Vulvar Cancer
Vulvar cancer refers to an abnormal, cancerous growth in the external female genitalia.
Vulvar cancer is a rare disease that occurs mainly in elderly women. The vulva refers to the external female genitalia, which includes the labia (Latin for lips), the opening of the vagina, the clitoris, and the space between the vagina and anus (perineum). Vulvar cancer can affect any part of the female genitalia, but usually affects the labia. There are two pairs of labia. The labia meet to protect the openings of the vagina and urethra (the tube that connects to the bladder). The outer, most prominent folds of skin are called labia majora, and the smaller, inner skin folds are called labia minora.
Most vulvar cancers are squamous cell carcinomas. Squamous cells are the main cell type of the skin. Squamous cell carcinoma often begins at the edges of the labia majora or labia minora or the area around the vagina. This type of cancer is usually slow growing and may begin with a precancerous condition referred to as vulvar intraepithelial neoplasia (VIN), or dysplasia. This means that precancerous cells are present in the surface layer of skin.
Other, less common, types of vulvar cancer are melanoma, basal cell carcinoma, adenocarcinomas, Paget's disease of the vulva, and tumors of the connective tissue under the skin. Melanoma, a cancer that develops from the cells that produce the pigment that determines the skin's color, can occur anywhere on the skin, including the vulva. It is the second most common type of vulvar cancer, and accounts for about 4% of cases. Basal cell carcinoma, which is the most common type of cancer that occurs on parts of the skin exposed to the sun, very rarely occurs on the vulva. Adenocarcinomas develop from glands, including the glands at the opening of the vagina that produce a mucus-like lubricating fluid.
Vulvar cancer is most common in women over 50 years of age. Additional risk factors for vulvar cancer include having multiple sexual partners, cervical cancer, and the presence of chronic vaginal and vulvar inflammations. This type of cancer is often associated with sexually transmitted diseases.
Cancer is caused when the normal mechanisms that control cell growth become disturbed, causing the cells to continually grow without stopping. This is usually the result of damage to the DNA in the cell. Studies have indicated several risk factors for vulvar cancer that include:
- Infection with human papillomavirus (HPV). This virus is a sexually transmitted disease that can cause genital warts.
- Cigarette smoking. Smoking in combination with HPV was found to be a particularly strong risk factor for vulvar cancer.
- Infection with human immunodeficiency virus (HIV). This virus, associated with AIDS, decreases the body's immune ability, leaving it vulnerable to a variety of diseases, including vulvar cancer.
- Herpes virus. This sexually transmitted virus (HSV2) is also associated with increased risk for vulvar cancer.
- Chronic vulvar inflammation. Long term irritation and inflammation of the vulva and vagina, which may be caused by poor hygiene, can increase the risk of vulvar cancer.
- Vulvar intraepithelial neoplasia (VIN). This abnormal growth of the surface cells of the vulva can sometimes progress to cancer.
If squamous cell vulvar cancer is present, it may appear as a raised red, pink, or white nodule. It is often accompanied by itching, pain, bleeding, vaginal discharge, and painful urination. Malignant melanoma of the vulva usually appears as a pigmented, ulcerated growth. Other types of vulvar cancer may appear as a distinct mass of tissue, sore and scaly areas, or cauliflower-like growths that look like warts. Any abnormalities should be reported to a gynecologist for examination.
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 see the area better. Additionally, the area may be treated with a dilute vinegar solution, 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 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, which means it has spread to other organs. This part of the diagnosis will be described by rating the cancer as stage I, II, III, or IV; with I being the least severe and IV being the most severe. Tests used to determine the stage include x ray and computed tomography scan (CT scan).
Treatment for vulvar cancer will depend on its stage and the patient's general state of health. The primary treatment for vulvar cancer is surgery to remove the affected vulvar area and possibly the associated lymph nodes. The surgery may be done by laser, to burn off a minimal amount of tissue, or scalpel, to remove more of the tissue. The choice will depend on the severity of the cancer. If a large area of the vulva is removed, it is called a vulvectomy. A vulvectomy may require skin grafts from other areas of the body to cover the wound. Surgery may also be followed by chemotherapy and radiation therapy to kill additional cancer cells. All three of these procedures have risks associated with them, which should be discussed with the care giver.
Survival depends strongly on how advanced the disease is, meaning what stage it is in. If diagnosed and treated early, the 5-year survival rate is 91%, it drops to only 15% in the advanced stage (stage IV).
The risk of cancer of the vulva can be decreased by reducing the risk factors for the cancer, most of which involve lifestyle factors. Specifically, to reduce the risk of vulvar cancer, women should not smoke and should refrain from engaging in risky sexual behavior. Good hygiene of the genital area to prevent infection and inflammation may also reduce the risk of vulvar cancer.
Regular gynecological examinations are necessary to detect precancerous conditions that can be treated before the cancer becomes invasive. Since some vulvar cancer is a type of skin cancer, the American Cancer Society also recommends self-examination of the vulva using a mirror. If moles are present in the genital area, use the ABCD rule:
- Asymmetry. A cancerous mole may have two halves of unequal size.
- Border irregularity. A cancerous mole may have ragged or notched edges.
- Color. A cancerous mole may have variations in color.
- Diameter. A cancerous mole may have a diameter wider than 6 millimeters (1/4 inch).
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