Vulvar cancer begin when cells in the vulva change and start to grow out of control. Out of control growth will result into development of mass called tumor. Tumor can either be benign or malignant. Benign tumor is the one is the one that is enclosed in one area and cannot spread to other parts of the body. Malignant tumor is the one that is not enclosed and can spread to other parts of the body. Malignant tumor is also called cancer.
Vulva is the external sexual organ (genitals) of a woman. It is made up of soft and fatty tissues. Vulva is made up of four main parts;
• Labia majora. Labia is a Latin word for lips. Labia majora are the two large outer lips surrounding the vulva.
• Labia minora. These are inner lips surrounding the vulva.
• Clitoris. This is a main sexual arousal organ in women. It is located at the point where the two labia minora meet.
• Bartholin glands. These are two small gland located at the opening of the vagina. Bartholin gland secret mucus that lubricate vagina.
Types of vulvar cancer
Vulvar cancer is divided into several types depending on the cells from which cancer develop. Types of vulvar cancer include the following;
• Squamous cell carcinoma. Squamous cells carcinoma of vulva develop from thin, flat (squamous) cells from the lining of vulva. This is the most common type of vulvar cancer in Tanzania.
• Adenocarcinoma. Adenocarcinoma of vulva develop from mucus producing cells (Bartholin gland) located in vaginal opening.
• Melanoma. Melanoma of vulva develop from cells that gives skin of the vulva its color (melanocytes).
• Sarcomas. These develop from muscles, fat and other connective tissues under the skin in the vulva. Once it develop, it has tendency of growing faster than other type of vulvar cancer.
Risk factors for vulvar cancer
When it comes to cancer, anything that increases your probability of developing cancer is called a risk factor. Risk factors only influence development of cancer but it does not directly cause cancer. Sometimes people with risk factors do not develop the disease while those with no risk factors do develop the disease. Knowing risk factors will help you live your life making some better healthy choices to reduce the risk. Risk factors of vulvar cancer include the following;
• Age. Vulvar cancer is more common in older women and the risk increase as the age increase.
• Vulva intraepithelial neoplasia (VIN). This is the precancerous condition that cause changes in the surface layer of vulva skin. Although this condition can disappear on its own, most women with VIN require treatment. This condition can sometime change into cancer.
• Human papilloma virus infection. There are various types called strains of Human papilloma virus (HPV). Some studies link infection with some strains of this virus with development of vulvar cancer. Although infection with this virus can be highly associated with development of cancer, but not always infections with this virus lead to development of cancer. Sexual activity with someone who has HPV is the most common way to get HPV.
• Smoking. Cigarette smoke has many chemicals with potential of causing cancer, so, a smoking woman is at increased risk of developing cancer including vulvar cancer than non-smoking ones. Chemicals from cigarettes do not only affect lungs. These harmful substances can be absorbed into the lining of the lungs and spread throughout the body. Among women who have a history of HPV infection, smoking further increases the risk of developing vulvar cancer.
• Lichen sclerosus. This is a skin disorder that affect the vulva making it thin and itchy. This condition increase the risk of a woman to develop cancer of vulva.
• Immune system deficiency. Weakened immune system increases chance for a woman to develop vulvar cancer. This Women who have had an organ transplant or who have human immunodeficiency virus (HIV) may be at higher risk of developing vulvar cancer because their immune system is not working normally.
Prevention of vulvar cancer
To prevent something you need first to know what causes it. Since the specific cause of vulvar cancer is still unknown, currently there is no proven way of completely preventing development of this cancer but there are some ways that may help reduce the risk of developing it. The following may help reduce the risk of developing vulva cancer;
• Taking HPV vaccine. Since HPV infection can lead to development of vulva cancer, taking HPV vaccine will help to reduce the risk of developing vulvar cancer.
• Using condoms. Using condom will help to protect you against HIV infection and will provide some protection against HPV although condom cannot completely protect you against HPV.
• Avoid having multiple sexual partners. This will help reduce chance of contacting HPV at some point in your life.
• Avoid smoking. Since smoking increase chances of a woman to develop vulva cancer, then the right choice will be to avoid smoking.
Early detection and screening
When it comes to cancer, early detection normally provide better treatment outcome. If vulva cancer is found early, chances for better treatment outcome are very high. For most cancers, early detection has been greatly contributed by the presence of screening processes. Screening is the process of running some tests to someone with no symptoms of the disease with the intention of determining presence or absence of the disease. Early detection of vulva cancer has been greatly contributed by regular pelvic exams and reporting to the doctor upon experiencing any signs or symptoms of vulvar cancer. If any abnormality is noticed during these regular pelvic examinations, your doctor will recommend for more tests to figure out what is wrong. Normally this involves being referred to a specialist known as gynecologist.
Signs and symptoms of vulvar cancer
People with vulvar cancer tend to experience some of the following symptoms. Sometimes those signs and symptoms may be as result of other medical conditions that is not cancer. Therefore, it is advised to go to the hospital upon experiencing any of the symptoms. The signs and symptoms of vulvar cancer include the following;
• Persistent Itching in the vulva
• A lump, swelling or wart-like growth on the vulva
• Burning pain when passing urine
• Thickened, raised skin patches (may be red, white or dark brown)
• A mole on the vulva that changes shape or color
• Hard or swollen lymph nodes in the groin area.
• Bleeding or discharge that is not menstruation
Diagnosis of vulvar cancer
Medical diagnosis simply means identification of nature of an illness by elimination of the symptoms. Normally people don`t go to hospital knowing they have cancer but during diagnostic procedures is when doctors detect the disease. Following suspicion of the disease, doctors normally run combination of tests to determine whether there are cancerous cells in the body or not and if there are cancer cells, how far have they spread. Along with thorough medical history and physical examination, doctors normally use combination of the following tests to diagnose cancer. Laboratory tests. Laboratory tests are important in ruling out other conditions and confirming diagnosis. For cancer diagnosis laboratory tests normally include blood tests, urine tests, tumor markers and other body fluids tests.
• Blood tests. Blood tests help to reveal level of different substances in the blood which will help doctors to know if there is anything wrong in the body. From blood tests doctors can see complete blood count which indicates number, size and maturity of blood cells. Also from the blood tests doctors can analyze if kidney and liver are working properly.
• Urine tests. Urine tests (urinalysis) involve laboratory examination of urine to check presence of blood, proteins, and other substances such as drugs. For instance, blood in the urine may be an indication of benign condition, infection or other health problem.
• Tumor markers. These are biomarkers (proteins) that can be produced by both cancer cells and normal body cells in response to cancer. Tumor markers are released into the blood or urine. Although studies are still conducted to determine role of these markers in diagnosing cancer because sometimes people with benign condition will have elevated level of these proteins. Also not all tumors have their markers and some markers are not specific to one type of tumor.
• Other body fluids. Despite being rarely used, sometimes body fluids can be tested in the lab during diagnosis of cancer. For instance, the use of cerebral spinal fluid (CSF) and pleural fluid. CSF is used in diagnosis of brain tumors while pleural fluid for lung cancer. Diagnostic imaging. Diagnostic imagings involve tests that create pictures of inside the body that help the doctor to see if there is tumor or not. There are several imaging tests used in cancer diagnosis depending on the type and location of cancer suspected. These imaging tests include;
• Computed tomography (CT) scan. CT scan machine is a donut-shaped scanner that uses x-rays to create series of pictures of body organs from different angles. This machine is linked to a computer where those series of pictures taken will be combined to create a 3D- image of inside the body. During the scanning process patient will lie still on the table which will slide into the scanner. In order to get a clear image, sometimes the doctor will inject the patient with a contrast material before scanning. From the images the doctor will be able to differentiate between healthy and unhealthy tissues.
• Magnetic resonance imaging (MRI). MRI is an imaging technique that uses powerful magnet and radio waves to take series of pictures of body organs and create a 3D image in a computer linked to a machine. Just like in CT, during MRI procedure the patient will lie on a table that will slide into a long round chamber. Also during this procedure, the doctor may inject the patient with a contrast material for clear image view.
• X-ray. This is an imaging technique that is uses low dose of radiation to create pictures of inside your body. Technician will position the patient and direct the x-ray beam to the intended part of the body.
• Ultrasound. Ultrasound is a diagnostic imaging procedure that uses high energy sound waves to produce images of organs inside the body. During the examination, a patient will lie on the table while the technician will slowly move a device called transducer on the skin over the part of the body that is being examined.
• PET scan. Positron emission tomography (PET) scan is an imaging test that uses radioactive glucose to create 3-D images of areas inside the body. Radioactive glucose is used for this test because cancer cells tend to absorb more glucose than normal body cells, so the scan will show which areas of the body has more glucose than others. Before the scan, doctor will inject the patient with tracer called radioactive glucose then during imaging the patient will be asked to lie on the table that will be moving back and forth through the scanner.
• Bone scan. Bone scan is used to examine bones. When it comes to cancer, bone scan is used for diagnosis of bone cancer or cancer that has metastasized into the bones. Before the test, patient will be injected with small amount of radioactive material that tends to collect more on abnormal parts of the bones. Then pictures that will be taken by a scan will indicate the distribution of those radioactive materials in the bones throughout the body.
Biopsy is a diagnostic procedure that involves removing a tissue sample from the body and examines it under microscope in the laboratory. Examination in the laboratory is normally done by a pathologist who will check if the cells in the tissue are cancerous or not. In most cancer cases, biopsy is considered to be the confirmatory test. Depending on the location and type of cancer, biopsy can be obtained in different ways. Some of them include;
• Using needle. By using a thin needle, doctors can draw same tissue or fluid for examination under microscope. This method can be used to draw some fluid (spinal tap), bone marrow (bone marrow aspiration), blood or small amount of tumor from the suspected organ such as liver and breast (fine needle aspiration).
• Surgery. Abnormal tissue samples are obtained while the doctor is performing the surgery. Tissues are then sent to the lab for examination during the surgery. If the surgeon removes just a portion of abnormal area, it is called incisional biopsy while when the entire tumor (abnormal site) is removed it is called excisional biopsy.
• Using endoscope. Endoscope is a thin, lighted tube with a camera (focusing telescope) at the end. It is used for viewing inside the body through natural openings like mouth and anus. During an examination if the doctor sees any abnormal tissue, then endoscope can also be used to take sample for that tissue. There are different kinds of endoscopy exams depending on the site of the body being examined. Some of the exams include colonoscopy (for rectum and colon), bronchoscopy (for trachea, bronchi and lungs) and esophagogastroduodenoscopy EGD (for esophagus, stomach and duodenum) In addition to medical history and physical examination diagnosis of vulva cancer normally involves the use of biopsy, CT scan, MRI scan and PET scan.
Treatment of vulvar cancer
Following cancer diagnosis, the doctor will break the news and it is normally not very easy to accept that it is cancer. The doctor will be there to help the patient process the news and to help the patient in taking the next steps. After the patient receives and processes the news that he/she has cancer, one of the most important steps that will follow is decision making. The doctor will present to the patient (relatives/parents/guardians) with all the possible treatment options and explain what they mean. Then with the help of the doctor, the patient (relatives/parents/guardian) will have to choose which treatment option is good depending on benefits of such option. Despite all the information given by the doctor, sometimes the patient may still be unsatisfied with what he/she has been told. In such situation, the patient is free and advised to seek a second opinion. Second opinion is the opinion that the patient may seek from another specialist (doctor) regarding his/her health problem and in this case it is cancer. Second opinion may include confirmation of the diagnosis, more clarification on your primary doctor recommendations or even reassurances that all the options have been explored. In addition to standard care treatment options, sometimes there are those new treatments or drugs or combination of treatments that have not been approved yet to be used as standard care treatments for a particular cancer (disease) but have shown some promising results that they may help. These type of treatments are called clinical trials. If there are some clinical trials for your case, the doctor may present to the patient or the patient may ask if there are any clinical trials for the particular cancer case. Over the years, have improved treatments and led to better outcomes to people diagnosed with various diseases including cancer. If you have decided to take part in clinical trial, you can also withdraw at any time
Treatment of vulvar cancer requires a team of doctors and other health care professionals. This team work together and it is called multidisciplinary team. Team may vary depending on the treatment option for a particular case. But normally multidisciplinary team for treatment of vulvar cancer includes, surgical oncologist, gynecologic oncologist, medical oncologist, radiation oncologist, radiation therapist, pathologist and other health care professionals like oncology nurses, physiotherapist and palliative care team. Treatment options include the following;
Surgery is the treatment option that involve the removal of tumor and surrounding healthy tissues by an operation. This treatment option is performed by a specialized doctor known as surgical oncologist but it may also be done by gynecologic oncologist (a doctor who is specialized in treatment of cancers of female reproductive system). When dealing with vulvar cancer, the extent of surgery will depend on the stage of the disease. Surgery that involve removing vulva is called vulvectomy. These surgery options include the following;
• Radical local excision. This involve cutting out the cancer and a larger area of normal tissue all around the cancer. The nearby lymph nodes in the groin may also be removed.
• Partial vulvectomy. This is sometimes known as radical modified vulvectomy. The affected part of the vulva together with some surrounding healthy tissues around the cancerous tissue are removed. Significant portion of the vulva is removed.
• Radical vulvectomy. The surgeon removes the entire vulva, sometimes including the clitoris. Usually, nearby lymph nodes are also removed.
• Lymphadenectomy. This is a surgery that involve removal of affected lymph nodes. This is also be done for diagnostic purpose, to test presence of cancer cells in the nodes.
Side effects of surgery
Possible side effects of surgery of the vulvar depends on type and extent of surgery. The side effects of surgery include the following;
• Risk of infection.
• Pain around the area of surgery
• Excess bleeding.
• Blood clots.
• Reaction from anesthesia
Chemotherapy is the use of drugs to destroy cancer cells or stop its growth. This treatment is given by a specialized doctor known as medical oncologist. Type of chemotherapy used for treatment of vulva cancer is known as systemic chemotherapy. In systemic chemotherapy drug gets into the bloodstream to reach cancer cells throughout the body. Generally chemotherapy is can be given through injection into vein (intravenously) by using a needle or given as a pill or capsule that is swallowed (orally). Chemotherapy can sometimes be given in combination with radiation therapy.
Side effects of chemotherapy
Side effects of chemotherapy depend on the dose given, type of drug used and periodic time by which it has been used. Some of the possible side effects include the following;
• Hair loss
• Nausea and/or vomiting
• Loss of appetite
• Feeling tired due to low red blood cells count
• Risk of infection due to decreased white blood cells
• Easily bruising and bleeding due to low blood platelets.
• Changed bowel habits such as constipation or diarrhea
Radiation therapy is a treatment of cancer by using high energy x-rays or other radiation particles to destroy cancer cells. Radiation therapy is given by a specialized doctor known as radiation oncologist. There are two main types of radiation therapy, internal radiation therapy (brachytherapy) and external beam radiation therapy. External beam radiation therapy is the one that is normally used when dealing with vulvar cancer.
• External beam radiation therapy. Involve directing beam of radiation to the tumor from the source (machine) which is positioned outside the body.
• Internal radiotherapy (brachytherapy). This delivers radiotherapy to the tumor from inside your body. It is not used often for vulvar cancer External beam radiation therapy can be delivered in different ways, including intensity-modulated radiation therapy (IMRT) and 3D conformal radiation therapy (3D-CRT). These techniques help to deliver radiation dose to the affected area without damaging surrounding tissue. These improvements have reduced the side effects from radiotherapy
Side effects of radiation therapy
Possible side effects of radiation therapy depends on the dose of radiation therapy given. These side effects normally go away soon after completion of treatment but also there are some medications that may help to relieve if they become too severe. Some of the Possible side effects include the following;
• Mild skin reactions at the site of irradiation
• Loose bowel movement
• Upset stomach
• Loss of appetite.
45 • Damage to healthy vaginal tissues (narrowing of vagina) Most of those side effects will go away soon after treatment is finished. If vagina becomes narrow and short it will make it difficult for sexual intercourse. To prevent this, the vagina may need to be stretched with a plastic tube called a vaginal dilator several times a week.