Squamous Cell Vulval Carcinoma and Pregnancy – A Review

European Oncology, 2010;6(2):47-52 DOI: http://doi.org/10.17925/EOH.2010.06.02.47


Maternal vulval carcinoma and pregnancy following vulval cancer are rare. However, vulval carcinoma in younger women is increasing, thus we are progressively more likely to encounter patients with either vulval carcinoma in pregnancy, or pregnancy following treatment for vulval cancer. Given the paucity of available information we performed a literature review considering the strategies employed in the management of these women. A computerised search (MEDLINE®/embase®) was performed to identify all registered articles pertaining to squamous cell vulval carcinoma diagnosed or treated in pregnancy, and all cases of pregnancy following treatment for vulval cancer. In addition, cross-references of all selected articles were checked. Twenty-four reports were identified in the literature. In total, 21 cases of vulval carcinoma in pregnancy and 13 cases of pregnancy following vulval cancer were considered. Reports in the literature of vulval cancer associated with pregnancy span a time period of over 65 years making the production of definitive guidelines problematic as significant changes in the management of vulval cancer and changes in obstetrical and neonatal care need to be accounted for. Longer-term maternal and neonatal outcomes are also difficult to substantiate. Centralised data collection would be beneficial in these rare tumours, and in other malignant tumours diagnosed and treated during pregnancy.

Acknowledgements: Manu Vatish would like to acknowledge The Fulbright Commission for their continued support.
Keywords: Vulval/vulvar carcinoma, squamous cell carcinoma, vulvectomy, pregnancy
Disclosure: The authors have no conflicts of interest to declare.
Received: April 28, 2010 Accepted August 18, 2010
Correspondence: Julia Palmer, c/o Dept Gynaecological Oncology, Royal Hallamshire Hospital, Glossop Rd, Sheffield, S10 2HL, UK. E: palmer006@btinternet.com

Carcinoma of the vulva accounts for 4% of all female genital tract malignancies.1 The incidence in the UK is two per 100,000 female population.2 Vulval cancer is rare in young women with rates of more than one per 100,000 among women aged 25–44 years in the UK.2 In the US, 15% of vulval cancers are reported to occur in women <50 years of age.3,4 Prior studies have reported an incidence of 3.3% in women <35 years old,5 2.3% in women <40 years old and 6.1% in women <45 years old.6

In recent years, an increased incidence of vulval cancer in younger women has been observed.7–10 The UK incidence in younger women has doubled in the last three decades.2 Predisposing factors include infection with human papillomavirus (HPV) or herpes simplex virus type 2,11–13 vulval intra-epithelial neoplasia (VIN), lichen sclerosis, smoking11,14 and immunosuppression. HPV is strongly linked with tumours in young women, with an 11-fold increase reported for VIN and early-stage cancer in women <45 years of age with serological evidence of HPV infection.15 The increased incidence of vulval cancer is linked worldwide with an increasing incidence of VIN16,17 in younger women caused by HPV infection.18–20 Immunosuppression in young patients is identified as accelerating the progression of VIN to invasive vulval squamous cell carcinoma.21 There is an increased risk in HIV-positive women,10,21,22 with a strong relationship for women <30 years of age.23,24 HIV is also reported to cause rapid progression of these cancers.25 In the UK the annual number of newly diagnosed HIV individuals has increased by 182% over the past 10 years, with the majority of newly diagnosed persons aged between 25 and 44 years.26

Reports of either vulval carcinoma presenting during pregnancy,25,27–29 or of pregnancy following treatment for vulval cancer, are rare29–31 because the majority of women with the condition are perimenopausal with completed families, post-menopausal or rendered infertile or of reduced fertility following treatment with radiotherapy and chemotherapy.31 With the increasing incidence of HPV, VIN and HIV, and a concomitant increase in the incidence of vulval carcinoma in younger women, we are progressively more likely to encounter patients with either vulval carcinoma in pregnancy or pregnancy following treatment for vulval cancer.
  1. Office of National Statistics Cancer statistics— registrations, England and Wales (1999) Series MB1 no 30. London, UK: The Stationery Office. Available at: http://www.statistics.gov.uk (accessed 10th Jan 2009).
  2. Cancer Research UK, Available at: http://info.cancerresearchuk.org/ cancerstats/types/vulva/incidence/?a=5441
  3. Henson D, Tarone R, Am J Obstet Gynecol, 1979;129:525–32.
  4. Rutledge F, Smith JP, Franklin EK, Am J Obstet Gynecol, 1970;106:1117.
  5. Choo YC, Gynecol Oncol, 1982;13:158–64.
  6. Gemmell AA, Haines M, J Obstet Gynaecol Br Emp, 1960;67:199–207.
  7. Messing MJ, Gallup DG, Obstet Gynecol, 1995;86:51–4.
  8. Jones RW, Baranyai J, Stables S, Obstet Gynecol, 1997;90:448–52.
  9. Heller DS, Cracchiolo B, Hameed M, May T, J Reprod Med, 2000;45:659–61.
  10. Majeed U, Sekowski A, Ooko F, SAJOG, 2006;12(3):156–60.
  11. Madeleine MM, Daling JR, Carter JJ, et al., J Natl Cancer Inst, 1997;89(20):1516–23.
  12. Sherman KJ, Daling JR, Chu J, et al., Epidemiology, 1991;2(4):257–62.
  13. Hildesheim A, Han CL, Brinton LA, et al., Obstet Gynecol, 1997;90(5):748–54.
  14. Daling JR, Sherman KJ, Hislop TG, et al., Am J Epidemiol, 1992;135:180–89.
  15. Basta A, Adamek K, Pitynski K, Eur J Gynaecol Oncol, 1999;20(2):111–14.
  16. Joura EA, Losch A, Haider-Angeler MG, et al., J Reprod Med, 2000;45(8):613–15.
  17. Joura EA, Epidemiology, Curr Opin Obstet Gynecol, 2002;14:39–43.
  18. Jones RW, Rowan DM, Stewart AW, Obstet Gynecol, 2005;106:1319–26.
  19. Judson PL, Habermann EB, Baxter NN, et al., Obstet Gynecol, 2006;107:1018–22.
  20. Acheson N, Ganesan R, Chan KK, Curr Obstet Gynaecol, 2000;10:12–17.
  21. Carter J, Carlson J, Fowler J, Gynecol Oncol, 1993;51:307–10.
  22. Kuhn L, Sun X-W, Wright TC, Curr Opin Obstet Gynecol, 1999;11:35–9.
  23. Frisch M, Biggar RJ, Goedert JJ, J Natl Cancer Inst, 2000;92(18):1500–1510.
  24. Sitas F, Pacella-Norman R, Carrara H, et al., Int J Cancer, 2000;88(3):489–92.
  25. Olayemi O, Aimakhu CO, Omigbodun AO, et al., J Obstet Gynaecol, 2002;22(4):441–2.
  26. The UK Collaborative Group for HIV and STI Surveillance, London: Health Protection Agency, Centre for Infections, 2007.
  27. Modares-Gilani M, Hasanzadeh M, Behtash N, MJIRI, 2005;19(2):185–7.
  28. Monaghan JM, Lindeque G, Br J Obstet Gynaecol, 1986;93:785–6.
  29. Collins CG, Barclay DL, Clin Obstet Gynecol, 1963;6:927.
  30. Dahle T, Acta Obstet Gynec Scand, 1959;38:448–52.
  31. Rubin A, Lewis GC, Am J Obstet Gynec, 1953;65(6):1347–9.
  32. Couvreux-Dif D, Lhommé C, Querleu D, Castaigne D, Verhaeghe Y, J Gynecol Obstet Biol Reprod, 2003;32:46–50.
  33. Lutz MH, Underwood PB, Rozier JC, Putney FW, Am J Obstet Gynecol, 1977;129:536–42.
  34. Lunin AB, Am J Obstet Gynec, 1949;57:742–7.
  35. Ghaemmaghami F, Hasanzadeh M, Int J Gynecol Cancer, 2006;16(1):225–30.
  36. Bakour SH, Jaleel H, Weaver JB, Kehoe S, Radcliffe KW, Gynecol Oncol, 2002;87:207–9.
  37. Kempers RD, Symmonds RE, Obstet Gynecol, 1965;26(5):749–51.
  38. Moore DH, Fowler WC, Currie JL, Walton LA, Gynecol Oncol, 1991;41:74–7.
  39. Sinavesaratnam V, Pathmananathan R, Asia-Oceania J Obstet Gynaecol, 1990;16(3):207–10.
  40. Alexander-Sefre F, Morcos M, Mohamid W, Minchin AJ, J Obstet Gynaecol, 1998;18(6):595–6.
  41. Russell PB, Am J Obstet Gynec, 1940;873–5.
  42. Keskin N, Iyibozkurt AC, Topuz S, et al., Eur J Gynaecol Oncol, 2008;29(4):399–401.
  43. Del Priore G, Schink JC, Lurain JR, Int J Gynecol Obstet, 1992;39:335–6.
  44. Rahman MS, Rahman J, Al-Sibai MH, Br J Obstet Gynaecol, 1982;89:244–6.
  45. Gitsch G, van Eijkeren M, Hacker NF, Gynecol Oncol, 1995;56:312–5.
  46. Regan MA, Rosenzweig BA, Am J Perinatol, 1993;10(4):334–5.
  47. Ogunleye D, Lewin SN, Huettner P, Gynecol Oncol, 2004;95:400–401.
  48. Palmer JE, Tidy JA. J Gynecol Oncol, 2009;20(4):254–6.
  49. Collins JH, Birch HW, Pailet M, Avent JK, Am J Obstet Gynec, 1960;80(1):167–71.
  50. Zutshi V, Mehta S, Sachdeva P, et al., J Obstet Gynecol India, 2007;57(4):356–7.
  51. Al-Ghamdi A, Freedman D, Miller D, Gynecol Oncol, 2002;84:94–101.
  52. Gitsch G, Kainz C, Studnicka M, et al., Arch Gynecol Obstet, 1992;252:25–30.
  53. Alloub MI, Barr BB, McLaren KM, et al., Br Med J, 1989;299:153–8.
  54. Carson LF, Twiggs LB, Okagaki T, et al., Obstet Gynecol, 1988;72:63–7.
  55. Monaghan JM, Gynaecological Oncology, Oxford: Blackwell Scientific Publications, Oxford, 1985.
  56. Somoye GO, Mocroft A, Olaitan A, Arch Gynecol Obstet, 2009:279(2):113–17.
  57. Hacker NF, van der Velden J, Cancer, 1993;71:1673–7.
  58. Royal College of Obstetricians & Gynaecologists, London: Management of vulval cancer, RCOG Press, 2006.
  59. Sedlis A, Homesley H, Bundy BN, et al., Am J Obstet Gynecol, 1987;156:1159–64.
  60. Homesley HD, Bundy BN, Sedlis A, Adcock L, Obstet Gynecol, 1986;68(6):733–40.
  61. Selman TJ, Leusley DM, Acheson N, et al., Gynecol Oncol, 2005;99:206–14.
  62. Levenback C, Burke TW, Morris M, et al., Gynecol Oncol, 1995;59:216–20.
  63. Decesare SL, Fiorica JV, Roberts WS, et al., Gynecol Oncol, 1997;66(3):425–8.
  64. de Hullu JA, Hollema H, Piers DA, et al., J Clin Oncol, 2000;18(15):2811–16.
  65. Ayhan A, Celik H, Dursun P, World J Surg Oncol, 2008;6:53.
  66. Oonk MH, Hollema H, de Hullu JA, van der Zee AG, Int J Gynecol Cancer, 2006;16:963–71.
  67. Nicklas A, Baker M, Semin Oncol, 2000;27:623–32.
  68. Silva LB, Silva-Filho AL, Traiman P, et al., Cancer, 2006;16:1454–7.
  69. Keleher A, Wendt R III, Delpassand E, Stachowiak AM, Kuerer HM, Breast J, 2004;10:492–5.
  70. Thomas G, Dembo A, DePetrillo A, et al., Gynecol Oncol, 1989;34:263–7.
  71. Lupi G, Raspagliesi F, Zucali R, et al., Cancer, 1996;77(8):1472–8.
  72. Moore DH, Thomas GM, Montana GS, et al., Int J Radiat Oncol Biol Phys, 1998;42(1):79–85.
  73. van Der Velden J, Ansink A, Cochrane Database Syst Rev, 2000(3):CD002224.
  74. Gerszten K, Selvaraj RN, Kelley J, Faul C, Gynecol Oncol, 2005;99(3):640–44.
  75. Beriwal S, Coon D, Heron DE, et al., Gynecol Oncol, 2008;109(2):291–5.
  76. Mayr NA, Wen BC, Saw BC, Obstet Gynecol Clin North Am, 1998;25(2):301–21.
  77. Kal HB, Strulkmans H, Lancet Oncol, 2005;6(5):328–33.
  78. Tabata T, Nishiura K, Tanida K, et al., Int J Gynecol Cancer, 2008;18:181–4.
  79. Machado F, Vegas C, Leon J, et al., Gynecol Oncol, 2007;105(2):446–50.
  80. Kumar S, Das JK, Pandey SK, Nepal Med Coll J, 2005;7(2):83–6.
  81. Kumar S, Lobo SW, Dubey AK, Pandey SK, Nepal Med Coll J, 2006;8(1):7–8.
  82. Shuey DL, Buckalew AR, Wilke TS, et al., Teratology, 1994;50(6):379–86.
  83. Cancer Research UK, Available at: http://info.cancerresearchuk.org/cancerstats/types/vulva/mortality/?a=5441>
  84. Office for National Statistics, 2005. Cancer survival: England and Wales, 1991–2001, less common cancers by age group. Office for National Statistics, UK.
Keywords: Vulval/vulvar carcinoma, squamous cell carcinoma, vulvectomy, pregnancy