Vulval cancer - Treating vulval cancer

Treatment for vulval cancer usually involves a combination of surgery, radiotherapy and chemotherapy.

Your treatment plan

Deciding what treatment is best for you can often be confusing. Your cancer team will recommend what they think is the best treatment option, but the final decision will be yours.

Before visiting hospital to discuss your treatment options, you may find it useful to write a list of questions that you would like to ask the specialist. For example, you may want to find out the advantages and disadvantages of particular treatments.

Surgery to remove vulval cancer

In most cases your treatment plan will involve some form of surgery. The type of surgery will depend on the stage of the cancer.

There are three surgical options to treat vulval cancer:

the cancerous tissue from your vulva is removed as a well as a margin of healthy tissue, usually around 1cm, as a precaution - radical wide local excision
a larger section of your vulva is removed, such as one or both of the labia and the clitoris - radical partial vulvectomy
this involves removing the whole vulva, including the inner and outer labia, and possibly the clitoris - radical vulvectomy

The time it will take you to recover from surgery will depend on the type of surgery and how extensive it was. For extensive operations such as a pelvic exenteration (see below) it may take up to eight weeks to recover.

Read more about recovering from the effects of surgery.

Assessing and removing groin lymph nodes

An additional surgical procedure is usually required to assess whether the cancerous cells have spread into one or more lymph nodes in your groin.

Sentinel node biopsy

In some circumstances this can be done during an operation to remove certain lymph nodes, known as sentinel nodes.

Sentinel nodes are identified by injecting a dye at the site of the tumour and studying its flow to locate the nodes closest to the tumour. These are then removed and checked for cancerous cells.

Groin lymphadenectomy

Depending on the results of the sentinel node biopsy, some or all of the nodes in your groin will need to be surgically removed. This type of operation is known as a lymphadenectomy.

With larger vulval tumours and in cases where the lymph nodes appear enlarged due to metastases, sentinel node biopsy is not suitable. Instead, the removal of all the lymph nodes in your groin is likely to be recommended. This is called a groin or inguino-femoral lymphadenectomy.

If lymph nodes are affected by cancer, further treatment with radiotherapy is likely to be advised.

Performing a lymphadenectomy does reduce the risk of the cancer returning but it can make you more vulnerable to infection and cause swelling in your legs due to a build-up of lymphatic fluid. This type of swelling is known as lymphoedema. Read more about the complications of surgery for vulval cancer.

Pelvic exenteration

In cases of advanced vulval cancer or if the cancer returns after previous treatment, an operation called a pelvic exenteration may be recommended. This involves removing your entire vulva as well as your bladder, womb and part of your bowel.

If a section of your bowel is removed it will be necessary to create a hole in your abdomen (a stoma), so the bowel can be passed through the stoma, into collection pouches that you wear next to your body.

This is known as a colostomy.

If your bladder is removed there are a number of options open to you. As with a colostomy, your urine can be passed out of your body into a pouch via a stoma, known as an ileal conduit urinary diversion. Or it may be possible to create a "new bladder" by removing a section of your bowel and using it to create a pouch to store urine in.

The section on complications of bladder cancer has more detailed information on the treatment options available to people who have had their bladder surgically removed.

Reconstruction

If only a small amount of tissue has been removed, the skin of the vulva can be neatly stitched together. Otherwise, it may be necessary to have a skin graft, where a piece of skin is taken from your thigh or abdomen to cover any wound in your vulva.

Another option is to have a skin flap, where an area of skin near the vulva is used to create a flap and cover the wound.

Radiotherapy

Radiotherapy involves using high-energy radiation, usually X-rays, to destroy cancerous cells.

Radiotherapy can be delivered as:

internal radiotherapy – where a radioactive implant is placed directly into cancerous tissue
external radiotherapy – where a machine beams the radioactive waves onto the section of the body that contains the cancer, from the outside

Radiotherapy can be used in three ways for vulval cancer. It can be given:

before surgery to try and shrink a large cancer - to help make the operation possible without removing nearby organs
after surgery to destroy any cancerous cells that may be left - for example for cases where cancer cells have spread to the lymph nodes in the groins
to relieve symptoms in cases where a complete cure is not possible – this is known as palliative radiotherapy

In some cases radiotherapy can be used, or combined with chemotherapy, as an alternative to surgery. This may be possible if it looks like surgery will cause extensive damage to your bladder or bowel and you are unwilling to have a stoma or new bladder.

Internal radiotherapy can be given in different ways for vulval cancer and they can vary between specialist centres. If internal radiotherapy is recommended for you, your MDT will be able to provide more information on what will be involved.

External radiotherapy is normally given in daily sessions, five days a week, with each session lasting around 10-15 minutes. Most people require four to five weeks of sessions.

While the radiation is effective in killing cancerous cells, it can also damage healthy tissues leading to a number of side effects, such as:

sore skin around the vulva area
diarrhoea
feeling tired all the time
loss of pubic hair
swelling of the vulva
narrowing of your vagina, which can make sex difficult
inflammation of your bladder (cystitis)

In younger women external radiotherapy can sometimes trigger an early menopause. This means they will no longer be able to have any children.

Chemotherapy

Chemotherapy is usually used in combination with radiotherapy or to control symptoms when a cure is not possible. It is also used as an alternative to surgery that would require a colostomy or ileal conduit urinary diversion (see above).

Chemotherapy uses medication which destroys cancer cells. It is usually given by injection.

The medicines used in chemotherapy can sometimes damage healthy tissue as well as the cancerous tissue. The side effects are common and include:

feeling sick
being sick
hair loss
sore mouth
mouth ulcers
tiredness

These side effects should stop once treatment has finished. Chemotherapy can also weaken your immune system, making you more vulnerable to infection.

It's important to report any symptoms of a potential infection, such as a high temperature, persistent cough or reddening of the skin to your multidisciplinary team. You should also avoid close contact with people known to have an infection.