Management of vaginal intraepithelial neoplasia

Vaginal intraepithelial neoplasia (VaIN) accounts for 0.4% of the lower genital tract intraepithelial disease. Various treatments have been reported often as small case series or reports.

An electronic search of the Ovid MEDLINE (from 1948 to present) and PubMed was performed, and only articles written in English were reviewed. All articles ranging from case reports to randomized controlled trials were included. This review critically appraises the published evidence for different treatment modalities and gives an overview of these options.

The 3 main modalities reported were surgery, brachytherapy, and medical management. Surgery included local excision, laser ablation, vaginectomy, and cavitational ultrasonic ablation. Medical management included topical 5% imiquimod, 5-fluorouracil, and tricholoroacetic acid. All treatments had good success rates for disease clearance with low rates of progression to cancer. Prerequisites for ablative treatments are the lesion is fully visible and adequately examined by biopsy to exclude invasion. Where invasion is suspected or cannot be excluded (e.g., at the vault suture line), surgical excision is essential. Brachytherapy and vaginectomy, although effective, have a limited place because of their related morbidity. Treatment choice may depend on the availability of equipment and expertise.

Conservative options in the form of laser ablation and topical agents are useful as first-line treatment methods especially in young women and for multifocal disease. Radical options like brachytherapy and vaginectomy should be reserved for highly selected cases. Evidence from a randomized controlled trial of first-line treatment with surgical and medical therapies is needed to compare treatment success and impact on quality of life.