Diagnosis & Management Of VAIN/VIN Richard Hutson Gynaecological Oncologist St. James’s University Hospital

Definition A condition where neoplastic cells are within the boundaries of surface epithelium Excludes:- Paget’s 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-III

VIN II with Koilocytosis

Paget’s Disease of the Vulva

Aetiology Strong association with STD’s 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 = 38-100 % Dinitrochlorobenzene; topical immunotherapy CO2 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