Atlas of pathophysiology, 2 Edition

Part II - Disorders

Vulvar Cancer

Cancer of the vulva accounts for approximately 4% of all gynecologic malignancies.

Age Alert

Vulvar cancer can occur at any age, even in infants, but its peak incidence is after age 60.

The most common vulvar cancer is squamous cell carcinoma. Early diagnosis increases the chance of effective treatment and survival. If lymph node dissection reveals no positive nodes, 5-year survival rate is 90%; otherwise, 50% to 60%.

Causes

Primary cause unknown

Predisposing factors

·   Leukoplakia (white epithelial hyperplasia), in about 25% of patients

·   Chronic vulvar granulomatous disease

·   Chronic pruritus of the vulva, with friction, swelling, and dryness

·   Pigmented moles that are constantly irritated by clothing or perineal pads

·   Irradiation of the skin such as nonspecific treatment for pelvic cancer

·   Infection with human papilloma virus

·   Obesity, hypertension, diabetes

Pathophysiology

Vulvar neoplasms may arise from varying cell origins. Because much of the vulva is made of skin, any type of skin cancer can develop there. The majority of vulvar cancers arise from squamous epithelial cells.

Signs and symptoms

In 50% of patients

·   Vulvar pruritus, bleeding

·   Small vulvar mass—may begin as small ulcer on the surface, which eventually becomes infected and painful

Less common

·   Mass in the groin

·   Abnormal urination or defecation

Diagnostic test results

·   Colposcopy and toluidine-blue staining identify biopsy sites.

·   Histologic examination of biopsy samples confirm diagnosis and identify the type of cancer.

Treatment

Small, confined lesions with no lymph node involvement

·   Simple vulvectomy or hemivulvectomy (without pelvic node dissection):

§  Personal considerations (young age of patient, active sexual life) may mandate such conservative management

§  Requires careful postoperative follow-up because it leaves the patient at risk for developing a new lesion

For widespread tumor

·   Radical vulvectomy

·   Radical wide local excision—can be as effective as more radical resection, but with much less morbidity

·   Depending on extent of metastasis, resection may include the urethra, vagina, and bowel, leaving an open perineal wound until healing—about 2 to 3 months

·   Plastic surgery, including mucocutaneous graft to reconstruct pelvic structures

·   Radiation therapy

Extensive metastasis, advanced age, or fragile health

·   Rules out surgery

·   Palliative treatment with irradiation of the primary lesion or chemotherapy

P.349

CARCINOMA OF THE VULVA

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