Gynecologic tumor board: a radiologist's guide to vulvar and vaginal malignancies

Abstract

Primary vulvar and vaginal cancers are rare female genital tract malignancies which are staged using the 2009 International Federation of Gynecology and Obstetrics (FIGO) staging. These cancers account for approximately 2,700 deaths annually in the USA. The most common histologic subtype of both vulvar and vaginal cancers is squamous cell carcinoma, with an increasing role of the human papillomavirus (HPV) in a significant number of these tumors. Lymph node involvement is the hallmark of FIGO stage 3 vulvar cancer while pelvic sidewall involvement is the hallmark of FIGO stage 3 vaginal cancer. Imaging techniques include computed tomography (CT), positron emission tomography (PET)-CT, magnetic resonance imaging (MRI), and PET-MRI. MRI is the imaging modality of choice for preoperative clinical staging of nodal and metastatic involvement while PET-CT is helpful with assessing response to neoadjuvant treatment and for guiding patient management. Determining the pretreatment extent of disease has become more important due to modern tailored operative approaches and use of neoadjuvant chemoradiation therapy to reduce surgical morbidity. Moreover, imaging is used to determine the full extent of disease for radiation planning and for evaluating treatment response. Understanding the relevant anatomy of the vulva and vaginal regions and the associated lymphatic pathways is helpful to recognize the potential routes of spread and to correctly identify the appropriate FIGO stage. The purpose of this article is to review the clinical features, pathology, and current treatment strategies for vulvar and vaginal malignancies and to identify multimodality diagnostic imaging features of these gynecologic cancers, in conjunction with its respective 2009 FIGO staging system guidelines.

Keywords: FIGO staging system; Pelvic imaging; Vaginal cancer; Vulvar cancer.

Conflict of interest statement

The authors declare that they have no conflict of interest.

© 2021. The Author(s).

Figures

Fig. 1

Relevant anatomy of the vulva. a Schematic of the vulva anatomy and lymphatic drainage pattern. The vulva is composed of the following components: mons pubis, clitoris, labia majora, labia minora, vaginal introitus, and the perineal body. The pattern of lymphatic drainage from the vulva occurs through a stepwise fashion from the superficial inguinal nodes, to the deep inguinal nodes, and then to the pelvic nodes. b Axial T2-weighted fat-saturated MR image shows the perineal body (asterisk), the urogenital triangle (anterior triangle), and anal triangle (posterior triangle). c Axial T2-weighted MR image shows the clitoris (large arrow), labia minora (small arrow), and labia majora (asterisks). d Axial T2-weighted image shows a superficial inguinal lymph node (yellow arrowhead) located anterolateral to the great saphenous vein (large arrow) and anterior to the femoral vessels (small arrow)

Fig. 2

46-year-old woman with FIGO stage 1 vulvar adenoid cystic carcinoma of the left Bartholin gland. Axial PET-CT shows an intensely FDG-avid soft tissue mass (arrow). There was no evidence of lymphadenopathy or distant metastases (not shown). The pathologic staging was pT1b N0 M0. The mass was excised and the patient subsequently received radiation therapy with chemosensitization

Fig. 3

69-year-old woman with FIGO stage 2 squamous cell carcinoma of the vulva. a Axial T1-weighted fat saturation with contrast MR image of the pelvis at the level of the vaginal introitus demonstrates irregular thickening in the right labia (arrow). b Sagittal T1-weighted fat-saturated MR image with contrast demonstrates enhancing soft tissue surrounding the distal urethra (arrow), a feature of FIGO 2 stage tumor. Cystoscopy confirmed urethral involvement by tumor with meatal stenosis

Fig. 4

75-year-old woman with FIGO stage 3 vulvar cancer who presented with vaginal spotting. a,b Axial PET-CT demonstrates an intensely FDG-avid left vulvar mass (arrow in a) with extension to the right lateral vaginal wall (arrow in b). c FDG-avid right inguinal adenopathy is present (circle)

Fig. 5

55-year-old woman with FIGO stage 4B squamous cell carcinoma of the vulva who presented with a malodorous vulvar mass. a Axial contrast-enhanced CT of the pelvis demonstrates a fungating vulvar mass (arrow). b Bulky left external iliac and inguinal lymphadenopathy was present (arrows). c Axial T1-weighted contrast-enhanced and d axial T2-weighted images show decreased size of the enhancing vulvar mass (solid arrow in c) and external iliac (dotted arrow) and inguinal (solid arrow in d) lymph nodes following radiation treatment

Fig. 6

51-year-old woman with FIGO stage 1B squamous cell carcinoma of the vulva status post-excision. a Axial PET-CT image 3 weeks after surgery shows intense linear FDG uptake along the right vulva (arrow). b Axial PET-CT image six months later shows decreased FDG uptake. The previous findings reflect post-treatment inflammation reaction (arrow)

Fig. 7

56-year-old woman with FIGO stage 4A SCC of the vulva status post-hysterectomy, bilateral oophorectomy, and radiation with recurrent disease 6 months later. a Axial T1-weighted contrast-enhanced and b DWI (b = 1000) MR images show a nodule measuring around 1 cm in the right vulva with enhancement and restricted diffusion (arrow). ADC image shows corresponding hypointensity (not shown). c Axial PET-CT image demonstrates soft tissue thickening in the right vulva with focal intense FDG uptake (arrow)

Fig. 8

Relevant MR anatomy of the vagina. a Sagittal T2-weighted MR image of the vagina (distended with gel) shows the upper (UV), middle (MV), and lower (LV) thirds. The image also shows the anterior and posterior fornices (solid arrows), cervix (C), and uterus (U). The dotted arrows demonstrate the T2-hypointense muscularis layer of the vagina. b Coronal T2-weighted MR image of the vagina shows the lateral fornices of the vagina (solid arrows). c Coronal T2-weighted MR image through the vagina demonstrates the puborectalis (solid arrow), levator ani (dotted arrow), and obturator internus (OI)

Fig. 9

51-year-old woman with a history of cervical cancer who developed FIGO stage 1 squamous cell carcinoma of the vagina. a Axial T1-weighted fat-saturated contrast-enhanced MR image shows thickening of the vagina (arrow). b Axial T2-weighted MR image shows no paravaginal involvement (arrow) with an intact vagina. c Sagittal T2-weighted images show that the tumor is confined to the vaginal wall with no involvement of the rectum (R) or bladder (B)

Fig. 10

51-year-old woman with FIGO stage 2 squamous cell carcinoma of the vagina. a Coronal oblique long-axis T2-weighted image through the vagina shows a hypointense mass arising from the left vaginal wall (arrow) and extending into the paravaginal soft tissue. b Coronal T1-weighted post-contrast image shows enhancement within the paravaginal soft tissue (arrow)

Fig. 11

58-year-old woman with FIGO stage 3 squamous cell carcinoma of the vagina who was treated with chemoradiation. a Axial CT before treatment shows an ulcerated mass in the right vaginal wall (arrow). There is a subtle area of hypodensity representing the non-ulcerated portion of the mass (circle). b Axial T1-weighted contrast-enhanced MR image after treatment shows enhancing tissue (arrow) compatible with residual tumor. c Coronal T1-weighted contrast-enhanced MR image shows that the lesion (solid arrow) is predominantly infralevator in location but extends superiorly to involve the levator ani muscle (dotted arrow)

Fig. 12

62-year-old woman with FIGO stage 4 vaginal cancer. a Axial T2-weighted MR image shows a complex soft tissue mass (arrow) with a cystic component at the superior edge of the vaginal cuff. The mass abuts several small bowel loops, with apparent tethering of surrounding structures. b Sagittal T2-weighted MR image shows that the mass invades the upper rectum (arrow). There is circumferential wall thickening of the upper rectum and sigmoid colon. R = rectum

Fig. 13

62-year-old woman with a history of FIGO stage 2 vaginal squamous cell carcinoma, status post-radiation therapy with vesicovaginal and colovaginal fistula. a Axial PET-CT image shows FDG-avid urine within the bladder (dotted arrow) extending into the vagina (solid arrow) and b rectum (dotted arrow)

Fig. 14

48-year-old woman with recurrent squamous cell carcinoma of the vagina. a Axial T2-weighted fat-saturated MR image shows a hyperintense mass within the left perineum causing mass effect on the left lateral vaginal wall (arrow) and extending into the left periurethral space. b DWI shows the lesion (arrow) with restricted diffusion