Almost all patients with invasive vulvar cancers will have symptoms.

Signs and Symptoms of Vulvar Intraepithelial Neoplasia (VIN)

The most common symptom of VIN is persistent itching that does not improve. However, most patients do not have symptoms. Areas of VIN are usually thicker and lighter in color than the surrounding skin. However, some cases of VIN can appear red, pink, or darker than the surrounding skin.

Because these symptoms can be caused by other conditions that are not pre-cancerous, some women fail to recognize the seriousness of their condition and attempt to treat the problem themselves with over-the-counter remedies. Sometimes even doctors may not recognize the condition at first.

Signs and Symptoms of Invasive Squamous Cell Cancer of the Vulva

The signs and symptoms of early invasive vulvar cancer are similar to those of symptomatic VIN. As invasion and growth progress, a distinct tumor is more likely to be recognized. The most common symptoms are a red, pink, or white bump or bumps with a wart-like or raw surface. An area of the vulva may appear white and feel rough.

About half of the women with vulvar cancer complain of persistent itching and a growth. Some also complain of pain, burning, painful urination, bleeding, and discharge not associated with the normal menstrual period. An ulcer that persists for more than a month is another sign.

Signs and Symptoms of other Types of Vulvar Cancers

Vulvar melanoma: The appearance of a darkly pigmented growth or a change in a mole that has been present for years may indicate melanoma. The ABCD rule can help tell a normal mole from one that could be melanoma.

—      Asymmetry: One-half of the mole does not match the other.

—      Border irregularity: the edges of the mole are ragged or notched.

—      Color: The color over the mole is not the same. There may be differing shades of tan, brown, or black and sometimes patches of red, blue, or white.

—      Diameter: The mole is wider than 6 mm (about 1/4 inch).

The most important sign of melanoma is a change in size, shape, or color of a mole. Some melanomas, however, do not fit the ABCD rule.

Bartholin gland cancer: A distinct mass on either side of the opening to the vagina may indicate a Bartholin gland carcinoma. However, similar symptoms may be due to a Bartholin gland cyst, which is much more common.

Paget disease: Soreness and a red, scaly area are symptoms of Paget disease of the vulva.

Verrucous carcinoma: This is one subtype of invasive squamous cell vulvar cancer with a particularly good prognosis. Verrucous carcinoma appears as cauliflower-like growths similar to genital warts.

Knowing what to look for can sometimes help with early detection, but it is even better not to wait until you notice symptoms. Have a regular Pap test and pelvic examination.

Medical History and Physical Examination

The first step is to take a complete medical history to check for risk factors and symptoms. Then your doctor will perform a complete physical examination, including a pelvic examination. He or she will feel your uterus, ovaries, cervix, and vagina for anything irregular. Your doctor will also look into the vagina and cervix using a speculum and will perform a Pap smear.

Biopsy

Although certain signs and symptoms may strongly suggest vulvar cancer, many of them can be caused by benign (non-cancerous) conditions. The only way to be certain that a vulvar cancer is present is to remove a small piece of tissue from the suspicious area to examine under the microscope. This procedure is called a biopsy. A pathologist (a doctor specializing in diagnosing diseases by laboratory tests) will look at the tissue sample under a microscope to see if cancer or a pre-cancerous condition is present and, if so, what type it is.

In order to find all areas of abnormal vulvar skin and to select the best areas to take a biopsy from, the doctor may rarely use toluidine blue to paint the vulva. This dye causes skin with certain diseases to turn blue, including vulvar intraepithelial neoplasia (VIN) and vulvar cancer.

The doctor may use a colposcope, an instrument with binocular magnifying lenses, or a hand held magnifying lens, to select areas to biopsy. The skin is treated with a dilute solution of acetic acid (which is also the main ingredient in vinegar) that causes areas of VIN and cancer to turn white, making them easier to see through the colposcope.

Once the abnormal areas are found, local anesthetic is injected into the skin to make it numb. If the abnormal area is small, it may be completely removed by an excisional biopsy. For this procedure, the doctor uses a scalpel to remove a small ellipse of skin and sews the skin edges together with surgical thread.

If the abnormal area is larger, a punch biopsy is used to take a small sample. The instrument used looks like a tiny apple corer and removes a small, cylindrical piece of skin 4 mm (about 1/6 inch) across. No stitches are needed after the punch biopsy. Depending on the results of the punch biopsy, additional surgery may be necessary.

Further testing

It is important to find out how far the cancer has spread. This is called staging (see below). The stage of your cancer is the most important factor in selecting the right treatment plan. The results of your physical examination and certain diagnostic tests will be used to determine the size of the tumor, how deeply it has invaded tissues at the site of origin, the extent of any invasion into surrounding organs, and the extent of metastasis (spread to lymph nodes or distant organs).

If your biopsy indicates that you have vulvar cancer, your health care professional will refer you to a gynecologic oncologist, a specialist in female reproductive system cancers. The first step will be a complete personal and family medical history to obtain information related to risk factors and symptoms of vulvar cancer.

The doctor will perform a complete physical examination to evaluate your general state of health. In addition, he or she will pay special attention to the lymph nodes, particularly those in the groin region, to check for evidence of metastasis. Depending on the biopsy results, several more tests may be done to determine if the vulvar cancer has spread to other areas.

Cystoscopy: This is an examination using a lighted tube to check the inside surface of the bladder. Some advanced cases of vulvar cancer can spread to the bladder, so any suspicious areas noted by this exam are removed for biopsy. This procedure can be done using a local anesthetic, but some patients may require general anesthesia. Your doctor will let you know what to expect before and after the procedure.

Proctoscopy: This is a visual inspection of the rectum using a lighted tube. Some advanced cases of vulvar cancer can spread to the rectum. A biopsy is performed on any suspicious areas.

Examination of the pelvis under anesthesia: This permits a more thorough examination that can better evaluate the extent of cancer spread to internal organs of the pelvis.

Imaging Tests

Chest x-ray: A plain x-ray of your chest will be done to see if your cancer has spread to your lungs. This is very unlikely unless your cancer is far advanced. This x-ray can be done in any outpatient setting. If the results are normal, you probably don’t have cancer in your lungs.

Computed tomography (CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, as does a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body (think of a loaf of sliced bread). The machine will take pictures of multiple slices of the part of your body that is being studied. Often after the first set of pictures is taken you will likely receive an intravenous injection of a “dye” or radiocontrast agent that helps better outline structures in your body. A second set of pictures is then taken.

CT scans take longer than regular x-rays and you will need to lie still on a table while they are being done. But just like other computerized devices, they are getting faster and your stay might be pleasantly short. The newest CT scanners take only seconds to complete the study. Also, you might feel a bit confined by the ring-like equipment you’re in when the pictures are being taken.

The contrast “dye” is injected through an IV line. Some people are allergic to the dye and get hives, a flushed feeling, or rarely more serious reactions like trouble breathing and low blood pressure. Be sure to tell your doctor if you have ever had a reaction to any contrast material used for x-rays. If you have, you may need medicine before you can have such an injection during your test.

You may also be asked to drink a contrast solution. This helps outline your intestine if your doctor is looking at organs in your abdomen. The CT scan will provide precise information about the size, shape, and position of a tumor, and can help find enlarged lymph nodes that might contain cancer.

Magnetic resonance imaging (MRI): MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body.

A contrast material might be injected just as with CT scans, but is used less often. MRI scans take longer — often up to an hour. Also, you have to be placed inside a tube-like piece of equipment, which is confining and can upset people with claustrophobia. The machine makes a thumping noise that you may find annoying. Some places will provide headphones with music to block this out. MRI images are particularly useful in examining pelvic tumors. They may often detect enlarged lymph nodes in the groin. They are also helpful in detecting cancer that has spread to the brain or spinal cord.

Positron emission tomography (PET): Positron emission tomography uses glucose (a form of sugar) that contains a radioactive atom. Cancer cells in the body absorb large amounts of the radioactive sugar and a special camera can detect the radioactivity. This test is useful to see whether the cancer has spread to lymph nodes. PET scans are also useful when your doctor thinks the cancer has spread, but doesn’t know where. PET scans can be used instead of several different x-rays because they scan your whole body. Newer devices combine a CT scan and a PET scan to even better pinpoint the tumor.