Vulva Cancer
Vulva= clitoris + labia majora + labia minora.
Lymphatic drainage of the vulva & lower 1/3 of
vagina= inguinal & femoral LN (first place of
metastasis) Cancer of the vulva is a skin cancer
involving any part of the external female sex
organ.
It most commonly develops in the labia minora,
the inner edges of labia majora, the perineum.
(can involve clitoris/ Bartholin glands).
Types of vulva cancer
The most common type is squamous cell cancer.
• Squamous cell carcinoma (SCC)
o Makes up 90% of vulvar cancers,
develops from squamous cells
o Include verrucous carcinoma (rare)
• Vulvar melanoma
o Makes up 2-4% of vulvar cancer,
develops from melanocytes
• Adenocarcinoma
o Rare, develops from glandular cells in
the Bartholin glands or other vulvar
glands.
o Extramammary paget’s disease is
included under this category
• Sarcoma
o Rare but grow faster than other types,
develops from muscle/ fat
• Basal cell carcinoma (BCC)
o Rare
Symptoms
• lump/bump/ wart like growth on vulva
• Itching, burning, soreness/pain in vulva
• Thicken, raised skin patches (red/white/dark
brown)
• Blood, pus or discharge from lesion +/-
offensive odour
• Hard/swollen lymph nodes in the groin area
Epidemiology & Pathophys
• Rare, disease300 Australian women
diagnosed yearly
• Commonly affect postmenopausal women,
average age of diagnosis @ 67.2
• Can however occur in younger women
• ?Pathways for vulvar carcinogenesis: HPV
infection or chronic inflammatory processes.
Risk factor
• Old age, women aged >60
• Nulliparity
• Smoking
• Phx of vaginal or cervical cancer
• Phx of Radiotherapy to pelvis
• Phx of vulvar intraepithelial neoplasia/ lichen
sclerosus
• Phx of HPV/ genital warts
Diagnosis/ investigations
• History + exam (external + internal)
• Colposcopy to exam vulva in detail + biopsy
(+/- local anaesthetic)
o If large areas of abnormalities are
identified, several biopsies will be
taken under GA. This is known as
vulvar mapping.
o Biopsy is indicated when there’s
clinical suspicious for malignancy
(asymmetry, border irregularity,
colour variation, bleeding/ nonhealing
ulcer)
• Cervical screening test (can be conducted
while speculum is in place, if due for one)
Some further testing could be conducted to
ascertain position/ check for metastasis
• Blood test (FBE, UEC, LFT)
• CT chest, abdo, pelvis (check for metastasis)
• CXR
• proctoscopy
• cystoscopy
• MRI
Staging
Using the staging system from International
Federation of Gynaecology and obstetrics (FIGO)
- Stage I: Ca in vulva/ perineum
- Stage II: Ca in vulva and/or perineum and
has spread to lower urethra, lower vagina
or the anus
 - Stage III: Ca in the vulva and/or perineum
and LN of the groin (regardless of spread
to urethra, vagina/ anus)
- Stage IV: Ca spread to upper urethra,
upper vagina, or more distant parts
Treatment
Treatment is dependent on the staging (FIGO
staging), the grading (degree of dysplasia: grade 1-3,
with 1 being low grade, well differentiated and 3 being
poorly differentiated), type of cancer, health state of
the patient. Options available area as follow.
• Surgery (one of the following type of surgery
may be done)
o Wide local excision: cancerous part
removed + 1 cm border of healthy
tissue(margin)
o Radical local excision: cancerous +
larger area of normal tissue
removed, LN in groin may be
removed
o Partial vulvectomy: (happened
with extensive disease) wide local
excision, resulting in significant
portion of vulva removed.
o Radical vulvectomy: (happened
with extensive disease) entire
vulva +/- clitoris removed, nearby
LN are removed. Reconstruction
surgery may be required. If large
area of skin is removed, skin graft/
skin flap may be necessary.
o LN dissection: inguinal LNs are
removed from one or both side. LN
removal can obstruct the flow of
lymphatic fluid causing
lymphoedema.
o Sentinel LN biopsy: dye is used to
identify the first LN of drainage.
This can avoid removing more LN
than necessary.
o Pelvic exenteration (for advanced
cancer): removal of all the affected
organs eg lower bowel, bladder,
uterus and vagina
• Radiotherapy= radiation to kill/ damage
cancer cell. Radiotherapy can be used before
surgery as neoadjuvant therapy or after
surgery as adjuvant therapy. Radiotherapy
might be preferred instead of surgery as a
palliative treatment. There are 2 types of
radiotherapy:
o External bean radiotherapy(EBRT):
daily radiation spanning 20 mins,
over 5-6 weeks. Advantage being:
EBRT will not make the patient
radioactive. It is safe for the
patient to be with other people
after treatment.
o Internal radiotherapy (aka
brachytherapy): placing
radioactive sources inside the
patient (not often use for vulvar
cancer)
• Chemotherapy uses cytotoxic drug to kill or
slow the growth of cancer cells. Treatment
may be given during a course of radiotherapy
to improve efficacy of the radiotherapy
treatment/ in cases when the cancer has
metastasis/ as a palliative treatment to relive
symptoms. Mode of delivery:
o Tablets
o (Topical) cream which can be
applied to the vulva
o (more commonly) intravenously
• Palliative treatment may include range of
treatment like radiotherapy, chemotherapy or
other drug therapies which primarily aims to
relieve pain/ symptoms. Another aspect of
palliative treatment is palliative care which
aim to meet the patient’s physical, emotional,
practical and spiritual needs.
Prognosis
Early diagnosis and treatment increase the
likelihood of a successful treatment. Prognosis is
dependent on
- Test results
- Type of vulvar cancer
- Stage and grade
- Response to treatment
- Other factors eg age general fitness and
med hx
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Reference:
- https://www.cancervic.org.au/cancer-
information/cancer-
types/cancer_types/vulvar-vaginal-
cancers/vulvar_cancer.html
- https://www.thewomens.org.au/health-
information/womens-cancers-pre-
cancers/vulvar-cancer/
- Gynaecology by ten teachers