European Society of Gynaecological Oncology Guidelines for the Management of Patients with Vulvar Cancer - Update 2023

Abstract

Background: As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) first published in 2017 evidence-based guidelines for the management of patients with vulvar cancer.

Objective: To update the ESGO guidelines based on the new evidence addressing the management of vulvar cancer and to cover new topics in order to provide comprehensive guidelines on all relevant issues of diagnosis and treatment of vulvar cancer.

Methods: The ESGO Council nominated an international development group comprised of practicing clinicians who provide care to vulvar cancer patients and have demonstrated leadership through their expertize in clinical care and research, national and international engagement and profile as well as dedication to the topics addressed to serve on the expert panel (18 experts across Europe). To ensure that the statements were evidence-based, new data identified from a systematic search were reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the international development group. Prior to publication, the guidelines were reviewed by 206 international practitioners in cancer care delivery and patient representatives.

Results: The updated guidelines cover comprehensively diagnosis and referral, staging, pathology, pre-operative investigations, surgical management (local treatment, groin treatment, sentinel lymph node procedure, reconstructive surgery), (chemo)radiotherapy, systemic treatment, treatment of recurrent disease (vulvar, inguinal, pelvic, and distant recurrences), and follow-up. Management algorithms are also defined.

Keywords: Vulvar and Vaginal Cancer.

Figure 1

Guidelines development process.

Figure 2

Schematic diagram showing measurement of depth of invasion in vulvar cancer. (A) Method of measurement from the adjacent most superficial dermal papilla to the deepest point of invasion. (B) Method of measurement from the basement membrane of the deepest adjacent dysplatic (tumor-free) rete ridge to the deepest point of invasion. Figure permission courtesy of Mr Norm Cyr.

Figure 3

Schematic drawing of the anatomy of the vulvar and inguinofemoral lymph nodes. Illustration of vulva and adjacent perineal structures for clinical drawing (A), schematic drawings of deep and superficial inguinofemoral lymph nodes, including Daseler regions, for evaluation of regional lymph nodes during clinical examination or by imaging (B). The clinical examination documents the site of the tumor (labia majora/minora/Bartholin gland, clitoris, mons pubis, or perineum) and laterality (if relevant), tumor focality, the size of each lesion separately, the closest distance to midline and infiltration of the urethra/vagina/anus, tumor mobility, and palpation of inguinofemoral lymph nodes (assessment of size, site, laterality, mobility/fixation, consistency, skin over the nodes/ulceration). The nodal status is documented either by ultrasound according to a standardized report published in 2021 by the Vulvar International Tumor Analysis (VITA) collaborative group or by MRI according to the 2021 European Society of Urogenital Radiology (ESUR) guidelines. Both modalities are documenting the size of lymph node metastasis/-es, number of lymph nodes involved, and the presence or absence of extracapsular spread. For describing the location of superficial inguinofemoral lymph nodes, virtual line drawn along femoral vein and second virtual line drawn perpendicular to first line and passing through saphenofemoral junction divide femoral triangle into: superomedial region (I); superolateral region (II); inferolateral region (III); and inferomedial region (IV). Central zone (V) is circled. Deep inguinofemoral nodes are located medial to femoral vein and cranial to lower margin of oval fossa (C). Pre-biopsy photograph is encouraged, particularly if the diagnostic phase and treatment phases are conducted in separate centers. LN, lymph node.