Regular ArticleThe Importance of the Groin Node Status for the Survival of T1 and T2 Vulval Carcinoma Patients
Abstract
The purpose of this study was to analyze (1) the prognostic factors for survival of T1 and T2 carcinoma patients and (2) the impact of the initial groin node status for the time to recurrence and site of recurrence. We performed a follow-up study on 190 women with a T1 or T2 squamous cell carcinoma of the vulva. Data were obtained on age and general medical condition, the clinical and histological characteristics of the primary tumor and the inguinofemoral lymph nodes, treatment, recurrences, and survival. The standard treatment was radical vulvectomy with bilateral inguinofemoral lymphadenectomy supplemented with postoperative radiotherapy to the primary site, groin, and pelvic side walls if groin metastases were present. Compared to patients without lymph node metastases in the groin, the relative risk of dying within a given time period was estimated to be 2.47 (limits of the 95% confidence interval: 1.24, 4.93) and 9.69 (3.90, 24.03) for patients with unilateral and bilateral node metastases, respectively. The number of metastatic lymph nodes or their intra- or extranodal growth was not associated with survival. The relative risk of dying within a given time period was 2.71 (1.36, 5.40) for patients with a T2 tumor compared to those with a T1 tumor and 2.37 (1.31, 4.31) for patients with vasoinvasive growth compared to those without capillary-lymphatic tumor infiltration. Tumor thickness, differentiation grade, and multifocal growth did not determine survival. In the multivariate Cox regression analysis, the presence of inguinofemoral lymph node metastases proved to be the most important prognostic factor for patients' survival. Of the 119 patients who underwent lymphadenectomy but in whom no groin node metastases were found, 6 (5%) patients manifested an early recurrence (i.e., residual cancer or a recurrence within 2 years after the diagnosis). In contrast, of the 51 patients with histologically documented groin node metastases, 15 (29.4%) manifested an early recurrence and these recurrences appeared equally distributed over the primary site and other sites. Only 1 of the 51 women with documented inguinofemoral lymph node metastases presented with the first manifestation of recurrent cancer in the groin. Groin node metastases did not increase the risk for late recurrences. The presence of inguinofemoral lymph node metastases (none/unilateral/bilateral) is the most important predictor of failure to survive. Groin node metastases are associated with early recurrences which seldomly manifest primarily in the groin if it is hospital policy to supplement the surgical excision with adjunctive radiotherapy.
References (0)
Cited by (191)
Navigating the Complexities of Lymph Node Management in Vulvar Cancer: Insights and Perspectives
2024, Practical Radiation OncologyFeasibility of intraoperative injection of radioactive tracer and blue dye for sentinel lymph node biopsy in vulvar cancer
2023, Gynecologic OncologyThe objective of this study was to examine the feasibility and success rate of intraoperative injection of radiotracer and blue dye performed by the surgeon without the use of preoperative lymphoscintigraphy for the detection of sentinel lymph nodes in clinically early stage vulvar cancer.
All patients with clinically early stage vulvar cancer who underwent attempted sentinel lymph node biopsy using intraoperative injection of Technetium-99 m (99mTc) tracer and blue dye performed by the surgeon after induction of anesthesia at single academic institution from 12/2009 to 5/2022 were identified. Demographic and clinicopathologic variables were collected. Data were compared using descriptive statistics.
One hundred sixty-four patients (median age 66.4 years) underwent intraoperative injection of radioactive tracer and dye for sentinel lymph node biopsy. Most patients (n = 156, 95.1%) were white. Squamous cell carcinoma accounted for 138 cases (84.1%), melanoma for 10 (6.1%), extra-mammary invasive Paget's disease for 11 (6.7%), and other histologies for 5 (3%). A majority of cases were stage I disease on final pathology (n = 119, 72.6%). Most patients (n = 117, 71%) had tumors located within 2 cm of the midline and underwent planned bilateral groin assessment, while 47 (29%) had well lateralized lesions and underwent unilateral groin assessment. For the patients undergoing unilateral groin assessment, 44 of 47 (93.6%) had successful unilateral mapping. Of the patients who underwent bilateral groin assessment, 87 of 117 (74.4%) had successful bilateral mapping, and 26 of 117 (22.2%) had successful unilateral mapping. Of the 26 patients who underwent bilateral assessment but only had unilateral mapping, 19 had unilateral mapping to ipsilateral groin but failed contralateral mapping, six had midline lesions with successful mapping to one groin but failed mapping to the other groin, and one had unilateral mapping to the contralateral groin but not ipsilateral groin. The total successful sentinel lymph node mapping rate in this cohort was 86.5% (243/281 total sentinel lymph node attempts).
In this cohort, the overall success rate of sentinel lymph node mapping and biopsy was 86.5%. The high rate of successful sentinel lymph node mapping supports the use of intraoperative radiotracer and blue dye injection by trained providers.
Invasive cancer of the vulva
2023, DiSaia and Creasman Clinical Gynecologic OncologyInvasive vulvar cancer is a relatively rare tumor, accounting for 4% of all female genital malignant neoplasms. Although classically a disease of elderly women, the trend in recent years is an increasing prevalence among younger women, which cannot be accounted for by immune suppression alone. Human papillomavirus (HPV) is a key age-dependent risk factor that causes preinvasive disease in the form of vulvar intraepithelial neoplasia (VIN) that is often associated with a history of tobacco use. HPV-related VIN lesions are rarer in older women, and these malignancies may be associated with chronic vulvar dystrophies, such as lichen sclerosis, although a direct association remains unproven. Staging is determined surgically and impacts prognosis significantly, with early stages having favorable prognoses while advanced stages portend a much poorer prognosis. Early-stage cancers are managed surgically in most cases with radical excision and lymphadenectomy. Advances in techniques have favored decreasing radicality of surgery with closer margins and sentinel lymph node biopsy. Locally advanced tumors often require combined chemoradiation. Metastatic disease is treated with systemic therapies, traditionally with cytotoxic chemotherapy, though immunotherapy is gaining favorability as more encouraging data are resulting. Recurrences may be local or distant, and more than 80% will occur in the first 2 years after therapy, demanding initial close follow-up.
Preoperative predictors of inguinal lymph node metastases in vulvar cancer – A nationwide study
2022, Gynecologic OncologyA combination of tumour size, differentiation grade and location may identify a group of vulvar squamous cell cancer (VSCC) patients with a very low risk of inguinal lymph node metastasis. We aim to examine these findings in a large national cohort of VSCC patients.
Population based prospective data on VSCC patients treated with vulvectomy and primary groin surgery was obtained from the Danish Gynaecological Cancer Database. Univariate chi-square and multivariate logistic regression analysis were used. Statistical tests were 2-sided. P-values of <0.05 were considered statistically significant.
In all, 388 VSCC patients were identified. Of these 264 (63.3%) were node negative and 121 (36.7%) node positive. Increasing tumour size (diameter ≤ 2 cm vs. > 2 to 4 cm), grade (1 vs. 2–3) and location of tumour to clitoris were all associated with a significantly increased risk of inguinal lymph node metastasis OR 2.81(95% CI 1.52–5.20), OR 3.19 (95% CI 1.77–5.74) and OR 2.74 (95% CI 1.56–5.20), respectively. Previous vulvar disease was not associated with lymph node metastasis.
No lymph node metastasis was demonstrated in patients with grade 1 tumours, tumour size less than 2 cm and located outside the clitoris area (n = 51).
VSCC patients with grade 1 tumours, ≤ 2 cm and without clitoral involvement have a very low risk of inguinal lymph node metastasis. These patients may be spared inguinal lymph node staging to decrease operating time and peri- and postoperative morbidity in the future. However, studies validating our findings are needed.
Population-level trends and outcomes of sentinel lymph node biopsy in vulvar cancer surgery in the United States
2022, Gynecologic OncologyTo examine population-level trends, characteristics, and outcomes related to nodal assessment for vulvar cancer surgery in the United States.
This is a retrospective cohort study querying the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. The study population was 5604 women with T1b or T2-smaller(≤4 cm) squamous cell carcinoma of the vulva who underwent primary vulvectomy from 2003 to 2018. The exposure allocation was based on nodal evaluation type: lymphadenectomy (LND; n = 3319, 59.2%), sentinel lymph node (SLN) biopsy (n = 751, 13.4%), or no surgical nodal evaluation (n = 1534, 27.4%). The main outcomes were (i) trends and characteristics related to SLN biopsy assessed by multinomial regression model, and (ii) vulvar cancer-specific survival assessed by competing risk analysis and inverse probability of treatment weighting propensity score. Sensitivity analysis included evaluation of external cohort with T1a disease (n = 1291).
The utilization of SLN biopsy increased from 5.7% to 23.3% in 2006–2018, while the proportion of LND decreased from 64.1% to 48.8% in 2010–2018, and these associations remained independent in multivariable analysis (adjusted-P < 0.05). In the propensity score weighted model, 5-year cumulative rate for vulvar cancer-specific mortality was 15.2% (interquartile range 12.1–18.9) for the SLN biopsy group and 16.9% (interquartile range 15.6–18.3) for the LND group (subdistribution-hazard ratio 0.90, 95% confidence interval 0.76–1.06, P = 0.217). The increasing SLN biopsy use was also observed in T1a disease from 1.3% to 7.3% during the study period (P < 0.001).
The landscape of surgical nodal evaluation is shifting from lymphadenectomy to SLN biopsy in vulvar cancer surgery in the United States. SLN biopsy-incorporated treatment approach was not associated with worse survival compared to LND.
Sentinel node in gynecological cancers
2022, Nuclear Medicine and Molecular Imaging: Volume 1-4Sentinel node biopsy (SNB) is a minimally invasive technique for assessing the nodal involvement in some gynecological cancers. This technique is safe and feasible in early stages of cervical and vulvar cancers, while is still matter of controversy in early endometrial, vaginal and ovarian cancers. It is indicated for squamous cell carcinoma of vulva with T < 4 cm, > 1 mm depth of invasion and cN0. In cervical cancer, it is advised in stages IA1 with lymphovascular invasion to IB2. In endometrial cancer, it may be considered in patients with apparent uterine-confined disease and cN0 or no obvious extra-uterine disease at exploration or even in high-risk histologies. Preoperative lymphoscintigraphy and SPECT/CT images are crucial to mapping the lymphatic drainage of gynecologic cancers for planning a tailored surgery. Indocyanine green-99mTc-nanocolloid has been recently used in vulvar and cervical cancers with good results, but remains to be confirmed in further studies. Intraoperatively, the handheld gamma probe may be supplemented with the use of a portable gamma camera or an intraoperative freehand SPECT. The ultra-staging should be performed in negative sentinel nodes at hematoxylin and eosin analysis for detecting micro-metastatic disease. Finally, SNB should be done in institutions with expertise in this procedure.