Vulvar Cancer

Vulva cancer accounts for about 5% of gynaecological cancers.  Vulval cancers often cause itch or pain and as the vulva is an external organ, an abnormal lesion will usually be visible or felt.  Vulval cancers are often a hard ulcer or lump, but can be more subtle and arise in background abnormal vulval skin conditions called vulvar intra-epithelial neoplasia (VIN) or lichen sclerosus (LSA).  Any doubts or concerns about a vulval lesion should be discussed with a doctor.

Symptoms

  • Itch – this is an almost invariable symptom in women with early vulvar cancer and should not be ignored
  • Lump
  • Bleeding
  • Pain
  • Ulceration

Spread

  • Local invasion into surrounding tissues
  • Via lymphatics to groin lymph nodes
  • Rarely via the blood stream to distant sites.

Risk Factors

  • HPV
  • Lichen sclerosis (LSA)
  • Vulvar Intra-epithelial neoplasia (VIN) – there are 2 types, so-called usual type VIN associated with HPV and differentiated VIN associated with LSA
  • Cigarette smoking
  • Immunosuppression

Evaluation of suspected vulvar cancer

  • History and physical examination
  • Ensure cervical screening is up to date
  • Colposcopy
  • Biopsy and histological analysis

Investigation of patients with proven vulvar cancer

  • Routine bloods – FBC and ELFT
  • CT scan of groins, abdomen, pelvis, chest (or chest Xray)

Treatment

The cornerstone of treatment is surgery.  The aim of surgery is for radical excision or clearance around the cancer of at least 8mm, with the depth of surgery taken down to the deep fascia.  Depending on the size and depth of the cancer, lymph glands may need to be taken from either or both groins.  If the cancer is less than 4 cm and there are no suspicious nodes, consideration will be given to removal of the sentinel lymph node (the most important node draining the site of the cancer).

Under some circumstances radiation may be used in the treatment.  This would be where the cancer is so close to the urethra or anus that surgical treatment would compromise bladder or rectal continence.  Sometimes radiation is used to treat small cancers of the clitoris to preserve that organ and radiation may be used where there are involved lymph nodes in the groins.

Follow up

As with the follow up of most gynaecological cancers, the follow up is typically every 3 months for the first 2 years and then 6 monthly for the following 3 years and then annually thereafter.