How the disease develops
Most vulvar tumors are squamous cell carcinoma. There are two main pathways for its development, and they differ according to age and pre-existing conditions.
The first is associated with the human papillomavirus of high oncogenic risk: first, a precancer is formed - vulvar intraepithelial neoplasia (VIN), which is more common in relatively young women. The second path is not associated with HPV and develops against the background of chronic dystrophic changes in the skin, primarily lichen sclerosus (kraurosis), which is typical for elderly patients.
Risk factors
- Age over 65 - most cases occur in older women
- High-oncogenic risk HPV and the presence of vulvar intraepithelial neoplasia
- Lichen sclerosus and other chronic vulvar dystrophies
- Smoking
- Previous history of cervical dysplasia or cancer
- Immunodeficiency, including HIV and use of immunosuppressants
Signs you shouldn't ignore
The most common and most underestimated complaint is persistent itching. It can exist for years before a visible tumor appears, and it is at this stage that the disease is still completely curable.
- Persistent itching and burning that does not go away after antifungal and anti-inflammatory treatment
- An ulcer, erosion or fissure that does not heal for more than two to three weeks
- Solid nodule, plaque, warty or papillomatous formation
- Areas of discoloration: whitish, bright red, pigmented
- Pain, bleeding, foul-smelling discharge
- Pain or burning when urinating when urine comes into contact with the ulcerated area
Diagnostics
- Осмотр гинеколога с внимательной оценкой всех отделов вульвы и промежности.
- Вульвоскопия — осмотр под увеличением с применением проб для выявления подозрительных участков.
- Биопсия изменённого участка с гистологическим исследованием — обязательный и решающий этап.
- Обследование на ВПЧ, цитология шейки матки — сопутствующие изменения встречаются часто.
- Оценка паховых лимфоузлов: пальпация, УЗИ, при необходимости пункция.
- Уточнение распространённости — МРТ или КТ малого таза.
The biopsy should not be delayed “until the end of the course of treatment.” If the change exists for several weeks and does not regress, the tissue needs to be examined - this is the only way to distinguish chronic inflammation from precancer and cancer.
Treatment
The main method is surgical, and its volume depends on the size of the tumor, the depth of germination and the condition of the inguinal lymph nodes. The modern approach strives for the most economical intervention where it is oncologically safe.
- For precancer (VIN) - local excision, laser treatment or local therapy
- For a small tumor - wide excision with sufficient distance from the edge
- For a widespread tumor - vulvectomy to the required extent
- Evaluation and, if indicated, removal of inguinal lymph nodes
- Radiation therapy - before or after surgery, as well as for lymph node damage
- Chemotherapy courses, including in combination with radiation therapy
- Reconstructive plastic stage and rehabilitation
Prevention and surveillance
- Vaccination against HPV
- Regular gynecological examinations, including after menopause - this is the group that is examined least often
- Observation and treatment of lichen sclerosus, rather than self-medication with hormonal ointments
- Quitting smoking
- Biopsy of any persistent vulvar skin change rather than long-term empirical therapy
- Regular self-examination of the external genitalia
