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Surgical Treatment of Vulvar Cancer

Vulvar cancer is a rare disease in which malignant (cancer) cells form in the tissues of the vulva. Vulvar cancer forms in a woman's external genitalia. The vulva includes the inner and outer lips of the vagina, the clitoris (sensitive tissue between the lips), and the opening of the vagina and its glands.

Vulvar cancer most often affects the outer vaginal lips. Less often, cancer affects the inner vaginal lips or the clitoris. Vulvar cancer usually develops slowly over a period of years. Abnormal cells can grow on the surface of the vulvar skin for a long time. This precancerous condition is called vulvar intraepithelial neoplasia (VIN) or dysplasia. Because it is possible for VIN or dysplasia to develop into vulvar cancer, treatment of this condition is very important.


Different Types

Vulvar cancer is classified according to its cell of origin. This can include:

  • Squamous Cell Carcinoma - Originating in the skin cells. This type accounts for about 90 per cent of cases.

  • Melanoma - Originating in the pigment cells deeper in the skin. This type accounts for about five per cent of cases.

  • Adenocarcinoma - Originating from the Bartholin’s glands, the structures that supply lubricant. This type accounts for less than one per cent of cases.

  • Sarcoma - Originating from fat cells. This type is quite rare.

  • Lymphoma - Originating from the immune cells. This type is quite rare.

  • Basal Carcinoma - A form of skin cancer. This type is quite rare.


Signs and Symptoms

In most cases, vulvar cancer causes early symptoms. Therefore, if you experience any of the symptoms of the condition, you should visit your doctor immediately. Common symptoms of vulvar cancer may include:

  • Vulvar itching that lasts more than one month

  • A cut or sore on the vulva that won't heal

  • A lump or mass on the vulva

  • Unexplained vulvar pain

  • Bleeding from the vulva that is different from your usual monthly bleeding

  • Burning in the area that lasts even after your doctor has treated the burning

  • Any change in size, color or texture of a birthmark or mole in the vulvar area


Causes and Risk Factors

Although researchers have yet to pinpoint the exact causes of vulvar cancer, they have identified known risk factors for the disease. Vulvar cancer risk factors include:

  • being infected with the human papillomavirus (HPV)

  • being infected with HIV

  • having lichen sclerosis, a skin condition that affects the vulva

  • smoking

  • family history of melanoma

  • being 70 or over (vulvar cancer, however, can be diagnosed in younger women)


Diagnosis

A gynecological examination will be used to observe the suspected area. During this examination, the physician may use a special magnifying instrument called a colposcope to view the area better. Additionally, the area may be treated with a dilute solution of acetic acid, which causes some abnormal areas to turn white, making them easier to see. During this examination, if any area is suspected of being abnormal, a tissue sample (biopsy) will be taken. The biopsy can be performed in the doctor's office with the use of local anesthetic. A wedge-shaped piece of tissue, which contains the suspect lesion with some surrounding normal skin and the underlying skin layers and connective tissue, will be removed. Small lesions will be removed in their entirety (excisional biopsy). The diagnosis of cancer depends on a microscopic analysis of this tissue by a pathologist.

The diagnosis for vulvar cancer will determine how advanced the cancer is and how much it has spread. This is determined by the size of the tumor and how deep it has invaded the surrounding tissue and organs, such as the lymph nodes. It will also be determined if the cancer has metastasized, or spread to other organs. Tests used to determine the extent of the cancer include x ray and computed tomography scan (CT scan). Endoscopic examination of the bladder (cystoscopy) and/or rectum (proctoscopy) may be performed if it is suspected that the cancer has spread to these organs.


Vulvar Cancer Stages 

The three ways that cancer spreads in the body are:

  • Through tissue. Cancer invades the surrounding normal tissue.

  • Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.

  • Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.


The following stages are used for vulvar cancer:

  • Stage I describes a small tumor that is confined to the vulva or the area of skin between your vaginal opening and anus (perineum). This cancer hasn't spread to your lymph nodes or other areas of your body.

  • Stage II tumors are those that have grown to include nearby structures, such as the lower portions of the urethra, vagina and anus.

  • Stage III cancer has spread to lymph nodes.

  • Stage IVA signifies a cancer that has spread more extensively to the lymph nodes, or that has spread to the upper portions of the urethra or vagina, or that has spread to the bladder, rectum or pelvic bone.

  • Stage IVB is a cancer that has spread (metastasized) to distant parts of your body.


How your surgeon decides which operation you need?

Different types of surgery can be used to treat cancer of the vulva. Which operation you have will depend on the stage of your cancer. Your surgeon will take into account

  • The spread of the cancer - how large an area is affected

  • The depth of the cancer - the surgeon must remove all the cancer together with a border of healthy tissue round it

  • Whether the cancer is likely to have spread to the lymph nodes in your groin

Your surgeon will want to try to leave as much normal skin as possible, while making sure that the cancer is completely taken away. Making sure all the cancer is removed is the most important factor in trying to cure the cancer. Many women are cured of their vulval cancer with surgery.


Before your Operation

  • If you smoke try to give up or cut down before your operation. This will help to reduce your risk of chest problems and will help your wound to heal after the operation. Your family doctor can give you information, help and support if you want to give up smoking.

  • You are usually admitted to hospital a day before your operation, but some women who have very small early stage cancers may have their surgery and go home on the same day or the following day. You will be given special elastic stockings (TED stockings) to wear during and after the surgery  to prevent blood clots forming in your legs.

  • A member of the surgical team will discuss the operation with you. You will also be visited on the ward by the doctor who will give you your anaesthetic (the anaesthetist).


Vulvar Cancer Treatment

Different types of treatments are available for patients with vulvar cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.


Four types of standard treatment are used:

Laser Therapy : Laser therapy is a cancer treatment that uses a laser beam (a narrow beam of intense light) to kill cancer cells.

Surgery : Surgery is the most common treatment for cancer of the vulva. The goal of surgery is to remove all the cancer without any loss of the woman's sexual function. One of the following types of surgery may be done:

  • Wide Local Excision - A surgical procedure to remove the cancer and some of the normal tissue around the cancer

  • Radical Local Excision - A surgical procedure to remove the cancer and a large amount of normal tissue around it. Nearby lymph nodes in the groin may also be removed

  • Vulvectomy - A surgical procedure to remove part or all of the vulva:

  • Skinning vulvectomy - The top layer of vulvar skin where the cancer is found is removed. Skin grafts from other parts of the body may be needed to cover the area.

  • Simple vulvectomy - The entire vulva is removed.

  • Modified radical vulvectomy - The part of the vulva that contains cancer and some of the normal tissue around it are removed.

  • Radical vulvectomy - The entire vulva, including the clitoris, and nearby tissue are removed. Nearby lymph nodes may also be removed.

  • Pelvic Exenteration - A surgical procedure to remove the lower colon, rectum and bladder. The cervix, vagina, ovaries, and nearby lymph nodes are also removed. Artificial openings (stoma) are made for urine and stool to flow from the body into a collection bag.

Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may have chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.


Radiation Therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. Radiation therapy may be used before surgery to shrink the size of the tumor or after surgery to destroy any remaining cancer cells. The most common type of radiation treatment is called external-bean radiation therapy, which is radiation given from a machine outside the body.When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy.

General side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most of these side effects go away soon after treatment is finished. Specific side effects may include narrowing of the vagina, damage to healthy vaginal tissue, and irritation of the intestines. The vagina may shorten and narrow so much that sexual intercourse is not possible. To prevent this, the vagina may need to be stretched with a plastic tube called a vaginal dilator several times a week.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, a body cavity such as the abdomen, or onto the skin, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Prevention and Early Detection

All women should have an annual gynecologic examination. During this exam, the doctor will take a family medical history and perform a general physical examination of the pelvis, during which the doctor will feel a woman’s uterus, vagina, cervix, and other reproductive organs to check for any unusual changes. Regular pelvic examinations can help detect cancer or precancerous conditions at an early stage. In addition, research has shown that certain factors can help prevent vulvar cancer.

  • Delaying first sexual intercourse until the late teens or older

  • Avoiding sexual intercourse with multiple partners

  • Avoiding sexual intercourse with someone who has had many partners

  • Practicing safe sex, including condom use (although condoms cannot fully protect against HPV)

  • Having regular gynecologic examinations to find and treat precancerous conditions

  • Not starting to smoke

  • Quitting smoking, if a smoker


Recurrent Vulvar Cancer

Recurrent vulvar cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the vulva or in other parts of the body.


Treatment Options for Recurrent Vulvar Cancer

It is important to have regular follow-up exams to check for recurrent vulvar cancer. Treatment of recurrent vulvar cancer may include the following:

  • Wide local excision with or without radiation therapy.

  • Radical vulvectomy and pelvic exenteration.

  • Radiation therapy and chemotherapy given during the same period of time, with or without surgery.

  • Radiation therapy followed by surgery or chemotherapy.

  • Radiation therapy as palliative treatment to relieve symptoms and improve quality of life.

  • A clinical trial of a new treatment.

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