The diagnosis of vulvar cancer is made by biopsy, which can often be done on an outpatient basis. The patient may be examined under anesthesia. Cystoscopy, proctoscopy, x-ray examination of the lungs, and intravenous urography as needed, are used for staging purposes. Suspected bladder or rectal involvement must be confirmed by biopsy.

Stages are defined by the Federation Internationale de Gynecologie et Obstetrique (FIGO) and the American Joint Committee on Cancer’s (AJCC) TNM classifications.[1] The definitions of the T categories correspond to the stages accepted by the FIGO and both systems are included for comparison. Staging is on a surgical rather than a clinical basis. The 1988 FIGO staging system provides far better discrimination of survival between stages than the 1970 FIGO clinical staging system.[2]

TNM Definitions

TNM CATEGORY/FIGO STAGE

Primary tumor (T)

• TX: Primary tumor cannot be assessed
• T0: No evidence of primary tumor
• Tis/0: Carcinoma in situ (preinvasive carcinoma)
• T1/I: Tumor confined to the vulva or vulva and perineum, 2 cm or less in greatest dimension
  • T1a/IA: Tumor confined to the vulva or vulva and perineum, 2 cm or less in greatest dimension, and with stromal invasion no greater than 1 mm.
  • T1b/IB: Tumor confined to the vulva or vulva and perineum, 2 cm or less in greatest dimension, and with stromal invasion greater than 1 mm.
• T2/II: Tumor confined to the vulva or vulva and perineum, more than 2 cm in greatest dimension
• T3/III: Tumor of any size with contiguous spread to the lower urethra and/or vagina or anus
• T4/IVA: Tumor invades any of the following: upper urethra, bladder mucosa, rectal mucosa, or is fixed to the pubic bone

  The depth of invasion is defined as the measurement of the tumor from the epithelial-stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion.

Regional lymph nodes (N)

• NX: Regional lymph nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1/III: Unilateral regional lymph node metastasis
• N2/IVA: Bilateral regional lymph node metastasis

Every effort should be made to determine the site and laterality of lymph node metastases. However, if "regional lymph node metastases, NOS" is the final diagnosis, then the patient should be staged as N1.

Distant metastasis (M)

• MX: Distant metastasis cannot be assessed
• M0: No distant metastasis
• M1/IVB: Distant metastasis (including pelvic lymph node metastasis)

AJCC Stage Groupings

Stage 0

• Tis, N0, M0

Stage I

• T1, N0, M0

Stage IA

• T1a, N0, M0

Stage IB

• T1b, N0, M0

Stage II

• T2, N0, M0

Stage III

• T1, N1, M0
• T2, N1, M0
• T3, N0, M0
• T3, N1, M0

Stage IVA

• T1, N2, M0
• T2, N2, M0
• T3, N2, M0
• T4, any N, M0

Stage IVB

• Any T, any N, M1

References:

1. Vulva. In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 243-9.
2. Hopkins MP, Reid GC, Johnston CM, et al.: A comparison of staging systems for squamous cell carcinoma of the vulva. Gynecol Oncol 47 (1): 34-7, 1992.