Vulva Cancer Treatment
Surgery, Radiation Therapy and Chemo

Vulva Cancer Treatment

Contents

• Introduction
• Determining The Treatment Plan
• Overview Of Surgeries
• Treatment By Cancer Stage
• How Are Recurrent Cancers Treated?
• How Is Vulvar Adenocarcinoma Treated?
• What Is The Treatment For Vulvar Melanoma?

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Guide To Cancer of the Vulva

Introduction

Small early stages of cancer of the vulva, which make up nearly 50 percent of cases, are usually treated by surgery alone. More advanced stages are usually treated with a combination of external radiation therapy and surgery. Surgery can be a relatively minor procedure in which a small tumor and some surrounding tissue are removed. Or it can be highly invasive and extensive involving total removal of the vulva and other surrounding organs. More recent therapy plans are tailoring a combination of surgery, chemo (see Chemotherapy Guide) and radiation according to the type and extent of the disease present. Clinical trials are currently underway into the effects of radiation and chemo before surgery in advanced stages of vulva cancer.

Determining The Treatment Plan

Once you have received a vulva cancer diagnosis and the cancer has been staged (vulva cancer staging) the next part of the process is for your healthcare team to recommend a treatment plan. As cancer is rarely a medical emergency, you will have time to think about your options without feeling hurried. You may even request a second opinion (in fact your health insurance company may insist on this). The type of treatment plan recommended will depend on the stage of your disease but other factors such as your age, general health and individual circumstances will also play a role. The vast majority of vulvar cancers are diagnosed as squamous cell, so we will deal with the treatment options for this type of disease first.

Overview Of Surgeries

Laser Surgery
This uses a laser beam to burn off a layer of vulva skin cells. It is only used for VIN and not invasive cancer. It is usually carried out under general anesthesia. There may be pain for 4 or 5 days after surgery and this can be relieved by using sitz baths and pain relievers.

Excision
This involves removing a section of the vulva skin by cutting (excision). It is also called a wide local excision. If more than a few millimeters are cut it may be called a radical wide local excision or simple partial vulvectomy.

Vulvectomy
This involves removing part of or the entire vulva. A skinning vulvectomy only removes a top layer of skin and is an option for treating extensive VIN (VIN3), but is rarely performed. Removing the entire vulva is known as a simple vulvectomy. A radical vulvectomy can be either partial or complete. A partial procedure involves removing part of the vulva including some deep tissue. A complete radical vulvectomy removes the entire vulva, deep tissues and the clitoris. Fortunately this is rarely needed.

Skin Grafts
Sometimes surgical procedures remove large parts of the vulva which then require skin grafts, using skin from other parts of the body. However, most of the time surgical wounds can be stitched back together. If a graft is needed it may be carried out by the gynecologic oncologist or later by a reconstructive plastic surgeon.

Pelvic Exenteration
This is a radical extensive operation which includes a vulvectomy and usually removal of pelvic lymph nodes, as well as removal of one or more of the following: bladder, lower colon, rectum, uterus, cervix and vagina. What is removed depends on the extent of cancer spread. If the rectum or colon is removed the woman will need to wear a colostomy bag so that fecal waste material can pass out of her body. If the bladder is removed a urostomy bag to collect urine will be needed. As 10 percent of women die during or shortly after this surgery it really is a treatment of last resort. It is more likely to considered in cases of recurrent vulva cancer.

Inguinal Lymph Node Dissection
If vulva cancer spreads to the lymph nodes in the groins, the nodes will have to be removed. This surgical procedure is called inguinal lymph node dissection. Only nodes on the side of the cancer need to be removed, but if cancer is in the middle, both will have to be cut out. Leg swelling (lymphedema) is a common complication of this surgery which is why a suction drain is placed in the incision wound before closing. It remains in place until fluid stops being collected in it.

Sentinel Lymph Node Biopsy
This is a more recent treatment which is sometimes carried out to prevent a lymph node dissection. Sentinel lymph nodes are usually the first to be infected by cancer. If the surgeon removes a sentinel node he can check it for signs of cancer. If it is clear, no further surgery is necessary. If it contains cancer the remaining nodes in the area will need to be removed. This procedure requires skilled surgeons, and some conservative doctors still prefer to carry out a full lymph node dissection for fear of missing cancer. If a lymph node is particularly large a fine needle aspiration (FNA) biopsy or surgical biopsy are alternative procedures.

Treatment of Vulvar Cancer By Stage (Squamous Cell)

Stage 0
Vulvar Intraepithelial Neoplasia, or VIN

Also known as vaginal carcinoma in situ, VIN is considered a precancerous condition. Treatment is based on the extent and location of the disease. It could include any of the following options:

Wide Local Excision: If it is restricted to one small area the suspicious cells are likely to surgically removed.
Topical Chemotherapy: Applying the chemo cream 5-fluorouracil (5-FU) to the affected area used to be a common treatment for VIN but it is used less frequently these days because it causes large painful sores. Imiquimod, another topical cream (but not a chemo drug) is another alternative.
Laser Surgery: This has largely replaced cryosurgery and has a near 100 percent cure rate.
Skinning Vulvectomy: Rarely performed.

Follow-up care for stage 0 is very important because VIN can recur or reappear in different parts of the vulva. The 5 year survival rate however is near to 100 percent. For signs of this disease, see Symptoms of vulva cancer.

Stage 1

There is still a good chance of cure with this stage of the disease. There is no standard procedure which can be applied to all women. First the following factors must be taken into consideration:

• The age of the woman.
• The condition of the healthy part of the vulva. In addition to a tumor is VIN also present?
• If lymph nodes around the tumor have been affected.

If there is only one tumor and no sign of VIN or lymph node infection (stage 1a) then radical local excision is the usual treatment choice, regardless of the woman's age. The tumor is removed along with a 1cm margin of normal tissue for safety around it. This procedure is normally combined with some exploration of the lymph nodes. If VIN or other abnormalities (stage 1b) also occur the treatment may depend on the woman's age. Older women with persistent long-standing symptoms and who are not sexually active may choose a radical vulvectomy. Younger women may choose to have the tumor removed by radical local excision and the remainder of the vulva to be treated by more conservative methods. This may include the use of topical steroids or laser therapy. In both younger and older women lymph nodes in the groin will need to be investigated or removed. A lymph node dissection or a sentinel node biopsy operation can be performed. If the woman is not physically able for the procedure then radiation therapy to the groin area will be given instead. A needle biopsy before radiation will determine if the nodes contain cancer.

Vulva cancer of the clitoris can cause particular problems. Removal of the clitoris may have major emotional and sexual consequences. Also because removal of the clitoris can interfere with lymph drainage in the area it can cause serious swelling. Radiation therapy can be applied to the area as one solution although the skin usually reacts quickly so treatment has to be halted for a few weeks. A radical local excision to remove a tumor may still preserve some of the clitoris.

Stage 2

Cancer has spread to structures near the vulva such as the lower third of the vagina, urethra and/or anus. This stage is usually treated with partial or radical vulvectomy and removal of the lymph nodes of the groin (or a sentinel node biopsy). Radiation therapy to the edges of the tissue removed by surgery may be needed as a follow-up to destroy any possible remaining cancer cells. The procedures may also be reversed, with radiation first and then surgery. Older women who may not be strong enough for surgery may just be treated with radiation. The 5 year survival rate for women without lymph nodes being affected in stage 2 ranges from 70 to 90 percent. This drops to 40 percent if cancer is detected in the nodes.

Stage 3

By this stage cancer has spread to the lymph nodes. Treatment is generally the same as stage 2. Surgery to remove the tumor will be required, either by radical wide local incision or partial/complete radical vulvectomy. The lymph nodes in the groin will also be removed. This is usually followed-up by radiation therapy (with or without chemotherapy). This is done to kill any possible remaining cancer cells and preserve as many of the surrounding structures as possible (vagina, anus etc). Occasionally radiation will be given before surgery in order to reduce the size of the tumor. If the woman is physically unable for surgery radiation, sometimes combined with chemo will be given. The chance of cure, as might be expected with advanced stages of cancer, is lower. The most important indicator is whether or not cancer cells are discovered in the lymph nodes.

Stage 4a

Cancer has spread more extensively to other organs such as the pelvis, rectum, bladder, upper vagina, urethra and/or pelvic bone. Surgery is the key treatment option and the goal is to physically remove as much of the cancer as possible. The extent of the surgery will depend on how far the disease has spread. The most common type of surgery is a radical vulvectomy. Pelvic exenteration is another option, but it is so radical and severe it is rarely performed. Radiation and chemo may also be given before or after surgery. Lymph nodes will be removed by surgery and radiation will be applied to the area. See also Cancer Surgery and Cancer Surgery Recovery.

Stage 4b

Cancer has spread to the lymph nodes and to other organs of the body like the liver or lungs. Surgery may be performed but it is not likely to be a cure. It may be done for palliative reasons, to relieve distressing symptoms such as bladder or bowel problems. Radiation therapy may also help to reduce the tumor size for a while. Patients at this stage usually consider enrolling in cancer clinical trials or using chemotherapy drugs which have not been proven as a treatment for either vulva cancer or cancer of the vagina.

See also:
Alternative Treatments to Cancer
Cancer Diet Foods
What are my chances of surviving? Vulva Cancer Survival Rates.

How Are Recurrent Cancers Treated?

If vulva cancer comes back after treatment it is called recurrent. It can come back to the same spot (local recurrence), the nearby lymph nodes (regional recurrence) or to distant sites (distant recurrence, or metastasis). In the vast majority of cases (80 percent) a recurrence occurs within 2 years of treatment. When it comes to prognosis and outlook for the patient, the sooner it comes back the better. Radiation or radical excision can be applied to a small local recurrence. An extensive return might be treated with radical vulvectomy or pelvic exenteration. If the tumor returns after 2 years a combination of surgery and radiation will be used. If the cancer has spread to other organs chemotherapy and or radiation may be given as palliative therapy. A cure is not expected but treatment focuses on reducing pain and symptoms. The woman will be encouraged to enter clinical trials for experimental treatments.

How Is Vulvar Adenocarcinoma Treated?

If the cancer is not invasive and Paget's disease is present treatment is usually a wide local excision or simple vulvectomy. If adenocarcinoma has invaded a Bartholin gland or vulva skin sweat gland then a partial radical vulvectomy is usually recommended along with removal of the groin lymph nodes (one or both depending on the site of the primary tumor).

How Is Vulvar Melanoma Treated?

This is no different to skin cancers in any other part of the body. They can be quite unpredictable and aggressive. Ideally they are treated with surgery and the regional lymph nodes are also removed.

Next, read about: Vulva Cancer Prevention.

Related Articles on Vulvar Cancers

For more issues, see the following:

• Vaginal cancer treatment: How doctors treat this disease.
• Causes of vulva cancer: Hypertension, diabetes and more.
• What is the best treatment for cancer?

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