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A postmenopausal woman in her late 50s presented with moderately differentiated keratinising vulvar squamous cell carcinoma (SCC) arising on a background of lichen sclerosus and vulvar intraepithelial neoplasia III. She underwent modified radical vulvectomy, bilateral inguinofemoral lymphadenectomy ( figure 1) and bilateral gluteal V-Y advancement flap surgery. Histopathology revealed a unifocal tumour, 6×4×1.6 cm with lymphovascular space invasion (LVSI), deep resected margin 0.6 cm and nearest introital margin 0.3 cm away from the tumour. Among 24 resected nodes, one had a 12 mm metastatic focus. Adjuvant External Beam Radiation Therapy with concurrent chemotherapy was initiated 6 weeks postoperatively, following optimal tissue healing. 3 weeks after the commencement of radiation, a 3×2 cm tender ulcerated nodule developed over the left lateral, and two nodules (1×1 cm) developed over the right mons pubis. Interstitial brachytherapy boost diminished former lesions. However, one new superficial (1×0.5 cm), violaceous, nontender nodule erupted over the right gluteal skin. Fine needle aspiration cytology confirmed SCC. The gluteal lesion increased to 4×4 cm, and three new lesions emerged within 3 weeks (figure 2). 18F-fluorodeoxyglucose whole body positron emission tomography-CT (18F-FDG-whole body-PET/CT) showed disease in pelvic lymph nodes, adrenal glands, kidney, liver, bilateral lungs, bony sites and brain. Owing to progressive disease (figure 3), palliative chemotherapy (paclitaxel+carboplatin) was administered. Patient expired within 20 days.