|Can Vulva Cancer Be Diagnosed Early?
The best way to detect cancer of the vulva early is to have a regular Pap screening and pelvic examination by your doctor. This screening enables physicians to find abnormal cells before they become cancerous, helping to prevent the onset of vulva and cancer of the vagina as well as cervical cancer. If a problem is detected the woman will be referred to a gynecologist, who specializes in the female genital system, for further testing.
Recognizing Signs And Symptoms
It is important to know the symptoms of vulva cancer so that you can report any suspicious changes to your doctor. Of course ideally it is better not to even wait for symptoms to occur, but rather use regular Pap tests to pick up changes even earlier.
Most women with the precancerous condition vulvar intraepithelial neoplasia (VIN) show no symptoms. The most likely symptom, if there is one, is an itching that does not go away. The woman might even try yeast infection treatments unsuccessfully to cure it. During a physical examination VIN may be detected by raised white areas on the vulvar skin, or the skin can appear pinker, darker and thicker than the surrounding tissue.
Almost all women with invasive cancer of the vulva will have symptoms. The early signs squamous cell (the most common type of vulva cancer) is similar to VIN but as the cancer grows a lump or tumor may be visible. The skin can become raw and red looking and raised white bumps on the surface will feel rough to touch. About 50 percent of women will also experience persistent itching and some complain of burning or painful urination and a bleeding discharge. An open sore or ulcer that will not heal is another clear indication. A less common type of vulvar cancer, verrucous carcinoma appears similar to genital warts with cauliflower shaped growths. A change in a mole that has been present in the vulva for years is a sign of vulvar melanoma. The mole can become darker, more ragged at the edge or grow in size. A distinct lump on either side of the vaginal opening can be a sign of Bartholin gland carcinoma; although more commonly it is a benign cyst. Paget disease can cause the vulva skin to turn red, scaly and sore.
How Is It Diagnosed?
The first thing a doctor will do is take a medical history to determine what symptoms, if any, you have and if you have any risk factors. Then he will carry out a pelvic examination, which is a physical exam of the reproductive organs - vulva, vagina, cervix, ovaries, fallopian tubes and ovaries. This exam can rule out many situation including pregnancy, vaginitis, cystoceles, vaginal dryness and genital warts. Next the doctor will carry out a Pap smear test, using a fine brush and a small spatula to scrape cells from the vulva, vagina and cervix. The cells are then fixed on a slide or in solution and sent to a lab for testing.
If there are signs of vulvar cancer the woman is usually referred at this point to a gynecologist for biopsy. This is the only way to determine for sure if cancer is present. A small area of tissue from the vulva is removed and sent to a pathologist for examination under microscope. This may be performed by punch biopsy which removes a core of skin about 4mm wide. No stitches are necessary. If the area to be assessed is smaller the gynecologist may inject a local anesthetic into the vulva and remove a slice of skin by scalpel (excisional biopsy). The skin may need sewing back together. In both procedures the doctor will probably use a colposcope, which is a lighted instrument with a magnifying lense, to select the best area for biopsy. A solution called acetic acid (similar to vinegar) may be swabbed on the area to turn the VIN areas white, making them easier to view through the colposcope. Using a colposcope in this manner is called a vulvoscopy.
Staging The Cancer
The presence of cancer will be determined by the biopsy. If the result is positive, the next step is to find out how far the cancer has spread: the size of the tumor, how deep it has grown into surrounding tissues, and if it has spread to distant organs via the lymph nodes or blood stream (metastasized). This process is known as vulva cancer staging. It is an essential part of the diagnostic process because it helps determine the optimal plan for vulva cancer treatment. It also helps predict prognosis and outcome for the patient (see Vulva Cancer Survival Rates). Several tests may be used in the staging process and these include:
An X-ray of the chest and lungs may be completed to check for other health problems that might interfere with the effectiveness of certain cancer treatments.
Computed Tomography (CT) Scan
CT scans provide better imaging of soft tissues than conventional X-rays which makes them more useful for evaluating tumors. The machine rotates around the body and produces detailed cross-sectional computer images as it does so. The patient may be injected with a contrast dye to help better outline the structures of the body. CT scans take longer than regular X-rays and the patient needs to lie still on the table while it is being done. They are not often needed for vulvar cancer patients but they can provide detailed information about the size, position and shape of a tumor. They can also help to locate any enlarged lymph nodes or to detect the sentinel node in the groin area if a sentinel lymph node procedure is necessary (this is similar procedure to a Sentinel Lymph Node Biopsy (SLNB), see Breast Biopsy).
Magnetic Resonance Imaging (MRI)
This test uses strong magnets and radio waves rather than X-rays. Like the CT scan it produces digital cross-sectional images of the body, but it also produces vertical images. MRI scans tend to be less comfortable for the patient than CT scans because they take longer to perform and the person has to lie inside a tube-shaped piece of equipment which some find claustrophobic. Contrast dyes are also usually administered. MRIs are rarely used for early stages of vulva cancer but they may be used in later stages to assess pelvic tumors. They are also useful to assess lymph nodes in the groin and to check if cancer has spread to the spinal cord or brain.
Positron Emission Tomography (PET) Scan
A PET scan is not commonly used for vulva cancer, however it may be useful if doctors suspect the cancer has spread to other parts of the body but are not exactly sure where. The test involves using glucose which contains a radioactive atom. Any malignant cells in the body will greedily take up the glucose at a faster rate than normal cells. The PET scan is then used for scanning areas of the body to identify which areas have amassed the glucose. New machines which combine PET and CT scans are even more accurate again.
Less Common Tests
This procedure involves using a cystoscope to look inside the bladder and the urethra. The scope is inserted through the vagina, up the urethra and into the bladder. Tiny surgical instruments on the end of the scope allow the doctor to remove a tiny sample of tissue for biopsy. It is commonly used for investigating persistent urinary tract infections and bladder stones. However it is used in this instance to check for signs of cancer spread. Most patients choose to have the procedure under general anesthesia. Traditionally cystoscopy was a standard part of the work-up for vulva cancer but it performed less often these days.
Proctoscopy or Proctosigmoidoscopy
This is a visual inspection of the rectum using a proctoscope, or lighted tube. The tube is lubricated and inserted into the anus. Typically it is used to check for hemorrhoids or rectal polyps. It was used in the past for vulvar cancer work-ups, but is not standard anymore.
Also known as intravenous pyelography, this uses an X-ray to check the urinary tract, specifically the kidneys, urethras, bladder and urethra. A contrast dye is injected into the hand or arm which then starts to filter to the urinary tract area turning the organs bright white. X-rays are then taken of the abdomen area. The procedure takes between 30 and 60 minutes. It is not usually performed for vulva cancer unless there are concerns that the disease is at an advanced stage.
For general advice, see our article on Cancer Diagnosis.
Questions To Ask Your Doctor
• What stage of cancer do I have?
• Based on my diagnosis, what is my best choice of treatment?
• What are the short and long-term effects of those treatments?
• Will I need skin grafts to the vulva?
• How long is the healing process?
• Will I retain all feelings in the vulva?
• Will my clitoris be preserved?
• Will I need lymph node dissection?
• What are my chances of lymphedema?
• Do you recommend counseling for me and my partner?
• How do I select a surgeon or doctor for treatment?
• What follow-up plan with my gyno/surgeon or oncologist will be necessary?
• Will I be cured?
• What is the chance of recurrence? (Recurrent vulva cancer)
• Will I need any rehabilitation services?
• Should I consider cancer clinical trials?