Vulval Cancer Treatment

Radiotherapy

Radiotherapy is used for the treatment of the cancer by employing high-power energy rays for killing the cancer cells while causing negligible damage to the healthy cells. Radiotherapy for vulval cancer could be administered either externally or internally or a merger of the two ways.

There are numerous means of administering radiotherapy for vulval cancer treatment. It could be done prior to surgery for attempting to shrivel the cancer and for making a smaller-scaled surgery possible. Radiotherapy could additionally be offered subsequent to surgery in case the cancer has not been totally eradicated or in case there is cancer present in the lymph nodes.

Radiotherapy is prevalently employed for vulval cancer treatment that has recurred or metastasized. In case the cancer is present in its advanced stages then the key objective could be to enhance quality of life by shrivelling tumour and allaying the symptoms. This is called as palliative radiotherapy.

At times, chemotherapy is offered alongside radiotherapy, this is known as chemoradiation. External radiotherapy and internal radiotherapy (also called brachytherapy) is used for the treatment of vulval cancer. A treatment course could involve solely external radiotherapy or it could comprise of 2 or more phases of the treatment- the foremost phase being external x-ray treatment, and the second could comprise of internal radiotherapy or further external treatment being given to a smaller-sized area.

Internal Radiotherapy

Internal radiotherapy is also known as interstitial radiotherapy or implant therapy or brachytherapy. It comprises of placing a radioactive substance directly inside the cancerous site. This emits an elevated dosage of radiotherapy directly to the tumor from within.

External Radiotherapy

During external radiotherapy, high-power x-rays arising from a machine are focussed on to the location of the cancer. External radiotherapy is generally administered in a sequence of brief, regular treatments given during weekdays lasting for nearly fifteen minutes and the number of treatments would be dependent on the form and extent of the cancer; however the entire span of the treatment would normally last for some weeks.

Prior to commencement of every radiotherapy session, the radiographer would assist the patient in watchfully positioning herself on a couch and ensuring complete comfort while seated. During the course of the treatment, one would need to be alone in the procedure room, though one could converse with the radiographer who is seated in the adjacent room and carrying out the procedure.

Radiotherapy is painless, though one has to be completely motionless while the treatment is being performed. As this form of treatment does not make one radioactive, it is completely safe to interact with near and dear ones, inclusive of kids subsequent to the treatment.

Side Effects

Radiotherapy done on the vulval and groin area could lead to common side effects like diarrhoea and weariness, and it could additionally cause other definite side effects ranging from mild to niggling, dependent on the radiotherapy strength dosage and the span of the treatment.

• Skin reactions
  Due to the sensitive nature of the vulva and groin, radiotherapy could lead to tenderness for which the specialist would recommend certain creams for allaying the pain. Solely using tepid water for washing the treated area and mildly patting it dry using a soft-textured cloth is advisable. It is essential to avoid using talc or scent as it could lead to irritation. Post-treatment care of the skin would be advised by the radiographer.
• Cystitis
  Radiotherapy done on the groin could lead to inflammation in the bladder lining (cystitis) that could make one feel the urge of frequent urination that might be accompanied by a burning sensation. Certain medicines could be prescribed for lessening the discomforting sensation experienced. Drinking plenty of water and other kinds of fluids for diluting the urine.
• Diarrhoea
  Radiotherapy could also lead to bowel irritation and lead to diarrhoea for which the doctor would prescribe certain medications. Staying hydrated during diarrhoea is crucial due to the amounts of fluids being lost.
• Weariness
  Radiotherapy could lead to fatigue and weariness, hence taking adequate amount of rest is essential.

The side effects mentioned above could last for many weeks and then eventually subside as the treatment concludes. It is imperative to inform the doctor in case side effects persist after this time period.

Hair Loss

Radiotherapy for vulval cancer could lead to pubic hair loss, though it could re-grow subsequent to treatment, however for some women this could be long-lasting.

Vaginal Constriction

Vaginal tenderness could ensue during the course of radiotherapy and for some weeks later. The irritation felt could lead to scars that could lead to the vagina narrowing and have lesser flexibility. This could make the sexual act quite discomforting or bothersome. One would be advised to make use of vaginal dilators along with lubricant jelly for keeping the vaginal wall open and maintaining suppleness. Dilators are generally plastic-made and advice on their usage would be provided by either the doctor or the nurse.

Application of a hormone cream to the vagina would be beneficial that are obtainable on prescription from the doctor. Having sex on a regular basis could additionally aid in averting vaginal shrinkage, though there would be dearth of readiness towards sex for quite some time.

Vulval swelling

Due to the sensitive nature of the vulval skin towards radiation, it could get swollen up for months or at times years subsequent to radiotherapy. The swelling could be lowered by mild, upward direction massaging, the advice for which could be provided by the specialist nurse or physiotherapist.

Skin variations

There could be long-standing discolouration (reddening or darkening) of the vulval skin.

Chemotherapy

Chemotherapy involves the usage of cancer-fighting drugs for annihilating cancer cells. The chemotherapy drugs could at times be administered via tablet or via shots given intravenously. Chemotherapy could mostly be given on an outpatient basis, though at times few days of hospitalization could be required.

Chemotherapy could be administered along with radiotherapy in an attempt to enhance the efficacy of the treatment.

Side effects

Chemotherapy could lead to disagreeable side effects; though in women having vulval cancer that has recurred or metastasized it could additionally give a better feeling by allaying the signs of cancer. Though most often side effects occur due to chemotherapy, they could be brought under control with the use of medicines. When chemotherapy and radiotherapy are given together, then the side effects due to radiotherapy could increase.

• Depleted blood cell production
  When the drugs are active in the system, they could additionally lower the normal blood cell count transitionally. This lowered blood cell count could make one more susceptible to infection and lead to fatigue. Antibiotics could be given in case one is having any symptoms of infection. Less frequently, anaemia could arise due to chemotherapy that might make blood transfusion necessary. When red blood cell count plummets there is dearth of adequate amounts of red blood cells that transport oxygen throughout the body leading to anaemia. This could lead to tiredness and lethargy. Blood transfusions could aid in allaying the signs.
• Feeling nauseous and vomiting
  Certain anti-emetics would be prescribed by the doctor for averting the feeling of nausea and puking that is quite effectual.
• Oral sores and lowered appetite
  Certain chemotherapy drugs could lead to oral sores or ulcers. Hence, regular use of mouth wash is essential.
• Hair Loss
  Few of the chemotherapy drugs could lead to hair loss though it would re-grow once the treatment has concluded. This generally takes about three to six months.

Surgery

Surgery is performed with the objective of removal of most of the cancers that are affecting the vulva. This is carried out by removal of the section of the skin that is affected by the cancer along with bordering normal tissues. Majority of the women also need the removal of their lymph nodes from either one or both groins at the time of surgery. Those women having larger sized tumour, another reconstructive vulval surgery would be needed.

Varied operations might be conducted for treating vulval cancer dependent on the extent and the location of the cancer. In case the cancer is quite small, only a diminutive part of the vulva needs to be removed, however in case the cancer has spread to a wider area then major surgery is required.

Examining Lymph Nodes for cancer

The lymph nodes present in the groin region are generally the foremost location where vulval cancer could metastasize to, hence in most situations, the removal of either one or both of the lymph nodes in the groins are done during the course of the surgery.

The lymph nodes are normally removed during the operation for removing cancer that involves making an incision in the groin. Subsequent to removal of the lymph nodes they are analysed for presence of cancer.

The removal of all the lymph nodes from one or both the groins could majorly have an effect on fluid drainage from the lower extremity of the body and the vulva. As a consequence, fluid build-up could occur in either one or both the legs – a condition known as lymphoedema that could endure for years on end.

Initial stage of vulval cancer i.e., stage 1a and atypical forms of vulval cancer like basal cell or verrucous carcinoma atypically metastasizes to the lymph nodes hence women having such form of vulval cancer do not generally require removal of their lymph nodes.

Checking sentinel nodes

The sentinel node is the foremost node where fluid drainage from the vulva takes place; hence it is the first lymph node where the cancer could metastasize. In case, the sentinel nodes are not inflicted with cancer, there would be no further spread of cancer to any more lymph nodes and hence no further removal of lymph nodes is needed.

For finding the sentinel node or nodes involves the injection of a small quantity of radioactive liquid near the cancerous site a few hours prior to the surgery.

During the course of the surgery, the doctor would infuse a blue coloured dye into the same spot. The node which exhibit blue staining and pick up the radioactive liquid would be the sentinel nodes that are taken out and checked for cancerous cells.

In case there is no cancer detected in the sentinel nodes, then no further removal of the any lymph nodes is necessary. In case cancer is detected in one or more sentinel nodes, then all the remnant lymph nodes would require removal or need radiotherapy treatment.

Surgical Removal of Vulval Cancer

• Radical wide local excision
  This surgery also known as radical local excision or wide local excision involves the removal of cancer that is generally no less than a centimetre in measurement from the location and part of the adjacent healthy tissues. Women having stage 1a cancer do not generally require lymph node removal.
• Partial Vulvectomy
  Partial removal of the vulva is called radical partial vulvectomy or partial vulvectomy with the operation being performed based on the placing of the cancer on the vulva.
• Radical Vulvectomy
  This procedure involves the complete removal of the vulva inclusive of both the outer and inner labia and the clitoris. Additionally the lymph nodes from either one or both the groins are removed that is known as lymph node dissection.

Vulval Reconstruction

In case needed reconstructive surgery of the vulva is generally performed during the same instance when the surgery for cancer removal is done.

In case just a tiny section of the skin tissue is being removed from the vulva then it could be possible to suture the remnant skin properly together. But when a wider portion of the skin is removed, then skin flaps or skin grafting could be needed. A skin flap comprises of a part of the skin near the vulva. The skin flap is part of the skin that is positioned onto the vulval region for covering the wound. Skin grafting comprises of removal of part of skin from another body part (generally the thighs or abdominal area) and then affixing it on the part from where the cancer has been taken out.

Pelvic Exenteration

In case cancer has metastasized to the organs located near the vulva like the womb, the bladder and at times the lower part of the bowel, it could still be removed with the aid of a major surgery. Recuperation from this form of surgery is both physically and mentally taxing due to which this is performed occasionally. Surgery could be beneficial to some women as it could totally remove the cancer despite being in the advanced staging.

A gynaecologist and a plastic surgeon would be part of this form of surgery. Plastic surgery would become necessary in case reconstruction of some organs which are removed in the process. This could comprise restoration or re-make of a new vulva, urethra – the tube conveying urine from the bladder to outside the body) or the vagina. In case the bladder or section of the bowel is taken out, then a new aperture or stoma could be made on the abdominal wall.

Subsequent to the operation, wearing a stoma bag would become necessary over the aperture for urine collection, in case there is bladder removal for collection of faeces in case section of the bowel has been removed.

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