Vulvar Tumor

Vulvar tumor = any tumor growing on the vulva. By nature they are benign or malignant. Benign vulvar tumors mainly include leiomyoma, fibroma, lipoma, papilloma, hidradenoma, neurofibroma, lymphangioma and hemangioma. Malignant tumors: vulvar squamous-cell carcinoma is most common, accounting for 90% of vulvar cancer; others include vulvar melanoma, vulvar basal-cell carcinoma and Bartholin-gland carcinoma. Etiology: vulvar infection, mechanical irritation, allergic vulvitis, vaginal foreign bodies, urine/feces irritation, Bartholin abscess, post-traumatic hematoma can all cause this. Benign vulvar tumors are rare; vulvar squamous-cell carcinoma is the most common malignant vulvar tumor, often on labia, clitoris and perineum. Cause is still unclear but coexists frequently with STDs (condyloma acuminatum, gonorrhea, syphilis, trichomoniasis); viral infection (HPV) may progress to invasive carcinoma; related to low/impaired immune function (post-renal-transplant, SLE); vulvar dystrophy and condyloma may progress to vulvar squamous carcinoma. Early stage: small hard nodules, masses or ulcers, often with pain or pruritus; late stage: typical erosion, mass or irregular papilloma, color white/grey/pink or pigmented; unilateral/bilateral inguinal nodes enlarged, hard and fixed. When tumor ulcerates or secondarily infects, urinary frequency, dysuria, dysuria and defecation difficulty may occur. But most patients have years of vulvar pruritus history (worse at night) before lesion; vulvar leukoplakia. Routine vaginal cytology smear helps detect concurrent vaginal/cervical/uterine cancer. Cytology has ~50% positive rate for vulvar tumor diagnosis; direct scraping from lesion or local tissue imprint raises positive rate. Treatments include surgery, radiotherapy and TCM. Since surgery and radiotherapy are local treatments with high recurrence, the best approach is integrated Chinese-Western medicine; for advanced patients unfit for surgery, with large unresectable lesions, TCM is preferred.

Common Symptoms

Vulvar leukoplakia; nodular lesion at urethral meatus; burning vulvar pain on urination; vulvar ulcer

Causes and Pathogenesis

Pruritus is a common vulvar symptom, caused by local or systemic factors; ten common causes: (1) Vulvar infection — STDs, viruses, bacteria, trichomonas, fungi causing vulvitis; vulva is the initial and common site. (2) Mechanical irritation — poor hygiene, vulvar dirt, tight underwear, sweat irritation. (3) Allergic vulvitis — allergic dermatitis from detergents, cosmetics, condoms and contraceptive devices. (4) Vaginal foreign bodies — long-term pessary, residual foreign body infecting/irritating vulva causing swelling/pain. (5) Urine/feces irritation — urinary disease, fecal contamination, diabetic glycosuria. (6) Systemic diseases — diabetes, SLE, papular psoriasis. (7) Vulvar malignancies — vulvar cancer, vulvar Paget's disease, vaginal cancer. (8) Bartholin abscess. (9) Unexplained vulvar pain — vulvar vestibular swelling/pain with frequency/urgency/diabetes syndrome; mechanism unclear. (10) Post-traumatic hematoma can also cause severe swelling/pain.

Treatment

Surgery, drug therapy, supportive therapy

Preventive Measures

Surgery is the main treatment for vulvar tumors. Surgical extent depends on clinical stage, lesion site, tumor-cell differentiation and depth of invasion, patient condition and age. Currently accepted: vulvar in-situ tumor can be treated with simple vulvectomy. Invasive carcinoma requires combined consideration of patient condition and stage; generally radical vulvectomy plus regional lymph-node dissection. Even if lesion invades only 3-5 mm, immature differentiation or vascular invasion may already have metastasis. Local simple excision is limited to patients unfit for major surgery. Because vulvar in-situ tumors are multicentric (Wilkinson et al. 1981) or multifocal (diSaia et al. 1981), lesions are often extensive: most patients have lesions over 3/4 of vulvar area, >20 foci, widely confluent. Thus vulvectomy is extensive, but since it is in-situ carcinoma limited to epidermis, excision depth can be limited to epidermis and dermis, preserving most subcutaneous fat (invasive-cancer margins may contain in-situ foci). Note: epithelial atypia often extends beyond gross lesion, so frozen section of excision margin is needed; if margin is atypical, widen excision or recurrence will occur. Clitoral skin is a common tumor site, but in young patients to preserve sexual function the clitoris and prepuce are often not removed — carefully weigh against surgical need; frozen margin section as above. Vulvar invasive carcinoma surgery: extensive vulvectomy down to fascia, with superficial/deep inguinal node dissection; pelvic node dissection is not routine because spread usually goes through inguinal nodes to pelvis; inguinal status predicts pelvic metastasis. In a series of 85 patients: 11 with positive pelvic nodes — 10 had clinically suspected (N2) or palpable (N3) inguinal metastasis, 1 had positive deep femoral (Cloquet) node; in 55 deep-femoral histology, 5 were positive and 2 had pelvic node metastasis; of 50 negative, none had pelvic metastasis. Low-grade vulvar tumors may grow very large but without metastasis and can be cured by thorough treatment. Surgical sequence for vulvar invasive cancer: first bilateral femoral and/or pelvic node dissection, then extensive vulvectomy; aim for one-stage completion. If elderly/frail cannot tolerate one stage, do extensive vulvectomy first, then inguinal dissection after vulvar incision heals; or if no clinical metastasis signs, do radical vulvectomy only.

Department to Visit

It is recommended to visit the Surgical Oncology department; an appointment can be booked on this platform before the visit.

Warm reminder: The above information is for health science reference only and cannot replace professional medical diagnosis. If you have related symptoms, please seek medical attention at a regular hospital promptly.