State of the art in vulvar cancer imaging

Abstract

Vulvar carcinoma is an uncommon tumor that predominantly affects postmenopausal women. Currently, there is no screening procedure for vulvar carcinoma; in most cases, it is diagnosed only when symptoms appear. The most widely used staging system is that developed by the International Federation of Gynecology and Obstetrics. Lymph node status is the most important prognostic factor. We searched the PubMed/Medline database to identify relevant English-language articles on vulvar cancer, with a special focus on its imaging evaluation. Magnetic resonance imaging is useful for local and nodal staging, as well as facilitating the planning of surgical interventions and radiotherapy. Computed tomography or positron-emission tomography/computed tomography can play an important role in nodal and distant disease assessment, whereas ultrasound is often used for image-guided biopsies. Imaging is pivotal for staging and treatment planning in vulvar carcinoma.

Keywords: Carcinoma; Lymph nodes; Radiology; Vulva; Vulvar neoplasms.

Figure 1

Schematic representation of the superficial and deep structures of the vulva.

Figure 2

Schematic representation of lymphatic drainage of carcinoma of the vulva.

Figure 3

FIGO stage IB vulvar carcinoma. A: Axial T2WI showing a right-sided vulvar lesion with intermediate signal intensity (arrow). B: Axial T2WI with fat suppression better delineated the tumor (arrow). C: Contrast-enhanced axial T1WI with fat suppression, showing the same tumor (arrow). Pathology, at surgery, revealed a 37 mm tumor with 5 mm of invasion, confirming the diagnosis of stage IB disease.

Figure 4

FIGO stage II vulvar carcinoma. A: Axial oblique T2WI with fat saturation, clarifying the extension to the anal wall (arrow). The patient was treated with chemoradiotherapy and showed no clinical evidence of disease at 6 months of follow-up. B: Sagittal T2WI showing a vulvar tumor extending to the lower thirds of the urethra (arrow) and vagina (open arrow).

Figure 5

FIGO stage III vulvar carcinoma. Axial T2WI showing an enlarged right inguinal lymph node (open arrow). Fine needle aspiration cytology of the lymph node confirmed the presence of tumor cells within the node.

Figure 6

FIGO stage IVA vulvar carcinoma. A: Sagittal T2WI with fat saturation showing involvement of the upper two thirds of the vagina (open arrow). The patient was treated with chemoradiotherapy and showed no clinical evidence of disease at two years of follow-up. B: Axial T2WI showing a central vulvar lesion with intermediate signal intensity involving the upper two thirds of the urethra (arrow). The patient was treated exclusively with radiotherapy, being ineligible for concurrent chemotherapy because of a low performance status. C: Sagittal T2WI showing a vulvar lesion with intermediate signal intensity (arrow) extending to the rectum (open arrow). The patient was treated with chemoradiotherapy and had a recurrence at 27 months after the initial diagnosis.

Figure 7

Recurrence of vulvar carcinoma. A: Contrast-enhanced sagittal CT showing extension to the floor of the bladder (arrow) at eight years after the initial diagnosis and four years after a first recurrence. B: Contrast-enhanced axial CT showing a necrotic right inguinal lymph node (arrow) extending to the skin, at 8 months after modified radical vulvectomy and bilateral inguinofemoral lymphadenectomy. C: Contrast-enhanced axial CT, with a bone-window setting, showing lytic metastases in the sternum (arrow). The patient was treated with chemoradiotherapy and had a recurrence at 13 months after the initial diagnosis.