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VIN & Condylomata Diagnosis & Surgical treatment

VIN & Condylomata Diagnosis & Surgical treatment. Ph. De Sutter. ISSVD VIN terminology 2 Pathways leading to vulvar carcinoma. VIN 1-2-3- CIS 1986 Cfr CIN terminology Low / High grade VIL ISSVD 2005 Not reproducible, reliably separated VIN 1: no evidence as cancer precursor

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VIN & Condylomata Diagnosis & Surgical treatment

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  1. VIN & CondylomataDiagnosis & Surgical treatment Ph. De Sutter

  2. ISSVD VIN terminology2 Pathways leading to vulvar carcinoma • VIN 1-2-3- CIS 1986 • Cfr CIN terminology • Low / High grade VIL • ISSVD 2005 • Not reproducible, reliably separated • VIN 1: no evidence as cancer precursor • LR-HPV associated / condyloma / flat warts • VIN • Usual type (warty, basaloïd)  non-keratinising SCC • HR-HPV associated • Younger women • Differentiated VIN  keratinising SCC • Associated with dermatologic disorders (Lichen Sclerosis) • Elderly women Ph. De Sutter VIN & Condyloma

  3. Genital wartsFlat warts / Condylomata acuminata • Are a sign of Low–Risk HPV infection (6, 11) • But can be associated with HR-HPV and precursors of invasive cancer (CIN, VAIN, VIN)! • Are often multifocal • Are an intraepithelial disease • Removal of the stromal tissue is not necessary • Removal of the skin appendages are not necessary Ph. De Sutter VIN & Condyloma

  4. VIN Usual (common) type • Incidence 5/100000 • Increasing • Young women 30-40y • Is associated with HR-HPV infection (16-18) • But can be associated with condylomata and other precursors of invasive cancer (CIN, VAIN)! • 22% concurrent, 71% history of CIN, VAIN, CxSCC • Often multifocal (40%) • Role of immunity • Smoking 60-80% • HIV / immunosuppressants • ? • Malignant progression <10% Ph. De Sutter VIN & Condyloma

  5. VIN Differentiated type • Rare lesion • 2-5% • Subtle histological diagnosis • Association with Lichen Sclerosus • No association with HR-HPV • Unifocal • Site of biopsy! • Older women • Unknown etiology •  High malignant potential Ph. De Sutter VIN & Condyloma

  6. Vulvar pathologyDiagnosis / pre-treatment assessment • Cervical cytology / HPV test • Colposcopy / Vulvoscopy • Photograph • Biopsy Ph. De Sutter VIN & Condyloma

  7. ColposcopyAssessment of multifocal disease • No treatment without colposcopy ! • Dermatologists! • Assessment lower genital tract • TZ cervix • Vagina • Vulva • Perineum • Anus Ph. De Sutter VIN & Condyloma

  8. Biopsy • Diagnosis / exclusion invasion • Atypical or suspect appearance • Avoid multiple biopsies • Edge of lesion • Condyloma • Refractory to medical treatment • Solitary or large ("giant") • Dermatologic disorder not responding to initial therapy • Tools • Local anesthesia • Keyes punch 1-4mm • Flat lesions • Punch / Rectangular LEEP • Proliferating / large lesions • Excisional biopsy Ph. De Sutter VIN & Condyloma

  9. Why treatment ? • Condylomata / VIN • Prevention of progression • Reduce transmissibility • Provide relief from symptoms • Cosmetic • Psychological • Relational • VIN • + Precancerous / undetermined malignant potential • 9% invasion if untreated • 3,3% if treated • Independend of technique, margins, focality • High risk of recurrence  40% • Independend of technique • Dependent of margins, focality Van Seters, Gynecol Oncol 2005 Ph. De Sutter VIN & Condyloma

  10. Individualized treatment • Gender • Site • Size • Number • Multifocality • Associated lesions • Patient acceptance • Follow-up • Previous treatments Risk of recurrence Risk of progression & invasion Anatomical disruption Psychosexual sequelae Ph. De Sutter VIN & Condyloma

  11. Treatment of VIN and condyloma • Often multifocal • Subclinical disease • Margins!? • Intraepithelial disease • Removal of the stromal tissue is not necessary • Removal of the skin appendages is not necessary • But VIN will involve the skin appendages in 50% • Depth of skin appendages • max 9.7mm • VIN in skin appendages • max 4.6mm • mean 1.2mm • Treatment to 2nd or 3th surgical plane should be effective • Papillary / upper reticular dermis Ph. De Sutter VIN & Condyloma

  12. Medical treatment • Podophyllin • Not to be applied by the patient • Systemic toxicity • Local burns if not washed off • Obsolete • Podophyllotoxin • 0.5% solution • 0.15% cream • 2x/day; 3days; 4 weeks Ph. De Sutter VIN & Condyloma

  13. Medical treatment • Trichloroacetic acid 50-80% • 1-3/week • Cheap • Safe if applied with care, not toxic • Short burning pain after application • Must not be washed off • Appropriate for small, fresh warts • 5-Fluorouracil cream (5-FU) • Difficult in use on keratinised skin • Pain / burning • Sometimes severe reaction • Can be applied for vaginal condylomata / VAIN Ph. De Sutter VIN & Condyloma

  14. Medical treatment • Aldara: Immune response modifier • Side effects!! • Condyloma • First line treatment • Pre-surgery • Post-surgery recurrences • VIN • CR 47%, PR 28% • …CR 80%, PR 10% • Duration of therapy …30w • Uncontrolled studies • Limited FU •  selected cases / complementary treatment Ph. De Sutter VIN & Condyloma

  15. Medical treatment • Photodynamic therapy (PDT) • Topical 5-aminolaevulinic acid • CR 40% • Small unifocal lesions (=surgery) • Interferon • Cidofovir • Therapeutic vaccination Ph. De Sutter VIN & Condyloma

  16. Selection for surgical treatment • VIN • Condylomata • Associated VIN • Associated cervico-vaginal lesions: • Condyloma, VAIN, CIN • Resistant or partial response to medical treatment (Aldara) • To extensive for medical treatment • To scanty for (expensive / long) medical treatment Ph. De Sutter VIN & Condyloma

  17. CondylomataTiming of surgical treatment Do not treat in the growing phase ! Wait long enough until lesions are stabilized Ph. De Sutter VIN & Condyloma

  18. LEEP ablation / resection • Local infiltration anaesthesia • Office treatment (cfr. CIN) • Limited (unifocal) • Condyloma • VIN • Only external locations • Vulva, introitus, perineum, • Patient compliance Ph. De Sutter VIN & Condyloma

  19. Surgical resection / (wide) local excision • Condylomata • Very large • Pedunculated • Large anal • Circumferential foreskin • VIN • Pathology! • Suspect for early invasion • Local resection / partial- / hemivulvectomy • No “skinning” vulvectomy Ph. De Sutter VIN & Condyloma

  20. CO² LASER superficial vulvectomy • General anaesthesia • CIN with vaginal extension • Vaginal condyloma / VAIN • Extensive, multifocal vulvar condyloma / VIN • Difficult delicate locations • Clitoris, urethra, anus Ph. De Sutter VIN & Condyloma

  21. Physical principles of LASER surgery • LASER is an instrument for thermal destruction • Limiting thermal spread and damage • This is also applicabel for electrosurgery ! Ph. De Sutter VIN & Condyloma

  22. Vulvar surgical planes 1. Basement membrane 2. Papillary dermis 3. Mid-reticular dermis 4. Deep reticular dermis Ph. De Sutter VIN & Condyloma

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