外阴癌淋巴结切除适应证和争议

外阴局部广泛切除术+腹股沟淋巴结切除术是目前外阴癌的基本手术方式。FIGO和NCCN指南均推荐FIGOⅠA期可不行腹股沟淋巴结切除术,所有ⅠB期或Ⅱ期患者,应该行腹股沟淋巴结切除术。晚期外阴癌在确定总体治疗方案前,应先明确腹股沟淋巴结状态,再确定后续处理方案。如果术前未发现可疑转移淋巴结,行双侧腹股沟、股淋巴结切除术;术前已明确淋巴结阳性者,建议仅切除肿大的淋巴结,术后给予腹股沟和盆腔放疗,最好避免系统性淋巴结切除术。在有关淋巴结切除的争议中,切除腹股沟、股淋巴结及采用三切口腹股沟横切口技术、保留大隐静脉等被大多数学者认可;但对于靠近中线但不侵犯中线的病灶是否可不切除双侧腹股沟淋巴结及外阴黑色素瘤、前庭大腺癌等少见病理类型的淋巴结切除指征尚有争议。

Indications and controversies of lymphadenectomy in vulva cancer

Vulva radical local excision and inguinofemoral lymphadenectomy are the standard surgical approach to vulva cancer.FIGO and NCCN guidelines recommend that groin dissection is not necessary for Stage ⅠA carcinoma of the vulva and all patients with FIGO stageⅠB or stageⅡlesions should have an inguinofemoral lymphadenectomy.It is desirable to determine the status of the groin nodes prior to planning the overall treatment for advanced vulvar cancer.If there are no suspicious nodes before surgery，bilateral inguinofemoral lymphadenectomy may be performed.If nodes are clinically positive，a complete lymphadenectomy should be avoided.Only enlarged nodes from the groin and pelvis should be removed if feasible，and the patient is given postoperative groin and pelvic radiation.There are some controversies about lymph node resection.Most scholars reach consensus on the such controversial issues as both inguinal and femoral nodes removal，groin dissection performed through a triple incision approach，groin dissection performed through a transverse incision approach，and the preservation of the saphenous vein.The need to perform bilateral lymphadenectomy for midline primary tumors not invading midline structures and the operation indication of inguinofemoral lymphadenectomy for bartholin gland carcinoma and melanoma remain to be investigated.