In Australia, vulval cancer is uncommon with only 400 women newly diagnosed every year. The incidence of vulval cancer has been rising by 25% since 2002 but its precursors (precancerous stages) have more than doubled. Typically vulval cancer is a disease of postmenopausal women. We distinguish two types:
- 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 a co-factor that often facilitates cancer growth.
- The second type is related to chronic inflammatory (vulval dystrophy) or autoimmune processes mainly in elderly women.
Most patients present with a fleshy, nodular or warty mass, plaque or ulcer on the labia. A biopsy of the lesions needs to be performed to secure a histological diagnosis or to determine if a preinvasive (precursor) lesion is present. Vulval cancer typically spread into groin and pelvic lymph nodes. Prior to treatment a CT scan of the pelvis, abdomen and chest needs to ascertain that the cancer has not spread beyond the vulva.
The vast majority of patients with vulval cancer benefit from surgery. The aim of surgery is to remove all cancerous tissue with a healthy tissue margin. The other aim is to determine the extent of the disease, especially in regards to the groin lymph nodes.
Surgery for vulval cancer will remove parts of the vulva and the lymph nodes in the groins. The extent of surgery is highly individual and will be tailored to the patent’s needs. 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 give an acceptable cosmetic result.
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 lymph node involvement is extremely low. Some patients with early vulval cancer limited to one side of the vulva will only require a groin node dissection on the affected side.
A new technique “sentinel node biopsy” 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.
For surgery, no bowel prep is required. Please fast at least 6 hours prior to surgery. Please stop smoking before the operation as it makes your postoperative management much easier. The procedure requires general anaesthesia.
The procedure is usually takes 2 to 3 hours. The incision on the vulval is highly individual but the incision for the groin node dissection will almost always be below and parallel to the inguinal crease.
When you wake up from general anaesthesia there will be some lines running in and out of you. A drip will give you the necessary fluids, a catheter will drain the urine from your bladder an oxygen mask will supply oxygen to the respiratory system. A drain may collect body fluid from the groins and/or the vulva. These lines will be removed once I am happy that your body functions return to normal and the lymphatic fluid production from the groins slows down.
The final histopathological report may take a few working days. It forms the basis for the decision if any further treatment is required. I will discuss the histopathological findings with you and sometimes I will recommend postoperative radiotherapy to the vulva and/or to the pelvis and the groins. If radiotherapy is required I will discus and make contact with the radiotherapist.
Surgery always carries risks. Before surgery, I do everything to minimise these risks. I give antibiotics before I do the incision in order to avoid skin and other infections. Commencing prior to surgery I give Heparin or calf compression stockings in order to prevent the formation of blood clots in the legs. At surgery sterile handling of instruments further reduces the risk of infectious complications. However, there are some immanent risks of surgery for vulval cancer:
- Wound healing: Especially in older patients with diabetes mellitus, in smokers or in obese patients the risk of wound infection and wound breakdown is significant.
- Lymph oedema: Lymphatic fluid usually drains from the legs via the lymph glands into the groin and from there into pelvis and the aorta back into the blood circulation. When lymph glands had to be removed, some fluid may accumulate in the legs. The risk of lymph oedema is high in patients who had to have 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.
- Other possible adverse events include ...
- Infections to the bladder, the abdominal wound, the lungs with resulting temperatures and septicaemia
- Thromboembolic complications (formation of blood clots) in the legs that can even travel to the lungs and cause life-threatening emboli. This risk is very small because of our efforts to minimise them.
You need to stay in hospital for 6 to 8 days. I recommend you have a good break for the two to four weeks. Especially I recommend avoiding intercourse, vaginal tampons and full baths and other factors that could disrupt wound healing or facilitate an infection.
Please notify me immediately if your condition becomes worse after you have been discharged from hospital.
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 on a daily basis and will be complemented by weekly chemotherapy doses. If this treatment is the best treatment available, I will refer my patient to appropriate specialists I work regularly with and who have a specific interest in the treatment of cervical cancer.
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.
Outcomes: 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 nodes and 25% to 40% for patients with positive nodes.