In Romania, women die, more than in any European country, from some of the most treatable and avoidable cancers: gynecological. Prof. Univ. Dr. Peltecu Gheorghe is the doctor thanks to whom Romanian women facing gynecological cancers began to have access to a treatment approach that has their health at the center. The specialist spoke to us about vulvar cancer, so find out why it occurs, how it manifests itself and how it is treated.
CSID: What causes vulvar cancer?
Prof. Univ. Dr. Peltecu Gheorghe: Vulvar cancer is one of the rarest gynecological cancers. Risk factors are advanced age, HPV infection, immunosuppressive diseases (HIV), and vulvar dysplasia (atrophy). There is evidence that vulvar cancer is actually two separate diseases. One type develops from vulvar lesions produced by HPV infection with cancerous strains and is increasingly common among young women. The second, which mainly affects older women, develops from non-cancerous lesions of the skin of the vulvar region, as a result of chronic inflammation (the itch-scratch-lichen sclerosus hypothesis). These lesions are multiple and recur more frequently.
Age is a risk factor. Less than 20% of vulvar cancers occur in women under 50, while 50% of vulvar cancers occur in women over 70.
HPV infection is an important risk factor. But unlike vaginal cancer where the incidence of HPV infection is 78%, the incidence of HPV in vulvar cancer is 25%. The strains most commonly involved are 16 and 18, and the risk of cancer is higher with persistent infection. As with cervical cancer, the HPV virus generates a precancerous lesion that then evolves into invasive cancer. Cancer associated with HPV infection (16 and 18) occurs in young, smoking women with concurrent HIV infection with multiple sexual partners.
CSID: How does vulvar cancer manifest itself in premenopausal women?
Prof. Univ. Dr. Peltecu Gheorghe: Vulvar cancer in young women has a faster evolution. It occurs at the level of a condyloma or wart of the vulva, a lesion produced by HPV strains, most commonly 16 and 18. This lesion grows and can ulcerate, bleed, become superinfected and produce itching or itching. Undetected early, the cancer can spread to the vagina, anus or urethra and metastasize to lymph nodes at the base of the thigh. Vulvar cancer before menopause occurs more frequently in smokers, in people with low immunity (HIV or autoimmune diseases) and with multiple sexual partners. In advanced cases, palpable nodes may appear in the thigh joint, which suggests nodal metastases.
CSID: How does vulvar cancer manifest itself in menopausal women?
Prof. Univ. Dr. Peltecu Gheorghe: Menopausal vulvar cancer can be asymptomatic for a long time or it can manifest itself through pruritus (itching), bleeding, the appearance of a tumor that grows and becomes ulcerated. Other times it may be a flat tumor or a discolored area of skin. The lesion may be single or there may be multiple lesions. Vulvar cancer in menopausal women develops starting from a vulvar dystrophic lesion that has a chronic evolution, during which the main sign is itching or itching, which causes scratching and skin lesions produced by it.
Due to the fact that vulvar dystrophic lesions are extensive, there is a possibility that in the case of conservative treatment of vulvar cancer, cancerous lesions with other vulvar locations may appear over time, which are not recurrences, but new cancers. Precancerous lesions in menopause have a slow progression to cancer. In advanced stages, ulcerated or ulcero-vegetative lesions are encountered, superinfected, which extend to the vagina, anus or urethra. Also in advanced cases, lymph nodes can be palpated at the wrist of the thigh, a fact that suggests lymph node metastases.
CSID: What is the treatment of vulvar cancer?
Prof. Univ. Dr. Peltecu Gheorghe: The treatment of vulvar cancer is surgical. It is recommended to apply the most limited surgical procedure that can cure the disease. This is because extensive vulvar surgeries profoundly affect a woman’s sex life and sexual identity. Total removal of the vulva, or radical vulvectomy, as it was done decades ago, is considered the most mutilating gynecological surgery and was accompanied by a major risk of infection. Today, even radical operations are performed using new techniques that considerably reduce the risk of infection.
The conservative attitude in vulvar cancer addresses not only the vulva, but also the inguinal nodes. A limited excision of the area containing the tumor with a margin of healthy tissue around it can be performed. Or, for more extensive lesions, half of the vulvar region can be removed (hemi-vulvectomy). The excision of the vulvar tumor is also accompanied by the treatment of the inguinal nodes, in the form of their complete extirpation or the excision of a single node, called the sentinel node, identified with the help of a radioactive substance. There are also situations in which vulvar cancer is detected early, is limited in surface area and requires only limited excision of the lesion.
How vulvar cancer is located
CSID: How can one know if a vulvar cancer is localized or extended to the lymph nodes or other organs?
Prof. Univ. Dr. Peltecu Gheorghe: The localized or extensive nature of vulvar cancer is determined following a gynecological consultation and some imaging investigations (ultrasound, CT or MRI). The gynecological consultation can highlight the extension of vulvar cancer to the vagina, urethra, anus, but also to the nodes at the base of the thigh, by palpation. Suspicion of the extension of vulvar cancer to the nodes at the base of the thigh is provided by ultrasound. For extension to neighboring organs (bladder, anus, rectum), pelvic nodes and other distant organs, the information provided by CT and MRI with contrast material is essential. Evidence of the spread of cancer is given by biopsy of suspicious structures.
CSID: What is the key to success in the treatment of vulvar cancer? Can vulvar cancer be treated? How?
Prof. Univ. Dr. Peltecu Gheorghe: The key to success in vulvar cancer treatment is early detection and diagnosis. It is a general principle in medicine. Early diagnosis allows conservative interventions that cure the disease, that do not alter the anatomy of the vulva and allow the preservation of the woman’s sexuality. In more advanced stages, but operable as a first treatment solution, a wide excision of the lesion can be done, with microscopic verification of the edges of healthy tissue, accompanied by the evaluation of the lymph nodes at the base of the thigh or their excision. If metastases are found at the level of these nodes, the decision is made for radiotherapy in these node areas.
In other operable situations, it is possible to resort to removing part of the vulva, an operation called hemivulvectomy, or even the entire vulva (radical vulvectomy) and the inguinal nodes, bilaterally. The treatment associated with operable stages can be radiotherapy of the inguinal nodes, if they contain metastases.
In locally advanced stages, chemotherapy and radiotherapy will be used. In cases that respond to this treatment, surgery can be performed later. Treatment decisions in vulvar cancer, as in all cases of oncological conditions, are made in an oncological committee (tumor board). There is some preliminary data to suggest that HPV vaccination before sex may reduce or even prevent vulvar cancer.
CSID: What investigations are needed both for diagnosis and to establish the treatment plan, depending on the staging of the cancer?
Prof. Univ. Dr. Peltecu Gheorghe: Vulvar cancer is the easiest to diagnose because it is visible. The cases presented to the doctor are late due to the negligence of the patient or her modesty, especially in menopausal women, where it occurs most frequently. The correct diagnosis is established by a gynecologist specialist who, after the clinical examination, will resort to biopsy. In order to establish the evolutionary stage of the disease, an ultrasound examination of the inguinal nodes (the base of the thigh) is necessary, as well as a computed tomography with contrast material to assess the extent of the disease at a distance.
There are two distinct types of vulvar cancer: one that occurs in young women before menopause and is caused by HPV infection, and another that occurs in menopause, on the background of dystrophic lesions of the vulva skin (lichen sclerosus), unrelated to HPV infection.
CSID: What does recovery mean after treatment? What should the patient expect?
Prof. Univ. Dr. Peltecu Gheorghe: Treatment of vulvar cancer is surgical and consists of removing the vulvar lesion(s) and the inguinal lymph nodes (at the base of the thigh). The extent of surgery depends on the extent of the cancerous lesion. Sometimes it is the limited removal of a single lesion, with surrounding healthy tissue (conservative surgery), other times it is necessary to remove the entire vulvar region (radical vulvectomy). It is the most mutilating surgical intervention in oncological gynecology as it profoundly alters the woman’s body image and her sexual identity. Radiotherapy is added to the surgical treatment in the case of metastases in the regional lymph nodes at the base of the thigh or pelvis.
CSID: What does the life of a vulvar cancer patient look like? What are her responsibilities so that the healing is 100%?
Prof. Univ. Dr. Peltecu Gheorghe: Vulvar cancer is curable if detected and treated in early stages. Vulvar cancer surgery is burdened by most local infectious complications. The most serious problems after surgery are related to sex life. Both through the anatomical changes created by surgery and radiation therapy, as well as through the profound impact on a woman’s sexual behavior.
CSID: How many types can vaginal/vulvar cancer be?
Prof. Univ. Dr. Peltecu Gheorghe: The most common vulvar cancer is squamous cell carcinoma, similar to that of the cervix and vagina (90%). Melanomas and cancers of some glands (Bartholin’s), as well as sarcomas, can also be found.
There are two types of vulvar cancer: one that occurs in young women before menopause and is caused by HPV infection, and another that occurs in menopause, due to dystrophic lesions of the vulva skin (lichen sclerosus), unrelated to HPV infection.
CSID: What does the life of a patient cured of cancer look like? How often should he return to the doctor and what investigations are necessary in order to prevent a relapse?
Prof. Univ. Dr. Peltecu Gheorghe: The life of a woman cured of vulvar cancer is normal, except for the sex life which initially causes great frustration and then resignation. Psychological counseling is more necessary than in other gynecological oncological diseases.
Foto: shutterstock
2024-03-11 15:50:40
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