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Diagnosis & Management Of VAIN/VIN

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.

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Diagnosis & Management Of VAIN/VIN

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

  2. 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

  3. Classification • VIN/VAIN I :- mild dysplasia; lower 1/3 • VIN/VAIN II :- mod. dysplasia; lower 2/3 • VIN/VAIN III :- severe dysplasia; > 2/3

  4. Symptoms • Pruritus (38-73 %) • Vulval pain / soreness • A lump / lesion • Asymptomatic

  5. Physical Signs • Papular & rough surfaced (warts) • Macular with indistinct/irregular borders • Micropapillary/granular associated with acanthosis • Pigmentation (brown/black) • White lesions (hyperkeratosis)

  6. Diagnosis • Histologically; biopsy always required • Biopsy under LA; use of EMLA • Punch / scalpel

  7. Normal Epithelium with L.S.

  8. VIN II-III

  9. VIN II with Koilocytosis

  10. Paget’s Disease of the Vulva

  11. Aetiology • Strong association with STD’s • HPV (43-79 %) • Younger women condyloma and koilocytes • Older women no koilocytosis • Smoking • Immunosuppressed

  12. 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

  13. Management in Young Women • Risk of invasion is small • Recurrence rate up to 84 % • > 20 % recurrent disease after simple vulvectomy • Regresses after pregnancy

  14. Who to Treat ? • Post menopausal presentation • Immunosuppressed / immunodeficient • Histologically progressive lesions on serial biopsy • Excessively hyperkeratotic lesions

  15. 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

  16. 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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