Cancer of the Vulva

CANCER OF THE VULVA

Primary cancer of the vulva represents 3% to 5% of all gyneco-logic malignancies and is seen mostly in postmenopausal women, although its incidence in younger women is increasing. The me-dian age for cancer limited to the vulva is 44 years, whereas the median age for invasive vulvar cancer is 61 years. Possible risk fac-tors include hypertension, obesity, diabetes, and immunosup-pression. Squamous cell carcinoma accounts for most primary vulvar tumors. Less common are Bartholin’s gland cancer and malignant melanoma. Little is known about what causes this dis-ease; however, increased risk may be related to chronic vulvar ir-ritation, vulvar disorders, HPV, and smoking.

Clinical Manifestations

Long-standing pruritus and soreness are the most common symp-toms of vulvar cancer. Itching occurs in half of all patients with vulvar malignancy. Bleeding, foul-smelling discharge, and pain may also be present and are usually signs of advanced disease. Can-cerous lesions of the vulva are visible and accessible and grow rel-atively slowly. Early lesions appear as a chronic dermatitis; later, the patient may note a lump that continues to grow and becomes a hard, ulcerated, cauliflower-like growth. Biopsy should be per-formed on any vulvar lesion that persists, ulcerates, or fails to heal quickly with proper therapy. Vulvar malignancies may appear as a lump or mass, redness, or a lesion that fails to heal.

The nurse is in an ideal position to encourage a woman to per-form vulvar self-examination regularly. Using a mirror, the pa-tient can see what constitutes normal female anatomy and learn about changes that should be reported (eg, lesions, ulcers, masses, and persistent itching). The nurse must urge women to seek health care if they notice anything abnormal because this is one of the most curable of all malignant conditions.

Medical Management

Vulvar intraepithelial lesions are preinvasive and are also called vulvar carcinoma in situ. They may be treated by local excision, laser ablation, chemotherapeutic creams (ie, 5-fluorouracil), or cryosurgery.When invasive vulvar carcinoma exists, primary treatment may include wide excision or removal of the vulva (vulvectomy). An effort is made to individualize treatment, depending on the extent of the disease. A wide excision is performed only if lymph nodes are normal. More pervasive lesions require vulvectomy with deep pelvic node dissection. Vulvectomy is very effective at prolonging life but is frequently followed by complications (ie, scarring, wound breakdown, leg swelling, vaginal stenosis, or rectocele). To reduce complications, only necessary tissue is removed.

Radiation is used to treat unresectable tumors or cancer that has spread to the lymph nodes. If a widespread area is involved or the disease is advanced, a radical vulvectomy with bilateral groin dissection may be performed. Excision and evaluation of the sen-tinel node, which drains the primary tumor, may be performed. If negative, full groin dissection may be omitted (Duffy, 2001). Antibiotic and heparin prophylaxis may be prescribed preopera-tively and continued postoperatively to prevent infection, deep vein thrombosis, and pulmonary emboli. Elastic compression stockings are applied to reduce the risk for deep vein thrombosis.

Clinical trials to determine the most effective treatment are difficult to conduct, as there are few patients with this condition. Morbidity with recurrence of the disease is high. Patterns can vary in patients.