Women's Health

Vulval cancer

Malignancy of the vulva, most often a squamous cell carcinoma arising either from HPV-related intraepithelial neoplasia in younger women or from long-standing lichen sclerosus in older women; it presents with a vulval lump, ulcer, persistent itch or bleeding, and delayed presentation is common because women do not report symptoms.

In a nutshell

Vulval cancer is usually squamous cell carcinoma and may be HPV-associated or HPV-independent on a background of differentiated VIN/lichen sclerosus. An unexplained vulval lump, ulceration or bleeding needs a NICE suspected-cancer referral; diagnosis requires specialist biopsy. Treatment is MDT-led tailored excision with risk-appropriate groin staging, and radiotherapy/chemoradiation for selected high-risk, unresectable or recurrent disease.

Classic presentation

An older woman with longstanding lichen sclerosus develops a persistent vulval lump or non-healing ulcer with itch and occasional bleeding.

Key points

Most are squamous cell carcinomas with HPV-associated and HPV-independent pathways; pathology distinguishes the background.
NICE recommends considering suspected-cancer referral for an unexplained vulval lump, ulceration or bleeding.
A punch or wedge biopsy including the lesion edge is preferred before definitive excision where possible.
Tumour site, size, depth of invasion and inguinofemoral node status determine staging and treatment.
Sentinel-node biopsy is for selected small, unifocal, clinically node-negative tumours; larger or multifocal disease needs another nodal pathway.
Treatment and follow-up are specialist MDT-led, with explicit psychosexual, lymphoedema and dermatosis support.

First-line investigation

Examine and document the lesion and groins, refer urgently, and arrange a specialist punch or wedge biopsy; image groins and stage further according to histology, size, site and nodes.

Management

Refer suspicious lesions promptly

An unexplained vulval lump, ulceration or bleeding warrants NICE suspected-cancer referral; a fungating or clinically highly suspicious lesion should reach a cancer centre without waiting for biopsy results.^3,1

Biopsy before definitive treatment

Use a specialist punch or wedge biopsy including the lesion edge, document site and size and send separate lesions separately; avoid excisional biopsy where possible until histology is available.¹

Treat through the gynaecological-oncology MDT

Use tailored radical local excision and risk-appropriate groin staging; sentinel-node biopsy is limited to selected small, unifocal, node-negative tumours, while larger or multifocal disease generally needs inguinofemoral lymphadenectomy.^1,4

Use adjuvant or primary radiotherapy when indicated

Discuss positive/close margins, nodal disease, locally unresectable, recurrent or metastatic disease in the MDT; radiotherapy with or without chemotherapy may be adjuvant, definitive or palliative according to the oncology plan.^1,4

Monitor recurrence and survivorship

Examine vulva and groins regularly, more closely in the first 2 years, manage dermatoses and treatment effects, and provide rapid re-referral for any new lesion; recurrent, multifocal or HPV-independent disease may need prolonged or lifelong review.^1,2

Exam traps

Do not keep treating a persistent vulval lesion as benign; biopsy it.
Lichen sclerosus is a precursor, so it warrants surveillance.
Groin nodes determine prognosis and must be assessed.
It can occur in younger women through the HPV pathway, not only the elderly.

Illustrations

Sensitive clinical image, hidden — Dermoscopy of vulval squamous cell carcinomaA dermoscopic close-up of vulval squamous cell carcinoma at the anterior commissure, showing an erythematous keratotic surface with erosions and irregular vascular structures. Sensitive image.Dr med. Hans Schulz, Wikimedia Commons · Public domain

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.