Surgical Treatment for Vulvar Cancer

Introduction:

Vulvar cancer occurs on the outer surface area of the female reproductive organ. Vulvar cancer usually forms as a sore or lump on the vulva. It often causes itching and discomfort. Vulvar cancer is most commonly diagnosed in old-aged women but can occur at any age. The treatment usually involves surgery to remove cancer and marginal surrounding healthy tissue. In some cases, the entire vulva is removed during the surgery. This article explains the surgical management of vulvar cancer.

What Are the Indications for Vulvar Cancer Surgery?

It is necessary to choose the correct case for surgery. The commonly indicated vulvar cancer cases for surgery are:

• Vulvar Dysplasia: In vulvar dysplasia cases, wide local excision is needed. This helps with the pathologic examination of the removed tissue, and the microscopic diagnosis helps in the assessment of surgical margins. This also assures the absence of invasive diseases.

• Squamous Cell Carcinoma: Surgical excision is usually indicated in patients with squamous cell carcinoma (proved by biopsy). If the lesion involves the anus or the upper urethra or is fixed to the pelvic bone, they are initially treated with neoadjuvant radiation and chemotherapy before surgical intervention. In most cases, this technique allows the preservation of the rectal sphincter or the urethral. Radiation may be used to spare the clitoris.

What Are the Surgical Options for Vulvar Cancer?

Surgery is the main treatment of choice for vulvar cancer. The doctor will suggest the most suitable type of surgery, the risks involved, and any possible complications. The type of surgery depends on how far cancer has spread. The tissue removed during surgery will be checked for cancer cells by a pathologist. This will help to confirm the type of vulvar cancer and the extent of cancer throughout the body. The following are the type of surgery used to treat vulvar cancer.

1) Local Excision (Removes Cancer Tissues and a Margin of Healthy Tissue) - This surgical procedure may be known as a radical or local excision. Local excision is commonly recommended for precancerous lesions and small cancers, and it may also involve the removal of the lymph node. This surgery involves cutting out the cancer region and a small amount (around one centimeter) of normal tissue surrounding it. Cutting out the margin of normal-looking tissue helps confirm that all cancerous tissues have been removed.

2) Vulvectomy (Removing the Vulva Partially or Entirely) - This type of surgical procedure is done by removing the entire vulva (radical vulvectomy) or part of the vulva (partial vulvectomy), including the underlying tissue. It is an option for larger cancers. Partial vulvectomy is recommended for cancers that are confined to the front or back of the vulva or either side of the vulva. In most cases, a large part of the vulva is surgically removed. Normally, the lymph nodes situated near the lesion are also removed. A radical vulvectomy is recommended for large cancers that cover the major portion of the vulva. The entire portion of the vulva is removed, which includes the clitoris and deep tissue around the vulva, as well as the nearby lymph nodes, are also removed. Before the surgery, the treatment that combines chemotherapy and radiation therapy is performed to shrink the size of a large tumor. This allows for less extensive surgery.

3) Sentinel Lymph Node Biopsy - To check whether cancer has spread to the lymph nodes, a procedure called sentinel node biopsy is done. This procedure identifies the lymph nodes most likely to contain cancer, which is then removed and analyzed. If cancer is not found in the first identified lymph nodes, then it is unlikely to be in any other lymph nodes. The sentinel lymph node can be identified with a radioactive tracer or a blue dye. A local anesthetic is injected into the tumor site, and then a radioactive dye is injected near the site of cancer, which is called lymphoscintigraphy. It normally takes place in a radiology department a day before the surgery or the morning of the surgery. This dye is injected to help identify the sentinel node. When injected, these dyes flow to the sentinel lymph node, which helps identify and remove the nodes. A sentinel lymph node biopsy can help the surgeon to avoid removing more lymph nodes than required and reduce the side effects such as lymphoedema.

4) Lymph Node Dissection - If cancer has spread to the lymph nodes, the surgeon will remove many lymph nodes from one or both sides of the groin to reduce the risk of cancer spreading to distant areas of the body. This is called lymphadenectomy or an inguinal lymph node dissection.

5) Reconstructive Surgery - The surgery removes vulvar cancer and preserves as much normal tissue as possible. Still, a margin of healthy tissue around the cancer is removed to reduce the risk of cancer recurrence in the same area.

The remaining skin is drawn together with stitches if a small area is involved, but a skin graft or skin flap is required if a large area is involved. In such a case, skin from the vulvar area is moved to cover the wound. This procedure is done as part of the first operation, along with an assistance of a reconstructive surgeon. In rare cases, a thin piece of skin from another part of the patient's body will be taken, such as the thigh or abdomen, and stitched onto the operation site.

What Are the Complications After the Surgery?

The surgery for vulvar cancer has some risk of complications that include:

• Infections.

• Problems with healing at the incision site.

• Fluid retention and leg swelling due to the removal of lymph nodes can occur, called lymphedema.

What Instructions Should Be Followed After the Vulvar Cancer Surgery?

• It is normal to have discomfort and pain immediately after surgery. For the initial 12 to 24 hours after the procedure, the pain medication will be given by vein or injection. Later after two days, pain medication will be given orally.

• Ice packs will be applied at the surgery site for the first 24 hours.

• Sitting is prohibited while in the hospital; healthcare professionals may encourage standing or lying.

• The incision site should be clean and dry. It must be cleaned twice to thrice daily by taking a sitz bath or hand-held showerhead. The area should be blown dry after the bath or shower.

• After bowel movement and urinating, the vulva area should be cleaned. After cleaning, the area should be dried by using a patting motion.

• Check for redness, drainage, swelling, or wound opening daily. If there are any changes, inform the doctor.

• Sitting for a long duration should be avoided because it can interfere with blood circulation and healing.

• A drain in each groin is attached if lymph node tissue is removed. These are placed during surgery. This will prevent fluid build-up under the incision. The drains are connected to a collecting bulb, and the drains will be blood-tinged initially and gradually become light yellow.

• The drains will be left in place for one to two weeks. The healthcare professionals will provide instructions on caring for and emptying the drains.

• Wear loose-fitting clothing.

• Do not use tampons, douching, or have sexual intercourse.

Conclusion:

The treatment of vulvar cancer depends on the staging of the cancer. Surgery is the most common treatment, and it varies depending on the moderate to advanced cancer stage. Surgery is often carried out in the advanced stage with chemotherapy and radiation.