Groin Recurrences in Node Negative Vulvar Cancer Patients After Sole Sentinel Lymph Node Dissection

Sir, Rodríguez-Trujillo et al 1 present a very interesting retrospective study on inguinal lymphadenectomy (IFL) vs sentinel lymph node dissection (SLN) in vulvar cancer. Several studies have been published analyzing this topic. 2,3 However, a prospective randomized study is still missing. Although SLN leads to lower morbidity, there are still concerns about whether SLN is as safe as IFL regarding groin recurrences and mortality. The GROINSS-V study encouraged all gynecologists to perform SLN by reaching excellent low recurrent rates (6/253, 2.4%) with an SLN-only approach. 2 However, as shown in a recent survey in German hospitals, only 57% of the participating clinics which usually perform SLN in vulvar cancer strictly followed the restrictions recommended by this study and national guidelines. 4 Obviously, we cannot expect to achieve same results as the GROINSS study if we do not stringently follow the protocol and recommendations. Covens et al 3 reported isolated groin recurrence rates of SLN (3.4%, 95% CI 1.8%-5.4%) vs IFL(1.4%, 95% CI 0.4%-2.9%) in a meta-analysis. Although recurrence rates in the SLN group appear to be higher, the difference was not statistically significant; however, the studies were heterogeneous and most of them evaluated small cohorts. We specifically analyzed groin recurrence rates of SLN and IFL in our cohort and reviewed the cases from other studies. 5 We also noticed a nonsignificant tendency to higher recurrence rates in SLN. Most noteworthy, however, is that groin recurrences normally lead to death (mortality 90.9%, range 66.7%-100%). Rodríguez-Trujillo et al 1 confirm our aforementioned concerns, although they recommended abandoning IFL. They report an isolated groin recurrence rate for SLN of 2/42 (4.8%) and for IFL 1/51 (2.0%) (P = 0.587). However, according to Table 2, there were three cases of groin recurrences after isolated SLN, leading to an even higher recurrence rate of 7.0% for the SLN group. Of course, in a small cohort, a single additional affected patient can lead to an apparent difference in the results, although not significant. But P values, especially in small cohorts with small effect sizes, are not very useful for reaching such strong conclusions. In our opinion, their results do not reliably show that SLN and IFL are equal and they should not encourage gynecologic oncologists to abandon IFL. Of course, SLN in vulvar cancer is an excellent technique to prevent severe quality of life-impairing morbidities. SLN appears to be comparable to IFL regarding oncological safety under restricted conditions in specialized centers. The risks and benefits of SLN have to be explained in detail to each patient based on the available data. Then the individual woman still has to decide whether she wants to take the potential risk of at least 1%-2% higher rate of groin recurrences with associated risk of death instead of a 10%-30% higher rate of postoperative complications.A previous study has reported that most women prefer oncological safety over reduced morbidity. 6 If SLN i...

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“…5 We also noticed a nonsignificant tendency to higher recurrence rates in SLN. Several studies have been published analyzing this topic.…”

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confidence: 59%

Should we really abandon inguinal lymphadenectomy in the treatment of vulvar cancer?

Klapdor

Hillemanns

2018

Acta Obstet Gynecol Scand

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“…19 An inguinofemoral recurrence of vulvar cancer is associated with very poor outcome. 10,11 Therefore, a deeper analysis of every case with a false-negative sentinel is necessary. In this study, we had 1 patient with an intraoperatively suspicious, palpable, nonsentinel lymph node that was negative for 99m Tc-nanocolloid and ICG and finally showed a tumor infiltration of 6 mm.…”

Section: Discussionmentioning

confidence: 99%

“…7Y10 The prognosis of an inguinal recurrence is poor and associated with a high mortality. 10,11 Therefore, high attention has to be directed to a correct application of both sentinel diagnostic and extirpation. The criterion standard of sentinel mapping in vulvar cancer is the use of radioactive technetium 99m ( 99m Tc)Ylabeled nanocolloid.…”

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confidence: 99%

Sentinel Lymphadenectomy in Vulvar Cancer Using Near-Infrared Fluorescence From Indocyanine Green Compared With Technetium 99m Nanocolloid

Soergel¹,

Hertel²,

Nacke³

et al. 2017

Int J Gynecol Cancer

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“…After a complete inguinofemoral or pelvic lymph node dissection, the same morbidity as in vulvar or cervical cancer patients is to expect. However, the prognosis of a nodal recurrence is poor and associated with a high mortality in vulvar and cervical cancer [11,16]. The gold standard of sentinel mapping in vulvar or cervical cancer is the use of radioactive technetium-99m-nanocolloide (Tc-99m).…”

Section: Introductionmentioning

confidence: 99%

Sentinel lymphonodectomy in early vaginal cancer using combined near infrared fluorescence from indocyanine green and technetium-99m nanocolloid – a first case report

Soerge¹,

Hillemanns²,

Klapdor³

et al. 2017

Clin Obstet Gynecol Reprod Med

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Nowadays, sentinel diagnostic is been made with technetium-99m-(Tc-99m)-nanocolloide as a radioactive marker and sometimes patent blue. In the last years, indocyanin green has been evaluated for sentinel diagnostic in different tumor entities. Indocyane greene is a fluorescent molecule which emits a light signal in the near infrared band after excitation. Our study aims to evaluate indocyanin green compared to the gold standard Tc-99m-nanocolloid.We report over a patient with an unifocal vaginal cancer. Sentinel diagnostic was carried out using Tc-99m-nanocolloid, indocyanin green and patent blue. After SPECT/CT, we examined each groin for light signals from the near infrared band, for radioactivity and for blue staining. A sentinel lymph node was defined as a Tc99m-nanocolloide positive lymph node. All sentinel lymph nodes and all additional blue or fluorescent lymph nodes were excised and tested; then sent to histologic examination.The procedure could be accomplished without problems. We found four sentinel lymph nodes with indocyanin green fluorescence, which were positive for radioactivity from Tc-99m and therefore defined as sentinel lymph nodes. Two further lymph nodes, which showed positivity for indocyanin green signals, but not for Tc-99m were found in the left groin. The final tumor stage was pT1b, pN0 (0/6, 0/4 SLN). We saw no adverse events or complications in this patient.Our case report shows that near infrared fluorescence deriving from ICG is a promising approach for sentinel identification in vaginal cancer. If studies using sentinel lymphonodectomy will be planned, a combined approach using Tc-99m-nanocolloide and indocyanin green could be useful.

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Groin Recurrences in Node Negative Vulvar Cancer Patients After Sole Sentinel Lymph Node Dissection

Cited by 37 publications

References 19 publications

Should we really abandon inguinal lymphadenectomy in the treatment of vulvar cancer?

Should we really abandon inguinal lymphadenectomy in the treatment of vulvar cancer?

Sentinel Lymphadenectomy in Vulvar Cancer Using Near-Infrared Fluorescence From Indocyanine Green Compared With Technetium 99m Nanocolloid

Sentinel lymphonodectomy in early vaginal cancer using combined near infrared fluorescence from indocyanine green and technetium-99m nanocolloid – a first case report

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