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Added: Alain Slama - Date: The information in this topic may have changed since it was written. This summary addresses squamous cell cancer of the vulva and vulvar intraepithelial neoplasias VINsome of which are thought to be precursors to invasive squamous cell cancers.

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The clitoris and Bartholin glands are less frequently involved. Estimated new cases and deaths from vulvar cancer in the United States in [ 3 ]. The vulva is the area immediately external to the vagina, including the mons pubis, labia, clitoris, Bartholin glands, and perineum. Anatomy of the vulva. The vulva includes the mons pubis, clitoris, urethral opening, inner and outer lips of the vagina, vaginal opening, and perineum.

Increasing age is the most important risk factor for most cancers. Other risk factors associated with vulvar cancer include the following:. In addition to the much higher prevalence of HPV in these subtypes than in the keratinizing subtypes, the basaloid and warty subtypes also share many common risk factors with Clit Northshore in pa cancers, including the following:.

Possible s and symptoms of invasive squamous cell cancers of the vulva include the following:. Prognosis depends on the pathologic status of the inguinal lymph nodes and whether spread to adjacent structures has occurred. The size of the primary tumor is less important in defining prognosis.

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Invasive and preinvasive neoplasms of the vulva may be HPV-induced and the carcinogenic effect may be widespread in the vulvar epithelium. As a result, patients are monitored regularly for s or symptoms of recurrence. Suspected bladder or rectal involvement must be confirmed by biopsy. The staging system does not apply to malignant melanoma of the vulva, which is staged like melanoma of the skin.

Grade is reported in registry systems and may differ between systems; a two- three- or four-grade system may be Clit Northshore in pa. If not specified, the following system is generally used:[ 1 ]. The pattern of spread is influenced by the histology.

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Risk factors for lymph node metastasis include the following:[ ]. Well-differentiated lesions tend to spread along the surface with minimal invasion, whereas anaplastic lesions are more likely to be deeply invasive. Spread beyond the vulva is either to adjacent organs such as the vagina, urethra, and anus, or via the lymphatics to the inguinal and femoral lymph nodes, followed by the deep pelvic nodes.

Hematogenous spread appears to be uncommon. Standard primary treatment for vulvar cancer is surgery. Patterns of practice in combining these treatments vary. Because there are few patients with advanced disease stages III and IVonly limited data are available on treatment efficacy in this setting, and there is no standard chemotherapy regimen for these patients. Physicians may offer eligible patients with stage III or IV disease participation in clinical trials. Since the s, the trend of surgical resection in patients with vulvar cancer has been toward more limited surgery, often combined with radiation therapy to minimize morbidity.

In addition, nonrandomized studies lack uniform staging definitions and clear descriptions of lymph node dissection or ancillary radiation. Another strategy to minimize the morbidity incurred by groin lymph node dissection in patients with early clinical-stage disease is SLND, reserving groin dissection for those with metastases to the sentinel node s.

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SLND may be useful when performed by a surgeon experienced in the procedure, and it may avoid the need for full groin lymph node dissection or radiation in patients with clinically nonsuspicious lymph nodes. Radical radiation therapy can be used for patients unable to tolerate surgery or when surgery is not an option because of the site or extent of disease. Some investigators recommend radiation therapy as a means to avoid the morbidity of lymph node dissection, but it is not clear whether radiation therapy can achieve the same local control rates or survival rates as lymph node dissection in early-stage disease.

A randomized trial to address the efficacy of radiation therapy in patients with clinically localized vulvar cancer has been reported. Although the planned accrual was patients, the study was stopped after 58 women were randomly ased to it because of worse outcomes in the radiation therapy arm. In summary, the trial was stopped prematurely, and little can be said about the relative efficacy of the two treatment approaches. Pelvic radiation therapy has been compared with pelvic node resection in the setting of documented groin node—positive disease.

There is no standard chemotherapy for vulvar cancer, and reports describing the use of this modality in the setting of metastatic or recurrent disease are anecdotal. Extrapolating from regimens used for anal or cervical squamous cell cancers, chemotherapy has been studied in combination with radiation in the neoadjuvant setting or as primary therapy in advanced disease.

Chemotherapy regimens have included various combinations of fluorouracil 5-FUcisplatin, mitomycin-C, or bleomycin. There is no clear evidence of improvement in survival or palliation. Given the advanced age and comorbidities of many patients with advanced or recurrent vulvar cancer, patient tolerance is a major consideration in the use of these agents. A systematic review of the use of neoadjuvant chemoradiation therapy in patients who were considered inoperable or who would have required extensive surgery, such as pelvic exenteration, colostomy, or urinary diversion, revealed no randomized trials.

In summary, there is evidence that neoadjuvant chemoradiation therapy with 5-FU plus either cisplatin or mitomycin-C may convert patients to a more operable status, but the evidence base is limited by study de. In addition to a paucity of randomized trials, interpretation of these studies is complicated by the lack of a standard definition of operability. There is limited evidence regarding the use of neoadjuvant chemoradiation therapy in advanced operable vulvar cancer, and the available data do not suggest an advantage to this approach.

A systematic review found only one randomized trial that addressed this issue, and it was published only in abstract form.

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Neoadjuvant therapy—related serious toxicity was high 13 of 24 patients; 10 patients had wound diastasis. Traditionally, there were three grades of VIN, however, there is little evidence that all three grades are part of the same biologic continuum or that grade 1 is even a cancer precursor.

High-grade VIN is usually managed with active therapy because of a higher risk for progression to invasive disease. In the same review, the spontaneous regression rate was 1. VIN lesions may be multifocal or confluent and extensive. It is important to perform multiple biopsies in treatment planning to exclude occult invasive disease.

VIN located in nonhairy areas can be considered an epithelial disease; however, VIN found in hairy sites usually involves the pilosebaceous apparatus and requires Clit Northshore in pa greater depth of excision because it can track along hair roots. The principal treatment approach is surgery, but there is no consensus on the optimal surgical procedure.

The goal is to remove or destroy the entire VIN lesion while preserving vulvar anatomy and function. Other more-limited surgical procedures, including separate excision of multiple lesions, are less deforming.

There are no reliable data comparing the efficacy and safety of the various surgical approaches.

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A systematic literature review identified only a single Clit Northshore in pa trial comparing any of the surgical approaches. The remainder of the surgical literature is derived from case series and is prone to important study biases. Whatever procedure is used, patients are at substantial risk of recurrence, particularly when the lesions are high grade or multifocal.

Nonsurgical approaches have been studied because of the physical and psychosexual morbidity associated with many vulvar surgical procedures. Some of these approaches, including topical fluorouracil, recombinant interferon gamma, bleomycin, and trinitrochlorobenzene, have been largely abandoned because of high recurrence rates or intolerable local side effects, such as pain, irritation, and ulceration. Photodynamic therapy, using topically applied 5-aminolevulinic acid as the sensitizing agent for nm laser light, has also been studied.

However, data are limited to small case series with variable response rates. Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria.

General information about clinical trials is also available. Radical local excision with ipsilateral or bilateral inguinal and femoral lymph node dissection may be indicated. For all other stage I lesions, Woman want real sex Lynxville well lateralized, without diffuse severe dystrophy, and with clinically negative nodes, a radical local excision with complete unilateral lymphadenectomy may be done.

For both stage I and stage II disease, radical local excision and sentinel node dissection is indicated and groin dissection is reserved for those with metastasis to the sentinel node s. Some investigators recommend radical excision and groin nodal radiation therapy as a means to avoid the morbidity of lymph node dissection. However, it is not clear whether radiation therapy can achieve the same local control rates or survival rates as lymph node dissection in early-stage disease.

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A randomized trial to address this issue in patients with clinically localized vulvar disease was stopped early as a result of early emergence of worse outcomes in the radiation therapy arm. For patients unable to tolerate radical surgery or deemed unsuitable for surgery Clit Northshore in pa of the site or extent of disease, radical radiation therapy may be associated with favorable survival.

Modified radical or radical vulvectomy with inguinal and femoral lymphadenectomy is the standard therapy. Radiation therapy is given to patients with large primary lesions and narrow margins. Radiation therapy to the pelvis and groin is given Clit Northshore in pa inguinal lymph nodes are positive. Localized adjuvant radiation therapy consisting of 45 Gy to 50 Gy may also be indicated when there is capillary-lymphatic space invasion and a thickness of greater than 5 mm, particularly if the nodes are involved.

Preoperative neoadjuvant radiation therapy or chemoradiation therapy may be used to improve operability and even decrease the extent of surgery required. For patients unable to tolerate radical surgery or deemed unsuitable for surgery because of the site or extent of disease, radical radiation therapy may be associated with long-term survival.

Radical vulvectomy and pelvic exenteration may be indicated for patients with stage IVA vulvar cancer. Surgery followed by radiation therapy may be done for large resected lesions with narrow margins. Localized adjuvant radiation therapy consisting of 45 Gy to 50 Gy may also be indicated when there is capillary-lymphatic space invasion and thickness greater than 5 mm. Neoadjuvant radiation therapy or chemoradiation therapy of large primary lesions to improve operability may be done, followed by radical surgery. For patients unable to tolerate radical vulvectomy or who are deemed unsuitable for surgery because of the site or extent of disease, radical radiation therapy may be associated with long-term survival.

There is no standard chemotherapy for metastatic disease, and reports describing the use of this modality are anecdotal. Regimens have included various combinations of fluorouracil, cisplatin, mitomycin-C, or bleomycin.

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Treatment and outcome depend on the site and extent of recurrence. Radiation therapy with or without chemotherapy may be associated with substantial disease-free periods in some patients with a small local recurrence. The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available.

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This section describes the latest changes made to this summary as of the date above. Updated statistics with estimated new cases and deaths for cited American Cancer Society as reference 3.

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