Surgery is usually the main treatment for vulval cancer.
How your surgeon decides which operation
Different types of surgery are used to treat cancer of the vulva. Which operation you have will depend on the stage of your cancer. Your surgeon will also take into account:
- the spread of the cancer – how large the affected area is and where the cancer is on your vulva
- the depth of the cancer – the surgeon must remove all the cancer together with a border of healthy tissue round it
- whether the cancer has spread to the lymph nodes in your groin
- your personal wishes, feelings and general health
Your surgeon will try to leave as much normal skin as possible while making sure that the cancer is completely taken away. Removing all the cancer is the most important factor in trying to cure the cancer. Many women with vulval cancer are cured with surgery alone.
Types of surgery
You might have a wide local excision. This is when the surgeon removes an area of your vulva. For larger cancers your surgeon might need to remove a larger part of your vulva. This is called a partial vulvectomy.
More rarely you might need to have your whole vulva removed. This is called a vulvectomy or a radical vulvectomy.
Your surgeon will also check your lymph nodes and they may need to remove them if the nodes contain cancer cells.
A wide local excision means that the surgeon removes the area containing the cancer, along with a border of healthy tissue around it. The border of healthy tissue is called the margin. The important thing is that the margin of healthy tissue does not contain cancer cells. This lowers the risk of the cancer coming back.
Your surgeon might also want to remove some nearby lymph nodes with this operation.
The surgeon removes some but not all of the vulva. Sometimes they have to remove other parts, for example, the clitoris. Your surgeon might also remove the lymph nodes in the groin. This may be on one or both sides of your groin, depending on where the cancer is.
This first diagram (below) shows a partial vulvectomy where the cancer is on one side of the vulva.
The next diagram (below) shows a partial vulvectomy where the cancer is at the top of the vulva.
The last diagram (below) shows a partial vulvectomy where the cancer is in the lower part of the vulva.
Surgery to remove the whole vulva is called a radical vulvectomy or vulvectomy. The surgeon removes the whole vulva, including the inner and outer lips of the vulva. You may have the clitoris removed as well.
The most common type of vulvectomy operation is called a 3 in 1, or triple incision. This means there is one incision to remove the vulva itself. And two more – one on each side – to remove the lymph nodes.
Lymph nodes are part of a system of tubes and glands in the body that filters body fluid and fights infection. It is important to know if the cancer has spread to the lymph nodes, as this helps the doctors decide if you need more treatment.
When you have surgery
If you have stage 1A vulval cancer you do not need any further tests to check for signs of cancer in your lymph nodes.
If your cancer is stage 1B or greater, your doctor will want to check your lymph nodes near the vulva to see if they contain cancer. Up until recently, the surgeon would remove all of the nearby lymph nodes to check for cancer spread. But this operation has side effects. Doctors are looking for other ways to check lymph nodes close to the vulva, so they do not need to remove lots of them.
Your doctor may suggest you have a test to check your lymph nodes if:
- your cancer is smaller than 4cm
- you only have one area of cancer
This test is called a sentinel node biopsy. You have it at the same time as surgery to remove the cancer (wide local excision).
How you have the test
For this test, the surgeon removes and checks the sentinel node (or nodes) for cancer. The sentinel node is the first node that fluid drains to from the vulva. This means it’s the first lymph node the cancer could spread to. If this node does not contain cancer, it’s unlikely that further lymph nodes contain cancer cells.
To find the sentinel lymph node, the doctor injects a dye or small amount of a weak radioactive chemical (called a tracer) into the area around the cancer. The dye or radioactive tracer follows the route of the fluid that drains from the vulva to the lymph nodes. The first lymph node that the dye or tracer reaches is the sentinel node.
The surgeon removes this and sends it to the lab. Here a specialist doctor (pathologist) examines it for cancer cells.
After the test
If it doesn't contain cancer cells, there is a good chance that the cancer has not spread. You will not need surgery to remove the rest of the lymph nodes.
You will need further treatment if there are cancer cells in one or more sentinel nodes. You might have surgery to remove all the remaining lymph nodes and you may also have radiotherapy to the groin area.
The lymph nodes in the groin are usually the first place where cancer cells spread from the vulva. Your surgeon may recommend you have an operation to remove the lymph nodes in the groin. This is called a lymph node dissection or lymphadenectomy. Your surgeon does this at the same time you have your vulval operation.
Removing the lymph nodes in this way reduces the risk of the cancer coming back. It also gives the doctor information about the stage of your cancer. This helps them decide whether you need more treatment.
Your surgeon may remove the lymph nodes on one or both sides of your groin. This will depend on the size and position of the cancer. Surgery to remove lymph nodes from your groin can affect fluid drainage in your legs. This can cause a build up of fluid called lymphoedema. This is more of a risk if you have radiotherapy after surgery.
Surgeons used to do this operation by removing the vulva and the lymph nodes together, through one large cut (incision). Now they usually make separate smaller incisions in the groins to remove the lymph nodes. By doing this it is easier for you to recover and you are less likely to have problems after the surgery.
Some women with advanced vulval cancer have surgery to remove some of the nodes in their groin. This is to relieve any symptoms that you may have, such as pain. Afterwards you usually have radiotherapy. This helps reduce the risk of the cancer spreading further.
This operation can affect the fluid drainage into the legs causing swelling (lymphoedema). This can happen soon after treatment or a long time after. It is difficult to say who will have this and when it might happen.
Sometimes advanced vulval cancer can spread from the vulva to other parts of your body, such as the bowel, bladder or womb. If this has happened to you, you may need to have a very big operation called a pelvic exenteration. This will include a radical vulvectomy. And your surgeon will also remove one or more of the following:
- lymph nodes in the pelvis or groin
- the lower part of your bowel
- back passage
- womb – the body of the womb (uterus) or neck of the womb (cervix) or both
This operation is rare for vulval cancer. Your surgeon will only consider this if you are fit enough to make a good recovery. But for some women it is worth doing, because it may cure even an advanced cancer.
This type of surgery is more often done for advanced cervical cancer. If you go to the page below, please remember to use your back button to get back to this section. The other information about cervical cancer will not apply to you if you have vulval cancer.
Other treatments along with surgery
Some women need to have treatment alongside their surgery. Doctors call this adjuvant treatment. Your specialist may suggest you have radiotherapy after your surgery.
You might have radiotherapy to the remaining vulval tissue, to lymph nodes in your groin, or both. The aim of this treatment is to try and kill off any remaining cancer cells. This lowers the risk of the cancer coming back in the future.
Your doctors may want you to have treatment before your operation. This is called neo adjuvant treatment. The treatment might shrink the cancer and make it easier to remove. It may mean that you can have a smaller operation.
Radiotherapy is the most commonly used adjuvant treatment. But your doctor may suggest chemotherapy at the same time. Some chemotherapy drugs help the radiotherapy to work.
Information and support
This cancer affects a deeply personal and private part of your body. A few people prefer not to know about their operation in advance. But for most women, it may help you to cope better if you understand exactly what is going to happen. It is important to feel supported.
Most hospitals carrying out this type of treatment will have a clinical nurse specialist. They support women having treatment for gynae cancers. This nurse is there to answer your questions or just talk about how you are feeling. If the nurse specialist isn't introduced to you soon after your diagnosis, do ask. You can make an appointment to see them.
There should be information available for you to take home with you if you want it. Ask your surgeon or specialist nurse for a booklet or printed web pages that you can read through. This will help you to work out what questions you need to ask next time you go to the hospital.
There is a UK support organisation for women having vulval cancer treatment. It is run by women who have been through what you are going through. Talking to other women who have already been there may be a big help. They are called VACO.