Table 2 Summary of the recommendations based on ≥ 80% agreement among experts

ESUR recommendations

Recommendations for MRI staging of vulvar cancer

 • Indications

  Tumour stromal invasion > 1 mm

  Tumour size > 4 cm

  Tumours with close proximity to or involvement of the urethra, vagina, or anus

 • Patient preparation:

  Fasting is recommended (4 – 6 h)

  The use of antiperistaltic agents is recommended (20 mg butyl scopolamine IM/IV or 1 mg of glucagon IV) unless their use is contraindicated due to patient medical background

  Supine patient positioning is recommended

  Vaginal gel is optional

  Rectal gel is not recommended

 • Hardware:

  The minimal recommended magnet field strength to stage vulvar cancer is 1.5 Tesla

 • Sequences and imaging planes:

  Pelvis

   T1WI

    Axial T1W Dixon sequence

   T2WI

    Axial, sagittal, and coronal two-dimensional T2W sequences

   T2W sequence with fat suppression is optional

    Slice thickness ≤ 4 mm

   T2WI with a small FOV (from the vaginal top to the entire perineum included)

    Axial or axial oblique (perpendicular to the urethra) and coronal or coronal oblique (parallel to the urethra)

    Slice thickness = 3 mm is recommended

   DWI-MRI

    In the axial plane, with a minimum of two b-values (low b = 0–50 or 100 s/mm², high b ≥ 800 s/mm²)

   DCE-MRI

    Three-dimensional (3D) spoiled gradient-echo fat-suppressed T1-weighted imaging (3D T1WI FS) imaging on axial or axial oblique before and after the administration of intravenous contrast for three scans to obtain arterial, portal and equilibrium phases (the last acquisition may be obtained in the most informative plane for each particular case)

  Upper abdomen (to evaluate the Kidneys and lymph nodes)

    T2W HASTE axial from the renal hila to the inguinal region

    DWI axial from the renal hila to the inguinal region

Recommendations for CT staging of vulvar cancer

 • Indications

  Regional or locally advanced disease (FIGO stages III–IVA) or suspicious distant metastases (FIGO stage IVB)—alternatively to CT, PET/CT may be performed in these cases

 • Protocol

  Chest, abdominal and pelvic CT with coverage of the inguinal region after the administration of intravenous contrast with image acquisition on portal-venous phase (60 – 80 s)

Recommendations for inguinofemoral lymph node US and biopsy

 • Indications

  Ultrasound of the inguinal regions with biopsy of suspicious lymph nodes (either by FNA or core biopsy) should be performed in all patients with either clinical (palpation) or radiological suspicion of lymph node metastasis depicted on MRI, CT, or PET/CT