GYNECOLOGIC ONCOLOGY
VULVAR CANCER
The vulva is the outer part of the female reproductive organs, which includes the labia majora (outer lips), the labia minora (inner lips) and the clitoris. Vulvar cancer can grow on any of these structures. There are different types of vulvar cancer, which develop from different types of cells in the vulvar region. For instance, squamous cell carcinomas and melanomas develop from vulvar skin cells, whereas adenocarcinoma grows from glandular cells (usually the Bartholin glands at the opening of the vagina which secrete lubricant during sexual stimulation) and sarcoma grows from connective tissue cells. Because vulvar cancers are palpable and visible, they can be diagnosed fairly early, if they are not mistaken for benign growths (such as, for instance, cysts, warts and herpes ulcers, amongst other things). Therefore, if a growth is present in the vulvar region, it is important to obtain a histological analysis and to identify the molecular makeup of the tumor cells.
Risk Factors
The causes for vulvar cancer are not well understood, but there are certain factors that can increase the risk of developing vulvar cancer. These include advanced age, a prior history of cancer, a prior history of benign conditions or precancerous vulvar growths, infection with HPV (human papilloma virus), a weakened immune system (either due to immunosuppressant drugs or due to an immunodeficiency condition such as HIV), or life style choices such as smoking.
Symptoms
Symptoms of vulvar cancer - though they may be confounded with benign and transient lesions - are fairly well recognizable. They include a palpable mass, skin discoloration, pain, itching and irregular bleeding and discharge. If such symptoms occur, it is important to obtain diagnostic work up in order to determine whether they are due to benign changes or signs of vulvar cancer.
Diagnosis
The first step to diagnose vulvar cancer is to obtain a physical exam, often with the help of a colposcope (microscope and light used to examine the vulva, vagina and cervix) - used on the vulva this is called a vulvoscopy. If these are suspicious, a biopsy can be performed, during which a cell sample is removed from the mass for histological analysis. In order to be able to identify the abnormal cells for the biopsy, a chemical agent (acetic acid) or other dye may be applied to the vulvar region prior to the biopsy. Once the tissue sample has been removed, a histological analysis examines the molecular makeup of the cells, thereby determining whether the cells are cancerous (mutated) or not. If the mass is clearly circumscribed, it may be removed entirely for histological analysis (instead of first obtaining a biopsy, thereby reducing the number of procedures necessary). Imaging (X-Ray, CT, MRI, PET) can sometimes be required in order to determine the size and shape of the mass and - in the case of cancer - see whether it has spread through the pelvic area.
Treatments
The main treatment for vulvar cancers is surgery. This can either be an excision of the cancerous mass - if the mass is small enough and sufficiently clearly circumscribed to allow for such an excision including negative margins (an outer boarder of the excised tissue that does not contain cancerous cells - this is done to make sure that no cancer remains behind to form new masses and metastasize to other parts of the pelvis and body). If an excision surgery is not possible, for instance because the mass is to large or has infiltrated an extensive area of the vulva, a partial or total (radical) vulvectomy (removal of the vulva) may have to be performed. Depending on the stage of the cancer, removal of a few or several lymph nodes may also be necessary. To reduce the size of the cancer and make it more easy to remove, radiation therapy and chemotherapy may be used prior to the surgery (neoadjuvant). Radiation and chemotherapy can also be used after the surgery, to reduce the risk of recurrence (adjuvant). Furthermore, immunotherapy is a promising (though still somewhat experimental) new form of treatment that increases the immune system's response to cancer cells, thereby leading to a natural elimination of these cells.