Vulvar Cancer

Vulvar cancer, the fourth most common gynecologic malignancy, accounts for about 3 to 4% of all gynecologic malignancies in the USA. The average age at diagnosis is about 70 years, and the incidence increases with age.

Vulvar pruritus is the most common presenting symptom, but many patients are asymptomatic. Lesions may appear erythematous and flat, condylomatous, or ulcerated; discharge or local discomfort is often present.

Vulvar dystrophy and other vulvar lesions must be differentiated from malignant lesions. Premalignant lesions may appear as white patches, brown pigmented areas, or granular red lesions. These lesions and all raised or ulcerated lesions should undergo biopsy. Dystrophic lesions (lichen sclerosus) or inflammatory lesions that do not respond within a few weeks to topical corticosteroid therapy should also undergo biopsy. Flat or slightly raised ulcerative lesions should undergo biopsy if they stain blue when swabbed with toluidine blue or if they turn white when swabbed with 3% acetic acid.

Prognosis is generally good for patients with early-stage lesions. The 5-year survival rate is 80 to 90% if lymph node metastasis is absent and 16 to 30% if lymph node metastasis is present.

Treatment of premalignant and malignant lesions is primarily surgical. Most women, even those who are debilitated, can have skin lesions removed under local anesthesia. Extensive condylomatous or in situ lesions are amenable to treatment with wide local excision or laser therapy. Minimally invasive lesions (< 1 mm) can be treated with partial vulvectomy alone.

Topical therapy with cytotoxic drugs (eg, 5% 5-fluorouracil cream) may be useful for some in situ lesions. Although treatment with 5-fluorouracil cream results in complete response in 50% of cases, it often causes vulvar irritation and painful superficial ulceration.

Radical vulvectomy, with unilateral or bilateral inguinal lymphadenectomy, is required for the staging and treatment of larger or deeply invasive tumors. Radiation therapy occasionally has an adjunctive role; preoperative chemotherapy or radiation therapy may make extensive tumors resectable.