| VAIN
and Vaginal Cancer
Overview
Mary M. Rubin, RNC, Ph.D., CRNP
Participants of this session will be able to:
Objectives:
1 ) Identify three reasons for performing vaginal
colposcopy.
2 ) Discuss three potential problems that complicate
vaginal colposcopy.
3 ) List two treatment modalities for VAIN.
Incidence
of Vaginal Pathology
1 ) Primary squamous vaginal carcinoma-incidence
of about 2/1,000,000 women
2 ) Accounts for about 1 % to 2 % of all genital tract
malignancies.
3 ) Incidence of the precursor state of (VAIN) is
unknown, but < CIN
4 ) Progressive potential of Low Grade VAIN to High
Grade VAIN is not established.
5 ) Prior to 1960 VAIN was rarely mentioned in the
literature. Increased awareness with colposcopic evaluation
of the entire lower genital tract following an abnormal
Pap smear.
6 ) About 1.5 % of patients with CIN (3 % of those
with HGSIL) will have concomitant VAIN.
7 ) VAIN lesions are found 71 % of the time in patients
with cervical or vulvar neoplasia.
Classification
of VAIN Lesions
1 ) VAIN 1= mild dysplasia or HPV changes (Low Grade
SIL in the Bethesda System)
2 ) VAIN 2= moderate dysplasia (HGSIL in the Bethesda
System)
3 ) VAIN 3= severe dysplasia or carcinoma in situ
(HGSIL in the Bethesda System).
Reasons
for Performing Vaginal Colposcopy
1 ) Abnormal Pap smear in patients with a normal cervix
at the time of colposcopy
2 ) Abnormal Pap smear in patients with primary cervical
or vulvar neoplasia
3 ) Abnormal Pap smear in immunosuppressed pts. with
a normal cervix at the time of colposcopy
4 ) Abnormal Pap smear following apparently successful
treatment for CIN
5 ) Diagnostic work-up treatment of multicentric HPV
infection
2.After
acetic acid
a. the epithelium turns acetowhite
1. contrast with epithelium containing extensive rugae
less easily detected
2. lesions may take longer to develop.
3. Vascular patterns in the vagina
a. Often indistinct or absent in contrast to the vivid
mosaic and punctation associated with CIN
b. more prominent vascular patterns often develop
late in the neoplastic process.
c.well developed vascular patterns of punctation or
mosaic and atypical irregularly branching vessels
are most often seen in lesions which are highly suspicious
for invasive cancer.
4. Application of half or quarter strength Lugol´s
solution
a. useful step in identifying those areas of HGSIL
which reject the iodine stain
b. partial iodine uptake areas are more often associated
with LGSIL.
5. Areas suspicious for cancer due to nodularity,
exophytic protrusion, or ulceration require biopsy
to rule out invasive vaginal cancer, irrespective
of the cytological grade.
Treatment
The
choice of treatment depends on the age of the patient,
the exent and location of the lesion, the presence
of the cervix, the availability of equipment, and
the surgical expertise of the practitioner.
1 ) Observation: Very effective in LGSIL since many
lesions will revert to normal or never progress.
2 ) CO2 Laser: Effective with extensive lesions for
ablative or excisional treatment.
3 ) 5 % - fluorouracil: Successfully used for eradication
of multifocal low grade lesions, esp. HPV.
4 ) Trichloroacetic acid: Has been successfully used
for eradication of focal low grade lesions.
5 ) Cryosurgery: May be used for small well defined
lesions
a) Can cause surrounding tissue damage with risk of
bowel and bladder damage
b) Failure rates are fairly high, most often due to
incomplete destruction.
6 ) Loop electro-excision: May be used for small well
defined lesions
a. Can cause surrounding tissue damage with risk of
bowel and bladder damage
b. Failure rates are fairly high, most often due to
incomplete destruction.
7 ) Vaginal excision: Often not required for diagnostic
purposes: can be used as Tx rather than laser.
Triage rules for conservative destruction
The following are mandatory:
1. Expert systematic colposcopy
2. Complete visualization of the disease
3. Cytologic, colposcopic, and histologic exclusion
of invasion or glandular disease
4. Representative biopsy of the most abnormal lesions
5. Treatment by the colposcopist under colposcopic
control
6. Close follow-up is mandatory
References
Anderson, M., Jordan, J., Morse, A., & Sharp,
F. (1997). A Text and Atlas of Integrated Colposcopy.
2nd. ed. St. Louis, MO: Mosby.
Burke, L., Antonioli, D., Ducatman, B. (1991). Colposcopy
Test and Atlas. Norwalk, Conn.: Appleton and Lange.
Campion, M.J., Ferris, D., diPaola, F.,Reid, R.,&
Miller, M. (1991). Modern Colposcopy: A Practical
Approach. Augusta, GA: Educational Systems, Inc.
Cartier, R., Cartier, I. (1993). Practical Colposcopy.
(3rd.ed.) Basal, Switzerland: S. Karger.
Guiuntoli, R., Atkinson, B., Ernst, C., Rubin, M.,
& Egan, V. (1987). Atkinson’s Correlative
Atlas of Colposcopy, Cytology, and Histopathology.
Philadelphia: J.B. Lippincott Company.
Hatch, K. (1989). Diagnosis and Treatment of Lower
Genital Tract Neoplasia. Handbook of Colposcopy, Boston.
Little Brown and Company, 1-25.
Isacson, C., & Kurman, R. (1995). The Bethesda
system: A new classification for managing Pap smears.
Contemporary Ob/GYN, 40(6),67-74.
Souter, P. (1993). A Practical Guide to Colposcopy.
Oxford: University Press.
Wright, C., Lickrish, G., & Shier, M. (1995).
Basic and Advanced Colposcopy. Komoka, ON: Biomedical
Communications. Inc.
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