Vulvar squamous cell carcinoma guidelines do not include tissue-sparing techniques as a treatment option

What is known about this subject in regard to women and their families?

• Current National Comprehensive Cancer Network guidelines for early-stage vulvar squamous cell carcinoma (SCC; T1a ≤1 mm invasion) and high-grade squamous intraepithelial lesion recommend wide local excision (at least 1 cm) as the primary treatment modality.
• Current excisional margins are often associated with disfigurement and functional deficits with psychologic, social, and sexual ramifications.

What is new from this article as messages for women and their families?

• We propose a new category of very early vulvar SCC (high-grade squamous intraepithelial lesion, differentiated vulvar intraepithelial neoplasia, T1a) to be considered in vulvar cancer treatment guidelines that would include vulvar organ-sparing approaches.
• Tissue-sparing procedures dermatologists commonly utilize may be reasonable treatment modalities for some patients with very early vulvar SCC.
• We aim to bring increased awareness to the role tissue-sparing approaches can play in very early vulvar SCC and their utility in preserving vulvar function and preventing morbidity.

National Comprehensive Cancer Network (NCCN) guidelines for early-stage vulvar squamous cell carcinoma (SCC; T1a ≤1 mm invasion) recommend wide local excision (WLE) as the primary treatment modality.¹ The guidelines incorporate a footnote on high-grade squamous intraepithelial lesions (HSIL) and recommend WLE for these lesions as well. For these early-stage SCCs, there is no recommendation for sentinel lymph node biopsy or lymphadenectomy as the risk of nodal metastases is less than 1%.¹ The guidelines on margin control for WLE state that efforts should be made to obtain surgical margins (at least 1 cm) at time of primary surgery. However, the guidelines also highlight that studies have called into question these margins, suggesting narrower margins as current excisional margins are often associated with disfigurement and functional deficits with psychologic, social, and sexual ramifications.^2,3

There is precedence for inclusion of tissue-sparing procedures in NCCN guidelines previously. For example, Penile Cancer guidelines include a section on “Principles of Penile Organ-Sparing Approaches” as well as “Primary Radiation/Chemoradiation Therapy (Penile Preservation)” which state that Tis, Ta, and T1 penile cancer may be amenable to conservative modalities, including topical therapy, WLE, laser therapy, glansectomy, external beam radiation therapy, brachytherapy, and Mohs micrographic surgery (MMS). Topical regimens, laser devices, and settings are included.

We suggest that the management of some cases of early vulvar SCC could benefit from an interdisciplinary approach between dermatology and gynecologic oncology. As NCCN Vulvar Cancer guidelines do not include tissue-sparing techniques for vulvar SCC, and dermatologists are not currently represented on the guideline committee, gynecologists may be less comfortable referring a patient for multidisciplinary evaluation with dermatology. However, the tissue-sparing procedures dermatologists commonly utilize may be reasonable treatment modalities for some patients with very early vulvar SCC, where larger excisions may be associated with increased morbidity. Such procedures may have utility for the following: HSIL, HPV-independent differentiated vulvar intraepithelial neoplasia, and T1a vulvar SCC. For example, reports available on use of MMS for select cases of SCC have found this may be an effective modality as a first-line therapy in select cases and in some treatment-refractory cases: 38 cases of vulvar SCC were treated with MMS with 4 reporting recurrence, however most cases were not early SCC, as the average tumor size was 18 mm and multiple had been treated with prior modalities including excision.⁴ Unfortunately, prospective studies on MMS for early vulvar SCC are lacking. Future studies should focus on efficacy and patient-reported outcomes with use of other tissue-sparing modalities for early vulvar SCC.

Herein, we propose a new category of very early vulvar SCC (HSIL, differentiated vulvar intraepithelial neoplasia, T1a) to be considered in vulvar cancer treatment guidelines that would include vulvar-organ sparing approaches (Fig. 1). We aim to bring increased awareness to the role tissue-sparing approaches can play in very early vulvar SCC and their utility in preserving vulvar function and preventing morbidity. We encourage increased multidisciplinary collaboration between dermatology, gynecology, and other pertinent specialties to consider incorporation of tissue-sparing modalities into future guidelines, providing additional treatment options for patients with a diagnosis of very early vulvar SCC.

Fig. 1.: Current and proposed NCCN Guidelines for vulvar SCC. *Special circumstances may allow the use of topical, laser, or radiation therapy. NCCN, National Comprehensive Cancer Network; SCC, squamous cell carcinoma; EBRT, external beam radiation therapy; HSIL, high-grade squamous intraepithelial lesions; dVIN, differentiated vulvar intraepithelial neoplasia; ILN, inguinal lymph nodes.

Conflicts of interest

None.

Funding

None.

Study approval

N/A.

Author contributions

CAV: Participated in writing of the paper and manuscript preparation. IIS: Participated in figure design and manuscript preparation. ANE: Participated in writing of the paper and manuscript preparation. CNK: Participated in writing of the paper and manuscript preparation.