Treatment of Squamous Cell Vulvar Cancer

The stage of a vulvar cancer is the most important factor in choosing treatment. Other factors that affect this decision include the exact location of the cancer on the vulva, the type of vulvar cancer, your age, your preferences, and your overall health.

Because vulvar cancer is rare, it's hard to study it well. Most experts agree that treatment in a clinical trial should be considered. This way women can get the best treatment available now and may also get the treatments that are thought to be even better.

Stage 0 (carcinoma in situ)

Treatment options for carcinoma in situ and for small pre-cancerous changes (vulvar intraepithelial neoplasia, or VIN) are the same. If left untreated, nearly all will progress to invasive vulvar cancer. Surgery, such as laser surgery, wide local excision, or a skinning vulvectomy may be used, depending on the size and location of the cancer. A topical therapy such as fluorouracil (5-FU) ointment or imiquimod cream may be applied to the abnormal areas. Even if treated, stage 0 cancers may recur (come back) or new stage 0 cancers may form on other areas of the vulva, so good follow-up care is important.

Stage I

Treatment options depend on the size and depth of the cancer and whether the patient also has VIN. If the depth of invasion is 1 mm or less (stage IA) and there are no other areas of cancer or VIN, the cancer is surgically removed along with a 1 cm (less than half an inch) rim (margin) of normal tissue around it.

For stage IB cancers, treatment may include a partial radical vulvectomy and inguinal lymph node dissection (removal of nearby groin lymph nodes). Sentinel lymph node biopsy may be done instead of the lymph node dissection. If cancer is found in the lymph nodes, radiation with chemotherapy may be given.

Another option rarely used for cancers that are larger and quite extensive is a complete radical vulvectomy and removal of the groin lymph nodes.

If the lymph nodes are not removed because the patient is not healthy enough to have the surgery, radiation therapy may be given to the groin areas. If the lymph nodes are enlarged, a needle biopsy may be done before treatment to see if the nodes contain cancer cells.

Patients who are not healthy enough to have any surgery may be treated with just radiation therapy alone.

Stage II

Stage II cancers have spread to structures near the vulva, such as the anus, the lower vagina, and/or the lower urethra. One option for treatment is partial radical vulvectomy (removal of the tumor, nearby parts of the vulva, and other tissues containing cancer). Surgery may also include removal of the lymph nodes in the groin on both sides of the body (or sentinel node biopsies). Radiation therapy may be given after surgery if cancer cells are at or near the margins (edges of the tissue removed by surgery).

For women who are too sick or weak from other medical problems to have surgery, radiation (with or without chemotherapy) may be used as the main treatment.

Stage III

Stage III cancers have spread to nearby lymph nodes. Treatment may include surgery to remove the cancer (either a radical wide local incision or partial or complete radical vulvectomy) and lymph nodes in the groin. This may be followed by radiation therapy. Sometimes chemotherapy (chemo) is given along with the radiation to help it work better.

These cancers may also be treated with radiation (with or without chemo) first, followed by surgery to remove any remaining cancer. This is often done to try to preserve normal structures such as the vagina, urethra and anus.

Radiation and chemo (without surgery) may be used as the main treatment for patients who cannot have surgery due to other medical problems.

Stage IVA

These cancers have spread more extensively to organs and tissues in the pelvis, such as the rectum (above the anus), the bladder, the pelvic bone, the upper part of the vagina, and the upper part of the urethra. When treated with surgery, the goal is to remove as much of the cancer as possible. The extent of the surgery depends on what organs contain cancer cells. Pelvic exenteration is an option, but it's rarely used.

The standard approach is to combine surgery, radiation, and chemo. Radiation therapy may be done before or after surgery. Chemo may also be given before surgery.

Radiation and possibly chemo can also be given to women who can't have surgery because of other medical problems.

Stage IVA also includes tumors with less spread to nearby organs, but spread to nearby lymph nodes that has caused the lymph nodes to become fixed (stuck to the underlying tissue) or ulcerated (become open sores). These cancers are often treated with radical vulvectomy and removal of the groin lymph nodes. Radiation (often with chemo) may be given either before or after surgery.

Stage IVB

These cancers have spread to lymph nodes in the pelvis or to organs and tissues outside the pelvis (like the lungs or liver). There is no standard treatment for them. Surgery is not expected to cure these cancers, but may be helpful in relieving symptoms, such as bowel or bladder blockages. Radiation may also be helpful in shrinking the cancer and improving symptoms. Chemo may also be an option. Experts recommend that these women enroll in a clinical trial.

Recurrent vulvar cancer

When cancer comes back after treatment, it's called recurrent cancer. Treatment options depend on how soon the cancer comes back and whether the recurrence is local (in the vulva), regional (in nearby lymph nodes), or distant (has spread to organs such as the lungs or bones).

If the recurrence is local, it may still be possible to remove the cancer by surgery or by using combinations of chemo, radiation therapy, and surgery.

When the cancer has grown too large or spread too far to be surgically removed (it's unresectable), chemo and/or radiation therapy may be used to help relieve symptoms such as pain, or to shrink the tumor so that surgery may become an option. If treatment is given only to relieve pain or bleeding, it's called palliative (symptom relief) therapy.

It's very important to understand that palliative treatment is not expected to cure a cancer. Women with advanced vulvar cancer are encouraged to enter a clinical trial where they may get new treatments that might be helpful but are as yet unproven.