Vulval cancer is a relatively rare condition with around 40 new cases per year in NZ. There are two different types:
- One type is related to Human Papilloma Virus infection (similar to cervical cancer) and this type is more common in young women. It encompasses approximately 60% of all vulval cancers. Smoking is a co-factor that often facilitates cancer growth.
- The second type is related to chronic inflammatory or autoimmune processes (e.g. lichen sclerosus) mainly in elderly women.
Symptoms
Vulval cancer can present with a lump/mass and itching. 94% of women presented with itching and 87% had symptoms for more than 6 months with 30% having symptoms for more than 5 years. Sometimes it arises from an area of precancer (VIN) which can present with similar symptoms.
Diagnosis
It is important that if vulval cancer is suspected than a biopsy should be done for pathological analysis. As vulval cancer can spread to the groins and other parts of the body, before any treatment can be instituted, a CT scan of chest, abdomen and pelvis should be done. The case will then be discussed as at the Multidisciplinary meeting (MDT)
Surgery
A large number of patients will benefit from surgery. The aim of the surgery is to remove the cancer with an adequate normal tissue around it. The other is to determine the extent of the disease with regards to the lymph nodes. The extent of surgery is highly individual. Surgery may sometimes include removal of parts of the vagina, outer parts of the urethra or the skin around the anus. Local flaps (plastic surgery) may be required to close the wound without tension and to give an acceptable cosmetic result.
Patients with very early vulval cancer with hardly any invasion of the cancer into the skin will not require a lymph node dissection because the chance of lymph node involvement is extremely low. Some patients with early vulval cancer limited to one side of the vulva will only require a groin node dissection on the affected side.
A new technique “sentinel node biopsy” is an alternative to “radical groin node dissection” technique to determine if the cancer has spread into the groin lymph nodes. The advantages of the sentinel node technique include shorter hospital stay and quicker recovery. The pros and cons of each method will be discussed.
Chemotherapy and / or Radiation Therapy
The multidisciplinary team makes the decision as to whether further treatment with radiation or chemotherapy is required after all the tissues are analyzed by the pathologist. This can help achieve a cure or prevent recurrence.
If surgery is not possible, a combination of radiotherapy with chemotherapy is standard treatment. Radiotherapy is given on a daily basis and will be complemented by weekly chemotherapy doses.
Follow-up
After treatment for vulval cancer, you will be seen initially every 6 months for 2 years then yearly for at least 5 years. If the cancer arises from a precancerous area called differentiated VIN then follow up will be lifelong. Further surgical excision may be necessary.
Follow up includes a groin examination an vulvoscopy (examining the vulva using a colposcope / microscope). Cessation of smoking after treatment of vulval cancer will halve the risk of recurrence.
Outcomes:
Cancers of all types and stages may recur. Recurrence may be local, in the pelvis or at distant sites. Treatment of recurrent cancer depends on the initial stage of the cancer (stages 1 to 4), the cell type of the cancer, the patient’s medical fitness and her wishes.
The presence of node metastases is the most important prognostic factor. Survival probability at five years’ ranges from 75% to 95% for patients with negative nodes and 25% to 40% for patients with positive nodes.
