General Medical Information

Invasive Vulvar Cancer

Neville F. Hacker

Squamous Cell Carcinoma
Squamous cell carcinoma of the vulva is predominantly a disease of postmenopausal women, with a mean age at diagnosis of approximately 65 years.

Clinical Features
Most patients present with a vulvar lump or mass, although there is often a long history of pruritus, usually associated with a vulvar dystrophy. Less common presenting symptoms include vulvar bleeding, discharge, or dysuria. Occasionally a large metastatic mass in the groin may be the initial presenting symptom, although this is much less common than in the past because women are now more likely to present with earlier-stage disease.

On physical examination, the lesion is usually raised and may be fleshy, ulcerated, leukoplakic, or warty in appearance. There is an increasing incidence of warty carcinoma of the vulva, and such lesions account for approximately 20% of all cases. These warty carcinomas may occur at any age after adolescence and are multifocal in approximately one third of the cases. They are often initially diagnosed as condylomata acuminata.

Most squamous carcinomas of the vulva occur on the labia majora, but the labia minora, clitoris, and perineum also may be primary sites. Approximately 10% of the cases are too extensive to determine a site of origin, and approximately 5% of the cases are multifocal.

As part of the clinical assessment, the groin lymph nodes should be evaluated carefully and a complete pelvic examination performed. A Papanicolaou smear should be taken from the cervix, and colposcopy of the cervix and vagina should be performed because of the common association with other squamous intraepithelial neoplasms of the lower genital tract.

Diagnosis
Diagnosis requires a wedge biopsy specimen, which usually can be taken in the office with the patient under local anesthesia. The biopsy specimen should include some surrounding skin and some underlying dermis and connective tissue so that the pathologist can adequately evaluate the depth and nature of the stromal invasion. It is preferable to leave the primary lesion in situ, if possible, to allow the treating surgeon to fashion adequate surgical margins.

Physician delay is a common problem in the diagnosis of vulvar cancer, particularly if the lesion has a warty appearance. Although isolated condylomata do not require histologic confirmation for diagnosis, any confluent warty lesion should be adequately biopsied before medical or ablative therapy is initiated.