26 Vulva
(Mucosal malignant melanoma is not included.)
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SUMMARY OF CHANGES
• The definitions of TNM and the Stage Grouping for this chapter have not changed from the Fifth Edition.
ANATOMY
Primary Site. The vulva is the anatomic site immediately external to the vagina. It includes the labia and the perineum. The tumor may extend to involve the vagina, urethra, or anus. It may be fixed to the pubic bone (Figure 26.1).
Regional Lymph Nodes. (See Chapter 27, Figure 27.3.) The femoral and inguinal nodes are the sites of regional spread. For pN, histologic examination of an inguinal lymphadenectomy specimen will ordinarily include six or more lymph nodes. Negative pathologic examination of a lesser number of nodes still mandates a pN0 designation. The concept of sentinel lymph node mapping where only one or two key nodes are removed is currently being investigated.
Metastatic Sites. The metastatic sites include any site beyond the area of the regional lymph nodes. Tumor involvement of pelvic lymph nodes, including internal iliac, external iliac, and common iliac lymph nodes, is considered distant metastasis.
DEFINITIONS
The definitions of the T categories correspond to the stages accepted by the Fed- eration Internationale de Gynecologie et d’Obstetrique (FIGO). Both systems are included for comparison.
Primary Tumor (T) TNM FIGO Definitions Categories Stages
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 (Figure 26.2)
C51.0 Labium majus C51.1 Labium minus C51.2 Clitoris
C51.8 Overlapping lesion of vulva
C51.9 Vulva, NOS
238 American Joint Committee on Cancer • 2006 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(1)(Figure 26.3A)
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(1)(Figure 26.3B)
T2 II Tumor confined to the vulva or vulva and perineum, more than 2 cm in greatest dimension (Figure 26.4)
T3 III Tumor of any size with contiguous spread to the lower urethra and/or vagina or anus (Figures 26.5A, B)
C51.9 C51.2
Urethra Vagina C51.1
C51.0
FIGURE 26.1. Anatomic sites and subsites of the vulva.
T1
T1
£2 cm TNM:
FIGO: I
TNM:
FIGO: I
£2 cm
FIGURE 26.2. T1 tumor confined to the vulva (top of figure, above dotted line) or vulva and perineum (bottom of figure, below dotted line), 2 cm or less in greatest dimension.
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T1a T1b
A B
£1 mm
£2 cm
>1 mm
£2 cm
FIGURE 26.3. T1a A is 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.(1) T1b B is tumor confined to the vulva or vulva and perineum, 2 cm or less in greatest dimension, and with stromal invasion greater than 1 mm.(1)
T2
T2
>2 cm TNM:
FIGO: II
TNM:
FIGO: II
>2 cm
FIGURE 26.4. T2 tumor confined to the vulva (top of figure, above dotted line) or vulva and perineum (bottom of figure, below dotted line) more than 2 cm in greatest dimension.
T3
T3 TNM:
FIGO: III
TNM:
FIGO: III
A
FIGURE 26.5. A. T3 is a tumor of any size with contiguous spread to the lower
240 American Joint Committee on Cancer • 2006 T4 IVA Tumor invades any of the following: upper urethra, bladder mucosa, rectal mucosa, or is fixed to the pubic bone (Figure 26.6)
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis
TNM:T3 FIGO: III
B
FIGURE 26.5. B. Cross-sectional diagram showing spread of tumor into anus and lower urethra.
T4 TNM:
FIGO: IVA
FIGURE 26.6. T4 is defined as tumor invading any of the following: upper urethra, bladder mucosa, rectal mucosa, or is fixed to the pubic bone.
N1 III Unilateral regional lymph node metastasis (Figure 26.7) N2 IVA Bilateral regional lymph node metastasis (Figure 26.8) 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 diag- nosis, 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)
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N1 FIGO: III
C77.4
FIGURE 26.7. N1: unilateral regional lymph node metastasis.
N2 FIGO: IVA
FIGURE 26.8. N2: bilateral regional lymph node metastasis.
242 American Joint Committee on Cancer • 2006 STAGE GROUPING (AJCC/UICC/FIGO)
0 Tis N0 M0
I T1 N0 M0
IA T1a N0 M0
IB T1b N0 M0
II T2 N0 M0
III T1 N1 M0
T2 N1 M0
T3 N0 M0
T3 N1 M0
IVA T1 N2 M0
T2 N2 M0
T3 N2 M0
T4 Any N M0
IVB Any T Any N M1
NOTE
1. 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.
