Vulvar Intraepithelial Neoplasia - VIN
(Squamous carcinoma in situ)
Laser surgery is the preferred method of treatment, in young patients and patients with multifocal lesions. Surgery in the form of wide local excision or occasionally simple vulvectomy may also be used for certain patients with intraepithelial neoplasia.
Wide local excision or simple vulvectomy is the usual treatment for basal cell carcinoma or Paget's disease. The use of topical fluorouracil (5-FU) is not recommended.
Invasive Carcinoma
Radical vulvectomy and en bloc regional lympadenectomy is the treatment method of choice for most types of invasive disease.
Modification of this standard treatment policy may be made on the basis of the patient's age, lesion size, depth of invasion, lesion location, and general medical condition. Radiation therapy may be used as primary treatment in inoperable cases and for recurrent disease following surgery, either locally or in nodal areas. In addition, patients with an operable lesion but medically unfit for radical surgery may be treated by primary radiotherapy. A variety of radiotherapeutic methods and techniques may be used.
Certain lesions involving the posterior vulva (fourchette), perineal body or anal margin may be treated with a combined approach using radiation and surgery.
Melanomas
Melanomas are usually treated surgically.
Extent of surgery is individualized based on lesion size and depth of invasion. (Node dissection is no longer part of the routine treatment of these lesions and is only done when suspicious or enlarged nodes are present.)
Estrogen Replacement Therapy - Site Specific Information
No data exist to show a contraindication for hormone replacement in cervical, vaginal or vulvar cancer. Many of these patients are young and at high risk for estrogen deprivation related morbidity. It is the feeling of the group that these patients should be encouraged to take estrogen replacement. In the presence of a uterus we recommend continuous estrogen and progestogen with the estrogen at a moderate dose (0.625-1.25 mg Premarin) and the progestogen at a low dose (2.5 mg Provera). Histologic studies have shown that continuous therapy with combined estrogen and progestogen induces an atrophic bland endometrium. This regime may result in some initial bleeding for the first one to two months but in general the women are amenorrheic.
An alternative regime would be to use cyclical estrogen and progestogen. This has the disadvantage of inducing a withdrawal bleed in some patients who have not had total ablation of the endometrium. Hematometra may develop if there is cervical stenosis present leading to abdominal pain or a mass.
Recommendation: Continuous estrogen and progestogen, e.g.:
Premarin; 0.625-1.25mg
Provera 2.5 mg
(note: these small doses of Provera do not seem to have the same deleterious effects on serum lipids as the higher doses.)
In the absence of a uterus there is no theoretical need for progestogen, therefore estrogen alone in usual doses is recommended.
Site Specific Information
Treatment is individualized. An external beam radiotherapy course involves six to seven weeks of treatment followed possibly by one to two weeks of additional nursing care.