Vulval carcinoma

Gynecological Oncology

Clinicals - History

Fact Explanation
History of immunosuppression and old age Vulval cancer is uncommon, comprising 4% of all gynaecological malignancies. Just over 1000 cases are diagnosed in the UK every year, making vulval cancer the 20th most common cancer among women. It is mainly a disease of older women, with the incidence increasing with age.80% of vulval cancers occur among women over the age of 60 years. Immunosuppression is a well known risk factor of vulval cancer.. History of immunosuppression and old age
Vulval cancer is uncommon, comprising 4% of all gynaecological malignancies. Just over 1000 cases are diagnosed in the UK every year, making vulval cancer the 20th most common cancer among women. It is mainly a disease of older women, with the incidence increasing with age.80% of vulval cancers occur among women over the age of 60 years. Immunosuppression is a well known risk factor of vulval cancer..
History of HPV infection Human papillomavirus (HPV) is reported as present in approximately 40 per cent of vulval carcinomas, with HPV 16 accounting for most HPV-positive cases. HPV is strongly linked with tumours in young women, with an 11-fold increase reported for VIN and early-stage cancer in women <45 years of age with serological evidence of HPV infection.The increased incidence of vulval cancer worldwide is believed to be linked to an increasing incidence of VIN in younger women caused by HPV infection.. History of HPV infection
Human papillomavirus (HPV) is reported as present in approximately 40 per cent of vulval carcinomas, with HPV 16 accounting for most HPV-positive cases. HPV is strongly linked with tumours in young women, with an 11-fold increase reported for VIN and early-stage cancer in women <45 years of age with serological evidence of HPV infection.The increased incidence of vulval cancer worldwide is believed to be linked to an increasing incidence of VIN in younger women caused by HPV infection..
History of Smoking The incidence of Vulval carcinoma is increasing, largely in younger women, associated with oncogenic HPV and smoking. An interaction between a combination of risk factors (e.g. genetic, HPV, smoking) is also possible. Genetic variation in Th1 cytokines has been shown to modify the risk of vulvar cancer among smokers .. History of Smoking
The incidence of Vulval carcinoma is increasing, largely in younger women, associated with oncogenic HPV and smoking. An interaction between a combination of risk factors (e.g. genetic, HPV, smoking) is also possible. Genetic variation in Th1 cytokines has been shown to modify the risk of vulvar cancer among smokers ..
History of VIN (valval intraepithelial neoplasia) and Lichen sclerosus VIN is a precancerous condition of the vulval skin, most commonly presenting with localised vulval pruritis.Two different types of VIN are recognised, undifferentiated VIN and differentiated VIN.If untreated, VIN may remain stable, spontaneously regress, or progress to vulval carcinoma.. Lichen sclerosus is a lymphocyte mediated dermatosis commonly presenting in the anogenital region of postmenopausal women.Lichen sclerosus has a 3–5 per cent risk of progression to vulval cancer and, in older women, squamous cell vulval carcinoma is often associated with lichen sclerosus and squamous hyperplasia.. History of VIN (valval intraepithelial neoplasia) and Lichen sclerosus
VIN is a precancerous condition of the vulval skin, most commonly presenting with localised vulval pruritis.Two different types of VIN are recognised, undifferentiated VIN and differentiated VIN.If untreated, VIN may remain stable, spontaneously regress, or progress to vulval carcinoma.. Lichen sclerosus is a lymphocyte mediated dermatosis commonly presenting in the anogenital region of postmenopausal women.Lichen sclerosus has a 3–5 per cent risk of progression to vulval cancer and, in older women, squamous cell vulval carcinoma is often associated with lichen sclerosus and squamous hyperplasia..
Pain They may present with persistent pain, soreness/burning sensation in the vulval area.When there is a background history of VIN or lichen sclerosus, particular attention should be paid to worsening symptoms or persisting symptoms that remain unresponsive to localised therapies.. Pain
They may present with persistent pain, soreness/burning sensation in the vulval area.When there is a background history of VIN or lichen sclerosus, particular attention should be paid to worsening symptoms or persisting symptoms that remain unresponsive to localised therapies..
Pruritis Women with vulval cancer may present with pruritis .Persistent itching can be found,. Pruritis
Women with vulval cancer may present with pruritis .Persistent itching can be found,.
Bleeding Presentation with bleeding is not uncommon and examination of the vulva in women reporting postmenopausal bleeding is crucial.. Bleeding
Presentation with bleeding is not uncommon and examination of the vulva in women reporting postmenopausal bleeding is crucial..
Painful urination Affected women sometimes complain painful urination.. Painful urination
Affected women sometimes complain painful urination..
Local extension Local extension of vulval carcinoma may involve the anus, vagina or rectum, all of which have lymphatic drainage direct to the pelvic wall.. Local extension
Local extension of vulval carcinoma may involve the anus, vagina or rectum, all of which have lymphatic drainage direct to the pelvic wall..
Recurrence Recurrences appear to be of two types, local and distant. The distant recurrences predominantly appear in the first year or two following treatment.They usually take the form of disease in the lymph nodes, beginning with the high pelvic and para aortic chain. In addition, pulmonary metastasis is not uncommon. The local recurrences tend to begin after three years.. Recurrence
Recurrences appear to be of two types, local and distant. The distant recurrences predominantly appear in the first year or two following treatment.They usually take the form of disease in the lymph nodes, beginning with the high pelvic and para aortic chain. In addition, pulmonary metastasis is not uncommon. The local recurrences tend to begin after three years..

Clinicals - Examination

Fact Explanation
Vulval lesion Vulval cancer may appear as a relatively discrete lesion in some cases. Thickened, raised, red, white or dark patches on the skin of the vulva may be apparent or an ulcer, open sore or growth/lump visible on the skin.The ulcer can persists for more than one month.. Vulval lesion
Vulval cancer may appear as a relatively discrete lesion in some cases. Thickened, raised, red, white or dark patches on the skin of the vulva may be apparent or an ulcer, open sore or growth/lump visible on the skin.The ulcer can persists for more than one month..
Vulval skin discoloration Alteration in vulval skin texture or discolouration can also be seen.. Vulval skin discoloration
Alteration in vulval skin texture or discolouration can also be seen..
Ulcer Squamous cell carcinomas account for more than 90 per cent of vulval cancers. The other 10 per cent includes melanomas, sarcomas, basal-cell carcinomas and adenocarcinomas. . SCC may appear as an exophytic or an endophytic ulcerated lesion. The labia majora and minora are preferentially involved. The majority of vulvar SCC are solitary. However, multifocal tumors are seen in 10% of cases. Clinical symptoms are usually related to the ulceration of the lesion. There is in average 12 to 18 months delay between initial symptoms and definitive histological diagnosis due to prescription of corticoid or antifungal topical therapy without detailed examination of the genitalia.. Ulcer
Squamous cell carcinomas account for more than 90 per cent of vulval cancers. The other 10 per cent includes melanomas, sarcomas, basal-cell carcinomas and adenocarcinomas. . SCC may appear as an exophytic or an endophytic ulcerated lesion. The labia majora and minora are preferentially involved. The majority of vulvar SCC are solitary. However, multifocal tumors are seen in 10% of cases. Clinical symptoms are usually related to the ulceration of the lesion. There is in average 12 to 18 months delay between initial symptoms and definitive histological diagnosis due to prescription of corticoid or antifungal topical therapy without detailed examination of the genitalia..
Vulval lump They may present with vulval lump or growth/wart-like growths.Women presenting with an unexplained vulval lump should be referred urgently for further investigation,, Vulval lump
They may present with vulval lump or growth/wart-like growths.Women presenting with an unexplained vulval lump should be referred urgently for further investigation,,
Anemia Hypoxia occurs in anemia , cancer, prolonged exercise, and long-term ischemia with durations of several hours or more . Hypoxia may induce cell death, although tumor cells may adapt to the hypoxic microenvironment by inducing a hypoxia-inducible factor (HIF)-1 mediated angiogenic response, and/or by altering their metabolic activity. The overall cellular consequences of hypoxia are a decreased proliferation rate, increased radio- and multidrug resistance, and increased invasive and metastatic potential. These adaptive responses promote tumor progression and treatment resistance to both radio and chemotherapy.Patients’ anemia may contribute to the establishment of intratumoral hypoxic conditions by reducing oxygen delivery to tumor tissues.. Anemia
Hypoxia occurs in anemia , cancer, prolonged exercise, and long-term ischemia with durations of several hours or more . Hypoxia may induce cell death, although tumor cells may adapt to the hypoxic microenvironment by inducing a hypoxia-inducible factor (HIF)-1 mediated angiogenic response, and/or by altering their metabolic activity. The overall cellular consequences of hypoxia are a decreased proliferation rate, increased radio- and multidrug resistance, and increased invasive and metastatic potential. These adaptive responses promote tumor progression and treatment resistance to both radio and chemotherapy.Patients’ anemia may contribute to the establishment of intratumoral hypoxic conditions by reducing oxygen delivery to tumor tissues..
Inguinofemoral lymph nodes Vulval squamous cell carcinoma (SCC) accounts for 3–5% of all gynecological malignancies. Positive inguinofemoral lymph nodes have been found to be the most important prognostic factor for vulvar SCC.. Vulval carcinoma spreads almost exclusively by local invasion and lymphatic metastasis. Hematogenous dissemination is distinctly unusual. Decussation of the lymphatic drainage does occur in the mons, providing a pathway for contralateral groin metastasis.The orderly lymphatic flow proceeds from the superficial (femoral and inguinal) groin nodes to the deep groin nodes located beneath the cribriform fascia in the femoral triangle and intimately associated with the femoral vessels.. Inguinofemoral lymph nodes
Vulval squamous cell carcinoma (SCC) accounts for 3–5% of all gynecological malignancies. Positive inguinofemoral lymph nodes have been found to be the most important prognostic factor for vulvar SCC.. Vulval carcinoma spreads almost exclusively by local invasion and lymphatic metastasis. Hematogenous dissemination is distinctly unusual. Decussation of the lymphatic drainage does occur in the mons, providing a pathway for contralateral groin metastasis.The orderly lymphatic flow proceeds from the superficial (femoral and inguinal) groin nodes to the deep groin nodes located beneath the cribriform fascia in the femoral triangle and intimately associated with the femoral vessels..

Investigations - Diagnosis

Fact Explanation
Thorough physical examination Diagnosis can be made only by physical examination and liberal use of tissue biopsy, So that thorough physical examination of the vulva should be carried out.. Thorough physical examination
Diagnosis can be made only by physical examination and liberal use of tissue biopsy, So that thorough physical examination of the vulva should be carried out..
Vulval biopsy and microscopic examination Women with suspicious vulval lesions or persistent vulval symptoms in spite of treatment should undergo vulval biopsy in order to detect cancer at the earliest opportunity.. The lesions
may assume a great variety of morphologic characteristics,
including exophytic and papillary or
endophytic and ulcerative.. Keratinizing Squamous Cell Carcinoma, is the most common histologic subtype of SCC. Neoplastic cells are mature with abundant eosinophilic cytoplasm and show keratin pearl. The nuclei are enlarged with prominent nucleoli and features readily identified in most cases include considerable nuclear atypia and mitotic activity..
Vulval biopsy and microscopic examination
Women with suspicious vulval lesions or persistent vulval symptoms in spite of treatment should undergo vulval biopsy in order to detect cancer at the earliest opportunity.. The lesions
may assume a great variety of morphologic characteristics,
including exophytic and papillary or
endophytic and ulcerative.. Keratinizing Squamous Cell Carcinoma, is the most common histologic subtype of SCC. Neoplastic cells are mature with abundant eosinophilic cytoplasm and show keratin pearl. The nuclei are enlarged with prominent nucleoli and features readily identified in most cases include considerable nuclear atypia and mitotic activity..
Fine needle biopsy Fine needle biopsy is also used. But it will show inconsistent results and are not accurate enough for routine assessment of groin node status.. Fine needle biopsy
Fine needle biopsy is also used. But it will show inconsistent results and are not accurate enough for routine assessment of groin node status..
Sentinel lymph node assessment The gold standard for detection of nodal metastases in vulval cancer remains histological evaluation of the surgically removed lymph nodes. Sentinel node identification is currently the most promising diagnostic tool for assessment of lymph node status in vulval cancer. Radio-labelled colloid in conjunction with a marking dye is used for the detection of the sentinel node, which is the first lymph node receiving lymphatic drainage from the tumour. The aim of sentinel lymph node biopsy is to establish the presence of groin node metastases in squamous-cell vulval cancer and therefore reduce the need for radical groin lymphadenectomy in sentinel lymph node-negative women, thus in turn reducing surgical morbidity.The International Sentinel Node Society has recommended performing sentinel lymph node biopsy only in patients with tumours <4cm, with the procedure on the whole recommended for early-stage tumours only. . Sentinel lymph node assessment
The gold standard for detection of nodal metastases in vulval cancer remains histological evaluation of the surgically removed lymph nodes. Sentinel node identification is currently the most promising diagnostic tool for assessment of lymph node status in vulval cancer. Radio-labelled colloid in conjunction with a marking dye is used for the detection of the sentinel node, which is the first lymph node receiving lymphatic drainage from the tumour. The aim of sentinel lymph node biopsy is to establish the presence of groin node metastases in squamous-cell vulval cancer and therefore reduce the need for radical groin lymphadenectomy in sentinel lymph node-negative women, thus in turn reducing surgical morbidity.The International Sentinel Node Society has recommended performing sentinel lymph node biopsy only in patients with tumours <4cm, with the procedure on the whole recommended for early-stage tumours only. .

Investigations - Management

Fact Explanation
Routine clinical vulvar, vaginal, and nodal examination All women with a diagnosis of vulval cancer should undergo regular post treatment follow-up, as should women with a prior diagnosis of VIN or other anogenital site cancer. Long-term review is recommended, as these women are at risk of recurrence, development of other anogenital site carcinomas and long-term morbidity from treatment regimens. Follow-up is recommended at three-monthly intervals for the first year, six-monthly intervals for years two and three, then annually.. Recommended follow-up includes clinical vulvar, vaginal, and nodal examination on a three to six monthly basis. Indication of routine morphological or metabolic imaging exams must be individualized.. Routine clinical vulvar, vaginal, and nodal examination
All women with a diagnosis of vulval cancer should undergo regular post treatment follow-up, as should women with a prior diagnosis of VIN or other anogenital site cancer. Long-term review is recommended, as these women are at risk of recurrence, development of other anogenital site carcinomas and long-term morbidity from treatment regimens. Follow-up is recommended at three-monthly intervals for the first year, six-monthly intervals for years two and three, then annually.. Recommended follow-up includes clinical vulvar, vaginal, and nodal examination on a three to six monthly basis. Indication of routine morphological or metabolic imaging exams must be individualized..
FBC Full blood count is performed as a pre operative investigation. Comorbidity assessment is important in this elderly population.. With the aim to assess the role of anemia, preoperative hemoglobin levels were recorded and found to be low in most of the patients.. FBC
Full blood count is performed as a pre operative investigation. Comorbidity assessment is important in this elderly population.. With the aim to assess the role of anemia, preoperative hemoglobin levels were recorded and found to be low in most of the patients..
Electrocardiogram Also used for pre operative assessment.. Electrocardiogram
Also used for pre operative assessment..
X ray Preliminary histological diagnosis is mandatory before radical treatment and a chest X-ray is a routine staging requirement.. X ray
Preliminary histological diagnosis is mandatory before radical treatment and a chest X-ray is a routine staging requirement..
USS High-resolution imaging may be used preoperatively to stage disease and potentially detect those women who may not require lymphadenectomy. Systematic review, however, suggests ultrasound.. USS
High-resolution imaging may be used preoperatively to stage disease and potentially detect those women who may not require lymphadenectomy. Systematic review, however, suggests ultrasound..
CT scan Although an attempt can be made preoperatively to stage vulval carcinomas using CT or MRI, high-resolution imaging may fail to detect micrometastases..For tumours >2 cm in diameter, computed tomography (CT) of the chest, abdomen and pelvis may be appropriate to detect disease above the inguinal ligament, which could change the planned treatment.. CT scan
Although an attempt can be made preoperatively to stage vulval carcinomas using CT or MRI, high-resolution imaging may fail to detect micrometastases..For tumours >2 cm in diameter, computed tomography (CT) of the chest, abdomen and pelvis may be appropriate to detect disease above the inguinal ligament, which could change the planned treatment..
MRI MRI and PET CT are not part of a routine work up and must be prescribed on individual basis.. MRI
MRI and PET CT are not part of a routine work up and must be prescribed on individual basis..
PET scan Positron emission tomography (PET) also use. But it also shows inconsistent results.And it is not accurate enough for routine assessment of groin node status.. PET scan
Positron emission tomography (PET) also use. But it also shows inconsistent results.And it is not accurate enough for routine assessment of groin node status..
Surgical excision and thorough pathological examination of the primary tumour Staging is only really achievable following surgical excision and thorough pathological examination of the primary tumour and corresponding lymph nodes where appropriate. Any biopsies or extirpated tissue should be reviewed by a pathologist with a specialist interest in gynaecological pathology. Staging for squamous-cell vulval carcinoma is performed using the International Federation of Gynecology and Obstetrics (FIGO) system.. Surgical excision and thorough pathological examination of the primary tumour
Staging is only really achievable following surgical excision and thorough pathological examination of the primary tumour and corresponding lymph nodes where appropriate. Any biopsies or extirpated tissue should be reviewed by a pathologist with a specialist interest in gynaecological pathology. Staging for squamous-cell vulval carcinoma is performed using the International Federation of Gynecology and Obstetrics (FIGO) system..
Vulval examination There are currently no recommended screening strategies for vulval cancer. Irrespective of a lack of screening strategies, both the ISSVD and the vulval health awareness campaign (VHAC) recommend self-examination for all women on a monthly basis. Although doctors may lack confidence both in vulval examination and in identifying lesions of significance, they recommend the promotion of vulval self-examination, particularly in the primary care setting.. Vulval examination
There are currently no recommended screening strategies for vulval cancer. Irrespective of a lack of screening strategies, both the ISSVD and the vulval health awareness campaign (VHAC) recommend self-examination for all women on a monthly basis. Although doctors may lack confidence both in vulval examination and in identifying lesions of significance, they recommend the promotion of vulval self-examination, particularly in the primary care setting..
Cervical cytology and/or cervical examination Cervical cytology and/or cervical examination are recommended, as women with carcinoma of the vulva are at an increased risk of developing other anogenital cancers, particularly cervical cancer.. Cervical cytology and/or cervical examination
Cervical cytology and/or cervical examination are recommended, as women with carcinoma of the vulva are at an increased risk of developing other anogenital cancers, particularly cervical cancer..

Management - Supportive

Fact Explanation
Wide local tumour excision Treatment for vulval cancer, like in many diseases, needs to be individualised, and women with vulval cancer should be referred for multidisciplinary management in a gynaecological cancer centre. The mean age of women with vulval cancer is 70 years, so medical comorbidities in particular must be accounted for, as should site and size of the primary tumour. Primary surgery followed by radiotherapy (if required) is the mainstay treatment for vulval cancer. Microinvasive or superficially invasive vulval cancer (FIGO stage IA) can be managed by wide local tumour excision without inguinofemoral lymph node dissection, as these women are not found to be at risk of lymph node metastases.In early vulval cancer, radical vulvectomy has been replaced by wide local tumour excision, which appears to be a safe alternative as the recurrence rate is low.. Wide local tumour excision
Treatment for vulval cancer, like in many diseases, needs to be individualised, and women with vulval cancer should be referred for multidisciplinary management in a gynaecological cancer centre. The mean age of women with vulval cancer is 70 years, so medical comorbidities in particular must be accounted for, as should site and size of the primary tumour. Primary surgery followed by radiotherapy (if required) is the mainstay treatment for vulval cancer. Microinvasive or superficially invasive vulval cancer (FIGO stage IA) can be managed by wide local tumour excision without inguinofemoral lymph node dissection, as these women are not found to be at risk of lymph node metastases.In early vulval cancer, radical vulvectomy has been replaced by wide local tumour excision, which appears to be a safe alternative as the recurrence rate is low..
Triple incision technique The traditional en bloc radical vulvectomy and bilateral inguinofemoral lymphadenectomy (‘butterfly incision’), which was associated with significant morbidity, has been replaced by the triple incision technique, which is regarded as safe provided that tumour-free margins of greater than 8mm are considered, as the combined incidence of skin-bridge and groin recurrence remains very low.. Triple incision technique
The traditional en bloc radical vulvectomy and bilateral inguinofemoral lymphadenectomy (‘butterfly incision’), which was associated with significant morbidity, has been replaced by the triple incision technique, which is regarded as safe provided that tumour-free margins of greater than 8mm are considered, as the combined incidence of skin-bridge and groin recurrence remains very low..
Bilateral inguinofemoral lymphadenectomy Depending on the position of the primary tumour, lymph nodes may be removed either unilaterally or bilaterally. Midline lesions (<1cm from the midline) require bilateral inguinofemoral node dissection. Omission of contralateral lymph node dissection in patients with laterally localised and small tumours, however, appears safe in patients with lateral early stage tumours. Omission of femoral lymph node dissection is regarded as unsafe.. Bilateral radical inguinofemoral (IF) nodal dissection carries a heavy potential morbidity (lymphocele, lymphoedema) and must therefore be individualized.. Bilateral inguinofemoral lymphadenectomy
Depending on the position of the primary tumour, lymph nodes may be removed either unilaterally or bilaterally. Midline lesions (<1cm from the midline) require bilateral inguinofemoral node dissection. Omission of contralateral lymph node dissection in patients with laterally localised and small tumours, however, appears safe in patients with lateral early stage tumours. Omission of femoral lymph node dissection is regarded as unsafe.. Bilateral radical inguinofemoral (IF) nodal dissection carries a heavy potential morbidity (lymphocele, lymphoedema) and must therefore be individualized..
Radical vulvectomy Used previously. The “traditional” radical vulvectomy is no longer systematically applied due to its major deleterious impact on vaginal function.. Radical vulvectomy
Used previously. The “traditional” radical vulvectomy is no longer systematically applied due to its major deleterious impact on vaginal function..
Superficial inguinal and deep femoral node dissection For early stage disease >2 cm, nodal staging must include superficial inguinal and deep femoral node dissection. The procedure may be carried out ipsilaterally in case of labia major lateralised disease. The dissection must be bilateral in case of midline disease (minor labia, periclitoral, periurethral, or perianal).. Superficial inguinal and deep femoral node dissection
For early stage disease >2 cm, nodal staging must include superficial inguinal and deep femoral node dissection. The procedure may be carried out ipsilaterally in case of labia major lateralised disease. The dissection must be bilateral in case of midline disease (minor labia, periclitoral, periurethral, or perianal)..
Radiotherapy In early-stage vulval cancer, surgery is the first-choice treatment for the groin lymph nodes, as groin irradiation as a primary treatment results in higher recurrence rates of groin node tumour. In spite of this, primary radiotherapy is a good alternative in specific situations (eg if medical comorbidity outweighs the risk of performing primary surgery).Radiotherapy is more commonly used as an adjuvant treatment following primary surgery. Present UK guidelines recommend adjuvant radiotherapy when inadequate surgical margins of excision are obtained or when either groin has two or more lymph nodes involved with microscopic metastatic disease, or there is complete replacement and/or extracapsular spread in any lymph node.In westernised society, advanced vulval cancer is fortunately now relatively uncommon. Advanced-stage disease (FIGO III–IV) may be difficult to manage, especially in cases where primary disease involves the anus, rectum, urethra, bladder or bulky groin nodes. Preoperative radiotherapy may allow for shrinkage of primary tumour (eg when trying to achieve sphincter-preserving surgery), although the ensuing surgery may be more complicated with increased morbidity.. Radiotherapy
In early-stage vulval cancer, surgery is the first-choice treatment for the groin lymph nodes, as groin irradiation as a primary treatment results in higher recurrence rates of groin node tumour. In spite of this, primary radiotherapy is a good alternative in specific situations (eg if medical comorbidity outweighs the risk of performing primary surgery).Radiotherapy is more commonly used as an adjuvant treatment following primary surgery. Present UK guidelines recommend adjuvant radiotherapy when inadequate surgical margins of excision are obtained or when either groin has two or more lymph nodes involved with microscopic metastatic disease, or there is complete replacement and/or extracapsular spread in any lymph node.In westernised society, advanced vulval cancer is fortunately now relatively uncommon. Advanced-stage disease (FIGO III–IV) may be difficult to manage, especially in cases where primary disease involves the anus, rectum, urethra, bladder or bulky groin nodes. Preoperative radiotherapy may allow for shrinkage of primary tumour (eg when trying to achieve sphincter-preserving surgery), although the ensuing surgery may be more complicated with increased morbidity..
Neoadjuvant chemoradiotheraphy Radiotherapy or radical chemoradiotherapy may also be considered for primary management.Radical radiotherapy is used in patients for whom surgery is not an option and is usually combined with chemotherapy. In patients with large tumours that can be treated only with anterior and/or posterior exenteration, complications of neoadjuvant therapy might outweigh complications of exenterative surgey,. Locally advanced vulvar carcinoma based on vaginal, urethral, or anal involvement is treated by concomitant chemoradiation associating external beam, brachytherapy implant, and radiosensitizing platinum chemotherapy. In this context, nodal staging may precede the initiation of the radiotherapy.. Neoadjuvant chemoradiotheraphy
Radiotherapy or radical chemoradiotherapy may also be considered for primary management.Radical radiotherapy is used in patients for whom surgery is not an option and is usually combined with chemotherapy. In patients with large tumours that can be treated only with anterior and/or posterior exenteration, complications of neoadjuvant therapy might outweigh complications of exenterative surgey,. Locally advanced vulvar carcinoma based on vaginal, urethral, or anal involvement is treated by concomitant chemoradiation associating external beam, brachytherapy implant, and radiosensitizing platinum chemotherapy. In this context, nodal staging may precede the initiation of the radiotherapy..

Management - Specific

Fact Explanation
Palliative care The prognosis of vulval cancer is related to lesion size, depth of invasion, the number of involved lymph nodes, presence or absence of extranodal spread, proportion of node replaced by metastasis, and the presence or absence of lymphovascular space involvement. The five year survival rate for women with positive nodal disease (<50 per cent), however, is much lower than for those with node-negative disease (>80 per cent). Vulval cancer predominantly affects older women. When significant medical comorbidity or frailty of old age is apparent, referral to palliative care is appropriate when multidisciplinary team review has deemed palliative surgery or palliative radiotherapy as an unsuitable option.. Palliative care
The prognosis of vulval cancer is related to lesion size, depth of invasion, the number of involved lymph nodes, presence or absence of extranodal spread, proportion of node replaced by metastasis, and the presence or absence of lymphovascular space involvement. The five year survival rate for women with positive nodal disease (<50 per cent), however, is much lower than for those with node-negative disease (>80 per cent). Vulval cancer predominantly affects older women. When significant medical comorbidity or frailty of old age is apparent, referral to palliative care is appropriate when multidisciplinary team review has deemed palliative surgery or palliative radiotherapy as an unsuitable option..
The HPV vaccination programme The HPV vaccination programme for England commenced in an aim to prevent premalignant cervical lesions and cervical cancer causally related to HPV types 16 and 18. Vaccination for HPV types 16 and 18 is estimated to reduce the incidence of cervical cancer cases by approximately 70 per cent. As the prevalence of HPV types 16 and 18 is also high in VIN and vulval carcinoma, particularly in younger women, it is probable that the vaccination programme will also result in a reduced incidence of premalignant vulval lesions and vulval cancer.. The HPV vaccination programme
The HPV vaccination programme for England commenced in an aim to prevent premalignant cervical lesions and cervical cancer causally related to HPV types 16 and 18. Vaccination for HPV types 16 and 18 is estimated to reduce the incidence of cervical cancer cases by approximately 70 per cent. As the prevalence of HPV types 16 and 18 is also high in VIN and vulval carcinoma, particularly in younger women, it is probable that the vaccination programme will also result in a reduced incidence of premalignant vulval lesions and vulval cancer..

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