What is Vulval Cancer
Vulval cancer is a rare disease in which cancerous cells (malignant) cells form in the tissues of the vulva. The vulva includes the inner and outer lips of the vagina, the clitoris (sensitive tissue between the lips above the urethra), and the opening of the vagina and its glands.
Vulval cancer most often affects the outer vaginal lips. Less often, it affects the inner vaginal lips or the clitoris.
It takes a few years for vulval cancer to develop. Abnormal cells can grow on the surface of the vulvar skin for a long time. This precancerous is called vulval intraepithelial neoplasia (VIN) or dysplasia. Because it is possible for VIN (dysplasia) to develop into vulvar cancer, treatment of this condition is very important. It prevents vulval cancer.
There are at least two different ways for vulval cancer to develop, the first related to HPV infection and the second related to chronic vulval inflammation (vulvar dystrophy, also called VIN) or autoimmune changes. HPV has been shown to be responsible for 60% of vulval cancers.
Early detection and treatment of VIN may prevent the development of cancer. It is important to say that most women found to have VIN will not develop vulval cancer.
Risk factors for vulval cancer include:
Human Papillomavirus (HPV) infection.
Vulval dysplasia (VIN), a precancerous vulval condition frequently caused by HPV infection.
A prior history of cervical cancer or pre cancer of the cervix (CIN).
Immunodeficiency syndromes e.g. HIV (Human Immunodeficiency Virus).
Cancer screening tests are important when you’re at risk but don’t have symptoms. They help find cancer at its earliest stage, when the chances for successful treatment are highest.
Unfortunately, there are no reliable screening tests to improve vulval cancer outcomes. However, having regular pelvic exams and knowing the signs of vulval cancer greatly improve the chances of early detection and successful treatment.
Unfortunately volval cancer often does not cause early symptoms. A doctor should see if any of the following problems occur:
- A lump in the vulva (opening to the vagina).
- Burning, pain or itching in the genital area.
- Bleeding not related to your periods.
- Tenderness in the vulval area.
- Change in a mole in the genital area.
These symptoms not necessarily mean that you have vulval cancer. However, it is important to discuss any of those, since they may signal other health problems.
Diagnosis and Staging
If you have symptoms that potentially could be related to vulval cancer, you will be examined and may required one or more of the following investigations:
A small sample of tissue from the vulva is taken so a dedicated gynaecologic pathologist can check for signs of cancer under a microscope. Other tests may help find out if you have vulvar cancer and if it has spread. These tests also may be used to learn if treatment is working.
It will take pictures of organs and tissues in the chest, pelvis and abdomen. An X-ray machine linked to a computer takes several pictures. You may receive contrast material by mouth and by injection into your arm or hand. The contrast material helps the organs or tissues show up more clearly. Abnormalities may show up on the CT scan. This could be a enlarged lymph node (lymph gland) for example.
PET (Positron Emission Tomography) Scan
You receive an injection of a small amount of radioactive sugar. A machine makes computerized pictures of the sugar being used by cells in your body. Cancer cells use sugar faster than normal cells, and areas with cancer look brighter on the pictures. PET can be associated with a CT scan, named PETCT scan which will give me the added benefit of both modalities in one single test.
It can show lung nodules potentially related to the vulval lump. I have been using more CT scan of the chest due its higher detection rate of chest disease.
The Stages of Vulval Cancer
Stage I: cancer has formed and is found in the vulva only or in the vulva and perineum (area between the rectum and the vagina). The tumour measures up to 2 centimetres and might have spread to tissue under the skin. Stage I vulvar cancer is further divided into stage IA and stage IB.
Stage IA: The tumour has spread 1millimetre or less into the tissue of the vulva.
Stage IB: The tumour has spread more than 1millimetre into the tissue of the vulva.
Stage II: Cancer is found in the vulva or vulva and perineum (space between the rectum and the vagina), and the tumour is larger than 2 centimetres.
Stage III: Cancer is of any size and either:
Is found only in the vulva or the vulva and perineum (space between the rectum and the vagina) and has spread totissue under the skin and to nearby lymph nodes on one side of the groin; or
Has spread to nearby tissues such as the lower part of the urethra (bladder opening) and/or vagina or anus, and may have spread to nearby lymph nodes on one side of the groin.
Stage IV: Is divided into stage IVA and stage IVB, based on where the cancer has spread.
Stage IVA: Cancer has spread to nearby lymph nodes on both sides of the groin, or has spread beyond nearby tissues to the upper part of the urethra (bladder opening), bladder, or rectum or has attached to the pelvic bone and may have spread to lymph nodes.
Stage IVB: Cancer has spread to distant parts of the body.
There are different types of treatment for patients with vulvar cancer. I will discuss in details with you which form of treatment is best indicated in your situation.
Three types of treatment are commonly used:
Surgery is the most common treatment for cancer of the vulva. The goal of surgery is to remove all the cancer without any loss of the woman’s sexual function. One of the following types of surgery may be done:
Radical Local Excision
This the most common type of surgery performed to treat vulval cancer. A surgical procedure to remove the cancer and some amount of normal tissue around it. Nearby lymph nodes in the groin may also be removed.
A surgical procedure to remove the entire vulva with some amount of normal tissue around it. Nearby lymph nodes in the groin may also be removed.
The entire vulva, including the clitoris, and nearby tissue are removed.
The aim of any of the above surgical interventions is to remove the entire cancerous tissue with some amount of normal tissues around it. After surgery, some patients still may have chemotherapy and/or radiation therapy in high risk situations. Treatment is given after the surgery to lower the risk that the cancer will come back, this is named adjuvant therapy.
Radiation therapy (radiotherapy) is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.
Chemotherapy is a cancer treatment that uses drugs (medications) to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. In vulval cancer, chemotherapy is injected into a vein from time to time; the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.
Your reviews will include a short history to make sure all is going well, pelvic examination covering lymph node areas, abdomen, and pelvis, and if indicated, imaging tests.
The usual follow-up for patients who have been treated for vulval cancer is as follows:
For the first two years: Every three months.
For the next three years: Every six months.
From five years onwards: Every year.
Dr Marcelo Nascimento
MD MSc FRANZCOG CGO
I am a clinical specialist in the treatment of gynaecological pre-cancers, cancersand complex non-cancer gynaecological conditions. I am dedicated to improving the quality of life for women with gynaecological conditions providing the highest quality of diagnosis, treatment and recovery pathways in a caring and supporting environment. I work with fertility-preserving surgery whenever possible which allows women more options for treatment without compromising oncologic outcomes.