Long-term outcomes of individualized management after sentinel lymph-node biopsy for vulvar cancer

Declining use of inguinofemoral lymphadenectomy in the treatment of clinically negative, pathologic node positive vulvar cancer

PURPOSE

The management of vulvar cancer with clinically negative groin lymph nodes but with positive sentinel lymph node biopsy (SLNB) is controversial, with options including inguinofemoral lymphadenectomy (IFL) and/or adjuvant chemotherapy and radiotherapy. We used the National Cancer Database (NCDB) to examine trends in the management of clinically node negative, pathologically node positive (cN-/pN+) patients.

METHODS

The NCDB was used to identify cN-/pN+ vulvar cancer patients. Demographic and clinical data were compared with chi-squared and Wilcoxon rank-sum tests. OS was analyzed with the Kaplan-Meier method and log-rank test. Cox proportional hazards regression was used to determine factors associated with OS.

RESULTS

A total of 885 cN-/pN+ vulvar cancer patients were identified between 2012 and 2016, during which the rate of SLNB alone increased from 3.6% to 11.7%, while the rate of IFL +/- SLNB decreased from 89.7% to 78.1% (p < 0.05). Radiation was used in 68.5% and 64.6% of the SLNB-alone and IFL +/- SLNB cohorts, respectively, with chemoradiation in 37.1% and 33.6%, respectively. OS was not different between patients who received SLNB-alone vs. IFL +/- SLNB (p = 0.644). Receipt of chemotherapy and radiation was associated with improved OS (p < 0.001).

CONCLUSIONS

Among cN-/pN+ vulvar cancer patients in the NCDB, the practice of performing IFL decreased over time as SLNB-alone became more common and the majority received radiation +/- chemotherapy. There was no difference in OS between SLNB-alone vs. IFL +/- SLNB. Patients treated with adjuvant chemoradiation had improved survival. Whether the favorable outcomes in the SLNB-alone cohort may be attributed to radiotherapy dose escalation or use of chemotherapy warrants further study.

Analysis of Short-Term Efficacy of Gasless Single-Port Laparoscopic Inguinal Lymphadenectomy Through Vulva Incision for Vulvar Cancer

Objective

To investigate the feasibility and short-term efficacy of gasless single-port laparoscopic inguinal lymphadenectomy through vulva incision (VEIL-V).

Methods

The data of 9 patients diagnosed as vulvar squamous cell carcinoma who underwent single-port laparoscopic inguinal lymph node dissection through vulvectomy incision were retrospectively analyzed. And 13 patients who underwent laparoscopic inguinal lymph node dissection through lower abdominal subcutaneous approach as the control group (VEIL-H). The operation time, blood loss, numbers of unilateral lymph nodes, hospitalization time, and complications between the two groups were compared.

Results

The operation time of VEIL-V was 56.11 ± 5.94 min, which were shorter than that of VEIL-H (74.62 ± 5.50 min; P = 0.013). Bleeding amount in the VEIL-H was 29.44 ± 2.56, which was significantly lower than that of the VEIL-H group (43.08 ± 4.14 ml; P = 0.021). In the two groups, the numbers of unilateral lymph nodes harvested were similar. The differences in the postoperative hospital stay, skin, and lymphatic complications were not statistically significant.

Conclusion

Compared with VEIL-H, gasless single-port laparoscopic inguinal lymphadenectomy through vulva incision reduces the difficulty of operation with shorter operation time, and less blood loss, which can be a safe and mini-invasive surgical approach.

Indocyanine green fluorescent image-guided inguinal sentinel lymph node biopsy in vulvar cancer

Objective

To demonstrate near-infrared fluorescence image-guided inguinal sentinel lymph node (SLN) biopsy in patients with vulvar cancer.

Methods

A 40-year-old woman with a 3-cm-sized palpable left vulvar mass was diagnosed with vulvar cancer on biopsy with protrusion into the vaginal cavity. Pelvic contrast-enhanced magnetic resonance imaging and F-18 fluorodeoxyglucose positron-emission tomography-computed tomography showed a small ulcerative enhancing lesion confined to the left vulva without distant metastasis. The patient was scheduled for radical vulvectomy with a left inguinal SLN biopsy. Indocyanine green was injected directly into the vulvar mass to map lymphatic drainage. A 4-cm-sized linear incision was made on the left inguinal crease, and the lymphatic channels of the left inguinal area were dissected under fluorescent image guidance using a 1588 Advanced Imaging Modalities Platform laparoscopic camera (Stryker, Kalamazoo, MI, USA).

Results

Fluorescence image-guided left inguinal SLN biopsy and radical vulvectomy were performed. The pathologic diagnosis confirmed vulvar adenoid cystic carcinoma with metastasis to the left inguinal lymph node (International Federation of Gynecology and Obstetrics stage IIIA). The patient was discharged without complications and received adjuvant radiotherapy.

Conclusion

This video demonstrates a successful ICG fluorescence image-guided left inguinal SLN biopsy in a vulvar cancer patient using a laparoscopic camera. Mapping of inguinal SLNs in patients with vulvar cancer may help in retaining surgical radicality while minimizing operative complications.