5% imiquimod cream three times weekly was found to clear VIN II/III (137,148). Studies have shown at least 75% overall response (148). Efficacy, however, may be limited when dysplasia extends into ducts of glands or into hair follicles (138). Invasive carcinoma must be ruled out prior to therapy, as invasive disease has been found after treatment with imiquimod. Further studies investigating efficacy are warranted.

In a case series, topical 5% 5-FU showed response rates of 50% to 60% (139). 5-FU, however, causes chemical desquamation that can result in significant discomfort, inflammation, and painful ulcerations. There has been one case report of successful treatment of extensive VIN III with topical 1% cidofo-vir. Further investigation is necessary to determine the role of these drugs in the treatment of VIN.

One small randomized, double-blind, crossover study evaluated topical IFN-a in 18 patients with VIN III. The study compared IFN-a versus IFN-a with nonoxyl-9 and showed 67% response rate in all patients, independent of the addition of nonoxyl-9 (143). Although the results appear promising, the efficacy cannot be determined until a placebo-controlled trial with more participants is performed.

For the low-grade VIN, surgery may be unnecessary. However, untreated VIN III lesions have a high incidence of conversion to invasive squamous cell carcinoma; typically, surgery is the best management (137). Surgical excision can be diagnostic as well as therapeutic, offering an advantage over ablative or medical management options. This is important because of the frequency of undetected coexisting invasive squamous cell carcinoma. In a case series of patients treated with excision, more than 20% had underlying invasive disease, the majority of which was more than 1 mm (137,149). Local excision with 5 mm margins is sufficient treatment in unifocal disease with disease-free biopsy margins and no evidence of stromal invasion (137). Although excision through the depth of the epidermis is satisfactory, removing some underlying dermis may be of added benefit to rule out invasive disease (139). Disfigurement is a disadvantage; however, excision and close follow-up reduce the chance of development of invasive cancer. Nonetheless, in a 15-year follow-up study of patients after surgical excision, recurrence or persistence occurred in 48%, and disease progressed to frankly invasive carcinoma in 7% (150). Despite the widespread use of surgical treatment, there are no systematic reviews or RCTs showing the effects of surgical treatment for VIN.

Several noncontrolled studies support the use of laser therapy (excision and vaporization) as alternative treatment for multiple, small lesions (138,139). Laser excision has a cure rate of up to 87% (136,150). The cure rate after one treatment with laser vaporization is up to 75% (137,138,151). Most other cases achieve disease control with a second or third treatment (138,139). Some patients who received additional treatment developed invasive squamous cell carcinoma subsequently (137). A retrospective cohort study showed a significant increase in disease recurrence or persistence with laser vaporization as compared to local excision (150); subsequent smaller uncontrolled studies have had varied results. It is essential to rule out invasive cancer before using laser vaporization, as this modality involves tissue ablation. Superficial laser treatment may be more appealing cosmetically than the other surgical techniques—for example, clitoral involvement—in which case precision minimizes deformity and sexual dysfunction (149). In areas with hair, dysplastic cells are deeper and superficial treatment is not appropriate; in this case, laser causes scarring and deformity. Recurrence is common in these regions; thus, standard surgical excision is preferable (140).

Skinning vulvectomy is recommended for more extensive lesions. Skin is removed subepidermally, allowing for preservation of subcutaneous tissue. Closure is either by reapproximation or with a skin graft (140).

Electrosurgery has been used with success and, when compared to laser, appears to be as efficacious in clearing disease, but further study is necessary (138,152). Though used in the past, cryosurgery can have up to 90% recurrence rate (153); however, data have been derived from studies with few participants. Because of the availability and better success of other options, electrosurgery is not recommended.

In uncomplicated cases, an alternative to standard therapy is PDT. Topical 5-aminolevulinic acid can be applied to the vulvar lesion and activated with light. Multiple noncontrolled studies show similar efficacy as conventional treatment options in clearing all grades of VIN. Advantages of PDT include short healing time and minimal disfiguration (144). However, PDT can be associated with significant patient discomfort, including burning sensations and pain; in addition, recurrence of VIN is common after this treatment (139) and response rates in multifocal lesions and lesions with increased pigmentation and hyper-keratosis are lower (144). Nonetheless, PDT deserves further investigation.

Was this article helpful?

0 0
From PMS To PPD

From PMS To PPD

The Stages Of A Woman’s Life Are No Longer A Mystery. Get Instant Access To Valuable Information On All The Phases Of The Female Body From Menstruation To Menopause And Everything In Between.

Get My Free Ebook


Post a comment