Evaluation of different treatment modalities for vulvar intraepithelial neoplasia (VIN): CO2 laser vaporization, photodynamic therapy, excision and vulvectomy
Introduction
Vulvar intraepithelial neoplasia (VIN) is thought to be a precursor of vulvar cancer. The frequency of VIN appears to have been increasing during the past two decades, and this increase has been especially pronounced in the younger population [1]. There is little consensus regarding the optimal method of management. The treatment for VIN 3 has classically been surgical excision or, in case of multifocal VIN 3, vulvectomy. With the disease being reported more frequently in younger women, there has been a gradual trend towards conservatism in the management of VIN lesion. Popular treatment modalities include carbon dioxide (CO2) laser vaporization or ablation and surgical excision. Unfortunately, recurrence rates after treatment have been reported to range from 10% to 50% and are thought to be related to the grade of VIN and margin status along with the multifocal nature of the condition and its relationship with HPV [2], [3]. Therefore, difficulties in the management of certain cases and the frequency of recurrences provide a challenge for gynecologists. 5-Aminolevulinic acid (ALA) photodynamic therapy (PDT) is a relatively new technique with unique properties that make it attractive for the local treatment of superficial epithelial disorders. The treatment is based on the systemic or topical application of ALA which is preferentially absorbed and induces protoporphyrin IX accumulation in neoplastic tissue. This is followed by the application of nonthermal light usually from a laser using certain wavelengths. The initial interaction of light with protoporphyrin IX results in the generation of singlet oxygen and oxygen radicals which are highly reactive oxidants capable of producing a local cytotoxic effect. PDT is a minimal invasive procedure that can be performed in an outpatient setting. It is less damaging to normal tissue than most other techniques. However, only few PDT studies for VIN are published so far, and only short-term results are reported [4], [5].
The aim of this retrospective study was to compare the long-term efficacy and the recurrence rate of four treatment modalities for VIN which are CO2 laser vaporization, PDT, surgical excision and vulvectomy.
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Materials and methods
From 1991 to 2001, all 93 patients with histologic diagnosis of VIN underwent either CO2 laser vaporization, PDT, excision or vulvectomy at the Department of Obstetrics and Gynecology, University Munich-Grosshadern. Of the 93 patients, 47 were treated with CO2 laser vaporization, 27 with PDT, 12 with excision and 7 with vulvectomy. The decision to select a patient for one of the treatment modalities was at the discretion of the surgeon. Simple vulvectomy was only performed in patients with
Results
Among the 93 treated patients, there were 19 (40.4%) patients with relapse after laser vaporization, 13 (48.1%) after PDT, 5 (41.7%) after surgical excision and none after vulvectomy (Table 1). The recurrence rates between the vulva organ conserving methods CO2 laser, PDT and surgical excision did not differ significantly (P = 0.81). However, significant differences were evident compared to vulvectomy (Table 1).
The mean age of the patients was 45 years (range 19–85 years), and 41 (44%) patients
Discussion
With increasing incidence of VIN in the younger population, in our study, 44% under 40 years, two primary objectives are mandatory for the management of VIN: the prevention of invasive vulvar cancer and the preservation of normal vulvar anatomy and function. Treatment sequelae associated with wide excisional therapy or even vulvectomy can result in vulvar mutilation and, in consequence, psychological distress as seen in one of our vulvectomy patients [7]. Therefore, thermal laser treatment and,
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