Vulvar Cancer

Key Features

Essentials of Diagnosis

• Two independent pathways for development: HPV or chronic inflammation

• History of prolonged vulvar irritation, with pruritus, local discomfort, or slight bloody discharge

• Early lesions may suggest or include nonneoplastic epithelial disorders

• Late lesions appear as a mass, an exophytic growth, or a firm, ulcerated area in the vulva

• Biopsy is necessary for diagnosis

General Considerations

• The majority of cancers of the vulva are squamous lesions; basal cell carcinomas are also found

• Several subtypes (particularly 16, 18, and 31) of the human papillomavirus (HPV) have been identified in some but not all vulvar cancers

• About 70–90% of vulvar intraepithelial neoplasia (VIN) and 40–60% of vulvar cancers are HPV associated

• Vulvar lichen sclerosus also is associated with an increased risk of developing vulvar cancer

• As with squamous cell lesions of the cervix, a grading system of VIN from mild dysplasia to carcinoma in situ is used

Demographics

• Usually occurs in women over 50 years of age

• The likelihood that a superimposed vulvar cancer will develop in a woman with a nonneoplastic epithelial disorder (vulvar dystrophy) is 1–5%

Clinical Findings

Symptoms and Signs

• Early lesions may suggest or include nonneoplastic epithelial disorders

• Late lesions appear as

  • A mass

  • An exophytic growth

  • A firm, ulcerated area in the vulva

Differential Diagnosis

• Vulvar intraepithelial neoplasia

• Chronic granulomatous lesions (eg, lymphogranuloma venereum, syphilis), condylomas, hidradenoma, or neurofibroma

• Genital warts (condyloma acuminata)

• Lichen sclerosus

• Psoriasis

• Lichen planus

• Epidermal inclusion cysts

• Hidradenomas, or neurofibromas

Diagnosis

Laboratory Tests

• Pathologic examination of biopsies of lesion(s)

Imaging Studies

• Preoperative colposcopy of vulva, vagina, and cervix

• CT or MRI of the pelvis or abdomen is generally not required except in advanced cases for planning therapeutic options

Diagnostic Procedures

• Biopsy is essential for the diagnosis and should be performed with any localized atypical vulvar lesion, including white patches

• Multiple skin-punch specimens can be taken in the office under local anesthesia, with care to include tissue from the edges of each lesion sampled

• Lichen sclerosus and other associated leukoplakic changes in the skin should be biopsied

Treatment

Medications

• A 7:3 combination of betamethasone and crotamiton is particularly effective for itching

• After an initial response, fluorinated steroids should be replaced with hydrocortisone because of their skin atrophying effect

• For lichen sclerosus

  • Apply clobetasol propionate cream 0.05% twice daily for 2–3 weeks, then once daily until symptoms resolve

  • Application one to three times a week ...