vulva cancer and vulval surgery

The vulva is the area of skin between a woman’s legs and makes up the outside part of the genital organs. It includes two outside lips (labia majora) typically covered in pubic hair and surround two
inner lips (labia minora).

The front of the vulva includes a small structure known as the clitoris, behind this is the urethra (the outlet for urine to pass) and further below is the vaginal opening.

The anus is not part of the vulva. In between the vaginal opening and anus is a smooth area of skin known as the perineum.

All of these areas are visible on the outside of the body.

Cancer is the uncontrolled growth of cells which are located in organs and tissues around the body. Normally cells divide themselves in an orderly controlled way, but sometimes this process can become out of control and the cells continue to divide developing a lump. This is also known as a tumour. Tumours can be either benign (non cancerous) or malignant (cancerous). Your doctor will be able to tell you whether the tumour is cancerous or not.

Cancer of the vulva is rare, on average 1,100 women are diagnosed with it each year in the UK. The majority of women are aged over 60, but an increasing number of younger women are now being diagnosed is on the increase continually. Vulval cancer can occur on any part of the vulva, but the inner edges of the labia majora and labia minora are the most common areas for it to develop.

Vulval cancers are normally categorised:

• Squamous Cell Carcinoma  9 out of 10 vulval cancers (90%) develop in the skin of the vulva from cells called squamous cells. This type of cancer usually takes years to develop and usually begins with pre cancerous changes to the vulval cells which over the years slowly change into cancerous cells
• Vulval Melanoma  This is the second most common type of vulval cancer. 4 out of 100 vulval cancers (4%) are melanoma and they develop from the pigment producing cells which give our skin its colour. Vulval melanoma typically looks like a dark patch on the vulva
• Verrucous Carcinoma  This is a rare slow growing squamous cell carcinoma that looks like a large wart
• Adenocarcinoma  This again is very rare and develops from cells that line the glands in the vulva
• Basal Cell Carcinoma  This type of cancer rarely affects the vulva. It develops from cells called basal cells which are found in the deep layer of the vulval skin. This is a slow growing cancer and almost never spreads anywhere else
• Sarcoma  This is one of the rarest cancers and develops from the cells found in tissues such as muscle and fat. They tend to grow more quickly then other vulval cancers.

There are a number of factors associated with vulval cancer. These include:

• Age  This risk develops with age, about 8 in 10 women (80%) who are diagnosed are over the age of 60
• Vulval skin conditions  Women who suffer from non cancerous vulval skin conditions are at a higher risk of developing vulval cancer. The two main types are: vulval lichen sclerosus and vulval lichen planus. 3-5 / 100 women (3-5%) who have lichen sclerosus can develop vulval cancer over time
• Human Papilloma Virus (HPV)  This is a very common infection usually passed during sexual intercourse. Most women with this infection do not have any problems as the body gets rid of the virus quickly, but in a number of women the virus remains and can lead on to abnormal changes in the vulva and surrounding skin
• Vulval Intraepithelial Neoplasia (VIN)  A pre-cancerous condition that can occur in the skin surrounding the vulva. Though in some women VIN can develop into vulval cancer. There are two categories: VIN usual type and VIN differentiated. VIN usual is interlinked with HPV infection and majority of women affected are under the age of 50. VIN differentiated is interlinked with linchen sclerosus and generally affects women over the age of 50
• Smoking  This increases a women’s risk of vulval cancer as smoking affects the way your immune system works and makes it less effective to fight infection. This could interlink with the HPV infection increasing chances of vulval cancer
• Pagets Disease  A condition that causes abnormal changes to the cells that cover the skin around the vulva. This is rare and usually only affects women who have been through the menopause.

You may experience some or all of these symptoms:

• Itching, burning or soreness of the vulva
• Lump, swelling or wart like growth of the vulva
• Red, white, dark patches on the skin of the vulva
• Thickened raised skin of the vulva
• Bleeding, or blood stained vaginal discharge not related to periods
• Pain when passing urine
• Tenderness or pain in the vulval area
• Sore or ulcerated area
• Mole on the vulva that changes shape or colour

Some of these symptoms occur due to other conditions and may not be cancer related.

Cancer of the vulva can take time to develop and like other cancers it is easier to treat/cure if diagnosed at an early stage.

A range of tests and investigations may be carried out by your GP prior to them referring you onto a specialist (gynaecologist) although you may expect the following to occur:

• Vaginal Examination  This is when the doctors examine your vulval area visually
• Biopsy  This is known as the most reliable way to test for cancer and is where the doctor takes a small sample of the tissue from the abnormal area and sends to the laboratory to be examined under
  the microscope
• Blood tests  this can include tests for your general health, see what levels your blood cells run at (full blood count) and check the liver and kidney function
• Chest X-Ray  to see whether your lungs and heart are healthy
• MRI Scan  this test uses magnetism for a more detailed picture of particular areas of your body
• PET Scan  A test to see if the cancer has spread using glucose to measure the activity of cells in different parts of the body.

Your cancer will be graded like other cancers and this will aid your doctor to know what the most appropriate treatment is for you. Grading usually happens from biopsies and they refer to the appearance of cells underneath the microscope.

• Grade 1 (Low)  The cancer looks like normal cells of the vulva growing slowly
  
• Grade 2 (Moderate)  The cells look more abnormal then grade 1 but not as abnormal then grade 3
• Grade 3 (High)  The cells look very abnormal. They grow very quickly and more likely to spread.

Staging is a term used to describe the cancer size and whether it has spread beyond where it had initially started.

The commonly used system for staging is below:

• Stage 1  The cancer is localised in the vulva and/or perineum only
• Stage 2  The cancer is any size and has spread to nearby areas (urethra, vagina and/or anus)
• Stage 3  The cancer has spread into the lymph nodes located on either side of your groin
• Stage 4  The cancer has spread to the lymph nodes in the pelvis and/or other areas of the body further away.