eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery

Surgical Treatment of Vulvar Cancer: Workup

Author: Robert V Higgins, MD, Clinical Associate Professor, Department of Obstetrics/Gynecology, University of North Carolina School of Medicine; Vice-Chairman of Academic Affairs, Associate Director of Gynecologic Oncology, Residency Director, Department of Obstetrics and Gynecology, Carolinas Medical Center
Coauthor(s): R Wendel Naumann, MD, Clinical Assistant Professor of Obstetrics and Gynecology, University of North Carolina at Chapel Hill; Associate Director, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Carolinas Medical Center; James Hall, MD, Director, Division of Gynecologic Oncology, Clinical Associate Professor, Department of Obstetrics and Gynecology, Carolinas Medical Center, University of North Carolina
Contributor Information and Disclosures

Updated: Nov 20, 2008

Workup

Laboratory Studies

Routine preoperative laboratory studies for vulvar cancer include serum electrolyte evaluations and a complete blood cell count.

No special testing is needed, except as indicated by the patient's medical condition.

Imaging Studies

  • Imaging studies other than routine chest radiographs have not been helpful in the evaluation of women with vulvar carcinoma, except to evaluate specific symptoms or nodal enlargement.
  • A CT scan may be useful to help evaluate nodal spread in the pelvis in women with evidence of groin node metastasis, but the sensitivity of CT scanning to help detect pelvic lymphadenopathy is approximately 30%. Because of the low sensitivity of imaging in detecting pelvic node metastasis, some authors have suggested laparoscopic assessment of the pelvic lymph nodes as an alternative.
  • MRI can be used to evaluate lymphatic spread but is of limited use because of the expense and the difficulty of evaluating the pelvic nodal group.
  • Positron emission tomography (PET) scanning holds some promise in improving the sensitivity of detecting small nodal metastasis. However, no report is currently available that documents the sensitivity or specificity of PET scan findings in persons with vulvar carcinoma.

Other Tests

  • Perform an ECG prior to surgery, if indicated.
  • Pulmonary function tests may be appropriate in women who smoke and are older than 50 years to help in perioperative management. Evaluation should also include an arterial blood gas analysis.

Diagnostic Procedures

Colposcopy can be performed on the vulva but is more difficult than colposcopy of the cervix because of the large surface area of the vulva and the variability in premalignant lesions. Because of the keratinized skin, acetic acid should be placed for at least 5 minutes prior to colposcopy. To facilitate biopsy, EMLA (ie, eutectic mixture of local anesthetics) cream may be applied to ameliorate the pain from lidocaine injection. A punch biopsy tool can be used to take a representative sample of the vulva. A biopsy should be performed on all lesions to ensure that a cancer is not missed when multiple dysplastic lesions are present.

Histologic Findings

Squamous carcinoma is the most common pathologic type of vulvar carcinoma. Various grading systems are described and may be prognostic. Other prognostic features include confluent growth patterns and lymph vascular involvement.

Melanoma accounts for approximately 10% of vulvar cancers. The staging and treatment is similar to other melanomas. Clark defined a classification system that describes prognosis based on invasion of melanoma to certain tissue levels.9  This system has been modified by Chung for use in vulvar melanoma.10  Similarly, the depth of invasion, as described by Breslow, can be used to predict prognosis.11

Sarcoma is relatively uncommon. Subtypes include leiomyosarcoma, malignant fibrous histiocytoma, and epithelioid sarcoma. In addition, a sarcoma can arise from any structure in the vulva; including blood vessels, skeletal muscle, and fat.

Basal cell carcinoma of the vulva is uncommon, but it can occur in elderly women. As with other basal cell carcinomas, local excision is usually curative.

Verrucous carcinoma resembles condylomata acuminata and is also called a Buschke-Lowenstein giant condyloma. This type of carcinoma is locally aggressive but does not have a propensity to spread via lymphatics. These tumors are thought to be associated with HPV type 6.

Adenocarcinoma may arise in the Bartholin gland, and it represents approximately 40% of tumor types from this location. This type of tumor may attain considerable size before detection. Removal of the Bartholin gland to exclude an underlying carcinoma is indicated for recurrent Bartholin gland abscesses or cysts or if asymptomatic enlargement occurs in persons older than 50 years.

Paget's disease usually manifests as a red, raised, pruritic lesion. Histologically, the lesion is noted to contain cells with prominent nuclei and an increased amount of cytoplasm. Paget's disease has been associated with underlying adenocarcinoma of the colon or sweat glands in 15% of cases. Although Paget's disease does not metastasize, because the histologic changes often extend past the gross extent on the skin, it is known to have a high rate of local recurrence. For this reason, a clinical margin of 2 cm is recommended at the time of excision.

Other carcinomas of the vulva are rare. Tumors can occur in the apocrine sweat glands, and breast carcinoma can also develop from ectopic breast tissue contained within the milk line that extends down into the vulva.

Staging

Because the results of clinical assessment of lymph node status are inaccurate, both the International Federation of Gynecology (FIGO) and the American Joint Commission on Cancer Staging have adopted surgical staging systems for vulvar carcinoma that take into account the pathologic status of the inguinal lymph nodes.

The depth of invasion is usually measured from the deepest point of invasion to the basement membrane of the most superficial adjacent dermal papillae. When defining microinvasive disease, many use this measurement. However, one should use care when interpreting the pathologic measurements because some studies use tumor thickness, which is measured from the deepest invasion to the surface of the skin or tumor.

  • FIGO staging of vulvar carcinoma (1995)
    • Stage 0 - Carcinoma in situ
    • Stage I - Confined to the vulva, smaller than or equal to 2 cm in greatest dimension
      • Stage IA - Invasion of less than or equal to 1 mm in depth
      • Stage IB - Invasion of more than 1 mm in depth
    • Stage II - Tumor confined to the vulva or perineum, larger than 2 cm
    • Stage III - Tumor of any size with positive findings from ipsilateral lymph nodes or invasion of the vagina, anus, or to lower two thirds of the urethra
    • Stage IV - Spread beyond the vulva
      • Stage IVA - Invasion of the upper third of the urethra, bladder mucosa, rectal mucosa, or pelvic bone or bilateral lymph node involvement
      • Stage IVB - Any distant metastasis, including pelvic lymph nodes
  • American Joint Commission on Cancer staging of vulvar carcinoma (1992)
    • Primary tumor (T)
      • TX - Primary tumor cannot be assessed
      • T0 - No evidence of primary tumor
      • TIS - Carcinoma in situ
      • T1 - Tumor confined to the vulva or to the vulva and perineum, smaller than or equal to 2 cm in greatest dimension
      • T2 - Tumor confined to the vulva and perineum, larger than 2 cm in greatest dimension
      • T3 - Tumor invasion into lower two thirds of the urethra, vagina, or anus
      • T4 - Tumor invades bladder mucosa, upper urethral mucosa, or rectal mucosa, or is fixed to the pelvic bone
    • Regional lymph node (N)
      • NX - Regional lymph nodes cannot be assessed
      • N0 - No regional lymph node metastasis
      • N1 - Unilateral regional lymph node metastasis
      • N2 - Bilateral regional lymph node metastasis
    • Distant metastasis (M)
      • MX - Presence of distant metastasis cannot be assessed
      • M0 - No distant metastasis
      • M2 - Distant metastasis (including pelvic lymph nodes)
    • Staging groups
      • Stage 0 - Tis, N0, and M0
      • Stage I - T1, N0, and M0
      • Stage II - T2, N0, and M0
      • Stage III - T1/T2, N1, and M0 or T3, N0/N1, and M0
      • Stage IVA - T4, N (any), and M0 or T (any), N2, and M0
      • Stage IVB - T (any), N (any), and M

More on Surgical Treatment of Vulvar Cancer

Overview: Surgical Treatment of Vulvar Cancer
Workup: Surgical Treatment of Vulvar Cancer
Treatment: Surgical Treatment of Vulvar Cancer
Follow-up: Surgical Treatment of Vulvar Cancer
Multimedia: Surgical Treatment of Vulvar Cancer
References
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Further Reading

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Keywords

vulvar cancer, vulvar carcinoma, vulva cancer, vulva carcinoma, vulva cancer treatment, carcinoma in situ of the vulva, vulvar CIS, Bowen disease, Bowen's disease, squamous cell carcinoma of the vulva, vulvar carcinoma, vulvectomy, vulvar malignancy, gynecologic cancer, gynecologic carcinoma, female genital cancer, human papilloma virus infection, HPV infection, sarcoma, leiomyosarcoma, malignant fibrous histiocytoma, epithelioid sarcoma, basal cell carcinoma, verrucous carcinoma, Buschke-Lowenstein giant condyloma, adenocarcinoma

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Contributor Information and Disclosures

Author

Robert V Higgins, MD, Clinical Associate Professor, Department of Obstetrics/Gynecology, University of North Carolina School of Medicine; Vice-Chairman of Academic Affairs, Associate Director of Gynecologic Oncology, Residency Director, Department of Obstetrics and Gynecology, Carolinas Medical Center
Robert V Higgins, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, North Carolina Medical Society, and Society of Gynecologist Oncologists
Disclosure: Merck Speaker's Bureau Honoraria Speaking and teaching

Coauthor(s)

R Wendel Naumann, MD, Clinical Assistant Professor of Obstetrics and Gynecology, University of North Carolina at Chapel Hill; Associate Director, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Carolinas Medical Center
R Wendel Naumann, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American College of Surgeons
Disclosure: Nothing to disclose.

James Hall, MD, Director, Division of Gynecologic Oncology, Clinical Associate Professor, Department of Obstetrics and Gynecology, Carolinas Medical Center, University of North Carolina
James Hall, MD is a member of the following medical societies: American Cancer Society, American College of Obstetricians and Gynecologists, American Medical Association, and Association of Professors of Gynecology and Obstetrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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