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Case History

image A 72-year-old woman is concerned about a vulvar lesion that has caused itching and pain for about twelve months. On examination, a 15 × 10 mm exophytic inflamed lesion is identified on the right labia majora. There is no palpable inguinal lymphadenopathy.

How do you investigate in a patient with a vulvar lesion suspicious for a malignancy?

What is the surgical management of the primary lesion in early vulvar cancer?

When is an inguinal lymph node dissection indicated in vulvar cancer?

Which patients are believed to be suitable for the sentinel lymph node technique?

What are the indications for post-operative radiotherapy in vulvar cancer?


image Vulvar cancer accounts for approximately 3%–5% of all gynaecological malignancies and 1% of all cancers in women, with an incidence rate of 1–2/100000. This incidence is ten times higher for women in their seventies. The most common symptom of vulvar cancer is localized pruritus. Other common symptoms are pain, bleeding, discharge and/or a vulvar mass. On examination the lesions may be fleshy, ulcerated or warty in appearance.

How do you investigate in a patient with a vulvar lesion suspicious for a malignancy?

As part of the clinical assessment the inguinal lymph nodes should be evaluated thoroughly to identify groin node metastasis, and a complete pelvic and rectal examination performed to evaluate the extent of disease. Furthermore, a cervical smear should be taken and a colposcopy of the cervix and vagina should follow because of the common associations with squamous lesions of the lower genital tract. Diagnosis is confirmed by a 4 mm Keys punch biopsy under local anaesthetic. The biopsy should include underlying stroma. It is better not to excise the entire lesion as the definitive excision is more difficult to perform. After the diagnosis of an invasive lesion is made, a computed tomography (CT) scan of the groins and pelvis is often helpful in detecting enlarged lymph nodes, especially in the presence of palpable groin nodes. A chest X-ray excludes pulmonary metastasis (Table 48.1).

Table 48.1Investigations for vulvar cancer
Table 48.2International Federation of Gynaecology and Obstetrics (FIGO) staging for carcinoma of the vulva

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