Symptoms, Diagnosis, Staging, and Treatment Approaches From a Gynecologic Oncologic Surgery Perspective

Vulvar cancer is one of the rare yet clinically highly significant gynecologic malignancies that develops in the female external genital region. The vulva (external genitalia) includes the labia majora, labia minora, clitoris, and the surrounding skin and soft tissues of these structures. Cancers arising in this area generally progress slowly; however, when not recognized in the early period, both the treatment process may become more challenging and outcomes that affect quality of life may occur.

Because vulvar cancer is rare, it is not sufficiently recognized in the community. Many individuals may interpret symptoms such as long-standing itching, redness, or a wound as a “simple skin problem.” However, these symptoms—especially if they do not resolve despite treatment—must be addressed with a gynecologic oncology perspective.

In this article, we comprehensively address vulvar cancer under the headings of symptoms, diagnostic process, staging, gynecologic oncologic surgical options, adjuvant treatments, and follow-up.

How Common Is Vulvar Cancer?

Vulvar cancer is a relatively less common disease among gynecologic cancers. Although it most often occurs in the postmenopausal older age group, cases diagnosed at younger ages have also been reported in recent years. This suggests that, in some cases, cellular changes associated with Human Papillomavirus (HPV) infections may play a role.

Most vulvar cancers are of the squamous cell carcinoma type. More rarely, subtypes such as melanoma, adenocarcinoma, or basal cell cancer may also be seen. The subtype is very important in terms of disease course and treatment planning.

Risk Factors for Vulvar Cancer

Vulvar cancer does not develop due to a single cause. Multiple factors may play a role together:

• Advanced age
• HPV-related cellular changes
• Long-standing vulvar skin diseases (especially lichen sclerosus)
• Conditions in which the immune system is suppressed
• Smoking
• A prior diagnosis of vulvar intraepithelial neoplasia (VIN)

The presence of these risk factors does not mean that cancer will definitely develop; however, their presence requires greater vigilance when symptoms occur.

What Are the Symptoms of Vulvar Cancer?

Symptoms of vulvar cancer often begin insidiously and increase over time. The most common symptoms are:

• Long-standing itching that does not respond to treatment
• Color changes in the vulvar region (whitening, darkening, or irregular pigmentation)
• A non-healing wound, fissure, or ulcer on the vulva (external genitalia)
• Induration, a raised area, or a palpable mass
• Burning, pain, or tenderness
• Bleeding with contact or spontaneously
• Swelling in the groin region

These symptoms alone do not establish a cancer diagnosis; however, especially in complaints that do not resolve over a long period or progressively worsen, the need for biopsy must be evaluated.

Diagnostic Process in Vulvar Cancer

The cornerstone of diagnosis in vulvar cancer is clinical examination and biopsy. During gynecologic examination, the location, size, surface characteristics of the lesion, and its relationship with surrounding tissues are assessed. A biopsy taken from suspicious areas confirms the diagnosis.

Although biopsy may be perceived as an anxiety-provoking procedure for patients, it is generally a short procedure that can be well tolerated under local anesthesia (numbing). Delayed diagnosis, however, may mean more extensive surgeries and longer treatment processes.

After diagnosis, imaging methods are used to evaluate the extent of disease. Once the diagnosis and possible extent of disease are assessed, treatment planning—primarily involving surgery—is carried out.

Why Is Staging Important in Vulvar Cancer?

Staging indicates how far the disease has spread and forms the basis of the treatment plan. The following factors are considered during staging:

• Tumor size and depth
• Spread to adjacent structures
• Whether there is involvement of the inguinal lymph nodes

In particular, the status of the inguinal lymph nodes is determinative both for disease course and the need for adjuvant treatment.

Gynecologic Oncologic Surgery Is the Foundation of Treatment

In vulvar cancer, the main backbone of treatment is surgery. The surgical approach is planned according to the stage of disease, tumor location, and the patient’s overall condition. The goal is to completely remove the cancer while minimizing functional and aesthetic losses as much as possible.

Wide Local Excision and Partial Vulvectomy

These are the most commonly performed methods in early-stage vulvar cancer. The tumor is removed together with clear margins of healthy tissue. The current approach aims to avoid unnecessary loss of tissue.

Evaluation of Lymph Nodes

The inguinal lymph nodes play a critical role in the spread of vulvar cancer. In appropriate patients, sentinel lymph node assessment (sentinel/breastguard lymph node) may be performed, which involves evaluation of the lymph node(s) closest to or most likely to be the first drainage site for the disease. This method may reduce complication risk by preventing unnecessary extensive lymph node dissections in some patients.

Radical Surgical Approaches

In more advanced stages or in extensive tumors, radical vulvectomy and broader surgical interventions may be required. Such surgeries should be planned by experienced gynecologic oncology teams.

When Do Radiotherapy and Chemotherapy Come Into Consideration?

In vulvar cancer, chemotherapy or radiotherapy is not applied to every patient. These treatments are generally planned as an addition to surgery (adjuvant):

• In patients with lymph node involvement
• In cases where surgical margins are not sufficiently clear
• In locally advanced disease

In some cases, they may also be preferred preoperatively (neoadjuvant) to reduce tumor size.

Post-Treatment Follow-Up and Quality of Life

After completion of treatment, regular follow-up is of great importance. During the follow-up period, the following are evaluated:

• Development of recurrence
• New vulvar lesions
• Lymphedema
• Sexual health and skin problems

Vulvar cancer treatment should aim not only to eliminate the disease but also to preserve the patient’s quality of life.

Frequently Asked Questions

Is vulvar cancer contagious?

No. Cancer is not contagious. However, some types of vulvar cancer may be associated with HPV. HPV is a virus that can be sexually transmitted; however, being an HPV carrier does not necessarily mean that vulvar cancer will develop. HPV is only one of the risk factors.

Does vulvar itching always mean cancer?

No. There are much more common causes of vulvar itching. Eczema, fungal infections, allergic reactions, or skin diseases such as lichen sclerosus can also cause itching. However, in cases of long-standing, recurrent, or treatment-resistant itching, gynecologic evaluation should обязательно be performed and, if necessary, a biopsy should be planned.

Is a smear test sufficient for diagnosis?

No. A smear test is used for screening for cervical (servical) cancer. In suspected vulvar cancer, diagnosis is made with a biopsy taken from the suspicious area.

In vulvar cancer, is the entire vulva always removed?

Not always. In early-stage and limited lesions, the goal is to remove the tumor with clear surgical margins while preserving as much tissue as possible. In more advanced or extensive disease, the scope of surgery may expand and larger surgical interventions may be necessary.

Why are lymph nodes so important?

The inguinal lymph nodes play an important role in the spread of vulvar cancer. Lymph node involvement is one of the most important factors determining both the stage of disease and the need for adjuvant treatment. Therefore, the status of lymph nodes must be evaluated in treatment planning.

Is sentinel lymph node performed in every patient?

No. The sentinel lymph node approach is evaluated in appropriate patients who meet certain criteria. It is not a standard procedure for all patients. In which patients it is safe and appropriate is determined based on tumor characteristics and the predicted extent of disease according to evaluations.

When is radiotherapy or chemotherapy necessary?

The necessity of these treatments varies depending on the stage of disease, lymph node involvement, the status of surgical margins, and pathological risk factors. While surgery alone may be sufficient in some patients, postoperative radiotherapy or chemoradiotherapy may be required in others.

Is sexual life affected after treatment?

It may be affected; however, this depends on the extent of surgery performed and the individual’s healing process. Therefore, when establishing the treatment plan, functional outcomes and quality of life must be taken into account. During follow-up, sexual health, pain management, and the aesthetics/care of the external genital region have an important place.

Can vulvar cancer recur?

Yes, there is a risk of recurrence in vulvar cancer. Therefore, regular check-ups, early recognition of new lesions, and management of concomitant skin diseases are of great importance.

When should I see a doctor?

If any of the following conditions are present, evaluation should not be delayed:

• Itching that does not resolve despite treatment
• A vulvar wound or ulcer lasting longer than 2–3 weeks
• A rapidly growing mass or a marked color change
• Unexplained bleeding after menopause

Early evaluation increases treatment options and contributes to a more favorable course.

Conclusion

Vulvar cancer is a type of gynecologic cancer with a high treatment success rate when detected early; however, its symptoms can often be overlooked. Taking findings such as persistent vulvar itching, a non-healing wound, color change, or a mass seriously and evaluating them appropriately is of great importance for accurate diagnosis and an appropriate treatment plan. In this process, being followed by an experienced gynecologic oncology team directly affects both treatment success and quality of life.

In Ankara, Prof. Dr. Ömer Lütfi Tapısız and Prof. Dr. Şadıman Kıykaç Altınbaş—who stand out with their expertise in gynecologic oncology in the diagnosis, surgical treatment, and follow-up processes of vulvar cancer—are among the specialist physicians you may consult in this field. To obtain information and schedule an appointment, you can contact us via our contact page.