Surgery or topical therapy for vulval intraepithelial neoplasia

[...]in a systematic review, occult invasive disease was noted in 3% of patients, who had mostly microinvasive cancers.2 This relatively low risk shifts the focus of management of high-grade squamous intraepithelial lesions away from detection of invasive cancer and towards symptom control and prevention of carcinogenesis. 20-30% of patients who undergo a surgical intervention have recurrence of disease, irrespective of the treatment modality,6 and neither cold-knife nor laser surgery can treat effectively the underlying cause of most high-grade squamous intraepithelial lesions--HPV infection.7 Topical treatment with the immune-modifier imiquimod is an effective alternative to surgery, with a durable complete response reported in 35% of patients and a partial response in 38%.8 Side-effects of imiquimod are pain and discomfort in the treatment area, fatigue, and headache. [...]alternative topical regimens with favourable toxic-effect profiles are needed. In the future, topical treatments could evolve to become the treatment of choice for people with high-grade squamous intraepithelial lesions, with cold-knife resection and laser vaporisation reserved for patients not responding to initial treatment. [...]results of phase 3 studies comparing these different treatment modalities are available, the choice of treatment will mainly be based on the individual patient's preference.