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

European consensus-based interdisciplinary guideline for invasive cutaneous squamous cell carcinoma. Part 1: Diagnostics and prevention-Update 2023

Invasive cutaneous squamous cell carcinoma (cSCC) is one of the most common cancers in white populations, accounting for 20% of all cutaneous malignancies. Overall, cSCC mostly has very good prognosis after treatment, with 5-year cure rates greater than 90%. Despite the overall favourable prognosis and the proportionally rare deaths, cSCC is associated with a high total number of deaths due to its high incidence. A collaboration of multidisciplinary experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), the European Society for Radiotherapy and Oncology (ESTRO), the European Union of Medical Specialists (UEMS), the European Academy of Dermatology and Venereology (EADV) and the European Organization of Research and Treatment of Cancer (EORTC), was formed to update recommendations on cSCC, based on current literature and expert consensus. Part 1 of the guidelines addresses the updates on classification, epidemiology, diagnosis, risk stratification, staging and prevention in immunocompetent as well as immunosuppressed patients.

Incidence of inguinofemoral lymph node metastases at the first local recurrence of vulvar cancer: a Dutch nationwide study

BACKGROUND

Up to 40% of vulvar cancer patients present with local recurrence within 10 years of follow-up. An inguinofemoral lymphadenectomy (IFL) is indicated if not performed at primary treatment. The incidence and risk factors for lymph node metastases (LNM) at first local recurrence, however, are unclear. Our aim was to determine the incidence of LNM at first local recurrence, in relation to previous groin treatment and clinicopathological factors.

METHODS

A multicenter cohort study including vulvar cancer patients with a first macroinvasive local recurrence after primary surgical treatment between 2000 and 2015 was conducted in the Netherlands. Groin status at local recurrence was defined as positive (N+), negative (N-) or unknown (N?) and based on histology, imaging and follow-up. Patient-, tumour- and treatment characteristics of primary and recurrent disease were analysed.

RESULTS

Overall, 16.3% (66/404) had a N+ groin status at first local recurrence, 66.4% (268/404) N- and 17.3% (70/404) N? groin status. The incidence of a N+ groin status was comparable after previous SLN and IFL, 11.5% and 13.8%, respectively. A N+ groin status was related to tumour size (25 vs.12 mm; P < 0.001), depth of invasion (5 vs. 3 mm; P < 0.001) and poorly differentiated tumours (22.9 vs. 11.9%; P = 0.050) at local recurrence.

CONCLUSIONS

The incidence of LNM at first local recurrence in vulvar cancer patients was 16.3%, and independent of previous type of groin surgery. In accordance with primary diagnosis, tumour size, depth of invasion, and tumour grade were significantly associated with a positive groin status.

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

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.

Evaluating the Risk of Inguinal Lymph Node Metastases before Surgery Using the Morphonode Predictive Model: A Prospective Diagnostic Study in Vulvar Cancer Patients

Ultrasound examination is an accurate method in the preoperative evaluation of the inguinofemoral lymph nodes when performed by experienced operators. The purpose of the study was to build a robust, multi-modular model based on machine learning to discriminate between metastatic and non-metastatic inguinal lymph nodes in patients with vulvar cancer. One hundred and twenty-seven women were selected at our center from March 2017 to April 2020, and 237 inguinal regions were analyzed (75 were metastatic and 162 were non-metastatic at histology). Ultrasound was performed before surgery by experienced examiners. Ultrasound features were defined according to previous studies and collected prospectively. Fourteen informative features were used to train and test the machine to obtain a diagnostic model (Morphonode Predictive Model). The following data classifiers were integrated: (I) random forest classifiers (RCF), (II) regression binomial model (RBM), (III) decisional tree (DT), and (IV) similarity profiling (SP). RFC predicted metastatic/non-metastatic lymph nodes with an accuracy of 93.3% and a negative predictive value of 97.1%. DT identified four specific signatures correlated with the risk of metastases and the point risk of each signature was 100%, 81%, 16% and 4%, respectively. The Morphonode Predictive Model could be easily integrated into the clinical routine for preoperative stratification of vulvar cancer patients.

The Role of Ultrasound in the Evaluation of Inguinal Lymph Nodes in Patients with Vulvar Cancer: A Systematic Review and Meta-Analysis

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.

Vulvar cancer staging: guidelines of the European Society of Urogenital Radiology (ESUR)

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.

Terms, definitions and measurements to describe sonographic features of lymph nodes: consensus opinion from the Vulvar International Tumor Analysis (VITA) group

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.

ACR Appropriateness Criteria® Staging and Follow-up of Vulvar Cancer

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.

Accuracy of computerized tomography in the preoperative evaluation of metastases in primary vulvar cancer - A population-based study

OBJECTIVE

To investigate the impact of a preoperative CT on surgical decision making in primary vulvar squamous cell carcinoma (VSCC) and the accuracy of detecting inguinal lymph node metastases (LNM). Secondly to assess prevalence and consequences of incidental findings and comorbidity using a CT.

METHODS

This population-based study comprised of surgically treated patients with primary VSCC, at a regional tertiary center, using the Swedish Quality Registry for Gynecological Cancer for identification, and medical records were reviewed. Results from the preoperative CT was compared with the histological analysis from the lymphadenectomy in the total cohort and between tumor size <4 cm versus ≥4 cm.

RESULTS

In total 134 women had undergone CT before sentinel node (SN) biopsy (n = 83) or inguinofemoral lymphadenectomy (IFL) (n = 51). Fiftyone patients (38%) had groin LNM. Accuracy of CT in detecting groin LNM was 76%; sensitivity 43% and specificity 96%. Positive (PPV) and negative predictive values (NPV) were 88% and 73% respectively. In tumors <4 cm (n = 87), sensitivity, specificity, PPV and NPV were 17%, 95%, 57% and 75% and in tumors ≥4 cm (n = 47) 67%, 100%, 100% and 69% respectively. CT altered surgical method from SN biopsy to IFL in only two cases. Incidental findings led to extra follow-up resulting in a benign diagnosis in 22 patients and major important findings in five patients.

CONCLUSION

In primary VSCC, a preoperative abdominal-inguinal CT is of limited value for surgical decision making. In tumors <4 cm, it may be omitted due to low diagnostic accuracy and disturbing incidental findings.

Pelvic Lymphadenectomy in Vulvar Cancer - Does it make sense?

Since the publication of the updated German guideline in 2015, the recommendations for performing pelvic lymphadenectomy (LAE) in patients with vulvar cancer (VSCC) have changed considerably. The guideline recommends surgical lymph node staging in all patients with a higher risk of pelvic lymph node involvement. However, the current data do not allow the population at risk to be clearly defined, therefore, the indication for pelvic lymphadenectomy is still not clear. There are currently two published German patient populations who had pelvic LAE which can be used to investigate both the prognostic effect of histologically verified pelvic lymph node metastasis and the relation between inguinal and pelvic lymph node involvement. A total of 1618 patients with primary FIGO stage ≥ IB VSCC were included in the multicenter AGO CaRE-1 study (1998 - 2008), 70 of whom underwent pelvic LAE. During a retrospective single-center evaluation carried out at the University Medical Center Hamburg-Eppendorf (UKE), a total of 514 patients with primary VSCC treated between 1996 - 2018 were evaluated, 21 of whom underwent pelvic LAE. In both cohorts, around 80% of the patients who underwent pelvic LAE were inguinally node-positive, with a median number of three affected groin lymph nodes. There were no cases of pelvic lymph node metastasis without inguinal lymph node metastasis in either of the two cohorts. Between 33 - 35% of the inguinal node-positive patients also had pelvic lymph node metastasis; the median number of affected groin lymph nodes in these patients was high (> 4), and the maximum median diameter of the largest inguinal metastasis was > 40 mm in both cohorts. Pelvic lymph node staging and pelvic radiotherapy is therefore probably not necessary for the majority of node-positive patients with VSCC, as the relevant risk of pelvic lymph node involvement was primarily found in node-positive patients with high-grade disease. More, ideally prospective data collections are necessary to validate the relation between inguinal and pelvic lymph node involvement.

British Gynaecological Cancer Society (BGCS) vulval cancer guidelines: Recommendations for practice

The purpose of this guideline is to collate evidence and propose evidence-based guidelines for the diagnosis and management of adult patients with vulva carcinoma treated in the UK. Malignant melanoma may present via similar routes and will be discussed. The reader is referred to the Ano-uro-genital Mucosal Melanoma Full Guideline [1] for more detailed recommendations. The management of vulval sarcoma is outside of the scope of this guideline. For further information, including details of guideline development and GRADE of recommendations, please see BGCS website for details (https://www.bgcs.org.uk/professionals/guidelines-for-recent-publications/).

Ultrasound morphometric and cytologic preoperative assessment of inguinal lymph-node status in women with vulvar cancer: MorphoNode study

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.

European interdisciplinary guideline on invasive squamous cell carcinoma of the skin: Part 1. epidemiology, diagnostics and prevention

Invasive cutaneous squamous cell carcinoma (cSCC) is one of the most common cancers in the white populations, accounting for 20% of all cutaneous malignancies. Factors implicated in cSCC etiopathogenesis include ultraviolet radiation exposure and chronic photoaging, age, male sex, immunosuppression, smoking and genetic factors. A collaboration of multidisciplinary experts from the European Dermatology Forum (EDF), the European Association of Dermato-Oncology (EADO) and the European Organisation of Research and Treatment of Cancer (EORTC) was formed to update recommendations on cSCC classification, diagnosis, risk stratification, staging and prevention, based on current literature, staging systems and expert consensus. Common cSCCs are typically indolent tumors, and most have a good prognosis with 5-year cure rates of greater than 90%, and a low rate of metastases (<4%). Further risk stratification into low-risk or high-risk common primary cSCC is recommended based on proposed high-risk factors. Advanced cSCC is classified as locally advanced (lacSCC), and metastatic (mcSCC) including locoregional metastatic or distant metastatic cSCC. Current systems used for staging include the American Joint Committee on Cancer (AJCC) 8th edition, the Union for International Cancer Control (UICC) 8th edition, and Brigham and Women's Hospital (BWH) system. Physical examination for all cSCCs should include total body skin examination and clinical palpation of lymph nodes, especially of the draining basins. Radiologic imaging such as ultrasound of the regional lymph nodes, magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography-computed tomography (PET-CT) scans are recommended for staging of high-risk cSCC. Sentinel lymph node biopsy is currently not recommended. Nicotinamide, oral retinoids, and topical 5-FU have been used for the chemoprevention of subsequent cSCCs in high-risk patients but are not routinely recommended. Education about sun protection measures including reducing sun exposure, use of protective clothing, regular use of sunscreens and avoidance of artificial tanning, is recommended.

The role of preoperative computerized tomography (CT) scan of the pelvis and groin in the management of clinically early staged vulva squamous cell carcinoma

INTRODUCTION

Vulvar squamous cell carcinoma (VSCC) commonly metastasises through groin lymphatics. However, the use of pre-operative imaging in detecting inguinal nodal metastasis before staging surgery or to triage patients for sentinel node biopsy remains unclear. Here, we investigated if pre-operative CT scan, the imaging choice in our cancer centre, influences the overall course of VSCC management in those patients without clinical evidence of groin lymphadenopathy.

METHOD

The study comprised of a prospective cohort of 225 patients with VSCC who underwent staging surgery within a regional tertiary gynaecological cancer centre. Comprehensive information of the cohort's demography, clinicopathological variables and outcome data were collected and analysed. Findings of pre-operative imaging were compared with histological findings of inguinal lymph nodes following groin lymphadenectomy. Statistical analyses were performed using SPSS V24.

RESULTS

Pre-operative CT scan was performed on 116 (56.6%) patients. The sensitivity and specificity of cross-sectional imaging in detecting groin lymphatic metastasis were 59.1% and 77.8%, respectively; while the positive (PPV) and negative predictive value (NPV) were 61.9% and 75.7%, respectively. In patients who had sentinel inguinal nodes biopsy, the sensitivity, specificity, PPV and NPV of CT scan in detecting inguinal node metastasis were 30.0%, 85.7%, 33.3% and 83.7%, respectively. There was no difference in disease-free and overall survival in those who received pre-operative imaging when compared to those who did not.

CONCLUSION

Pre-operative CT scan may be omitted in early stage VSCC prior to surgical staging as it does not affect overall management and surgical outcomes.

Approaches to Perineural, Lymphovascular, and Single-Cell Disease

BACKGROUND

Mohs micrographic surgeons should be adept in identifying and managing perineural invasion (PNI), lymphovascular invasion (LVI), and single-cell spread (SCS), features denoting high-risk behavior of basal cell carcinoma (BCC), cutaneous squamous cell carcinoma (cSCC) and microcystic adnexal carcinoma (MAC).

OBJECTIVE

The purpose of this article is to review the literature and guidelines regarding the diagnosis of PNI, LVI, and SCS in BCC, cSCC, and MAC and examine the role of advanced diagnostic studies, adjuvant therapy, and reconstructive techniques of these high-risk tumors.

MATERIALS AND METHODS

We performed a literature search including the following terms: PNI, LVI, SCS, BCC, cSCC, keratinocyte carcinoma, MAC, sentinel lymph node biopsy, radiation, chemotherapy, and staging. Relevant studies, case reports, and review articles were included, as well as National Comprehensive Cancer Network guidelines.

RESULTS

Pancytokeratin immunohistochemistry may aid in the diagnosis of high-risk features of BCC and cSCC. Reconstruction of the Mohs defect should be carefully considered to allow for thorough inspection. Radiation therapy should be considered as an adjuvant treatment option for high-risk cSCC and BCC. Close surveillance for recurrence is warranted.

CONCLUSION

The Mohs surgeon should be competent in identification of high-risk tumors and to understand how best to manage, further treat, and follow these tumors.

State of the art in vulvar cancer imaging

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.

Fusion of ultrasound and 3D single-photon-emission computed tomography/computed tomography to identify sentinel lymph nodes in vulvar cancer: feasibility study

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.

Nodal staging of high-risk cutaneous squamous cell carcinoma

BACKGROUND

While progress has been made in defining the clinical and histopathologic features of high-risk cutaneous squamous cell carcinoma (HRcSCC), optimal staging guidelines remain elusive.

OBJECTIVE

We seek to guide clinical practice regarding nodal staging options for patients with HRcSCC via review of evolving definitions of HRcSCC, nodal staging options, and how nodal staging may impact treatment and affect outcomes.

METHODS

This was a retrospective review of the published peer-reviewed literature regarding risk stratification, nodal staging, and treatment and outcomes for patients with HRcSCC via PubMed.

RESULTS

For patients without clinical lymphadenopathy, based on literature from head and neck SCC, preoperative nodal staging with ultrasonography may be more useful than computed tomography or magnetic resonance imaging. Early nodal disease is usually curable, and therefore obtaining a sentinel lymph node biopsy specimen may be considered in those with negative imaging while we await studies of nodal staging outcomes.

LIMITATIONS

More data are needed to validate the relationships between primary tumor stage and sentinel lymph node biopsy status and to determine if early detection of nodal disease impacts survival for patients with HRcSCC.

CONCLUSION

It is reasonable to consider nodal staging for patients with HRcSCC (Brigham and Women's Hospital stage T2b and T3) in the absence of clinically palpable lymphadenopathy via radiographic imaging and, if negative, sentinel lymph node biopsy.

The Complementary Role of Imaging and Tumor Biomarkers in Gynecological Cancers: An Update of the Literature

Gynecological tumors, including endometrial, cervical and ovarian cancer, have increased in incidence over time. The widespread introduction of screening programs and advances in diagnostic imaging methods has lead to a progressive increase in gynecological cancer detection. Accurate diagnosis and proper monitoring of disease remain the primary target for a successful treatment. In the last years, knowledge about cancer biomarkers has considerably increased providing great opportunities for improving cancer detection and treatment. In addition, in the last few years there has been an important development of imaging techniques. Nowadays, a multimodal approach including the evaluation of serum tumor biomarkers combined with imaging techniques, seems to be the best strategy for assessing tumor presence, spread, recurrence, and/or the response to treatment in female cancer patients In this review we provide an overview of the application of biomarkers combined with novel imaging methods and highlight their roles in female cancer diagnosis and follow-up.

Diagnosis, Therapy and Follow-up Care of Vulvar Cancer and its Precursors. Guideline of the DGGG and DKG (S2k-Level, AWMF Registry Number 015/059, November 2015

Purpose: This is an official guideline, published and coordinated by the Arbeitsgemeinschaft Gynäkologische Onkologie (AGO, Study Group for Gynecologic Oncology) of the Deutsche Krebsgesellschaft (DKG, German Cancer Society) and the Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG, German Society for Gynecology and Obstetrics). The number of cases with vulvar cancer is on the rise, but because of the former rarity of this condition and the resulting lack of literature with a high level of evidence, in many areas knowledge of the optimal clinical management still lags behind what would be required. This updated guideline aims to disseminate the most recent recommendations, which are much clearer and more individualized, and is intended to create a basis for the assessment and improvement of quality care in hospitals. Methods: This S2k guideline was drafted by members of the AGO Committee on Vulvar and Vaginal Tumors; it was developed and formally completed in accordance with the structured consensus process of the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). Recommendations: 1. The incidence of disease must be taken into consideration. 2. The diagnostic pathway, which is determined by the initial findings, must be followed. 3. The clinical and therapeutic management of vulvar cancer must be done on an individual basis and depends on the stage of disease. 4. The indications for sentinel lymph node biopsy must be evaluated very carefully. 5. Follow-up and treatment for recurrence must be adapted to the individual case.

Imaging Features of Uncommon Gynecologic Cancers

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.

Relevance of computerized tomography in the preoperative evaluation of patients with vulvar cancer: a prospective study

Background

The purpose of the study was to determine whether inclusion of computerized tomography (CT) in the prospective evaluation of vulvar cancer changed the surgical treatment strategy in terms of detection of lymph node metastases, tumor spread and comorbidity, and additionally to examine the logistical influence of adding further examinations prior to treating out-hospital patients referred from geographically distant areas.

Methods

During an 8 month period we conducted a prospective study of patients with newly diagnosed or recurrent vulvar cancer consecutively referred to Copenhagen University Hospital, Rigshospitalet. The patients underwent a gynecological examination, chest x-ray and a preoperative CT scanning of the chest, abdomen and pelvis. It was registered whether the radiological findings regarding the extent of the tumor, lymph node involvement, incidental findings and comorbidity changed the surgical treatment plan. Further, the logistical influence of the long referral distances was registered.

Results

Thirty patients with a median age of 69 years (range 44–93 years) were included in the study. CT did not significantly change the initial surgical treatment plan for the patients. CT did not reveal lymph node enlargement outside the inguinofemoral area and was inaccurate compared to the sentinal node examination of the local lymph nodes. CT diagnosed no cases with distant metastases from the primary malignancy, but two cases with a secondary malignant disease were found.

Conclusions

CT scanning has no clinical impact as a routine screening examination prior to surgery. It may delay treatment, but can add important information when clinically indicated.

Sentinel node assessment for diagnosis of groin lymph node involvement in vulval cancer

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.

Ultrasound examination and fine needle aspiration cytology-useful for followup of the regional nodes in penile cancer?

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.

Merkel cell carcinoma in a patient with noninvasive vulvar Paget's disease

We present the first case of inguinal Merkel cell carcinoma of unknown primary origin in a patient with vulvar Paget's disease. Correlation with immune suppression of both entities warrants further investigation. Additionally, this case highlights the value of ultrasound scanning in the detection of inguinal metastasis.

Update on the management of high-risk squamous cell carcinoma

Cutaneous squamous cell carcinoma (CSCC) is the second most common malignancy occurring in white patients in the United States and incidence rates are increasing. While the majority of the 87,000-760,000 cases that occur yearly in the U.S. are curable, 4% develop lymph node metastases and 1.5% die from the disease. Given the frequency of occurrence of CSCC, it is estimated to cause as many deaths yearly as melanoma, with the majority occurring in patients with high risk tumors or in those at high risk for metastasis due to a variety of host factors, most commonly systemic immunosuppression. There are currently no standardized prognostic or treatment models to assist clinicians in most effectively identifying and managing these patients. Identification of patients at risk for poor outcomes as well as standardization regarding classification, staging, and treatment of high-risk tumors is critical for optimizing patient care. In this article, available literature on the classification and management of high risk CSCC is briefly summarized, emphasizing new information.

Detection and credibility of sentinel node in vulvar cancer: a single institutional study and short review of literature

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.

Current controversies in the management of patients with early-stage vulvar cancer

PURPOSE OF REVIEW

The purpose of this review is to outline current controversies in management of early-stage vulvar cancer. The main focus will be on the procedures for assessing the sentinel node and the treatment of those with evidence of metastatic involvement.

RECENT FINDINGS

Assessment of the sentinel node has recently been introduced into the standard treatment of early-stage squamous cell vulvar cancer. The combination of a radioactive tracer and blue dye is the most accurate technique for sentinel node detection. Preoperative imaging is recommended to rule out gross nodal involvement and ultrasound with fine needle aspiration cytology by an experienced radiologist appears to have the highest sensitivity/specificity for detecting metastases, although large comparative studies are not available. All patients with sentinel node metastases require additional treatment to the groin, independent of the size of metastasis in the sentinel node and currently this involves inguinofemoral lymphadenectomy. Further research is ongoing to investigate the role of radiotherapy instead of lymphadenectomy. The little experience there is of sentinel node biopsy in vulvar melanoma suggests that the procedure is feasible and inclusion criteria should follow those of cutaneous melanoma.

SUMMARY

Sentinel node biopsy is safe in treatment of early-stage vulvar cancer. Ongoing studies are investigating the optimal additional treatment for patients with a positive sentinel node in terms of efficacy and morbidity.

The accuracy of the sentinel lymph node concept in early stage squamous cell vulvar carcinoma

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.

Sentinel lymph node biopsy using dynamic lymphoscintigraphy combined with ultrasound-guided fine needle aspiration in penile carcinoma

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.

Validation of the accuracy of the sentinel lymph node procedure in patients with vulvar cancer: results of a multicenter study in Germany

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.

Sentinel lymph node in vulvar cancer

BACKGROUND

The aim of the study was to assess the feasibility, efficacy, and accuracy of the sentinel lymph node (SLN) procedure in vulvar cancer.

METHODS

From April 2004 to September 2006, all patients with vulvar cancer, clinical stages I and II, underwent SLN detection, followed by a complete inguinofemoral lymphadenectomy. Demographic, surgical, and pathologic data on all patients were prospectively entered in a database.

RESULTS

Forty-two patients underwent the SLN procedure. One patient was excluded from further analysis due to metastases to the vulva. The detection rate for at least 1 SLN per patient was 95%, with bilateral SLNs detected in 46% of patients. There was a trend toward improved ability to detect bilateral SLNs and proximity of the cancer to the midline (r = 0.996; P = .057). No contralateral SLNs were identified in patients with lateral vulvar lesions (>1 cm from the midline). For 'close-to-midline' (< or =1 cm from the midline) lesions, SLNs were detected in 93% of ipsilateral groins and bilateral SLNs were found in 46% of patients, whereas lesions abutting the midline had unilateral and bilateral SLN detected in 100% and 93%, respectively. Sixteen of 41 patients (39%) and 18 of 68 groins (26%) revealed metastatic disease in the lymph nodes; all were correctly identified by the SLN procedure. There were no false-negative SLN results.

CONCLUSIONS

SLN dissection is feasible and safe to perform in vulvar cancer. The ability to identify bilateral sentinel inguinal lymph nodes appears to be related to the proximity of the vulvar cancer to the midline.