Vulvar Cancer Treatment

What are the treatment options for vulvar cancer?

Treatment for vulvar cancer depends on several factors, including the cancer's stage, location, size, and type. A gynecologic oncologist typically helps develop the treatment plan.

The main treatment approaches include:

• Surgery

• Radiation therapy

• Chemotherapy

• Immunotherapy and other systemic treatments in selected circumstances

• Clinical trials

• Supportive and palliative care

For many people with early-stage vulvar cancer, surgery is the primary treatment. More advanced disease may require a combination of therapies.

Surgery for vulvar cancer

Surgery is the most common treatment for vulvar cancer. The goal is to remove the cancer completely while preserving as much healthy tissue and normal function as possible. The extent of surgery depends on the tumor's size, location, and depth of invasion.

Wide local excision

During a wide local excision, the surgeon removes the cancer and a surrounding margin of healthy tissue. This approach may be appropriate for smaller, localized tumors. The removed tissue is examined to determine whether cancer cells are present at the surgical margins. A negative margin means no cancer cells were found at the edge of the removed tissue.

Radical local excision

Radical local excision removes the tumor along with a larger amount of surrounding and underlying tissue. This may be necessary for cancers that have invaded deeper layers of the vulva.

Partial or radical vulvectomy

A vulvectomy involves removing part or all of the vulva.

• Partial vulvectomy: Removes the affected portion of the vulva.

• Modified radical vulvectomy: Removes a larger portion of vulvar tissue.

• Radical vulvectomy: Removes the entire vulva and may involve additional tissue and lymph node removal.

Surgeons increasingly aim to use tissue-sparing approaches whenever they can safely remove the cancer.

Lymph node surgery

Some patients require removal of lymph nodes in the groin to determine whether cancer has spread. Procedures may include:

• Sentinel lymph node biopsy: Removal of the first lymph nodes most likely to contain cancer cells.

• Inguinofemoral lymph node dissection: Removal of multiple lymph nodes from the groin and upper thigh.

The choice depends on tumor characteristics and whether lymph nodes appear suspicious.

Reconstructive surgery

Some patients may benefit from reconstructive surgery following removal of vulvar tissue. Reconstruction can help with wound healing, preserve function, and improve quality of life. Plastic or reconstructive surgeons may work alongside gynecologic oncologists when more extensive procedures are necessary.

Radiation therapy for vulvar cancer

Radiation therapy uses high-energy radiation to destroy cancer cells. It may be recommended:

• After surgery when there is an increased risk of recurrence

• When cancer has spread to lymph nodes

• Before surgery to shrink a large tumor

• When surgery is not possible

• To relieve symptoms from advanced or recurrent cancer

External beam radiation therapy

External beam radiation therapy directs radiation toward the tumor or surrounding tissues from a machine outside the body. Treatment is usually delivered over multiple sessions. Modern techniques can help limit radiation exposure to surrounding healthy tissues.

Side effects of radiation therapy

Potential side effects include:

• Skin redness, irritation, or breakdown

• Fatigue

• Diarrhea

• Urinary irritation

• Vaginal dryness or narrowing

• Swelling of the legs

• Long-term changes in vulvar or vaginal tissue

Your radiation oncology team can recommend treatments to help manage these symptoms.

Chemotherapy for vulvar cancer

Chemotherapy uses medications to kill cancer cells or interfere with their growth. Unlike some other gynecologic cancers, vulvar cancer is not routinely treated with chemotherapy alone when the disease is localized. Chemotherapy may be used alongside radiation therapy, particularly for locally advanced cancer. This approach is called chemoradiation.

Chemotherapy medications

Medications that may be used in selected circumstances include:

• Cisplatin

• Carboplatin

• Paclitaxel

• Fluorouracil (5-FU)

The most appropriate treatment depends on the disease setting, prior treatments, overall health, and available evidence. Because vulvar cancer is rare, there is no single universally accepted chemotherapy regimen for metastatic disease.

Chemotherapy side effects

Potential side effects vary by medication but may include:

• Nausea and vomiting

• Fatigue

• Low blood counts

• Increased infection risk

• Neuropathy

• Kidney problems

• Hearing changes

• Hair loss

Your care team may prescribe medications to prevent or manage many of these side effects.

Immunotherapy for vulvar cancer

Immunotherapy helps the immune system recognize and attack cancer cells. Immune checkpoint inhibitors, such as pembrolizumab (Keytruda), have been studied in patients with advanced or recurrent vulvar squamous cell carcinoma. However, immunotherapy is not an established standard treatment for every patient with vulvar cancer. In certain advanced cases, an oncologist may consider immunotherapy based on tumor biomarkers, a tumor-agnostic FDA indication, clinical trial eligibility, or individualized off-label treatment decisions.

Biomarker testing

For advanced or recurrent vulvar cancer, doctors may recommend molecular testing to identify characteristics that could influence treatment.

Examples include:

• PD-L1 expression: A protein associated with immune signaling that may help inform certain immunotherapy decisions.

• Microsatellite instability-high (MSI-H) or mismatch repair deficiency (dMMR): Biomarkers that can identify tumors potentially eligible for certain immunotherapies.

• High tumor mutational burden (TMB-H): A characteristic that may support eligibility for certain biomarker-based treatments in specific circumstances.

Not every patient needs every biomarker test. Results must be interpreted in the context of the cancer type, disease stage, prior treatment, and current drug indications.

How is recurrent vulvar cancer treated?

Recurrent vulvar cancer is cancer that returns after treatment.

It may return:

• In the vulva

• In nearby lymph nodes

• In other areas of the pelvis

• In distant organs

Treatment depends on where the cancer returns, what treatments were previously received, and whether the recurrent cancer can be removed. A localized recurrence may be treated with additional surgery or radiation. More extensive recurrent disease may require systemic therapy, clinical trial participation, or symptom-directed treatment.

Supportive and palliative care

Supportive care helps patients manage symptoms and treatment-related side effects. It can be provided at any stage of cancer and alongside treatment intended to cure or control the disease.

Supportive services may include:

• Pain management

• Wound and skin care

• Lymphedema therapy

• Pelvic floor physical therapy

• Sexual health counseling

• Nutritional support

• Mental health services

• Financial and transportation assistance

Palliative care is not limited to end-of-life care. Its purpose is to improve comfort, function, and quality of life.

Follow-up after vulvar cancer treatment

Regular follow-up appointments are important because vulvar cancer can recur, and some patients remain at risk for additional vulvar precancerous changes.

Follow-up may include:

• Examination of the vulva

• Evaluation of groin lymph nodes

• Assessment of treatment-related side effects

• Imaging when clinically indicated

• Biopsy of suspicious new lesions

Follow-up appointments are generally more frequent during the first few years after treatment.