Vulvar cancer staging: guidelines of the European Society of Urogenital Radiology (ESUR)

Abstract

Objective: The aim of the Female Pelvic Imaging Working Group of the European Society of Urogenital Radiology (ESUR) was to develop imaging staging guidelines for vulvar cancer and to propose standardised MRI protocols and reporting.

Methods: The guidelines recommended from the ESUR in this article resulted from a questionnaire analysis regarding imaging staging of vulvar cancer that was answered by all members of the Female Pelvic Imaging Working Group. Only the answers with an agreement equal to or more than 80% were considered. Additionally, the literature was reviewed to complement and further support our conclusions.

Results: The critical review of the literature and consensus obtained among experts allows for recommendations regarding imaging staging guidelines, patient preparation, MRI protocol, and a structured MRI report.

Conclusions: Standardising image acquisition techniques and MRI interpretation reduces ambiguity and ultimately improves the contribution of radiology to the staging and management of patients with vulvar cancer. Moreover, structured reporting assists with the communication of clinically relevant information to the referring physician.

Keywords: Guidelines; Magnetic resonance imaging; Protocol; Staging; Vulvar cancer.

Fig. 1

a Schematic illustration of vulvar anatomy: b–e show MRI normal findings and vulvar anatomy in axial T2WI sequences

Fig. 2

a Schematic illustration of FIGO stage I. Axial T2WI (b), axial fat saturation T2WI (c) and DWI with b-value = 800 s/mm² (d) shows a vulvar tumour measuring < 2 cm, with pathologic proven stromal invasion of 4 mm, corresponding to FIGO stage IB. SI—Stromal invasion

Fig. 3

Axial T2WI (a), axial T1WI fat saturation before (b), and after gadolinium (c) shows a vulvar tumour measuring 2.5 cm, corresponding to FIGO stage IB. Note the increased conspicuity of the tumour in the contrast-enhanced sequence (c)

Fig. 4

a Schematic illustration of FIGO stage II. Sagittal (b) and axial (c) T2WI of the pelvis show a large tumour (arrows) with invasion of the lower third of the urethra—FIGO II. Axial T2WI of the groins (d) shows bilateral enlarged inguinofemoral lymph (arrowheads) proved to be reactive on cytology

Fig. 5

Axial T2WI (a) shows an intermediate signal intensity tumour (arrow), measuring 3 cm, with central necrosis and invasion of the external urethral meatus (arrowhead)—FIGO II. On DWI, the tumour is depicted by a high-signal intensity lesion on DWI (b-value = 1000 s/mm²) (arrow), and low-signal intensity on the corresponding ADC map (arrow). On T1WI fat saturation contrast-enhanced sequence (d), the tumour shows early arterial enhancement of its solid component (arrow), with no enhancement of the central necrotic portion. Note the increased conspicuity of the lesion in DWI-MRI (b) and c and in DCE-MRI (d)

Fig. 6

Schematic illustration of FIGO stage III

Fig. 7

Pathologically proven inguinofemoral lymph node metastasis in different patients (FIGO III): a coronal fat saturation T2WI shows bilateral enlarged heterogeneous lymph nodes with necrotic changes depicted by intra-nodal high-signal intensity areas; b axial CT shows left inguinofemoral enlarged node with low-attenuation necrotic centre; c axial CT shows heterogeneous enlarged left inguinofemoral node

Fig. 8

Axial contrast-enhanced T1WI a shows left inguinal lymphadenopathy (arrow) with restricted diffusion (arrow) on DWI (b). At different levels, axial contrast-enhanced T1WI (c) depicts left external obturator muscle involvement (*), and DWI (d) shows restricted diffusion of the primary vulvar tumour (arrowhead)

Fig. 9

a Schematic illustration of FIGO stage IVA1. Examples of stage IVA1 vulvar carcinomas (*) in different patients: b sagittal T2WI sequences shows vulvar tumour with invasion of the upper third of the urethra (arrow); c sagittal contrast-enhanced T1WI sequence shows vulvar tumour with invasion of the upper third of the vagina (arrow); d sagittal T2WI sequences shows vulvar tumour with invasion of the rectum (arrow)

Fig. 10

Schematic illustration of FIGO stage IVA2

Fig. 11

a Schematic illustration of FIGO stage IVB. Axial fat saturation T2WI shows left external iliac lymph node metastasis (arrow), depicted by increased lymph node size and heterogeneity. In another patient, coronal CT (c) and (d) shows vulvar tumour (*) with inguinal lymph node involvement (open arrow), internal iliac lymph node involvement (arrow), and hepatic metastasis (arrowhead)