Cancer of the vulva
Cancer of the vulva is a relatively rare localization of oncology in the gynecological area, accounting for up to 8% of all malignant tumors affecting the female body. In most situations, such as a specific pathology of squamous cell carcinoma of the vulva recorded in older women aged over 70 years, due to the fact that in the pathogenesis of this disease is very important the presence of involutive pathological changes of the mucous membranes of the genitals. At the same time, cancer specialists noted an increase in the incidence of vulvar cancer among women of reproductive age, which is caused by an increase in the level of infection of women with specific viruses that affect the gynecological sphere.
Verification of the diagnosis in a primary visual examination of the patient is often possible at a late stage of development, when the prognosis of vulvar cancer is extremely unfavorable. Oncogynecologists apply the division of vulvar cancer into forms depending on the localization of pathomorphological changes. Thus, a leader takes a squamous cell carcinoma of the vulva, is localized to the large labia and clitoris, while the development of changes in the mucosa of the labia minora, Bartholin's glands and the urethra is relatively rare. If we consider particularly
clinical markers vulvar cancer, it should be noted that they do not have high specificity and are in the appearance of itching up to pain in the affected area, bleeding or purulent vaginal discharge, and in some situations even exophytic palpable tumors.
to establish a definite diagnosis "cancer of the vulva" is necessary to conduct a thorough examination, which implies manual pelvic examination, vulvoskopiyu, cytological examination of vaginal smear and histology of biopsy material. Among medical measures used in the treatment of women suffering from this pathology, radiotherapy for vulvar cancer in combination with the use of chemotherapeutic drugs is widely used.
With the rational and appropriate use of available in the arsenal of medical treatment methods, relapse of vulvar cancer is excluded. In case of untimely verification of the diagnosis, as well as treatment, the extremely unfavorable prognosis of vulvar cancer with the development of the lethal outcome from early metastasis is not fully observed.
reasons
vulvar cancer When considering the etiopathogenesis of cancer of the vulva should be noted the important role of modifiable and modifiable risk factors in the form of an elderly patient's age, chronic viral infection of the external genitalia of human papilloma virus, the presence of background gynecologic pathology( squamous hyperplasia, intraepithelial neoplasia), obesity, Dysmetabolic and dyshormonal disorders.
A major problem for the patient is the immediate later recourse to medical care due to the low level of social protection, lack of awareness of the malignant nature of the disease, and the hope for self-healing. Unfortunately, most patients seek advice on oncogynecologists at the stage of a complicated course of the disease, when chemotherapy and radiotherapy for vulvar cancer is ineffective and the only method of treatment is surgical, which is palliative.
Depending on the pathological manifestations of cancer of the vulva is divided into exophytic shape in which the neoplasm is represented bundle, towering over the mucosal surface Endophytic manifesting A crater ulcer with sealed edges and diffuse, in which is formed a diffuse infiltrate solid consistency. Distinctive pathogenetically determined features of vulvar cancer is the tendency to rapid aggressive flow and spread of malignant atypical cells to remote areas of the female body, which is caused by a wide network of lymphatic reservoirs.
In the initial stage of pathomorphological changes, the size of the neoplasm does not exceed 20 mm and does not extend beyond the borders of the vulva. Further pathogenetic development of vulvar cancer is to increase the size of the malignant neoplasm and spread to the vagina and perianal region. In view of the powerful development of the lymphatic system, malignant cells attack the regional lymph nodes quite rapidly, after which the proliferation of atypical cells and the formation of distant metastases are noted in the lymphatic collectors.
Symptoms and signs of vulvar cancer
In the onset of vulvar cancer development, a woman develops unpleasant sensations of a nonspecific character in the form of itching and burning in the perineum, which creates the impression of an inflammatory disease. In some patients, from the initial period of vulvar cancer development, tumorous neoplasms appear on the mucous external genital organs, similar to genital warts characteristic of activating the papillomavirus.
In case of diffuse-infiltrative form of vulvar cancer, the disease is manifested by the appearance in the soft tissues of the external genital organs of a nodule of a dense consistency or limited compaction of tissues. Later on, a solid ulcer defect develops at the lesion site, prone to bleeding, having uneven dense margins and a necrotic altered bottom. Patients suffering from diabetes often often have vulvar cancer with a bright red ulcer. To perform the differentiation of the ulcerative defect identified by specialists of the oncogynecological profile, a biopsy method is used, in which the affected tissue site is taken with further histological and pathomorphological verification.
With the spread and increase of the tumor process, the cancer of the vulva provokes the development of pain, especially during movement, which indicates the germination of cancer into the underlying tissues, in particular, the clitoris. According to average statistical data, almost 90% of women turn to the oncologist for advice on the detection of neoplasm on the genitals only a year later. However, given the progressive aggressive course of vulvar cancer, this delay is extremely unfavorable, since the late stages of this pathology have negative predictions for recovery.
Separately, we should mention various kinds of precancerous pathological diseases of the female sexual sphere, against which vulvar cancer usually develops. So, the leading positions are occupied by genital warts, affecting mainly women of reproductive age and representing neoplasms in the form of warts, prone to fusion and the formation of plaques. In the elderly, women often develop kraurosis, manifested by atrophy of the vulva, which also applies to non-modifiable risk factors for vulvar cancer. Visual manifestations of kraurosis is the wrinkling of the soft tissues of the external genital organs and narrowing of the entrance to the vagina. The pathomorphological background for the development of vulvar cancer is the thinning of the mucocutaneous membranes that visually resemble parchment.
In 20% of cases, leukoplakia is accompanied by the development of dysplasia of the epithelium of the vulva and, as a consequence, vulvar cancer, provided there is no timely medical correction. Manifestations of leukoplakia are the formation of whitish spots, limited by the mucous membranes of the vulva.
Given the absence of precancerous changes, the clinical course of vulvar cancer can be latent and relatively slow. With delayed progression of tumor growth, adjacent organs and structures are involved in the tumor process at later stages. However, an unfavorable fact is the early metastasis of cancer cells from the vulva into the regional lymphatic reservoirs. It is noteworthy that the lesion of the lymph nodes may be asymmetrical, so when taking ultrasound, this feature should be considered. With the progressing course of the metastatic tumor process and the absence of timely medical correction, a lethal outcome is observed in 100% of cases.
vulvar cancer stages As any cancerous disease, vulvar cancer is usually divided at the stage depending on the clinical and pathomorphological changes detected in the patient. In practice, oncogynecologists use the clinical classification of FIGO, developed by the International Federation of Oncogynecologists and Obstetricians.
So, by the abbreviation "T" is meant the definition of the primary tumor process. In a situation where available diagnostic methods do not allow you to determine the criteria for assessing the primary tumor, the abbreviation "Tx" is taken to diagnosis, and if the primary tumor process is not determined at all, "T0".
When determining a pre-invasive carcinoma by the gynecologist, "Tis( FIGO: 0)" is used. So, in case when the tumor process is limited and does not spread beyond the vulva, and the diameter of the tumor does not exceed 20 mm, it is necessary to establish "T1( FIGO: I)".Detection of stromal invasion by the tumor process up to 10 mm, the stage of vulvar cancer is defined as "T1a( FIGO: IA)", and if more than 10 mm - "T1b( FIGO: IB)".
A distinctive feature of the development of the "T2( FIGO: II)" stage of vulvar cancer is an increase in neoplasm of more than 20 mm, but without the spread of the tumor process beyond the vulva. For stage "T3 and / or N1( FIGO: III)" of vulvar cancer, the progression of the tumor substrate to the nearby structures and tissues of the lower urethra, the vagina, the anal ring and the unilateral defeat of the lymphatic collectors is characteristic. Step
"T4 and / or N2( FIGO: IVA)" is a terminal cancer of the vulva and tumor spread implies substrate to the mucosa of the bladder, the rectum with the fixation to the bones of the pelvis and bilateral lymph collectors.
The nodes of the inguinal and femoral segments are considered as regional lymphatic reservoirs for vulvar cancer. When tumor cells are affected by the primary localization of cancer of the lymphatic pelvic floor, this is a distant metastasis. So, if there is insufficient data on the damage to the lymphatic reservoirs, the abbreviation "Nx" is used. In the case of unilateral metastasis of the vulva cancer, the abbreviation "N1" is issued in the diagnosis, and "N2" for the bilateral one.
The distant metastasis of vulvar cancer is labeled as "M".In the case of complete absence of data on the presence of signs of distant metastasis, confirmed by instrumental diagnostic methods, the abbreviation "M0" is used, and in the presence of distant metastasis, it is necessary to make a diagnosis "M1( FIGO: IVB)" indicating the localization of the metastatic process.
A separate link in the pathomorphological classification of vulvar cancer is histopathological, produced after histological examination of the tissues of lymph nodes after lymphadenectomy. Depending on the differentiation of the cellular material, the tumor process in vulvar cancer is divided into high-, medium- and low-grade, which is clinically important for establishing a prognosis for a patient's recovery.
Diagnosis of vulvar cancer
For early verification of the diagnosis of "cancer of the vulva," the evaluation of anamnestic data, which makes it possible to determine the presence of factors predisposing to this oncopathology, is of particular importance. Thus, the main background for vulvar cancer pathological conditions is later menarche and opposite the early onset of menopause, high fertility with the early termination of the reproductive period, frequent inflammatory diseases localized in the structures of the reproductive system.
Often the first gynecological examination of a woman suffering from cancer of the vulva, allows you to establish a diagnosis. Thus, the most aggressive clinical course of vulvar cancer in women is observed when it is localized in the clitoral projection, which is caused by early metastasis of tumor cells into adjacent lymphatic collectors. And at the same time, the most diagnosed variant of the pathology is cancer of the large labia.
Diagnosis of vulvar cancer, localized in the projection of the Bartholin gland is somewhat difficult and requires the use of additional instrumental diagnostic techniques. A distinctive diagnostic marker of vulvar cancer is the multifocality of malignant foci, which is mainly due to lymphogenous metastasis.
If we consider the issue of laboratory diagnosis of vulvar cancer, it should be noted that at the moment modern technologies allow the use of highly specific techniques that help to verify the diagnosis at an early stage in the development of pathomorphological changes. So, the initial link in the laboratory diagnosis of vulvar cancer is the cytological examination of smears from the mucous membrane in the area affected by the tumor substrate. In addition, vulvoscopy and photodynamic diagnostics are available methods for diagnosing vulvar cancer. Histological laboratory tests for vulvar cancer are carried out only after preliminary sampling of the biopsy material, which takes place during surgical interventions. Thus, histological examination can be attributed to retrospective methods of diagnosis of vulvar cancer.
The most informative for the early detection of invasive forms of vulvar cancer is instrumental diagnostic methods in the form of ultrasound scanning with concomitant puncture biopsy and cytological examination of the smear.
Additional radiographic diagnostic tools that allow visualization of distant metastases are radiography and computed tomography with contrast. Diagnosis and determination of further tactics for the management of a patient suffering from cancer of the vulva should be handled by an oncogynecologic specialist.
Treatment of vulvar cancer
The immediate goal in treating such a pathology as vulval cancer is the removal of the tumor substrate, as well as the implementation of prevention in order to avoid recurrence of vulvar cancer and the development of metastasis.
Absolute indications for the hospitalization of a patient in a hospital with cancer of the vulva are the prerequisites for the use of operative, radiotherapy and chemotherapeutic treatment.
The maximum efficiency with regard to the elimination of vulvar cancer is operative. If the patient has any background precancerous pathology in the form of intraepithelial dysplasia of the vulva, preliminary laser ablation and photodynamic therapy are necessary.
Chemotherapy methods to eliminate vulvar cancer in its pure form are extremely rare, as numerous randomized analyzes have not confirmed their sufficient effectiveness. In a situation where vulvar cancer is of limited nature, preoperative chemotherapy is often used. In addition, the indication for the use of chemotherapeutic treatment methods as an adjunct to radiotherapy for vulvar cancer is the presence of verified distant metastases in the patient.
The volume and feature of the operational benefit for vulvar cancer directly depends on the clinical stage of the development of pathomorphological changes, as well as the histological form. At the zero stage of vulvar cancer development, the surgical manual consists in carrying out a wide excision within the unchanged cancerous tissue with subsequent laser ablation. In a situation where vulvar cancer is common, a simple vulvectomy is used as a surgical aid.
Diagnosis of a microinvasive form of vulvar cancer in a patient is an indication for radical excision or simple vulvectomy without concomitant lymphadenectomy. In a situation where the patient develops the first stage of vulvar cancer, the scope of the surgery consists in performing a radical vulvectomy in combination with a one-sided pahovedderna lymphadenectomy. The only exception is the medial localization of the malignant neoplasm in the region of the clitoris, which should be accompanied by bilateral lymphadenectomy.
With the development of stage II or more of the vulvar cancer, combined treatment is recommended, implying the implementation of a radical vulvectomy with bilateral pahovedderennoy lymphadenectomy. In the postoperative period, the patient is shown conducting radio wave therapy, especially with unfavorable histological forms of vulvar cancer. Absolute indications for postoperative radiotherapy and chemotherapy are metastatic lesions of inguinal metastases and signs of extracapsular growth.
Prevention of vulvar cancer
The complexity of the prevention of vulvar cancer development lies in the late detection of pathology, since most women seek medical care at the stage of a common tumor process. Late treatment is often due to the slow-progressive clinical course of vulvar cancer with no specific pathognomonic clinical manifestations, and the lack of timely verification of precancerous background diseases.
The complexities of early diagnosis, and therefore timely treatment of vulvar cancer, is that this pathology is prevalent among older women who rarely seek advice from a gynecologist because of the end of the reproductive period. In some situations, pathological and clinical markers of vulvar cancer are not so specific and mask the manifestations of inflammatory diseases of the gynecological profile, that doctors do not prescribe a puncture biopsy in time.
Thus, the initial and perhaps the most important part of preventive measures for vulvar cancer is careful collection of anamnestic data for women at risk, assessment of clinical markers and rational use of diagnostic measures.
Cancer of the vulva - which doctor will help ?If there is or suspected cancer development, the vulva should immediately seek advice from such doctors as an oncologist, gynecologist.
