Clinical Features and Risk of Recurrence among Patients with Vaginal Intraepithelial Neoplasia
January 1, 2002 4 minutes read
Clinical Features and Risk of Recurrence among Patients with Vaginal Intraepithelial Neoplasia
Abstract & Commentary
Synopsis: Many patients with vaginal intraepithelial neoplasia have recurrence following treatment.
Source: Dodge JA, et al. Gynecol Oncol. 2001;83: 363-369.
Primary neoplasia of the vaginal epithelium is an uncommon condition. Both vaginal intraepithelium neoplasia (VAIN) and invasive cancer occur infrequently in the United States. However, most studies of this condition have been limited to small series. Dodge and colleagues performed a retrospective chart review of all cases that occurred at their institution between 1989 and 2000. The pathology from each case was reviewed to be certain that the original diagnosis was correct. After this review, their series consisted of 121 patients with any grade of VAIN. The charts of these patients were reviewed and a large number of variables were collected including demographic information, grade of VAIN, location of VAIN, treatment type, and recurrence. Unfortunately, Dodge et al only required a follow-up of 7 months and 1 post-treatment Pap smear to be included in the study. While they state this represents a longer follow-up than other studies, it is still short. Dodge et al mention this as one of the weaknesses of their study.
Of the 121 patients, 33% had VAIN I, 46% VAIN II, and 21% VAIN III. The mean age of the patients was 35 years (± 17 years). Almost all the patients had colposcopy and directed biopsies, but 8 patients had biopsy of a suspicious lesion seen with the naked eye. Nearly 80% of the lesions were located in the upper third of the vagina and 61% of the lesions were multifocal. In this series, 28 women had a prior hysterectomy.
Twenty percent of the patients had follow-up cytology only, 19% were treated with 5 fluorouracil (5-FU), 48% were treated with CO2 laser, and 13% with partial vaginectomy.
None of the 13 patients treated with partial vaginectomy had a recurrence of their lesion. In contrast, 38% of those treated with CO2 laser and 59% of those treated with 5-FU had recurrence.
Two patients developed invasive vaginal cancer. Both patients had multifocal lesions and both were treated with 5-FU. One had previously had a hysterectomy for CIN III and also had VIN III. The length of time from first diagnosis of VAIN to the development of vaginal cancer was 54 months and 24 months in these 2 patients.
Statistical analysis was able to identify 2 factors that predicted recurrence of VAIN: multifocality and method of treatment. Interestingly, age, smoking, HRT use, grade of VAIN, location of VAIN, and association with either CIN or VIN were not predictive of recurrence.
Comment by Kenneth L. Noller, MD
I have always thought that VAIN is an interesting condition. It has not been well studied because it is relatively rare. This study is interesting, mostly because it reports one of the larger series of patients with VAIN in the literature. However, there is virtually no new information in the article. Dodge et al found that VAIN is associated with CIN and VIN, that 5-FU is a terrible treatment for the condition, that CO2 laser has many recurrences, and surgical excision has the fewest. Multifocal lesions are harder to cure than unifocal, and most VAIN occurs in the upper vagina. All of these facts have been documented in prior, smaller studies.
In every article I read there was always some information that was not supplied by the researchers that I wish I knew. Dodge et al briefly mention the 2 patients that developed invasive cancer but provide little detail. I would be most interested in knowing how many women with VAIN I and no history of CIN or VIN had progression of disease. I strongly suspect that it is rare and that most lesions will spontaneously disappear. It would have been nice to have had that information reported since this is a relatively large series.
I also would have liked to have had more information on the 2 patients who developed invasive cancer. While one patient was described as previously having CIN III and VIN III, it is not clear whether she had VAIN I or VAIN II on initial presentation. Virtually no information is given about the past history of the other patient. Nor is there any information provided concerning the immune status of these patients.
Finally, it is clear that there is no place for the use of 5-FU in the treatment of VAIN. Indeed, in my opinion, there is no longer any indication for the use of 5-FU anywhere in the lower genital tract for intraepithelial lesions.
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