Vulvar cancer develops in the external female genitalia — the labia majora, labia minora, clitoris, vestibule, and perineum. It accounts for approximately 4–5% of all gynaecological cancers and predominantly affects women over 60, though a second peak of HPV-related disease occurs in younger women. The overall incidence is increasing, driven partly by rising HPV infection rates in younger cohorts and increasing longevity.
Vulvar cancer follows two distinct biological pathways: (1) HPV-driven disease (particularly HPV 16/18) in younger women, often preceded by vulvar intraepithelial neoplasia (VIN); and (2) HPV-independent disease in older women, typically arising from chronic inflammatory skin conditions — particularly lichen sclerosus — through a differentiated VIN precursor. Both pathways ultimately produce squamous cell carcinoma, the dominant histological type.
Specialist surgical management is central to vulvar cancer treatment. Dr. Nishtha Tripathi Patel performs wide local excision, radical vulvectomy, and sentinel lymph node biopsy for vulvar cancer at Sterling Hospitals and KD Hospital, Ahmedabad.
Trust Signals
- Specialty: Gynecologic Oncology
Types of Vulvar Cancer
- Squamous cell carcinoma (SCC) — accounts for over 90% of vulvar cancers. Two subtypes: HPV-related usual type SCC (younger women, multifocal, often preceded by VIN usual type) and non-HPV-related keratinising SCC (older women, unifocal, arising in differentiated VIN on a background of lichen sclerosus).
- Melanoma — second most common vulvar malignancy (~5%). Arises from melanocytes in the vulvar skin. Often presents as a dark, irregularly pigmented lesion. Staging and treatment follow melanoma protocols rather than standard vulvar cancer protocols.
- Adenocarcinoma of Bartholin’s gland — rare; arising from the Bartholin’s glands at the vaginal introitus. Often initially misdiagnosed as a benign Bartholin’s cyst, particularly in younger women.
- Extramammary Paget’s disease of the vulva — an intraepithelial adenocarcinoma presenting as a red, eczematous plaque. Often extensive and multifocal. May be associated with an underlying invasive adenocarcinoma or a concurrent internal malignancy (particularly rectal or bladder cancer).
- Basal cell carcinoma — rare; same histology as skin basal cell carcinoma. Locally destructive but rarely metastasises; treated with wide local excision.
Symptoms and When to Seek Evaluation
Vulvar cancer and its precursor lesions are frequently missed or misdiagnosed as benign skin conditions. Persistent vulvar symptoms lasting more than 4–6 weeks without clear explanation should be evaluated by a gynaecologist.
- Persistent vulvar itching (pruritus vulvae) — the most common presenting symptom. Often attributed to thrush or eczema for months or years before a correct diagnosis is made.
- A lump, ulcer, thickening, or area of skin discolouration on the vulva
- Vulvar pain or tenderness
- Burning sensation, particularly after urination
- Bleeding from the vulvar area not related to menstruation
- Skin changes — thickening, pale white areas (associated with lichen sclerosus), or persistent warty lesions
- A swollen lymph node in the groin (inguinal lymphadenopathy), which may indicate nodal spread
Red flags requiring urgent gynaecological assessment: any ulcer or mass on the vulva; a white thickened area on the vulva that does not improve with steroid treatment; any bleeding, discharge, or change in an existing vulvar lesion.
Diagnosis and Staging (FIGO 2021)
Diagnosis:
- Vulvoscopy — magnified examination of the vulva under colposcopic light, with application of acetic acid to highlight abnormal areas.
- Punch biopsy — tissue diagnosis from any suspicious area under local anaesthesia. Essential before any treatment planning. Multiple biopsies may be needed for multifocal VIN lesions.
- Inguinal lymph node assessment — clinical palpation, ultrasound with fine needle aspiration cytology (FNAC) of suspicious nodes, and MRI pelvis.
- MRI pelvis — assesses tumour depth, clitoral involvement, proximity to urethra/anus, and lymph node status.
- CT chest/abdomen/pelvis — for clinically advanced or node-positive disease.
FIGO 2021 staging:
- Stage I — tumour ≤2 cm, confined to the vulva or perineum; no nodal spread
- IA: Stromal invasion ≤1 mm
- IB: Stromal invasion >1 mm
- Stage II — tumour >2 cm confined to the vulva or perineum; no nodal spread
- Stage III — tumour of any size with spread to lower urethra, vagina, or anus; or positive lymph nodes
- IIIA: 1–2 positive inguinal nodes ≤5 mm, or 1 node >5 mm
- IIIB: ≥3 positive nodes ≤5 mm, or ≥2 nodes >5 mm, or extracapsular spread
- Stage IVA — upper urethra/vagina, bladder/rectal mucosa, or fixed nodes
- Stage IVB — distant metastasis
Treatment
Modern vulvar cancer treatment prioritises individualized surgery that removes the tumour completely while minimising the impact on sexual function, continence, and quality of life.
- Wide local excision (WLE) — for Stage IB–II tumours, removing the primary tumour with 1–2 cm margin. The preference for conservative wide excision over radical vulvectomy has significantly improved quality of life outcomes without compromising survival, provided margins are clear.
- Radical vulvectomy — removal of the entire vulva (labia majora, labia minora, clitoris, and perineum), reserved for multifocal or centrally placed tumours not amenable to conservation. A significant operation with psychosexual implications; reconstruction is discussed pre-operatively.
- Sentinel lymph node biopsy (SLNB) — the standard of care for clinically node-negative patients with tumours >1 mm depth (Stage IB and above). A radioactive tracer and/or blue dye is injected peri-tumourally to identify the sentinel inguinofemoral lymph node. If negative, formal lymphadenectomy is avoided, substantially reducing lymphoedema risk. The GROningen International Study on Sentinel nodes in Vulvar cancer (GROINSS-V) validated SLNB as safe with less than 3% groin recurrence rate in sentinel node–negative patients.
- Inguinofemoral lymphadenectomy (IFL) — bilateral groin lymph node dissection for node-positive disease, failed sentinel node mapping, or tumours invading midline structures. Major source of morbidity including lymphoedema (40–70%), wound breakdown, and lymphocyst formation.
- Adjuvant radiotherapy — to the groin and pelvis for patients with ≥2 positive inguinal lymph nodes, extracapsular nodal spread, or positive surgical margins not amenable to re-excision.
- Primary chemoradiotherapy — for locally advanced disease involving the anus or urethra where surgery would require colostomy or urinary diversion. Chemoradiotherapy can shrink tumours sufficiently to allow subsequent sphincter-sparing surgery.
- VIN (pre-cancer) treatment — topical imiquimod (particularly for HPV-related VIN), laser ablation, surgical excision, or — for differentiated VIN — early surgical excision given higher progression risk.
Treatment planning is guided by Dr. Nishtha Tripathi Patel, Consultant Gynecological Oncosurgeon in Ahmedabad.
Consultation available in Ahmedabad, Surat, Vadodara, and Gandhinagar.
Frequently Asked Questions
- What is lichen sclerosus and how does it relate to vulvar cancer?
Lichen sclerosus (LS) is a chronic inflammatory skin condition affecting the vulva and perianal area. It causes severe itching, white thickened or wrinkled skin, and progressive scarring that can affect urination and sexual intercourse. While LS is not cancer, it is associated with a small but real lifetime risk (approximately 3–5%) of developing squamous cell carcinoma of the vulva through a non-HPV pathway (differentiated VIN). Women with known lichen sclerosus should have annual vulvoscopic examination by a gynaecologist and report any new ulcers, lumps, or non-healing areas promptly. With adequate steroid treatment and surveillance, the cancer risk can be significantly reduced.
- What is vulvar intraepithelial neoplasia (VIN)?
VIN is a pre-cancerous condition of the vulvar skin. It is classified as either “usual type VIN” (uVIN, HPV-related, predominantly in younger women) or “differentiated VIN” (dVIN, arising on a background of lichen sclerosus in older women). uVIN has a lower progression risk (~4–10%) and may regress spontaneously, particularly during pregnancy or after immunological recovery. dVIN carries a much higher progression risk (up to 50%) and should be treated surgically without delay. Treatment options for VIN include surgical excision, laser ablation, and topical imiquimod (for uVIN only). Regular follow-up after treatment is essential as VIN frequently recurs.
- What is a sentinel lymph node biopsy and will I need it?
Sentinel lymph node (SLN) biopsy is a technique to check whether cancer has spread to the inguinal (groin) lymph nodes — the first site of spread from vulvar cancer — without removing all the groin nodes. A radioactive tracer and/or blue/fluorescent dye is injected around the tumour before surgery. The sentinel node (the first draining node) is identified and removed. If it is cancer-free, the remaining groin nodes are very unlikely to be involved, and full lymphadenectomy can be avoided. This reduces the risk of chronic leg lymphoedema (a significant complication of full lymph node dissection) from ~40% to under 5%. SLN biopsy is recommended for patients with Stage IB or above, tumours not involving midline structures, and clinically node-negative groins.
- Will surgery affect my sexual function?
The impact on sexual function depends primarily on the extent of surgery. Wide local excision (removing only the area of cancer) typically has minimal impact on sexual function and sensation. More extensive surgery (involving the clitoris or requiring reconstruction) can affect sexual sensation and body image. Modern vulvar cancer surgery aims to be as conservative as oncologically safe — removing the tumour with clear margins while preserving as much anatomy as possible. Psychological support and referral to a specialist psychosexual counsellor are an important part of post-treatment care. Most patients can resume sexual activity 6–8 weeks after surgery once healing is complete.
- How do I know if something on my vulva is serious?
Any change on the vulva that persists for more than 4–6 weeks and does not respond to simple treatment (such as antifungal or steroid cream) should be evaluated by a gynaecologist. Features that require prompt assessment include: a new lump, ulcer, or thickening; a white patch or skin change that is growing; bleeding from a vulvar lesion; a swollen lymph node in the groin; or persistent pain or itching that is not controlled by standard treatments. A simple punch biopsy under local anaesthetic can confirm or exclude a significant diagnosis within days. Early detection of vulvar cancer or its precursors is associated with much less extensive surgery and far better outcomes.