Vulvar cancer is the abnormal growth of cells on the outer side of the female genitalia. Symptoms of cancer may include pain, reddish skin, or growth on the vulva.

Vulvar Cancer

Medilink Consultant clinic

Online Consultation

ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

Overview

Vulvar cancer can develop in any region of the vulva, the exterior part of the female genital organs around the vaginal opening. The survival ratio is relatively high when it is diagnosed and treated early. Vulvar cancer is a rare cancer of the vulva in women.&nbsp;

Vulvar cancer is most usually found in:

<ul>
	<li>The inner lips (labia minora)</li>
	<li>The outer lips (labia majora)</li>
	<li>The skin between the vagina and the anus (perineum) 
	&nbsp;</li>
</ul>

This kind of cancer frequently begins as vulvar intraepithelial neoplasia, a condition in which healthy skin cells surrounding the vulva develop unusual changes. If the defective cells are not treated, they can develop into cancer.&nbsp; 
&nbsp;

Vulvar cancer develops typically slowly over time. Precancerous lesions usually appear first and are identified as abnormal cell development in the skin&#39;s outermost layer. These precancerous lesions are known as vulvar intraepithelial neoplasia (VIN). 
&nbsp;

In 2019, vulvar cancer resulted in the death of 1,347 women (0.6 per 100,000) in the United States<a href="#accordion">[1]</a>. According to a recent assessment, around 15% of all vulvar cancers develop in females under the age of 40<a href="#accordion">[2]</a>. 
&nbsp;

There are various kinds of vulvar cancer: 
&nbsp;

<ol>
	<li>
	<h5>Squamous Cell Carcinoma (SCC)</h5>
	</li>
</ol>

This type of cancer develops in the thin, flat cells lining the vulva&#39;s surface. It is the most prevalent type and accounts for over 90% of all vulvar cancers<a href="#accordion">[3]</a>.

It may be caused by the human papillomavirus (HPV), particularly in younger women. Typically, it may take years for obvious symptoms to appear. A subtype of squamous cell carcinoma known as verrucous carcinoma is a kind of cancer that grows slowly and resembles a wart. 
&nbsp;

<ol start="2">
	<li>
	<h5>Vulvar (Mucosal) Melanoma</h5>
	</li>
</ol>

Melanoma originates in the cells (melanocytes) that give skin its colour . These cells are&nbsp; also located in the lining of the vulva. Although melanoma may typically be found in areas commonly exposed to the sun, it can also develop in the absence of sun exposure.

The majority of vulvar melanomas are black or dark brown, but they can also be white, pink, red, or other colours. They can be found throughout the vulva. However, the majority are situated on the clitoris or the labia minora. It accounts for 2% to 4% of all vulvar cancers<a href="#accordion">[3]</a>. 
&nbsp;

<ol start="3">
	<li>
	<h5>Sarcoma</h5>
	</li>
</ol>

It is an uncommon type of vulvar cancer that originates in the muscle, bone, or connective tissue cells. The majority of these cancers are malignant. It can affect anybody at any age, including kids. 
&nbsp;

<ol start="4">
	<li>
	<h5>Adenocarcinoma</h5>
	</li>
</ol>

It is an uncommon type of vulvar cancer that grows from glandular (mucus-producing) cells in the Batholin&rsquo;s glands. It is responsible for a tiny proportion of vulvar cancers. 
&nbsp;

<ol start="5">
	<li>
	<h5>Basal Cell Carcinoma (BCC)</h5>
	</li>
</ol>

It is a relatively rare variety that begins in the tall (basal) cells in the lower layer of the skin. 
&nbsp;

Signs and Symptoms

Symptoms of vulvar cancer vary. Various kinds of vulvar cancer may have different signs and symptoms; in some occurrences, no symptoms are present. 
&nbsp;

The symptoms of vulvar cancer (if present) are as follows:

<ul>
	<li>Itching, burning, and vulval soreness or discomfort</li>
	<li>A bump, sore, inflammation or a growth resembling a wart on the vulva</li>
	<li>Ulceration (the development or growth of an ulcer on a body part)</li>
	<li>Skin patches in the vulva that are thickened and elevated (may be red, white or dark brown)</li>
	<li>A mole on the vulva alters the shape or colour</li>
	<li>Blood, pus or other kinds of discharge leaking from a lesion or tender spot in the vulva</li>
	<li>Firm and swollen lymph nodes in the groin area</li>
	<li>Pelvic discomfort during sex or peeing</li>
	<li>Tenderness around the vulvar region 
	&nbsp;</li>
</ul>

It is quite challenging to self-examine the vulva, so if you experience genital pain or detect any of the symptoms described above, see your general practitioner (GP). 
&nbsp;

Causes

Cancer develops when cells in a certain part of your body divide and grow too quickly. This results in the formation of a lump of tissue known as a tumour.

The precise causes of vulvar cancer are unknown. However, several factors can increase your chances of developing it. 
 
Among these are

<ul>
	<li>Advancing age</li>
	<li><a href="https://merisehat.pk/disease/human-papillomavirus-hpv">Human papillomavirus (HPV)</a> infection</li>
	<li>Vulval intraepithelial neoplasia (VIN)</li>
	<li>Family history of melanoma</li>
	<li>Cervical or vaginal cancer</li>
	<li><a href="https://merisehat.pk/disease/hiv-61">HIV</a> or <a href="https://merisehat.pk/disease/aids">AIDS</a></li>
	<li>Skin diseases that can affect the vulva, for example, lichen sclerosus</li>
	<li>Smoking 
	&nbsp;</li>
</ul>

<ul>
	<li>
	<h5>Advancing Age</h5>
	</li>
</ul>

Vulvar cancer is more frequent in older women. Generally, every year more than 40 out of 100 (greater than 40%) new cases occur in females aged 75 and above4. However, it can also occur in young women and has been observed in women in their twenties. But getting vulvar cancer at such a young age is highly rare. 
&nbsp;

<ul>
	<li>
	<h5>Human Papilloma Virus (HPV)</h5>
	</li>
</ul>

The term &quot;human papillomavirus&quot; (HPV) refers to viruses that affect the skin and the mucous membranes surrounding the body, such as those in the cervix, anus, mouth, and throat. It spreads during intercourse, especially anal and oral sex.

There are numerous forms of HPV, and almost everyone is infected with the virus at some point in their lives. In most situations, the virus does not cause&nbsp; any harm or complications. 
&nbsp;

However, HPV is present in at least four out of every ten women with vulvar cancer, suggesting that it may raise your risk of developing the disease5. HPV induces alterations in cells of the cervix, which can lead to cervical cancer. The virus is considered to have a similar effect on vulva cells, known as VIN. 
&nbsp;

<ul>
	<li>
	<h5>Vulval Intraepithelial Neoplasia (VIN)</h5>
	</li>
</ul>

Vulval intraepithelial neoplasia (VIN) is characterized by precancerous alterations in the skin&#39;s top layer (epithelium) covering the vulva. VIN is not cancer, but it has the potential to evolve into vulval carcinoma. This normally takes a long time, over 10 years.

In certain circumstances, the atypical cells may disappear on their own. However, due to the risk of cancer, treatment to remove the damaged cells is frequently advised. 
&nbsp;

VIN symptoms include persistent irritation of the vulva and elevated discoloured patches, which are similar to those of vulval cancer. Consult your doctor if you are experiencing any of these symptoms. 
&nbsp;

VIN is classified into two types:

<ol>
	<li>High-Grade Squamous Intraepithelial Lesion (HSIL)</li>
</ol>

This type is more common in younger women aged 45 to 504. It has been linked to long-term human papillomavirus (HPV) infections. 
&nbsp;

<ol start="2">
	<li>Differentiated Vin (dVIN)</li>
</ol>

This is a rare type mainly observed in older women. It is linked to a skin disorder known as lichen sclerosus. Although most cases of VIN will not progress to cancer, it is impossible to predict which will and which won&#39;t. A doctor should treat or closely monitor everyone suffering from this ailment. 
&nbsp;

<ul>
	<li>
	<h5>Skin Conditions</h5>
	</li>
</ul>

Vulval cancer is linked to some long-term vulval skin disorders. 
&nbsp;

They are as follows:

<ul>
	<li>Lichen sclerosus</li>
	<li>Lichen planus 
	&nbsp;</li>
</ul>

Lichen sclerosus is the most frequent of them. It causes irritation and, in some cases, discomfort in the vulva. This is most common in women over the age of 60. Females who experience lichen sclerosus may also develop differentiated vulval intraepithelial neoplasia (dVIN). Lichen sclerosus and lichen planus induce long-term (chronic) inflammation of the vulvar skin.

It is expected that vulval cancer will affect less than 5% of women who develop one of these disorders4. However, it is unclear whether addressing these diseases lowers the risk. 
&nbsp;

<ul>
	<li>
	<h5>Smoking</h5>
	</li>
</ul>

Smoking raises your chances of getting VIN and vulval cancer. This could be because smoking weakens the immune system, making it less capable of clearing the HPV virus from your body and making it more susceptible to the effects of the virus. 
&nbsp;

Diagnosis

If you have vulvar cancer, it is critical to seek treatment from a gynecologic oncologist, medical professional specialized in treating gynecologic cancers. They can oversee your care from diagnosis to treatment completion and follow ups later . The earlier vulvar cancer is detected, the less probable it will require significant surgery for treatment.Among the tests are: 
&nbsp;

<ol>
	<li>
	<h5>&nbsp;Physical Examination</h5>
	</li>
</ol>

Your doctor will most likely examine your groin and pelvic area, including your genitals. A nurse may be present throughout the checkup, and you may request a family member to accompany you.

At the same time, the doctor may perform an internal examination to check your vagina and cervix. This entails your doctor putting an instrument called a speculum into your vagina to allow for an inspection of the vagina and cervix. 
&nbsp;

<ol start="2">
	<li>
	<h5>Colposcopy</h5>
	</li>
</ol>

Your doctor may use a colposcope (magnification equipment) to inspect your vulva and vagina in considerable detail. The colposcope does not enter your vagina; your doctor examines it from the outside. The doctor will apply a liquid to your vulva and vagina to help the colposcope see abnormal cells. This may sting or burn, and you may experience a brown discharge as a result. 
&nbsp;

<ol start="3">
	<li>
	<h5>Removing A&nbsp;Sample Of Tissue For Testing (Biopsy)</h5>
	</li>
</ol>

Your doctor may advise removing a skin sample for testing to evaluate whether an area of suspicious skin on your vulva is cancerous. A local anaesthetic is used to numb the area before removing all or part of the suspicious area using a scalpel or other appropriate cutting tool.

The tissue samples will be submitted to a laboratory, where they will be examined under a microscope by a pathologist. The pathologist will be able to determine whether or not the cells are malignant and the type of vulvar cancer it is. 
&nbsp;

<ol start="4">
	<li>
	<h5>Cervical Screening Test</h5>
	</li>
</ol>

Your medical professional may perform a cervical screening test. This test has overtaken the Pap test and diagnoses cancer-causing HPV kinds in the cervix or vaginal cells. 
&nbsp;

<ol start="5">
	<li>
	<h5>Staging</h5>
	</li>
</ol>

Your doctor will be able to tell you the cancer stage based on the tests&#39; findings. This is a method of describing its size and whether or not it has spread. Your doctor may also inform you about the grade of the cancer cells. This indicates how quickly cancer may spread. Knowing the stage and grade of your cancer allows your doctor to propose the best treatment for you. 
&nbsp;

<h5>Stages Of Vulvar Cancer</h5>

When cancer is identified, it is classified according to its stage, which indicates how far it has spread. Vulvar cancers are staged on a scale of 0 to 4. The lower the stage, the less cancer has spread and the better the chances of successful treatment. The five primary stages are as follows: 
&nbsp;

<ul>
	<li>Stage 0</li>
</ul>

Stage 0 cancer is defined as very early cancer that is limited to the surface of the vulva&#39;s skin.

<ul>
	<li>Stage I</li>
</ul>

Cancer is solely present on the vulva or perineum (area between the rectum and the vagina) in this stage. Stage I is further subdivided into IA and IB based on tumour size less than or more than two centimetres (peanut size), and progress into the tissue less or more than one millimetre (tip of a pencil).

<ul>
	<li>Stage II</li>
</ul>

Any size tumor that has progressed to other body regions, such as the lower vagina, anus or lower urethra is defined as stage II. There is no involvement of lymph nodes at this stage.

<ul>
	<li>Stage III</li>
</ul>

Cancer has progressed to one or more neighbouring lymph nodes. Stage III is further subdivided into IIIA, IIIB, and IIIC based on the number and size of affected lymph nodes.

<ul>
	<li>Stage IV</li>
</ul>

In this stage, cancer has spread to the upper section of the urethra or vagina, or to distant body regions. Stage IV is further subdivided into IVA and IVB based on whether the advancement is limited around the vulva or has extended far.

If you&#39;ve been diagnosed with a definite stage of cancer, ask your healthcare professional to describe the characteristics of the specific stage and what it implies.

<ul>
	<li>Early-Stage Vulvar Cancer</li>
</ul>

Stages 1 and 2 vulvar cancers are considered early-stage malignancies with a good possibility of being effectively treated.

<ul>
	<li>Advanced-Stage Vulvar Cancer</li>
</ul>

Stage 3 and 4 cancers are normally considered advanced-stage cancers, and a complete cure for these two stages of cancer may not always be attainable. 
&nbsp;

<ol start="6">
	<li>
	<h5>&nbsp;Additional Tests</h5>
	</li>
</ol>

Additional tests may be required to identify the size and location of cancer and whether it has spread. Among these tests are

<ul>
	<li>A computerized tomography (CT) or magnetic resonance imaging (MRI) scan</li>
	<li>A blood test</li>
	<li>Chest X-Ray</li>
	<li>Proctoscopy</li>
	<li>Cystoscopy 
	&nbsp;</li>
</ul>

Treatment

The kind, stage, and position of your cancer, as well as your general health and preferences, all affect your treatment options for vulvar cancer. If your cancer is caught early enough, it is often feasible to totally eradicate it. However, if cancer has spread, this may not be practicable.

Surgery, radiation, and chemotherapy may be used to treat vulvar cancer. You may receive one of these therapies or a mix of them. 
&nbsp;

The options are as follows:

<ul>
	<li>
	<h5>Surgery</h5>
	</li>
</ul>

The following procedures are used to treat vulvar cancer: 
&nbsp;

1. Removing The Cancer And A&nbsp;Margin Of Healthy Tissue (Excision)

This type of surgery, also known as wide local excision or radical excision, includes removing the tumour and a tiny amount (at least 1 cm) of surrounding normal tissue. By removing a perimeter of normal-looking tissue, surgeons may verify that all malignant cells have been eliminated. 
&nbsp;

2. Removing Part Of The Vulva Or the Entire Vulva (Vulvectomy)

Your vulva is partially or completely removed. There are various kinds:

<ul>
	<li>Skinning Vulvectomy</li>
</ul>

Your doctor removes only the top layer of skin from your vulva.

<ul>
	<li>Simple Vulvectomy</li>
</ul>

This surgery removes the whole vulva and the tissue beneath the skin.

<ul>
	<li>Partial Or Modified Radical Vulvectomy</li>
</ul>

This surgery includes removing the majority of your vulva as well as any neighbouring lymph nodes.

<ul>
	<li>Radical Vulvectomy</li>
</ul>

Your doctor will remove the entire vulva and any surrounding lymph nodes.

People with more advanced tumours may also consider combining radiation therapy and chemotherapy to reduce the tumour before surgery, which may allow for less invasive surgery. 
&nbsp;

3. Removing&nbsp; Few Nearby Lymph Nodes (Sentinel Node Biopsy)

The surgeon may perform a procedure known as sentinel node biopsy to assess whether cancer has progressed to the lymph nodes. This process determines which lymph nodes are most likely to contain cancer, allowing them to be removed and studied. Cancer is unlikely to be identified in any other lymph nodes if it is not found in the first lymph nodes. 
&nbsp;

4. Removing Many Lymph Nodes

If cancer has advanced to the lymph nodes, many of the lymph nodes may be removed by surgery to lessen the risk of cancer spreading to other parts of the body.

The time it will take you to heal from the surgery will depend on the kind of surgery and its extensiveness. 
&nbsp;

<h5>Risks Of Surgery</h5>

Your surgeon will inform you about the potential dangers related to the kind of surgery you are having. For example

<ul>
	<li>Modified sensation in your vulva</li>
	<li>Healing issues around the cut</li>
	<li>Bleeding</li>
	<li>Infection</li>
	<li>Blood clots</li>
	<li>Trouble having sex 
	&nbsp;</li>
</ul>

The removal of lymph nodes can result in fluid retention and swelling of the leg, a disease known as lymphedema. 
&nbsp;

<ul>
	<li>Palliative Care</li>
</ul>

In some situations of vulvar cancer, your medical team may discuss palliative care with you. Palliative care intends to improve your quality of life by reducing cancer symptoms.

Palliative care can alleviate discomfort and aid in managing other signs and symptoms, in addition to slowing the spread of vulvar cancer. 
&nbsp;

Treatment may include

<ul>
	<li>Radiation therapy.</li>
	<li>Chemotherapy.</li>
	<li>Other drug therapies. 
	&nbsp;</li>
	<li>
	<h5>Radiation Therapy (Radiotherapy)</h5>
	</li>
</ul>

Radiation therapy is also referred to as radiotherapy. To kill cancer cells, radiation therapy employs high-powered energy beams such as X-rays and protons. Radiation therapy for vulvar cancer is often delivered by a machine that moves around your body, directing radiation to specific locations on your skin (external beam radiation). 
&nbsp;

Radiation therapy will be administered depending on the following:

<ul>
	<li>Stage of cancer</li>
	<li>Its size</li>
	<li>If it has spread to the lymph nodes</li>
	<li>How many nodes are affected 
	&nbsp;</li>
</ul>

Radiation therapy can be employed before, after, or in place of surgery. In most situations, you&#39;ll have external radiotherapy, in which a machine focuses radiation beams onto the area of the body containing cancer.

Radiotherapy is usually delivered in daily sessions, five days a week, for a few minutes each session. Typically, the entire course of treatment will last a few weeks. Occasionally, radiation therapy is paired with chemotherapy, which can make cancer cells more sensitive to radiation. 
&nbsp;

<ul>
	<li>
	<h5>Chemotherapy</h5>
	</li>
</ul>

Chemotherapy is a treatment that employs drugs to either kill or slow the growth of cancer cells. Chemotherapy can be administered in the form of tablets, a cream applied to the vulva, or, more frequently, by injection into a vein. 
&nbsp;

Chemotherapy may be an option for those with advanced vulvar cancer that has progressed to other body parts. Treatment for vulvar cancer in women may be given:

<ul>
	<li>During radiation therapy, to increase the effectiveness of the treatment.</li>
	<li>To control cancer that has progressed to other body parts.</li>
	<li>As a palliative treatment to alleviate cancer symptoms. 
	&nbsp;</li>
	<li>
	<h5>Targeted Drug Therapy</h5>
	</li>
</ul>

Targeted drug therapies target specific abnormalities found in cancer cells. This therapy can induce cancer cells to die by blocking these abnormalities. Targeted therapy may be an option for advanced vulvar cancer treatment. 
&nbsp;

<ul>
	<li>
	<h5>Immunotherapy</h5>
	</li>
</ul>

Immunotherapy makes use of your immune system to combat cancer. Cancer cells produce proteins that aid in their concealment from immune system cells so that your body&#39;s disease-combating immune system is unable to attack your cancer. Immunotherapy works by disturbing that process. Thus, it may be a treatment option for advanced vulvar cancer. 
&nbsp;

<ul>
	<li>
	<h5>Laser Therapy</h5>
	</li>
</ul>

Laser therapy kills cancer cells by utilizing high-intensity light. The light beams are directed through a thin tube known as an endoscope, which is used to target and destroy tumours. Laser therapy is less likely to result in scarring and bleeding than other kinds of treatment. The doctor can frequently do it on an outpatient basis, which entails you can leave the hospital on the same day as your treatment. 
&nbsp;

<ul>
	<li>
	<h5>Pelvic Exenteration</h5>
	</li>
</ul>

Pelvic exenteration may be done in cases of advanced or serious vulvar cancer. Your surgeon may remove the following, depending on where cancer has progressed:

<ul>
	<li>Cervix</li>
	<li>Rectum</li>
	<li>Bladder</li>
	<li>Lower colon</li>
	<li>Lymph nodes</li>
	<li>Vulva</li>
	<li>Ovaries</li>
	<li>Vagina 
	&nbsp;</li>
</ul>

If your bladder, colon and rectum are removed, your medical professional will make an opening called a stoma through which urine and stool will exit your body. 
&nbsp;

Although the specific origin of vulvar cancer is unknown, certain variables tend to raise your risk, including 
&nbsp;

<ul>
	<li>
	<h5>Having A&nbsp;Compromised Immune System</h5>
	</li>
</ul>

People who take immune-suppressing drugs, such as those who have had an organ transplant, and those who have illnesses that impair the immune system, like human immunodeficiency virus (HIV), are at a higher risk of vulvar cancer. 
&nbsp;

<ul>
	<li>
	<h5>Having A&nbsp;History Of Vulvar Precancerous Conditions</h5>
	</li>
</ul>

Vulvar intraepithelial neoplasia (VIN) is a precancerous condition that raises the chances of developing vulvar cancer. The vast majority of cases of vulvar intraepithelial neoplasia do not progress to malignancy, although a small percentage do. As a result, your doctor may advise treatment to eliminate the abnormal cells and&nbsp; advise periodic follow-up exams. 
&nbsp;

<ul>
	<li>
	<h5>Having A&nbsp;Skin Disorder Involving The Vulva</h5>
	</li>
</ul>

Lichen sclerosus, which affects thin and itchy vulvar skin, raises the risk of vulvar cancer. 
&nbsp;

At this moment, the cause of vulvar cancer is unknown. However, several medical conditions are thought to promote the disease&#39;s development. Preventive measures include: 
&nbsp;

<ul>
	<li>Avoiding identified risk factors</li>
	<li>Using condoms</li>
	<li>Smoking cessation</li>
	<li>Having frequent physical examinations</li>
	<li>Getting an HPV vaccination</li>
	<li>Regular Pap tests and pelvic examinations</li>
	<li>Checking your entire body for unusual mole growth and your vulva for any indicators of vulvar cancer frequently 
	&nbsp;</li>
</ul>

The HPV vaccine can protect against the HPV strains that cause the majority of cervical, vaginal, and vulvar malignancies. HPV vaccines are only effective against some kinds of HPV. They cannot be used to treat a previously diagnosed HPV infection. One of the vaccines should be administered before a person becomes sexually active to be most useful. 
&nbsp;

The Giant Steps In Surgical Downsizing Toward A Personalized Treatment Of Vulvar Cancer<a href="#accordion">[6]</a>.

There have been significant changes in the customised surgical treatment for vulvar cancer.&nbsp; For many years, radical surgery, such as en bloc resection, was the primary treatment option and the pattern of care, despite its high complication rate and frequent disfigurement. Taussing and Way pioneered the radical vulvectomy method, which included en bloc bilateral inguinal-femoral lymphadenectomy; a modified radical vulvectomy with a large radical resection of the main tumour was established.

To reduce problems such as lymphedema or sexual dysfunction, a more tailored and conservative surgical technique involving large local or wide radical excisions is required. Dimensions, staging, depth of invasion, presence of carcinoma at surgical margins of resection, and grading must all be considered for effective surgical care of vulvar cancer, to make treatments as customised as possible.

Modified vulvectomy and wide local excision are known to preserve the patient&rsquo;s quality of life and are associated with fewer side effects such as sexual dysfunction, lymphedema, and urinary complications. 
&nbsp;

Key Points

<ul>
	<li>Vulvar cancer is a malignancy that occurs in the vulvar region.</li>
	<li>Vulvar cancer is becoming more common in younger women between the ages of 35 and 45.</li>
	<li>Symptoms of vulvar cancer include intense itching, burning, and discomfort on the vulva.</li>
	<li>The HPV vaccine can protect against HPV strains that cause the majority of cervical, vaginal, and vulvar malignancies.</li>
	<li>Age, infection with specific forms of HPV, smoking, and HIV infection are all risk factors for developing vulvar cancer in women. 
	&nbsp;</li>
</ul>

[1] Vaginal and vulvar cancers statistics. Centers for Disease Control and Prevention.

[2] Alkatout I, Schubert M, Garbrecht N, Weigel MT, Jonat W, Mundhenke C, et al. Vulvar cancer: epidemiology, clinical presentation, and management options. Int J Womens Health. 2015;7:305

[3] Vulvar cancer - introduction. Cancer.Net.

[4] Risks and causes. Risks and causes | Vulval cancer | Cancer Research UK.

[5] Vulvar Cancer - Causes. NHS choices.

[6] Giannini A, D’Oria O, Chiofalo B, Bruno V, Baiocco E, Mancini E, et al. The giant steps in surgical downsizing toward a personalized treatment of vulvar cancer. J Obstet Gynaecol Res. 2022;48(3):533–40