vulvar cancer accounts for 25% of gynecological cancers , and 90% of cases are squamous carcinoma . tumor type and infiltration depth are crucial in determining treatment . treatment of the groin nodes is recommended when infiltration depth is 1  mm or more or when tumor size is 2  cm or more ( t1b tumors ) . in our institute , treatment of groin nodes consists of either a sentinel node procedure or an inguinal - femoral lymphadenectomy , depending on the size of the tumor and the number of tumor foci . different treatment schedules are applicable for superficially invasive tumors ( if smaller than 2  cm diameter ) and for nonsquamous carcinomas . it is therefore clearly of importance that the biopsy report should , where possible , include tumor type and infiltration depth . these features , in combination with a clinical assessment of tumor diameter , should enable an appropriate decision about treatment to be made . in the netherlands , patients with vulvar malignancies the slides are reviewed by pathologists experienced in gynecopathology as part of the preoperative workup . the extra work and resources involved in reviewing all tumors are discussed and debated in several papers [ 15 ] , although literature on this topic is relatively scarce . it is clear that review is costly and time consuming . both laboratories have to organize the exchange of tissue blocks and slides , which is time consuming for administrative assistants . reviewing slides costs time for the pathologist and the review may potentially delay treatment , increasing stress for patients and relatives . the objective of this paper is to determine the impact of pathology review on patient management in patients with vulvar cancer . in addition , we investigate the adequacy of the pathology reports , with regard to tumor type , infiltration depth , and , for excision biopsies , resection margins . we conducted a retrospective chart review of all patients referred and treated for cancer of the vulva at erasmus mc , rotterdam , in the period from january 1 , 2001 , to april 1 , 2006 . such patients areexamined by the gynecologist - oncologist at the outpatient department where the location of the tumor , its size , and the number of lesions are recorded . review of the histology is requested in all cases and the slides are revised by a pathologist experienced in gynecopathology prior to surgery . information was drawn from the original and review pathology reports and from hospital charts . the data collected included patient characteristics , type of specimen ( incisional versus excisional biopsy ) , biopsy site , histological type of the tumor , tumor grade , infiltration depth , and , for excisional biopsies , resection margins . where patients had had several biopsies , each biopsy was classed as a separate review . any extra histological biopsy that was required in the tertiary centre for proper treatment planning was recorded . a discrepancy was defined either as a difference in histological type or in measurement of infiltration depth , where one report stated that infiltration depth was less than 1  mm and the other stated that there was invasion to a depth of more than 1  mm ( this being the critical cutoff for treatment of the groin nodes ) . a histology report was considered  adequate  when it described tumor type , depth of infiltration , and  in excisional biopsies  resection margins . sometimes the pathologist was unable for technical reasons to accurately measure depth of infiltration . if this problem was clearly described in the report we regarded this as being a comment on depth of infiltration . patients were referred to our clinic from 19 hospitals , each referring between one and 24 patients . a total of 121 tumors in 112 patients were included . mean age at biopsy was 71.9 years . the number of biopsies ranged from one to six with a mean of 1.4 . in 93 patients , a diagnosis of carcinoma of the bartholin gland was made in the original report while the review diagnosis was squamous carcinoma with infiltration depth of more than 1  mm . in one further case , a third opinion was sought from an expert pathologist in another institute to confirm a rare mix of verrucous carcinoma and conventional squamous carcinoma . in three patients , it was necessary to rebiopsy , since the original biopsies were inconclusive regarding tumor type . our findings with regard to infiltration depth are shown in table 2 . where the depth of infiltration was missing from the original report , this was usually found to be > 1  mm on review . there were 17 reviews where it was not possible to measure infiltration depth ; in 16 of these cases the definitive vulvectomy specimen showed a depth of infiltration > 5  mm . the remaining patient received palliative treatment and therefore there was no definitive specimen . a report stating histological type and depth of infiltration was considered there was no grade stated in 41 reports from the referring institutes and in 20 of the review reports . in our study on slide review in vulvar cancer we found only one instance where the management of the patient changed as a result of the pathology review . this was a case where a patient was referred with a tumor of a bartholin cyst which on review was classified as a squamous carcinoma of the vulva . carcinoma of bartholin 's gland is , however , not the same entity as vulvar carcinoma and treatment protocols differ . there were therefore no cases referred to our institute with squamous carcinoma of the vulva where management altered as a result of slide review . in a large number of cases , the report was incomplete ; in 44% of the original reports , a comment on depth of infiltration was missing . in the review reports , squamous carcinoma of the skin is very well - known to pathologists and vulvar carcinoma resembles other squamous carcinomas of the skin histologically ; however , treatment differs markedly , and histological typing alone is insufficient for treatment planning in the case of vulvar tumors . histopathologists need therefore to include the infiltration depth in their reports on squamous carcinoma from this site . the available literature on this topic shows a rate between 0% and 15.8% for major discrepancy . it is not possible from our study , or from the wider literature , to calculate how many histology reviews would be necessary to find one major discrepancy , nor the cost of this review process . ideally these issues should be clarified by a cost - benefit study before protocols relating to the process of referral and treatment in tertiary centers are altered . we doubt however whether slide review is necessary for vulvar cancer , and this view is shared by other authors [ 3 , 5 ] . based on the findings of this study , we have altered the protocol for our clinic . we now request slide review only in specific circumstances : when the tumor is less than 10  mm in linear extension , when the infiltration depth is 1  mm or less , when there is no residual tumor on inspection , and for any tumor described as nonsquamous cancer . for excision biopsies , in addition , pathologists in the referring clinics are requested to include infiltration depth , the presence of capillary - lymphatic space invasion , and width of resection margins in their report .
hypothesis . 
 pathology slide review in vulvar cancer is only necessary in a restricted number of cases . methods . a retrospective chart review of all cases of vulvar cancer treated in a tertiary centre between january 1 , 2000 , and april 1 , 2006 . 
 histopathology reports from the referring and tertiary centre were compared . 
 results . 121 pathology reports from 112 patients were reviewed . 
 of the original reports , 56% were deemed adequate , commenting on tumor type and depth of infiltration ; of the reviews , 83% were adequate . 
 conclusion . 
 there were no discrepancies that influenced patient management . 
 we suggest that vulvar cancer biopsies need to be reviewed only when the tumor is less than 10  mm in linear extension , when the infiltration is 1  mm or less , when there is no residual tumor on inspection , and in any nonsquamous cancer .