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Author′s response to letter to editor on VULCAN study

Dear Editor, In response to the letter by van der Velden J and Fons G, we appreciate their comments and we would like to thank them for their detailed critical review in order to improve the VULCAN study interpretation. Regarding their first comment, we are sure that after they read the full paper by Joura EA (reference 3) they noticed it refers to the correlation of vulvar intraepithelial neoplasm (VIN) with invasive vulvar cancer. The authors state an increase of VINrelated vulvar cancer in the last decades from 2% to 21%. In our opinion it could be caused by a higher detection rate at younger ages. In addition, data published posteriorly corroborate this finding, showing an increment in the VIN and vulvar cancer rates with a peak age at 40–50 years. We agree that the pioneers of conservative management in vulvar cancer reported it almost 40 years ago; however, it has been during the last decade when most of the groups have shifted to more conservative techniques with the implementation of wide excision instead of radical vulvectomy, and sentinel node biopsy instead of inguinal lymphadenectomy. We think it is proof of the general trend in gynecological oncology such as in cervical cancer and its nervesparing surgical treatment (reported for the first time 60 years ago by Kobayashi). With respect to Reference 8, we agree that we included it by mistake, we apologize for that. We would like to clarify that a professional health science statistician carried out all statistical analyses. Table 1 in the study is correct, and it reflects the data included by the researchers. In some cases the researchers included the FIGO stage but left nodal status missing, so even if the FIGO stage was III, we could not identify whether positive nodes were unilateral, contralateral, or bilateral. The differences between FIGO stage III for squamous cancers (356 patients) and nodal involvement (274 patients) correspond to missing data on nodal status, which do not invalidate these results. Concerning Tables 2 and 3 in the study, you are completely right, there were typographical errors in the columns that we did not notice at the time of undertaking several corrections. We unintentionally switched the HRs and 95% CIs of Tables 2 and 3. So the hazard ratios and confidence intervals from Table 2 corresponded to Table 3; and those from Table 3 corresponded to Table 2. We apologize for that mistake. The significance of each factor was correct, and the lack of administration of chemotherapy still remains one of the most important factors for local recurrence and overall survival. Please find included with this letter the corrected values of the tables (Tables 1 and 2). We hope that after these clarifications, the VULCAN study can help with a better understanding of the role of prognostic factors in squamous cell carcinoma of the vulva.