Vulvar & Vaginal Cancer: Treatment and Function-Preserving Care

A persistent vulvar sore, lump, itching or skin change should be examined rather than repeatedly treated as an infection without reassessment. Vaginal cancer may cause abnormal bleeding, discharge, pain or a mass. These symptoms also occur in benign conditions; biopsy establishes the diagnosis.

Most are squamous cell carcinomas, but melanoma, glandular tumors and sarcoma require different pathways. For a vaginal lesion, the team must exclude spread or recurrence from the cervix, endometrium or vulva. A cancer involving the cervix in a person with an intact uterus may be classified as cervical cancer rather than a new primary vaginal cancer.

Early invasive vulvar cancer is usually treated by excision, aiming for clear margins while preserving urinary, bowel and sexual function. The extent ranges from local removal to a more extensive vulvectomy. Reconstructive planning is useful when closure, wound healing or function may be difficult.

Invasive tumor at a margin may require further excision or radiation if re-excision is not feasible. A narrow but clear margin is a different situation: it should not automatically trigger mutilating surgery to meet an old fixed distance rule. Laser treatment used for selected precancerous lesions does not replace treatment for invasive cancer.

Sentinel-node assessment can reduce the amount of groin surgery in carefully selected patients: a single invasive tumor under 4 cm, invasion beyond 1 mm using the appropriate assessment, and no suspicious groin nodes. Midline location affects whether both groins must be mapped. Larger or multifocal tumors, suspicious nodes or failed mapping require a different nodal plan.

A positive sentinel node is not one uniform result. GROINSS-V II supports groin radiation as an alternative to completion dissection for selected metastases no larger than 2 mm, including isolated tumor cells, under the studied approach. Larger deposits require more extensive treatment; the low-volume result cannot be applied to them. Ask about deposit size, extranodal extension and the plan for each groin.

Disease near or involving the urethra, anus or vagina may make primary surgery very extensive. Chemoradiation can be considered to control disease while avoiding or reducing an exenterative operation. The primary tumor and relevant nodes need a coordinated plan; persistent disease after treatment may still require surgery.

After surgery, nodal burden, extranodal extension and margins influence whether radiation or chemoradiation is advised. Some contemporary pathways also incorporate immunotherapy in selected settings. The team should distinguish established local treatment from additions based partly on evidence from other gynecologic cancers, and explain authorization and access.

Selected small early vaginal tumors may be removed surgically when clear margins are achievable without excessive functional loss or a likely need for postoperative radiation. For many patients, particularly with more extensive local disease, definitive radiation is central. Pelvic MRI helps map the lesion; the upper or lower vaginal location changes which nodal regions need attention.

External-beam treatment addresses the tumor region and relevant nodes. Image-guided brachytherapy places radiation close to the residual tumor, allowing a focused dose while limiting exposure to the bladder and bowel. A vaginal cylinder may suit a superficial target; thicker or irregular disease can require interstitial needles. Availability of the appropriate brachytherapy expertise should be discussed before treatment starts.

Concurrent cisplatin may improve radiosensitivity when appropriate, but kidney function, hearing and general fitness affect suitability. Much of the chemotherapy approach is informed by cervical cancer experience because vaginal cancer is rare; it should not be presented as if every combination has its own large vaginal-cancer randomized trial.

For recurrence, first establish whether it is local, nodal or distant and review the original radiation fields. A localized recurrence may still have a surgical or specialist re-irradiation option. More widespread disease usually calls for systemic treatment, often a platinum/taxane-based approach, with attention to symptoms and tolerance.

KEYNOTE-158 studied pembrolizumab in 101 patients with previously treated advanced vulvar squamous cancer: about 11% responded, and some responses lasted. It was not a randomized comparison and does not show that most patients benefit. The small vaginal-cancer evidence base should not be confused with this vulvar cohort.

A separate route is a tumor-agnostic indication. In the US, pembrolizumab can apply to qualifying unresectable/metastatic MSI-H or dMMR solid tumors, or TMB-high tumors at least 10 mutations/Mb, after progression on prior treatment and with no satisfactory alternative, using an authorized test. PD-L1 or HPV positivity alone is not an all-purpose approval for these sites. Clinical-trial eligibility, autoimmune risk and prior immunotherapy need individual review.

Fudan University Shanghai Cancer Center · Shanghai, China

Offers care for rare vulvar and vaginal cancers, including vulvar reconstruction and gynecologic interstitial radiation. Review the need for tissue repair and the planned radiation technique.

MD Anderson Cancer Center · Houston, United States

Its gynecologic service treats both vulvar and vaginal cancers. A multidisciplinary review can compare surgery, radiation and medicines for the confirmed primary site.

Memorial Sloan Kettering Cancer Center · New York, United States

For vulvar cancer, its care pathway addresses surgery and recovery needs. Ask about the surgical extent and arrangements for wound healing, swelling and sexual health.

Vulvar squamous cancer is classified as HPV-associated or HPV-independent. Block-pattern p16 staining supports HPV association; p53 helps characterize HPV-independent disease and related precursor lesions. HPV-negative disease is still cancer and may arise alongside skin disorders such as lichen sclerosus. Precancerous VIN or VaIN is not the same as invasive cancer.

The report should distinguish tumor size, depth, margins and nodal findings. FIGO 2021 changed how vulvar invasion depth can be measured; confirm the method before using a depth threshold to omit groin treatment. Imaging assesses deeper structures and spread, but cannot reliably exclude microscopic nodal disease.

After vulvar surgery, agree on wound cleaning, pain relief and when to report infection or wound separation. Groin surgery or radiation can cause leg or genital lymphedema; early specialist assessment can help manage swelling. Continuing care for underlying vulvar skin disease is important even when the tumor has been removed.

Vaginal radiation can cause dryness, narrowing, pain with penetration, urinary or bowel symptoms and premature menopause. Discuss lubricants, pelvic-floor or sexual-health support and a clinician-guided dilator plan after appropriate healing. Fertility questions should be raised before pelvic treatment. New bleeding, a new lesion or persistent pain should be assessed rather than attributed automatically to treatment scars.

Surveillance includes direct examination of the treated area and relevant nodes, symptom review and selected imaging. Follow-up also checks for other lower-genital-tract abnormalities when indicated; a reassuring cervical screening result does not replace examination of a symptomatic vulva or vagina.

• Biopsy and operation pathology: exact site, histology, invasion depth, margins, p16/HPV and any p53 results.
• Groin mapping and node reports, including laterality, deposit size and extranodal extension.
• Pelvic MRI and staging images; any previous radiation plan, dose summary and brachytherapy record.
• Prior drugs and response, current wound or swelling issues, urinary/bowel symptoms and sexual or fertility priorities.

If a vaginal lesion originates from a cervical cancer, use the cervical cancer pathway alongside specialist review.