What is vulval cancer?
Vulval cancer is a malignant disease that starts on the external women’s genitals. In Australia, vulval cancer is uncommon with only 400 women newly diagnosed every year. Typically vulval cancer is a disease of postmenopausal women.
Types of vulval cancer
There are two types of vulval cancer:
- One type is related to HPV infection (similar to cervical cancer) and this type is more common in young women. It encompasses approximately 60% of all vulval cancers. Smoking is also risk factor that can facilitate this cancer growth.
- The second type is related to chronic inflammatory (vulval dystrophy) or autoimmune processes and is mainly diagnosed in elderly women.
Symptoms of vulval cancer may include:
- A lump on the vulva. Most patients present with a fleshy, nodular or warty mass, plaque or ulcer on the labia.
- Persistent itching, tenderness or burning of the vulva that does not go away.
- Changes in the skin of the vulva, including colour changes or growths that look like a wart or ulcer.
- Abnormal bleeding.
If you have any signs or symptoms of vulval cancer, you should speak to your GP in the first instance and request a physical examination with a biopsy of any suspicious areas.
The diagnosis of vulval cancer involves a physical examination, and a biopsy of any suspicious skin lesions if required. Vulval cancer can spread into the groin and pelvic lymph nodes. A CT scan of the pelvis, abdomen and chest needs to be conducted to ascertain that the cancer has not spread beyond the vulva.
Risk factors of vulval cancer may include:
- VIN (vulval intraepithelial neoplasia, a precancerous condition)
- Noncancerous skin conditions called vulval lichen sclerosus and vulval lichen planus
- Weakened immune system
- Previous cervical or vaginal cancer
- Abnormal cervical screening test history.
Most patients with vulval cancer benefit from surgery. The primary aim of surgery is to remove all cancerous tissue. During surgery I also determine the extent of the disease, particularly to verify if the cancer has spread to the lymph nodes in the groin. Surgery usually takes between 2 to 3 hours and requires general anaesthesia.
Surgery for vulval cancer will remove parts of the vulva and usually the lymph nodes in the groins. Surgery may 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 provide an acceptable cosmetic result.
The extent of surgery will be dependent on the spread of the disease. For example, 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 the cancer spreading is extremely low. Some patients with early vulval cancer limited to one side of the vulva only require a groin lymph node dissection on the affected side.
A new technique “sentinel node biopsy” (pictured) has largely replaced the old fashioned “radical groin node dissection” technique to determine if the cancer has spread into the groin lymph nodes. This technique requires a nuclear scan which I will arrange for in the morning of the surgery. The advantages of the sentinel node technique include shorter hospital stay and quicker recovery.
In brief, we will inject a radiotracer into the skin tissue next to the tumour in the medical imaging department in the morning of your procedure. The radiotracer will be transported to the next lymph node (usually located in the groin). A gamma camera will detect the radiotracer and make images from the region. The radiographer will mark the highlighted node.
In the operating theatre I will have surgical equipment available (similar to a Geiger counter) that will allow me to locate the marked groin node to excise it. We assume that if that one node is cancer-free, all other nodes will be cancer-free also.
If surgery is not possible (patients with involvement of the clitoris, the bladder or the rectum and anus) a combination of radiotherapy with low dose chemotherapy is standard treatment. Radiotherapy is given daily and will be complemented by weekly chemotherapy doses. I will refer my patients to appropriate specialists I work regularly with who have a specific interest in the treatment of vulval cancer.
Prior to surgery
For surgery, no bowel prep is required. Patients are asked to fast at least 6 hours prior to surgery. I advise to stop smoking before the operation as it makes postoperative management much easier.
When you wake up from general anaesthesia a drip will give you the necessary fluids and an oxygen mask to your face will supply you with oxygen. Patients will require a catheter to drain the urine from your bladder. A drain may also collect body fluid from the groins and/or the vulva. These will be removed once I am happy that your body functions return to normal and the lymphatic fluid production from the groins slows down.
You will be required to stay in hospital for 5 to 8 days after surgery. I recommend you have a good break for 2-4 weeks following surgery. I particularly recommend avoiding intercourse, vaginal tampons and full baths and other factors that could disrupt wound healing or facilitate an infection.
The final histopathological report may take a few days, and will determine if any further treatment is required. I will discuss the histopathological findings with you and depending on the extent of the cancer I may recommend postoperative radiotherapy to the vulva and/or to the pelvis and the groins. If radiotherapy is required, I will organise and refer you to a radiotherapist.
Please notify me immediately if your condition becomes worse after you have been discharged from hospital.
Surgery always carries risks. Before surgery, I do everything to minimise these risks. Risks that may occur during vulval cancer surgery include:
- Wound infection: The risk of wound infection and wound breakdown is significant especially in older patients with diabetes, in smokers or in obese patients. I prescribe antibiotics before surgery to avoid skin and other infections.
- Lymphedema: When lymph glands are removed, some fluid may accumulate in the legs. The risk of lymphedema is higher in patients who had a lymph node dissection plus radiotherapy.
- Deviation of the urinary stream
- Surgery to the vulva does not affect the ovaries and the hormonal status. The only exemption is if radiotherapy is recommended to the pelvis. In this case the ovaries would certainly become affected. Alternatively, the ovaries could be transposed surgically to bring them out of the radiation field.
- Infections to the bladder, and the lungs which can result in temperatures and septicaemia
- Thromboembolic complications (formation of blood clots) in the legs that can travel to the lungs and cause life-threatening emboli. This risk is very small because of our efforts to minimise them. I prescribe Heparin (blood thinner) or calf compression stockings to prevent the formation of blood clots in the legs.
After treatment, you should be seen regularly for follow-up for at least 5 years. These examinations will include pelvic examinations and sometimes imaging methods if needed.
Cancers of all types and stages may recur. Recurrence may be local (vaginal), in the pelvis or at distant sites (abdomen, lungs). 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.
Survival rates for vulval cancer depend on the initial stage and patient’s age at diagnosis. 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 lymph nodes and 25% to 40% for patients with positive lymph nodes.