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Pennington E, Bell S, Hill JE. Should video laryngoscopy or direct laryngoscopy be used for adults undergoing endotracheal intubation in the pre-hospital setting? A critical appraisal of a systematic review. JOURNAL OF PARAMEDIC PRACTICE : THE CLINICAL MONTHLY FOR EMERGENCY CARE PROFESSIONALS 2023; 15:255-259. [PMID: 38812899 PMCID: PMC7616025 DOI: 10.1002/14651858] [Citation(s) in RCA: 2444] [Impact Index Per Article: 2444.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The safety and utility of endotracheal intubation by paramedics in the United Kingdom is a matter of debate. Considering the controversy surrounding the safety of paramedic-performed endotracheal intubation, any interventions that enhance patient safety should be evaluated for implementation based on solid evidence of their effectiveness. A systematic review performed by Hansel and colleagues (2022) sought to assess compare video laryngoscopes against direct laryngoscopes in clinical practice. This commentary aims to critically appraise the methods used within the review by Hansel et al (2022) and expand upon the findings in the context of clinical practice.
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Affiliation(s)
| | - Steve Bell
- Consultant Paramedic, North West Ambulance Service NHS Trust
| | - James E Hill
- University of Central Lancashire, Colne, Lancashire
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2
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Schwab R, Stewen K, Bührer TL, Schmidt MW, van der Ven J, Anic K, Linz VC, Hamoud BH, Brenner W, Peters K, Heimes AS, Almstedt K, Krajnak S, Weikel W, Battista MJ, Dannecker C, Hasenburg A. Current Approaches to the Management of Sentinel Node Procedures in Early Vulvar Cancer in Germany: A Web-Based Nationwide Analysis of Practices. J Clin Med 2023; 12:jcm12052048. [PMID: 36902834 PMCID: PMC10004173 DOI: 10.3390/jcm12052048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/20/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Lymph node involvement is the most important prognostic factor for recurrence and survival in vulvar cancer. Sentinel node (SN) procedure can be offered in well-selected patients with early vulvar cancer. This study aimed to assess current management practices with respect to the sentinel node procedure in women with early vulvar cancer in Germany. METHODS A Web-based survey was conducted. Questionnaires were e-mailed to 612 gynecology departments. Data were summarized as frequencies and analyzed using the chi-square test. RESULTS A total of 222 hospitals (36.27%) responded to the invitation to participate. Among the responders, 9.5% did not offer the SN procedure. However, 79.5% evaluated SNs by ultrastaging. In vulvar cancer of the midline with unilateral localized positive SN, 49.1% and 48.6% of respondents, respectively, would perform ipsilateral or bilateral inguinal lymph node dissection. Repeat SN procedure was performed by 16.2% of respondents. For isolated tumor cells (ITCs) or micrometastases, 28.1% and 60.5% of respondents, respectively, would perform inguinal lymph node dissection, whereas 19.3% and 23.8%, respectively, would opt for radiation without further surgical intervention. Notably, 50.9% of respondents would not initiate any further therapy and 15.1% would opt for expectant management. CONCLUSIONS The majority of German hospitals implement the SN procedure. However, only 79.5% of respondents performed ultrastaging and only 28.1% were aware that ITC may affect survival in vulvar cancer. There is a need to ensure that the management of vulvar cancer follows the latest recommendations and clinical evidence. Deviations from state-of-the-art management should only be after a detailed discussion with the concerned patient.
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Affiliation(s)
- Roxana Schwab
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
- Correspondence:
| | - Kathrin Stewen
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Theresa-Louise Bührer
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Mona W. Schmidt
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Josche van der Ven
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Katharina Anic
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Valerie C. Linz
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Bashar Haj Hamoud
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany
| | - Walburgis Brenner
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Katharina Peters
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Anne-Sophie Heimes
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Katrin Almstedt
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Slavomir Krajnak
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Wolfgang Weikel
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Marco J. Battista
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Christian Dannecker
- Department of Gynecology and Obstetrics, University Medical Center Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany
| | - Annette Hasenburg
- Department of Gynecology and Obstetrics, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany
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Groin Surveillance by Serial Ultrasonography Rather Than Sentinel Node Biopsy or Inguinofemoral Lymphadenectomy for Patients with Vulvar Cancer: A Pilot Study. Cancers (Basel) 2023; 15:cancers15030831. [PMID: 36765789 PMCID: PMC9913428 DOI: 10.3390/cancers15030831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/21/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
A pilot study was conducted to determine whether 3-monthly groin ultrasonography could eliminate groin dissection after a negative bilateral groin ultrasound in three groups of patients: (i) Those with a unifocal stage 1B squamous cell carcinoma of up to 20 mm in diameter. (ii) Those with an ipsilateral squamous cell carcinoma of any size which extended to within 1 cm either side of the midline. These patients underwent ipsilateral inguinofemoral lymphadenectomy and ultrasonic surveillance of the contralateral groin. (iii) Patients with multifocal invasive lesions with the largest individual focus 20 mm or less in diameter. Three additional patients were added because they either refused groin dissection or were considered unfit for surgery. All ultrasonically positive nodes were confirmed histologically. Thirty-two patients were entered, and no patients were lost to follow-up. Forty-three groins were followed. With a median follow-up of 37 months, three positive nodes (9.4%) were detected. One patient died of her recurrence (3.1%), and 39 groins (90.7%) were preserved. The overall sensitivity of ultrasonic surveillance was 100% (95% CI: 44-100%), with a specificity of 97% (95% CI: 83-99%) and a negative predictive value of 100% (95% CI: 88-100%). This pilot justifies a larger study on serial ultrasonography in lieu of groin dissection in selected patients with vulvar cancer.
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4
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Verri D, Moro F, Fragomeni SM, Zaçe D, Bove S, Pozzati F, Gui B, Scambia G, Testa AC, Garganese G. The Role of Ultrasound in the Evaluation of Inguinal Lymph Nodes in Patients with Vulvar Cancer: A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14133082. [PMID: 35804853 PMCID: PMC9265034 DOI: 10.3390/cancers14133082] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/19/2022] [Accepted: 06/19/2022] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Currently, around 30% of vulvar cancer cases at first diagnosis are spread to the inguinal lymph nodes. Preoperative staging of patients affected by vulvar carcinoma is still a hot topic. To date, MRI has shown a great diagnostic accuracy on defining disease extension to soft tissue and deep organs. At present, regarding the study of inguinal nodes, the PET/CT scan has shown a high negative predictive value, although in the presence of a suspicious/positive report it should be taken with caution. We report the results of a study aimed to investigate the role of groin ultrasound in the assessment of lymph nodal status in vulvar cancer. Furthermore, this review represents the most accurate collection of papers available in the literature. This work demonstrates that groin ultrasound can be considered a valuable tool for risk assessment of the presence of groin lymph node metastases. Achieving a high diagnostic accuracy would allow tailored surgical planning with access to minimally invasive surgery techniques for an increasing number of patients. Abstract Objective. To determine the efficacy of ultrasound in assessing the inguinal lymph nodes in patients with vulvar cancer. Methods. A systematic review of published research up to October 2020 that compares the results of ultrasound to determine groin node status with histology was conducted. All study types that reported primary data on the role of ultrasound in the evaluation of groin lymph nodes in vulvar cancer were included in the systematic review. Data retrieved from the included studies were pooled in random-effects meta-analyses. Results. After the screening and selection process, eight articles were deemed pertinent for inclusion in the systematic review and meta-analysis. The random-effects model showed a pooled Se of 0.85 (95% CI: 0.81–0.89), Sp of 0.86 (95% CI: 0.81–0.91), PPV of 0.65 (95% CI: 0.54–0.79) and NPV of 0.92 (95% CI: 0.91–0.94). There was a pooled LR+ and LR− of 6.44 (95% CI: 3.72–11.4) and 0.20 (95% CI: 0.14–0.27), respectively. The pooled accuracy was 0.85 (95% CI: 0.80–0.91). Conclusions. Although the studies had small sample sizes, this review represents the best summary of the data so far. Ultrasound has revealed high sensitivity and high negative predictive value in the assessment of nodal status in vulvar cancer.
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Affiliation(s)
- Debora Verri
- Gynecology and Breast Care Center, Mater Olbia Hospital, 07026 Olbia, Italy; (D.V.); (S.B.); (G.G.)
| | - Francesca Moro
- Unità di Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (F.M.); (F.P.); (G.S.); (A.C.T.)
| | - Simona Maria Fragomeni
- Unità di Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (F.M.); (F.P.); (G.S.); (A.C.T.)
- Correspondence: ; Tel.: +39-3669392149; Fax: +39-0630156279
| | - Drieda Zaçe
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Sonia Bove
- Gynecology and Breast Care Center, Mater Olbia Hospital, 07026 Olbia, Italy; (D.V.); (S.B.); (G.G.)
| | - Federica Pozzati
- Unità di Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (F.M.); (F.P.); (G.S.); (A.C.T.)
| | - Benedetta Gui
- Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Giovanni Scambia
- Unità di Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (F.M.); (F.P.); (G.S.); (A.C.T.)
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Antonia Carla Testa
- Unità di Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (F.M.); (F.P.); (G.S.); (A.C.T.)
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Giorgia Garganese
- Gynecology and Breast Care Center, Mater Olbia Hospital, 07026 Olbia, Italy; (D.V.); (S.B.); (G.G.)
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
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Virarkar M, Vulasala SS, Daoud T, Javadi S, Lall C, Bhosale P. Vulvar Cancer: 2021 Revised FIGO Staging System and the Role of Imaging. Cancers (Basel) 2022; 14:2264. [PMID: 35565394 PMCID: PMC9102312 DOI: 10.3390/cancers14092264] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 01/27/2023] Open
Abstract
Vulvar cancer is a rare gynecological malignancy. It constitutes 5-8% of all gynecologic neoplasms, and squamous cell carcinoma is the most common variant. This article aims to review the etiopathogenesis revised 2021 International Federation of Gynecology and Obstetrics (FIGO) classification and emphasize imaging in the staging of vulvar cancer. The staging has been regulated by FIGO since 1969 and is subjected to multiple revisions. Previous 2009 FIGO classification is limited by the prognostic capability, which prompted the 2021 revisions and issue of a new FIGO classification. Although vulvar cancer can be visualized clinically, imaging plays a crucial role in the staging of the tumor, assessing the tumor extent, and planning the management. In addition, sentinel lymph node biopsy facilitates the histopathological staging of the draining lymph node, thus enabling early detection of tumor metastases and better survival rates.
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Affiliation(s)
- Mayur Virarkar
- Department of Diagnostic Radiology, University of Florida College of Medicine, 655 West 8th Street, C90, 2nd Floor, Clinical Center, Jacksonville, FL 32209, USA; (M.V.); (C.L.)
| | - Sai Swarupa Vulasala
- Department of Diagnostic Radiology, University of Florida College of Medicine, 655 West 8th Street, C90, 2nd Floor, Clinical Center, Jacksonville, FL 32209, USA; (M.V.); (C.L.)
| | - Taher Daoud
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA; (T.D.); (S.J.); (P.B.)
| | - Sanaz Javadi
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA; (T.D.); (S.J.); (P.B.)
| | - Chandana Lall
- Department of Diagnostic Radiology, University of Florida College of Medicine, 655 West 8th Street, C90, 2nd Floor, Clinical Center, Jacksonville, FL 32209, USA; (M.V.); (C.L.)
| | - Priya Bhosale
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA; (T.D.); (S.J.); (P.B.)
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6
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Nikolić O, Sousa FAE, Cunha TM, Nikolić MB, Otero-García MM, Gui B, Nougaret S, Leonhardt H. Vulvar cancer staging: guidelines of the European Society of Urogenital Radiology (ESUR). Insights Imaging 2021; 12:131. [PMID: 34550489 PMCID: PMC8458511 DOI: 10.1186/s13244-021-01075-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 08/11/2021] [Indexed: 12/02/2022] Open
Abstract
Objective The aim of the Female Pelvic Imaging Working Group of the European Society of Urogenital Radiology (ESUR) was to develop imaging staging guidelines for vulvar cancer and to propose standardised MRI protocols and reporting. Methods The guidelines recommended from the ESUR in this article resulted from a questionnaire analysis regarding imaging staging of vulvar cancer that was answered by all members of the Female Pelvic Imaging Working Group. Only the answers with an agreement equal to or more than 80% were considered. Additionally, the literature was reviewed to complement and further support our conclusions. Results The critical review of the literature and consensus obtained among experts allows for recommendations regarding imaging staging guidelines, patient preparation, MRI protocol, and a structured MRI report. Conclusions Standardising image acquisition techniques and MRI interpretation reduces ambiguity and ultimately improves the contribution of radiology to the staging and management of patients with vulvar cancer. Moreover, structured reporting assists with the communication of clinically relevant information to the referring physician.
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Affiliation(s)
- Olivera Nikolić
- Center of Radiology, Clinical Center of Vojvodina, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 1-9, 21000, Novi Sad, Serbia
| | - Filipa Alves E Sousa
- Department of Radiology, Centro Hospitalar Universitário de Lisboa Central, Alameda Santo António Dos Capuchos, 1169-050, Lisboa, Portugal.
| | - Teresa Margarida Cunha
- Department of Radiology, Instituto Português de Oncologia de Lisboa Francisco Gentil, R. Prof. Lima Basto, 1099-023, Lisbon, Portugal
| | - Marijana Basta Nikolić
- Center of Radiology, Clinical Center of Vojvodina, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 1-9, 21000, Novi Sad, Serbia
| | | | - Benedetta Gui
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Radiologia Generale Ed Interventistica Generale, Area Diagnostica Per Immagini, Dipartimento Diagnostica Per Immagini, Radioterapia Oncologica ed Ematologia, Rome, Italy
| | - Stephanie Nougaret
- Department of Radiology, Montpellier Cancer Institute, 15 INSERM, Montpellier Cancer Research Institute, U1194, University of Montpellier, 208 Avenue des Apothicaires, 34295, Montpellier, France
| | - Henrik Leonhardt
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska University Hospital, Bruna straket 11B, 413 45, Gothenburg, Sweden
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7
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Fischerova D, Garganese G, Reina H, Fragomeni SM, Cibula D, Nanka O, Rettenbacher T, Testa AC, Epstein E, Guiggi I, Frühauf F, Manegold G, Scambia G, Valentin L. Terms, definitions and measurements to describe sonographic features of lymph nodes: consensus opinion from the Vulvar International Tumor Analysis (VITA) group. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:861-879. [PMID: 34077608 DOI: 10.1002/uog.23617] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/29/2020] [Accepted: 02/08/2021] [Indexed: 06/12/2023]
Abstract
In centers with access to high-end ultrasound machines and expert sonologists, ultrasound is used to detect metastases in regional lymph nodes from melanoma, breast cancer and vulvar cancer. There is, as yet, no international consensus on ultrasound assessment of lymph nodes in any disease or medical condition. The lack of standardized ultrasound nomenclature to describe lymph nodes makes it difficult to compare results from different ultrasound studies and to find reliable ultrasound features for distinguishing non-infiltrated lymph nodes from lymph nodes infiltrated by cancer or lymphoma cells. The Vulvar International Tumor Analysis (VITA) collaborative group consists of gynecologists, gynecologic oncologists and radiologists with expertise in gynecologic cancer, particularly in the ultrasound staging and treatment of vulvar cancer. The work herein is a consensus opinion on terms, definitions and measurements which may be used to describe inguinal lymph nodes on grayscale and color/power Doppler ultrasound. The proposed nomenclature need not be limited to the description of inguinal lymph nodes as part of vulvar cancer staging; it can be used to describe peripheral lymph nodes in general, as well as non-peripheral (i.e. parietal or visceral) lymph nodes if these can be visualized clearly. The association between the ultrasound features described here and histopathological diagnosis has not yet been established. VITA terms and definitions lay the foundations for prospective studies aiming to identify ultrasound features typical of metastases and other pathology in lymph nodes and studies to elucidate the role of ultrasound in staging of vulvar and other malignancies. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D Fischerova
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - G Garganese
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
- Dipartimento Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - H Reina
- Department of Gynecological Ultrasound and Prenatal Diagnostics, Women's Hospital, University Hospital of Basel, Basel, Switzerland
| | - S M Fragomeni
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - D Cibula
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - O Nanka
- Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - T Rettenbacher
- Department Radiologie, Universitäts Klinik für Radiologie II, Innsbruck, Austria
| | - A C Testa
- Dipartimento Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - E Epstein
- Department of Clinical Science and Education, Karolinska Institute, Sodersjukhuset, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Sodersjukhuset, Stockholm, Sweden
| | - I Guiggi
- Department of Obstetrics and Gynecology, North West Tuscany Hospital, Livorno, Italy
| | - F Frühauf
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - G Manegold
- Department of Gynecological Ultrasound and Prenatal Diagnostics, Women's Hospital, University Hospital of Basel, Basel, Switzerland
| | - G Scambia
- Dipartimento Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - L Valentin
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
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8
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Lakhman Y, Vargas HA, Reinhold C, Akin EA, Bhosale PR, Huang C, Kang SK, Khanna N, Kilcoyne A, Nicola R, Paspulati R, Rauch GM, Shinagare AB, Small W, Glanc P. ACR Appropriateness Criteria® Staging and Follow-up of Vulvar Cancer. J Am Coll Radiol 2021; 18:S212-S228. [PMID: 33958115 DOI: 10.1016/j.jacr.2021.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/21/2022]
Abstract
Vulvar cancer is an uncommon gynecologic tumor and one of several human papillomavirus-associated malignancies. Squamous cell carcinoma is the most prevalent histologic subtype of vulvar cancer, accounting for the majority of cases. Imaging plays an important role in managing vulvar cancer. At initial diagnosis, imaging is useful to assess the size and extent of primary tumor and to evaluate the status of inguinofemoral lymph nodes. If recurrent disease is suspected, imaging is essential to demonstrate local extent of tumor and to identify lymph node and distant metastases. In this publication, we summarize the recent literature and describe the panel's recommendations about the appropriate use of imaging for various phases of patient management including initial staging, surveillance, and restaging of vulvar cancer. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Yulia Lakhman
- Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Hebert Alberto Vargas
- Memorial Sloan Kettering Cancer Center, New York, New York, Chief, Body Imaging Service, Memorial Sloan Kettering Cancer Center
| | | | - Esma A Akin
- George Washington University Hospital, Washington, District of Columbia
| | | | - Chenchan Huang
- New York University Langone Medical Center, New York, New York
| | - Stella K Kang
- New York University Medical Center, New York, New York
| | - Namita Khanna
- Emory University, Atlanta, Georgia, Society of Gynecologic Oncology
| | | | - Refky Nicola
- Roswell Park Cancer Institute, Jacobs School of Medicine and Biomedical Science, Buffalo, New York
| | | | - Gaiane M Rauch
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Atul B Shinagare
- Brigham & Women's Hospital Dana-Farber Cancer Institute, Boston, Massachusetts
| | - William Small
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, Illinois, Professor and Chairman, Department of Radiation Oncology, Loyola University, Director, Cardinal Bernardin Cancer Center
| | - Phyllis Glanc
- Specialty Chair, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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9
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Garganese G, Fragomeni SM, Pasciuto T, Leombroni M, Moro F, Evangelista MT, Bove S, Gentileschi S, Tagliaferri L, Paris I, Inzani F, Fanfani F, Scambia G, Testa AC. Ultrasound morphometric and cytologic preoperative assessment of inguinal lymph-node status in women with vulvar cancer: MorphoNode study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:401-410. [PMID: 31237047 DOI: 10.1002/uog.20378] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 06/11/2019] [Accepted: 06/17/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To assess the accuracy of preoperative ultrasound examination for predicting lymph-node (LN) status in patients with vulvar cancer. METHODS This was a single-institution retrospective observational study of all women with a histological diagnosis of vulvar cancer triaged to inguinal surgery within 30 days following ultrasound evaluation between December 2010 and January 2016. For each groin examined, 15 morphological and dimensional sonographic parameters associated with suspicion for LN involvement were examined. A morphometric ultrasound pattern (MUP) was expressed for each groin, classifying the inguinal LN status into five groups (normal; reactive-but-negative; minimally suspicious/probably negative; moderately suspicious; and highly suspicious/positive) according to subjective judgment, followed by stratification as positive or negative for metastasis according to morphometric binomial assessment (MBA). In cases of positive MBA, fine-needle aspiration cytology was performed. Combining the information obtained from MUP and cytologic results, a binomial final overall assessment (FOA) was assigned for each groin. The final histology was considered as the reference standard. Comparison was performed between patients with negative and those with positive LNs on histology, and receiver-operating-characteristics curves were generated for statistically significant variables on univariate analysis, to evaluate their diagnostic ability to predict negative LN status. RESULTS Of 144 patients included in the analysis, 87 had negative inguinal LNs and 57 had positive LNs on histology. A total of 256 groins were analyzed, of which 171 were negative and 85 showed at least one metastatic LN on histology. The following parameters showed the greatest accuracy, with the best balance between specificity and sensitivity, in predicting negative LN status: cortical (C) thickness of the dominant LN (cut-off, 2.5 mm; sensitivity, 90.0%; specificity, 77.9%); short-axis (S) length of the dominant LN (cut-off, 8.4 mm; sensitivity, 63.9%; specificity, 90.6%); C/medulla (M) thickness ratio of the dominant LN (cut-off, 1.2 mm; sensitivity, 70.4%; specificity, 91.5%), the combination of S length and C/M thickness ratio (sensitivity, 88.9%; specificity, 82.4%); and the FOA analysis (sensitivity, 85.9%; specificity, 84.2%). CONCLUSIONS Preoperative ultrasound assessment, with or without the addition of cytology, has a high accuracy in assessing inguinal LN status in patients with vulvar cancer. In particular, the combination of two ultrasound parameters (S length and C/M thickness ratio) provided the greatest accuracy in discriminating between negative and positive LNs. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Garganese
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - S M Fragomeni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Unità di Ginecologia Oncologica, Rome, Italy
| | - T Pasciuto
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, STAR Center (Statistics Technology Archiving Research Center), Rome, Italy
| | - M Leombroni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Unità di Ginecologia Oncologica, Rome, Italy
| | - F Moro
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Unità di Ginecologia Oncologica, Rome, Italy
| | - M T Evangelista
- Ginecologia Oncologica, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - S Bove
- Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - S Gentileschi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Unità di Chirurgia Plastica, Rome, Italy
- Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - L Tagliaferri
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Rome, Italy
| | - I Paris
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Unità di Ginecologia Oncologica, Rome, Italy
| | - F Inzani
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Unità di Gineco-patologia e Patologia Mammaria, Rome, Italy
| | - F Fanfani
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Unità di Ginecologia Oncologica, Rome, Italy
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - G Scambia
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Unità di Ginecologia Oncologica, Rome, Italy
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - A C Testa
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Unità di Ginecologia Oncologica, Rome, Italy
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
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Ramanathan S, Tirumani SH, Ojili V. Nodal metastasis in gynecologic malignancies: Update on imaging and management. Clin Imaging 2020; 59:157-166. [DOI: 10.1016/j.clinimag.2019.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 10/25/2019] [Accepted: 11/14/2019] [Indexed: 01/18/2023]
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11
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Querleu D, Rychlik A, Guyon F, Floquet A, Planchamp F. [Management of the nodal disease in vulvar cancers. The ESGO guidelines]. Bull Cancer 2019; 107:715-720. [PMID: 31586525 DOI: 10.1016/j.bulcan.2019.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 06/15/2019] [Indexed: 11/15/2022]
Abstract
The European Society of Gynaecologic Oncology (ESGO) guidelines cover the whole field of common clinical situations in gynecologic oncology. Their elaboration follows a strict process including a systematic review of the literature, the setting up of a group of expert on the basis of scientific production, geographical balance, and multidisciplinarity, and an external review by users and patients. The recommendations for the management of vulvar cancer were elaborated in 2015 and published in 2017. They are available in open access on the ESGO website, and can be incorporated in clinical practice using the free ESGO guidelines smartphone application. This review is a selection of the sections addressing the diagnostic and strategical aspects of the management of lymph nodal disease in vulvar cancer. An additional review of the recent literature published since 2015 has been carried out. The management of nodal disease in vulvar cancer encompasses a diagnostic and a therapeutic component. Clinical and imaging assessment still play a major role, whilst the identification of the sentinel node is currently a mainstay of assessment of the nodal status in early vulvar cancer. The therapeutic component is based on the rational use of full lymph node dissection and (chemo)radiation.
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Affiliation(s)
- Denis Querleu
- Institut Bergonié, 229, cours de l'Argonne, 33000 Bordeaux, France.
| | | | - Frédéric Guyon
- Institut Bergonié, 229, cours de l'Argonne, 33000 Bordeaux, France
| | - Anne Floquet
- Institut Bergonié, 229, cours de l'Argonne, 33000 Bordeaux, France
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12
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Abstract
Vulvar carcinoma is an uncommon tumor that predominantly affects postmenopausal
women. Currently, there is no screening procedure for vulvar carcinoma; in most
cases, it is diagnosed only when symptoms appear. The most widely used staging
system is that developed by the International Federation of Gynecology and
Obstetrics. Lymph node status is the most important prognostic factor. We
searched the PubMed/Medline database to identify relevant English-language
articles on vulvar cancer, with a special focus on its imaging evaluation.
Magnetic resonance imaging is useful for local and nodal staging, as well as
facilitating the planning of surgical interventions and radiotherapy. Computed
tomography or positron-emission tomography/computed tomography can play an
important role in nodal and distant disease assessment, whereas ultrasound is
often used for image-guided biopsies. Imaging is pivotal for staging and
treatment planning in vulvar carcinoma.
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Affiliation(s)
- Maria Ana Serrado
- Radiology Department, Hospital Central do Funchal, Funchal, Portugal
| | - Mariana Horta
- Radiology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, Portugal
| | - Teresa Margarida Cunha
- Radiology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, Portugal
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13
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Garganese G, Bove S, Zagaria L, Moro F, Fragomeni SM, Ieria FP, Gentileschi S, Romeo P, Di Giorgio D, Giordano A, Scambia G, Testa AC. Fusion of ultrasound and 3D single-photon-emission computed tomography/computed tomography to identify sentinel lymph nodes in vulvar cancer: feasibility study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:545-551. [PMID: 31152573 DOI: 10.1002/uog.20364] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 05/23/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To evaluate the feasibility of fusion of ultrasound imaging and three-dimensional (3D) single-photon-emission computed tomography/computed tomography (SPECT/CT) in detecting sentinel lymph nodes in women with vulvar cancer. METHODS This was a prospective pilot single-center study. Patients with vulvar cancer who were candidates for sentinel lymph-node biopsy were enrolled between December 2018 and February 2019. Fusion imaging virtual navigation using 3D SPECT/CT and ultrasound was performed to investigate the tumor-draining lymph node. All clinical, imaging, surgical and histological information was collected prospectively and entered into a dedicated Excel file. Feasibility and success of fusion imaging virtual navigation and time needed to perform the three steps of fusion imaging were evaluated. RESULTS Ten lymph-node sites were evaluated in five consecutive women with a histological diagnosis of vulvar cancer. Fusion imaging virtual navigation was feasible and completed successfully for all (10/10) draining sites. Median overall time to perform fusion imaging was 32 (range, 25-40) min and the time decreased from the first to the last examination. CONCLUSIONS The present study demonstrated that fusion imaging virtual navigation using 3D SPECT/CT and ultrasound is feasible and able to detect sentinel lymph nodes in women with vulvar carcinoma. Fusion imaging using ultrasound for detection of sentinel lymph nodes opens up multiple diagnostic and therapeutic opportunities in gynecological oncology. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Garganese
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Area Salute della Donna, Rome, Italy
- Mater Olbia Hospital, Gynecology and Breast Care Center, Olbia, Italy
| | - S Bove
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Area Salute della Donna, Rome, Italy
- Mater Olbia Hospital, Gynecology and Breast Care Center, Olbia, Italy
| | - L Zagaria
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, UOC Medicina Nucleare, Rome, Italy
| | - F Moro
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Area Salute della Donna, Rome, Italy
| | - S M Fragomeni
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Area Salute della Donna, Rome, Italy
| | - F P Ieria
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, UOC Medicina Nucleare, Rome, Italy
| | - S Gentileschi
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Area Salute della Donna, Rome, Italy
| | - P Romeo
- Università Cattolica del Sacro Cuore, Istituto di Clinica Ostetrica e Ginecologica, Rome, Italy
| | - D Di Giorgio
- Mater Olbia Hospital, Gynecology and Breast Care Center, Olbia, Italy
| | - A Giordano
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, UOC Medicina Nucleare, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Medicina Nucleare, Rome, Italy
| | - G Scambia
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Area Salute della Donna, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Clinica Ostetrica e Ginecologica, Rome, Italy
| | - A C Testa
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Area Salute della Donna, Rome, Italy
- Università Cattolica del Sacro Cuore, Istituto di Clinica Ostetrica e Ginecologica, Rome, Italy
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14
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Angelico G, Santoro A, Inzani F, Spadola S, Fiorentino V, Cianfrini F, Carbone C, Garganese G, Rossi ED, Scambia G, Zannoni GF. Ultrasound‐guided FNA cytology of groin lymph nodes improves the management of squamous cell carcinoma of the vulva: Results from a comparative cytohistological study. Cancer Cytopathol 2019; 127:514-520. [DOI: 10.1002/cncy.22154] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/03/2019] [Accepted: 05/03/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Giuseppe Angelico
- Department of Woman and Child Health and Public Health, Pathology Area Agostino Gemelli University Hospital Foundation, Scientific Institute for Research and Healthcare Rome Italy
| | - Angela Santoro
- Department of Woman and Child Health and Public Health, Pathology Area Agostino Gemelli University Hospital Foundation, Scientific Institute for Research and Healthcare Rome Italy
| | - Frediano Inzani
- Department of Woman and Child Health and Public Health, Pathology Area Agostino Gemelli University Hospital Foundation, Scientific Institute for Research and Healthcare Rome Italy
| | - Saveria Spadola
- Department of Woman and Child Health and Public Health, Pathology Area Agostino Gemelli University Hospital Foundation, Scientific Institute for Research and Healthcare Rome Italy
| | - Vincenzo Fiorentino
- Department of Woman and Child Health and Public Health, Pathology Area Agostino Gemelli University Hospital Foundation, Scientific Institute for Research and Healthcare Rome Italy
| | - Federica Cianfrini
- Department of Woman and Child Health and Public Health, Pathology Area Agostino Gemelli University Hospital Foundation, Scientific Institute for Research and Healthcare Rome Italy
| | - Claudia Carbone
- Department of Woman and Child Health and Public Health, Pathology Area Agostino Gemelli University Hospital Foundation, Scientific Institute for Research and Healthcare Rome Italy
| | - Giorgia Garganese
- Department of Woman and Child Health and Public Health, Woman Health Area Agostino Gemelli University Hospital Foundation and Catholic University of the Sacred Heart, Scientific Institute for Research and Healthcare Rome Italy
| | - Esther D. Rossi
- Department of Woman and Child Health and Public Health, Pathology Area Agostino Gemelli University Hospital Foundation, Scientific Institute for Research and Healthcare Rome Italy
| | - Giovanni Scambia
- Department of Woman and Child Health and Public Health, Woman Health Area Agostino Gemelli University Hospital Foundation and Catholic University of the Sacred Heart, Scientific Institute for Research and Healthcare Rome Italy
| | - Gian F. Zannoni
- Department of Woman and Child Health and Public Health, Pathology Area Agostino Gemelli University Hospital Foundation, Scientific Institute for Research and Healthcare Rome Italy
- Department of Woman and Child Health and Public Health, Woman Health Area Agostino Gemelli University Hospital Foundation and Catholic University of the Sacred Heart, Scientific Institute for Research and Healthcare Rome Italy
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15
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Abstract
OBJECTIVE The role of imaging in patients with suspected gynecologic malignancies is to provide an accurate diagnosis to achieve the best and most tailored treatment plan. Uncommon cancers pose a distinct challenge, because current knowledge of these diseases is still limited. Our purpose is to highlight the role of cross-sectional imaging techniques, including ultrasound, CT, MRI, and PET/CT, in the diagnosis and pretreatment stratification of patients with rare gynecologic cancers. CONCLUSION This review shows the relevance of imaging findings for diagnosis, staging, and treatment planning in patients with uncommon uterine, cervical, vaginal, vulvar, and ovarian cancers.
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Paño B, Sebastià C, Ripoll E, Paredes P, Salvador R, Buñesch L, Nicolau C. Pathways of lymphatic spread in gynecologic malignancies. Radiographics 2016; 35:916-45. [PMID: 25969940 DOI: 10.1148/rg.2015140086] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Precise radiologic evaluation of regional adenopathic involvement in pelvic gynecologic tumors is fundamental to clinical practice because of its prognostic and therapeutic significance. Likewise, the identification of metastatic adenopathies at posttreatment imaging is essential for assessing response and detecting recurrence. Similar to urologic neoplasms, gynecologic neoplasms most often spread regionally to the pelvic and retroperitoneal lymph nodes, following the normal drainage pathways of the pelvic organs. Familiarity with routes of dissemination, treatment options, and means of analyzing lymph node characteristics is crucial to determine the extent of disease. Two staging systems can be used in characterizing gynecologic malignancies: the FIGO (International Federation of Gynecology and Obstetrics) system, which is the most commonly and universally used, and the TNM (tumor, node, metastasis) system, which is based on clinical and/or pathologic classification. Anatomic assessment with multidetector computed tomography (CT) and magnetic resonance (MR) imaging is still the most commonly used technique for the detection of lymph node spread, which is mainly based on morphologic criteria, the most important of which is nodal size. However, size has limited diagnostic specificity. Consequently, functional imaging techniques such as diffusion-weighted MR imaging, positron emission tomography combined with CT, lymphoscintigraphy, and sentinel lymph node mapping, which are based on molecular and physiologic activity and allow more precise evaluation, are often incorporated into diagnostic imaging protocols for staging of gynecologic malignancies.
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Affiliation(s)
- Blanca Paño
- From the CDIC, Departments of Radiology (B.P., C.S., E.R., R.S., L.B., C.N.) and Nuclear Medicine (P.P.), Hospital Clínic de Barcelona, Villarroel 170, 08036 Barcelona, Spain
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Computed tomography, magnetic resonance imaging and FDG positron emission tomography in the management of vulvar malignancies. Eur Radiol 2014; 25:1267-78. [PMID: 25477274 DOI: 10.1007/s00330-014-3530-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/11/2014] [Accepted: 11/19/2014] [Indexed: 01/16/2023]
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Lawrie TA, Patel A, Martin‐Hirsch PPL, Bryant A, Ratnavelu NDG, Naik R, Ralte A. Sentinel node assessment for diagnosis of groin lymph node involvement in vulval cancer. Cochrane Database Syst Rev 2014; 2014:CD010409. [PMID: 24970683 PMCID: PMC6457826 DOI: 10.1002/14651858.cd010409.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Vulval cancer is usually treated by wide local excision with removal of groin lymph nodes (inguinofemoral lymphadenectomy) from one or both sides, depending on the tumour location. However, this procedure is associated with significant morbidity. As lymph node metastasis occurs in about 30% of women with early vulval cancer, accurate prediction of lymph node metastases could reduce the extent of surgery in many women, thereby reducing morbidity. Sentinel node assessment is a diagnostic technique that uses traceable agents to identify the spread of cancer cells to the lymph nodes draining affected tissue. Once the sentinel nodes are identified, they are removed and submitted to histological examination. This technique has been found to be useful in diagnosing the nodal involvement of other types of tumours. Sentinel node assessment in vulval cancer has been evaluated with various tracing agents. It is unclear which tracing agent or combination of agents is most accurate. OBJECTIVES To assess the diagnostic test accuracy of various techniques using traceable agents for sentinel lymph node assessment to diagnose groin lymph node metastasis in women with FIGO stage IB or higher vulval cancer and to investigate sources of heterogeneity. SEARCH METHODS We searched MEDLINE (1946 to February 2013), EMBASE (1974 to March 2013) and the relevant Cochrane trial registers. SELECTION CRITERIA Studies that evaluated the diagnostic accuracy of traceable agents for sentinel node assessment (involving the identification of a sentinel node plus histological examination) compared with histological examination of removed groin lymph nodes following complete inguinofemoral lymphadenectomy (IFL) in women with vulval cancer, provided there were sufficient data for the construction of two-by-two tables. DATA COLLECTION AND ANALYSIS Two authors (TAL, AP) independently screened titles and abstracts for relevance, classified studies for inclusion/exclusion and extracted data. We assessed the methodological quality of studies using the QUADAS-2 tool. We used univariate meta-analytical methods to estimate pooled sensitivity estimates. MAIN RESULTS We included 34 studies evaluating 1614 women and approximately 2396 groins. The overall methodological quality of included studies was moderate. The studies included in this review used the following traceable techniques to identify sentinel nodes in their participants: blue dye only (three studies), technetium only (eight studies), blue dye plus technetium combined (combined tests; 13 studies) and various inconsistent combinations of these three techniques (mixed tests; 10 studies). For studies of mixed tests, we obtained separate test data where possible.Most studies used haematoxylin and eosin (H&E) stains for the histological examination. Additionally an immunohistochemical (IHC) stain with and without ultrastaging was employed by 14 and eight studies, respectively. One study used reverse transcriptase polymerase chain reaction analysis (CA9 RT-PCR), whilst three studies did not describe the histological methods used.The pooled sensitivity estimate for studies using blue dye only was 0.94 (68 women; 95% confidence interval (CI) 0.69 to 0.99), for mixed tests was 0.91 (679 women; 95% CI 0.71 to 0.98), for technetium only was 0.93 (149 women; 95% CI 0.89 to 0.96) and for combined tests was 0.95 (390 women; 95% CI 0.89 to 0.97). Negative predictive values (NPVs) for all index tests were > 95%. Most studies also reported sentinel node detection rates (the ability of the test to identify a sentinel node) of the index test. The mean detection rate for blue dye alone was 82%, compared with 95%, 96% and 98% for mixed tests, technetium only and combined tests, respectively. We estimated the clinical consequences of the various tests for 100 women undergoing the sentinel node procedure, assuming the prevalence of groin metastases to be 30%. For the combined or technetium only tests, one and two women with groin metastases might be 'missed', respectively (95% CI 1 to 3); and for mixed tests, three women with groin metastases might be 'missed' (95% CI 1 to 9). The wide CIs associated with the pooled sensitivity estimates for blue dye and mixed tests increased the potential for these tests to 'miss' women with groin metastases. AUTHORS' CONCLUSIONS There is little difference in diagnostic test accuracy between the technetium and combined tests. The combined test may reduce the number of women with 'missed' groin node metastases compared with technetium only. Blue dye alone may be associated with more 'missed' cases compared with tests using technetium. Sentinel node assessment with technetium-based tests will reduce the need for IFL by 70% in women with early vulval cancer. It is not yet clear how the survival of women with negative sentinel nodes compares to those undergoing standard surgery (IFL). A randomised controlled trial of sentinel node dissection and IFL has methodological and ethical issues, therefore more observational data on the survival of women with early vulval cancer are needed.
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Affiliation(s)
- Theresa A Lawrie
- Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupEducation CentreBathUKBA1 3NG
| | - Amit Patel
- University Hospitals Bristol NHS Foundation TrustGynaecological OncologySt Michaels HospitalSouthwell StreetBristolUKBS2 8EG
| | - Pierre PL Martin‐Hirsch
- Royal Preston Hospital, Lancashire Teaching Hospital NHS TrustGynaecological Oncology UnitSharoe Green LaneFullwoodPrestonLancashireUKPR2 9HT
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Nithya DG Ratnavelu
- Northern Gynaecological Oncology CentreGynaecological OncologyQueen Elizabeth HospitalSheriff HillGatesheadTyne and WearUKNE9 6SX
| | - Raj Naik
- Northern Gynaecological Oncology CentreQueen Elizabeth HospitalGatesheadTyne and WearUKNE9 6SX
| | - Angela Ralte
- Queen Elizabeth HospitalPathology DepartmentGatesheadUKNE9 6SX
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van de Nieuwenhof HP, Oonk MHM, de Hullu JA, van der Zee AGJ. Vulvar squamous cell carcinoma. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.09.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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de Gregorio N, Ebner F, Schwentner L, Friedl TW, Deniz M, Látó K, Kreienberg R, Janni W, Varga D. The role of preoperative ultrasound evaluation of inguinal lymph nodes in patients with vulvar malignancy. Gynecol Oncol 2013; 131:113-7. [DOI: 10.1016/j.ygyno.2013.07.103] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 07/23/2013] [Accepted: 07/24/2013] [Indexed: 11/27/2022]
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Djajadiningrat RS, Teertstra HJ, van Werkhoven E, van Boven HH, Horenblas S. Ultrasound examination and fine needle aspiration cytology-useful for followup of the regional nodes in penile cancer? J Urol 2013; 191:652-5. [PMID: 23994372 DOI: 10.1016/j.juro.2013.08.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2013] [Indexed: 12/22/2022]
Abstract
PURPOSE Routine followup of the groins of patients with penile squamous cell carcinoma after primary treatment consists of physical examination together with ultrasound of the groins, followed by fine needle aspiration cytology if suspicious. We assessed the value of this routine followup. MATERIALS AND METHODS Using ultrasound and fine needle aspiration cytology we assessed 247 patients during followup who were treated from 2004 to 2010 and underwent dynamic sentinel node biopsy only or observation of the inguinal regions. A negative result was defined as no evidence of metastatic disease after at least 2 years of followup. We calculated the sensitivity, specificity, and positive and negative predictive values of ultrasound and ultrasound guided fine needle aspiration cytology using standard statistical methods. RESULTS Recurrence was diagnosed in 47 of 247 patients (55 groins). In 40 of 55 groins (73%) recurrence was detectable by physical examination. In 12 of 15 cases of nonpalpable recurrence (80%) ultrasound guided fine needle aspiration cytology revealed the recurrence. We considered 217 groins to be suspicious on ultrasound followed by fine needle aspiration cytology. Fine needle aspiration cytology revealed tumor in 49 groins and showed false-positive findings in 1 patient after negative completion lymphadenectomy. Sensitivity and specificity were 87.3% (48 of 55 cases) and 99.9% (1,304 of 1,305), respectively. CONCLUSIONS Although inguinal recurrence manifests clinically in most patients, ultrasound guided fine needle aspiration cytology detected 80% of metastatic disease in patients with nonpalpable disease. Therefore, it has great value for detecting lymph node metastases during followup.
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Affiliation(s)
| | - H Jelle Teertstra
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Erik van Werkhoven
- Department of Biometrics, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hester H van Boven
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Simon Horenblas
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Derdelis G, Zygouris D, Grigoriadis C, Terzakis E. Conservative Management of Vulvar Cancer Stages I–II: Past and Future. J Gynecol Surg 2011. [DOI: 10.1089/gyn.2010.0079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Grigorios Derdelis
- Second Department of Gynecology, Anticancer Hospital of Athens “Agios Savvas”, Athens, Greece
| | - Dimitrios Zygouris
- Second Department of Gynecology, Anticancer Hospital of Athens “Agios Savvas”, Athens, Greece
| | - Charalampos Grigoriadis
- Second Department of Gynecology, Anticancer Hospital of Athens “Agios Savvas”, Athens, Greece
| | - Emmanouil Terzakis
- Second Department of Gynecology, Anticancer Hospital of Athens “Agios Savvas”, Athens, Greece
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Fischerova D. Ultrasound scanning of the pelvis and abdomen for staging of gynecological tumors: a review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:246-266. [PMID: 21898632 DOI: 10.1002/uog.10054] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
This Review documents examination techniques, sonographic features and clinical considerations in ultrasound assessment of gynecological tumors. The methodology of gynecological cancer staging, including assessment of local tumor extent, lymph nodes and distant metastases, is described. With increased technical quality, sonography has become an accurate staging method for early and advanced gynecological tumors. Other complementary imaging techniques, such as computed tomography and magnetic resonance imaging, can be used as an adjunct to ultrasound in specific cases, but are not essential to tumor staging if sonography is performed by a specialist in gynecological oncology. Ultrasound is established as the method of choice for evaluating local extent of endometrial cancer and is the most important imaging method for the differential diagnosis of benign and malignant ovarian tumors. Ultrasound can be used to detect early as well as locally advanced cancers that extend from the vagina, cervix or other locations to the paracolpium, parametria, rectum and sigmoid colon, urinary bladder and other adjacent organs or structures. In cases of ureteric involvement, ultrasound is also helpful in locating the site of obstruction. Furthermore, it is specific for the detection of extrapelvic tumor spread to the abdominal cavity in the form of parietal or visceral carcinomatosis, omental and/or mesenteric infiltration. Ultrasound can be used to assess changes in infiltrated lymph nodes, including demonstration of characteristic sonomorphologic and vascular patterns. Vascular patterns are particularly well visualized in peripheral nodes using high resolution linear array probes or in the pelvis using high-frequency probes. The presence of peripheral or mixed vascularity or displacement of vessels seems to be the sole criterion in the diagnosis of metastatic or lymphomatous nodes. In the investigation of distant metastases, if a normal visceral organ or characteristic diffuse or focal lesions (such as a simple cyst, hepatic hemangioma, renal angiomyolipoma, fatty liver (steatosis)) are identified on ultrasound, additional examinations using complementary imaging methods are not required. If, however, less characteristic findings are encountered, especially when the examination result radically affects subsequent therapeutic management, an additional examination using a complementary imaging method (e.g. contrast-enhanced ultrasound, computed tomography, magnetic resonance imaging, positron emission tomography) is indicated.
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Affiliation(s)
- D Fischerova
- Gynecological Oncology Centre, Department of Obstetrics and Gynecology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
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Akrivos N, Rodolakis A, Vlachos G, Sotiropoulou M, Papantoniou V, Biliatis I, Haidopoulos D, Thomakos N, Simou M, Antsaklis A. Detection and credibility of sentinel node in vulvar cancer: a single institutional study and short review of literature. Arch Gynecol Obstet 2011; 284:1551-6. [PMID: 21465249 DOI: 10.1007/s00404-011-1884-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 03/10/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the detectability and credibility of sentinel lymph node (SLN) in vulvar cancer. METHODS With Tc99m-nanocolloid and methylene blue, we identified SLNs in 34 patients. In 27 cases both tracers were used, while in 7 only blue dye was used. Completion lymphadenectomy was performed in all patients. SLNs and non-SLNs were sent separately for pathologic evaluation. RESULTS At least one SLN was identified in all patients. Detection rate per groin was not significantly higher in the combined versus blue dye only technique (42/50 vs. 10/14, p = 0.43). 99m-Tc was not superior to blue dye in detecting SLN (42/50 vs. 50/64, p = 0.65). Midline location of the tumor did not seem to negatively affect the procedure. Four false negatives were observed in three patients with tumors >4 cm. Negative predictive value of SLN was 100% for grade I tumors ≤ 4 cm in patients ≤ 71 years. CONCLUSION Tc-99m does not seem to be superior to methylene blue in the detection of SLN in vulvar cancer. Patients of younger age with small, well-differentiated tumors appear to be the most suitable candidates for lymphatic mapping.
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Affiliation(s)
- Nikolaos Akrivos
- Department of Obstetrics and Gynecology, Alexandra Hospital, University of Athens, 9, Antheon str, 14235 Athens, Greece.
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Affiliation(s)
- G Branagan
- Salisbury NHS Foundation Trust, Odstock, Salisbury, Wilts, UK.
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Smith JH. Other tumours and lesions of cervix, vulva and vagina. Diagn Cytopathol 2010. [DOI: 10.1016/b978-0-7020-3154-0.00025-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Radziszewski J, Kowalewska M, Jedrzejczak T, Kozlowicz-Gudzinska I, Nasierowska-Guttmejer A, Bidzinski M, Siedlecki JA. The accuracy of the sentinel lymph node concept in early stage squamous cell vulvar carcinoma. Gynecol Oncol 2009; 116:473-7. [PMID: 19922986 DOI: 10.1016/j.ygyno.2009.10.072] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2009] [Revised: 10/20/2009] [Accepted: 10/26/2009] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of the study was to determine the feasibility and accuracy of the sentinel lymph node (SLN) identification in vulvar carcinoma patients. METHODS Sixty-two patients with clinical early stage vulvar cancer underwent SLN detection procedure, followed by a complete inguinofemoral lymphadenectomy. The SLN was identified intraoperatively using lymphoscintigraphy with technetium-99m as well as patent blue V staining. The resected lymph nodes (LN) were submitted for histological examination by hematoxylin-eosin staining (H-E) and cytokeratin immunohistochemistry (IHC) and examined by the reverse transcriptase-polymerase chain reaction (RT-PCR) assay. RESULTS A total of 109 inguinal LN were dissected in 56 patients. SLNs were identified in 76% groins with patent blue V and in 99% with the use of Tc-99m. The accuracy differed significantly (p<0.0001). An H-E examination combined with IHC revealed 7 false-negative SLNs. The sensitivity of this method was 73% (95% CI, 64% to 81%) and the negative predictive value for a negative SLN finding was 92% (95% CI, 87% to 97%). The RT-PCR assay showed 8 false-negative SLNs. The sensitivity of the RT-PCR-based assay was 83% (95% CI, 75% to 90%) and the negative predictive value for a negative SLN was 88% (95% CI, 82% to 94%). The two diagnostic methods were found not to differ significantly. CONCLUSIONS In SLN mapping, the Tc-99m colloid lymphoscintigraphy is superior to the blue dye staining. Our data do not support the concept of the SLN identification as a highly accurate procedure in predicting the inguinofemoral LN status in patients with early stage vulvar cancer.
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Affiliation(s)
- Jakub Radziszewski
- Department of Brachytherapy, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland.
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The management of vulval cancer. Cancer Treat Rev 2009; 35:533-9. [DOI: 10.1016/j.ctrv.2009.01.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Revised: 01/10/2009] [Accepted: 01/19/2009] [Indexed: 11/18/2022]
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Imaging in primary penile cancer: current status and future directions. Eur Radiol 2009; 20:36-47. [DOI: 10.1007/s00330-009-1521-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Revised: 05/16/2009] [Accepted: 06/23/2009] [Indexed: 02/05/2023]
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El-Ghobashy A, Saidi S. Sentinel lymph node sampling in gynaecological cancers: Techniques and clinical applications. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2009; 35:675-85. [DOI: 10.1016/j.ejso.2008.09.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Revised: 09/02/2008] [Accepted: 09/03/2008] [Indexed: 11/26/2022]
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Crawshaw JW, Hadway P, Hoffland D, Bassingham S, Corbishley CM, Smith Y, Pilcher J, Allan R, Watkin NA, Heenan SD. Sentinel lymph node biopsy using dynamic lymphoscintigraphy combined with ultrasound-guided fine needle aspiration in penile carcinoma. Br J Radiol 2009; 82:41-8. [PMID: 19095815 DOI: 10.1259/bjr/99732265] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The purpose of this study was to assess the utility of sentinel lymph node lymphoscintigraphy (SLNL) and ultrasound-guided fine needle aspiration cytology (FNAC) in patients with penile carcinoma. A prospective study was undertaken of 64 patients with stage T1 (or greater) clinically N0 squamous cell carcinoma of the penis. Patients underwent SLNL and bilateral groin ultrasonography with or without FNAC. Following intradermal blue dye, patients underwent unilateral or bilateral sentinel lymph node excision biopsy (SNB). 17 patients had sentinel nodes that contained metastases (21 nodal basins). Lymphatic drainage was demonstrated in all patients by lymphoscintigraphy. Bilateral drainage was seen in 57/64 patients. 61/64 patients had ultrasonography of the inguinal basins on the same day as FNAC of 38 basins. FNAC showed malignancy in eight basins. FNAC was negative in six basins, which were subsequently shown to be positive following SNB. 82 inguinal basins did not warrant FNAC by ultrasound criteria, of which 5 contained metastases at SNB. The sensitivity and specificity of ultrasonography was 74% and 77%, respectively. The positive and negative predictive values were 37% and 94%, respectively. Two patients had a negative initial SNB; however, ultrasonography identified a metastatic node and re-evaluation of the sentinel node confirmed micro-metastases. There has been no evidence of recurrence in any patients with negative SNB (during 6-28 months' follow-up). In conclusion, when investigating clinically stage N0 penile cancer, the combination of SNB and groin ultrasonography, with or without FNAC, identifies accurately those with occult nodal metastases. Ultrasonography alone is not adequate as a staging technique, and SNB alone might miss between 5% and 10% of metastases.
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Affiliation(s)
- J W Crawshaw
- Department of Radiology, St George's Hospital, London, UK.
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Leveridge M, Siemens DR, Morash C. What next? Managing lymph nodes in men with penile cancer. Can Urol Assoc J 2008; 2:525-31. [PMID: 18953451 DOI: 10.5489/cuaj.922] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The management of patients with squamous cell carcinoma of the penis is often daunting given its rarity and subsequent lack of high-level evidence to support our decision-making. This culminates in the complex surgical issues involving the management of the regional lymph nodes, which is of critical importance to both quantity and quality of life for these patients. This review aims to highlight the decisive issues surrounding the management of the pelvic and inguinal lymph nodes in the setting of squamous cell carcinoma of the penis, and to spotlight recently published information that adds credence to accepted management strategies of both the clinically positive and negative groin after successful management of the primary lesion.
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Hampl M, Hantschmann P, Michels W, Hillemanns P. Validation of the accuracy of the sentinel lymph node procedure in patients with vulvar cancer: results of a multicenter study in Germany. Gynecol Oncol 2008; 111:282-8. [PMID: 18804850 DOI: 10.1016/j.ygyno.2008.08.007] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2008] [Revised: 08/07/2008] [Accepted: 08/11/2008] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate the diagnostic accuracy of the sentinel node procedure in patients with vulvar cancer, a multicenter study was launched in Germany in 2003 involving 7 oncology centers. PATIENTS AND METHODS Between 2003 and 2006, 127 women with primary T1-T3 vulvar cancer were entered in the study and treated with sentinel node removal after application of (99m)Technetium labeled nanocolloid and/or blue dye. Subsequently, in all women a complete inguinofemoral lymphadenectomy and the adequate vulvar operation were performed. Sentinel lymph nodes were examined by routine pathologic examination (H&E), followed by step-sectioning and immunhistochemistry if negative. RESULTS The sentinel node procedure was successful in 125 out of 127 cases, in 2 cases no sentinel nodes were detected. 21 patients received unilateral lymphadenectomy, 103 women were operated on both groins. In 39 women out of 127, positive lymph nodes in one or both groins were identified (30.7%). In 36 women, the sentinel nodes were also positive (sensitivity 92.3%). We had three cases with a false negative sentinel node (false negative rate: 7.7%), all of these women presenting with tumors in midline position. One tumor was a T1 tumor (10 mm), 2 tumors being classified as T2 (40 and 56 mm, respectively). In one additional case (18 mm T1 tumor, midline position), the sentinel was positive in the right groin, but false negative on the left side. CONCLUSIONS This study shows that identification of SLN in squamous cell cancer of the vulva is feasible, however not highly accurate depending on tumor localization and size. The false negative rate seems to be acceptable if the procedure is restricted to stage 1 tumors with clinically negative lymph node status. Tumors situated in or close to the midline seem to be less suitable for this procedure. Implementation of SLNB into clinical practice should be performed with care and only by experienced teams as to avoid preventable groin relapses.
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Affiliation(s)
- Monika Hampl
- Department of Gynecology and Obstetrics, Heinrich Heine University, Duesseldorf, Germany
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Non-invasive and minimally invasive staging of regional lymph nodes in penile cancer. World J Urol 2008; 27:197-203. [PMID: 18594830 DOI: 10.1007/s00345-008-0288-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Accepted: 05/25/2008] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION The management of the regional lymph nodes in penile cancer patients, particularly when these lymph nodes are impalpable, remains controversial. Prophylactic bilateral inguinal lymphadenectomy is associated with high morbidity and is often unnecessary. However, there is no non-invasive or minimally invasive staging technique that can determine the lymph node status of penile cancer patients with 100% accuracy. METHODS We reviewed the current literature to examine the role of non-invasive and minimally invasive techniques for staging regional lymph nodes in penile cancer with particular reference to clinically impalpable disease. RESULTS Cross-sectional imaging (un-enhanced CT and MRI) modalities have a role in the assessment of patients with palpable inguinal basins and in locating distant metastases, but are unreliable in staging impalpable regional lymph nodes. The spatial resolution of lymphotropic nanoparticle enhanced MRI (LNMRI) and positron emission tomography (PET)/CT are limited to several millimetres and so these modalities cannot reliably detect micro-metastases (<2 mm). Ultrasound (US) and fine-needle aspiration cytology (FNAC) are indicated in staging palpable inguinal basins but are unreliable in isolation in the assessment of impalpable lymph nodes. They are, however, useful as an adjunct to dynamic sentinel lymph node biopsy (DSLNB) in lowering false-negative rates. CONCLUSIONS While we await staging modalities that can equal the results of DSLNB with fewer disadvantages, histological staging in the form of DSLNB remains the best minimally invasive staging modality we can offer at risk patients presenting with clinically node negative groins.
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Barton DPJ, Moskovic E, Sohaib A. Accuracy of magnetic imaging of inguinofemoral lymph nodes in vulval cancer. Int J Gynecol Cancer 2007; 17:1179; author reply 1180. [PMID: 17433063 DOI: 10.1111/j.1525-1438.2007.00935.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Bipat S, Fransen GA, Spijkerboer AM, van der Velden J, Bossuyt PMM, Zwinderman AH, Stoker J. Is there a role for magnetic resonance imaging in the evaluation of inguinal lymph node metastases in patients with vulva carcinoma? Gynecol Oncol 2006; 103:1001-6. [PMID: 16859737 DOI: 10.1016/j.ygyno.2006.06.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Revised: 05/30/2006] [Accepted: 06/07/2006] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To study the accuracy of magnetic resonance imaging (MRI) in lymph node detection in patients with vulva carcinoma. METHODS Sixty patients with diagnosed vulva carcinoma underwent MRI examination for preoperative evaluation of lymph nodes. MRI images were read independently and retrospectively by two radiologists, both unaware of physical examination and surgery findings. The following characteristics of each lymph node with a short-axis diameter of >or=8 mm were recorded: size (axial, sagittal and coronal); aspect (homogeneous, with fatty center or partial fat); margin (smooth, lobulated/speculated or indistinct); shape: (round, ovoid or elongated). Based on these characteristics, each lymph node was classified as malignant or benign and subsequently each groin was classified as malignant or benign. Histopathology obtained at sentinel node procedure or by inguinofemoral lymphadenectomy was used as reference standard. Per groin sensitivity, specificity, positive and negative predictive values were calculated. Kappa statistics on per groin basis were calculated to express interobserver agreement. RESULTS One hundred nineteen groins were examined either by sentinel node procedure or surgery, of which 23 groins were malignant. Sensitivity, specificity, positive and negative predictive values were 52%, 85%, 46% and 87% for observer 1 and 52% 89%, 52% and 89% for observer 2. The interobserver agreement was 104/119 (kappa 0.62), representing good agreement. CONCLUSION At this stage there is no role for standard MRI in evaluating lymph node involvement in patients with vulva carcinoma.
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Affiliation(s)
- Shandra Bipat
- Department of Radiology, G1-231, Academic Medical Center, Meibergdreef 1105 AZ, University of Amsterdam, The Netherlands.
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Adib T, Barton DPJ. The sentinel lymph node: Relevance in gynaecological cancers. Eur J Surg Oncol 2006; 32:866-74. [PMID: 16765015 DOI: 10.1016/j.ejso.2006.03.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2005] [Accepted: 03/23/2006] [Indexed: 10/24/2022] Open
Abstract
AIMS Sentinel lymph node (SLN) detection is widely practiced in the management of patients with malignant melanoma and beast cancer. Large studies on SLN detection and determination of nodal status have led to changes in the surgical management of the regional lymph nodes in these diseases. More recently attention has focused on other solid cancers, including gynaecological cancers. METHODS An extensive literature review of published reports on the SLN in gynaecological cancers was undertaken and the reports were categorised according to the level of evidence provided. RESULTS Vulva cancer is the most frequently investigated gynaecological cancer with regard to SLN detection because of its anatomical location and easily accessible nodal basin. Although there are no randomised controlled trials, some data suggest SLN detection in vulval cancer may alter clinical practice and reduce the number of groin lymphadenectomies. The lymphatic drainage of the other gynaecological organs is less predictable, the nodal basin less accessible or less well defined, the techniques not standardised and the evidence for the applicability of SLN detection in the management of these cancers is weak. CONCLUSION Sentinel lymph node detection in vulval cancer may reduce the need for radical groin lymphadenectomy and thereby reduce morbidity. SLN detection for other gynaecological cancers has little potential to alter clinical practice.
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Affiliation(s)
- T Adib
- Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, 4th Floor Lanesborough Wing, St. George's Hospital, Blackshaw Road, London SW17 0QT, UK
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van Rijk MC, Teertstra HJ, Peterse JL, Nieweg OE, Olmos RAV, Hoefnagel CA, Kroon BBR. Ultrasonography and Fine-needle Aspiration Cytology in the Preoperative Evaluation of Melanoma Patients Eligible for Sentinel Node Biopsy. Ann Surg Oncol 2006; 13:1511-6. [PMID: 17009151 DOI: 10.1245/s10434-006-9106-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Revised: 04/21/2006] [Accepted: 06/05/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ultrasonography with fine-needle aspiration cytology (FNAC) has proven to be a valuable diagnostic tool in the preoperative workup of patients with breast cancer or penile cancer eligible for sentinel lymph node biopsy. The aim of this study was to evaluate the use of this technique in the initial assessment of patients with primary cutaneous melanoma. METHODS A total of 107 patients with cutaneous melanoma eligible for sentinel node biopsy with clinically negative nodes were studied prospectively. Patients underwent ultrasonography of potentially involved basins and FNAC in case of a suspicious lymph node. The sentinel node procedure was omitted in patients with tumour-positive lymph nodes in lieu of lymph node dissection. RESULTS Ultrasonography with FNAC correctly identified disease preoperatively in two of the 107 patients (2%). Thirteen of the 22 patients (59%) with a suspicious node on ultrasonographic imaging but a tumour-negative fine-needle aspirate were shown to have involved nodes. Of the 85 patients with ultrasonographically normal nodes, 25 (29%) were shown to have metastases. Of the total of 43 involved basins, 16 contained metastases > 2 mm and 25 < or = 2 mm. CONCLUSIONS In our hands, the sensitivity and specificity of preoperative ultrasonography to detect lymph node involvement in patients with melanoma are 34% and 87%, respectively. In combination with FNAC, this is 4.7% and 100%, respectively. This yield is insufficient for this technique to be used as a routine diagnostic tool in the selection of patients eligible for sentinel node biopsy.
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Affiliation(s)
- Maartje C van Rijk
- Department of Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066, CX, Amsterdam, The Netherlands.
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Oonk MHM, Hollema H, de Hullu JA, van der Zee AGJ. Prediction of lymph node metastases in vulvar cancer: a review. Int J Gynecol Cancer 2006; 16:963-71. [PMID: 16803470 DOI: 10.1111/j.1525-1438.2006.00387.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The aim of this study was to review the literature on currently available non- and minimally-invasive diagnostic methods and analysis of primary tumor characteristics for prediction of inguinofemoral lymph node metastases in patients with primary squamous cell carcinoma of the vulva. We used the English language literature in PubMed and reference lists from selected articles. Search terms included vulvar carcinoma, prognosis, lymph node metastases, ultrasound, computer tomography, magnetic resonance imaging, positron emission tomography, and sentinel lymph node. No study type restrictions were imposed. Currently no noninvasive imaging techniques exist that are able to predict lymph node metastases with a high enough negative predictive value. A depth of invasion < or =1 mm is the only histopathologic parameter that can exclude patients for complete inguinofemoral lymphadenectomy. No other clinicopathologic parameter allows exclusion of lymph node metastases with a high enough negative predictive value. The minimally invasive sentinel node procedure is a promising technique for selecting patients for complete lymphadenectomy, but its safety has not been proven yet.
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Affiliation(s)
- M H M Oonk
- Department of Gynaecologic Oncology, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
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Singh K, Orakwue CO, Honest H, Balogun M, Lopez C, Luesley DM. Accuracy of magnetic resonance imaging of inguinofemoral lymph nodes in vulval cancer. Int J Gynecol Cancer 2006; 16:1179-83. [PMID: 16803503 DOI: 10.1111/j.1525-1438.2006.00456.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Inguinofemoral lymphadenectomy contributes to the high morbidity related to surgical treatment of vulval cancer. The objective of this study was to assess the accuracy of magnetic resonance imaging (MRI) in predicting inguinofemoral lymph nodes metastasis in women with vulval cancer. We reviewed the clinical, MRI, surgical, and pathologic findings of 59 women with vulval cancer who were treated at our institution from January 2000 to June 2004. Histology was available for 39 women who had undergone inguinofemoral lymphadenectomy. Clinical and MRI findings were compared with histology result to assess test accuracy. MRI had a positive likelihood ratio (LR+) of 4.8 (95% confidence interval of 2.7-8.6) and negative likelihood ratio (LR-) of 0.17 (0.06-0.49). It had a sensitivity of 85.7% (63.7-97), specificity of 82.1% (69.6-91.1), positive predictive value (PPV) of 64.3% (44.1-81.4), and negative predictive value (NPV) of 93.9% (83.1-98.7). Clinical examination had an LR+ of 6.1 (1.8-21.6) and LR- of 0.69 (0.5-0.96). It had a sensitivity of 35% (15.3-59.4), specificity of 94.3% (84.3-98.8), PPV of 70% (34.7-93.3), and NPV of 79.4% (67.3-88.5). Kappa statistics for interobserver and intraobserver agreement were 0.9091 and 0.8475, respectively. MRI assessment was accurate in predicting negative nodal status that is clinically useful in identifying women who can be spared inguinofemoral lymphadenectomy. It is noninvasive and is superior to clinical assessment. In clinical practice, this should encourage toward nodal sparing surgery, thus lowering surgical-related patient morbidity.
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Affiliation(s)
- K Singh
- Department of Gynaecological Oncology, Birmingham Women's Hospital, Metchley Park Road, Birmingham B15 2TG, UK.
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Land R, Herod J, Moskovic E, King M, Sohaib SA, Trott P, Nasiri N, Shepherd JH, Bridges JE, Ind TEJ, Blake P, Barton DPJ. Routine computerized tomography scanning, groin ultrasound with or without fine needle aspiration cytology in the surgical management of primary squamous cell carcinoma of the vulva. Int J Gynecol Cancer 2006; 16:312-7. [PMID: 16445651 DOI: 10.1111/j.1525-1438.2006.00340.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We set out to study whether computerized tomography (CT) scanning of the vulva and the groin and groin ultrasound scanning (USS) alone or with fine needle aspiration cytology (FNAC) (USS/FNAC) influenced or could influence the surgical management of primary squamous cell carcinoma of the vulva (SCCaV). Forty-four patients underwent surgery for primary SCCaV following radiologic imaging by one or more modalities. Patient details included the clinical assessment of the carcinoma, radiologic findings, the operation performed, and whether the decision regarding the type and extent of surgery for the vulval carcinoma and, in particular, for the groin node dissection was or could be influenced by the radiologic findings. The age range was 38-87 years, with a median of 74 years. A total of 75 groin dissections were performed. Twenty-five of the 44 patients (56.8%) did not have groin node metastasis, 14 had unilateral metastasis (31.8%), and 5 (11.4%) had bilateral metastasis. All cases with histologically proven nodal status were analyzed to compare the preoperative imaging status with the histology. The calculated sensitivity, specificity, negative predictive value, and positive predictive value for CT were 58%, 75%, 75%, and 58%, for USS alone-87%, 69%, 94%, and 48%, and for USS-guided FNAC-80%, 100%, 93%, and 100%, respectively. There was no patient in whom surgical planning for the vulval carcinoma or the groin nodes was or could be altered by the CT findings. The data do not support the routine use of CT scanning in patients with primary SCCaV, either in assessment of the primary vulval carcinoma or in detecting groin nodal metastases. For the groin nodes, USS/FNAC is superior to CT in assessing disease status. In contrast to CT, USS/FNAC may have a useful clinical role in the management of the groin nodes in vulval carcinoma.
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Affiliation(s)
- R Land
- Department of Surgical Gynaecologic Oncology, Royal Marsden Hospital, London SW3 6JJ, United Kingdom
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Thangavelu A, Andrew A, Buxton EJ. Groin recurrence following Stage 1A squamous cell carcinoma of the vulva. Gynecol Oncol 2005; 101:172-4. [PMID: 16274738 DOI: 10.1016/j.ygyno.2005.09.057] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2005] [Revised: 09/27/2005] [Accepted: 09/30/2005] [Indexed: 11/15/2022]
Abstract
BACKGROUND It has been well established that stage 1 squamous cell carcinomas of the vulva with a depth of stromal invasion less than 1 mm have a <1% risk of lymph node involvement. The treatment for these stage 1A tumours has therefore been to perform radical wide local excision without removal of groin nodes. CASE We present two cases of stage 1A microinvasive cancer of the vulva that presented with groin recurrence 3 months and 3 years following their primary surgery respectively. CONCLUSION The current management of stage 1A tumours may need to be re-evaluated to include some form of lymph node assessment in view of these rare but nonetheless aggressive tumours.
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Affiliation(s)
- Amudha Thangavelu
- Department of Obstetrics and Gynaecology, St. James' University Hospital, Beckett Street, Leeds LS9 7TF, UK.
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Selman TJ, Luesley DM, Acheson N, Khan KS, Mann CH. A systematic review of the accuracy of diagnostic tests for inguinal lymph node status in vulvar cancer. Gynecol Oncol 2005; 99:206-14. [PMID: 16081147 DOI: 10.1016/j.ygyno.2005.05.029] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2005] [Revised: 05/15/2005] [Accepted: 05/18/2005] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine the accuracy of minimally and non-invasive tests to assess the groin node status in squamous cell vulvar cancer. METHODS A systematic review of published research from 1979 to 2004 that compares the results of tests to determine groin node status with histology at inguinofemoral lymphadenectomy was made. Studies included in the review were those that compared the index test to the standard surgical intervention of inguinofemoral lymphadenectomy and allowed the construction of two-by-two tables. From these tables, sensitivity, specificity, and the likelihood ratios (with 95% confidence intervals) were reported and, where feasible, meta-analysis was used to pool results for each test separately. Sentinel node biopsy using technetium-99m-labelled nanocolloid ((99m)Tc) had a pooled sensitivity and negative LR of 97% (91-100 95% CI) and 0.12 (0.053-0.28 95% CI), respectively, and was the most accurate test reviewed. CONCLUSION Five diagnostic tests were identified in a total of 29 studies (961 groins). Although the studies were small and the design often poor, this represents the best summary of the data to date. Sentinel node identification using (99m)Tc appeared to be the most promising test for accurately excluding lymph node metastases in squamous cell vulvar cancer and potentially reducing the radicality of surgery. Its efficacy as a tool in reducing the need for radical surgery and associated patient morbidity without reducing survival needs further assessment probably in a randomised control trial.
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Affiliation(s)
- T J Selman
- Birmingham Women's Hospital, Metchley Park Road, Edgbaston, Birmingham B15 2TG, UK.
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Kroon BK, Horenblas S, Lont AP, Tanis PJ, Gallee MPW, Nieweg OE. Patients with penile carcinoma benefit from immediate resection of clinically occult lymph node metastases. J Urol 2005; 173:816-9. [PMID: 15711276 DOI: 10.1097/01.ju.0000154565.37397.4d] [Citation(s) in RCA: 224] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE In this retrospective study we compared the clinical outcome of early vs delayed excision of lymph node metastases in patients with penile squamous cell carcinoma. MATERIALS AND METHODS A total of 40 patients with a T2-3 penile carcinoma with lymph node metastases were included in this study. All patients initially presented with bilateral impalpable lymph nodes. In 20 patients (50%) metastases were removed when they became clinically apparent during meticulous followup (median interval 6 months, range 1 to 24). There were 20 patients (50%) who underwent resection of inguinal metastases detected on dynamic sentinel node biopsy before they became palpable. The histopathological characteristics of the tumors and lymph nodes were reevaluated. RESULTS The 2 populations were similar in terms of patient age, T-stage, pathological tumor grade, vascular invasion and infiltration depth. Disease specific 3-year survival of patients with positive lymph nodes detected during surveillance was 35% and in those who underwent early resection, 84% (log rank p = 0.0017). In multivariate analysis early resection of occult inguinal metastases detected on dynamic sentinel node biopsy was an independent prognostic factor for disease specific survival (p = 0.006). CONCLUSIONS Early resection of lymph node metastases in patients with penile carcinoma improves survival.
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Affiliation(s)
- B K Kroon
- Department of Urology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Kroon BK, Horenblas S, Deurloo EE, Nieweg OE, Teertstra HJ. Ultrasonography-guided fine-needle aspiration cytology before sentinel node biopsy in patients with penile carcinoma. BJU Int 2005; 95:517-21. [PMID: 15705071 DOI: 10.1111/j.1464-410x.2005.05330.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To assess the accuracy of ultrasonography (US)-guided fine-needle aspiration cytology (FNAC) for detecting occult lymph node metastases in patients with squamous cell carcinoma of the penis. PATIENTS AND METHODS Forty-three patients with 83 clinically node-negative inguinal regions were assessed with US and FNAC. The results were compared with histology from subsequent dynamic sentinel-node biopsy (DSNB) or inguinal lymph node dissection. RESULTS Thirty-four groins in 27 patients were considered to be suspicious by US and the lymph nodes were aspirated. Nine nodes contained tumour cells and this was confirmed by subsequent lymph node dissection. The sensitivity and specificity of US-guided FNAC were 39% (nine of 23) and 100% (60 of 60), respectively. The number of groins requiring DSNB was reduced by 11% (nine of 83). CONCLUSION US-guided FNAC can be used as the initial investigation in clinically node-negative groins. If tumour is confirmed then therapeutic inguinal lymph node dissection can be earlier and fewer DSNBs are required.
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Affiliation(s)
- Bin K Kroon
- Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Thomas JM, Clark MA. Selective lymphadenectomy in sentinel node-positive patients may increase the risk of local/in-transit recurrence in malignant melanoma. Eur J Surg Oncol 2004; 30:686-91. [PMID: 15256245 DOI: 10.1016/j.ejso.2004.04.004] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2004] [Indexed: 11/27/2022] Open
Abstract
AIM To determine whether sentinel lymph node biopsy (SLNB) for cutaneous malignant melanoma, particularly when followed by selective lymphadenectomy (SL) if involved nodes are found, alters the incidence of local/in-transit recurrence. METHODS A literature overview of SLNB with or without SL has been performed, concentrating on the reported site(s) of first recurrence, and with specific reference to the incidence of local/in-transit recurrence. This is compared to the incidence after wide local excision (WLE) alone. RESULTS The incidence of local/in-transit recurrence after WLE alone is 2.5-6.3% over a given range of tumour thickness, and is 9.0% after SLNB (with or without SL). In the latter group, the local/in-transit recurrence rate is 5.7% following SLNB alone in SN-negative patients, and is 20.9% after SLNB plus SL in SN-positive patients. CONCLUSIONS The incidence of local/in-transit recurrence following selective lymphadenectomy in sentinel node-positive patients may be greater than four times the incidence expected. This possible iatrogenic risk should be confirmed or refuted by randomised controlled trial. Until then the SLNB procedure should be regarded as experimental and not performed outside validation trials.
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Affiliation(s)
- J M Thomas
- Melanoma and Sarcoma Unit, Department of Surgery, The Royal Marsden Hospital, 203 Fulham Road, London SW3 6JJ, UK.
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