The Farber Center: For Radiation Oncology

Vulvar cancer is a rare disease in which cancer cells form in the tissues of the vulva.
Vulvar cancer forms in a woman's external genitalia. The vulva includes the inner and outer lips of the vagina, the clitoris, and the opening of the vagina and its glands.
Vulvar cancer usually develops slowly over a period of years. Abnormal cells can grow on the surface of the vulvar skin for a long time. This precancerous condition is called vulvar intraepithelialneoplasia (VIN) or dysplasia. Because it is possible for VIN or dysplasia to develop into vulvar cancer, treatment of this condition is very important.

Vulvar cancer often does not cause early symptoms. When symptoms occur, they may be caused by vulvar cancer or by other conditions.

• A lump in the vulva.
• Itching that does not go away in the vulvar area.
• Bleeding not related to menstruation (periods).
• Tenderness in the vulvar area.

Risk Factors

• HPV Having human papillomavirus infection.
• Older age:The risk of vulvar cancer increases with age, though it can occur at any age. The average age at diagnosis is 65.
• Being infected with the human immunodeficiency virus (HIV). This sexually transmitted virus weakens the immune system, which may make you more susceptible to HPV infections, thereby increasing your risk of vulvar cancer.
• Having a history of precancerous conditions of the vulva. Vulvar intraepithelial neoplasia is a precancerous condition that increases the risk of vulvar cancer. Most women with vulvar intraepithelial neoplasia will never develop cancer, but a small number do go on to develop invasive vulvar cancer. For this reason, your doctor may recommend treatment to remove the area of abnormal cells and periodic follow-up checks.
• Having a skin condition involving the vulva. Lichen sclerosus, which causes the vulvar skin to become thin and itchy, increases the risk of vulvar cancer.

Examining your vulva. Your doctor may conduct a physical exam of your vulva to look for abnormalities.

Using a special lens to examine your vulva. During a colposcopy exam, your doctor uses a device that works like a magnifying glass to closely inspect your vulva for abnormal areas.

Removing a sample of tissue for testing (biopsy). To determine whether an area of suspicious skin on your vulva is cancer, your doctor may recommend removing a sample of skin for testing. During a biopsy procedure, the area is numbed with a local anesthetic and a scalpel or other special cutting tool is used to remove all or part of the suspicious area. Depending on how much skin is removed, you may need stitches.

Imaging tests. Images of your chest or abdomen may show whether the cancer has spread to those areas. Imaging tests may include X-ray, computerized tomography (CT) and magnetic resonance imaging (MRI).

STAGING (AJCC)

Stage 0 (Carcinoma in Situ)
Abnormal cells are found on the surface of the vulvar skin. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Stage I
Cancer has formed and is found in the vulva only or in the vulva and perineum (area between the rectum and the vagina). The tumor is 2 centimeters or smaller and has spread to tissue under the skin. Stage I vulvar cancer is further divided into stage IA and stage IB.

• Stage IA: The tumor has spread 1 millimeter or less into the tissue of the vulva.
• Stage IB: The tumor has spread more than 1 millimeter into the tissue of the vulva.

Stage II
Cancer is found in the vulva or the vulva and perineum (space between the rectum and the vagina), and the tumor is larger than 2 centimeters.

Stage III
Vulvar cancer, the cancer is of any size and either:

• Is found only in the vulva or the vulva and perineum and has spread to tissue under the skin and to nearby lymph nodes on one side of the groin; or
• Has spread to nearby tissues such as the lower part of the urethra and/or vagina or anus, and may have spread to nearby lymph nodes on one side of the groin.

Stage IV

• Stage IVA: Cancer has spread to nearby lymph nodes on both sides of the groin, or has spread beyond nearby tissues to the upper part of the urethra, bladder, or rectum, or has attached to the pelvic bone and may have spread to lymph nodes.
• Stage IVB: Cancer has spread to distant parts of the body.

LASER THERAPY
a cancer treatment that uses a laser beam to kill cancer cells.

SURGERY
the most common treatment for cancer of the vulva. The goal of surgery is to remove all the cancer without any loss of the woman's sexual function. One of the following types of surgery may be done:

• Wide local excision: A surgical procedure to remove the cancer and some of the normal tissue around the cancer.
• Radical local excision: A surgical procedure to remove the cancer and a large amount of normal tissue around it. Nearby lymph nodes in the groin may also be removed.
• Vulvectomy: A surgical procedure to remove part or all of the vulva:
• Skinning vulvectomy: The top layer of vulvar skin where the cancer is found is removed. Skin grafts from other parts of the body may be needed to cover the area.
• Simple vulvectomy: The entire vulva is removed.
• Modified radical vulvectomy: The part of the vulva that contains cancer and some of the normal tissue around it are removed.
• Radical vulvectomy: The entire vulva, including the clitoris, and nearby tissue are removed. Nearby lymph nodes may also be removed.
• Pelvic exenteration: A surgical procedure to remove the lower colon, rectum, and bladder. The cervix, vagina, ovaries, and nearby lymph nodes are also removed. Artificial openings (stoma) are made for urine and stool to flow from the body into a collection bag.

It may be necessary to have radiation or chemotherapy or both after surgery. Also, if surgery is not an option, radiation therapy, often with chemotherapy is used as primary treatment.

RADIATION THERAPY
is the use of high-dose X-rays to destroy cancer cells and shrink tumors.
Radiation may come from a machine outside the body (external radiation therapy).
Radiation may come from the placement a radiation source inside the body (internal radiation therapy, or brachytherapy).

CHEMOTHERAPY
is the use of medicine to destroy cancer cells. Chemotherapy is called a systemic treatment because the medicines enter the bloodstream, travel through the body, and can destroy cancer cells that may have escaped the vagina. Chemotherapy is often used in combination with radiation after surgery or as primary treatment.

Possible Treatment Side Effects
Dr. Farber, Dr. Spierer, and their staff at The Farber Center for Radiation Oncology will discuss potential side effects with you before, during, and after treatment, and ensure that your experience is personalized.