Risk factors and treatment for recurrent vulvar squamous cell carcinoma.

Recurrent disease occurs in 12-37% of patients with vulvar squamous cell carcinoma (VSCC). Decisions about treatment of recurrent VSCC mainly depend on the location of the recurrence and previous treatment, resulting in individualized and consensus-based approaches. Most recurrences (40-80%) occur within 2 years after initial treatment. Currently, wide local excision is the treatment of choice for local recurrences. Isolated local recurrence of VSCC has a good prognosis, with reported 5-year survival rates of up to 60%. Groin recurrences and distant recurrences are less common and have an extremely poor prognosis. For groin recurrences, surgery with or without (chemo) radiotherapy is a treatment option, depending on prior treatment. For distant recurrences, there are only palliative treatment options. In this review, we give an overview of the available literature and discuss epidemiology, risk factors, and prognostic factors for the different types of recurrent VSCC and we describe treatment options and clinical outcome.

Tumour-free margins in vulvar squamous cell carcinoma: Does distance really matter?

BACKGROUND: There is no consensus on the width of tumour-free margins after surgery for vulvar squamous cell carcinoma (VSCC). Most current guidelines recommend tumour-free margins of ≥8 mm. The aim of this study was to investigate whether a margin of <8 mm is associated with an increased risk of local recurrence in VSCC. METHODS: A meta-analysis of the available literature and a cohort study of 148 VSCC patients seen at a referral centre from 2000 to 2012 was performed. The primary end-point of the cohort study was a histologically confirmed ipsilateral local recurrence within 2 years after primary treatment in relation to the margin distance. RESULTS: Based on 10 studies, the meta-analysis showed that a tumour-free margin of <8 mm is associated with a higher risk of local recurrence compared to a tumour-free margin of ≥8 mm (pooled risk ratio, 1.99 [95% confidence interval {CI}: 1.13-3.51], p = 0.02). In the cohort study, we found no clear difference in the risk of local recurrence in the <8 versus ≥8 mm group; however, 40% of the patients in the <8 mm group received additional treatment. Tumour-positive margin was the only independent risk factor for local recurrence in the multivariable analysis (hazard ratio, 0.21 [95% CI: 0.08-0.55]). CONCLUSIONS: This work provides important data to question the commonly used 8-mm margin as a prognosticator for local recurrence. More research is needed to address the question of whether additional treatment improves the prognosis in patients with a tumour-free margin of <8 mm.

'See and treat' approach for high-grade squamous intraepithelial cervical lesions.

PURPOSE OF INVESTIGATION: Evaluation of the over-treatment percentage when choosing a 'see and treat' approach in patients with de- viant cervical smear test results. MATERIALS AND METHODS: The authors performed a retrospective chart review among women who were treated for cytological low-grade squamous intraepithelial lesion (LSIL) or high-grade squamous intraepithelial lesion (HSIL) from January 2009 until December 2010. All patients who were treated for deviant Pap-smears were analyzed. Patient characteristics were taken into account when performing the analysis. Data were analyzed using SPSS. Logistic regression was performed to determine the influence of age, smoking, and the reason to perform the Pap-smear. RESULTS: A total of 723 patients with deviant Pap-smear results were analysed. High-grade cervical intraepithelial neoplasia (CIN) was found in 70.3% of the patients with a Pap 3A average dysplasia (low-grade squamous intraepithelial lesion). This indicates that 29.7% of the patients would be over-treated with a 'see and treat' approach. For Pap 3B (high-grade intra-epithelial lesion) or higher the over-treatment percentage was 6.7% or less. CONCLUSION: Potential risks of a loop electrosurgical excision procedure (LEEP) on future pregnancies and fertility should be taken into account when treating fertile patients for potential CIN. This should be part of the counseling process of patients with a Pap 3A average dysplasia. A 'see and treat' approach can and probably should be proposed to patients with a Pap 3B or higher.