Vulvar Cancer
This guideline is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Management of proven vulval cancer
Preparation for radical vulvectomy
Postoperative review & follow-up
Staging and types of vulval cancer
Cancer of the vulva, in the past, was most common at two age groups, around 40 & around 70 years. In HIV +ve patients vulval ca is occurring in women in their 20s.
VIN and lichen sclerosus are premalignant conditions that may lead to vulval ca. CIN like VIN may be associated with HPV. Always check the cervix, & do a Pap if not done recently.
Surgery is the mainstay of treatment. There is a move towards wide local excision (2cm margin) where possible. Radiotherapy accompanies surgery where indicated post op, & may be used with chemo to shrink large lesions pre-op.
Diagnosis and work up
- A raised lesion on the vulva, or one that bleeds, is ulcerated, or associated with a past history of dysplasia is suggestive of possible malignancy
- Large lesions require simple biopsy.
- Small or uncertain lesions require vulvoscopy & biopsy
- Full history & complete physical examination
- Describe the full extent of the lesion
- Search for metastases:
- Inspect for vaginal & anal spread and biopsy if necessary
- Look for inguinal nodes & arrange fine needle aspiration if the diagnosis remains uncertain, otherwise await lymphadenectomy
- Pap smear (if not recently done) & inspect the cervix
- Chest x-ray
- FBC, U&E, RPR, & HIV (+/- CD4)
- Involve an experienced consultant
Management of proven vulval cancer
- The decision to perform wide local excision with a 2 cm margin for a laterally placed lesion should be taken by an experienced surgeon. A larger lesion requires lymphadenectomy as there is more likely invasion >1mm (the limit of micro-invasion)
- Midline lesions & large lesions will require radical vulvectomy including lymph node dissection for which the patient should be prepared
- If the tumor invades the anus, organize for colostomy to be done as a separate procedure – counsel well, call a stoma sister, consult a surgeon
- If the tumor is very large or inoperable, radiotherapy or chemotherapy may be given before vulvectomy – such patients should be seen at the weekly oncology meeting for initial assessment & for discussion of possible surgery after initial radiotherapy
- Large lesions may require a skin flap
Preparation for radical vulvectomy
- Explain the operation to the patient. In most cases, the clitoris will be removed (in sexual terms this leaves the G spot - 3cm from the introitus, anterior vaginal wall, & the deep vaginal orgasm). A ‘triple incision’ will be used. Flaps may be required, & may require plastic surgery assistance
- Cross-match 2 units of blood on standby for theatre
- An ICU bed will not normally be needed
Postoperative wound breakdown
- Wound breakdown is relatively common after radical vulvectomy
- Take a wound swab for MC&S
- Give oral cloxacillin or intravenous amoxicillin/ampicillin & or treat according to swab results
- Dress with saline, absorbent polymers, honey etc. (acetic acid for Pseudomonas)
Postoperative review & follow-up
- Patients who have positive nodes on histology & have not received radiotherapy will need to be presented at the weekly oncology meeting
- Patients with surgery alone are followed up at their own hospitals, as for cervical cancer
- Look for recurrence at each visit, as early treatment of a central recurrence frequently results in cure
- Patients who smoke must be urged to stop; smoking is associated with a higher risk of recurrence
Staging and types of vulvar cancer (FIGO 2009 and 2018)
- Stage 1a: Tumor confined to vulva or perineum, <2cm, <1mm invasion no nodal spread
- Stage 1b: Tumour >2cm, or >1mm invasion, no nodes
- Stage 2: Tumor, any size, confined to vulva or perineum involving lower 1/3 urethra, lower 1/3 anus, no nodal spread
- Stage 3a(i): 1 lymph node met >/=5mm
- Stage 3a(ii): 1-2 lymph node mets <5mm
- Stage 3b(i): 2 or more lymph nodes >/= 5mm
- Stage 3b(ii): 3 or more nodes <5mm
- Stage 3c: Positive nodes with extracapsular spread
- Stage 4a(i): Invasion of upper 2/3 vagina or urethra, mucosa of bladder or rectum or fixed to bone
- Stage 4a(ii): Fixed or ulcerated inguino-femoral nodes
- Stage 4b: Distant metastases, including spread to pelvic nodes
The TNM classification is also used, & N refers to nodal metastases & M to other metastases where appropriate.
The majority of vulval cancers (85%) are squamous (epidermoid). Melanoma (pigmented or not) accounts for 5%. Melanoma is staged using Clark’s or Breslow’s classifications. Sarcomas & adenocarcinomas (including Bartholin’s gland carcinoma) also occur.