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Published in Justin C. Konje, Complete Revision Guide for MRCOG Part 2, 2019
I Radical excision with bilateral inguinal lymphadenectomyThis is a rare vulval cancer. Histologically, it is usually a squamous carcinoma or adenocarcinoma. The current evidence base is insufficient to suggest different management from squamous tumours. The lesions are often deep-seated or likely to be associated with metastatic disease. The close proximity to the anal sphincter may necessitate partial resection with reconstruction and this may necessitate a defunctioning temporary colostomy. Any perimenopausal or postmenopausal woman with a persisting Bartholin abscess or cyst should be suspected of having a possible carcinoma. Appropriate biopsies and histological review should be undertaken. In general, these cancers have a poorer prognosis than squamous cell carcinoma of the vulva and often multiple treatment modalities are required. There are no data regarding the use of selective lymphadenectomy in Bartholin gland carcinoma. These patients will require bilateral inguinofemoral lymphadenectomy (because of the proximity of the gland to the midline). (British Gynaecological Cancer Society and The Royal College of Obstetricians and Gynaecologists, London, 2014)
Vulvar Cancer
Published in Malte Renz, Elisabeth J. Diver, Whitfield B. Growdon, Oliver Dorigo, Synopsis of Key Gynecologic Oncology Trials, 2019
Malte Renz, Elisabeth J. Diver, Whitfield B. Growdon, Oliver Dorigo
GROINSS-V-IICitation: NCT01500512, ongoingBackground: If sentinel lymph nodes are positive, patients typically undergo inguinofemoral lymph node dissection If lymph nodes with metastasis >5 mm, >1 intranodal metastasis and/or extranodal spread—postoperative external-beam radiotherapy recommendedDesign: Prospective trialTo investigate the safety of omitting inguinofemoral lymphadenectomy in SLN-positive patients and replacing it with adjuvant radiotherapy
Premalignant and malignant disease of the lower genital tract
Published in Helen Bickerstaff, Louise C Kenny, Gynaecology, 2017
Untreated groin lymph node metastases are invariably fatal but it is not possible to predict whether groin nodes are involved using current radiological techniques. The standard approach until recently has been to carry out full inguinofemoral lymphadenectomy; that is, to remove all the lymph nodes in the groin for all patients where the tumour depth of invasion exceeds 1 mm. Tumours with less than 1 mm depth of invasion are extremely unlikely to have groin node metastases (less than 5%). Lymph drainage for lateral vulval tumours is to the ipsilateral groin nodes, but lesions within 10 mm of the midline drain to nodes on either side of the groin, necessitating bilateral groin lymphadenectomy. Groin lymphadenectomy is a highly morbid procedure, associated with significant postoperative and long-term complications, including wound healing problems, infection, venous thromboembolism, prolonged hospital stay, lymphocyst and chronic lymphoedema. Since groin node metastases affect just 15% of patients undergoing surgery for vulval cancer, many women are being exposed to the unnecessary risks and long-term sequelae of groin lymphadenectomy without receiving any direct benefit from it.
Perineural Invasion as a Predictive Biomarker of Groin Metastases and Survival Outcomes in Vulvar Cancer: A Meta-Analysis
Published in Cancer Investigation, 2022
Vasilios Pergialiotis, Loukas Ferousis, Aggeliki Rouvali, Efstathia Liatsou, Dimitrios Haidopoulos, Alexandros Rodolakis, Nikolaos Thomakos
Vulvar cancer is the 4th most common gynecological malignancy accounting for approximately 3–5% of all gynecological cancers (1). Significant geographic and temporal variations are observed; however, it is estimated that as more women become vaccinated against human papilloma virus (HPV), its incidence will gradually fall within the next decade (2). The American Cancer Society reported about 6190 new cases of invasive VC and about 1200 related deaths in the United States in 2018 (3). Squamous cell carcinoma (SCC) is the most common type, with an age-related incidence ranging from four cases every one million among women in their 30 s to around 200 every one million among women older than 70 years old (4). Surgery is the gold standard of treatment for most tumors, ranging from wide local excision to radical vulvectomy with inguinofemoral lymphadenectomy or sentinel lymph node biopsy in selected cases (5,6). Adjuvant chemotherapy and radiotherapy are used to prevent recurrence and improve surgical outcomes for patients with vulvar SCC. However, the recurrence and mortality rates remain as high as 40% and the 5-year survival rate in patients with locally advanced disease ranges between 30 and 50% (6).
Use of Negative Pressure Wound Therapy Systems after Radical Vulvectomy for Advanced Vulvar Cancer
Published in Cancer Investigation, 2020
Vittorio Quercia, Gabriele Saccone, Antonio Raffone, Antonio Travaglino, Mariano Favale, Pietro D’Alessandro, Bruno Arduino, Ilma Floriana Carbone, Luigi Insabato, Diego Ribuffo, Fulvio Zullo
All women included in the study received en Bloc radical vulvectomy with complete bilateral inguinofemoral lymphadenectomy. The vulvectomy was performed to remove the primary lesion to the depth of the perineal fascia with a 2-cm circumferential margin.
Sentinel lymph node biopsy based on anatomical landmarks and locoregional mapping of inguinofemoral sentinel lymph nodes in women with vulval cancer: an operative technique
Published in Journal of Obstetrics and Gynaecology, 2023
Fong Lien Kwong, Miski Scerif, Jason KW Yap
Vulval cancer accounts for 3–5% of all gynaecological cancers with over 90% of histological subtypes being comprised of squamous cell cancer (VSCC). Inguinal lymph node involvement is the strongest predictor of mortality (Morrison et al.2020) and the gold standard treatment involves a radical excision of the tumour and inguinofemoral lymphadenectomy, except in FIGO stage 1a disease where the risk of inguinal nodal metastasis is less than 1% (Hacker and Van Der Velden, 1993). The risk of occult nodal involvement in women with stage 1b disease is approximately 30% and nodal staging is therefore recommended in this population. Traditionally, unilateral or bilateral complete lymphadenectomy was the standard of care to assess for nodal metastasis in women with vulval cancer. Unfortunately, total inguinofemoral lymphadenectomy is associated with significant morbidity in up to 70% of cases, usually manifest in the form of lower limb lymphoedema which may persist as a lifelong indisposition in some subjects (Giannini et al. 2022). Furthermore, nearly two-thirds of women with vulval cancer are aged over 65 and thusly present with multiple medical co-morbidities including frailty (Corrado and Garganese, 2022). Inguinal sentinel lymph node (SLN) biopsy was subsequently proposed as an alternative diagnostic approach to triage women into those who mandate a total lymphadenectomy and those who do not and is now the standardised treatment for early-stage VSCC following results from a multicentre study (GROINSS-V) which have demonstrated the safety and accuracy of this technique (Te Grootenhuis et al.2016). The premise for this approach is that lymphatic drainage from the vulva follows a non-random fashion and cancer metastases usually spread to the SLN first. All studies to date have largely concentrated on the safety of SLN biopsies on oncological outcomes or establishing the role of various factors which could impact its detection rate including the use of different dyes and histopathological examination techniques (Meads et al.2014, Wang et al.2022). In contrast, the surgical technique for SLN biopsy or the role of SLN mapping has received less attention and there is a lack of standardised surgical methods for harvesting SLNs. Herein, we describe a technique whereby we rely on the anatomical landmarks to facilitate easy and quick access to SLNs so that surgical time and morbidity associated with ‘over-harvesting’ of lymph nodes can be minimised. Our technique is based on the assumption that the location of the long saphenous vein remains consistent even in obese subjects and thus serves as an important marker for orientation. For our operations, only Technetium-99 is used and all our patients undergo a SPECT-CT scan prior to their surgery. We performed a prospective study to define the territorial distribution of the inguinofemoral SLNs relative to the long saphenous vein. To the best of our knowledge, there are no other studies describing the mapping of groin SLN in vulval cancer following the publication of results from the GROINSS-V study.