Groin surgery and the sentinel lymph node

Vulvar cancer is a rare disease. Squamous-cell carcinomas account for 90% of vulvar cancers. The main mode of spread is lymphogenic to the inguinofemoral lymph nodes. Therefore, elective uni- or bilateral inguinofemoral lymphadenectomy is part of the standard treatment in combination with radical (wide) local excision of the vulvar tumour. Lymph drainage studies in relation to the biological behaviour of vulvar cancer are presented, as well as the anatomy and surgery of the groin. The sentinel lymph node procedure is a relatively new method of staging in vulvar cancer which may lead to the omission of inguinofemoral lymphadenectomy in those patients identified as not having inguinofemoral lymph node metastases. The accuracy of this technique appears to be high, but its safety still has to be proven. Moreover, the role of additional histopathological techniques for the examination of the sentinel lymph nodes needs to be established.     

What doctors and patients think about false-negative sentinel lymph nodes in vulvar cancer

The sentinel lymph node procedure is a relatively new, minimally-invasive method for the assessment of nodal status in malignancies such as breast cancer, cutaneous melanoma and vulvar cancer. Although highly accurate, this new method is inevitably associated with a certain false-negative rate, possibly leading to worse survival in a small subset of patients. The clinical implementation of the sentinel lymph node procedure is therefore a matter of ongoing debate, especially among doctors. The aim of this study was to assess opinions on the acceptable false-negative rate of the sentinel lymph node procedure in patients with vulvar cancer, who in the past had undergone standard routine radical vulvectomy and complete inguinofemoral lymphadenectomy (and frequently experienced complications), and in gynecologists treating patients with vulvar cancer.

Structured questionnaires were sent to both patients and gynecologists. The patients had been treated for vulvar cancer between 1985 and 1993, and were all in complete remission with a median follow-up of 118 months (range: 76–185). Questions to the patients dealt with experienced side-effects of the standard treatment and opinion on the acceptable false-negative rate of the sentinel lymph node procedure.

The response rate among patients was 91% (106/117). Forty per cent of the patients experienced one or more infections in the legs (cellulitis) and 49% of the patients still experience either severe pain and/or severe lymphedema in the legs. Sixty-six per cent of the patients preferred complete inguinofemoral lymphadenectomy in preference to a 5% false-negative rate of the sentinel lymph node procedure of 5%. Their preference was not related to age or the side-effects they had experienced. The response rate among gynecologists was 80% (80/100), of whom 60% were willing to accept a 5–20% false-negative rate of the sentinel lymph node procedure.

While gynecologists may consider the sentinel lymph node procedure to be a promising diagnostic tool, the majority of vulvar cancer patients, who have undergone complete inguinofemoral lymphadenectomy in the past and have frequently experienced complications, would not advise introduction of this technique because they do not want to take any risk of missing a lymph node metastasis.     

What doctors and patients think about false-negative sentinel lymph nodes in vulvar cancer

The sentinel lymph node procedure is a relatively new, minimally-invasive method for the assessment of nodal status in malignancies such as breast cancer, cutaneous melanoma and vulvar cancer. Although highly accurate, this new method is inevitably associated with a certain false-negative rate, possibly leading to worse survival in a small subset of patients. The clinical implementation of the sentinel lymph node procedure is therefore a matter of ongoing debate, especially among doctors. The aim of this study was to assess opinions on the acceptable false-negative rate of the sentinel lymph node procedure in patients with vulvar cancer, who in the past had undergone standard routine radical vulvectomy and complete inguinofemoral lymphadenectomy (and frequently experienced complications), and in gynecologists treating patients with vulvar cancer. Structured questionnaires were sent to both patients and gynecologists. The patients had been treated for vulvar cancer between 1985 and 1993, and were all in complete remission with a median follow-up of 118 months (range: 76-185). Questions to the patients dealt with experienced side-effects of the standard treatment and opinion on the acceptable false-negative rate of the sentinel lymph node procedure. The response rate among patients was 91% (106/117). Forty per cent of the patients experienced one or more infections in the legs (cellulitis) and 49% of the patients still experience either severe pain and/or severe lymphedema in the legs. Sixty-six per cent of the patients preferred complete inguinofemoral lymphadenectomy in preference to a 5% false-negative rate of the sentinel lymph node procedure of 5%. Their preference was not related to age or the side-effects they had experienced. The response rate among gynecologists was 80% (80/100), of whom 60% were willing to accept a 5-20% false-negative rate of the sentinel lymph node procedure. While gynecologists may consider the sentinel lymph node procedure to be a promising diagnostic tool, the majority of vulvar cancer patients, who have undergone complete inguinofemoral lymphadenectomy in the past and have frequently experienced complications, would not advise introduction of this technique because they do not want to take any risk of missing a lymph node metastasis.     

The side of groin node metastases in unilateral vulvar carcinoma

The purpose of this study was to analyze the occurrence of ipsilateral, bilateral and contralateral inguinofemoral node metastases in unilateral vulvar carcinoma. One hundred and eighty-five women with a T1 or T2 squamous cell carcinoma who underwent radical vulvectomy with bilateral inguinofemoral lymphadenectomy were surveyed. Inguinofemoral lymph node metastases were found in 23 (22.1%) out of the 104 patients with a unilateral primary tumor. These lymph node metastases were found solely on the ipsilateral side in 21 (91.3%) out of the 23 patients. One patient presented with bilateral extranodal growth in the groins. Another patient with a history of endometrial carcinoma had a right-sided vulvar tumor with contralateral groin node metastases. Half a year later, she was diagnosed with recurrent endometrial cancer on the right pelvic side-wall. Our study endorses clinical evidence that the preferential lymph flow is to the ipsilateral groin. Established lymph node metastases may disturb the normal lymph flow with contralateral metastases as a possible consequence.     

Impact sur la survie de la procédure du ganglion sentinelle dans le cancer de la vulve : analyse de la SEER database

ObjectivesVulvar cancer is usually treated with vulvectomy and bilateral groin lymphadenectomy, which result in serious morbidities while only 30% of patients have positive nodes. The sentinel node technique has good sensitivity and specificity for detecting lymph node involvement while minimizing postoperative morbidity. The aim of this study was to evaluate the specific and overall survival impact of sentinel lymph node procedure versus inguinofemoral lymphadenectomy in patients with vulvar cancer.Patients and methodsThis is a retrospective study from the Surveillance, Epidemiology, and End Results (SEER) database on patients with vulvar squamous cell carcinoma, T1 or T2 stage, metastatis-free, followed between 2004 and 2008.ResultsOne thousand and thirty eight patients had a systematic groin lymphadenectomy and 56 a sentinel node technique (including 22 with an associated lymphadenectomy because of a positive sentinel node). There is no significant difference in overall or specific survival between the two groups. In multivariate analysis, age, T stage and nodal status are prognostic factors for overall and specific mortality (P < 0.05).Discussion and conclusionSentinel node technique is not associated with an excess risk of mortality or recurrence.     

Further data on the usefulness of sentinel lymph node identification and ultrastaging in vulvar squamous cell carcinoma

OBJECTIVE: The aim was to determine the feasibility of surgical identification and pathological ultrastaging of sentinel nodes (SNs) in vulvar carcinoma and to evaluate whether SN negativity rules out the possibility of metastasis in other nodes and can therefore avoid conventional lymphadenectomy. MATERIAL AND METHODS: In 26 patients with vulvar squamous cell carcinoma the SNs were detected using both peritumoral injection of (99m)Tc and blue dye (isosulfan or methylene) before the surgical procedure. Dissection of the SNs was followed by standard lymphadenectomy and vulvar exeresis. For pathological ultrastaging at least eight histological sections of every node separated 400 microm were evaluated using hematoxylin & eosin and immunostaining against cytokeratin. RESULTS: We identified the SNs in 25/26 patients (96%). In 19 patients (76%) the SN was unilateral and in 6 (24%) it was bilateral. A total of 46 SNs were isolated. Metastatic carcinoma was identified in 9 SNs from 8 patients (30.8%). Thirty-eight percent (3 of 8) patients with metastatic SNs presented micrometastasis detected only in ultrastaging. Seven (3.3%) of 239 nonsentinel nodes (non-SNs) showed metastasis. No metastatic implant was detected in non-SNs when SNs were negative in patients without clinical suspicious adenopathy (100% negative predictive value). CONCLUSION: Inguinofemoral lymph nodes can be confidently avoided when sentinel node metastases are excluded by histological ultrastaging. This may reduce the surgical morbidity of conventional inguinofemoral lymphadenectomy, without worsening vulvar cancer prognosis.     

Carcinoma of the vulva. Clinicopathologic factors involved in inguinal and pelvic lymph node metastasis

Eighty-five women with vulvar squamous cell carcinoma were subjected to radical vulvectomy with bilateral inguinal and femoral node dissection or to radical vulvectomy with bilateral inguinofemoral and deep pelvic node dissection. The association between lymph node status (metastatic or not) and several parameters was analyzed: tumor location, size and clinical stage; tumor thickness, histologic grade and mitotic index; blood vessel, lymphatic and perineural infiltration; and lymphocytic and plasma cell infiltrates. There were no metastases to the pelvic lymph nodes without previous inguinal lymph node involvement. Unilateral vulvar carcinomas did not have contralateral metastatic nodes when there was no ipsilateral nodal involvement. Lymphatic vessel infiltration showed a statistically significant correlation with inguinal node metastases (P less than .05). No correlation was found between lymph node metastasis and tumor size, clitoral invasion, tumor thickness, histologic grade, blood vessel and perineural infiltration, lymphocytic and plasma cell infiltrates, and mitotic index.     

Basal Cell Carcinoma of the Vulva with Groin Node Metastasis

There have been five previous well-documented cases of rectastatic vulvar basal cell cancer in the literature. We now present the sixth case—an 86-year-old patient with vulvar basal cell cancer metastatic to an ipsilateral groin node. She was treated with radical vulvectomy and bilateral inguinofemoral lymphadenectomy and remains free of disease 1 year later.     

Vulvar malignancy

Treatment of invasive vulvar malignancy has become more individualized during the past decade. In the past, radical vulvectomy with bilateral inguinofemoral lymphadenectomy was the standard therapy for invasive squamous cell carcinoma and melanoma of the vulva. This is no longer always the case. The treatment of stage I and stage II invasive squamous cell carcinoma of the vulva has become more individualized. Less radical surgery appears to produce the same results as ultraradical surgery. Wide local excision of early lesions associated with ipsilateral lymph node dissection appears to be adequate therapy in many cases. Likewise, treatment of early melanoma (0.75 mm in thickness) can be managed by wide local excision with or without groin dissection of the ipsilateral side. This more conservative approach has resulted in significantly fewer postoperative complications and has improved the self-image of many women undergoing treatment for vulvar malignancy.     

Sentinel lymph node identification in a primary ductal carcinoma arising in the vulva

Primary or metastatic breast-like carcinoma of the vulva is a rare event. Because of the similarity with breast ductal carcinoma, we think that the same principles used for treatment of orthotopic breast cancer can be applied, as well as the use of sentinel lymph node technique, which is widely accepted in the management of early-stage breast cancer. We report a 49-old-year postmenopausal woman who was referred to our institution after small biopsy of a 3.5- x 3-cm right vulvar tumor. Histopathologically, infiltration of the vulvar dermis by a ductal carcinoma of mammary gland type was reported. At operation, the sentinel node technique revealed two sentinel nodes in the right inguinal area. Although these nodes proved negative for malignancy, the patient underwent wide local excision of tumor and complete ipsilateral inguinofemoral lymphadenectomy. The remaining excised nodes were negative. Surgical specimen proved estrogen- and progesterone-positive receptors, the reason for which the patient received tamoxifen adjuvant therapy. This report represents the first case in the world literature of primary breast carcinoma arising in the vulva in which sentinel lymph node identification has been possible. Because of the rarity of this condition, the pathologic similarity of this tumor along with currently accepted guidelines for the management of breast cancer supports the possibility of local excision and sentinel lymph node identification as a possible alternative to inguinofemoral lymphadenectomy.     

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。     

Isolated skin bridge metastasis following modified radical vulvectomy and bilateral inguinofemoral lymphadenectomy

Separate vulvar and groin incisions have significantly reduced the morbidity of vulvar cancer surgery. We describe a patient with FIGO stage II squamous vulvar cancer, who developed an ipsilateral tumor recurrence in the skin bridge between the vulva and the groin within 7 months of modified radical vulvectomy and bilateral inguinofemoral lymphadenectomy, using triple incisions. The recurrence was treated by wide local excision alone and she remains free of disease 2 years later. Although rare, the potential for failing to excise tumor emboli in the lymphatics of the skin bridge must be recognized when the triple incision technique is used in the surgical treatment of vulvar cancer.     

Complications following combined surgery (radical vulvectomy versus wide local excision) and radiotherapy for the treatment of carcinoma of the vulva: report of 73 patients

Cancer of the vulva is uncommon, accounting for only 5% of all gynecologic malignancies, and usually occurs in women over 60 years of age. The historic treatment of choice for invasive squamous cell carcinoma of the vulva is radical vulvectomy with bilateral inguinal lymphadenectomy, which has produced excellent long-term survival. We retrospectively analyzed the complications of wide local excision plus postoperative radiotherapy compared with those of radical vulvectomy and bilateral lymphadenectomy plus pre-or postoperative radiotherapy in 73 patients with vulvar cancer. There were no significant differences among these treatments in terms of primary tumor control, 5-year disease-free survival, and overall survival. Based on these results, the best treatment alternative for advanced vulvar cancer is wide local excision plus radiotherapy, as this method retains the high survival of traditional therapy but has less morbidity.     

Invasive carcinoma of the vulva. Changing trends in surgical management

Four hundred fifteen patients who had invasive carcinoma of the vulva were treated with primary surgery from July 1, 1955, through June 30, 1989. Three hundred seventy-six (90%) of the patients had squamous carcinoma. Two hundred fourteen patients (52%) had radical vulvectomy with inguinofemoral lymphadenectomy. Twenty-four patients (6%) underwent radical vulvectomy with pelvic exenteration for advanced disease, and 55 patients (13%) had nonradical operations. The remaining 122 patients (29%) underwent radical vulvectomy, inguinofemoral lymphadenectomy, and pelvic lymphadenectomy. The primary morbidity was associated with lymphedema (8.6%) and groin wound breakdown (54%). No intraoperative deaths occurred among the 415 patients treated surgically, but there were 17 deaths (4%) within 28 days of operation. The absolute 5-year survival rate was 85% in patients with negative inguinofemoral lymph nodes and 39% when these lymph nodes were positive for metastatic carcinoma. The overall absolute 5-year survival rate was 67%.     

Surgical management of stage I and II vulvar cancer: The role of the sentinel node biopsy. Review of literature

Abstract. Makar APH, Scheistroen M, van den Weyngaert D, Tropé CG. Surgical management of stage I and II vulvar cancer: The role of the sentinel node biopsy. Review of literature.
Recognition of the psychosexual consequences of radical vulvectomy and better understanding of the lymphatic drainage and histopathologic features of vulvar cancer have led to a more conservative surgical approach, especially in patients with early-stage disease. Every patient with early vulvar cancer should be managed individually and the risk of conservative therapy balanced against the dangers and advantages of more radical therapy. The results of the sentinel node (SN) procedure in early cancer of the vulva are encouraging, and it might be possible in the near future to avoid the morbidity of inguino-femoral lymphadenectomy. This article reviews surgical management of early vulvar cancer and the place of SN biopsy.     

Radical vulvectomy and bilateral groin lymphadenectomy utilizing separate groin incisions: report of a case with recurrence in the intervening skin bridge

Postoperative wound breakdown is very common following the en bloc dissection of the vulva and inguinal/femoral lymph nodes for carcinoma of the vulva. To decrease the incidence of wound morbidity, techniques have been described for performing the inguinal/femoral lymphadenectomy through separate groin incisions. This approach leaves a bridge of tissue between the vulvar excision and the lymph node dissection. A case of stage I squamous cell carcinoma of the vulva that was treated with a radical vulvectomy and bilateral inguinal/femoral lymphadenectomy utilizing separate groin incisions is presented. This patient later developed a recurrence in the tissue bridge between the vulvar and groin excisions. The mechanism for this recurrence is discussed.     

Comparison of recurrence after vulvectomy and lymphadenectomy with and without sentinel node biopsy in early stage vulvar cancer

OBJECTIVES: To determine the usefulness of sentinel lymph node biopsy in early stage vulvar cancer and to assess recurrences after surgical treatment with sentinel node identification or surgical treatment without sentinel node identification. METHODS: We reviewed the records of 55 patients with early stage vulvar cancer operated on between 1995 and 2005. A prospective series of 28 patients who underwent vulvectomy and lymphadenectomy with intraoperative sentinel lymph node identification between 2000 and 2005 (SLN group) was compared with a retrospective series of 27 patients who underwent vulvectomy and lymphadenectomy without sentinel node procedure between 1995 and 2000 (non-SLN group). Patients in the sentinel node identification group underwent preoperative lymphoscintigraphy (technetium-99 colloid albumin injection around the tumor) and intraoperative mapping with isosulfan blue dye. RESULTS: In the SLN group, 9 tumors were T1 and 19 were T2, with a total of 40 groins dissected and 9 positive nodes in 7 patients. Sixty-two sentinel lymph nodes were detected with a mean of 2.2 sentinel nodes per patient (range 0-4). A false negative case was found. In the non-SLN group, 7 tumors were T1 and 20 were T2, with a total of 49 groins dissected and 9 positive nodes in 6 patients. Recurrence occurred in 8 patients (28.6%) in the SLN group and in 6 (26.9%) in the non-SLN group (P=0.8). CONCLUSIONS: Sentinel lymph node identification in early stage vulvar cancer is a feasible. Analysis of recurrence may allow considering this procedure as a possible alternative to inguino-femoral lymphadenectomy.     

Groin recurrence after micrometastasis in a sentinel lymph node in a patient with vulvar cancer

BACKGROUND: The sentinel lymph node concept is attractive in vulvar cancer because of the potential to avoid the morbidity associated with formal groin dissection. CASE: An 84-year-old patient with a T2 carcinoma of the anterior vulva underwent surgery including bilateral sentinel node excision after identification with technetium-labeled nanocolloid. Frozen section histology showed a tumor deposit <1 mm in diameter in a left groin node whereas four nodes in the right groin were apparently negative. Completion lymphadenectomy was performed only for the left groin. Final histology including serial sectioning showed a micrometastasis in one of seven nodes from the right groin; no further treatment was given. Sixteen months postoperatively the patient developed a recurrence in the right groin; the left groin was free of tumor. CONCLUSION: This case indicates that groins with a micrometastasis detected by sentinel lymph node excision require further treatment.     

Das Sentinellymphknotenverfahren beim Vulvakarzinom

Although the local and regional radicality in treating vulvar carcinoma could be reduced during the last years, the inguinal lymphadenectomy with its short term and long term morbidity will remain in most cases a necessary part of the surgical treatment. Therefore, since some years, there are studies to find out whether the procedure of sentinel lymph node biopsy could be used in vulvar cancer. The results up to now show an almost hundred percent rate for identification of the sentinel node using radioactive tracer alone or in combination with vital dye. Histological diagnosis of metastases in a sentinel node yields very high values for sensitivity and specificity. The sentinel lymph node procedure in vulvar cancer, however, is not sufficiently evaluated up to now to replace the standard of complete inguinal lymphadenectomy.     

Primeros resultados de la disección del ganglio centinela en los carcinomas epidermoides vulvares

Objective

The aim was to analyse our first results in the sentinel lymph node procedure in vulvar cancer, as regards the detection rate, false negative cases and relation with cancer recurrence or not.

Material and methods

Retrospective study of first 9 cases of sentinel lymph node detection in vulvar squamous cell carcinoma, between June 2004 and December 2007.

Results

We identified the sentinel node in 8 out of 9 patients (88% detection rate). There were no false negative cases, giving a negative predictive value of 100%. Only one patient with a negative sentinel node died of vulvar cancer. She also had Fanconi anaemia.

Conclusions

Sentinel lymph node detection in patients with squamous cell carcinoma of the vulva is feasible, and can be an alternative to conventional inguinofemoral lymphadenectomy.