Vulvar cancer and vulvar intraepithelial neoplasia (VIN): FIGO 2021 staging, usual vs differentiated VIN, the 3-step management, sentinel node biopsy and radiotherapy

Also known as Vulvar cancer · Vulvar carcinoma · Vulval cancer · Vulvar intraepithelial neoplasia · VIN · VIN usual type · VIN differentiated type · Squamous cell carcinoma of the vulva

Exam-exhaustive FRANZCOG fellowship topic on vulvar cancer and vulvar intraepithelial neoplasia (VIN): the FIGO 2021 vulvar cancer staging reproduced verbatim with the new depth-of-invasion definition and lymph node substages, the ISSVD 2004 classification of VIN into usual (HPV-related) and differentiated (lichen sclerosus-related) types, the 3-step management of VIN, vulvar cancer surgery (wide local excision versus radical vulvectomy, inguinofemoral node assessment with sentinel node biopsy as the new standard), the wound breakdown and lymphoedema rates, and the radiotherapy indications. Cross-links lichen sclerosus. Anchored to the Olawaiye 2021 FIGO vulvar staging revision, the GROINSS-V long-term follow-up (Te Grootenhuis 2016), the ISSVD 2004 VIN terminology (Sideri) and the Rahm 2022 population-based surgical complications study. RANZCOG-primary, globally tagged.

high7 referencesUpdated 27 July 202611 min readVerification in progress

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8 MCQs

One-line fellowship answer

Vulvar cancer is staged with the FIGO 2021 system (depth of invasion measured from the adjacent dysplastic rete ridge; lymph node substages by size and extracapsular spread), and over 90 percent are squamous cell carcinomas arising by two pathways: HPV-associated (younger women, usual-type VIN) and HPV-independent (older women, differentiated VIN on lichen sclerosus). VIN is classified per the ISSVD 2004 terminology into usual type (HPV-related, warty/basaloid) and differentiated type (lichen sclerosus-related), managed by the 3-step approach (biopsy to exclude invasion; treat; surveil). Surgery is wide local excision (radical local excision) with sentinel lymph node biopsy — the new standard for early-stage, node-negative disease — reserving radical vulvectomy and inguinofemoral lymphadenectomy for advanced or node-positive disease. Radiotherapy is indicated for positive nodes, close/unresectable margins, and as primary therapy for locally advanced disease.^[1]^[2]^[3]

A 68-year-old woman presents with an eight-year history of vulval lichen sclerosus and a new 2 cm ulcer on the right labium majus that has not healed over three months. This is not a "lichen sclerosus flare" — it is vulvar squamous cell carcinoma until a punch biopsy proves otherwise. Your job is to biopsy the ulcer edge, stage the lesion with the FIGO 2021 system, and plan surgery built around sentinel node biopsy rather than the morbid en-bloc radical vulvectomy with bilateral inguinofemoral lymphadenectomy of a generation ago. The FIGO 2021 staging, the sentinel node evidence, and the wound-morbidity numbers are the three things an examiner wants you to defend.^[1]^[2]^[4]

Overview and definition

Vulvar cancer accounts for about 4 percent of all gynaecological cancers, with about two-thirds of cases occurring in higher-income regions. The median age at diagnosis is in the mid-60s. Squamous cell carcinoma comprises over 90 percent of vulvar malignancies; the remainder include melanoma, basal cell carcinoma, Paget disease and Bartholin gland carcinoma.^[1]

Vulvar cancer arises by two distinct pathogenic pathways, and recognising which pathway a patient is on changes your counselling and surveillance:^[1]^[3]

HPV-associated pathway — driven by high-risk HPV, producing usual-type VIN (warty/basaloid) and basaloid or warty SCC in younger women.
HPV-independent pathway — driven by chronic lichen sclerosus inflammation, producing differentiated VIN and keratinising SCC in older women.^[1]

Why this matters — the burden in numbers

about 77%Vulvar SCC 5-year survival (Stage IB)node-negative local disease; from the FIGO 2021 NCDB analysis

2.5% at 5 yrGroin recurrence after negative sentinel nodeGROINSS-V long-term — sentinel biopsy is safe

4% vs 39%Lymphoedema: sentinel vs full groin dissectionthe morbidity argument for sentinel biopsy

about 4%Lifetime SCC risk in vulvar lichen sclerosuslower with ultrapotent corticosteroid — cross-link

^[1] ^[2] ^[4]

References7Show

[1]Olawaiye AB, Cotler J, Cuello MA, Bhatla N, Okamoto A, Wilailak S, et al. FIGO staging for carcinoma of the vulva: 2021 revision. Int J Gynaecol Obstet, 2021.PMID 34520062
[2]Te Grootenhuis NC, van der Zee AG, van Doorn HC, van der Velden J, Vergote I, Zanagnolo V, et al. Sentinel nodes in vulvar cancer: Long-term follow-up of the GROningen INternational Study on Sentinel nodes in Vulvar cancer (GROINSS-V) I. Gynecol Oncol, 2016.PMID 26428940
[3]Sideri M, Jones RW, Wilkinson EJ, Preti M, Heller DS, Scurry J, et al. Squamous vulvar intraepithelial neoplasia: 2004 modified terminology, ISSVD Vulvar Oncology Subcommittee. J Reprod Med, 2005.PMID 16419625
[4]Rahm C, Adok C, Dahm-Kähler P, Bohlin KS Complications and risk factors in vulvar cancer surgery - A population-based study. Eur J Surg Oncol, 2022.PMID 35148915
[5]Frumovitz M, Levenback CF Lymphatic mapping and sentinel node biopsy in vulvar, vaginal, and cervical cancers. Oncology (Williston Park), 2008.PMID 18533402
[6]Sibarani CNR, Salima S, Suardi D, Winarno GNA, Adrianto N, Bogar KJ, et al. Risk Factors for Recurrence in Vulvar Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis. Cancer Med, 2026.PMID 42503484
[7]Laufer J, Scasso S, Papadia A Different tracers for sentinel node detection in gynecologic oncology. Curr Opin Oncol, 2024.PMID 39007233