The vulva is the external sexual organs in a woman. It is made up of two pairs of lips called labia between which are two holes. The largest is the introitus or entry to the vagina. The vagina is the passage between the uterus (womb) and the outside world. The smaller hole is the urethra which is the outlet from the bladder through which urine is passed.
Cancer of the vulva is an uncommon cancer, which arises from the skin covering the vulva. There are less than 100 cases each year in Queensland. Most women are over 50 years of age with the most common age group for this cancer being in the 70-79 years age group. However, it does appear that vulval cancer is becoming more common in younger women between 30 & 50 years.
Women who have constant itching or changes in colour or the way the vulva looks are at increased risk of this disease and should see their doctor. Furthermore, a doctor should be seen if there is any bleeding or discharge not related to menstruation (periods), burning/itching or pain in the vulva, or if the skin of the vulva looks white, feels rough or develops a lump.
If there are symptoms a doctor may do certain tests to help in making the diagnosis and to check for the presence of cancer. This will begin with an examination to carefully look at the vulva and feel for any lumps.
A colposcopic examination may be undertaken which will give the doctor a magnified view of the skin over the vulva. Sometimes the diagnosis may be obvious to the naked eye. The doctor may then go on to cut a small piece of skin (called a biopsy) from the vulva to be examined by a pathologist under a microscope. The patient will either be given some local anaesthetic to numb the area prior to taking the biopsy or if necessary admission to hospital can be arranged for this to be done under anaesthetic.
The outcome for treatment of cancer of the vulva is dependent on the stage of the cancer at the time of treatment,
Once the diagnosis of vulval cancer has been made further tests will need to be done prior to undertaking treatment. These tests include blood tests, x-rays and possibly an electrocardiograph (ECG).
The following stages are used for cancer of the vulva:
The disease only exists in the surface skin and has not yet started to invade the deeper tissues. Strictly speaking this is not cancer but pre-cancer also abbreviated to VIN.
The cancer is found only in the vulva and/or the skin between the vagina and the anus (perineum). Furthermore, the cancer is 2 centimetres or less in size.
Cancer is found in the vulva and/or the space between the vagina and the anus (perineum) and the tumour is larger than 2 centimetres in size.
The cancer is found in the vulva and/or the skin between the vagina and the anus (perineum) and has spread to involve any one or more of the following: the urethra (tube through which urine passes when the bladder is emptied), the vagina, the anus and/or has spread to the groin lymph nodes. Lymph nodes are small bean shaped structures that help in fighting infection.
Cancer has spread beyond the urethra, vagina and anus into the lining of the bladder and/or bowel, or it may have spread to lymph nodes in the pelvis or to other parts of the body.
Recurrent cancer of the vulva means that the cancer has come back (recurred) after it has been treated. It may recur in the vulva, in one or both groins, in the pelvis or elsewhere in the body.
If a patient's cancer has recurred it is NOT re-staged. A patient who
originally had Stage I cancer who develops a recurrence, say in the lungs some
time later, does NOT then have Stage IV cancer; they have recurrent metastatic
Stage I cancer.
All stages of cancer of the vulva can be treated.
One or more of the following types of treatment may be advised.
Surgery - an operation to cut the cancer out. The type of surgery will need to be tailored to the stage and site of the cancer. For example, it may involve removing an area only skin deep or it may involve a wide local excision of skin which takes out the cancer with an area of normal tissue around the cancer and it may involve removing the lymph nodes from one or both groins. This surgery will be described and discussed with you in detail.
Radiotherapy - the use of high energy x-rays to kill the cancer cells or to shrink the cancer prior to other treatment such as surgery.
Chemotherapy - using drugs to kill the cancer cells.
Treatment of cancer of the vulva depends on the stage of the disease, the type of disease and the patient's age and overall medical condition.
Treatment is by local excision for relatively small lesions up to a few centimetres in maximum dimension. If the lesions are multifocal and/or widespread then it may be better to treat these by a skinning vulvectomy. This involves literally skinning the abnormal area of the vulva and possible covering the defect with a split skin graft.
The primary approach is a wide local excision of the lesion. This may involve removal of one side of the vulva, called a hemi-vulvectomy. It is important to get at least 1 centimetre of normal tissue around the cancer. If the cancer comes close to the midline then it may be wise to treat the whole vulva by excision i.e. a radical vulvectomy.
If the cancer invades to a depth of more than 1 millimetre then the lymph nodes should be removed from the groin. Whether this should be done for one or both groins depends on the size and site of the cancer.
This would generally be treated by a radical vulvectomy involving the removal of the whole vulva and removal of the lymph nodes in both groins. If cancer is found in the groin nodes then further treatment with radiotherapy to the pelvis may be advised.
This may be treated by radical vulvectomy involving the removal of the whole vulva and removal of the lymph nodes in both groins. However, the feasibility of this approach will depend very much on the degree to which the urethra or vaginal or anus are affected.
At times and in order to minimise the surgery; initial treatment may be by radiotherapy and chemotherapy to reduce the size of the tumour, followed by surgical removal.
In this group of patients the treatment very much needs to be individualised to suite the situation. It may involve any combination of surgery/radiotherapy/chemotherapy.
Recurrent Vulva Cancer
This will depend very much on the site of the recurrence. It may involve surgical removal of the recurrence followed by radiotherapy or radiotherapy by itself or with chemotherapy. These choices have to be made on an individual case by case basis.
It is important that patients have proper follow-up after treatment of cancer. The usual follow-up protocol is to be seen
Every 3 months for the first 2 years,
Every 6 months from 3 to 5 years, then
Every years thereafter.
Follow-up involves taking a brief history covering the time since the last visit. A physical examination is then undertaken with careful checking of the vulva and groins.
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