How is vulvar cancer diagnosed?
Medical history and physical exam
The first step is for the doctor to take your complete medical history to check for risk factors and symptoms. Then your doctor will give you a complete physical exam, including a pelvic exam. He or she will feel your uterus, ovaries, cervix, and vagina for anything irregular. Your doctor will also use a speculum to look at your vagina and cervix and may do a Pap test.
Certain signs and symptoms might strongly suggest vulvar cancer, but many of them can be caused by conditions that aren't cancer. The only way to be certain that cancer is present is to do a biopsy. In this procedure, a small piece of tissue from the suspicious area is removed and examined under the microscope. A pathologist (a doctor specializing in diagnosing diseases by laboratory tests) will look at the tissue sample under a microscope to see if cancer or a pre-cancerous condition is present and, if so, what type it is.
Rarely, the doctor will paint the vulva with a dye (toluidine blue) to find all areas of abnormal vulvar skin and to select the best areas to biopsy. This dye causes skin with certain diseases -- including vulvar intraepithelial neoplasia (VIN) and vulvar cancer -- to turn blue.
The doctor might use a colposcope (an instrument with binocular magnifying lenses that stays outside the body) or a hand-held magnifying lens to select areas to biopsy. The vulva is treated with a dilute solution of acetic acid (like vinegar) that causes areas of VIN and cancer to turn white, making them easier to see through the colposcope. Examining the vulva with magnification is called vulvoscopy.
Once the abnormal areas are found, a numbing medicine (local anesthetic) is injected into the skin so you won’t feel pain. If the abnormal area is small, it may be completely removed (called an excisional biopsy) with a scalpel. Sometimes stitches are needed.
If the abnormal area is larger, a punch biopsy is used to take a small sample. The instrument used looks like a tiny apple corer and removes a small, cylindrical piece of skin 4 mm (about 1/6 inch) across. No stitches are usually needed after the punch biopsy. Depending on the results of the punch biopsy, additional surgery may be necessary.
To learn more about biopsies, see our document, Testing Biopsy and Cytology Specimens for Cancer.
If you have cancer, tests will be done to see how far it has spread. The results of your physical examination and certain diagnostic tests will be used to determine the size of the tumor, how deeply it has grown into tissues at the site where it originated, if it has grown into nearby organs, and if it has metastasized (spread to lymph nodes or distant organs). This is called staging. The stage of your cancer is the most important factor in selecting the right treatment plan. (See the section "How is vulvar cancer staged?" for more details)
If your biopsy shows that you have vulvar cancer, your health care professional will refer you to a gynecologic oncologist, a specialist in female reproductive system cancers. The specialist will also look at your complete personal and family medical history to learn about related risk factors and symptoms of vulvar cancer.
The doctor will perform a complete physical examination to evaluate your general state of health, paying special attention to the lymph nodes, particularly those in your groin region, to check for signs of cancer spread. Depending on the biopsy results, several more tests may be done to determine if the vulvar cancer has spread to other areas.
This examination uses a lighted tube to check the inside surface of the bladder. Some advanced cases of vulvar cancer can spread to the bladder, so any suspicious areas noted by this exam are removed for biopsy. This procedure can be done using a local anesthetic, but some patients may need general anesthesia. Your doctor will let you know what to expect before and after the procedure. This procedure was used more often in the past, but is no longer a standard part of the work-up of a woman with vulvar cancer.
This is a visual inspection of the rectum using a lighted tube. Some advanced cases of vulvar cancer can spread to the rectum. Any suspicious areas are biopsied. Proctoscopy was used more often in the past, but is no longer a standard part of the work-up of a woman with vulvar cancer.
Examination of the pelvis under anesthesia
Putting the patient under anesthesia permits a physician to do a more thorough exam that can better evaluate how much the cancer has spread to internal organs of the pelvis.
A plain x-ray of your chest might be done to check for other health problems that might make certain treatments difficult to tolerate. This x-ray can be done in any outpatient setting.
Computed tomography (CT)
The computed tomography (CT) scan is an x-ray test that produces detailed cross-sectional images of your body. Instead of taking one picture, like a standard x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body. For vulvar cancer, a CT scan can help find enlarged lymph nodes that might contain areas of cancer spread. It can also be helpful to see if the cancer has spread to other organs.
A CT scanner has been described as a large donut, with a narrow table in the middle opening. You will need to lie still on the table while the scan is being done. CT scans take longer than regular x-rays, and you might feel a bit confined by the ring while the pictures are being taken.
Before the test, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures such as blood vessels in your body.
The injection can cause some flushing (redness and warm feeling). A few people are allergic to the dye and get hives, or rarely, have more serious reactions like trouble breathing and low blood pressure. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.
CT scans are not often needed in vulvar cancer patients. They might be done in patients with large tumors or enlarged lymph nodes. They can also be helpful in deciding whether to do a sentinel lymph node procedure to check groin lymph nodes for cancer spread (this procedure is discussed in more detail in the "Surgery for vulvar cancer" section).
Magnetic resonance imaging (MRI)
Magnetic resonance imaging (MRI) scans use radio waves and strong magnets instead of x-rays to make images of the body. The energy from the radio waves is absorbed by the body and then released in a specific pattern formed by the type of tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. Like a CT scanner, this produces cross sectional slices of the body. An MRI can also produce slices that are parallel with the length of your body. As with a CT scan, a contrast material might be used, but it is not needed as often.
MRI scans are more uncomfortable than CT scans. They take longer -- often up to an hour. You have to be placed inside tube-like equipment, which is confining and can upset people with claustrophobia (a fear of close spaces). If you have trouble with close spaces, let your doctor know before the MRI scan. Sometimes medicine can be given just before the scan to reduce anxiety. Another option is to use a special "open" MRI machine that is less confining and more comfortable for such people, the drawback being that the images from these machines are not as good. The machine also makes a buzzing or clanging noise that some people find disturbing. Some places will provide headphones with music to block this sound.
MRI images are particularly useful in examining pelvic tumors. They may often detect enlarged lymph nodes in the groin. They are also helpful in detecting cancer that has spread to the brain or spinal cord. However, they are rarely used in patients with early vulvar cancer.
Positron emission tomography (PET)
Positron emission tomography (PET) uses glucose (a form of sugar) that contains a low-level radioactive atom. Because cancer cells use glucose at a higher rate than normal cells, they absorb more of the radioactive sugar. The areas of radioactivity are detected with this test. You will be injected with the special glucose, and then about an hour later you will be moved onto a table in the PET scanner. You lie on the table for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body. The picture is not finely detailed like a CT or MRI scan, but it provides helpful information about your body.
This test can be helpful for spotting collections of cancer cells, and seeing if the cancer has spread to lymph nodes. PET scans are also useful when your doctor thinks the cancer has spread, but doesn’t know where (although they aren’t useful for finding cancer spread in the brain). PET scans can be used instead of several different x-rays because they scan your whole body. Often, a machine that combines a PET scanner and a CT scanner (called a PET/CT) is used, which gives more information about areas of cancer and cancer spread.
For more information about scans and x-rays, see our document Imaging (Radiology) Tests.
Last Medical Review: 07/02/2014
Last Revised: 12/11/2014