Vulvar Cancer

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Early Detection, Diagnosis, and Staging TOPICS

How is vulvar cancer diagnosed?

Signs and symptoms of vulvar cancers and pre-cancers

Vulvar intraepithelial neoplasia

Most women with vulvar intraepithelial neoplasia (VIN) have no symptoms at all. When a woman with VIN does have a symptom, it is most often itching that does not go away or get better. An area of VIN may look different than normal vulvar skin. It is often thicker and lighter than the normal skin around it. However, an area of VIN can also appear red, pink, or darker than the surrounding skin.

Because these changes are often caused by other conditions that are not pre-cancerous, some women don't realize that they might have a serious condition. Some try to treat the problem themselves with over-the-counter remedies. Sometimes doctors might not even recognize the condition at first.

Invasive squamous cell cancer of the vulva

Almost all women with invasive vulvar cancers will have symptoms. The symptoms of early invasive vulvar cancer are similar to those that can be seen with VIN. As the cancer grows, a distinct tumor may be seen. The cancer might appear as a red, pink, or white bump (or bumps) with a wart-like or raw surface. The area could also appear white and feel rough.

About half of the women with vulvar cancer complain of persistent itching and a growth. Some also complain of pain, burning, painful urination, and bleeding and discharge not associated with the normal menstrual period. An open sore (ulcer) that persists for more than a month is another sign.

Verrucous carcinoma, a subtype of invasive squamous cell vulvar cancer, appears as cauliflower-like growths similar to genital warts.

Vulvar melanoma

Melanoma can appear as a darkly pigmented growth. A change in a mole that has been present for years can also indicate melanoma. The ABCD rule can be used to help tell a normal mole from one that could be melanoma.

Asymmetry: One-half of the mole does not match the other.

Border irregularity: the edges of the mole are ragged or notched.

Color: The color over the mole is not the same. There may be differing shades of tan, brown, or black and sometimes patches of red, blue, or white.

Diameter: The mole is wider than 6 mm (about 1/4 inch).

The most important sign of melanoma is a change in size, shape, or color of a mole. Still, not all melanomas fit the ABCD rule.

Bartholin gland cancer

A distinct mass (lump) on either side of the opening to the vagina can be the sign of a Bartholin gland carcinoma. More often, however, a lump in this area is from a Bartholin gland cyst, which is much more common.

Paget disease

Soreness and a red, scaly area are symptoms of Paget disease of the vulva.

Knowing what to look for can sometimes help with early detection, but it is even better not to wait until you notice symptoms. Get regular well-women exams.

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 will take a Pap smear.

Biopsy

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 toluidine blue dye 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) or a hand-held magnifying lens to select areas to biopsy. The vulva is treated with a dilute solution of acetic acid (which is also the main ingredient in 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, local anesthetic is injected into the skin to make it numb. If the abnormal area is small, it may be completely removed by an excisional biopsy. In this procedure, the doctor removes a small area of skin with a scalpel. Sometimes stitches may be 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.

Further testing

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.

Cystoscopy

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.

Proctoscopy

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. This test 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

This permits a more thorough exam that can better evaluate how much the cancer has spread to internal organs of the pelvis.

Imaging tests

Chest x-ray

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. A CT scan can provide information about the size, shape, and position of tumors and can be helpful to see if the cancer has spread to other organs. It can also help find enlarged lymph nodes that might have cancer cells.

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 medication 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 cancers use glucose at a higher rate than normal tissues, the radioactivity tends to concentrate in the cancer. A special camera is used to detect the radioactivity. This test can be helpful for spotting small collections of cancer cells, and can be useful in 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. PET scans can be used instead of several different x-rays because they scan your whole body. Special devices combine a CT scan and a PET scan to even better pinpoint the tumor. However, these scans are rarely used in patients with early vulvar cancer.


Last Medical Review: 02/05/2013
Last Revised: 02/13/2014