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 = %
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