Real-time Fluorescent ICG and 99m-Tc Nanocolloid Tracer Navigation in Bilateral Sentinel Lymph Node Mapping of Vulvar Cancer

STUDY OBJECTIVE

The effectiveness of sentinel lymph node (SLN) biopsy has been validated by 2 prospective trials, GROINS VI and GOG 173 [1,2]. According to the European Society of Gynaecological Oncology guideline in patients with unifocal tumors with a diameter of <4 cm, in the absence of suspected inguinal lymph nodes, SLN biopsy is recommended. The use of a radioactive tracer is mandatory [2]. Using indocyanine green (ICG) increases the detection of the vulvar sentinel node from 89.7% to 100% [3]. This video aimed to share our experience about the feasibility, safety, and usefulness of the surgical identification of SLN in vulvar cancer using real-time fluorescent ICG with 99m-technetium (Tc) nanocolloid.

DESIGN

A stepwise demonstration of the technique with narrated video footage.

SETTING

Tertiary level hospital "IRCCS Istituto Nazionale dei Tumori," Milano, Italy.

INTERVENTIONS

A 50-year-old woman was diagnosed as having vulvar cancer on biopsy of 1.5 cm size vulvar lesion under the clitoris area and referred to our operative unit. F-18 fluorodeoxyglucose positron emission tomography computed tomography showed no extravulvar disease. The patient was scheduled for radical vulvectomy and bilateral inguinal SLN biopsy. (Video still 1) In this video, the surgical procedure involved double location of SLN, first with the 99m-Tc detector followed by ICG identification. We used an ICG dilution of 2.5 mg/mL in sterile water and injected 4 mL around the tumor 5 to 10 minutes before visualization. First a handheld gamma probe used to identify the location of the SLNs with 99m-Tc. The fluorescence imaging was performed by the quest imaging system (FLUOPTICS, Middenmeer, The Netherlands) that combines autofluorescence and fluorescence perfusion imaging (Video Still 2). Second, we performed the SLN biopsy using a dark mode procedure to identify the IGC tracer (Video Still 3). The fluorescence imaging enables the detection of these markers through some millimeters of tissue, and ICG has the advantage that is visible through the skin [4].

CONCLUSION

This video shows a successful combined 99m-Tc and ICG fluorescence image-guided bilateral SLN biopsy in a vulvar cancer patient using a near-infrared optical imaging system (FLUOPTICS). ICG for SLN mapping seems to be safe in women with vulvar cancer with a satisfactory detection rate. This may help in retaining surgical radicality while minimizing operative complications.

Comorbidity in patients with Lichen sclerosus: a retrospective cohort study

Lichen sclerosus (LS) is a chronic lymphocyte mediated inflammatory mucocutaneous disease of unknown aetiology with a predilection for the anogenital region, and affecting both sexes. The disease is characterized by pain, intolerable itching and scarring. In late stages of LS, disfiguring scarring can drastically alter the structural anatomical architecture of the genitals. The association between genital LS and different malignant tumours is a concern that needs to be further investigated. An association between LS and several autoimmune diseases has been confirmed in recent studies. All registered citizens of Region Jönköping, Sweden were included in the present study. Patients diagnosed with LS (n = 5680) between 2001 and 2021 were identified using ICD-10 code L90.0 and selected as cases. All other individuals (n = 362 568) served as controls. Odds ratios (ORs) for the selected comorbidity were calculated and adjusted for age and sex. The cumulative incidence of LS for the entire population over a 20-year period was 1.54% (15.4 per 1000 people). The cumulative incidences over a 20-year period for females and males were 2.13% and 0.97%, respectively. This study confirmed the association between LS and vulvar cancer (OR = 17.4; 95% CI 12.1-25.3), penis cancer (OR = 9.1; 95% CI 4.3-18.9), prostate cancer (OR = 2.0; 95% CI 1.6-2.4) and breast cancer (OR = 1.6; 95% CI 1.4-1.8). LS was also associated with Crohn´s disease (OR = 2.0; 95% CI 1.6-2.6) and diabetes mellitus type 1 (OR = 1.9; 95% CI 1.6-2.1). The present study revealed novel important data regarding the association of LS with cancer and autoimmune diseases, emphasising the importance of sufficient treatment and follow-up of patients with LS. However, future studies are needed to confirm these results and the potential role of LS in the development of cancer.

Vaginal dryness: individualised patient profiles, risks and mitigating measures

Vaginal dryness (VD) affects both pre- and postmenopausal women at any age. Since the hormonal regulation changes during the climacteric period are considered as being the main course of the VD, affected women prefer not to talk about the problem. However, the problem does exist, and unfortunately if any, relatively minor group in the population possesses the health literacy at sufficient level to understand that VD is a suboptimal health condition which carries a multi-factorial character. Thereby, some of the contributing factors are clearly preventable and, therefore, if treated properly, have a potential to milden the VD. Current chapter demonstrates specific signs and symptoms of Flammer syndrome in women suffering from vaginal dryness, although individualised patient profiles clearly discriminate between pre- and postmenopausal women regarding the subgroup-specific symptoms. Noteworthy, about 20% of the VD patients involved in the study notify a delayed or even impaired wound healing observed for themselves over a couple of years. Optimising modifiable risk factors accompanying FS phenotype at the level of primary prevention is strongly recommended. Individualised patient profiles provide important information for VD mitigating measures tailored to the person. Further, future projects should essentially deal with the complexity of vulvar-vaginal dryness as part of the Sicca syndrome in individuals with FS phenotype, in order to prevent genital female cancers which may occur at any age. In contrast to the human papilloma virus as possible trigger of the disease, the role of the vulvar-vaginal dryness as an important risk factor is strongly underestimated in currently applied diagnostic and treatment approaches.

Clinical Approach to Diagnosis and Management of Cancer of the Cervix and Vulva

This content presents pathology of the cervix and vulva - its diagnosis, staging, treatment, and prognosis. The authors distinguish between the clinical staging of cervical cancer and the surgical staging of vulvar cancer and note advances in surgical, medical, and radiation oncology in the treatment of both cervical and vulvar carcinoma that allow for individualization of patient treatment resulting in improved oncologic outcomes and improved quality of life. Treatment algorithms are presented based on the varying stages at which the cancer is diagnosed.