Vulvar cancer constitutes approximately 5% of gynecological malignancies. This type of cancer is often seen in the seventies, and due to the increasing lifespan of women, it is becoming more common. Patients often present with complaints of itching and, more rarely, with symptoms such as masses, bleeding, pain, and discharge. Approximately 90% of vulvar cancers are squamous cell carcinoma, while malignant melanoma, Bartholin gland adenocarcinoma, invasive Paget’s disease, basal cell carcinoma, verrucous carcinoma, sarcomas, and metastatic tumors make up the remaining 10%, representing rare types of vulvar cancer. Squamous cell carcinomas rarely spread through lymphatic channels or, more rarely, through neighboring and hematogenous routes. The status of inguinofemoral lymph nodes, associated with this pattern of spread, is the most important prognostic factor and plays a significant role in FIGO staging. The 5-year overall survival rate for patients with bilateral lymph node involvement is approximately 29%, and when pelvic nodes are involved, survival is around 10-15%.
The most important step in the treatment of vulvar cancer is surgical treatment. However, nowadays, considering that vulvar cancer patients are often in the elderly age group, have additional medical conditions, and taking into account the risks associated with surgery, a more individualized treatment approach has come to the forefront, moving away from radical surgery. In early-stage vulvar cancers, the argument for performing the operation through separate incisions has gained importance, and there have been developments in the field of chemoradiotherapy for the treatment of advanced-stage cancers.
Surgical Management of Early-Stage Disease Patients with FIGO stage I disease can be managed with wide local excision if the lesion is unifocal, and the remaining vulva is normal. In early-stage disease, if the disease-free surgical margin is at least 8 mm, the risk of local recurrence is close to zero. Since the tissue contracts and shortens after excision and fixation, the disease-free margin should be at least 15 mm in fresh surgical specimens. If there is widespread intraepithelial neoplasia or lichen, radical vulvectomy or wide local excision can be considered as an option.
Management of Advanced-Stage Disease Approximately 30-40% of vulvar cancer patients are diagnosed with stage III-V disease and are managed with en bloc radical vulvectomy, bilateral inguinofemoral lymphadenectomy, and partial resection of the urethra, vagina, or anus. In such patients, multidisciplinary evaluation is required, involving gynecologic oncologists, plastic surgeons, urologists, colorectal surgeons, radiation oncologists, and medical oncologists.
RADIOTHERAPY The vulvar skin is thin and sensitive, making it less tolerant of radiotherapy. Acute reactions associated with radiotherapy include inflammation, erythema, and dry and wet desquamation. Skin necrosis is much less common with modern radiotherapy techniques. These can hinder the completion of treatment in most patients. Late reactions include thinning of the skin, subcutaneous edema and fibrosis, and narrowing of the introitus.
Content Update Date: December 26, 2022