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Diagnosis & Management Of VAIN/VIN Richard Hutson Gynaecological Oncologist St. Jamess University Hospital
Definition A condition where neoplastic cells are within the boundaries of surface epithelium Excludes:- Pagets disease of the Vulva Melanoma-in-situ Maturation disorders
Classification VIN/VAIN I :- mild dysplasia; lower 1/3 VIN/VAIN II :- mod. dysplasia; lower 2/3 VIN/VAIN III :- severe dysplasia; > 2/3
Symptoms Pruritus (38-73 %) Vulval pain / soreness A lump / lesion Asymptomatic
Physical Signs Papular & rough surfaced (warts) Macular with indistinct/irregular borders Micropapillary/granular associated with acanthosis Pigmentation (brown/black) White lesions (hyperkeratosis)
Diagnosis Histologically; biopsy always required Biopsy under LA; use of EMLA Punch / scalpel
Normal Epithelium with L.S.
VIN II with Koilocytosis
Pagets Disease of the Vulva
Aetiology Strong association with STDs HPV (43-79 %) Younger women condyloma and koilocytes Older women no koilocytosis Smoking Immunosuppressed
Natural History of VIN / VAIN No established rates of progression or regression Risk of invasion is small Risk of invasion more likely women > 45; immunosuppressed; SLE; multifocal disease
Management in Young Women Risk of invasion is small Recurrence rate up to 84 % > 20 % recurrent disease after simple vulvectomy Regresses after pregnancy
Who to Treat ? Post menopausal presentation Immunosuppressed / immunodeficient Histologically progressive lesions on serial biopsy Excessively hyperkeratotic lesions
Treatment Techniques W.L.E. (8mm margin) Skinning Vulvectomy; skin graft, 27% rec. Vulvectomy; rarely employed Topical 5 FU; failure rate = % Dinitrochlorobenzene; topical immunotherapy CO 2 laser; to upper reticular dermis
Summary HPV and multifocal disease commoner in young women Unifocal and HPV neg. lesions in post-men. Women CIN found in 33% of women with VIN VIN assoc. with 25-33% vulval cancers 50% vulval cancers assoc. with non- neoplastic disorders
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