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Topical imiquimod could be an alternative, noninvasive, treatment modality for high-grade cervical intraepithelial neoplasia (CIN). However, evidence is limited, and there are no studies that compared treatment effectiveness and side effects of topical imiquimod cream to standard large loop excision of the transformation zone (LLETZ) treatment. A multi-center, nonrandomized controlled trial was performed among women with a histologic diagnosis of CIN 2/3. Women were treated with either vaginal imiquimod (6.25 mg 3 times weekly for 8 to 16 wk) or LLETZ according to their own preference. Successful treatment was defined as the absence of high-grade dysplasia at the first follow-up interval after treatment (at 20 wk for the imiquimod group and at 26 wk for the LLETZ group). Secondary outcome measures were high-risk human papillomavirus (hrHPV) clearance, side effects, and predictive factors for successful imiquimod treatment. Imiquimod treatment was successful in 60% of women who completed imiquimod treatment and 95% of women treated with LLETZ. hrHPV clearance occurred in 69% and 67% in the imiquimod group and LLETZ group, respectively. This study provides further evidence on topical imiquimod cream as a feasible and safe treatment modality for high-grade CIN. Although the effectiveness is considerably lower than LLETZ treatment, imiquimod treatment could prevent initial surgical treatment in over 40% of women and should be offered to a selected population of women who wish to avoid (repeated) surgical treatment of high-grade CIN.

ABSTRACTIntroduction: Vulvar squamous cell carcinoma (VSCC) develops via two different pathways: TP53mutations in a background of lichen sclerosus or a persistent infection with high-risk human papilloma virus (HPV). The latter group of tumor responds better to treatment than the non-virally induced VSCC. This may be explained by a difference in the tumor immune microenvironment (TME).Areas covered: This review summarizes literature on TME of VSCC and its precursors, and extrapolates this to foster the development of new therapeutic strategies.Expert opinion: Both types of VSCC and their precursors are infiltrated with variable numbers of M2 macrophages, regulatory T cells and CD8+ T cells, indicating that they express targetable tumor antigens. Type 1 T cell immunity in precursor lesions is associated with fewer recurrences and better clinical responses to immunotherapy. Escape of these lesions and progression toward VSCC is associated with the downregulation of HLA Class I, increased expression of co-inhibitory molecules, infiltration with immunosuppressive cells and the local production of immunosuppressive enzymes and cytokines. More in-depth studies of the VSCC TME are required to fully comprehend the impact of the immune system on VSCC, and subsequently to identify patients who will benefit from immunotherapeutic strategies.

The true incidence of incisional hernia after wound dehiscence repair remains unclear because thorough long-term follow-up studies are not available. Medical records of all patients who had undergone wound dehiscence repair between January 1985 and January 1999 at the Erasmus University Medical Center Rotterdam were reviewed. Long-term follow-up was performed by physical examination of all patients in February 2001. One hundred sixty-eight patients underwent wound dehiscence repair. Of those, 42 patients (25%) died within 60 days after surgery. During a median follow-up of 37 months (range, 3–146 months), 55 of the remaining 126 patients developed an incisional hernia. The cumulative incidence of incisional hernia was 69 per cent at 10 years. Significant independent risk factors were aneurysm of the abdominal aorta (10-year cumulative incidence of 84%, P= 0.02) and severe dehiscence with evisceration (10-year cumulative incidence of 78%, P= 0.01). Wound dehiscence repair by interrupted sutures had no better outcome than repair by continuous sutures. Suture material did not influence incidence of incisional hernia. Incisional hernia develops in the majority of patients after wound dehiscence repair, regardless of suture material or technique. Aneurysm of the abdominal aorta and severe dehiscence with evisceration predispose to incisional hernia.