Vulvar Cancer

21.03.2024

VULVA CANCER DIAGNOSIS AND TREATMENT

Vulvar cancer is a type of cancer that develops in the vulva, the outer part of women's sexual organs. The vulva includes areas such as the lips (labia majora and labia minora), clitoris, vaginal entrance, and perineum. Vulvar cancer usually begins in the skin or mucous membranes of the vulva and can spread over time. Risk factors include HPV (Human Papillomavirus) infections, age, smoking, genital hygiene practices and sexual activity. Early diagnosis and treatment is of great importance in vulvar cancer because treatment success is higher in the early stages. Therefore, regular gynecological examinations and preventive measures such as HPV vaccination can help prevent vulvar cancer. Vulvar cancer can create physical and psychological challenges for patients, so it is also important for patients to receive emotional and social support.

WHAT ARE THE RISK FACTORS?

Vulvar cancer risk factors may include:

HPV (Human Papillomavirus) Infection: HPV plays an important role in the development of vulvar cancer. Particularly high-risk HPV types (for example, HPV 16 and 18) may increase the risk of vulvar cancer.

Age: Generally, the risk of vulvar cancer increases with age. Especially women aged 50 and over are at higher risk.

Smoking: Smoking may increase the risk of vulvar cancer.

Chronic Vulvar Disorders: Long-term skin problems, such as chronic vulvar irritation or inflammation, can increase the risk of vulvar cancer.

Fungal Infections: Chronic fungal infections (for example, Candida infections) may increase the risk of vulvar cancer.

Vulvar Intraepithelial Neoplasia (VIN): Vulvar precancerous lesions, called VIN, may increase the risk of vulvar cancer.

Previous Pelvic Radiation Therapy: Those who have had radiotherapy to the pelvic area may be at risk of vulvar cancer.

Weak Immune System: A weak immune system can reduce resistance to HPV infections and increase the risk of vulvar cancer.

Family History: People with a family history of vulvar cancer may be at higher risk due to genetic factors.

Vulvar cancer risk factors may vary from individual to individual, and not everyone is at the same risk. But understanding risk factors can help you be aware of early detection and preventive measures. Getting the HPV vaccine, paying attention to sexual health precautions and having regular gynecological examinations are important steps in reducing the risk of vulvar cancer.

Image 1: Vulvar cancer is a type of cancer seen in the female external genitalia.

HOW DOES IT OCCUR?

Vulvar cancer development mechanisms are a complex process and may occur as a result of the interaction of various factors. One of the most important mechanisms is high-risk HPV (Human Papillomavirus) infections. HPV can infect vulvar cells, causing changes in the DNA of these cells and contributing to the formation of precancerous lesions (VIN). However, HPV infection alone is not enough and other factors play a role in the development of vulvar cancer. Vulvar skin problems, such as chronic vulvar irritation, fungal infections, and previous vulvar lesions, can also increase the risk of cancer. Additionally, genetic factors and immune system weakness may also be effective in developmental mechanisms. Vulvar cancer occurs as a result of this complex combination of factors, and early diagnosis and preventive measures play an important role in reducing the risk.

WHAT ARE THE SYMPTOMS?

Symptoms of vulvar cancer may include:

Painless Swellings or Outward Growths in the Vulva: Abnormal swellings, nodules or outgrowths may be seen in the vulva area.

Itching or Burning: Vulvar cancer can cause genital discomfort such as itching, burning or irritation.

Vulvar Pain or Discomfort: Pain, discomfort, or painful intercourse may be experienced in the vulva.

Bleeding: Vaginal bleeding, bloody vaginal discharge, or bloody urine may occur due to vulvar cancer.

Ulcerations: Vulvar cancer can create open sores or ulcerations on the vulva.

Color Changes: Changes in vulva color, redness, or skin lesions may occur.

Lymph Node Swelling: Vulvar cancer may cause swollen lymph nodes in advanced stages.

If these symptoms suggest that you may have vulvar cancer, you should consult a doctor. Early diagnosis and treatment can increase treatment success, so it is important for people with any concerning symptoms to contact a physician.

HOW IS IT DIAGNOSED?

The diagnosis of vulvar cancer is made as a result of medical tests and examination. The first step is to take a detailed patient history regarding the patient's symptoms and medical history. Then, a physical examination is performed and abnormal appearances, lesions or swellings in the vulva area are evaluated. One of the most commonly used methods for diagnosis is to perform a biopsy. During this process, samples are taken from suspicious tissue and the presence of cancer cells is confirmed by pathological examination. Additionally, imaging tests such as computed tomography (CT) or magnetic resonance imaging (MRI) may be used to determine the stage of the cancer. Diagnosis is important for establishing the patient's cancer type, stage and treatment plan and should be carried out by an oncologist.

WHAT ARE THE PATHOLOGICAL TYPES?

Vulvar cancer can have various pathological types that may arise from different cell types. Pathological types of vulvar cancer can be listed as follows:

Squamous Cell Carcinoma: It is the most common type of vulvar cancer and arises from the surface cells of the vulvar tissue.

Bartholin’s Gland Carcinoma: It is a type of cancer originating from the Bartholin glands in the vulva.

Adenocarcinoma: It originates from the gland cells of the vulva tissue and is less common.

Melanoma: It is a type of cancer that originates from melanocytes in the vulva, cells that produce pigment.

Pathological types of vulvar cancer may affect the biological characteristics of the cancer and the treatment approach. Once diagnosed, pathological examination helps determine the type and stage of the cancer and is important in shaping the treatment plan. The pathological type, the patient's medical history, and the characteristics of the cancer must be taken into account to determine the appropriate treatment for each patient.There are some receptors and molecular markers that should be examined in the treatment of vulvar cancer. These are evaluated to understand the biological characteristics of cancer and personalize treatment. First of all, HPV (Human Papillomavirus) status, especially the presence of high-risk HPV types, helps us understand the origin of cancer and potential risks. The status of hormonal receptors ER (Estrogen Receptor) and PR (Progesterone Receptor) is effective in determining hormonal treatment options. Her2 (Human Epidermal Growth Factor Receptor 2) expression is important in identifying some types of vulvar cancer and selecting targeted therapies. Additionally, PD-L1 (Programmed Death-Ligand 1) expression is examined to evaluate the potential for immunotherapy treatment. These receptors and markers play a critical role in creating the treatment plan and meeting the patient's cancer-specific needs. However, which markers to test and which treatment options to use should be determined by an oncologist, taking into account the patient's medical history and the characteristics of the cancer.

Image 2: Vulvar cancer can manifest itself as skin changes, itching and sores on the female external genitalia.

HOW IS TUMOR STAGING DONE?

Staging of vulvar cancer is a process used to determine the extent and progression of cancer. This staging process is important in determining the patient's treatment options and predicting prognosis. Staging of vulvar cancer is done as follows:

Stage 0 (Carcinoma in Situ or VIN 3):This early stage refers to a stage where cancer cells are confined to the layer just below the surface of the vulva.

Stage I: At this stage, the cancer is limited to tissues on or near the surface of the vulva.

Stage II: The cancer has spread further in the vulva area, but is still limited to this area.

Stage III: At this stage, the cancer has spread beyond the vulvar area and may have spread to surrounding lymph nodes or other pelvic organs.

Stage IV: At this advanced stage, the cancer has metastasized to organs outside the vulvar area or to other parts of the body.

Vulvar cancer staging is usually done by physical examination, imaging studies such as computed tomography (CT), magnetic resonance imaging (MRI), and sometimes positron emission tomography (PET), and pathological examination. As a result of these stagings, the stage of the cancer is determined and the treatment plan is created according to this information. The treatment plan for each patient is personalized based on the specific condition of the cancer and the patient's health condition.

HOW IS TREATMENT DONE ACCORDING TO STAGES?

Different treatment approaches can be used in the treatment of vulvar cancer, depending on the stage and type of cancer and the general health status of the patient. Here is a general treatment approach according to vulvar cancer stages:

Stage 0 and Stage I: Among the treatment options, surgical intervention plays a key role. This surgery involves removing the tumor and trying to control the cancer. It may often be necessary to remove some or all of the vulvar skin (vulvectomy). Adjuvant treatments such as radiotherapy or sometimes chemotherapy may also be used after surgery, but are determined individually for each patient.

Stage II and Stage III: Treatment usually involves surgery, although surgery may be applied to a more widespread area. In this case, vulvectomy may be performed on a larger area and lymph nodes may need to be removed. Adjuvant treatments such as radiotherapy or chemotherapy can often be used after surgery. If cancer has spread to lymph nodes or other organs, additional treatments targeted to these areas may be required.

Stage IV: Treatment usually focuses on palliative treatments. Palliative treatments are used to control symptoms, manage pain and improve quality of life. Options such as systemic treatments (chemotherapy, targeted drugs) and immunotherapy can be used at this stage.

The treatment plan is customized for each patient and is determined by taking into account the patient's health status, the biological characteristics of the tumor and other factors. Vulvar cancer treatment requires a multidisciplinary approach and should be managed by an oncologist, surgeon, radiation oncologist, and other specialists.

Image 3: HPV vaccine protects against anogenital cancers, including vulvar cancer.

WHAT ARE THE SYSTEMIC DRUGS USED IN TREATMENT?

Some chemotherapies, hormonal drugs, smart drug therapies and immunotherapies used in the treatment of vulvar cancer may include:

Chemotherapy drugs:

Platinum-based chemotherapy: Platinum-containing drugs such as carboplatin or cisplatin are usually used.

Paclitaxel or docetaxel: These drugs can treat cancer cells by stopping them from growing.

Smart Drug Treatments:

Bevacizumab: This drug can be used to treat peritoneal cancer by preventing the tumor's vessels from growing.

Immunotherapies:

Immunotherapy is a newer approach to treating vulvar cancer and is used specifically for patients with certain molecular markers. Immunotherapies include:

Pembrolizumab: This drug can be used as immunotherapy in patients who are PD-L1 positive.

Nivolumab: It is an immunotherapy option for patients with positive PD-L1 expression.

The treatment plan is determined depending on the specific condition of the patient, the characteristics and stage of the tumor. Therefore, vulvar cancer treatment is created by a specialist doctor according to the individual needs of the patient.

HOW SHOULD FOLLOW-UP BE CARRIED OUT AFTER RECOVERY?

Follow-up after vulvar cancer treatment is important to monitor the patient's health and evaluate possible recurrences or response to treatment. The follow-up program usually includes regular doctor exams, blood tests (such as CA-125 levels), imaging studies (computed tomography or magnetic resonance imaging), and monitoring of symptoms. Frequency of follow-up may vary depending on the patient's stage of cancer, response to treatment, and other individual factors. Follow-up plays a critical role for early diagnosis and early detection of possible recurrences or complications. Patients should follow follow-up plans regularly, report their symptoms, and keep in touch with physicians. In this way, the quality of life after vulvar cancer treatment can be increased and patients can be ensured a healthy recovery.