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7 Staging system

The TNM classification5 and the FIGO staging system6,7 classify vulvar cancer on the basis of the size of the
tumour T, whether the cancer has spread to lymph nodes N), and whether it has spread to distant sites M
Table 1. By convention, the depth of invasion is defined from the epithelial-stromal junction of the most
superficial adjacent dermal papilla to the deepest point of invasion of the tumour8. Inguinal and femoral nodes
are the initial sites of regional spread and involvement of pelvic lymph nodes is considered distant metastasis.

The FIGO staging system was last reviewed in 2009 by the FIGO Committee on gynecologic oncology6,7 in
close collaboration with the American joint commission on cancer and the Union of international cancer control.
It should be noted that as part of this revised FIGO staging system, the pathologist must report not only the
number of nodes with metastatic disease but also the size of the metastases and the presence or absence of
extranodal spread.

7.1 Summary of available scientific evidence

No studies assessing the performance of the TNM classification have been identified.

Three retrospective studies9-11 assessing the performance of the revised FIGO staging system have LoE 2-
been identified. The new staging system has generally been considered appropriate. This has seen a
major downstaging of between 18.3% to 42% of patients. This has mainly involved old patients with
stage II disease being downstaged to stage IB. Among the 1,131 patients enrolled in these studies,
only 6 patients were upstaged by the new system < 1%. Nevertheless, Tabbaa et al.10 suggested that
tumours > 4 cm in diameter had a less favourable prognosis. A potential limitation with the revised
FIGO staging system is that the number of patients with stage II disease will be very low. From the
three retrospective studies above9-11, about 20% of patients were classified as stage II in the old
FIGO staging system, whereas it is likely to be less than 5% in the revised system.

7.2 Previous initiatives

No previous initiative presenting guidelines on the staging system to use was identified.

7.3 Development group comments

The development group recommends using the TNM classification because it more accurately reflects the status
of the primary tumour and lymph nodes.

7.4 Guidelines

 Vulvar cancer should be staged according to FIGO and/or TNM classification3.

3 Throughout these recommendations advanced stage of disease is defined as clinical T3 and/or N3.

 VULVAR CANCER - GUIDELINES 
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