Screening Women with an intact cervix should undergo routine cytologic screening. Because VAIN is nearly always accompanied by CIN, the Pap test result is likely to be positive when VAIN is present. The vagina should be carefully inspected by colposcopic examination at the time of colposcopy for any CIN lesion. Particular attention should be paid to the upper vagina. Women who have persistent abnormal Pap tests without evident cervical pathology and those with abnormal cytology after treatment of CIN should be examined carefully for VAIN. For women in whom the cervix was removed for high-grade cervical neoplasia, Pap testing should be performed at regular intervals (e.g., yearly), depending on the diagnosis and severity of lesion.
Figure 19.17 Human papillomavirus (HPV)/vaginal intraepithelial neoplasia grade 1 (VAIN 1). Note the surface spicules with partial uptake of Lugol’s stain.
Diagnosis Colposcopic examination and directed biopsy are the mainstays of diagnosis of VAIN. Typically, the lesions are located along the vaginal ridges, are ovoid in shape and slightly raised, and often have surface spicules. VAIN 1 lesions usually are accompanied by a significant amount of koilocytosis, indicating their HPV origin (Fig. 19.17). VAIN 2 exhibits a thicker acetowhite epithelium, a more raised external border, and less iodine uptake (Fig. 19.18A). When VAIN 3 occurs, the surface may become papillary, and the vascular patterns of punctation and mosaic may occur (Fig. 19.18B). Early invasion is typified by vascular patterns similar to those of the cervix.
Treatment Patients with VAIN 1 and HPV infection do not require treatment. These lesions often regress, are multifocal, and recur quickly when treated with ablative therapy. VAIN 2 lesions can be managed expectantly or treated by ablation. VAIN 3 lesions are more likely to harbor an early invasive lesion. In a study of 32 patients who underwent upper vaginectomy for VAIN 3, occult invasive carcinoma was found in 9 patients (28%) (135). It is recommended in older patients that VAIN 3 lesions located in the dimples of the vaginal cuff be excised to rule out occult invasive cancer. VAIN 3 lesions that are adequately sampled to rule out invasive disease can be treated with laser therapy. The major advantage of laser vaporization therapy is the ability to control the depth and width of destruction by direct vision through the colposcope. The other advantage of laser therapy is the rapid posttreatment healing phase. This process takes about 3 to 4 weeks, after which time a new epithelium has formed completely and, in most cases, has a mature glycogen-containing epithelium.