VULVAR CANCER – Causes and Risk Factors, Stages, Clinical Manifestations, Diagnostic Evaluations, Management and Nursing Management

Vulvar cancer is an uncommon cancer of the outer surface area of the female genitalia. Vulvar cancer most often affects the outer vaginal lips. Less often, cancer affects the inner vaginal lips or the clitoris.

Most vulvar cancers are squamous cell carcinomas – a type of skin cancer – that develop slowly over years. A small number of vulvar cancers begin as melanoma. Rarely, vulvar cancers develop in the mucus-producing glands on the sides of the vaginal opening. The sexually transmitted infection human papillomavirus (HPV) is believed to play a role in developing this form of vulvar cancer.

 

CAUSES AND RISK FACTORS

Although the exact cause of vulvar cancer isn’t known, certain factors appear to increase risk of the disease. These factors include:

• Age: About 50 percent of women with vulvar cancers are older than 70 when they are diagnosed. This cancer isn’t limited to older women, however.
• HPV infection: This sexually transmitted disease is present in younger women who have vulvar cancer. Having HPV or using unsafe sex practices that put at greater risk of HPV infection, increases risk of vulvar cancer.
  
• Smoking: smoking exposes to cancer-causing chemicals that may increase risk of vulvar cancer. Women with a history of genital warts or HPV have an even further increased risk of vulvar cancer if they smoke.
  
• Human immunodeficiency virus (HIV): this virus weakens the immune system, which may make more susceptible to HPV infections, thereby increasing risk of vulvar cancer.
  
• Vulvar intraepithelial neoplasia: though most cases of this precancerous condition won’t turn into vulvar cancer, the condition does increase risk of vulvar cancer and should be monitored by doctor.
  
• Lichen sclerosus: about 4 percent of women with this condition, which causes the vulva to become thin and itchy, later develop vulvar cancer.
  
• A history of melanoma or suspicious moles: if patient have a family or personal history of this serious type of skin cancer anywhere on body, or if have a personal or family history of unusual moles, are at increased risk of a vulvar melanoma.​
  

STAGES FOR VULVAR CANCER

Stage 0: Abnormal cells are found on the surface of the vulvar skin. Stage 0 is also called carcinoma in situ.

Stage I: cancer has formed and is found in the vulva only or in the vulva and perineum (area between the rectum and the vagina). The tumor is 2 centimeters or smaller and has spread to tissue under the skin.

Stage III: The cancer is of any size and either: is found only in the vulva or the vulva and perineum and has spread to tissue under the skin and to nearby lymph nodes on one side of the groin; or has spread to nearby tissues such as the lower part of the urethra and/or vagina or anus, and may have spread to nearby lymph nodes on one side of the groin.

Stage IV: cancer spread to bladder, bowel, pelvic bone, pelvic lymph nodes, and/or other parts of the body.

 

CLINICAL MANIFESTATIONS

Vulvar cancer often does not cause early symptoms. When symptoms occur, they may be caused by vulvar cancer or by other conditions. A doctor should be consulted if any of the following problems occur:

• A lump in the vulva
• Vulvar itching (pruritus) that does not go away in the vulvar area
  
• Bleeding not related to menstruation (periods)
  
• Tenderness in the vulvar area
  
• Pain, vaginal discharge, and/or painful urination (dysuria)
  
• Skin changes, such as color changes or thickening
  

 

DIAGNOSTIC EVALUATIONS

• Physical exam and history
• Biopsy
  
• Cystoscopy and Proctoscopy
  
• Intravenous pyelogram (IVP)
  
• Chest X-ray
  
• Computerized tomography
  
• Magnetic resonance imaging (MRI)
  
• Positron emission tomography (PET)
  

 

MANAGEMENT

Treatment options for vulvar cancer depend on the type and stage of cancer and include surgical removal of the tumor, radiation therapy, chemotherapy or a combination of these.

 

1. Surgery: The more advanced a vulvar cancer is, the more tissue that may need to be surgically removed. Options include:

• Laser surgery: if the cancer is in the early noninvasive stages, laser surgery is an option. Doctor aims a laser beam at the layer of vulva that contains cancer, killing the cancer cells.
  
• Wide local excision: a surgical procedure to remove the cancer and some of the normal tissue around the cancer
  
• Radical local excision: a surgical procedure to remove the cancer and a large amount of normal tissue around it. Nearby lymph nodes in the groin may also be removed.
  
• Vulvectomy: several types of vulvectomy exist. A skinning vulvectomy removes only the top layer of skin where the cancer is. Doctor may graft skin from another part of body to cover this area. A simple vulvectomy involves removing the entire vulva. These types of vulvectomies are performed in people with noninvasive vulvar cancer. In a radical vulvectomy, the entire vulva, including the clitoris, and nearby tissue are removed. Nearby lymph nodes may also be removed.
  
• Pelvic exenteration: A surgical procedure to remove the lower colon, rectum, and bladder. The cervix, vagina, ovaries and nearby lymph nodes are also removed. Artificial openings (stoma) are made for urine and stool to flow from the body into a collection bag.
  
• Lymph node removal: vulvar cancer often spreads to the lymph nodes in the groin, so doctor may remove these lymph nodes. Doctor may also tie off a major vein, the saphenous vein. Some doctors will try to avoid closing this vein to prevent additional risk of leg swelling that can occur with this procedure. After the procedure, patient will need a suction drain in the incision for several days.
  

 

2. Radiation therapy: Radiation given from outside the body (external beam radiation) is usually used only to treat the lymph nodes in the groin and pelvis, not the vulva itself. Sometimes it’s used with the hope of shrinking a large tumor so that it can be removed with less extensive surgery. Treated skin may look and feel sunburned for six to 12 months. Also, if radiation is used on the pelvic area, patient may experience problems with urination and premature menopause.

3. Chemotherapy: Chemotherapy uses drugs, often a combination of drugs, to destroy cancer cells. It can be given through a vein, by mouth or through skin (topically). Like radiation, chemotherapy may be used to shrink a large tumor before surgery. The most frequently used chemotherapies include cisplatin, methotrexate,bleomycin and mitomycin C.

 

NURSING MANAGEMENT

Avoiding risks: Patient can help prevent vulvar cancer by avoiding sexual behaviors that put at risk of sexually transmitted diseases such as HPV and HIV, both conditions that increase risk of vulvar cancer. These behaviors include not having sex at a young age, not having multiple partners, and not having sex with someone who’s had multiple partners. Condoms may lessen the risk of HPV transmission, but they cannot fully protect against HPV.
In addition, a vaccine against some forms of HPV is effective in preventing vulvar cancer as well as cervical and vaginal cancers. The vaccine is currently recommended for young women as they become sexually active, and its use is being studied in young men. Not smoking also reduce risk of vulvar cancer.
Regular exams: patient can help prevent invasive vulvar cancer by being aware of the signs and symptoms of vulvar cancer and having regular gynecologic exams to monitor for precancerous changes that may lead to vulvar cancer. When vulvar cancer is detected early, it’s highly treatable. The overall five-year survival rate is 96 percent when the lymph nodes aren’t involved. The rate drops to 64 percent if the cancer has spread to the lymph nodes.

 

 

VULVAR CANCER – Causes and Risk Factors, Stages, Clinical Manifestations, Diagnostic Evaluations, Management and Nursing Management