Title ISUOG ECO CANCER.pdf ✅

366 Fischerova D, et al. Int J Gynecol Cancer 2024;34:363–378. doi:10.1136/ijgc-2023-004609 Review (ranging from 40% to 89%) depending on the diagnostic criteria used.42–46 However, novel MRI techniques (eg, DWI (diffusion- weighted imaging); DCE (dynamic contrast-enhanced)-, and high- resolution T2WI (T2-weighted imaging) series) are promising for improving locoregional staging.31 High-quality ultrasound or MRI examination for local (loco-regional) staging purposes should be complemented by a structured imaging report to communicate clinically relevant information to the referring physician. Patients who are not candidates for sentinel lymph node biopsy (if they have multifocal tumors, unifocal tumors with size ≥4 cm, and/or suspicious inguinofemoral nodes in pre-operative evalua- tion) should undergo further imaging in addition to the ultrasound or pelvic MRI assessment to exclude distant metastases. Thoracic and abdominal contrast-enhanced CT (CECT) or whole-body 18F-fluo- rodeoxyglucose positron emission tomography combined with CT (FDG-PET-CT) should be performed to exclude pelvic lymph node involvement and other distant metastases (Figure 2).31 47 48 New MRI sequences such as T2WI ultrafast spin echo sequences and whole-body DWI may be useful for assessing the upper abdomen and diagnosing distant nodal metastases.31 The location of the primary tumor and any suspicious regional and distant lymph nodes should be documented in a schematic drawing within a standardized systematic checklist (Online Supple- mental Appendix S1). Current Guidelines and the Role of Imaging in Vulvar Cancer Staging Following the updated 2023 ESGO guidelines for the management of patients with vulvar cancer9 : ► Pre-operative work-up includes a medical history; general assessment of co-morbidities; frailty assessment; clinical examination; biopsy of all suspicious areas followed by patho- logic review; and imaging as indicated. Figure 2 Imaging by ultrasound, CECT, and FDG-PET-CT (depicting locoregional spread and distant spread in a patient in her 80s, diagnosed with squamous cell vulvar cancer FIGO stage IVB. For local staging, transperineal ultrasound using a convex array probe in the transverse plane allows visualization of tumor infiltration in the clitoris (A) and labia majora bilaterally (B). The same vulvar pathology is depicted as hyperdense tissue on CECT (C) with high FDG-avidity on FDG-PET- CT (D). Regional lymph nodes in the groins are evaluated by transcutaneous ultrasound using a linear array probe (according to the Vulvar International Tumor Analysis (VITA) Group consensus for the evaluation of inguinofemoral lymph nodes) (E, F).18 Two pathologic lymph nodes (Ln1 and Ln2) above the fascia lata and the femoral vessels on the right side (E, F) are seen: Ln1 is partially infiltrated while Ln2 shows complete infiltration. The same pathology is depicted as enlarged inguinal lymph nodes on CECT (G), highly FDG-avid on FDG-PET-CT (H). Pelvic lymph nodes are assessable by ultrasound using an endoluminal probe inserted transvaginally and metastatic lymph nodes are seen around the right (Ln3) and left (Ln4) (I, J) iliac vessels. The enlarged iliac lymph node is clearly visualized on the right side (Ln3) on CECT (K) and as highly FDG-avid on FDG-PET- CT (L). The location and size of this vulvar lesion made a transvaginal ultrasound approach possible. Online Supplemental Video S1 shows ultrasound and other imaging methods in vulvar cancer. CECT, contrast-enhanced CT; FDG-PET-CT, 18F- fluorodeoxyglucose positron emission tomography combined with CECT. FIGO, International Federation of Gynecology and Obstetrics; Ln, lymph node.