Dysplasies de haut grade ou carcinome in situ
Les dysplasies de haut grade comportent les lésions prémalignes de la vulve qui nécessitent un traitement local. Une exploration par vulvoscopie (microscope permettant de détecter des lésions non visibles à l’œil nu) peut être parfois nécessaire pour déterminer l’extension locale de la maladie. En fonction de l’extension, des caractéristiques de la maladie et de l’âge, un traitement par vaporisation laser, par crème Imiquimod (crème qui augmente la réponse immunitaire locale face à la maladie), ou un traitement chirurgical seront proposés.
Vulvar cancer
The vulva is the external part of a woman’s genitals, whereas the vagina is one of the internal parts. Vulvar cancer is a rare type of cancer that affects 1 or 2 women in 100,000. It occurs most frequently in women who have gone through menopause, often at around the age of 70, and is usually caused by the Human Papilloma Virus (HPV). However, it may be preceded by a precancerous phase in the form of a pre-existing skin disease (lichen sclerosus).
Diagnosis
Symptoms of vulvar cancer can include a lump or wart-like growth on the vulva, an open sore on the vulva, persistent itching, or an area of the vulva that changes color. Diagnosis involves a clinical examination with biopsies of the lesions. This examination may be carried out by your gynecologist, a surgeon or an oncologist and may require a general anesthetic. If the clinical examination suggests that the disease has spread across the vulvar or reached the inguinal lymph nodes, an MRI and /or PET (positron emission tomography) scan may be carried out.
Treatment
Following diagnosis, every case is discussed at a multidisciplinary team (MDT) meeting during which the specialists involved in treating gynecological cancers will decide on the most appropriate treatment options for each patient. The treatment offered will depend on the patient’s age, the presence of any underlying conditions, the location of the tumor and how far it has spread. Thus, treatment may involve surgery alone or surgery followed by external radiotherapy (especially if there are affected lymph nodes). In some cases, interstitial brachytherapy may also be necessary.
The medical team may ask if you would be prepared to take part in a clinical trial. As well as giving patients the opportunity to benefit from a new form of treatment, clinical trials may be used to improve understanding of how cancer arises and develops, or to evaluate patients’ quality of life and see how it can be improved.
Surgery is the main type of treatment for cancers of the vulva. The aim is to remove the diseased tissue, including a safety margin, while preserving the patient’s body image and the function of the vulva. Surgery may be combined with a lymph node dissection (sentinel node or lymphadenectomy) in one or both sides of the groin. The sentinel nodes are the first lymph nodes into which the tumor drains, so if these nodes are free of cancer, the other nodes are usually healthy and do not need to be removed. This reduces the risks and possible consequences of extensive lymph node removal.
The second part of the operation involves using reconstructive surgery techniques to repair the areas removed. Depending on the size of the area concerned, surgical treatment for vulvar cancer may require a multidisciplinary approach involving complex reconstruction techniques provided by our reconstructive surgery team.
Radiotherapy uses ionizing radiation to destroy cancer cells.
External radiotherapy: Before treatment begins, the area to be treated is determined by taking a 3-dimensional scan of the tumor (or affected area) and the neighboring organs, which have to be protected (preparation stage). A medical physicist then calculates the dose of radiation you will receive and how this dose will be distributed (dosimetry stage). This is why there is always a waiting period between the decision to use radiotherapy and the start of treatment.
A course of radiotherapy usually involves 25 radiotherapy sessions, provided from Monday to Friday (5 sessions a week) over a period of 5 to 6 weeks. Each session lasts 15 minutes. Most of this time is spent checking the positioning and targeting of the radiation. The actual treatment time is very short. Radiation is invisible and the treatment is completely painless, so you will not feel a thing. Radiotherapy sessions do not make you radioactive and you do not have to take any precautions with respect to the people around you when the session is over.
Brachytherapy: This is a form of internal radiotherapy in which radiation is applied directly to the area being treated. It involves inserting an applicator, under general anesthetic, so it is in contact with the tumor, and then injecting a radioactive material (iridium) through it. Compared with external radiotherapy, brachytherapy targets radiation precisely on the vulva, thereby allowing higher doses to be used while preventing harm to healthy organs. Brachytherapy requires a short stay in hospital (2 or 3 days), because the radioactive source is injected through the applicator for 15 to 30 minutes every hour. You must remain lying down throughout the treatment, but you are isolated only during the periods in which the radiation is injected. As a result, you are free to receive visits from healthcare staff and from family and friends for 30 minutes every hour. You will not be radioactive, even during the treatment periods, and your room will be a traditional hospital room apart from the presence of an afterloader (machine that delivers the radiation dose).
Brachytherapy may seem restrictive because you have to remain lying down throughout, but it is entirely painless, so you won’t feel a thing during treatment sessions. In addition, no anesthetic is needed to remove the applicator. The nursing staff will answer any questions you may have.