Injection of Autologous Stromal Vascular Fraction enriched lipoaspirate for the treatment of vulvar Lichen Sclerosus - a pilot study

Lichen sclerosis (LS) is a chronic inflammatory dermatosis with a high
prevalence in the genital area in peri- or postmenopausal women. Shame and
ignorance often result in late reporting and hesitation to seek help. Vulvar LS
presents with progressive pruritus and pain, sexual and urinary dysfunction,
reduced quality of life and an increased risk of squamous cell carcinoma of the
vulva.The lifetime risk for women with LS to develop vulvar squamous cell
carcinoma is estimated at 5%. In patients treated for vulvar cancer, the
presence of LS appears to affect the incidence of recurrence of squamous cell
carcinoma. The true prevalence of LS is not known; estimates range from 1 in 30
elderly women and 1 in 59 women in a general gynecology practice. A Dutch
historical cohort of 3038 woman indicates an increase of nearly 100% in the
incidence of LS from 7.4 to 14.6 per 100,000 woman-years between 1991 and 2011.

LS typically begins as white, polygonal papules that coalesce into shiny
porcelain-white plaques involving the perivaginal and perianal areas. Vulvar LS
may progress to obliteration of the labia minora and stenosis of the introitus.
Diagnosis is often made on clinical appearance. Punch biopsy, followed by
histological examination is the golden standard to confirm the diagnosis. The
etiology and pathogenesis of LS are largely unknown and may include genetic,
auto-immune, infectious, environmental and hormonal factors. Inflammation and
fibroblast-to-myofibroblast transdifferentiation in the papillary dermis
culminate in fibrogenesis in the upper dermis. Histological examinations of
classic LS indicate epidermal atrophy, a typical band-like lympho-histiocytic
infiltrate in the dermo-epidermal junction and compact hyperkeratosis with
stratum corneum, which often is thicker than the greatly effaced epidermis. In
time, edema in the papillary (upper) dermis is replaced by a dense, homogenous
fibrotic tissue as the lesion matures. Histopathological findings of LS tissue
include the occurrence of tissue hypoxia and ischemia, followed by inflammatory
processes (T-cell infiltration and TH1-cytokine accumulation in the tissue),
resulting in epithelial damage (reduced CD44 expression) and fibrogenesis
(accumulation of extracellular matrix proteins and hyaluronic acid).

The preferred treatment for genital LS are very potent topical corticosteroids
(e.g., clobetasol propionate), which may relief clinical symptoms (pruritus and
pain) and reduce clinical indicators on physical examination (i.e. ulceration,
hyperkeratosis, erythema, ecchymosis, atrophy and depigmentation). Although
randomized trials that compare therapies for vulval LS are elusive, several
other topical therapeutic options have been proposed (e.g. topical testosterone
or progesterone), but proven not to be effective. In case of
treatment-resistant LS, topical treatment with tacrolimus or pimecrolimus
(inhibition of T-cell activation) can be considered, but evidence on its
effectiveness is sparse. Tissue fibrosis and its associated disfigurement often
cannot be prevented by topical treatment and result in persistent sexual and
urinary dysfunction and reduction in quality of life. A surgical approach is
only considered in severe vaginal introitus stenosis, urinary retention, and
synechiae, yet surgery creates scars and is characterized by a high recurrence
rate of the original pathology.

Transfer of adipose tissue, also known as lipofilling, is recognized as a
promising and novel technique for the treatment of a range of pathologies. This
is strongly supported by clinical trials as well as more fundamental studies in
preclinical models. The white adipose tissue harbors a mesenchymal cell
population with stem cell-like properties, which holds regenerative as well as
angiogenetic, immunomodulatory and differentiative potential. These
regenerative cells can be isolated from the adipose tissue through standard
lipofilling procedures, after which the lipograft is fractionated using
mechanical dissociation and subsequent isolation of Stromal Vascular Fraction
(SVF) using density centrifugation. The advantage of the use of SVF is believed
to be in two areas. Firstly, the so-called FAT-SVF procedure (Fractionation of
Adipose Tissue to obtain Stromal Vascular Fraction with harvesting, processing
and injection of the therapeutic product) can all be executed in a short *one
stop* procedure in day surgery. Additionally, the distinctive heterogeneous
cellular composition of SVF may be responsible for better therapeutic outcomes
observed in comparative pre-clinicall studies. Cells from the SVF are currently
used for many medical indications: burns sequelae, radiotherapy tissue damage,
reconstruction after oncological surgery, improvement of facial nerve function,
the experimental treatment of ischaemic cardiomyopathy and intervertebrate disc
regeneration.

To reduce fibrogenesis and adverse tissue remodeling in vulvar LS, pioneering
studies have used lipofilling to treat women with therapy-resistant LS. In 2010
Casabona et al. proposed lipofilling in combination with injection of Platelet
Rich Plasma (PRP) for the treatment of LS and reported favorable outcomes. A
later study by Boero et al used lipofilling solely for the treatment of
therapy-resistant LS. Vulvar tropism of the skin and mucosa improved in 34 out
of 36 women (94%) and the routine usage of topical corticosteroids was stopped
in 34 out of 36 women. More importantly, the quality-of-life and sexual
functioning were improved as assessed by the validated DLQI and FSFI
questionnaires. In addition, several small studies have evaluated the efficacy
of lipofilling in the treatment of severe vulvar LS, confirming the reduction
of symptoms, increased quality-of-life and increased sexual functioning without
any report of adverse events. Hence, lipofilling might represent a promising
alternative for current topical corticosteroid treatment in LS. Although
clinical improvements have been reported from these studies, limitations should
be mentioned: small sample sizes, short follow up period (maximum of two
years) and no analysis included on the mechanism of regeneration of sclerosis
at tissue levels.

To quantify clinical and histological improvements in patients with vulvar
lichen sclerosus after treatment with SVF enriched lipofilling.

A prospective pilot study.

All patients will receive autologous SVF enriched lipoaspirate: 20 ml of
lipoaspirate will be added to 2 ml of SVF resulting in a total of 22 ml of SVF
enriched aspirate to be injected in the vulvar region (with 0,1 ml of volume
for every 0,1 cm2 epithelium).

To-date, only minor complications have been noticed when performing
lipoharvesting: swelling of the harvesting site, neuropraxy due to collision of
the cannula against a sensible nerve and hypersensitivity of harvesting site.
There is a very low risk of fatembolism and risks related to the anaestetic
procedure.