Page 137 - Strategies for non-invasive managementof high-grade cervical intraepithelial neoplasia - prognostic biomarkers and immunotherapy Margot Maria Koeneman

Imiquimod: physicians’ awareness, attitudes and experiences
VAIN (n = 12)
CIN (n = 5)
Would you recommend treatment of VAIN/CIN with imiquimod,
and would you apply it again?
- Yes 12 (100%) 5 (100%) - No 0 (0%) 0 (0%)
* Percentages add up to >100% because some respondents treated more than one patient and reported on both disease regression and persistence or progression.
CIN, cervical intraepithelial neoplasia; VAIN, vaginal intraepithelial neoplasia.
The most common reasons for choosing imiquimod to treat VAIN were recurrence after laser and/or excisional therapy (n = 5) and the estimation that laser or excisional therapy would be too difficult or impossible (n = 4). The reasons for choosing imiquimod to treat CIN were recurrence after LLETZ (n = 3), large CIN lesions that demanded a large LLETZ in patients with a future pregnancy wish (n = 1), and refusal by the patient to undergo LLETZ (n = 1).
In both VAIN and CIN, imiquimod was applied via vaginal capsules, vaginal suppositories, vaginal
tampons, or vaginal applicators. The respondents used a fairly consistent treatment dose and 7 protocol: it generally consisted of 2–3 applications per week for 12–16 weeks. The exception
was one respondent who applied imiquimod five times per week for 6 weeks to treat VAIN. All respondents used one 6.25 mg sachet per application.
Treatment efficacy was mostly evaluated by colposcopy, with diagnostic biopsies on indication. Four respondents combined colposcopy with cervical cytology after imiquimod treatment of VAIN. One respondent performed cervical cytology only after imiquimod treatment of CIN.
The treatment outcome was documented by 11 of the 12 respondents for VAIN and by all five respondents for CIN (table 3). Nine respondents (75%) experienced treatment success in VAIN and all five respondents experienced treatment success in CIN: invasive therapy was no longer needed. Only one respondent reported disease progression, in VAIN. All respondents would apply the therapy again. Since this study did not aim to systematically document treatment outcome, overall treatment efficacy cannot be derived from the results. Side effects of imiquimod treatment of VAIN and CIN were common: all but one of the respondents reported that the treatment had side effects. The side effects consisted of vaginal and vulvar pain, vulvar erythema, vulvar erosion and/or ulceration, vaginal discharge, flu-like symptoms, arthralgia, and fatigue. The side effects were subjectively graded by the respondents and were generally considered to be mild to moderate; only one respondent documented severe side effects. Nevertheless, five respondents stated that at least one of their patients had stopped treatment due to the side effects (three for VAIN patients and two for CIN patients).
Taking into consideration the efficacy and side effects of imiquimod treatment, all respondents stated that they would use imiquimod again in patients with VAIN and CIN.
Future application of imiquimod
All participants were informed in the questionnaire of the results of a recent RCT on the efficacy of imiquimod in high-grade CIN.[11] On the condition that the study results were validated in
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