Vulvar cancer: symptoms, stages, diagnosis and treatment

Vulvar cancer is a malignant tumor of the external female genitalia, which includes the labia majora and minora, clitoris, vaginal vestibule, and the perineal skin adjacent to the vulva. The disease is considered rare but clinically significant because it often develops against a background of long-standing precancerous and chronic inflammatory changes, and early symptoms are often mistaken for "ordinary irritation," itching, or dermatitis for months. [1]

According to GLOBOCAN 2022, 47,336 new cases of vulvar cancer and 18,579 deaths were registered worldwide, with an age-standardized global incidence rate of 0.83 per 100,000. In the United States, according to the American Cancer Society's estimate for 2025, approximately 7,130 new cases and approximately 1,750 deaths were expected. This confirms that the tumor is rare, but not uncommon, and it remains a significant problem for gynecological oncology. [2]

The vast majority of vulvar tumors are squamous cell carcinoma. Current reviews and guidelines emphasize that this tumor has two main developmental pathways: one is associated with the human papillomavirus and is more common in younger women; the other is not associated with the human papillomavirus, develops against the background of chronic degenerative and inflammatory diseases, especially lichen sclerosus, and is more common in older women. [3]

There is currently no separate screening for vulvar cancer similar to that for cervical cancer. Therefore, the primary tools for early detection remain attentiveness to symptoms, a low threshold for vulvar examination, and mandatory biopsy of any suspicious lesion. Early diagnosis largely determines whether organ-preserving treatment will be sufficient or whether more invasive therapy will be required. [4]

Table 1. Key facts about vulvar cancer

Parameter	Meaning
Localization	External female genitalia
The most common histological type	Squamous cell carcinoma
Global new cases in 2022	47,336
Global deaths in 2022	18,579
Age-standardized global incidence rate	0.83 per 100,000
Is there organized screening?	No
The main method of confirming the diagnosis	Biopsy

Table based on: GLOBOCAN 2022, National Cancer Institute, ESGO 2023. [5]

Code according to ICD-10 and ICD-11

In the International Classification of Diseases, 10th revision, vulvar cancer is coded under the category C51 - malignant neoplasm of the vulva. Within this category, more precise subcategories are used: C51.0 for the labia majora, C51.1 for the labia minora, C51.2 for the clitoris, C51.8 for overlapping lesions of the vulva, and C51.9 for unspecified vulvar site. This helps to more accurately reflect the anatomical area of the lesion in clinical documentation and oncology statistics. [6]

The International Classification of Diseases, 11th revision, uses block 2C70 - malignant neoplasms of the vulva. Within it, 2C70.0 is allocated for basal cell carcinoma of the vulva, 2C70.1 for melanoma of the vulva, 2C70.2 for squamous cell carcinoma of the vulva, 2C70.Y for other specified malignant neoplasms of the vulva, and 2C70.Z for unspecified malignant neoplasm of the vulva. The explanatory note specifically states that this block also includes the skin of the vulva. [7]

Table 2. Coding of vulvar cancer

Classification	Code	Meaning
ICD 10	C51	Malignant neoplasm of the vulva
ICD 10	C51.0	Labia majora
ICD 10	C51.1	Labia minora
ICD 10	C51.2	Clitoris
ICD 10	C51.8	Overlapping lesion of the vulva
ICD 10	C51.9	Vulva, unspecified
ICD 11	2C70	Malignant neoplasms of the vulva
ICD 11	2C70.2	Squamous cell carcinoma of the vulva

Table basis: International Classification of Diseases, 10th revision and International Classification of Diseases, 11th revision browser. [8]

Epidemiology

Vulvar cancer is a rare tumor, but its incidence is increasing in some regions, particularly among women under 60 years of age. ESGO's 2023 updated guidelines indicate that there were approximately 16,506 new cases in Europe in 2020, and broader reviews highlight a gradual increase in incidence, likely related to both population aging and changes in human papillomavirus prevalence. [9]

In the United States, SEER data show that the age-standardized incidence rate is 2.6 per 100,000 women per year, and the mortality rate is 0.6 per 100,000. The lifetime risk is estimated at approximately 1 in 333 women, and approximately 58% of cases are diagnosed at a localized stage. This is important because early detection has a significant impact on survival. [10]

Age distribution is uneven. The American Cancer Society reports that less than 20% of cases occur in women under 50, while more than half of invasive tumors occur in women over 70. The average age at diagnosis of invasive vulvar cancer is around 70 years, while noninvasive lesions and precancer are often detected approximately 20 years earlier. [11]

Epidemiology is closely linked to two pathogenetic pathways. Virus-associated tumors are more often observed in younger patients, while virus-independent keratinizing forms are more common in older women with chronic vulvar dermatoses. However, official sources provide varying estimates of the proportion of virus-associated tumors: the National Cancer Institute estimates approximately half of cases, the Centers for Disease Control and Prevention estimates approximately 69%, and some national guidelines cite intermediate values of approximately 60%. This discrepancy is due to different attribution methods and sample composition. [12]

Table 3. Epidemiological indicators

Indicator	Meaning
New cases worldwide in 2022	47,336
Deaths worldwide in 2022	18,579
Age-standardized global incidence	0.83 per 100,000
Age-standardized world mortality rate	0.30 per 100,000
Europe, new cases in 2020	about 16,506
United States, morbidity	2.6 per 100,000
United States, mortality	0.6 per 100,000
The proportion of localized stages in SEER	about 58%
Five-year relative survival for all stages combined	about 71%

Table based on: GLOBOCAN 2022, ESGO 2023, SEER, American Cancer Society. [13]

Reasons

There is no definitive single cause of vulvar cancer, but modern gynecological oncology identifies two main mechanisms of development. The first is associated with persistent infection with the high-risk human papillomavirus (HPV) and a preexisting high-grade squamous intraepithelial lesion. The second is not associated with the HPV and often develops against the background of chronic inflammatory-dystrophic diseases, primarily lichen sclerosus, through differentiated intraepithelial neoplasia of the vulva. [14]

The virus-associated pathway is more common in younger women and is biologically closer to tumors of the cervix and anal canal. In this group, integration of the viral genome into cells and disruption of cell cycle regulation are of great importance. The virus-independent pathway, in contrast, typically develops more slowly, is more common in older patients, and is often associated with a more aggressive course, as differentiated intraepithelial neoplasia of the vulva can more quickly progress to invasive cancer. [15]

In practice, this means that vulvar cancer is not a single, uniform disease. This single term covers at least two biologically distinct groups of tumors with different ages of onset, different precancerous backgrounds, and partially different molecular profiles. This is important for prevention, treatment, and prognosis. [16]

Risk factors

Established risk factors include age, human papillomavirus, smoking, human immunodeficiency virus, immunodeficiency states, previous vulvar intraepithelial lesions, and chronic inflammatory skin diseases of the vulva. ESGO 2023 and the American Cancer Society list these factors as key factors in the development of the disease. [17]

Age remains one of the strongest risk factors for invasive disease. More than half of invasive tumors are diagnosed after age 70, while precancerous and virus-associated forms often appear significantly earlier. This reflects the distinction between virus-dependent and virus-independent pathways of carcinogenesis. [18]

Vulvar lichen sclerosus deserves special mention. Modern reviews and clinical data indicate that the risk of malignancy for this condition is typically estimated at approximately 2%-6%, with the risk being higher in the absence of adequate treatment. This does not mean that most women with lichen sclerosus will inevitably develop cancer, but it does mean that long-term monitoring and appropriate treatment are essential. [19]

Table 4. Risk factors for vulvar cancer

Risk factor	Meaning
Old age	Particularly important for virus-independent forms
Persistent human papillomavirus infection	Particularly important for virus-associated forms
Smoking	Increases the risk of virus-associated carcinogenesis
Human immunodeficiency virus and other immunodeficiencies	Worsen control of viral infection and precancer
Lichen sclerosus	The main background for some virus-independent forms
Preexisting vulvar intraepithelial neoplasia	Indicates an existing precancerous process
Prior pelvic radiation therapy	Mentioned as an additional risk factor
Chronic inflammatory dermatoses of the vulva	Maintain a long-term pathological background

Table based on: ESGO 2023, American Cancer Society, StatPearls, Johns Hopkins, lichen sclerosus reviews. [20]

Pathogenesis

The pathogenesis of vulvar cancer is structured around two biological pathways. In the virus-associated variant, long-term, high-risk human papillomavirus infection causes genetic and epigenetic changes in squamous epithelial cells, leading to precancerous lesions and then to invasive tumors. This group of tumors is characterized by overexpression of the p16 protein as an indirect marker of the virus-mediated pathway. [21]

In the virus-independent variant, chronic inflammation and epithelial damage play a leading role, accompanied by lichen sclerosus and differentiated intraepithelial neoplasia of the vulva. This pathway is more often accompanied by p53 protein abnormalities, occurs in older women, and often progresses more rapidly. Modern reviews emphasize that differentiated intraepithelial neoplasia of the vulva is considered the immediate precursor of many virus-independent squamous cell tumors. [22]

Lymphatic spread is particularly important for this tumor because the status of the inguinofemoral lymph nodes is a key prognostic factor. Therefore, staging and surgical selection largely revolve around the assessment of the inguinofemoral lymphatic basin. [23]

Symptoms

While some women with early vulvar cancer may be virtually asymptomatic, the disease most often causes local complaints. A 2025 review by the Mayo Clinic indicates that the most common symptoms are persistent itching, pain, a burning sensation, and the development of a nodule, ulcer, or wart-like growth. Women often notice an area of thickened skin, discoloration, or a non-healing fissure. [24]

Other symptoms include bleeding outside of menstruation, pain, contact bleeding, unpleasant discharge from the ulcer, and discomfort during urination or sexual intercourse. If the disease has spread, hard or enlarged inguinal lymph nodes may develop. Cancer Australia and the Mayo Clinic describe this combination of symptoms as a typical reason for immediate evaluation. [25]

The main problem is that these complaints are often long misinterpreted as "thrush," irritation, dermatitis, or age-related changes. ESGO clearly states that diagnostic delays in vulvar cancer can be very significant, and one of the most common reasons for the delay is the misinterpretation of vulvovaginal inflammation. [26]

Table 5. The most common symptoms of vulvar cancer

Symptom	Why is it important?
Persistent vulvar itching	One of the most common early symptoms
Ulcer or non-healing fissure	Requires biopsy
Nodule or wart-like lesion	Suspected of having a tumor
Pain, burning, soreness	Often combined with local lesions
Change in color or thickening of the skin	May reflect an invasive or precancerous process
Bloody discharge	Particularly disturbing outside of menstruation
Enlarged inguinal lymph nodes	May indicate regional spread

Table based on: Mayo Clinic, Cancer Australia, 2025 review. [27]

Classification, forms and stages

By histological type, the vast majority of vulvar tumors are squamous cell carcinoma. Less common are melanoma, basal cell carcinoma, adenocarcinoma, Paget's disease, and sarcomas. However, it is squamous cell carcinoma that determines the primary treatment and staging algorithms used in most gynecologic oncology guidelines. [28]

Current staging is based on the 2021 revision of the International Federation of Gynecology and Obstetrics. This version simplified the stages, modified the definition of invasion depth, and allowed the use of cross-sectional imaging data in staging. The role of lymph nodes was also revised, and micrometastases and macrometastases were now treated according to modern gynecologic oncology guidelines. [29]

Stage I refers to tumor confined to the vulva. Stage II refers to tumors extending to the lower third of the urethra, lower third of the vagina, or anus with negative nodes. Stage III refers to more widespread local disease and/or regional metastases to the inguinofemoral lymph nodes. Stage IV refers to bone fixation, fixed or ulcerated regional nodes, or distant metastases. [30]

Table 6. 2021 International Federation of Gynecology and Obstetrics staging in simplified form

Stage	Description
I	The tumor is limited to the vulva
IA	Size up to 2 cm and invasion depth up to 1 mm
IB	Size greater than 2 cm or invasion depth greater than 1 mm
II	Any size with transition to the lower third of the urethra, lower third of the vagina or anus, without node involvement
III	Lesion of the upper parts of adjacent structures and/or non-fixed regional metastases
IIIA	Upper 2 thirds of the urethra, upper 2 thirds of the vagina, bladder mucosa, rectal mucosa or regional metastases up to 5 mm
IIIB	Regional metastases more than 5 mm
IIIC	Regional metastases extending beyond the node capsule
IV	Fixation to bone, fixed or ulcerated nodes, or distant metastases
IVA	Pelvic bone lesions or fixed or ulcerated regional nodes
IVB	Distant metastases

Basis for table: 2021 revision of the International Federation of Gynecology and Obstetrics staging system. [31]

Complications and consequences

Untreated vulvar cancer can lead to localized tissue destruction, chronic pain, bleeding, infection, urinary dysfunction, urethral, vaginal, and anal involvement, and regional spread to the inguinal and femoral lymph nodes. In later stages, pelvic and distant metastases may occur, and the prognosis worsens significantly. [32]

Treatment can also have significant consequences. Vulvar and inguinofemoral lymph node surgery can impact body image, sexual function, walking, urination, and quality of life. Lower extremity lymphedema following inguinofemoral lymphadenectomy is a particularly significant issue, leading to the rapid development of less invasive approaches in recent years, such as sentinel lymph node biopsy. [33]

Recurrence carries a worse prognosis, particularly if it occurs in the inguinofemoral nodes or at distant sites. ESGO notes that inguinofemoral recurrences often occur within the first 2 years and are associated with a poor prognosis. Therefore, not only radical initial treatment but also competent follow-up is essential for patients. [34]

When to see a doctor

You should consult a doctor not when pain is already severe, but when any lesion on the vulva persists, changes, itches, bleeds, or is painful. Persistent itching, an ulcer, a nodule, a thickened area, an unusual wart-like plaque, or a change in skin color on the vulva require an examination and often a biopsy. This is especially important in older women and in patients with lichen sclerosus. [35]

ESGO specifically emphasizes that any vulvar complaints should be examined without unnecessary delay, and any suspicious areas should be verified with a targeted biopsy. In clinical practice, it is precisely delay and months of treatment "for inflammation" that lead to late diagnosis. [36]

If local symptoms are accompanied by a painful or hard lump in the groin, severe bleeding, a rapidly growing ulcer, or urinary dysfunction, consultation should be especially urgent. Such signs may indicate not only local but also regional spread of the disease. [37]

Diagnostics

Diagnosis begins with a routine physical examination, but it must be very thorough. ESGO 2023 recommends examining the vulva in all women with complaints, taking clinical drawings and/or photographs of the lesion, and also assessing the inguinal-femoral lymph nodes. In addition to the vulva itself, it is advisable to evaluate the vagina, cervix, and anus, as the lower anogenital tract may have multiple associated lesions. [38]

The gold standard for confirmation is a punch biopsy or incisional biopsy of the suspicious lesion. ESGO explicitly recommends making the diagnosis this way and avoiding a primary excisional biopsy, as it can complicate further treatment and the evaluation of the possibility of a sentinel lymph node biopsy. The Mayo Clinic also emphasizes that only a biopsy can definitively determine whether cancer is present. [39]

Further imaging depends on the stage. For very early-stage tumors with limited superficial invasion, additional imaging is not necessary. In patients being considered for sentinel lymph node biopsy, ESGO recommends ultrasound of the inguinal-femoral lymph nodes. In all other cases, computed tomography (CT) of the chest, abdomen, and pelvis, or positron emission tomography (PET) combined with CT, is recommended. For tumors from stage T2 and with unclear imaging, magnetic resonance imaging is indicated to assess for invasion of adjacent structures. [40]

If inguinofemoral nodes are suspicious based on imaging, they should be confirmed by fine-needle aspiration cytology or core biopsy if this may change the initial management. This approach allows for early identification of the need for more extensive surgery, chemoradiation, or a change in the amount of radiation therapy. [41]

Table 7. Step-by-step diagnosis of vulvar cancer

Step	What are they doing?	For what
1	Examination of the vulva and inguinofemoral nodes	The focus and possible regional spread are determined
2	Photo documentation	They clarify the location, size and dynamics
3	Punch biopsy or incisional biopsy	The diagnosis is confirmed morphologically.
4	Evaluation of the vagina, cervix, and anus	Concomitant lesions of the lower anogenital tract are sought.
5	Ultrasound examination of the inguinofemoral nodes	Preoperative monitoring is required for some patients.
6	Computed tomography or positron emission tomography with computed tomography	They are looking for pelvic and distant metastases
7	Magnetic resonance imaging	Specify local spread to neighboring structures
8	Biopsy of a suspicious lymph node	Confirm metastatic lesions

Basis for table: ESGO 2023, Mayo Clinic, 2025 review of international guidelines. [42]

Differential diagnosis

The differential diagnosis for suspected vulvar cancer is quite broad because the symptoms are often nonspecific. StatPearls notes that the tumor can mimic atopic dermatitis, psoriasis, lichen sclerosus, lichen planus, lichen simplex chronicus, contact dermatitis, candidiasis, cutaneous melanoma, basal cell carcinoma of the skin, and even rare lymphoproliferative or vesicular diseases.[43]

This is why persistent itching, a white plaque, or an ulcer on the vulva should not be treated blindly for too long. Clinically, distinguishing dermatosis from an invasive tumor can be difficult, and in the presence of lichen sclerosus and precancerous lesions, the picture can be mixed. In such situations, a biopsy, not experience by eye, is the deciding factor. [44]

In everyday practice, it is especially common to differentiate vulvar cancer from chronic dermatosis, infection, and benign cystic lesions. But the physician's task is broader: not only to detect cancer, but also to recognize its precursors, primarily high-grade squamous cell intraepithelial lesion and differentiated intraepithelial neoplasia of the vulva. [45]

Treatment

Vulvar cancer treatment today almost always relies on a multidisciplinary approach. ESGO 2023 emphasizes that the plan should be discussed by a team of specialists, and treatment should preferably be performed at a center with experience in this type of tumor. This is important not only for oncological control but also for preserving function, reducing complications, and choosing the right surgical procedure. [46]

Surgery remains the mainstay of treatment for early-stage cancers. The National Cancer Institute and Mayo Clinic indicate that in most cases, the first step is removal of the tumor along with some surrounding healthy tissue. The current trend is to avoid overly mutilating surgeries and, whenever possible, perform radical but organ-preserving removal. [47]

For localized tumors, wide local excision or radical local excision is generally preferred over total mutilating vulvectomy, if this is oncologically safe. ESGO specifically notes that it is acceptable to strive for less radicality in order to preserve the clitoris, urethra, and anal canal when this does not compromise tumor control. The question of sufficient resection margin width remains controversial, but the goal remains tumor removal with negative margins. [48]

Management of the inguinal-femoral lymph nodes is a key element of modern treatment. For very superficial stage T1a tumors, inguinal lymph node dissection is usually unnecessary. For deeper tumors, it is necessary, as nodal status has the greatest impact on prognosis. [49]

A major advancement in recent years has been sentinel lymph node biopsy. ESGO recommends it for patients with unifocal tumors less than 4 cm, deeper than stage T1a, and without suspicious inguinofemoral nodes based on examination and imaging. This approach allows for the avoidance of complete inguinofemoral lymphadenectomy in some patients and significantly reduces the risk of lymphedema and other complications. [50]

If a sentinel lymph node is not found, an inguinofemoral lymphadenectomy must be performed. If tumor cells are detected in the sentinel node, further management depends on the extent of the lesion. For macrometastases larger than 2 mm, ESGO recommends an inguinofemoral lymphadenectomy on the affected side. [51]

The approach to sentinel lymph node micrometastases has also changed. Following the GROINSS-V II trial, it became possible to forego inguinofemoral lymphadenectomy in favor of radiation therapy if the sentinel node contains only micrometastases up to 2 mm or isolated tumor cells. The ESGO noted that with this approach, the rate of isolated inguinal recurrence was low—approximately 1.6% after 2 years—making the strategy clinically acceptable for selected patients. [52]

Postoperative radiation therapy is used when the risk of local or regional recurrence is high. The most compelling indications include positive resection margins, lymph node involvement, tumor extension beyond the nodal capsule, and other unfavorable factors. ESGO notes that postoperative radiation therapy is indicated for all patients with positive margins if re-excision is not possible, and in the case of nodal disease, it is often a critical part of treatment. [53]

In locally advanced disease, chemoradiation plays an increasingly important role. A 2025 review and the National Cancer Institute emphasize that for large tumors that involve adjacent structures, concurrent radiation therapy with chemotherapy can be used both preoperatively and as the primary radical option, especially if radical surgery would require exenteration or result in severe loss of function. [54]

In extremely common cases, pelvic exenteration may be considered, but this is an exceptional situation for carefully selected patients. Therefore, the current trend is, whenever possible, to replace highly mutilating interventions with a more conservative, but oncologically appropriate, chemoradiation strategy. ESGO explicitly states that in locally advanced disease in previously unirradiated patients, definitive chemoradiation is recommended, and exenteration is considered only in selected cases. [55]

For recurrent, unresectable, or metastatic cancer, systemic therapy is individualized, and the evidence base is weaker than for cervical cancer. A 2025 review noted that systemic treatment is often modeled on other virus-associated tumors. The National Cancer Institute notes that for stage IVB, there is no standard, universal treatment, and chemotherapy is used in those who can tolerate it. [56]

Immunotherapy has become one of the most discussed new approaches. The 2025 update for KEYNOTE-158 reported an overall response rate of approximately 10.9% for pembrolizumab, and a 2025 meta-analysis of immune checkpoint inhibitors overall showed a pooled objective response rate of approximately 21%, with combinations appearing more active than monotherapy. This is not a revolution or a new universal standard for everyone, but it is already a viable option for some patients with advanced or relapsed disease. [57]

Table 8. Modern approaches to the treatment of vulvar cancer

Situation	Basic tactics
Early localized process	Wide or radical local excision
Unifocal tumor less than 4 cm without suspicious nodes	Sentinel lymph node biopsy
Sentinel node macrometastasis greater than 2 mm	Inguinal-femoral lymphadenectomy
Micrometastasis in the sentinel node up to 2 mm	Inguinal radiotherapy instead of total lymphadenectomy in selected patients
Positive resection margin	Re-excision or postoperative radiation therapy
Locally advanced process	Chemoradiation therapy with possible subsequent surgery
Distant metastases or unresectable recurrence	Individual systemic therapy, symptomatic radiation therapy, immunotherapy in some patients

Table basis: ESGO 2023, National Cancer Institute 2024, review 2025, meta-analysis 2025. [58]

Prevention

There is no specific screening for vulvar cancer, so prevention is based not on mass testing but on reducing risk factors and promptly treating pre-existing lesions. A 2025 review clearly states that the most effective strategy for reducing incidence is timely treatment of precancerous and predisposing lesions. [59]

Vaccination against the human papillomavirus plays an important role. Since a significant proportion of vulvar tumors are associated with the human papillomavirus, vaccination can reduce the risk of corresponding precancerous and invasive processes in the long term. The Centers for Disease Control and Prevention and the National Cancer Institute explicitly classify vulvar cancer as a virus-associated tumor. [60]

Equally important are smoking cessation and proper management of chronic vulvar dermatoses, particularly lichen sclerosus. Timely treatment of lichen sclerosus and biopsy of any changing lesions are effective secondary prevention of virus-independent vulvar cancer. [61]

Table 9. Preventive measures

Measure	What is it for?
Vaccination against human papillomavirus	Reduces the risk of virus-associated pathway
Quitting smoking	Reduces the risk of virus-associated carcinogenesis
Treatment of lichen sclerosus	Reduces the risk of virus-independent pathway
Low threshold for biopsy of suspicious lesions	Helps detect precancer and early cancer
Regular examinations for chronic vulvar dermatoses	Allows you to notice the transformation earlier

Table based on: National Cancer Institute, Centers for Disease Control and Prevention, reviews of lichen sclerosus and vulvar cancer. [62]

Forecast

Prognosis depends most on the stage and lymph node status. According to the American Cancer Society and SEER, the five-year relative survival rate is approximately 86% for localized disease, approximately 53% for regional disease, and approximately 19% for distant metastases. For all stages combined, the five-year relative survival rate is estimated at approximately 71%. [63]

This means that early diagnosis of this tumor is critical. When the disease is confined to the primary site, the chances of long-term control are significantly higher. Once the inguinofemoral nodes are involved or distant metastases have developed, treatment becomes more difficult and outcomes are poorer. [64]

The prognosis for local and regional recurrences also varies. A 2025 meta-analysis on immunotherapy estimates that five-year survival for locoregional recurrence may be approximately 50%–70%, for lymphatic recurrence – approximately 27%, and for distant metastatic disease – approximately 14%. This emphasizes the importance of appropriate initial treatment and follow-up. [65]

Table 10. Five-year relative survival by SEER stage

SEER Rating	Five-year relative survival
Localized	86%
Regional	53%
Remote	19%
All stages together	71%

Table based on: American Cancer Society and SEER. [66]

FAQ

Is vulvar cancer always a disease of older women?
No. Invasive cancer is indeed more often diagnosed in older women, but virus-associated forms and precancerous conditions can occur significantly earlier. Moreover, in recent decades, the incidence of the disease in women under 60 has been increasing in a number of countries. [67]

Does vulvar itching always indicate cancer?
No. Itching is much more often associated with dermatoses, candidiasis, contact irritation, or chronic inflammation. However, persistent itching, especially if accompanied by a plaque, ulcer, nodule, or skin discoloration, requires examination and often a biopsy. [68]

Can a diagnosis be made without a biopsy?
No. Physical examination and imaging can help suspect a tumor and assess its spread, but definitive confirmation is only possible with a biopsy. ESGO specifically recommends punch biopsy or incisional biopsy as the standard for initial verification. [69]

Is it true that not all inguinal lymph nodes are removed anymore?
Yes. In cases of early unifocal disease less than 4 cm and the absence of suspicious nodes, sentinel lymph node biopsy is increasingly being performed. This allows some patients to avoid a complete inguinofemoral lymphadenectomy and reduce the risk of lymphedema. [70]

Has immunotherapy become standard for all patients with advanced vulvar cancer?
No. Immunotherapy shows promise, but it is not yet a universal solution for everyone. Current data show modest but significant activity in some patients with advanced or recurrent disease, so its role remains individualized. [71]

Is there a test that can be routinely performed for the early detection of vulvar cancer?
No. There is no specific, organized screening. The best prevention remains attentiveness to symptoms, treatment of precancerous and chronic dermatoses, vaccination against the human papillomavirus, and a low threshold for biopsy of suspicious lesions. [72]

Key points from experts

Maaike H. M. Oonk, PhD, is a gynecologic oncologist at University Medical Center Groningen, University of Groningen, the Netherlands. She chaired the international working group for the 2023 ESGO Guidelines Update on the Management of Vulvar Cancer. The key practical message from this school of thought is that any suspicious vulvar tumor or ulcer should be biopsied early, and treatment should preferably be centralized in specialized centers, because outcomes depend on the experience of the team and the appropriate choice of surgical extent. [73]

Alexander B. Olawaiye, MD, professor of gynecologic oncology, University of Pittsburgh, Magee-Womens Hospital of UPMC. He is an author of the 2025 update on vulvar cancer and a co-author of the 2021 International Federation of Gynecology and Obstetrics staging revision. His main clinical thesis is that vulvar cancer requires an individualized approach based on histologic type and stage, and that in locally advanced disease, chemoradiation therapy may be an effective alternative to particularly mutilating surgeries. [74]

Nicholas Reed, Consultant Clinical Oncologist, Beatson Oncology Centre, Emeritus Professor of Oncology, University of Glasgow. His expertise and clinical practice focus on the treatment of gynecological tumours, including rare forms. The key thesis of the radiation school he represents is that radiation and chemoradiation therapy for vulvar cancer are increasingly important not only in palliative care but also in organ-preserving radical strategies for some patients with locally advanced disease. [75]