Presentation of Vulvar Cancer
Vulvar cancer most commonly presents as a single mass or ulcer on the labia majora or minora, often accompanied by pruritus, pain, irritation, and sometimes bleeding or discharge. 1
Common Presenting Features
Primary Symptoms
- Pruritus (itching) - most common symptom
- Pain or irritation
- Vulvar bleeding or discharge
- Asymptomatic in some cases 1
Physical Findings
- Single mass or ulcer (most common presentation in HPV-negative tumors)
- Multifocal lesions (more common in HPV-positive tumors)
- Location distribution:
- Labia majora (most common site)
- Labia minora
- Clitoris
- Mons pubis
- Perineum 1
Appearance Variations
The appearance of vulvar cancer can vary considerably:
- Nodular growth
- Ulcerative lesion
- Raised plaque
- Pigmented lesion (in melanoma cases)
- Porcelain-white papules/plaques (if arising from lichen sclerosus) 2
Risk Factors and Associated Findings
- HPV infection (especially high-risk strains HPV-16 and HPV-18) - present in up to 69% of cases 1
- Concurrent cervical neoplasia (more common in HPV-positive tumors) 1
- Advanced age (most common in postmenopausal women) 3
- Chronic inflammation of the vulva
- Smoking
- Immunocompromised state 1
Diagnostic Approach
When vulvar cancer is suspected:
- Perform careful visual examination assessing color, size, distribution, and associated findings (ulceration, bleeding)
- Palpate to evaluate consistency, tenderness, mobility, and depth
- Check for inguinal lymphadenopathy (though clinical palpation has high false-negative rate) 1, 2
- Obtain biopsy of suspicious areas for definitive diagnosis 1
- Consider imaging (MRI, CT, PET/CT) for larger tumors (T2 or greater) or if metastasis is suspected 1
Important Considerations
- Most patients present with early-stage (localized) disease 1
- Lymph node status is the most important prognostic factor in vulvar cancer 1
- The 5-year survival rate is 86% for vulvar-confined disease but drops to 57% with regional lymph node metastases 1
- Squamous cell carcinoma accounts for 90% of vulvar cancers 1
- Less common types include basal cell carcinoma (less than 5% of vulvar neoplasms) 4 and melanoma 5
Pitfalls in Diagnosis
- Misattribution of symptoms to hemorrhoids, leading to delayed diagnosis 1
- Confusion with benign conditions like Bartholin gland cysts, lichen sclerosus, or keratoacanthoma 2, 6
- Inadequate biopsy technique (need to include underlying stroma and avoid necrotic areas) 1
- Failure to examine the vagina and cervix for concurrent neoplasia 1
Early recognition and prompt biopsy of suspicious vulvar lesions are essential for timely diagnosis and improved outcomes, particularly in older women presenting with persistent vulvar symptoms.