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Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 284374, 6 pages doi:10.1155/2011/284374 Review Article Selective Inguinal Lymphadenectomy in the Treatment of Invasive Squamous Cell Carcinoma of the Vulva Christopher P. DeSimone, Jeffrey Elder, and John R. van Nagell Jr. Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The University of Kentucky Chandler Medical Center- Markey Cancer Center, 800 Rose Street, Lexington, KY 40536-0293, USA Correspondence should be addressed to Christopher P. DeSimone, firstname.lastname@example.org Received 6 January 2011; Accepted 5 April 2011 Academic Editor: E. W. Martin Copyright © 2011 Christopher P. DeSimone et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. En bloc radical vulvectomy with bilateral inguinofemoral lymphadenectomy has now been replaced by radical wide excision and selective inguinal lymphadenectomy based on the stage and location of invasive vulvar cancer. Early stage lateral cancers can be eﬀectively treated by radical wide excision and ipsilateral superﬁcial inguinal lymphadenectomy. Lymph node mapping using perilesional injection of radiocolloid and blue dye may identify sentinel lymph nodes which can be removed, thereby avoiding the morbidity of full inguinal lymphadenectomy in selected patients with early stage disease. 1. Introduction the contralateral inguinal lymph nodes if there is no evidence of ipsilateral lymph node metastases. Likewise, it is unusual Although squamous cell carcinoma of the vulva is not com- for the deep inguinal nodes (below the cribriform fascia) to mon, it is occurring with increasing frequency in younger be involved in the absence of superﬁcial inguinal lymph node women, particularly in those exposed to human papilloma spread. The current International Federation of Gynecology virus (HPV). With eﬀorts at education, many patients are and ObstetricsStaging System forvulvarcancerisnow based presenting with early stage disease which is amenable to on surgical ﬁndings as illustrated in Table 1 and reﬂects the surgery. This year, there will be approximately 3500 new extent and location of inguinal lymph node metastases. casesofvulvarcancerinthe United States, representing 5% of all gynecologic cancers . The surgical management of 3. Surgery of the Primary Vulvar Lesion this disease has evolved from en bloc resection of the entire vulva with bilateral superﬁcial and deep inguinofemoral lym- The Basset-Way operation which was the standard of care phadenectomy to a more conservative approach involving in the operative management of patients with vulvar cancer radical wide excision of the primary lesion and speciﬁc included the en bloc resection of the primary lesion and types of inguinal lymphadenectomy based on the stage and surrounding vulvarskinaswell asthe skin over both groins anatomic location of disease. (Figure 2(a)). Although this procedure was curative in the majority of cases, the wound defect was signiﬁcant and incisional breakdown and lymphedema of both lower 2. Anatomic Pathways of Spread and Staging extremities were common. Currently, the surgical treatment The lymphatic drainage of the vulva has been studied of vulvar cancer involves radical wide excision of the primary extensively and described in numerous publications [2, 3]. lesion and inguinal lymphadenectomy through separate Generally, lateralizing lesions (>1cm beyond the midline) groin incisions (Figure 2(b)). Heaps and colleagues  drain to the ipsilateral superﬁcial inguinal lymph nodes, reported that local control of vulvar cancers could be whereas midline lesions can drain to either side (Figure 1). achieved in 100% of cases provided that a 1 cm margin of It is extremely rare for lateralizing vulvar cancers to spread to normal skin was included in the surgical specimen. These 2 International Journal of Surgical Oncology (a) (b) Figure 1: Lateral vulvar lesions >1 cm from the midline (a) spread initially to the ipsilateral superﬁcial inguinal lymph nodes, whereas midline lesions can spread to both groins (b). (a) (b) Figure 2: The Bassett-Way operation includes en bloc radical resection of the primary lesion and surrounding vulvar skin as well as the skin over both groins (a). Radical wide excision of the vulvar cancer includes a margin of at least 1 cm of normal skin around the entire lesion. Inguinal lymphadenectomy is performed through separate groin incisions (b). observations were conﬁrmed by De Hullu and coworkers  a method to identify regional lymph node metastases in who reported that there was no local recurrence of T or breast cancer [12, 13] and cutaneous melanoma and has T vulvar cancers when a margin of at least 8 mm normal now been evaluated in patients with early stage vulvar cancer. skin was excised with the primary lesion. In contrast, patients Speciﬁcally, 1-2 mCi of radiocolloid is injected intradermally with a margin of <8 mm had a local recurrence rate of 22%. around the lesion (Figure 3), and a hand held gamma At present, it is recommended that a margin of at least 1 cm detection device is used to identify the sentinel lymph of normal skin around the circumference of the primary node(s). Recently, lymphoscintigraphy has been combined vulvar lesion be included in the surgical specimen and that with intraoperative perilesional injection of isosulfan blue the underlying subcutaneous tissue be removed to the level as a method to identify sentinel nodes in the inguinal area. of the perineal fascia. Inguinal lymphadenectomy is then Localization of the sentinel node(s) is usually apparent 5–15 performed through separate incisions. minutes after injection of blue dye and 30 minutes after injec- tion of radiocolloid. Selman and colleagues  performed a systematic review of the accuracy of sentinel lymph node 4. Sentinel Lymphadenectomy detection in identifying inguinal lymph node metastases in Sentinel lymph node excision is now being recommended in vulvar cancer and reported that the combination of 99 mTc selected patients with early stage squamous cell carcinoma radiocolloid and isosulfan blue dye successfully detected as a means to avoid the operative morbidity associated with sentinel lymph nodes in 97% of cases. It also had a negative inguinofemoral lymphadenectomy [8–10]. It is estimated predictive value (NPV) of 99.1%. Further analysis has that only 25–30% of patients with early stage vulvar cancer indicated that sentinel lymph node mapping is most accurate have lymph node metastases, and complete inguinofemoral in patients with early stage lateral vulvar cancers . lymphadenectomy is associated with postoperative wound A persisting concern about sentinel lymph node mapping complications and lower extremity edema in 30–40% of in vulvar cancer is the frequency of groin recurrences in patients . Sentinel lymph node mapping using radio- patients with negative sentinel lymph nodes. In a multi- labelled ultraﬁltered sulfur colloid was initially reported as institutional observational study, Van Der Zee and coworkers International Journal of Surgical Oncology 3 Table 1: FIGO staging of invasive cancer of the vulva. of patients having sentinel node excision were signiﬁcantly reduced when compared to that of women undergoing Stage I Tumor conﬁned to the vulva complete inguinofemoral lymphadenectomy. These authors Lesions ≤2 cm in size conﬁned to the vulva or concluded that sentinel node dissection, performed by a IA perineum and with stromal invasion ≤1.0 mm , quality-controlled multidisciplinary team, should be oﬀered no nodal metastasis to selected patients with early stage vulvar cancer as a Lesions >2 cm in size conﬁned to the vulva or means to avoid the postoperative morbidity associated with IB perineum with stromal invasion greater than 1.0 mm , inguinofemoral lymphadenectomy. no nodal metastasis There is a deﬁnite learning curve in the performance Tumor of any size with extension to adjacent perineal and interpretation of lymph node mapping, and it is Stage II structures (1/3 lower urethra, 1/3 lower vagina, anus), recommended that a multidisciplinary group within each no nodal metastasis institution perform sentinel node mapping in at least 10– Tumor of any size with or without extension to adjacent 20 cases before it becomes an accepted procedure [10, 16]. Stage III perineal structures (1/3 lower urethra, 1/3 lower vagina, If sentinel lymph nodes cannot be identiﬁed by mapping or anus) with positive inguinofemoral lymph nodes if there is uncertainty concerning interpretation of ﬁndings, a IIIA With 1 lymph node metastasis (≥5 mm), superﬁcial inguinal lymphadenectomy should be performed. (i) With 2 or more lymph node metastases (≥5 mm), Patients with a positive sentinel node should undergo a IIIB (ii) 3 or more lymph node metastases (<5 mm) full inguinofemoral lymphadenectomy followed by postop- IIIC With positive nodes with extracapsular spread erative radiation therapy to the involved groin and pelvis. Tumor invades other regional (2/3 upper urethra, 2/3 However, if the sentinel lymph nodes identiﬁed by mapping Stage IV upper vagina) or distant structures are histologically negative after review by an experienced Tumor invades any of the following: multidisciplinary team, no further treatment is indicated. (i) Upper urethra and/or vaginal mucosa, bladder It should be emphasized that optimal candidates for sen- IVA mucosa, rectal mucosa, or ﬁxed to pelvic bone, tinel lymph node mapping are patients who have lateral T or (ii) Fixed or ulcerated inguinofemoral lymph nodes T unifocal vulvar cancers <4 cm diameter with nonpalpable IVB Any distant metastasis including pelvic lymph nodes groin nodes . This procedure is less accurate in patients The depth of invasion is deﬁned as the measurement of the tumor from the with midline vulvar lesions or those with advanced stage epithelial-stromal junction of the adjacent most superﬁcial dermal papilla to disease and clinically palpable inguinal nodes . the deepest point of invasion. 5. Superﬁcial Inguinal Lymphadenectomy Many surgeons concerned about the accuracy of sentinel lymph mapping have elected to perform superﬁcial inguinal lymphadenectomy as the treatment of choice in patients with early stage vulvar cancer, believing that the superﬁcial inguinal nodes are themselves “sentinel nodes.” Speciﬁcally, all inguinal lymph nodes above the cribriform fascia are removed en bloc (Figure 4). Approximately 8–10 lymph nodes are excised, and the saphenous vein is preserved in order to decrease the frequency of postoperative lower extremity lymphedema [18, 19]. Berman and coworkers  reported the outcomes of 50 patients with T vulvar cancers <1 cm diameter with stromal invasion >5mm who underwent radical wide excision and superﬁcial inguinal lymphadenectomy. Women with positive superﬁcial inguinal nodes underwent deep inguinal lymphadenectomy and radiation, whereas patients with negative superﬁcial inguinal Figure 3: Sentinel lymph node mapping. Sentinel lymph nodes nodes received no further treatment. There were no isolated are localized by perilesional injection of 99 mTc radiocolloid and groin recurrences noted during a follow-up period of 36 isosulfan blue dye. months. Importantly, only 1 patient died of recurrent cancer, and wound complications were observed in only 12% of patients. These authors concluded that radical wide  performed the sentinel node procedure in 623 groins of excision of the primary lesion and superﬁcial inguinal 403 assessable patients. Two hundred ﬁfty-nine patients with lymphadenectomy was the treatment of choice for most unifocal vulvar cancers <4 cm diameter and negative sentinel women with early stage vulvar cancer and no evidence of nodes were followed without additional therapy for a median enlarged inguinal lymph nodes on clinical examination. A of 35 months. Six groin recurrences (2.3%) were observed, persisting concern of this approach has been a signiﬁcant and the 3-year survival of these patients was 97%. Impor- but low incidence of groin recurrence in patients with tantly, both short-term morbidity and long-term morbidity negative superﬁcial inguinal lymph nodes at the time of 4 International Journal of Surgical Oncology Figure 5: Radical wide excision and bilateral inguinofemoral Figure 4: Radical wide excision and ipsilateral superﬁcial inguinal lymphadenectomy is performed for midline vulvar cancers. This lymphadenectomy is performed for lateral T or T vulvar cancers. 1 2 illustration depicts the right superﬁcial inguinal lymph nodes and All lymph nodes above the cribriform fascia are removed and the the left deep femoral lymph nodes which are seen along the medial saphenous vein is preserved. aspect of the fossa ovalis. lymphadenectomy. Two investigators have reported a 4– At one time, patients with positive superﬁcial or deep 7% incidence of subsequent ipsilateral groin failure after inguinal nodes were treated by pelvic lymphadenectomy. negative primary superﬁcial groin dissection [21, 22]. This However, a prospective trial conducted by the Gynecologic is worrisome since the majority of patients with groin Oncology Group showed that patients with inguinal lymph recurrence died of their disease. However, these studies were node metastasis at the time of groin dissection who were retrospective and in one series  the anatomic location treated by postoperative inguinal and pelvic radiation had of the primary vulvar lesion was not reported. In the most a signiﬁcant survival advantage when compared to similar recent investigation , vulvar cancers that recurred in the patients treated by pelvic lymphadenectomy . Patients in groin after negative superﬁcial inguinal lymphadenectomy the radiation therapy arm received 45–50 Gy to the involved were central periclitoral lesions and the number of lymph groin and pelvis, whereas patients randomized to pelvic nodes removed was small (∼3 per groin). Therefore, these lymphadenectomy underwent a standard extraperitoneal authors recommend superﬁcial inguinal lymphadenectomy excision of the obturator, external iliac, internal iliac, and as the initial surgical approach in patients with lateral Stage I common iliac lymph nodes. This trial showed a statistically or Stage II vulvar cancers provided that an adequate number signiﬁcant survival advantage to patients in the radiation of superﬁcial inguinal lymph nodes (8–10) are removed . therapy arm (68% versus 54% observed survival) on interim Currently, superﬁcial inguinal lymphadenectomy should be analysis . Therefore, most vulvar cancer patients with considered only in patients with lateral T and T vulvar 1 2 positive superﬁcial or deep inguinal lymph node metas- cancers having >1 mm stromal invasion and no clinical tases at the time of inguinal lymphadenectomy are treated evidence of enlarged groin nodes. now by postoperative radiation to the involved groin and pelvis. 6. Deep Inguinal Lymphadenectomy Anatomic studies have indicated that some superﬁcial 7. Unilateral versus Bilateral inguinal nodes may be located within the interstices of the Inguinal Lymphadenectomy cribriform fascia and could be missed by purely superﬁcial inguinal lymphadenectomy . Therefore, some surgeons Anatomic studies have conﬁrmed that eﬀerent lymphatics choose to perform deep inguinal lymphadenectomy rou- from the lateral vulva drain initially to the ipsilateral tinely at the time of superﬁcial inguinal lymphadenectomy. superﬁcial inguinal lymph nodes [2, 27]. Likewise, lateral The deep femoral lymph nodes are always located within vulvar cancers (>1 cm beyond the midline) do not spread the opening of the fossa ovalis medial to the femoral vein, to the contralateral inguinal lymph nodes without ﬁrst and no lymph nodes are distal to the lower margin of the involving the ipsilateral inguinal nodes [27, 28]. These fossa ovalis or lateral to the femoral vein (Figure 5). For this anatomic observations have led toclinicaltrials evaluating reason, incision of the deep fascia of the adductor canal and the eﬃcacy of radical wide excision and ipsilateral inguinal dissection of the femoral vessels, sometimes performed as lymphadenectomy in the treatment of lateral vulvar cancers. part of this procedure, are unnecessary. 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