Vulvar and vaginal intraepithelial neoplasia in HIV-infected women
- William R Robinson, MD
William R Robinson, MD
- Professor of Gynecologic Oncology
- Tulane Medical School
Women with human immunodeficiency virus (HIV) infection are at an increased risk of vulvar and vaginal neoplasia [1-5]. As with cervical neoplasia, the incidence and severity of vulvar and vaginal premalignant and malignant disease appear to correlate with worsening immunosuppression [6-8]. Furthermore, despite standard therapy, HIV-infected women with vulvar or vaginal neoplasia have higher rates of persistence and recurrence than the general population, again similar to cervical neoplasia [9,10].
Screening, diagnosis, and treatment for vulvar and vaginal intraepithelial neoplasia (VIN and VAIN) in HIV-infected women will be reviewed here. Vulvar and vaginal neoplasia in the general population are discussed separately. (See "Vulvar intraepithelial neoplasia" and "Vaginal intraepithelial neoplasia".)
The Vulvar Oncology Subcommittee of the International Society for the Study of Vulvar Diseases (ISSVD) published a classification system for VIN in 2004 . The term VIN was limited to histologically high-grade squamous lesions (formerly termed VIN 2 and VIN 3), for which treatment is indicated to prevent progression to cancer . Lesions previously referred to as VIN 1 were no longer classified as VIN. This topic review will adhere to the 2004 ISSVD nomenclature except when data are reported from studies that used the previous classification. (See "Vulvar intraepithelial neoplasia", section on 'Terminology'.)
VIN and VAIN are precursors to vulvar and vaginal cancer and are more common in women infected with HIV [12-14]. In the general United States population, the estimated incidence of VIN and VAIN is 2.9 and 0.2 to 0.3 per 100,000 women, respectively. (See "Vaginal intraepithelial neoplasia", section on 'Epidemiology' and "Vulvar intraepithelial neoplasia", section on 'Epidemiology and risk factors'.)
The incidence of VIN and VAIN in HIV-infected women has not been extensively studied, but the available data are consistent with increased risk:
Subscribers log in hereLiterature review current through: Jul 2017. | This topic last updated: Jul 26, 2017.References
- Maiman M, Fruchter RG, Serur E, et al. Human immunodeficiency virus infection and cervical neoplasia. Gynecol Oncol 1990; 38:377.
- Clark RA, Brandon W, Dumestre J, Pindaro C. Clinical manifestations of infection with the human immunodeficiency virus in women in Louisiana. Clin Infect Dis 1993; 17:165.
- Robinson WR, Morris CB. Cervical Neoplasia: Pathogenesis, Diagnosis, and Management. In: Hematologic and Oncologic Aspects of HIV Infection - Hematology/Oncology Clinics of North America, Krown SE, Von Roenn JH (Eds), WB Saunders, Philadelphia 1996. Vol 10, p.1163.
- Korn AP, Abercrombie PD, Foster A. Vulvar intraepithelial neoplasia in women infected with human immunodeficiency virus-1. Gynecol Oncol 1996; 61:384.
- Chiasson MA, Ellerbrock TV, Bush TJ, et al. Increased prevalence of vulvovaginal condyloma and vulvar intraepithelial neoplasia in women infected with the human immunodeficiency virus. Obstet Gynecol 1997; 89:690.
- Spitzer M. Lower genital tract intraepithelial neoplasia in HIV-infected women: guidelines for evaluation and management. Obstet Gynecol Surv 1999; 54:131.
- Schäfer A, Friedmann W, Mielke M, et al. The increased frequency of cervical dysplasia-neoplasia in women infected with the human immunodeficiency virus is related to the degree of immunosuppression. Am J Obstet Gynecol 1991; 164:593.
- Robinson WR, Barnes SE, Adams S, Perrin MS. Histology/cytology discrepancies in HIV-infected obstetric patients with normal pap smears. Gynecol Oncol 1997; 65:430.
- Maiman M, Fruchter RG, Clark M, et al. Cervical cancer as an AIDS-defining illness. Obstet Gynecol 1997; 89:76.
- Dedes KJ, Beneder C, Samartzis N, et al. Outcome of treated anogenital intraepithelial neoplasia among human immunodeficiency virus-infected women. J Reprod Med 2008; 53:947.
- Sideri M, Jones RW, Wilkinson EJ, et al. Squamous vulvar intraepithelial neoplasia: 2004 modified terminology, ISSVD Vulvar Oncology Subcommittee. J Reprod Med 2005; 50:807.
- Conley LJ, Ellerbrock TV, Bush TJ, et al. HIV-1 infection and risk of vulvovaginal and perianal condylomata acuminata and intraepithelial neoplasia: a prospective cohort study. Lancet 2002; 359:108.
- Jamieson DJ, Paramsothy P, Cu-Uvin S, et al. Vulvar, vaginal, and perianal intraepithelial neoplasia in women with or at risk for human immunodeficiency virus. Obstet Gynecol 2006; 107:1023.
- Massad LS, Silverberg MJ, Springer G, et al. Effect of antiretroviral therapy on the incidence of genital warts and vulvar neoplasia among women with the human immunodeficiency virus. Am J Obstet Gynecol 2004; 190:1241.
- Massad LS, Xie X, Greenblatt RM, et al. Effect of human immunodeficiency virus infection on the prevalence and incidence of vaginal intraepithelial neoplasia. Obstet Gynecol 2012; 119:582.
- Huh WK. Human papillomavirus infection: a concise review of natural history. Obstet Gynecol 2009; 114:139.
- Chaturvedi AK, Madeleine MM, Biggar RJ, Engels EA. Risk of human papillomavirus-associated cancers among persons with AIDS. J Natl Cancer Inst 2009; 101:1120.
- Brown JE, Sunborg MJ, Kost E, et al. Vulvar cancer in human immunodeficiency virus-seropositive premenopausal women: a case series and review of the literature. J Low Genit Tract Dis 2005; 9:7.
- Taube JM, Nichols AD, Bornman LS, et al. Langerhans cell density and high-grade vulvar intraepithelial neoplasia in women with human immunodeficiency virus infection. J Cutan Pathol 2007; 34:565.
- Garland SM, Hernandez-Avila M, Wheeler CM, et al. Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases. N Engl J Med 2007; 356:1928.
- Daling JR, Madeleine MM, Schwartz SM, et al. A population-based study of squamous cell vaginal cancer: HPV and cofactors. Gynecol Oncol 2002; 84:263.
- Palefsky J. Human papillomavirus infection in HIV-infected persons. Top HIV Med 2007; 15:130.
- Del Priore G, Herron MM. Retinoids for vulvar dysplasia in the HIV-infected patient. Int J Gynaecol Obstet 1996; 55:77.
- Wendling J, Saiag P, Berville-Levy S, et al. Treatment of undifferentiated vulvar intraepithelial neoplasia with 5% imiquimod cream: a prospective study of 12 cases. Arch Dermatol 2004; 140:1220.
- Ahr A, Rody A, Kissler S, et al. [Risk factors for recurrence of vulvar intraepithelial neoplasia III (VIN III)]. Zentralbl Gynakol 2006; 128:347.
- Aynaud O, Buffet M, Roman P, et al. Study of persistence and recurrence rates in 106 patients with condyloma and intraepithelial neoplasia after CO2 laser treatment. Eur J Dermatol 2008; 18:153.
- Robinson WR. Long-Term Follow-Up of HIV-Infected Women with Cervical Dysplasia. AIDS Patient Care STDS 2015; 29:517.
- CLINICAL MANIFESTATIONS
- DIAGNOSTIC EVALUATION
- Vulvar neoplasia
- - Vulvar examination
- - Vulvar colposcopy and biopsy
- Vaginal neoplasia
- - Vaginal examination
- - Vaginal cytology, colposcopy, and biopsy
- Vulvar neoplasia
- Vaginal neoplasia
- Highly active antiretroviral therapy
- SUMMARY AND RECOMMENDATIONS