Vaginal and Vulvar Cancer

Definition | Aetiology | Risk Factors | Clinical Presentation | Investigations | Management | When to Refer | References

Definition

Vaginal and vulvar cancers are rare gynaecological malignancies. Vaginal cancer originates in the vaginal tissues, while vulvar cancer begins in the external genitalia. Both cancers are often associated with human papillomavirus (HPV) infection.

Aetiology

Both vaginal and vulvar cancers typically arise from squamous cells, which are the thin, flat cells lining these areas. The development of these cancers is often linked to persistent infection with high-risk HPV types, particularly HPV 16. Other contributing factors include chronic inflammation, lichen sclerosus, and immunosuppression.

Risk Factors

Several factors increase the risk of developing vaginal or vulvar cancer:

• HPV Infection: Persistent infection with high-risk HPV types is a significant risk factor.
• Age: The risk increases with age, particularly in women over 60.
• Smoking: Smoking increases the risk of both vaginal and vulvar cancers, likely due to its impact on the immune system's ability to clear HPV infections.
• Immunosuppression: Conditions like HIV/AIDS or the use of immunosuppressive medications increase susceptibility to HPV infections and subsequent cancer development.
• Lichen Sclerosus: A chronic inflammatory skin condition that affects the vulva, increasing the risk of vulvar cancer.
• Previous Cervical Cancer: A history of cervical cancer or pre-cancerous conditions increases the risk of vaginal cancer.
• Chronic Vulvar Irritation: Conditions causing long-term irritation or inflammation of the vulva can increase cancer risk.

Clinical Presentation

Vaginal and vulvar cancers can present with various symptoms, which often overlap. Common symptoms include:

Vaginal Cancer

• Abnormal Vaginal Bleeding: This includes postmenopausal bleeding, bleeding after intercourse, or intermenstrual bleeding.
• Vaginal Discharge: Unusual or persistent discharge, which may be watery, bloody, or foul-smelling.
• Pain during Intercourse: Pain or discomfort during sexual activity.
• Pelvic Pain: Persistent pain or discomfort in the pelvic region.
• Mass or Lump: A palpable mass in the vagina, which may be discovered during a routine pelvic exam.

Vulvar Cancer

• Itching: Persistent itching of the vulva is a common early symptom.
• Skin Changes: Changes in the colour or texture of the vulvar skin, including thickening, lumps, or sores that do not heal.
• Bleeding or Discharge: Unexplained bleeding or discharge not related to menstruation.
• Pain or Discomfort: Persistent pain or tenderness in the vulva.
• Ulceration: The presence of an open sore or ulcer that does not heal.
• Lump or Mass: A noticeable lump or growth on the vulva, which may be felt during self-examination or clinical examination.

Investigations

If vaginal or vulvar cancer is suspected, the following investigations are typically performed:

• Physical Examination: A thorough examination of the vulva and vagina, including palpation of any masses and inspection for skin changes or lesions.
• Biopsy: A tissue sample from the suspicious area is taken for histopathological examination to confirm the diagnosis.
• Colposcopy: A detailed examination of the vagina and cervix using a colposcope, often performed if vaginal cancer is suspected.
• Imaging: MRI, CT, or PET scans may be used to assess the extent of the disease and check for metastasis if cancer is confirmed.
• HPV Testing: Testing for high-risk HPV types may be conducted, particularly if the cancer is suspected to be HPV-related.
• Cystoscopy or Proctoscopy: These may be performed to assess if the cancer has spread to the bladder or rectum, particularly in advanced cases.

Management

Treatment of vaginal and vulvar cancers depends on the stage at diagnosis, the type of cancer, and the patient’s overall health:

Primary Care Management

As a Physician Associate, your role includes recognising the signs and symptoms of these rare cancers and facilitating timely referral to secondary care. Educating patients on the importance of reporting persistent vulvar or vaginal symptoms is also crucial.

Secondary Care Management

Treatment in secondary care typically involves a combination of the following:

• Surgery:
  • Wide Local Excision: Removal of the cancerous tissue along with some surrounding healthy tissue to ensure clear margins.
  • Vulvectomy: Removal of part or all of the vulva, depending on the extent of the cancer.
  • Vaginectomy: Partial or complete removal of the vagina in cases of vaginal cancer.
  • Lymphadenectomy: Removal of nearby lymph nodes to check for cancer spread.
• Radiotherapy: Often used after surgery to destroy any remaining cancer cells, or as the primary treatment in patients who are not surgical candidates.
• Chemotherapy: May be used in advanced cases or when the cancer has spread beyond the vulva or vagina.
• Topical Treatments: For very early-stage vulvar cancers, topical chemotherapy or immunotherapy creams may be used.
• Follow-Up Care: Regular monitoring and follow-up are essential to detect any recurrence early.

When to Refer

Urgent referral to a gynaecologist or oncologist is warranted in the following situations:

• Persistent or unexplained vulvar itching, pain, or changes that do not resolve with standard treatment.
• Unexplained vaginal bleeding, particularly postmenopausal bleeding or bleeding after intercourse.
• Presence of a vulvar or vaginal mass, ulcer, or non-healing sore.
• Abnormal findings on pelvic examination or colposcopy that suggest malignancy.

References

1. NHS (2024) Vaginal Cancer. Available at: https://www.nhs.uk/conditions/vaginal-cancer/ (Accessed: 26 August 2024).
2. NHS (2024) Vulval Cancer. Available at: https://www.nhs.uk/conditions/vulval-cancer/ (Accessed: 26 August 2024).
3. National Institute for Health and Care Excellence (2024) Gynaecological Cancers: Recognition and Management. Available at: https://www.nice.org.uk/guidance/ng12 (Accessed: 26 August 2024).
4. British Medical Journal (2024) Vulval and Vaginal Cancer: Diagnosis and Management. Available at: https://www.bmj.com/content/350/bmj.h2866 (Accessed: 26 August 2024).

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