Further Reading

1. Marsden DE and Hacker NH. (2001) Contemporary management of Primary carcinoma of the Vulva. Gynecologic Oncology. 81: 799813. Review of the clinical management of vulval carcinoma.

2. Vulval Cancer (1999). In: Guidance on Commissioning Cancer Services. Improving Outcomes in Gynaecological Cancers. The Research Evidence. NHS Executive, pp. 131-133. Summary of the research evidence for current management of vulval carcinoma.

3. Odicino F, Favalli G, Zigliani L andPecorelli S. (2001) Staging of Gynecologic malignancies. Gynecologic Oncology. 81 (4): 753-770. Describes the current staging system for vulval carcinoma.

4. Sohaib SA, Richards PS, Ind T, Jeyarajah AR, Shepherd JH, Jacobs IJ and Reznek RH. (2002) MR imaging of carcinoma of the vulva. Am. J. Roentgenol. 178(2): 373-377. Retrospective review of MRI findings in 22 patients with vulval carcinoma.

5. Hawnaur JM, Reynolds K, Wilson G, Hillier V, Kitchener HC. (2002) Identification of inguinal lymph node metastases from vulval carcinoma by magnetic resonance imaging: an initial report. Clin. Radiol. 57:995-1000. Describes the technique and results of high resolution MRIfor staging the inguinal lymph nodes in vulval cancer.

6. Grey AC, Carrington BM, Hulse PA, Swindell R and Yates W. (2000) Magnetic resonance appearance of normal inguinal nodes. Clin. Radiol. 55:124-130. Defines normal values for Inguinal lymph node measurements on pelvic MRI.

7. Moskovic EC, Shepherd JH, Barton DP, Trott PA, Nasiri N and Thomas JM. (1999) The role of high resolution ultrasound with guided cytology of groin lymph nodes in the management of squamous cell carcinoma of the vulva: a pilot study. Br. J. Obstet. Gynaecol. 106(8): 863-867. Study using ultrasound to stage the inguinal lymph nodes in vulval cancer.

Inguinal Lymph Node Mri

Figure 8.1. Normal vulval anatomy.

Coronal T2W1 showing normal vulval anatomy. Clitoris (C); labium majora (LM); body of pubis (P); bladder (B); uterus (U); symphysis pubis (arrow).

Figure 8.2. T1 Vulval carcinoma.

(a) Transaxial T2W (b) sagittal T2W and (c) coronal T1W images showing a small (<2.0cm) tumour (T)

(enclosed by hatched line) confined to the right side of the vulva, adjacent to but not invading the perineal structures. Normal lymph node (arrow), normal lymph node with fatty replacement (arrowhead), uterus (U), vagina (V), anal canal (AC), urethra (asterisk).

Figure 8.3. T2 Vulval carcinoma - posterior tumour.

(a) Transaxial T2W1 and (b) coronal TIW1 showing tumour (T) exceeding 2.0 cm in diameter centred on the posterior aspect of the left side of the vulva. Uterus (U); anal canal (AC).

Figure 8.4. T2 Vulval carcinoma - anterior tumour.

(a) Transaxial T2W1 and (b) sagittal T2W1 showing tumour (T) (enclosed by hatched line) exceeding 2.0 cm in diameter centred on the anterior aspect of the left side of the vulva. There is possible vaginal and urethral involvement suggested on the sagittal image but this was excluded by interrogation of more cranially located transaxial images.

Figure 8.5. T3 Vulval carcinoma.

(a) Transaxial T2W1 and (b) sagittal T2W1 showing posteriorly located vulval tumour (T), which has spread to anal margin.

Figure 8.6. T4Vulval carcinoma.

Figure 8.6. T4Vulval carcinoma.

(a) Transaxial T2W1 (b) coronal T2W1 and (c) sagittal T2W1 showing extensive vulval carcinoma. The tumour (T) has extended through the vagina (arrows) to infiltrate the anal canal and rectum at the ano-rectal junction (arrowheads), staging this asT4 disease. With such large tumours differentiation between those ofvulval and vaginal origin can be difficult. Locating the epicentre ofthe lesion and review of the clinical history and examination findings are useful indicators.

Figure 8.7. N1 Vulval carcinoma.

(a) Coronal T1W1 and (b) transaxial T2W1 showing a cystic metastasis in a right superficial inguinal lymph node (arrows). There are normal left inguinal nodes (arrowheads). The T1W1 demonstrates that the metastatic node is not composed of fat.

Vulval Carcinoma
Figure 8.8. N2 Vulval carcinoma.

(a) Coronal T1W1 and (b) coronal T2W fat-suppressed image showing bilateral enlarged metastatic superficial inguinal lymph nodes (arrows). On the left side there is extranodal spread (arrowheads) shown to advantage in (b) and a cystic area (asterisk) due to nodal necrosis.

Figure 8.9. N2 Vulval carcinoma

(a) and (b) Coronal T1W images showing left inguinal (arrows), left external iliac (arrowheads), left common iliac (open arrowheads) and left para-aortic lymph node (asterisk) metastases.

Vulvae Ray
Figure 8.10. Recurrent vulval carcinoma.

(a) and (b) Transaxial T2W1 (c) coronal T2W1 and (d) sagittal T2W1 showing recurrent vulval cancer following radiotherapy. The tumour (T) is centred on the right side of the natal cleft. It infiltrates the external anal sphincter (arrows) and vagina at the introitus (arrowheads). Surgical treatment of this lesion would involve an extended radical vulvectomy and colonic stoma formation. (Figure courtesy of Dr. Hulse, Christie Hospital.)

Figure 8.11. Recurrent vulval carcinoma.

(a) Transaxial T2W1 (b) coronal T2W1 and (c) sagittal T2W1 showing extensive recurrent vulval carcinoma, following radical vulvectomy.The vulvectomy void (asterisk) is evident in (a) and (c).The tumour (T) has infiltrated the anus (arrows), posterior margin of the vagina (arrowheads) and the perineal aspect of the distal urethra (crossed arrow), (d) Coronal T2W1 in the same patient showing a right inguinal lymph node metastasis (LN) which has an irregular margin indicating extranodal extension of tumour. (Figure courtesy of Dr. Carrington, Christie Hospital.)

Figure 8.12. Inguinal lymph node pitfall

(a) Coronal T1W1 and (b) coronal fat-suppressed T2W1 in a patient who had a vulvectomy for vulval carcinoma a few weeks previously. There is an enlarged right inguinal lymph node (arrows) which has a hyperintense focus in its lower pole (arrowheads) in (b). This is an equivocal finding for a metastatic or hyper-plastic node, although the high signal focus favours metastatic disease. On histology it was benign.

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