History and Updates of the GROINSS-V Studies

Identification of groin node metastasis in squamous cell vulval cancer using preoperative [18F] FDG-PET/CT. Can unnecessary lymphadenectomy be prevented?

INTRODUCTION

Vulval cancer is the 4th most common gynaecological cancer. The International Federation of Gynaecology and Obstetrics(FIGO) staging requires a histopathological dissection of the primary tumour and the inguinofemoral lymph nodes(IFLN).However, radiological methods of IFLN assessment often lack accuracy, leading to unnecessary IFLN dissections carrying significant morbidity.

AIM OF THE STUDY

To determine its accuracy of [18F] FDG-PET/CT as a pre-operative assessment tool for the groin lymph node in vulval squamous cell carcinoma.

METHODOLOGY

The predictive value of PET/CT in preoperative assessment of the groin node metastasis was assessed retrospectively in patients with vulval cancer, treated in St. James's Hospital Dublin (2010-2022). SUVmax of the nodal uptake of each inguinal area (if present) was calculated and correlated to histologically confirmed groin metastasis. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of PET/CT in predicating groin node metastasis were calculated. Overall survival was also calculated.

RESULTS

Out of the 200 patients 107(53.3%) had a full histopathological assessment of inguinal area and a PET/CT. Patients had either bilateral or unilateral IFLN histology, yielding 197 groins. The sensitivity of PET/CT for IFLN metastasis was 60.0% and specificity was 92.10%. The PPV was 74.30% and the NPV was 88.60 %. The mean SUVmax was 7(range 1.6-30.0 for metastatic nodes (true positive) and 2.18(range 1.9-3.1) for histologically negative nodes (false positive).

CONCLUSION

This study showed that PET/CT has a moderate sensitivity to identify those at risk of lymph node metastasis. Further prospective studies are required to validate the use of PET-CT in discriminating metastatic from non-metastatic IFLN.

Benchmarking vulvar cancer wound care practice in Australia and New Zealand: A cross-sectional study

PURPOSE

This study aimed to investigate current vulvar cancer wound care practices in Australia and New Zealand, identify knowledge of evidence supporting practice, explore enablers and barriers and determine areas for future improvement and research.

METHODS

An online cross-sectional survey collected quantitative and qualitative data from 64 nurses and doctors between May and July 2023. Descriptive statistics and content analysis were conducted. A consumer advisory group contextualised findings within lived experiences.

RESULTS

Common vulvar wound care practices included wound irrigation (n = 48, 83 %) and perineal drying (n = 40, 69 %), along with urinary catheters (n = 50, 86 %) and drains (n = 33, 57 %). Not using a wound dressing was common (n = 41, 71 %). Using silver (n = 25, 39 %), topical (n = 11, 17 %) or prophylactic (n = 2, 3 %) antibacterial agents were less common. Only 23 % (n = 15) of respondents reported knowledge of organisational guidance and care was commonly determined by practitioner preference, clinical assessment, and specialist wound nurse review. Reported enablers included guidance documents, clear instructions, clinician expertise, effective communication, and a well-informed patient. Reported barriers included infection, comorbidities, clinician variability, lack of evidence, systematic barriers, poor communication, and wound access challenges. The most common suggestion for improvement was the development of evidence based guidance. Four priority areas for future research were identified as; building an evidence base, evaluating the patient experience, investigating the impact of reducing risk factors and evaluating education interventions.

CONCLUSIONS

By benchmarking current wound care practices following surgery for vulvar cancer in Australia and New Zealand, priorities to direct future research and practice change efforts are supported.

Impact of sentinel node use in lymphedema formation among gynecologic cancer patients

PURPOSE OF REVIEW

The most common surgical procedure associated with lymphedema formation is the regional lymphadenectomy. One of the advantages of sentinel node biopsy is the reduction of the risk of lymphedema formation. The purpose of this review is to collect and analyze the most relevant and recent evidence of the use of sentinel node biopsy and its implication on the development of postoperative lymphedema in gynecological cancer.

RECENT FINDINGS

The current evidence of the use of sentinel node biopsy in cervical cancer to reduce lymphedema is heterogeneous and more data is needed to establish its role.Sentinel lymph node biopsy in endometrial cancer is a staging procedure with lower surgical complications, as well as lymphedema formation; while the results of prospective trials evaluating its impact on quality of life are still lacking.Sentinel lymph node biopsy in vulvar cancer minimizes the need for extensive dissection and reduces the incidence of complications associated with overharvesting of lymph nodes such as lymphedema without compromising oncological outcomes.

SUMMARY

The prevalence of lymphedema in gynecological cancer varies based on the surgical treatment or additional therapies applied. Over the past years, one of the most important surgical modifications to decrease lymphedema formation has been implementation of sentinel lymph node technique mainly in vulvar cancer patients.

Imaging in Vulval Cancer

Vulval cancer is a rare gynaecological cancer, accounting for 3% of all gynaecological malignancies, with 47,000 cases in 2022 globally. Various imaging modalities are widely used in conjunction with clinical assessment in the diagnosis and staging of vulval cancers; however, there is significant heterogeneity in which modalities are recommended in international guidelines, reflecting the paucity of evidence in this area. We reviewed the current evidence for the role of imaging in vulval cancer. A systematic search of the literature was performed on the PubMed database using the MeSH terms 'vulval neoplasm' and 'diagnostic imaging'. We found that there is insufficient evidence to support the routine use of imaging for primary vulval tumours. For nodal assessment, there is no ideal imaging modality with sensitivity or specificity that is superior to other modalities. For distant metastases, CT CAP and FDG-PET/CT have the most evidence to support their use. In conclusion, the evidence for role of imaging in vulval cancer is limited by the heterogeneity of the study design and diagnostic criteria used in each study and the small sample size and retrospective nature of most studies.

Upfront boost to gross disease followed by elective pelvic radiation improves compliance to radiation therapy delivery metrics in locally advanced vulvar cancer

Locally advanced cancer of the vulva (LACV) is commonly diagnosed in older women (>65 years), and is treated using combined multimodality therapy (CMT) that includes radiation therapy (RT). Compliance to optimal RT metrics, including completion of > 20 fractions, overall treatment duration of < 8 weeks (56 days), and < 1 week intra-treatment break is associated with better disease outcomes. However, published results note that a significant number of patients with LACV do not adhere to these metrics. The aim of our study is to evaluate whether a modified sequence of RT delivery, treating the localized boost volume upfront followed by the larger elective nodal volume is associated with improved compliance to optimal RT delivery metrics.

Nano-tracers for sentinel lymph node detection: current trends in technique and application

Sentinel lymph node (SLN) detection and biopsy is a critical staging component for several cancers. Apart from established methods using dyes or radiolabeled colloids, newer techniques are emerging, like near-infrared fluorescent compounds, targeted molecular radiopharmaceuticals and magnetic nano-tracers. In the overview section of this review, we categorize SLN detection tracers based on their principle of use. We discuss the merits of existing tracers and provide a glimpse of in-development formulations. A subsequent clinical section explores the expanded role of SLN detection in management of various cancers, citing current medical guidelines and the leading conclusions of long-term clinical trials. The concluding section tries to provide a perspective of promising developments and the work required to bring them to clinical fruition.

Selective Removal of Only Clinically Suspicious Positive Lymph Nodes Instead of a Complete Inguino-Femoral Lymph Node Dissection in Squamous Cell Carcinoma of the Vulva

BACKGROUND

The oncological safety of only removing bulky, positive groin lymph nodes followed by radiotherapy without performing a complete inguino-femoral node dissection (IFL) in squamous cell cancer of the vulva is based on two small studies. The aim of this study was to confirm the oncological safety of this treatment policy.

METHODS

The survival of consecutive patients with clinically suspicious and pathologically positive groin nodes treated with the selective removal of these nodes followed by radiotherapy was compared with the survival in historical controls matched for the variables extranodal spread and diameter of the metastasis > 15 mm and treated with a complete IFL.

RESULTS

There was no difference in disease-specific survival between patients treated with debulking (n = 40) versus complete IFL (n = 37) (43.1% vs. 44.8%, p = 0.336, respectively). Overall, survival and groin recurrence-free survival did not differ between the groups either.

CONCLUSION

This retrospective study in a cohort of women with vulvar cancer corroborates previous smaller studies that have shown that the selective removal of suspicious inguinal nodes yields similar oncological outcomes compared with patients matched for important prognostic variables and treated with a complete IFL when both are followed by radiotherapy.

Role of Sentinel Lymph Node Biopsy for Skin Cancer Based on Clinical Studies

The sentinel lymph node is the first lymph node from the primary tumor. Sentinel lymph node biopsy (SLNB) is a surgical procedure that can detect occult nodal metastasis with relatively low morbidity. It may also have a therapeutic effect via regional disease control. The Multicenter Selective Lymphadenectomy-I (MSLT-I) trial revealed a prognostic benefit from SLNB in melanoma patients. However, it remains unclear whether there is a prognostic benefit from SLNB in patients with nonmelanoma skin cancer owing to a lack of randomized prospective studies. Nevertheless, SLNB provides important information about nodal status, which is one of the strongest factors to predict prognosis and may guide additional nodal treatment. Currently, SLNB is widely used in the management of not only patients with melanoma but also those with nonmelanoma skin cancer. However, the utilization and outcomes of SLNB differ among skin cancers. In addition, SLNB is not recommended for routine use in all patients with skin cancer. In this review, we provide a summary of the role of SLNB and of the indications for SLNB in each skin cancer based on previously published articles.

Leading New Frontiers in Vulva Cancer to Build Personalized Therapy

Approximately 3 in 1000 women will receive a diagnosis of vulvar cancer at some point in their lives [...].

Prognostic role of perineural invasion in vulvar squamous cell carcinoma: A systematic review and meta-analysis

The prognostic role of perineural invasion (PNI) in vulvar squamous cell carcinoma (VSCC) has not been fully established since few studies on this topic are currently available in the literature. In the present study, we conducted a systematic review and metanalysis of literature data in order to determine if PNI could be an independent prognostic predictor of patient's survival in VSCC. Four electronic databases (PubMed, ISI Web of Science, Scopus and Google Scholar) were searched from their inception to December 2021 for all studies assessing the prognostic value of PNI in VSCC. Multivariate hazard ratios (HRs) for overall survival (OS), disease-specific survival (DSS), and progression-free survival (PFS) were pooled. Six studies with 1048 patients were included. PNI was significantly associated with decreased OS (HR = 2.687; p < 0.001), DSS (HR = 2.375; p = 0.014) and PFS (HR = 1.757; p = 0.001), with no statistical heterogeneity among studies and no significant risk of bias across studies. The present meta-analysis highlights that PNI is independently associated with unfavorable prognosis in patients with VSCC. Therefore, PNI should be included in the pathological report of VSCC and considered in combination with other risk factors as a possible criteria for prognostic assessment adjuvant treatment planning inclusion.