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.[1].
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.[2].
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 .[4].
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.[2]. 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.[2].
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.[2].
Pruritis Women with vulval cancer may present with pruritis .Persistent itching can be found,[2].
Bleeding Presentation with bleeding is not uncommon and examination of the vulva in women reporting postmenopausal bleeding is crucial.[2].
Painful urination Affected women sometimes complain painful urination.[2].
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.[3].
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.[3].
References
  1. EDEY KATHARINE, MURDOCH JOHN. FIGO staging in vulval and endometrial cancer. [online] December, 12(4):245-249 [viewed 22 August 2014] Available from: doi:10.1576/toag.12.4.245.27616
  2. PALMER JULIA E., GILLESPIE ALAN M.. Diagnosis and management of squamous-cell vulval carcinoma. Trends Urology, Gynecol. Sexual Health [online] 2010 March, 15(2):20-25 [viewed 22 August 2014] Available from: doi:10.1002/tre.132
  3. DI SAIA PJ, MORROW CP, TOWNSEND DE. Cancer of the vulva. Calif Med [online] 1973 Jun, 118(6):13-18 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1454947
  4. RUMBOLD AR, TAN SE, CONDON JR, TAYLOR-THOMSON D, NICKELS M, TABRIZI SN, DAVY ML, O’BRIEN MM, CONNORS CM, ZARDAWI I, STANKOVICH J, GARLAND SM. Investigating a cluster of vulvar cancer in young women: a cross-sectional study of genital human papillomavirus prevalence BMC Infect Dis [online] :243 [viewed 23 August 2014] Available from: doi:10.1186/1471-2334-12-243

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.[1].
Vulval skin discoloration Alteration in vulval skin texture or discolouration can also be seen.[1].
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. [1]. 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.[2].
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,[1],
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.[3].
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.[3]. 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.[4].
References
  1. PALMER JULIA E., GILLESPIE ALAN M.. Diagnosis and management of squamous-cell vulval carcinoma. Trends Urology, Gynecol. Sexual Health [online] 2010 March, 15(2):20-25 [viewed 22 August 2014] Available from: doi:10.1002/tre.132
  2. LéONARD B, KRIDELKA F, DELBECQUE K, GOFFIN F, DEMOULIN S, DOYEN J, DELVENNE P. A Clinical and Pathological Overview of Vulvar Condyloma Acuminatum, Intraepithelial Neoplasia, and Squamous Cell Carcinoma Biomed Res Int [online] 2014:480573 [viewed 23 August 2014] Available from: doi:10.1155/2014/480573
  3. VAN DE NIEUWENHOF HP, DE HULLU JA, KAANDERS JH, BULTEN J, MASSUGER LF, VAN KEMPEN LC. Hemoglobin level predicts outcome for vulvar cancer patients independent of GLUT-1 and CA-IX expression in tumor tissue Virchows Arch [online] 2010 Dec, 457(6):693-703 [viewed 23 August 2014] Available from: doi:10.1007/s00428-010-0981-x
  4. DI SAIA PJ, MORROW CP, TOWNSEND DE. Cancer of the vulva. Calif Med [online] 1973 Jun, 118(6):13-18 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1454947

Differential Diagnoses

Fact Explanation
Paget disease of the vulva Paget’s disease of the vulva (PDV) is a rare locally recurrent chronic disease, accounting for less than 1% of vulval neoplasms. The vulva remains the most frequently involved site with 65% of extramammary Paget’s disease located in this area. It occurs predominantly in postmenopausal Caucasian women. The rarity of this disease has caused difficulties in its characterization. They also occur as a normal constituent of genital skin in association with mammary like glands of the vulva.It appears as a pink eczematoid area with white islands of hyperkeratosis that is accompanied by pruritus in 70% of patients . A palpable mass should raise concern for underlying invasive disease.[3].
VIN Usual type VIN (warty, basaloid, or mixed) occurs in young women. The incidence peaks at 45–49 years old, and has increased in recent years and has nearly doubled in the last decades, especially in young women. It is causally related to HPV infection. Other risk factors include smoking and immunosuppression. The lesions are frequently multifocal and have the potential to progress to invasive carcinoma. Differentiated VIN affects older women, tends to be unifocal, and unicentric. It is not associated with HPV infection, but it is associated with vulval dermatosis, mainly lichen sclerosus.The disease is asymptomatic in about 50% of cases. When symptomatic, the main complaints include itching, pruritus, pain, and dyspareunia. The appearance is variable from unique to multifocal lesions, flat, raised, or eroded, white, grey, red, or brown. After visual or colposcopic examination, such lesions should be biopsied for histological examination. A complete gynaecologic examination is of paramount importance to exclude any multicentric lesions that may affect the cervix, the vagina, and the anal region. The diagnosis of VIN can be subtle. To avoid delay, the physician must exercise a high degree of suspicion. Vulvar biopsy should be used liberally.[1].
Lichen sclerosus, Lichen sclerosus is a lymphocyte mediated dermatosis commonly presenting in the anogenital region of postmenopausal women. Although of somewhat uncertain aetiology, autoimmune or hormonal mechanisms are suggested. 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. Here the vulval skin becomes fragile, pale and white in appearance. Vulval atrophy may develop with loss of vulval features (labia/clitoris). Fissures and fusion of the labia, clitoral hood and urethra may occur.[2].
Genital herpes Clinical presentation, alone, is seldom sufficient to diagnose genital herpes. While some patients present with the classic constellation of bilateral ulcerative lesions, tender inguinal lymphadenopathy, constitutional signs such as fever, and complaints of headache, malaise, and dysuria.Recent studies have shown that recurrent episodes as well as subclinical virus shedding vary in frequency among individuals and, over time, within an individual. Subclinical virus shedding is up to three times more frequent in the first 3 months after acquisition of genital herpes than in later month.[4].
Condyloma acuminatum (CA) Condyloma acuminatum, intraepithelial neoplasia, and squamous cell carcinoma are three relatively frequent vulval lesions.Vulval human papillomavirus (HPV) infection is responsible for the development of benign tumors such ascondylomata acuminata. Condylomata acuminate are vulvar exophytic benign tumors which result usually (90%) from HPV types 6 and 11 (several other HPV types can be involved) . Up to 83% of women with external genital warts or a history of external genital warts have a concomitant cervical HPV infection.The following risk factors have been described, including smoking, hormonal contraceptives, multiple sexual partners, and early coital age. Patients who develop CA complain of painless bumps and, less frequently, of pruritus, discharge, or bleeding. Lesions are commonly multiple (multicentric) and multifocal, also affecting the perianal, vaginal, and cervical regions, but oral and laryngeal regions may also be involved. Latent illness may become active with pregnancy and immunosuppression. Lesions may regress spontaneously, remain stable, or progress in size and/or number.CA are soft, raised masses, with smooth, verrucous, or lobulated aspects that may appear as pearly, filiform, fungating, or plaque-like eruptions. The surface commonly shows finger-like projections, generally nonpigmented. They mainly occur in the moist areas of the labia minora and vaginal opening, but virtually, all genital regions may be affected (fourchette, labia minora/majora, pubis, clitoris, urethral meatus, perineum, perianal region, anal canal, introitus, vagina, and ectocervix). Therefore, minutious colposcopic examination, using acetic acid 2–5%, is of crucial importance to detect potentially multiple involved sites.[1].
References
  1. LéONARD BORIS, KRIDELKA FREDERIC, DELBECQUE KATTY, GOFFIN FREDERIC, DEMOULIN STéPHANIE, DOYEN JEAN, DELVENNE PHILIPPE. A Clinical and Pathological Overview of Vulvar Condyloma Acuminatum, Intraepithelial Neoplasia, and Squamous Cell Carcinoma. BioMed Research International [online] 2014 December, 2014:1-11 [viewed 23 August 2014] Available from: doi:10.1155/2014/480573
  2. PALMER JULIA E., GILLESPIE ALAN M.. Diagnosis and management of squamous-cell vulval carcinoma. Trends Urology, Gynecol. Sexual Health [online] 2010 March, 15(2):20-25 [viewed 23 August 2014] Available from: doi:10.1002/tre.132
  3. ASMOUKI HAMID, OUMOULOUD RACHID, ABOULFALAH ABDERRAHIM, SOUMMANI ABDERRAOUF, MARRAT ABDELOUAHED. Paget’s Disease of the Vulva in Premenopausal Woman Treated with Only Surgery: A Case Report. Case Reports in Oncological Medicine [online] 2012 December, 2012:1-4 [viewed 23 August 2014] Available from: doi:10.1155/2012/854827
  4. ASHLEY RL, WALD A. Genital Herpes: Review of the Epidemic and Potential Use of Type-Specific Serology Clin Microbiol Rev [online] 1999 Jan, 12(1):1-8 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88903

Investigations - for 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.[3].
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.[1]. The lesions may assume a great variety of morphologic characteristics, including exophytic and papillary or endophytic and ulcerative.[3]. 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.[2].
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.[1].
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. [1].
References
  1. PALMER JULIA E., GILLESPIE ALAN M.. Diagnosis and management of squamous-cell vulval carcinoma. Trends Urology, Gynecol. Sexual Health [online] 2010 March, 15(2):20-25 [viewed 22 August 2014] Available from: doi:10.1002/tre.132
  2. LéONARD B, KRIDELKA F, DELBECQUE K, GOFFIN F, DEMOULIN S, DOYEN J, DELVENNE P. A Clinical and Pathological Overview of Vulvar Condyloma Acuminatum, Intraepithelial Neoplasia, and Squamous Cell Carcinoma Biomed Res Int [online] 2014:480573 [viewed 22 August 2014] Available from: doi:10.1155/2014/480573
  3. DI SAIA PJ, MORROW CP, TOWNSEND DE. Cancer of the vulva. Calif Med [online] 1973 Jun, 118(6):13-18 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1454947

Investigations - Fitness for Management

Fact Explanation
FBC Full blood count is performed as a pre operative investigation. Comorbidity assessment is important in this elderly population.[1]. With the aim to assess the role of anemia, preoperative hemoglobin levels were recorded and found to be low in most of the patients.[2].
Electrocardiogram Also used for pre operative assessment.[1].
References
  1. EDEY KATHARINE, MURDOCH JOHN. FIGO staging in vulval and endometrial cancer. [online] December, 12(4):245-249 [viewed 22 August 2014] Available from: doi:10.1576/toag.12.4.245.27616
  2. VAN DE NIEUWENHOF HP, DE HULLU JA, KAANDERS JH, BULTEN J, MASSUGER LF, VAN KEMPEN LC. Hemoglobin level predicts outcome for vulvar cancer patients independent of GLUT-1 and CA-IX expression in tumor tissue Virchows Arch [online] 2010 Dec, 457(6):693-703 [viewed 23 August 2014] Available from: doi:10.1007/s00428-010-0981-x

Investigations - Followup

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.[1]. 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.[2].
References
  1. PALMER JULIA E., GILLESPIE ALAN M.. Diagnosis and management of squamous-cell vulval carcinoma. Trends Urology, Gynecol. Sexual Health [online] 2010 March, 15(2):20-25 [viewed 22 August 2014] Available from: doi:10.1002/tre.132
  2. LéONARD B, KRIDELKA F, DELBECQUE K, GOFFIN F, DEMOULIN S, DOYEN J, DELVENNE P. A Clinical and Pathological Overview of Vulvar Condyloma Acuminatum, Intraepithelial Neoplasia, and Squamous Cell Carcinoma Biomed Res Int [online] 2014:480573 [viewed 22 August 2014] Available from: doi:10.1155/2014/480573

Investigations - Screening/Staging

Fact Explanation
X ray Preliminary histological diagnosis is mandatory before radical treatment and a chest X-ray is a routine staging requirement.[2].
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.[1].
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.[1].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.[2].
MRI MRI and PET CT are not part of a routine work up and must be prescribed on individual basis.[3].
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.[1].
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.[1].
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.[1].
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.[1].
References
  1. PALMER JULIA E., GILLESPIE ALAN M.. Diagnosis and management of squamous-cell vulval carcinoma. Trends Urology, Gynecol. Sexual Health [online] 2010 March, 15(2):20-25 [viewed 22 August 2014] Available from: doi:10.1002/tre.132
  2. EDEY KATHARINE, MURDOCH JOHN. FIGO staging in vulval and endometrial cancer. [online] December, 12(4):245-249 [viewed 22 August 2014] Available from: doi:10.1576/toag.12.4.245.27616
  3. LéONARD B, KRIDELKA F, DELBECQUE K, GOFFIN F, DEMOULIN S, DOYEN J, DELVENNE P. A Clinical and Pathological Overview of Vulvar Condyloma Acuminatum, Intraepithelial Neoplasia, and Squamous Cell Carcinoma Biomed Res Int [online] 2014:480573 [viewed 22 August 2014] Available from: doi:10.1155/2014/480573

Management - General Measures

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.[1].
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.[1].
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.[1]. Bilateral radical inguinofemoral (IF) nodal dissection carries a heavy potential morbidity (lymphocele, lymphoedema) and must therefore be individualized.[2].
Radical vulvectomy Used previously. The “traditional” radical vulvectomy is no longer systematically applied due to its major deleterious impact on vaginal function.[2].
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).[2].
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.[1].
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,[1]. 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.[2].
References
  1. PALMER JULIA E., GILLESPIE ALAN M.. Diagnosis and management of squamous-cell vulval carcinoma. Trends Urology, Gynecol. Sexual Health [online] 2010 March, 15(2):20-25 [viewed 22 August 2014] Available from: doi:10.1002/tre.132
  2. LéONARD B, KRIDELKA F, DELBECQUE K, GOFFIN F, DEMOULIN S, DOYEN J, DELVENNE P. A Clinical and Pathological Overview of Vulvar Condyloma Acuminatum, Intraepithelial Neoplasia, and Squamous Cell Carcinoma Biomed Res Int [online] 2014:480573 [viewed 22 August 2014] Available from: doi:10.1155/2014/480573

Management - Specific Treatments

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.[1].
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.[1].
References
  1. PALMER JULIA E., GILLESPIE ALAN M.. Diagnosis and management of squamous-cell vulval carcinoma. Trends Urology, Gynecol. Sexual Health [online] 2010 March, 15(2):20-25 [viewed 22 August 2014] Available from: doi:10.1002/tre.132