Vulvar cancer

　　The etiology of vulvar cancer is not yet clear. According to the prodromal manifestations before onset, the relevant factors are as follows:

　　Vulvar leukoplakia

　　This disease is closely related to the onset of external cervical cancer. According to statistics, about 30～50% of patients have leukoplakia before onset. Due to the lack of unified understanding and diagnostic criteria for leukoplakia of the vulva, it is not suitable for comparative analysis, so there are different opinions on this issue at present. The consensus is that the white spot of the vulvar skin or mucosa should not be called 'leukoplakia', but 'white lesion', and named according to clinical and microscopic characteristics. 'Vulvar leukoplakia' is only applicable to patients with atypical hyperplasia of vulvar epithelium (N0vak 1974). The histological characteristics should have varying degrees of cellular atypia (Lever, 1975). Zhang Baohe believes that vulvar leukoplakia should be classified according to the presence or absence of atypical hyperplasia and cancer (1977). As early as 1940, Taussing believed that 50% of vulvar leukoplakia could develop into cancer, 70% of squamous cell carcinoma patients had leukoplakia, and Framklin's retrospective study in 1972 believed that 50% of untreated leukoplakia were doomed to develop into cancer. The vulvar pathology was hyperplastic lesions that were not treated, and 10～20% could develop into cancer, and those with atypical hyperplasia were more likely to develop into cancer (Gardner, 1969). The incidence of cancer in patients with vulvar dystrophy (also known as vulvar white lesion) is less than 5% (Jeffcoate, 1966), and China's Cao Quansun et al. reported (1980) as 2%. It can be seen that the key lies in whether the squamous epithelium of the vulva is hyperplastic, and cannot predict the possibility of cancer based on the whitening of the vulvar skin or mucosa.

　　The chronic ulcer caused by syphilis is closely related to external cervical cancer

　　In general reports, the incidence of syphilis history is 13～50%, Peking Union Medical College Hospital determined 28 cases of external cervical cancer with positive Conval reaction, accounting for 28.5%, and it is believed that the positive rate of syphilis serum reaction in external cervical cancer cases is 5～6 times higher than that in general patients. JapazeH et al. (1977) counted that 20% of the 192 cases of external cervical cancer had positive serum syphilis, and Lnmin (1949) counted that 60% of external cervical cancer had lymphogranuloma. The book 'Practical Gynecology' collected 162 cases of external cervical cancer from 5 units in Shandong (1956～1964), of which 41% had a sexual history, all of which indicate that external cervical cancer may be related to sexually transmitted diseases.

　　Third, chronic inflammation stimulation of the vulva

　　Possible predisposing factors JapazeH et al. found from epidemiological statistics that 64% of people are overweight, and 24% are diabetic. Overweight and diabetic patients often have acute and chronic vulvar inflammation, which promotes precancerous lesions.

　　Fourth, viral etiology

　　In the etiological study of Bowen's disease, the virus particles were found in the electron microscope (Bhawen, 1980), and the cases of verrucous protuberances are very likely to be caused by the virus (JapazeH, 1977). For example, 15% (Framklin, 1972) to 34% (Merril, 1970) of vulvar cancer is accompanied by cervical cancer (in situ or invasive cancer), and herpesvirus type 2 is related to the onset of cervical cancer. The chronic lymphogranulomatosis caused by the virus is one of the most common granulomas.

　　It is recently believed that human papillomavirus (HPV) can cause condyloma latum, which may be one of the causes of cervical cancer or other cancers. Because in patients with cervical intraepithelial neoplasia, that is, precancerous lesions and in situ squamous cell carcinoma of the cervix, this virus and warts coexist. HPV can be found in the cells by hybridization technology and can be detected in the cells by peroxidase special staining method. The relationship between herpesvirus type 2 and HPV is that the former acts as a catalyst for the latter.

　　For reproductive organ tumors like vulvar cancer, women should pay special attention to some special complications:

　　1. Spread: The local tumor in the vulva gradually increases in size, but rarely invades the fascia of the muscular layer or adjacent structures such as the periosteum of the pubic bone. Once the vagina is invaded, it will quickly involve the levator ani muscle, rectum, urethral opening, or bladder.

　　2. Lymphatic metastasis: The vulva has abundant lymphatic vessels, and the lymphatic capillary plexus of the vulva is interconnected, so the cancer in one side of the vulva can spread through both sides of the lymphatic vessels. Initially, it may metastasize to the superficial inguinal lymph nodes, then to the femoral canal lymph nodes located below the inguinal region, and from there enter the pelvic iliac external, obturator, and iliac internal lymph nodes, and finally metastasize to the para-aortic lymph nodes and left subclavian lymph nodes. The cancer in the clitoris can bypass the superficial inguinal lymph nodes and directly reach the femoral canal lymph nodes. The cancer in the posterior part of the vulva and the lower end of the vagina can avoid the superficial inguinal lymph nodes and directly metastasize to the pelvic lymph nodes.

　　The main symptoms of vulvar cancer include nodules and tumors in the vulva, often accompanied by a history of pain or itching, some patients may present with vulvar ulcers that do not heal, and in the late stage, patients may have increased purulent or bloody discharge, urinary pain, and other discomforts.

　　 Vulvar cancer can be divided into four stages in clinical practice.

　　One: Stage I: All lesions are confined to the vulva, with the largest diameter at 2 centimeters or less, and no suspicious metastasis to inguinal lymph nodes.

　　Two: Stage II: All lesions are confined to the vulva, with the largest diameter exceeding 2 centimeters, and no suspicious metastasis to inguinal lymph nodes.

　　Three: Stage III: Lesions extend beyond the vulva, with no metastasis to inguinal lymph nodes or suspicious metastasis.

　　Four: Stage IV: Any of the following conditions belong to it.

　　1. Fixed or ulcerated inguinal lymph nodes, definitely indicative of metastasis in clinical terms;

　　2. Lesions invade the mucosa of the rectum, bladder, or urethra, or the tumor is fixed to the bone.

　　3. Metastasis to distant sites or palpation of deep pelvic lymph nodes.

　　The prevention of vulvar cancer mainly focuses on personal hygiene, especially vulvar hygiene, and timely hospital examination should be sought when itching occurs.

　　1. Pay attention to the hygiene of the vulva, avoid long-term stimulation by secretions.

　　1. If there is vulvar itching, active treatment should be sought, and it should be noted not to use strong irritant drugs to clean the vulva.

　　2. If nodules, ulcers, and white lesions on the vulva are found, medical attention should be sought promptly.

　　3. If the pathological examination of the biopsy shows atypical hyperplastic lesions, it is considered a precancerous lesion, and a simple vulvar resection should be performed, with all the excised tissue sent for pathological examination to carefully search for any cancerous changes. If cancer is confirmed, the surgery should be expanded, even extensive vulvar radical surgery, and close follow-up is required after surgery, with attention to recurrence.

　　For the clinical examination of vulvar cancer, methods such as cytological examination, Doppler ultrasound, CT examination, and magnetic resonance imaging are used.

　　One: Gross observation:

　　1. Squamous cell carcinoma can manifest as simple ulcers, white lesions, subcutaneous tumors, or polypoid lesions. In the early stage, the epidermal papillae infiltrate the stroma, gradually forming subcutaneous nodules, which may ulcerate, become smaller, and be misdiagnosed as inflammation. In the late stage, it may develop into cauliflower-like overgrowths or ulcers.

　　2. Bowen's disease presents as dark red rough spots with clear but irregular boundaries, covered with crusts. After removing the crusts, granulation tissue and exudate are seen. The lesions of Paget's disease show eczematous changes, are red, slightly elevated, and accompanied by white lesions or small granules. Sometimes superficial ulcers and crusts may form.

　　Two: Microscopic examination:

　　1. Squamous cell carcinoma, most of which are well-differentiated, often showing the formation of epithelial pearls or keratotic phenomena; however, the clitoris or vaginal part is poorly differentiated. In addition, nucleic acid synthesis disorders can also be seen in adjacent normal tissues, indicating that it is necessary to excise the entire vulva during the treatment of vulvar cancer.

　　2. Bowen's disease is characterized by hyperkeratosis of the epidermis, incomplete keratosis, hyperplasia of the prickle layer, disordered cell arrangement, deeply stained nuclei with atypical shapes. The basement membrane of the epidermis is intact, and typical Paget's cells may be present in the deep layer of the epidermis. These cells are large, round, oval, or polygonal, with empty and translucent cytoplasm. The basement membrane of the epidermis is intact, but the range of tumor cell involvement often exceeds the visible edge of the lesion. Diagnosis of Paget's disease requires attention to the possibility of sweat gland carcinoma beneath the epithelium.

　　3. Adenocarcinoma, characterized by glandular hyperplasia, multi-layered epithelium, disordered arrangement, deeply stained nuclei with atypical shapes.

　　To prevent vulvar cancer, attention should be paid to the following points:

　　1. Do not eat too much salty and spicy food.

　　2. Avoid eating overcooked, undercooked, expired, and deteriorated foods. For the elderly, the weak, or those with certain genetic predisposition to diseases, eat some anti-cancer foods and alkaline foods with high alkaline content appropriately, and maintain a good mental state.

　　The treatment of vulvar cancer is mainly surgical, with radiotherapy and chemotherapy as adjuvant treatments. The surgical treatment of vulvar cancer needs to be tailored to the clinical stage, extent, and degree of lesion infiltration of the patient, and can be divided into conservative surgery, radical surgery, and extended surgery, with very significant differences. The principle is to strictly control the indications for surgery and ensure the sufficient resection of the vulva and surrounding tissues, and to determine the range of lymph node dissection based on the size, location, pathological differentiation of the local vulvar cancer lesion, and the condition of inguinal lymph node enlargement.

　　First, the common surgical treatment principles for vulvar cancer:

　　1. Stage 0: Unilateral lesion, local vulvar resection; for multiple lesions, simple vulvar resection.

　　2. Stage I a: Local or unilateral extensive vulvar resection after the lesion.

　　3. Stage I b: Extensive vulvar resection and lymph node dissection on the same side or both sides of the inguinal lymph nodes as the lesion.

　　4. Stage II: Extensive vulvar resection and bilateral inguinal lymph node dissection and/or pelvic lymph node dissection.

　　5. Stage III: Similar to Stage II or concurrent with the removal of the skin of the lower urinary tract, vagina, and anal area.

　　6. Stage IV: In addition to extensive vulvar resection, bilateral inguinal lymph node dissection, and pelvic lymph node dissection, the appropriate surgical approach is selected based on the involvement of the bladder, upper urinary tract, or rectum.

　　For many years, the traditional treatment for vulvar cancer has been extensive vulvar radical resection and bilateral inguinal lymph node dissection, with some cases also involving pelvic lymph node dissection. The standard radical vulvar resection involves the removal of the entire vulvar skin, subcutaneous fat, and bilateral inguinal deep and superficial lymph nodes. This surgical approach typically uses a large butterfly-shaped incision, and this treatment often brings a certain degree of physical and psychological impact to patients, along with severe complications such as wound infection, flap necrosis, and lower limb edema. With the continuous deepening of research and understanding, some changes have occurred in the treatment concept of vulvar cancer in recent years, which should be said to be more scientific, more considerate of the effectiveness of treatment, and more attentive to the quality of life of patients. For example, for minimal invasive vulvar cancer, it is not necessary to perform radical vulvar resection, and there is no need to perform inguinal lymph node dissection. For early lateral cases, it is possible to perform lymph node dissection on the affected side only, and the lymph nodes on the opposite side can be left untouched. Local or locally extended radical vulvar resection can be used instead of radical vulvar resection. Efforts are made to preserve the great saphenous vein and prevent lymphedema. Currently, the trend in treatment tends to focus on two aspects: first, maximizing the preservation of the physiological structure of the vulva and providing appropriate treatment for early patients, that is, individualized treatment; second, combining the advantages of surgery, radiotherapy, and chemotherapy to reduce surgical trauma, improve treatment effectiveness, and enhance the quality of life of patients, that is, comprehensive treatment.

　　Second, Radiotherapy and Chemotherapy Treatment

　　For patients with locally advanced vulvar cancer, especially those who are difficult to remove completely by surgery, radiotherapy and chemotherapy can play a certain complementary and auxiliary role for surgery. It can not only reduce the tumor to a certain extent, reduce surgical trauma, improve the quality of surgery, but also reduce postoperative recurrence, and may improve the prognosis of vulvar cancer patients to varying degrees. Radiotherapy and chemotherapy also have certain efficacy for patients who cannot undergo surgery or cannot tolerate surgery.

　　Third, Vulvar Radiotherapy

　　Commonly used for:

　　1. Preoperative local irradiation, followed by surgery after the tumor is reduced.

　　2. Postoperative irradiation of pelvic lymph nodes after extensive vulvar resection.

　　3. Treatment of residual or recurrent cancer after surgery. Chemotherapy is mainly used for the treatment of advanced vulvar cancer or recurrent cancer, and can be administered by intravenous injection and local arterial perfusion methods.