Gynecological-cancers-Vulva-cancer (ELearningPage)

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      <HtmlField Name="References"><![CDATA[<p>Yutaka U, et al.J Skin Cancer. 2011; 2011: 951250.<br>
<br>
National Cancer Institute. SEER data: <a href="https://seer.cancer.gov/statfacts/html/vulva.html%20">Surveillance, epidemiology and end results.</a><br>
<br>
Hacker NF,et al. Cancer of the vulva. Int J GynecolObstet 2012;119(Suppl 2): S90-6.
<br>
<br>
Olsen J, et al. Incidence and cost of anal, penile, vaginal and vulvar cancer in Denmark. BMC Public Health 2012; 12:1082-9.
</p>
<p><a href="https://www.esgo.org/media/2016/10/ESGO-Vulvar-cancer-Brochure.pdf">Vulvar Cancer Brochure</a></p>]]></HtmlField>
      <HtmlField Name="Author"><![CDATA[Tine Henrichsen Schnack, Department ofGynecologic Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen Denmark]]></HtmlField>
      <HtmlField Name="TakeHomeMessage"><![CDATA[<ul>
    <li>Vulva cancer is a rare disorder affecting predominantly elderly women</li>
    <li>VC is caused by high risk HPV (40%) or lichen sclerosis (60%)</li>
    <li>The 5-year disease specific survival in localized VC is good</li>
    <li>Treatment with surgery in vulva and the groins are often mutilating</li>
    <li>Metastatic inguinal lymph nodes are the most important prognostic factor
    </li>
</ul>]]></HtmlField>
      <HtmlField Name="PageContent"><![CDATA[<p>Gynecological cancers encompass malignancies in the female reproductive organs: </p>
<ul>
    <li><a href="~/link.aspx?_id=2913C25234B04C14B0457452A3DE9561&amp;_z=z">Ovarian cancer</a>, including cancer in the fallopian tubes and primary peritoneal cancer</li>
    <li><a href="~/link.aspx?_id=E116D8F166A9425D83E03A6403F30C45&amp;_z=z">Uterine cancer</a>, endometrial cancer and sarcoma (from the uterine myomatous wall)</li>
    <li><a href="~/link.aspx?_id=7578134A038949228AFEF818ECBEC7F9&amp;_z=z">Cervical cancer</a></li>
    <li><a href="~/link.aspx?_id=D93B5C0688894D13AE1BE99E397A899F&amp;_z=z">Vaginal cancer</a></li>
    <li>Vulval cancer</li>
    <li><a href="~/link.aspx?_id=3C51AE6E129243F3B1228B840BA4031C&amp;_z=z">Trophoblast tumor</a>, originating from placental tissues </li>
</ul>
<h2>Introduction</h2>
<p>Gynecological cancers are classified according to FIGO (International Federation of Gynecology and Obstetrics, see Table 1), rather than the traditional TNM-classification. Localized/small tumors (FIGO stage I) have significantly better survival than tumors with distant spread (Typically FIGO stage IV). Cancers that generally are detected early (such as endometrial cancer after postmenopausal bleeding) have a mostly good prognosis, while ovarian cancer with few early signs are mostly diagnosed late and thus have a poorer overall survival rate. The only preventable gynecological cancer (HPV-vaccination, see Chapter Premalignant lesions of the uterine cervix) is also the only one with a good screening option (cervical smear/HPV-test, described in the Approach to the patient chapter, part Performing cervical cytology). Following mass vaccination the incidence of cervical cancer will likely decrease in the coming decades. Endometrial cancer on the other hand has displayed an increased incidence due to the general aging of the population in combination with obesity. </p>
<p>The different cancers and their treatment are described in the specific sub-chapters. The Nordic countries have guidelines that differ slightly. Links to specific Nordic/European guidelines are displayed in the FIGO table (Table 1).</p>
<table class="vandret-layout">
    <thead>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="col">Cancer type</th>
            <th class="vandret-layoutTableOddCol" scope="col">FIGO I</th>
            <th class="vandret-layoutTableEvenCol" scope="col">FIGO II</th>
            <th class="vandret-layoutTableOddCol" scope="col">FIGO III</th>
            <th class="vandret-layoutTableEvenCol" scope="col">FIGO IV</th>
        </tr>
    </thead>
    <caption>Table 1. FIGO (International Federation of Gynecology and Obstetrics) classification of gynecological cancer, simplified version.</caption>
    <tbody>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Ovarian </th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">one/both ovaries</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Pelvic tumor extension: </td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Metastasis above pelvic brim:</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Distant metastasis:</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Fallopian tube</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">one/both tubes</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Uterus/ovaries/tubes/bladder/rectum</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Retroperitoneal lymph nodes</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Pleura/thorax</td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Peritoneum</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">0/+ ascites</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Primary peritoneal cancer</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Peritoneal implants, capule spleen/liver</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Liver/Spleen/inguinal lymph nodes</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Uterine sarcoma</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Uterus only</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Pelvis: adnexa/extraadnexal</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Above pelvis, pelvic /paraortic l.n*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Bladder/rectum or distant metastasis</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Endometrial </th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Endometrium/myometrium</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Cervical stroma</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Uterine serosa/tubes/ovaries/vagina/l.n*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Bladder/rectum or distant metastasis</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row"><strong></strong>
            <p>Cervix</p>
            </th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Cervix only</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Upper 2/3 vagina, parametrium (not pelvic wall)</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Lower 1/3 vagina, pelvic wall, hydronephrosis, l.n*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Bladder/rectum or distant metastasis</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Vagina</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Vagina only</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Paravaginal, not pelvic wall</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Pelvic wall, pelvic l.n.*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Bladder/rectum or distant metastasis</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Vulva</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Vulva/peritoneum</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Lower part urethra,vagina,anus</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Middle parts urethra,vagina,anus, groin l.n.*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">
            <p>Higher parts urethra,vagina,anus, Distant metastasis</p>
            </td>
        </tr>
    </tbody>
</table>
<p><em>* l.n.= lymph nodes&nbsp;</em></p>
<p><em>Relevant guidelines regarding gynecological cancer:</em></p>
<p><em><strong>ESGO</strong>: <a href="https://www.esgo.org/explore/guidelines/">European Society of Gynecologic Oncology</a></em></p>
<p><em><strong>NSGO</strong>: <a href="https://nsgo.org/guidelines-2/">Nordic Society of Gynecologic Oncology</a></em></p>
<p><em><strong>National guidelines</strong></em></p>
<p><em><strong>DGCG</strong>: <a href="http://dgcg.dk/">Dansk Gynekologisk Cancer Gruppe</a></em></p>
<p><em><strong>Finland</strong>: <a href="https://gynekologiyhdistys.fi/wp-content/uploads/2019/12/HOITOSUOSITUKSET_FINGOG_12_2019_final.pdf">Finnish</a></em></p>
<p><em><strong>Iceland</strong>:</em></p>
<p><em><strong>NFGO</strong>: <a href="https://www.legeforeningen.no/foreningsledd/fagmed/norsk-gynekologisk-forening/veiledere/veileder-i-gynekologisk-onkologi-2015/">Norsk Forening Gynekologisk Onkologi</a></em></p>
<p><em><strong>Sweden</strong>: <a href="https://www.cancercentrum.se/samverkan/cancerdiagnoser/gynekologi/">Regionala Cancercentrum i Samverkan-Gynekologisk cancer</a></em></p>
<p>&nbsp;</p>
<h3>The disease</h3>
<p>
Vulva cancer (VC) is a rare cancer located in the vulva and/or perineum. Squamous cell carcinomas (SCC) accounts for 90 % of VC cases. This chapter describes SCC VC only.
</p>
<p>There are two distinctively different pathways in VC SCC (2). The most common pathway starts with Lichen sclerosis (LS) (Please see the Benign vulvovaginal diseases chapter) (60%) and the precursor lesion is differentiated vulvar intraepithelial neoplasia (dVIN). The second pathway is driven by an infection with high risk Human Papilloma Virus (HPV) mainly HPV16 and HPV18.</p>
<h2>Epidemiology</h2>
<p>
In the western countries the incidence of VC is 2-3 cases per 100.000 women per year.  The incidence of vulvar cancer is most common in the elderly population with a median age of 68 years. An increase in the incidence of VC has been observed in the younger age groups due to high-risk HPV infection, because of changes in sexual behavior.
</p>
<h2>Risk Factors</h2>
<p>
</p>
<h3>Pathway caused by high-risk HPV</h3>
<ul>
    <li>
    Smoking</li>
    <li>Sexual habits (number of partners, age at first sexual intercourse)</li>
    <li>Immuno-suppression.</li>
    <li>HSIL</li>
    <li>Diabetes</li>
</ul>
<p>
</p>
<h3>Pathway caused by Lichen Sclerosis</h3>
<ul>
    <li>
    Family history of lichen sclerosis and vulvar cancer</li>
    <li>Increasing age</li>
    <li>Severity of Lichen Sclerosis</li>
    <li>DVIN</li>
</ul>
<h2>Symptoms</h2>
<p>
Most patients have more than one of the following symptoms:
</p>
<ul>
    <li>Pain, burning, soreness or pruritus in the vulva</li>
    <li>Swelling, polyp, lump or ulcer in the vulva</li>
    <li>Elevation and/or irregularity of surface contour</li>
    <li>Color change of the skin in vulva (whitening or pigment deposition)</li>
    <li>Clinical wart (true condyloma is uncommon in the elderly women)</li>
    <li>Palpable enlarge groin lymph nodes</li>
    <li>Lichenoid changes in the vulva</li>
</ul>
<h2>Diagnostics</h2>
<p>
No evidence for prophylactic screening in VC exists. Early detection and treatment of premalignant precursor lesion (Lichen sclerosus) is essential to prevent development into SCC VC.
<br>
<br>
If vulvar cancer is suspected, the following examination and test are used:
</p>
<ul>
    <li>Gynecological examination</li>
    <li>A punch biopsy of all suspicious lesions. Excisional biopsies should be avoided outside a cancer center.</li>
    <li>Palpation of groin lymph nodes</li>
    <li>PAP-smear to exclude HPV related cervical pathology</li>
    <li>MR, PET-CT and/or CT of thorax abdomen pelvis</li>
</ul>
<h2>Treatment</h2>
<p>
Standard of care is:</p>
<h3>Early Stage (FIGO I-III)
<table class="vandret-layout">
    <thead>
        <tr>
            <th class="vandret-layoutTableEvenCol" scope="col">Cancer type</th>
            <th class="vandret-layoutTableOddCol" style="text-align: left;" scope="col">FIGO I</th>
            <th class="vandret-layoutTableEvenCol" style="text-align: left;" scope="col">FIGO II</th>
            <th class="vandret-layoutTableOddCol" style="text-align: left;" scope="col">FIGO III</th>
            <th class="vandret-layoutTableEvenCol" style="text-align: left;" scope="col">FIGO IV</th>
        </tr>
    </thead>
    <caption>Table 1. FIGO (International Federation of Gynecology and Obstetrics) classification of gynecological cancer, simplified version.</caption>
    <tbody>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Ovarian </th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">one/both ovaries</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Pelvic tumor extension: </td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Metastasis above pelvic brim:</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Distant metastasis:</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Fallopian tube</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">one/both tubes</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Uterus/ovaries/tubes/bladder/rectum</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Retroperitoneal lymph nodes</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Pleura/thorax</td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Peritoneum</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">0/+ ascites</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Primary peritoneal cancer</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Peritoneal implants, capule spleen/liver</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Liver/Spleen/inguinal lymph nodes</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Uterine sarcoma</th>
            <td class="vandret-layoutTableOddCol">Uterus only</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Pelvis: adnexa/extraadnexal</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Above pelvis, pelvic /paraortic l.n*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Bladder/rectum or distant metastasis</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Endometrial </th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Endometrium/myometrium</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Cervical stroma</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Uterine serosa/tubes/ovaries/vagina/l.n*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Bladder/rectum or distant metastasis</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row"><strong></strong>
            <p>Cervix</p>
            </th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Cervix only</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Upper 2/3 vagina, parametrium (not pelvic wall)</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Lower 1/3 vagina, pelvic wall, hydronephrosis, l.n*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Bladder/rectum or distant metastasis</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Vagina</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Vagina only</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Paravaginal, not pelvic wall</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Pelvic wall, pelvic l.n.*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Bladder/rectum or distant metastasis</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Vulva</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Vulva/peritoneum</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Lower part urethra,vagina,anus</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Middle parts urethra,vagina,anus, groin l.n.*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">
            <p>Higher parts urethra,vagina,anus, Distant metastasis</p>
            </td>
        </tr>
    </tbody>
</table>
</h3>
<p><em>* l.n.= lymph nodes&nbsp;</em></p>
<ul>
    <li>Local excision of the tumor in the vulva and removal of groin lymph nodes either by the sentinel node procedure or by inguinal lymphadenectomy.</li>
    <li>Primary chemoradiation therapy if: 1) tumor involves more than 1 cm of the urethra, 2) tumor involves vagina 3) tumor involves the anal sphincter. </li>
</ul>
<p>
</p>
<h3>Late stage disease (FIGO stage IV)</h3>
<ul>
    <li>Primary chemotherapy.</li>
</ul>
<p>
</p>
<h3>Adjuvant chemoradiation therapy</h3>
<ul>
    <li>
    Inadequate surgical margins where re-resection is not possible</li>
    <li>Regional lymph node metastasis</li>
</ul>
<h2>Prognosis</h2>
<p>
Early stage VC, which is localized to vulva, has an excellent prognosis (five-year overall survival between 95-97 %. However, the mortality is high if metastasis to the inguinal lymph nodes or distant metastasis are found (five-year overall survival 50-75% and 20-30 %, respectively. The overall relative 1- and 5-year survival for all stages of the disease is 88% (84-92) and 71% (67-75), respectively.
</p>
<h2>Relapse</h2>
<p>
Local relapse in the vulva is common even after radical treatment for early stage disease. Inguinal and distant recurrences are associated with a high mortality.</p>
<p>&nbsp;</p>
<p><strong>Keywords: </strong>Vulva cancer, human Papilloma virus, Lichen Sclerosis, HSIL
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<h2>Multiple choice quiz</h2>
<p><a href="https://mcq.nfog.org/start/chapter/53">https://mcq.nfog.org/start/chapter/53</a></p>]]></HtmlField>
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