The potential risk of contralateral non-sentinel groin node metastasis in women with early primary vulvar cancer following unilateral sentinel node metastasis: a single center evaluation in University Hospital of Düsseldorf

Abstract

Background Since the introduction of sentinel node biopsy (SLNB) in unifocal vulvar cancer (diameter of < 4 cm) and unsuspicious groin lymph nodes, the morbidity rate of patients has significantly decreased globally. In contrast to SLNB, bilateral inguinofemoral lymphadenectomy (IFL) has been associated with increased risk of common morbidities. Current guidelines (NCCN, ESGO, RCOG, and German) recommend that in cases of unilaterally positive sentinel lymph node (SLN), bilateral IFL should be performed. However, two recent publications by Woelber et al. and Nica et al. contradict the current guideline, since a significant rate of positive non sentinel lymph nodes in IFL contralaterally was not observed [Woelber et al. 0% (p = 0/28) and Nica et al. 5.3% (p = 1/19)]. Methods A retrospective single-center analysis conducted in the University Hospital of Dusseldorf, evaluating vulvar cancer patients treated with SLNB from 2002 to 2018. Results 22.2% of women (n = 4/18) were found to have contralateral IFL groin metastasis after an initial diagnosis of unilateral SLN metastasis. The depth of tumor infiltrating cells correlated significantly and positively with the rate of incidence of groin metastasis (p = 0.0038). Conclusion Current guideline for bilateral IFL should remain as the standard management. Therefore, this depth may be taken into account as an indication for bilateral IFL. The management of VC and SLNB should be performed in a high volume center with an experienced team in marking SLN and performing the adequate surgical procedure. Well conducted counseling of the patients outlining advantages but also potential oncological risks of this technique especially concerning rate of groin recurrence is critical.

The Sentinel Lymph Node in Treatment Planning: A Narrative Review of Lymph-Flow-Guided Radiotherapy

“…Two retrospective monocentric studies suggested not treating contralateral groin, since they found very low rates of contralateral involvement: 0% (0/28) patients and 5.3% (1/19) patients, respectively [29,30]. However, a recent study reported a higher rate of contralateral involvement, at 22.2% (4/18) of patients, after an initial diagnosis of unilateral metastasis, supporting current guidelines in favor of contralateral prophylactic treatment by either lymphadenectomy or radiotherapy [31].…”

European Society of Gynaecological Oncology Guidelines for the Management of Patients with Vulvar Cancer - Update 2023

“…[86][87][88] In contrast, data from a single institution identified contralateral positivity in 22% (4/18). 89 A more recent larger (n=244), prospective study from the GROINSS-V trial group provides evidence to support the omission of further treatment to the unaffected groin, providing bilateral drainage has been identified for true midline tumors. The authors found the incidence of a non-sentinel, contralateral metastasis to be 2.9% (7/244; 95% CI 1.4% to 5.8%), comparable to the risk of groin recurrence after a negative SNL dissection.…”

Risk factors of non-sentinel lymph node metastasis in 443 breast cancer patients with sentinel lymph node-positive

“…[ 5 , 6 ] However many scholars challenge this paradigm and believe that ALND for patients with positive SLNs may be an excessive treatment, since 40% to 70% of breast cancer patients with SLN metastasis do not have non-sentinel lymph node (NSLN) metastasis. [ 7 – 9 ] The purpose of our study was to analyze the risk factors associated with NSLN metastasis in SLN-positive breast cancer patients.…”