High-grade vaginal intraepithelial neoplasia: can we be selective about who we treat?

OBJECTIVE: To determine the role of conservative management in high-grade vaginal intraepithelial neoplasia (HG VaIN). DESIGN: Retrospective observational study. SETTING: Northern Gynaecological Oncology Centre, Gateshead, UK. POPULATION: A total of 100 women with histologically-proven HG VaIN. METHODS: Review of patient records from 1995 to 2011. MAIN OUTCOME MEASURES: Rates of progression to cancer, treatment remission, and disease recurrence, particularly post-treatment when vaginoscopy is normal but cytology is abnormal. RESULTS: Of 100 women referred, 69 underwent initial treatment of whom 47 (68%) went into remission: of these, seven developed a recurrence after a median follow-up of 29 months (range 15-214 months). Of the 31 women managed conservatively with cytological and vaginoscopic surveillance, no cancers developed after a median follow-up of 35 months (range 2-230 months). Rate of overall progression to cancer was 3% and all were detected among the initial treatment group after a median of 59 months (range 8-249 months). Post-treatment, when normal vaginoscopy was accompanied by abnormal cytology, two categories existed. Of 24 cases with low-grade cytological abnormality, recurrence of HG VaIN occurred in seven (29%) after a median follow-up of 12 months (range 2-110 months). Of 19 cases with HG cytological abnormality, 15 (79%) developed recurrence at a median follow-up of 7 months (range 2-21 months), giving a hazard ratio 5.6 (95% confidence interval 2.0-15.5, P = 0.001). CONCLUSIONS: It is possible to select women with HG VaIN for conservative surveillance with excellent results. The majority of women undergoing initial treatment will enter remission. Post-treatment, if cytological abnormality develops in the presence of normal vaginoscopy, the majority of women will develop histological HG VaIN recurrence.