Vulval cancer symptoms and treatment

This page presents information on the symptoms, treatment and staging of vaginal cancer. It also includes information on screening and prevention.

Vulval cancer symptoms and treatment

 
 

Vulval cancer symptoms

The majority of patients diagnosed with vulval cancer present with an enlarging lump or ulcer on the vulva. Many patients have a long history of vulval soreness and irritation and may have had previous biopsies showing vulval intraepithelial neoplasia (VIN) or lichen sclerosus. 1

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Staging of Vulval cancer

After biopsy has confirmed the presence of vulval cancer, staging is carried out with assistance of computed tomography (CT) scanning or magnetic resonance imaging (MRI). According to international data for women treated in 1996-98, 11% of vulval cancer patients present with in situ tumours, 56% with stage I or II tumours, 18% with stage III, and 7% with stage IV. 2

Older patients are more likely to present with advanced vulval cancer. In a recent British series, 67% of patients aged over 60 presented with vulval cancer stage III or IV, whereas 52% of patients under 60 had tumours localised to the vulva. 3

Table 6.1 shows the FIGO staging guidelines for vulval cancer.

Table 6.1: FIGO staging guidelines for cancer of the vulva

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Vulval cancer treatment

While the mainstay of treatment for vulval cancer is surgical excision, the current emphasis for management of VIN is on conservative treatments, such as wide local excision or hemi-vulvectomy, rather than total vulvectomy; laser ablation is also employed. 4

An early-stage UK trial has shown the possible benefits of an HPV vaccine in women with VIN, 5 and other experimental treatments include an anti-viral cream to treat HPV 6, 7 and photodynamic therapy. 8 Regular follow-up is important as recurrences are relatively common. 4,9, 10

Early vulval cancer is treated with surgery. 11 With advanced or multifocal disease a total vulvectomy is indicated, but in many cases, particularly where the tumour is well lateralised, a wide local excision of the primary tumour or a hemi-vulvectomy and unilateral lymph node dissection gives excellent local control. 12-14

Depending on the position of the primary tumour, lymph nodes may be removed on both sides. The depth of excision and the width of the excision margins are important prognostic factors for local control. 15 Sentinal node biopsy may help to identify those patients at low risk of inguinal lymph node involvement, who are unlikely to benefit from lymphadenectomy. 16, 17

Local radiotherapy is used as an adjuvant to surgery for deeper lesions, where adequate clear margins are not obtained or where nodes are involved. 18, 19

Radical radiotherapy is used in patients for whom surgery is not an option and may be combined with chemotherapy. 20

Cure of advanced vulval cancer requires combined modality treatment using radiotherapy with concomitant chemotherapy and radical surgery. A small trial of pre-operative chemoradiotherapy and radical surgery in patients presenting with grossly enlarged or fixed inguinal nodes showed that local control in the nodes was achieved for 36/37 patients and at the primary site for 29/38. 21

Another group of women in this trial who presented with locally advanced primary tumours, which would have required exenteration (operation in which all the contents of a body cavity are removed) for control, were treated under the same regimen and results showed that a good level of local control was achieved while mainly avoiding exenterative surgery. 22

Combined modality treatment is associated with very high acute morbidity and should only be considered in the very fittest patients. Where elderly and frail patients present with very advanced and inoperable local disease, referral to palliative care specialists may be more appropriate. 23

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Vulval cancer screening and prevention

Regular surveillance for early vulval cancer or pre-cancer is recommended for women with a previous diagnosis of anogenital cancer or VIN, 4 and the International Society for the Study of Vulvovaginal Disease recommends monthly self-examination for all women. 24

Preliminary trials of immunotherapies have been promising for VIN, although numbers of trial participants have been small and larger-scale trials are needed to confirm results. 5,25, 26

If smoking rates and levels of HPV infection remain at current levels, we may see a continuation of the increasing trend for vulval cancer, observed since the mid-1990s. In this case, vulval cancer will affect greater numbers of pre-menopausal women. Given that we know the role played by both smoking and HPV in the causation of vulval cancer, there is strong potential to reduce incidence, especially by tackling smoking rates.

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References for vulva cancer symptoms and treatment

  1.  Ansink, A.C. and A.P. Heintz., Epidemiology and etiology of squamous cell carcinoma of the vulva. Eur J Obstet Gynecol Reprod Biol, 1993. 48(2): p. 111-5
  2.  Beller, U., et al., Carcinoma of the vulva. Int J Gynaecol Obstet, 2003. 83 Suppl 1: p. 7-26
  3.  Woolas, R.P. and J.H. Shepherd, Current developments in the management of vulval carcinoma, in The Yearbook of Obstetrics and Gynecology, P.M.S. O'Brien, Editor. 1999, RCOG Press.
  4.  Jones, R.W., Vulval intraepithelial neoplasia: current perspectives. Eur J Gynaecol Oncol, 2001. 22(6): p. 393-402
  5.  Davidson, E.J., et al., Immunological and clinical responses in women with vulval intraepithelial neoplasia vaccinated with a vaccinia virus encoding human papillomavirus 16/18 oncoproteins. Cancer Res, 2003. 63(18): p. 6032-41
  6.  Wendling, J., et al., Treatment of undifferentiated vulvar intraepithelial neoplasia with 5% imiquimod cream: a prospective study of 12 cases. Arch Dermatol, 2004. 140(10): p. 1220-4
  7.  Buck, H.W. and K.J. Guth Treatment of vaginal intraepithelial neoplasia (primarily low grade) with imiquimod 5% cream. J Low Genit Tract Dis, 2003. 7(4): p. 290-3
  8.  Campbell, S.M., et al., Photodynamic therapy using meta-tetrahydroxyphenylchlorin (Foscan) for the treatment of vulval intraepithelial neoplasia. Br J Dermatol, 2004. 151(5): p. 1076-80
  9.  Dodge, J.A., et al., Clinical features and risk of recurrence among patients with vaginal intraepithelial neoplasia. Gynecol Oncol, 2001. 83(2): p. 363-9
  10.  Hillemanns, P., et al., Evaluation of different treatment modalities for vulvar intraepithelial neoplasia (VIN): CO(2) laser vaporization, photodynamic therapy, excision and vulvectomy. Gynecol Oncol, 2006. 100(2): p. 271-5
  11.  Hacker, N.F., et al. Radical vulvectomy and bilateral inguinal lymphadenectomy through separate groin incisions. Obstet Gynecol, 1981. 58(5): p. 574-9
  12.  Hacker, N.F., et al., Individualization of treatment for stage I squamous cell vulvar carcinoma. Obstet Gynecol, 1984. 63(2): p. 155-62
  13.  Burke, T.W., et al., Radical wide excision and selective inguinal node dissection for squamous cell carcinoma of the vulva. Gynecol Oncol, 1990. 38(3): p. 328-32
  14.  Ansink, A. and J. van der Velden, Surgical interventions for early squamous cell carcinoma of the vulva. Cochrane Database Syst Rev, 2000(2): p. CD002036
  15.  Heaps, J.M., et al., Surgical-pathologic variables predictive of local recurrence in squamous cell carcinoma of the vulva. Gynecol Oncol, 1990. 38(3): p. 309-14
  16.  Selman, T.J., et al., A systematic review of the accuracy of diagnostic tests for inguinal lymph node status in vulvar cancer. Gynecol Oncol, 2005. 99(1): p. 206-14
  17.  Plante, M., M.C. Renaud, and M. Roy, Sentinel node evaluation in gynecologic cancer. Oncology (Williston Park), 2004. 18(1): p. 75-87; discussion 88-90, 95-6
  18.  Homesley, H.D., et al., Radiation therapy versus pelvic node resection for carcinoma of the vulva with positive groin nodes. Obstet Gynecol, 1986. 68(6): p. 733-40
  19.  van der Velden, K. and A. Ansink, Primary groin irradiation vs primary groin surgery for early vulvar cancer. Cochrane Database Syst Rev, 2001(4): p. CD002224
  20.  de Hullu, J.A., et al., Management of vulvar cancers. Eur J Surg Oncol, 2006. 32(8): p. 825-31
  21.  Montana, G.S., et al., Preoperative chemo-radiation for carcinoma of the vulva with N2/N3 nodes: a gynecologic oncology group study. Int J Radiat Oncol Biol Phys, 2000. 48(4): p. 1007-13
  22.  Moore, D.H., et al., Preoperative chemoradiation for advanced vulvar cancer: a phase II study of the Gynecologic Oncology Group. Int J Radiat Oncol Biol Phys, 1998. 42(1): p. 79-85
  23.  Snijders-Keilholz, T., et al., Management of vulvar carcinoma radiation toxicity, results and failure analysis in 44 patients (1980-1989). Acta Obstet Gynecol Scand, 1993. 72(8): p. 668-73
  24.  International Society for the Study of Vulvovaginal Disease, Vulvar cancer FAQs.
  25.  Davis, G., J. Wentworth, and J. Richard, Self-administered topical imiquimod treatment of vulvar intraepithelial neoplasia. A report of four cases. J Reprod Med, 2000. 45(8): p. 619-23
  26.  Baldwin, P.J., et al., Vaccinia-expressed human papillomavirus 16 and 18 e6 and e7 as a therapeutic vaccination for vulval and vaginal intraepithelial neoplasia. Clin Cancer Res, 2003. 9(14): p. 5205-13