Vulval cancer and vaginal cancer — Rapid

Synopsis

Recognise persistent vulval and vaginal symptoms, biopsy before destructive treatment, distinguish HPV-related and inflammatory pathways and coordinate organ-preserving local treatment, site-specific nodal staging, chemoradiation and functional rehabilitation.

Persistent vulval itch, soreness, ulcer, lump or architectural change requires examination and a punch or incisional biopsy; repeated antifungal or steroid treatment must not delay tissue.
Most vulval cancer is squamous: one pathway is HPV related, while the other arises through lichen sclerosus and differentiated VIN with p53 abnormalities.
Map and biopsy the lesion before wide excision so depth, histology, relation to clitoris, urethra and anus and the correct nodal plan can be agreed.
MRI pelvis is preferred for local extension in larger vulval and vaginal cancer; CT or PET-CT assesses groin, pelvic nodes and distant spread according to stage.
For unifocal vulval SCC smaller than 4 cm, more than 1 mm invasive and with clinically and radiologically negative groins, sentinel-node biopsy is the preferred low-morbidity nodal staging option.
Midline or near-midline vulval lesions can drain bilaterally and require a bilateral sentinel or groin strategy; a positive sentinel result enters burden-specific groin treatment.
Early vulval cancer is treated by radical local excision with adequate pathological margins rather than routine radical vulvectomy, preserving uninvolved anatomy.
Locally advanced vulval cancer may receive primary chemoradiation to avoid exenterative surgery, with biopsy-confirmed residual disease considered for salvage.
Primary vaginal cancer is rare and is diagnosed only after excluding cervical and vulval origin; definitive radiotherapy with brachytherapy is central for most invasive disease.
Small superficial upper-vaginal tumours may be surgically treated in selected patients, but level, prior hysterectomy and organ relationships demand specialist planning.
Treat lichen sclerosus effectively with potent topical corticosteroid and lifelong self-examination and review; symptom improvement does not remove the need to biopsy a new focal lesion.
Imiquimod is a specialist option for selected HPV-associated vulval HSIL, not for suspected invasive cancer or differentiated VIN.
Plan wound, lymphatic, urinary, bowel, sexual, vaginal-dilator and psychological rehabilitation before treatment.

Key red flags

Persistent vulval itch, soreness, ulcer, lump, colour or texture change requires visual examination and biopsy rather than repeated empirical antifungal treatment.

A hard fixed vulval lesion, enlarged groin node, clitoral or urethral involvement or severe focal pain suggests invasive disease.

Postcoital or postmenopausal bleeding, watery discharge, vaginal mass or dyspareunia requires speculum examination and directed biopsy.

Fever, crepitus, spreading perineal erythema, severe pain out of proportion or systemic toxicity suggests necrotising or deep infection.

Urinary retention, hydronephrosis, rectal symptoms, fistula or pelvic sidewall pain suggests locally advanced vaginal or vulval cancer.

A new ulcer or nodule within lichen sclerosus or differentiated VIN needs prompt re-biopsy even if the inflammatory disease is under treatment.

Necrotising infection or haemorrhage

Crepitus, spreading erythema, shock, severe disproportionate pain or brisk bleeding requires immediate resuscitation and source control.

Investigation priorities

First-line complete vulvovaginal examinationFirst stepFirst line

Map lesion number, size, site, colour, texture and relation to clitoris, urethra, vagina, anus and groin nodes.

Preferred pelvic MRIPreferred

Define tumour depth, vagina, urethra, anus, bladder, rectum, pelvic sidewall and nodes for surgery and radiotherapy.

Management branches

Persistent lesionBiopsy before repeated empirical treatment

Vulval or vaginal itch, pain, bleeding, ulcer, lump or texture change persists or recurs.

Perform a complete trauma-informed vulval, vaginal, cervical, anal and groin examination and assess infection, immune suppression and lichen-sclerosus history.
Obtain one or more labelled punch or incisional biopsies from the most suspicious areas before ablation, imiquimod or wide excision.
Once invasion is proven, obtain MRI and nodal or distant staging appropriate to site and refer to the specialist gynaecological oncology MDT.

Key medicines

Cisplatin with definitive radiotherapyGive cisplatin 40 mg/m² intravenously once weekly during external-beam radiotherapy, often for five or six doses, using the exact centre hydration, renal and dose-cap protocol.Monitor creatinine clearance, magnesium, marrow, hearing, neuropathy, hydration and infection and do not compromise timely brachytherapy merely to deliver another cisplatin dose.

Clobetasol propionate for lichen sclerosusApply clobetasol propionate 0.05% ointment thinly once nightly for 4 weeks, then on alternate nights for 4 weeks, then twice weekly for 4 weeks before review and individual maintenance.Demonstrate the small amount and correct sites, review response and maintenance and biopsy any persistent thickened, eroded, ulcerated or new focal area rather than escalating steroid blindly.

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