Vulval Cancer

Treatment Of Vulval Cancer

Below summaries the main points for all treatments in accordance to British Gynaecological Cancer Society (BGCS) vulval cancer guidelines: An update on recommendations for practice 2023. Please read the guidelines attached for further details.

British guidelines for vulva cancers Download

Just like with any cancer, the treatment depends on the location, size, stage, grade, age, general health and medical history of the patient.

Surgery

Overview And Preparation

Additional Resources For Preparation For Surgery

Main Types Of Surgery Of The Vulva

Additional Resources For Main Types Of Surgery

By Dr PK Mohan on Medical Education Briefs

https://youtu.be/38FG1AWp01A?si=ZZGeHR2pk6uuxy0y By Dr PK Mohan on Medical Education Briefs

Different types of closures on surgical wounds

The four key phases in wound healing post-surgery

An alternative summary of the wound healing process

Robotic Surgery and Vulval Cancer

Vulvar Cancer Treatment by Robotic Gynec Oncologist – Cancerclinix

Treatment for Vulval Squamous Cell Carcinoma

Squamous cell carcinoma of the vulva is the most common type of vulval cancer. Staging is an important process that can be defined by either radiological techniques, for instance, ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) or it can be achieved through surgical biopsy and histology. The purpose is to help identify the size of the tumour which will guide in the necessary prognosis and treatment.

Types Of Stoma

The purpose of stoma is for the colon to be taken throughout the abdominal wall to decompress the intestine.

Iliac colostomy onto the left lower abdomen.

Transverse colostomy on the upper abdomen.

Surgery For VSCC – A Closer Look

A gentle reminder: This is in accordance to the British Guidelines and contains key points. Please visit the guidelines directly for additional information.

Early stages – VIN/VAIN

Additional Resources of VIN

An example of VIN via physical examination

1) VSCC – lymphadenectomy – Sentinel Lymph Node Biopsy

Supporting Images For SLNB

**Anatomy of the groin nodes from Berek and Novak’s Gynaecology 15^th ed**

Bilateral drainage commonly applied for tumours that are midline.

What are the lymphatic drainage in the human body?

Upper & Lower Limb Lymphatic Drainage: Inguinal and Axillary Lymph Nodes (Clinical Guide) By Human Anatomy Education Dr Akram Jaffar

**Anatomical and radiological identification using Tech-99 of the vessels (lymphovenular point) in the leg. Type 1 is most relevant as it is situated in the groin area.**

The sentinel lymph node is the first lymph node which gets affected when the primary tumour grows out of its site via the lymphatic capillaries.

British Guidelines For The Application of SLNB

Ipsilateral Versus Contralateral Lymphadectomy

SAME CONCEPT WITH SLNB

Royal College of Obstetricians and Gynaecologists (2014) Guidelines for the Diagnosis and Management of Vulval Carcinoma.

Ultrastaging may take place by sectioning at 200 micrometres and immunohistochemistry with epithelial marker AE1/AE3 to detect if there is any micro metastatic disease.

Further information, please see the guidelines

What If There Is Large Lymph Nodes Being Affected Greater Than 4cm (>4cm)?

2) VSCC – lymphadenectomy – Inguinal Femoral Lymph Node Biopsy

3) VSCC – lymphadenectomy – Fine Needle Aspiration Biopsy

However, if there is suspected groin nodes on imaging, USS-guided fine needle aspiration (FNA) or core biopsy, where node positivity would change management.

Common Challenges In Lymph Node Biopsy and Lymphadenectomy

Cellulitis

Cellulitis is the infection of the dermis of the skin caused by the bacterium Beta haemolytic streptococci. It commonly affected the lower legs. It is commonly associated with lymphangitis which is the inflammation of the lymphatic vessel where it appears as red streaks on the skin near the streptococcal infection and may result in lymphoedema. Another common cause of cellulitis is the inflammation of the lymph nodes where they appear swollen, painful and soft. They are commonly acute (sudden) and localised. Their normal role is to help combat infection.

Lymphoedema

Lymphoedema is the build up of lymph in the tissue that commonly occurs due to inflammation, tumour, injury, parasites and other obstructions.

The lymph is a colourless fluid that bathes the tissues, drained by lymphatic vessels and is filtered through lymph nodes before returning back to the blood.

It commonly affects the lower the limbs, abdomen and pelvis after surgery like inguinal femoral lymph node dissection (IFLND) in 17 to 50% are affected but more so in patients with surgery and radiotherapy.

Removing less lymph nodes helps prevent lymphoedema.

Pre-operative measurements like height and weight for body mass index (BMI) is important as high levels of BMI, lack of exercise and pre-existing lymphoedema leads to more risk of lymphoedema.

Lymphoscintinography presentation with Tech 99 radiotracer. In each image, there is a gradual build up of lymphoedema and this can be established by the intensity of the radiotracer emitted.

The inguinal lymph nodes has two chains: horizontal and vertical. The horizontal drives below the inguinal ligament whereas, the vertical goes down the saphenous vein. The most common place detected for oedema is the tibia (lower limb). If oedema is present, it indicates that oedema may also appear in the anterior abdominal wall and the external genitalia. This can be identified in the lower back and sacral region.

How Can You Overcome Lymphoedema?

Compression garments – this adds pressure on the area and help overcome the build up.

Manual lymphatic drainage

Pneumatic compression: Air-inflated sleeves that adds pressure to the limb, blood systemic circulation (improve venous return), lower swelling, prevent blood clots. It is commonly between 20 to 120 mmHg (blood pressure).

Patients before operation and post operation aim to maintain healthy lifestyle: weight, exercise and daily skin care.

Lymphaticovenular anastomosis – the joining of the lymphatic vessel with the vein. This is commonly performed for early stage lymphoedema, especially if cellulitis has been repeated.

Drainage by suction helps after IFLND.

A presentation of the joining between the vein and the lymphatic vessel to ease off the lymphoedema

A schematic presentation of the lymphovenous bypass in the lower limb to divert the flow of the blood.

What Happens After Lymphadenectomy?

Please see guidelines for further details.

Reconstructive Surgery

It is a form of surgical art that requires to design and make structures to help:

Complete curative surgery with margins.
Maintain function of the organs
Wound-healing
Lower risk of scarring

Types Of Reconstructive Options For Wound Closure

Types of flaps. For every defect of the vulva, there is an appropriate flap that can be designed. The lotus shape is chosen for the reconstructive design as the shape of the labia majora, and the minora consists of folds of skin in an oval/petal shape or “lip shape”. This requires a recap of the anatomical presentation of the vulva. The labia majora have fat-filled folds of skin that extend on either side of the vaginal vestibule from the mons towards the anus. The labia minora, i.e., small lips, are a pair of flat folds containing spongy connective tissue with a vascular supply and are situated medial to the labia majora. The structures within the vulva contain several openings: perineal body, urethral orifice, vaginal orifice, and anal orifice. Other structures found are the clitoris, which contains crura, glans, and body. The crura arise from the ischiopubic ramus; the midline contains the body, and there is also the glans. Either side of the vaginal orifice contains the bulbs of the vestibule that have the vestibular glands, e.g., Bartholin’s glands. It is important to distinguish between a flap and a graft. The flap is not a complete removal of the skin; it is still attached by one end and thus has the blood and nerve supply in a pedicle. However, the flap is used to repair the defect in another part of the body. The free end of the flap is sewn into the area to be repaired within a few weeks; when the flap has healed into the new site, the other end is detached, and the remainder of the flap is sewn in. On the other hand, a skin graft is when a piece of skin is cut from a healthy location and is used to heal a damaged area of skin, like a form of transplantation.

A recap on the anatomical structure of the vulva

The different shapes of the lotus petals that are commonly used to reconstruct the vulva.

Here is an example of a vulval resection and how a triangular flap has been excised in order to resolve the vulva wound

A closer look of how a lotus-shaped flap of tissue can be used to be reconstruct the vulva.

Though the most common site in where flaps are commonly taken is the thigh, it is important to be aware of the different forms of cutaneous and dermal flaps as they vary depending on the location, blood supply, amount of muscle, depth of fascia and surrounding.

A presentation of the main classification of the blood supply and location

The structure of the skin and the blood and nerve supply that are found under the epidermis in the deep dermal and subcutaneous tissues.

The Anal Margin And Vulval Cancer

Both images illustrates the anatomy of the anus, the former is in black, grey and white mode whereas the other in colour mode.

The anal structure is the end of the large intestine and where stools/faeces/poo leave the body. The anus is relevant because the anal orifice/opening is part of the vulva. The pelvis is where the female reproductive system is situated alongside the gastrointestinal tract (rectum, sigmoid colon and coils of the ileum), urinary (ureters, bladder), fascia (coverings) and the peritoneum that connects with the organs. The levator ani is the muscle that lifts the anus. The anal canal is the termination point and is surrounded by anal sphincters that help release defecation. One is made of smooth muscle, and the other is skeletal.

The anal canal begins at the narrowing of the rectal ampulla at the anorectal junction, where there is a section where the anus connects with the rectum that stores stools/faeces/poo. More specifically, the rectum enters the puborectalis sling at the apex (tip) of the anal sphincter complex. It extends distally for approximately 4 cm and ends at the anal verge.

There is also a Dentate line, transitional zone, anal verge, and anal margin. The anal verge connects the canal to the outside skin at the anus, called the perianal skin, otherwise known as the anal margin, and is within a 5 cm radius of the anal verge. The anal margin contains pigmented skin with folds surrounding the anus. . If the anal margin is involved in the vulval disease or cancer, primary treatment with chemoradiation is given.

There are different types of cells found in the anus. The perianal skin is made of non-keratinised squamous cells and also sweat glands (e.g. apocrine) and hair follicles. However, they are not found in the lining of the lower anal canal. The lining of the canal consists of mucus glands and ducts to help lubricate the area. They are also found in the rectum. The transitional zone contains cuboid-like shapes. The dentate line is found in the middle of the anal canal and functions as the site where mucus is emptied into the anus from the glandular cells that produce it. It is visible macroscopically (naked eye) but not on MRI scan. This can be overcome by the use of transanal endoscopic ultrasound for supervision and localised tumours.

However, transanal endoscopic ultrasound has several disadvantages: operator dependency, inability to assess stenotic tumours (tumours arising from abnormal passage), and regional lymph nodes higher in the pelvis or groins are outside the FOV of endosonography, and supplementary MRI is needed for N (node) staging.

FDG PET/CT helps in the diagnosis and treatment of anal carcinoma, as 98% of anal cases are particularly because up to 98% of anal tumours are FDG-avid (positive). Perirectal lymph nodes are commonly irradiated. However, PET/CT has low sensitivity but can detect pelvic and inguinal lymph nodes.

The cells found above the anal verge are anal cancer, whereas cancers below the anal verge are referred to as cancers of the perianal skin. Anal margin tumours can be treated by surgical excision alone, whereas anal canal tumours have a worse prognosis and are treated with chemoradiotherapy.

Staging helps define anal margin tumours, which can be treated by local excision if small (< 2 cm), well differentiated, do not involve the sphincter, and have no nodal spread. Defunctioning colostomy is considered for patients with transmural vaginal involvement (at risk of development of an anorectal-vaginal fistula), those with fecal incontinence, and those with severe anal pain and obstructive symptoms. During staging, assessment of the cervix and vulva is important because of the common viral cause of vulval, cervical, and anal neoplasms.

Vulval Paget’s disease can affect skin anywhere in the body, especially the perianal vulva and chest. Vulval melanoma arises in melanin-containing cells, and a very small number of anal cancers are melanomas and are hard to see.

Therefore, according to the British guidelines, a temporary or permanent stoma with excision/removal of the necessary amount of anal margin is recommended. The role of chemoradiotherapy in the treatment of vulval cancers. Chemoradiotherapy decreases the size to preserve the anus. After radiotherapy, local flap reconstruction is done to the flap field, but this needs to be measured based on the length-to-breadth ratio. If it is difficult to assess, frozen sections should be done before flaps for reconstruction.

The different forms of stoma appliances: some are one-piece drainable, non-drainable and others are two-piece drainable. Other appliances include wire closure, clip, clamp and narrow valve. The purpose of the stoma is to release the stool contents from the colon of the large intestine.

Flow chart from on cancers with anal margin, anal canal and other forms of anal carcinoma. Kochhar, R., Plumb, A.A., Carrington, B.M. and Saunders, M. (2012). Imaging of Anal Carcinoma. *American Journal of Roentgenology*, 199(3), pp.W335-W344. doi:10.2214/ajr.11.8027.

Limitations Of Post-Reconstructive Surgery

When flap has been reconstructed, there may be a few issues but every issue has a surgical solution.

Other Treatments For Vulval Cancer

Treatment For Specific Types Of Vulval Cancers

Please Click Here

References For Vulval Surgery

American Cancer Society (2026) Anal Cancer. Available at: https://www.cancer.org/cancer/types/anal-cancer.html (Accessed: 2^nd October 2026)

British Association of Dermatologists (2026) Imiquimod cream. Available at: https://www.bad.org.uk/pils/imiquimod-cream (Accessed: 30^th September 2026)

Cancer Research UK (2028) Chemotherapy for vulval cancer. Available at: https://www.cancerresearchuk.org/about-cancer/vulval-cancer/treatment/chemotherapy (Accessed: 30^th September 2026)

Cleveland Clinic (2026) Volumetric Modulated Arc Therapy (VMAT). Available at: https://my.clevelandclinic.org/health/treatments/17626-volumetric-modulated-arc-therapy-vmat (Accessed: 30^th September 2026)

Hoppe-Seyler, K., Bossler, F., Braun, J.A., Herrmann, A.L. and Hoppe-Seyler, F. (2018). The HPV E6/E7 Oncogenes: Key Factors for Viral Carcinogenesis and Therapeutic Targets. Trends in Microbiology, [online] 26(2), pp.158–168. doi:10.1016/j.tim.2017.07.007.

Kochhar, R., Plumb, A.A., Carrington, B.M. and Saunders, M. (2012). Imaging of Anal Carcinoma. American Journal of Roentgenology, 199(3), pp.W335-W344. doi:10.2214/ajr.11.8027.

Lobna Ouldamer, Z. Chraibi, Flavie Arbion, Barillot, I. and Body, G. (2013). Bartholin’s gland carcinoma: Epidemiology and therapeutic management. 22(2), pp.117–122. doi:10.1016/j.suronc.2013.02.004.

Management of Vulval Carcinoma. Available at: https://www.rcog.org.uk/media/dqwnw2a1/vulvalcancerguideline.pdf (Accessed: 1^st October 2026)

Morrison, J., Baldwin, P., Hanna, L., Andreou, A., Buckley, L., Durrant, L., Edey, K., Faruqi, A., Fotopoulou, C., Ganesan, R., Hillaby, K. and Taylor, A. (2024). British Gynaecological Cancer Society (BGCS) vulval cancer guidelines: An update on recommendations for practice 2023. PubMed, 292, pp.210–238. Doi: 10.1016/j.ejogrb.2023.11.013.

National Cancer Institute (2026) Vulvar Cancer Treatment (PDQ®)–Health Professional Version. Available at: https://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq (Accessed: 17^th August 2026)

Royal College of Obstetricians and Gynaecologists (2014) Guidelines for the Diagnosis and Management of Vulval Carcinoma. Available at: https://www.rcog.org.uk/media/dqwnw2a1/vulvalcancerguideline.pdf (Accessed: 1^st October 2026)

The Eve Appeal (2026) Vulval cancer Available at; https://eveappeal.org.uk/information-and-advice/gynaecological-cancers/vulval-cancer/ (Accessed: 7^th August 2026)