Vulval conditions

In this episode of PodMD, experienced sub-specialist Gynaecological Oncologist Dr Rhett Morton will be discussing conditions of the vulva, including vulval dermatoses, vulval pre-cancer, vulval cancer, how a patient typically presents, treatment options, the major risks of these conditions, when to refer and more.


  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Rhett Morton

    Dr Rhett Morton is an experienced sub-specialist Gynaecological Oncologist who treats and manages patients with confirmed or suspected gynaecological cancers, pre-cancers and benign gynaecological conditions requiring complex surgery. Dr Morton is based in The Wesley Hospital in Auchenflower.

    Today, we’ll be discussing the topic of ovarian cancer.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Rhett, thanks for talking with us on PodMD today.

    Rhett : Thank you for having me

    Question 1
    The topic of today’s discussion is the Vulva.
    Rhett, can you describe for our listeners about conditions affecting the Vulva?

    Rhett: Absolutely. Vulval conditions are a really broad range of conditions that often present with similar symptoms, mainly being local vulval symptoms or skin symptoms. But in terms of the range of conditions, it can include dermatitis that can be the atopic or contact related. There are several dermatosis that affect the vulval skin, including lichen sclerosus and lichen planus, and even psoriasis. There are infections that can affect the vulval skin, including Candidiasis and HSV, and and the more common condition that we see in older women is vaginal and vulval atrophy, or thinning of the skin related to menopause.

    There are various pain syndromes that can affect and cause symptoms on the vulva. And the two conditions really that we’ll be focusing on today, particularly as it relates to the gynecological cancer is vulval intraepithelial neoplasia or VIN or VIN for short and vulval cancer, predominantly. This is a squamous cell cancer that affects the vulval skin, but there are also some rarer subtypes, including melanoma. Today we’ll mainly be focusing on vulval squamous cell carcinoma.

    Question 2
    How would a patient with V.I.N or vulval cancer typically present?

    Rhett: The most common symptoms for both of these conditions really are around local skin conditions and vulval itch or peritus is the main presenting symptom for almost all women. They might describe it in different ways, such as an itch that they need to scratch or a burning sensation. They can also describe it as stinging and just generalize discomfort in the area. They may also describe actual pain, and for me you see, that’s quite a significant warning sign and can often indicate the development of a of a localised cancer.

    They may not have any of those symptoms, though, and may have just noticed a lump in the skin, or a bump, or even just an area of subtle thickening of the skin. They may have noticed some bleeding, either on contact or spontaneously, or they may have noticed an ulcerated area of skin there. Interestingly though, a lot of women can actually be asymptomatic completely, even with a fully developed vulval skin cancer and some of these abnormalities are only detected on routine examination, particularly at the time of the cervical screening test. Or just on a general physical examination.

    Question 3
    What are the risks of these conditions?

    Rhett: So the main risk for development of a vulval cancer, particularly a squamous cell cancer, is having one of these pre-cancerous conditions VIN. We’re now learning a lot about this VIN in the there are two very distinct subtypes of the VIN and one of them is closely related and caused by human papilloma virus and we term that as HPV associated VIN. And the two high risk subtypes of human papilloma virus type 16 and 18, which are covered in the HPV vaccination account for most cases of Vulval VIN, that’s HPV associated. The other type is independent of HPV and we at the moment do not believe that HPV has a role in its development. There is some new molecular studies that are essentially showing that this type of VIN is related to a mutation in the tumor suppressor gene TP 53, and we can look for that on biopsies by doing immunohistochemistry to look for a P53 mutation on that immunohistochemistry.

    This type of VIN has a very high risk of progression to cancer somewhere in the order of 85% of cases of HPV independent VIN will progress to cancer and it’s usually over a much shorter time course than the HPV associated subtype. The other term for HPV independent VIN is differentiated VIN and that may be more familiar to the listeners. So in terms of HPV associated VIN, it accounts for less cases of both pre invasive disease and also cancer and only about 30% and the risk of progression to cancer from the precancerous stage is also lower. So the risk is about 15% over a 10-year time period.

    Generally, other risks of developing vulval pre cancer and cancer and include of course age. Smoking is one of the main risk factors for development of a HPV associated pre cancer and cancer as is chronic immunosuppression and women who are on medical immunosuppression for things such as organ transplants are at very high risk and require close surveillance. There is also a related condition called lichen sclerosis, and that’s particularly related to differentiated VIN and we know now that untreated lichen sclerosis does also increase your risk of developing a vulval cancer.

    Question 4
    What are the treatment options?

    Rhett: So the different types of pre cancer on the vulva have quite different treatments. And cancer, we usually divide into early stage cancers, locally advanced cancers and metastatic cancers. I guess first of all, I’d just like to highlight that these conditions are unfortunately very difficult to treat and they’re often associated with the high risk of treatment failure and recurrence. In terms of HPV associated VIN there, there are several treatment options. The mainstay of treatment traditionally has always been surgical excision of the skin and there are some benefits in doing that in that we remove the area and can confirm histologically that there is no invasive occult cancer there. But these surgeries can also be quite disfiguring, and it is a very sensitive area on the body. There are some midline structures, including the clitoris, urethra and anus that are difficult to treat and preserve with surgery and therefore some other treatments have come into use a a treatment that can be used to preserve those midline structures still with reasonable rates of cure is laser ablation treatment, and more recently we’re using imiquimod or aldara as an immune modulator to treat these precancerous changes related to HPV associated pre cancer.

    In terms of non-HPV associated pre cancer or differentiated VIN, the mainstay is still surgical excision and this is because of the high risk of a coexisting cancer and progression to cancer. And so surgical excision is the main treatment. In terms of cancer, if we have an early-stage cancer that looks like it’s localized to the vulva, we tend to prefer to treat with surgical excision. And the main risk of spread of this cancer from the vulval skin is to the groin, lymph nodes and so we typically look at the vulva and the groin in isolation, tumors on the vulva that are invading more than a millimeter in depth have an increased risk of spread to the groin, lymph nodes and therefore we evaluate the lymph nodes with surgery, either with a Sentinel node biopsy or a full lymph node dissection, and then based on the results of that, patients may be recommended to have adjuvant treatment with chemotherapy and radiation.

    Often women will present with locally advanced cancers, so either a very large tumour on the vulva that involves midline structures, or the vagina, or they may present with bulky groin nodal involvement and often their upfront treatment will be chemotherapy and radiation. In terms of advanced presentations of vulval cancer, the outlook for women at the moment is quite poor, unfortunately, and their prognosis is poor. Palliative chemotherapy is often offered in an in an in an attempt to control disease, but not in a way that it can be curative. Another option is best supportive and palliative care for women.

    Question 5
    Have there been any developments in treatment in the last years or are there any in trials or development now?

    Rhett: This is a really good question and a really exciting question. Unfortunately, historically vulval cancer and pre cancer has been very, very under researched. I guess there are probably a couple of reasons for that. It is quite relatively a very rare cancer. It only accounts for about 4% of all gynecological cancers. And for forming clinical trials in in such a rare cancer is very difficult. There’s also, I think, a lot of. Perhaps taboo in in in the in the medical community and also in the patient population as well about vulval disorders, but with ongoing community education, I think that is changing both the medical and general community. And so research is really gaining momentum. Recently, within the last two years, there’s been a large randomised controlled trial published looking at treatment of HPV related VIN, where they compared surgical excision with Aldara or imiquimod. And really excitingly, they were found to both have comparable rates of cure and that Aldara was not inferior to the surgical excision. And so the rates of cure were around 75% for both treatment arms. So based on that trial, we’re currently able to recommend or offer women Aldara treatment knowing that it appears to be a safe, non inferior option to surgical excision. In terms of differentiated VIN or non HPV associated VIN, there’s a lot of research going into looking at the molecular profile of these pre invasive changes in the skin and in the hope that we will find new targeting mutations that we can either target with drugs or modify the radicality of our surgical management.

    In terms of treatment of cancer, really historically the treatment of vulval cancer was very radical surgery that essentially removed the entire vulva and historically they would also do the lymph node dissection on block with the vulva removing all lymph nodes including the skin bridge between the groins involved are, and, so most of the progress that’s been made over treat over the years in terms of treatment of this disease is has focused on less radical treatment that’s more acceptable to patients, less disfiguring, associated with less long term morbidity. And so wide local excision has now become the standard of care, and this is resulting in less disfiguring surgery. And similarly, there’s been a lot of research into Sentinel node biopsies instead of doing full groin dissections, so that’s associated with a much lower risk of lymphedema and lymphocystis. And post operative complications. And we now know based on several recent trials that central lymph nodes are a safe, safe alternative to full groin dissection in selected women. There’s also, as I said before, some ongoing research into molecular subtyping of these vulval cancers and how we can use that to direct the extent and radicality of surgery that’s required. Although I said that the prognosis for women with advanced and metastatic vulval cancer is quite poor, there are some ongoing trials into immunotherapy, which are looking promising. So things such as pembrolizumab are showing some benefits in women who previously been thought to have incurable disease with a very poor prognosis.

    Question 6
    Are there any warning signs a GP or their patient can look out for?

    Rhett: The warning signs that there may be a development of a vulval pre cancer or cancer include vulval skin, itching or peritus, and this is probably the most common symptom that patients report. It may be new in onset or it may have been going on for several months, and occasionally even several years before patients present. They may have also noticed a vulval or lump or bump that’s different. They may have also noticed some vulval skin bleeding. Sometimes these conditions are actually asymptomatic and they may be just noted. As a white plaque or a thickening of the skin that has been seen by the patient during self-examination or is picked up by a healthcare provider during collection of a cervical screening test. The progression of these precancerous conditions to a cancer is often associated with development of vulval pain, and often this pain can be very severe. And also the formation of a lump that can potentially become ulcerated.

    Question 7
    What is the likelihood of recurrence of the condition?

    Rhett: So unfortunately, the likelihood of recurrence for all of these conditions is quite high. In terms of HPV associated VIN, all of the treatments that we can offer are usually successful at removing the precancerous cells, but the human papilloma virus has a propensity to live on the skin, particularly in older women. And we’re realising this more and more now that we’re screening for cervix cancer with the HPV primary screening program, is that the HPV virus can lie dormant in the skin for many years, and unfortunately at the moment we don’t have a treatment or even a test for HIV presence on the vulva. So for that reason, recurrence of HPV associated VIN, the risk is still present even after treatment. It’s around 5 to 10% chance over the first five years after treatment. And therefore for women who’ve been treated for this, we do follow them closely over time

    The risk for recurrence of differential VIN or HPV Independent VI N is actually much higher, unfortunately. So 1 in 3 women will recur at some point over the first three years after their treatment, and that’s even after surgical excision with clear margins. The recurrence risk of cancer really depends on both the subtype of cancer. So is it a HPV associated cancer, or is it HPV independent? And it also depends on the stage of cancer that patients have been treated with at diagnosis. We know that if there has been involvement of the groin nodes, prognosis is poorer. For instance, if patients present and have treatment for an early stage cancer without involvement of groin nodes, they have an overall. Five year survival that is very good of the reign of 80 to 90%. However if nodes are or groin nodes are involved at diagnosis, their prognosis over the next five years in terms of overall survival is greatly reduced in the region of 25 to 40%.

    Question 8
    When should a GP refer?

    Rhett: My recommendation would be if there is any concern about an abnormal examination, so if a patient presents with symptoms or if you know anything on a routine examination. Then definitely the patient should be referred for examination and biopsy. Or if the patient has a normal examination but they have persistent local vulval symptoms. When we see these women in the clinic, essentially we do vulvoscopy and we use acetic acid and often HPV associated VIN is not obvious to the naked eye without that next step of a specialist examination. So I think absolutely if the patient has ongoing vulval symptoms, but things look normal on examination, I would recommend referral either to a gynecologist or a dermatologist, or a gynecological oncologist, so that vulvoscopy and a biopsy can be performed.

    Question 9
    What role does the GP play in the treatment of these conditions?

    Rhett: I would say it’s it’s the main role actually that the GP can play the most important role in in the management of these patients. As GP’s are the people who have the most contact with these patients, they know them the the best and often patients will have the closest relationship with their GP’s and I believe would be most comfortable talking about vulval symptoms with them. So definitely I think early detection would be key. So going back to if a patient self-reports any valuable symptoms, examination should be performed and an early referral of if there are any concerns, because early detection of these precancerous changes can be cured and they can definitely prevent the progression to cancer.

    As we spoke about previously, women are quite high risk of recurrence after treatment for this and and typically we would see them every six monthly in the clinic if they had a precancerous condition after treatment. And usually every three monthly if they had had a cancer treated. But in between those visits, it would be really important if a patient presented with recurrent symptoms or any local symptoms, any groin symptoms that they have a thorough history and examination and a phone call to their treating team. These treatments can be quite disfiguring, and there is a lot of negative effect or potential negative effect on both body image, sexual function and I think GP’s would have a prime role in in helping support women through who have been treated for these conditions in terms of psychosocial support and sexual support.

    In terms of managing risk factors, definitely smoking is one of the main risk factors for HPV associated vulval pre cancer and cancer. So any assistance in smoking reduction and cessation will really both reduce their risk of recurrence and improve their overall health. At the moment, we are gathering evidence about the efficacy of vaccination for HPV in women who are of an older age bracket or who may have missed the catch up program and I think in the future, given that HPV associated vulval cancer is mainly related to 16 and 18, which are the two main subtypes covered in the HPV vaccine that that probably we will be seeing a reduction in in that subtype of vulval cancer and hopefully we’ll see some evolving evidence that actually offering older women HPV vaccination would hopefully reduce their risk of developing vulval cancer.

    At the moment we’ve got some trials ongoing and we and we don’t have the full research there to support funding for that vaccination. But it would be definitely something I would be discussing with patients. We do have some evidence that in women who’ve been treated for sorry not vulval but cervical pre cancer, that offering them a vaccination at the time of treatment does reduce their risk of recurrence of that cervical pre cancer and my hope would be in the future that we can actually prove that may be the case for vulval cancer and pre cancer as well.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on vulval conditions?

    Rhett: Thanks very much for having me today. The three take home messages I’d like to express is that. Volvo skin symptoms are common, but they’re not normal and they should be taken seriously with the full history and examination and not on referral with any concerns. The second point is that examination, I think is essential and a lot of women feel uncomfortable around having a vulval examination, and I also believe that a lot of health practitioners also feel uncomfortable about examining women’s vulvas. And I think that that is fine, that it should be recognised and the patient can always be referred on to someone else who can offer them that examination. And the third thing would be to just have a very low threshold for referral for further assessment and biopsy, particularly in women who have abnormal findings on examination or who have a normal examination but persistent symptoms.

    Thanks for your time and the insights you’ve provided.

    Rhett: Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.