CARCINOMA OF THE VULVA

CARCINOMA OF THE VULVA

CARCINOMA OF THE VULVA

Vulvar cancer is a type of cancer that occurs on the outer surface area of the female genitalia. The vulva is a woman’s external genitals. It includes:

  • the lips surrounding the vagina (labia minora and labia majora)
  • the clitoris, the sexual organ that helps women reach sexual climax
  • the Bartholin’s glands, 2 small glands each side of the vagina

The majority of cancers of the vulva are squamous lesions that classically have occurred in women over 50 years of age. Several subtypes (particularly 16, 18, and 31) of HPV have been identified in some but not all vulvar cancers. About 70–90% of vulvar intraepithelial neoplasia (VIN) and 40–60% of vulvar cancers are HPV associated. As with squamous cell lesions of the cervix, a grading system of VIN from mild dysplasia to carcinoma in situ is used.

Symptoms of vulval cancer

Symptoms of vulval cancer can include:

  • a persistent itch in the vulva
  • pain, soreness or tenderness in the vulva
  • raised and thickened patches of skin that can be red, white or dark
  • a lump or wart-like growth on the vulva
  • bleeding from the vulva or blood-stained vaginal discharge between periods
  • an open sore in the vulva
  • a burning pain when peeing
  • a mole on the vulva that changes shape or colour

Types of vulvar cancer

The type of cell in which vulvar cancer begins helps your doctor plan the most effective treatment. The most common types of vulvar cancer include:

  • Vulvar squamous cell carcinoma. This cancer begins in the thin, flat cells that line the surface of the vulva. Most vulvar cancers are squamous cell carcinomas.
  • Vulvar melanoma. This cancer begins in the pigment-producing cells found in the skin of the vulva.

Diagnosis

Biopsy is essential for the diagnosis of VIN and vulvar cancer and should be performed with any localized atypi­cal vulvar lesion, including white patches. Multiple skin-punch specimens can be taken in the office under local anesthesia, with care to include tissue from the edges of each lesion sampled. Colposcopy of vulva, vagina, and cervix can help in identifying areas for biopsy and in plan­ning further treatment.

Benign vulvar disorders that must be excluded in the diag­nosis of carcinoma of the vulva include chronic granulo­matous lesions (eg, lymphogranuloma venereum, syphilis), condylomas, hidradenoma, or neurofibroma. Lichen scle­rosus and other associated leukoplakic changes in the skin should be biopsied. The likelihood that a superimposed vulvar cancer will develop in a woman with a non-neoplastic epithelial disorder (vulvar dystrophy) is 1–5%.

Vulvar cancer generally spreads by direct extension into the vagina, urethra, perineum, and anus, with discontinu­ous spread into the inguinal and femoral lymph nodes. CT or MRI of the pelvis or abdomen is generally not required except in advanced cases for planning therapeutic options.

Treatment

A. General Measures

Early diagnosis and treatment of irritative or other predis­posing causes, such as lichen sclerosis and VIN, should be pursued. A 7:3 combination of betamethasone and crota­miton is particularly effective for itching. After an initial response, fluorinated steroids should be replaced with hydrocortisone because of their skin atrophying effect. For lichen sclerosus, recommended treatment is clobetasol propionate cream 0.05% twice daily for 2–3 weeks, then once daily until symptoms resolve. Application one to three times a week can be used for long-term maintenance therapy.

B. Surgical Measures

High-grade VIN may be treated with a variety of approaches including topical chemotherapy, laser ablation, wide local excision, skinning vulvectomy, and simple vulvectomy. Small, invasive basal cell carcinoma of the vulva should be excised with a wide margin. If the VIN is extensive or mul­ticentric, laser therapy or superficial surgical removal of vulvar skin may be required. In this way, the clitoris and uninvolved portions of the vulva may be spared.

Invasive carcinoma confined to the vulva without evi­dence of spread to adjacent organs or to the regional lymph nodes is treated with wide local excision and inguinal lymphadenectomy or wide local excision alone if invasion is less than 1 mm. To avoid the morbidity of inguinal lymphadenectomy, some guidelines recommend sentinel lymph node sampling for women with early-stage vulvar cancer. Patients with more advanced disease may receive preoperative radiation, chemotherapy, or both.

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