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