The 2021 update refined the Prognostic Node groups (Stage III) based on absolute node size and extracapsular spread.
Guidelines & Evidence
Clinical Details
Section 1
When to Use
Primary Clinical Uses
Surgical/pathological staging of primary vulvar squamus cell carcinoma and melanomas
Major determinant for the extent of inguinofemoral lymph node dissection
Guiding the necessity for adjuvant groin/pelvic radiotherapy
The 2021 Update
The 2021 FIGO update made critical modifications regarding lymph node morphology. Extracapsular spread (ECS) in the groin nodes is now officially recognized as overwhelmingly prognostic and immediately upstages the patient to IIIC.
Section 2
Formula & Logic
Stage I — Confined to Vulva/Perineum (No Nodal Spread)
IA
Tumor ≤ 2 cm AND stromal invasion ≤ 1 mm
IB
Tumor > 2 cm OR stromal invasion > 1 mm
Stage II — Local Adjacent Spread (No Nodal Spread)
II
Extension to lower 1/3 of urethra, lower 1/3 of vagina, or anus
Stage III — Inguinofemoral Lymph Nodes
IIIA
1 or 2 lymph nodes with metastasis < 5 mm AND no extracapsular spread
IIIB
≥ 3 nodes (< 5mm) OR ≥ 1 node (≥ 5 mm) AND no extracapsular spread
IIIC
ANY lymph node metastasis with Extracapsular Spread (ECS)
Stage IV — Deep Regional or Distant Spread
IVA
Upper 2/3 urethra/vagina, bladder/rectal mucosa, fixed to pelvic bone, or fixed/ulcerated nodes
IVB
Distant metastasis, including pelvic lymph nodes
Section 3
Pearls/Pitfalls
Nodal Nuances
Groin node status is the single most important prognostic factor for overall survival.
Note that pelvic lymph node involvement (iliac/obturator) bypasses Stage III completely and is classified as Stage IVB (distant metastasis).
Stage IA patients have an essentially zero risk of nodal metastases. They strictly require wide local excision only and should be spared the severe morbidity of groin dissection.
Section 4
Next Steps
Surgical Management Guidelines
01
Stage IA: Wide local excision (WLE). Observation of groins.
Stage IB / II (Central tumor, <2cm from midline): WLE + bilateral inguinofemoral lymph node evaluation.
04
Positive Sentinel Node or ECS: Proceed to full genitofemoral lymphadenectomy and immediate planning for adjuvant groin/pelvic radiotherapy.
Section 5
Evidence Appraisal
Current Guidelines
FIGO staging for carcinoma of the vulva: 2021 revision.
Olawaiye AB et al. • Int J Gynaecol Obstet.. 2021;Formalized the devastating prognostic impact of extracapsular spread by moving it to its own category (IIIC) and restructured tumor invasion depth metrics.
Section 6
Literature
Historical Context
Prior to the 1990s, vulvar cancer was uniformly treated by the brutal "en bloc" radical vulvectomy with bilateral groin dissections. Modern staging allows for highly targeted, tissue-sparing surgery to prevent catastrophic lymphedema while maintaining survival rates.
