Chi_Principles and Practice of Gynecologic Oncology 8e

Chapter 2.5 ■ Vulvar Cancer: Clinical Presentation, Diagnostic Evaluation, and Workup 17

❚ Figure 2.5-1. A: Early-stage VSCC. B, C: Advanced-stage VSCC. VSCC, vulvar squamous cell carcinoma.

nodes ( Table 2.5-1 ), but more research is needed for consensus. Suspicious LNs should be biopsied if the findings would alter the surgical plan. Staging The International Federation of Gynecology and Obstetrics (FIGO) adopted a modified surgical staging system for vulvar cancer in 1989, which was revised in 1995, 2009, and more recently in 2021 (7) ( Table 2.5-2 ). The 2021 staging revision was formulated in collaboration with the U.S. National Cancer Database and is the first from FIGO to incorporate data analyses to validate prognostics. The 2021 revi sion includes a new definition for depth of invasion (see Pathol ogy section), allows findings from cross-sectional imaging to be incorporated, and now uses the same definition for LN metastases utilized in cervical cancer. Just as with the recently updated FIGO 2018 cervical cancer staging, LNs with isolated tumor cells (ITCs) will be staged as node negative, whereas micrometastases or mac rometastases will be staged as node positive, or stage III.

tumors less than 4 cm and clinically nonsuspicious LNs, imaging of the groins is recommended to rule out gross nodal involvement prior to the SN procedure. Different imaging techniques have been studied for their ability to rule out groin node metastases ( Table 2.5-1 ). The combination of ultrasound-guided fine needle aspiration (FNA) biopsy and ultrasound has shown an excellent sensitivity and specificity at 80% to 93% and 82% to 100%, respectively. An ad vantage of ultrasound is its minimally invasive nature, although a disadvantage is that the accuracy is highly operator depen dent. Nowadays, pelvic magnetic resonance imaging (MRI) with vaginal gel and contrast is increasingly being utilized to evaluate the relationship of the disease to adjacent structures as well as for staging of the inguinal and pelvic LNs. Computed tomogra phy (CT) and positron emission tomography (PET) CT can be used in the assessment of distant disease. However, the sensitiv ity of CT and MRI is not sufficient to omit a lymphadenectomy based on imaging results ( Table 2.5-1 ). Fluorodeoxyglucose (FDG)-PET-CT shows promising values of sensitivity and spec ificity for the distinction between negative nodes and metastatic

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