Vulva Cancer Treatment
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Small early stages of cancer of the vulva, which make up nearly 50 percent of cases, are usually treated by surgery alone. More advanced stages are usually treated with a combination of external radiation therapy and surgery. Surgery can be a relatively minor procedure in which a small tumor and some surrounding tissue are removed. Or it can be highly invasive and extensive involving total removal of the vulva and other surrounding organs. More recent therapy plans are tailoring a combination of surgery, chemo (see Chemotherapy Guide) and radiation according to the type and extent of the disease present. Clinical trials are currently underway into the effects of radiation and chemo before surgery in advanced stages of vulva cancer.
Once you have received a vulva cancer diagnosis and the cancer has been staged (vulva cancer staging) the next part of the process is for your healthcare team to recommend a treatment plan. As cancer is rarely a medical emergency, you will have time to think about your options without feeling hurried. You may even request a second opinion (in fact your health insurance company may insist on this). The type of treatment plan recommended will depend on the stage of your disease but other factors such as your age, general health and individual circumstances will also play a role. The vast majority of vulvar cancers are diagnosed as squamous cell, so we will deal with the treatment options for this type of disease first.
Inguinal Lymph Node Dissection
Sentinel Lymph Node Biopsy
Follow-up care for stage 0 is very important because VIN can recur or reappear in different parts of the vulva. The 5 year survival rate however is near to 100 percent. For signs of this disease, see Symptoms of vulva cancer.
There is still a good chance of cure with this stage of the disease. There is no standard procedure which can be applied to all women. First the following factors must be taken into consideration:
If there is only one tumor and no sign of VIN or lymph node infection (stage 1a) then radical local excision is the usual treatment choice, regardless of the woman's age. The tumor is removed along with a 1cm margin of normal tissue for safety around it. This procedure is normally combined with some exploration of the lymph nodes. If VIN or other abnormalities (stage 1b) also occur the treatment may depend on the woman's age. Older women with persistent long-standing symptoms and who are not sexually active may choose a radical vulvectomy. Younger women may choose to have the tumor removed by radical local excision and the remainder of the vulva to be treated by more conservative methods. This may include the use of topical steroids or laser therapy. In both younger and older women lymph nodes in the groin will need to be investigated or removed. A lymph node dissection or a sentinel node biopsy operation can be performed. If the woman is not physically able for the procedure then radiation therapy to the groin area will be given instead. A needle biopsy before radiation will determine if the nodes contain cancer.
Vulva cancer of the clitoris can cause particular problems. Removal of the clitoris may have major emotional and sexual consequences. Also because removal of the clitoris can interfere with lymph drainage in the area it can cause serious swelling. Radiation therapy can be applied to the area as one solution although the skin usually reacts quickly so treatment has to be halted for a few weeks. A radical local excision to remove a tumor may still preserve some of the clitoris.
Cancer has spread to structures near the vulva such as the lower third of the vagina, urethra and/or anus. This stage is usually treated with partial or radical vulvectomy and removal of the lymph nodes of the groin (or a sentinel node biopsy). Radiation therapy to the edges of the tissue removed by surgery may be needed as a follow-up to destroy any possible remaining cancer cells. The procedures may also be reversed, with radiation first and then surgery. Older women who may not be strong enough for surgery may just be treated with radiation. The 5 year survival rate for women without lymph nodes being affected in stage 2 ranges from 70 to 90 percent. This drops to 40 percent if cancer is detected in the nodes.
By this stage cancer has spread to the lymph nodes. Treatment is generally the same as stage 2. Surgery to remove the tumor will be required, either by radical wide local incision or partial/complete radical vulvectomy. The lymph nodes in the groin will also be removed. This is usually followed-up by radiation therapy (with or without chemotherapy). This is done to kill any possible remaining cancer cells and preserve as many of the surrounding structures as possible (vagina, anus etc). Occasionally radiation will be given before surgery in order to reduce the size of the tumor. If the woman is physically unable for surgery radiation, sometimes combined with chemo will be given. The chance of cure, as might be expected with advanced stages of cancer, is lower. The most important indicator is whether or not cancer cells are discovered in the lymph nodes.
Cancer has spread more extensively to other organs such as the pelvis, rectum, bladder, upper vagina, urethra and/or pelvic bone. Surgery is the key treatment option and the goal is to physically remove as much of the cancer as possible. The extent of the surgery will depend on how far the disease has spread. The most common type of surgery is a radical vulvectomy. Pelvic exenteration is another option, but it is so radical and severe it is rarely performed. Radiation and chemo may also be given before or after surgery. Lymph nodes will be removed by surgery and radiation will be applied to the area. See also Cancer Surgery and Cancer Surgery Recovery.
If vulva cancer comes back after treatment it is called recurrent. It can come back to the same spot (local recurrence), the nearby lymph nodes (regional recurrence) or to distant sites (distant recurrence, or metastasis). In the vast majority of cases (80 percent) a recurrence occurs within 2 years of treatment. When it comes to prognosis and outlook for the patient, the sooner it comes back the better. Radiation or radical excision can be applied to a small local recurrence. An extensive return might be treated with radical vulvectomy or pelvic exenteration. If the tumor returns after 2 years a combination of surgery and radiation will be used. If the cancer has spread to other organs chemotherapy and or radiation may be given as palliative therapy. A cure is not expected but treatment focuses on reducing pain and symptoms. The woman will be encouraged to enter clinical trials for experimental treatments.
If the cancer is not invasive and Paget's disease is present treatment is usually a wide local excision or simple vulvectomy. If adenocarcinoma has invaded a Bartholin gland or vulva skin sweat gland then a partial radical vulvectomy is usually recommended along with removal of the groin lymph nodes (one or both depending on the site of the primary tumor).
This is no different to skin cancers in any other part of the body. They can be quite unpredictable and aggressive. Ideally they are treated with surgery and the regional lymph nodes are also removed.
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