A.G.J. van der Zee

Risk factors for short- and long-term complications after groin surgery in vulvar cancer

Background:The cornerstone of treatment in early-stage squamous cell carcinoma (SCC) of the vulva is surgery, predominantly consisting of wide local excision with elective uni- or bi-lateral inguinofemoral lymphadenectomy. This strategy is associated with a good prognosis, but also with impressive treatment-related morbidity. The aim of this study was to determine risk factors for the short-term (wound breakdown, infection and lymphocele) and long-term (lymphoedema and cellulitis/erysipelas) complications after groin surgery as part of the treatment of vulvar SCC.Methods:Between January 1988 and June 2009, 164 consecutive patients underwent an inguinofemoral lymphadenectomy as part of their surgical treatment for vulvar SCC at the Department of Gynaecologic Oncology at the Radboud University Nijmegen Medical Centre. The clinical and histopathological data were retrospectively analysed.Results:Multivariate analysis showed that older age, diabetes, ‘en bloc’ surgery and higher drain production on the last day of drain in situ gave a higher risk of developing short-term complications. Younger age and lymphocele gave higher risk of developing long-term complications. Higher number of lymph nodes dissected seems to protect against developing any long-term complications.Conclusion:Our analysis shows that patient characteristics, extension of surgery and postoperative management influence short- and/or long-term complications after inguinofemoral lymphadenectomy in vulvar SCC patients. Further research of postoperative management is necessary to analyse possibilities to decrease the complication rate of inguinofemoral lymphadenectomy; although the sentinel lymph node procedure appears to be a promising technique, in ∼50% of the patients an inguinofemoral lymphadenectomy is still indicated.

What doctors and patients think about false- negative sentinel lymph nodes in vulvar cancer

The sentinel lymph node procedure is a relatively new, minimally-invasive method for the assessment of nodal status in malignancies such as breast cancer, cutaneous melanoma and vulvar cancer. Although highly accurate, this new method is inevitably associated with a certain false-negative rate, possibly leading to worse survival in a small subset of patients. The clinical implementation of the sentinel lymph node procedure is therefore a matter of ongoing debate, especially among doctors. The aim of this study was to assess opinions on the acceptable false-negative rate of the sentinel lymph node procedure in patients with vulvar cancer, who in the past had undergone standard routine radical vulvectomy and complete inguinofemoral lymphadenectomy (and frequently experienced complications), and in gynecologists treating patients with vulvar cancer. Structured questionnaires were sent to both patients and gynecologists. The patients had been treated for vulvar cancer between 1985 and 1993, and were all in complete remission with a median follow-up of 118 months (range: 76–185). Questions to the patients dealt with experienced side-effects of the standard treatment and opinion on the acceptable false-negative rate of the sentinel lymph node procedure. The response rate among patients was 91% (106/117). Forty per cent of the patients experienced one or more infections in the legs (cellulitis) and 49% of the patients still experience either severe pain and/or severe lymphedema in the legs. Sixty-six per cent of the patients preferred complete inguinofemoral lymphadenectomy in preference to a 5% false-negative rate of the sentinel lymph node procedure of 5%. Their preference was not related to age or the side-effects they had experienced. The response rate among gynecologists was 80% (80/100), of whom 60% were willing to accept a 5–20% false-negative rate of the sentinel lymph node procedure. While gynecologists may consider the sentinel lymph node procedure to be a promising diagnostic tool, the majority of vulvar cancer patients, who have undergone complete inguinofemoral lymphadenectomy in the past and have frequently experienced complications, would not advise introduction of this technique because they do not want to take any risk of missing a lymph node metastasis.

Modern management of vulvar cancer.

Purpose of review The radical surgical approach in the treatment of vulvar cancer patients has led to a favourable prognosis for the majority of patients with early stage vulvar cancer. However, morbidity is impressive, leading to more individualized treatment. The authors have reviewed the most recent literature on the pros and cons of the modifications in treatment, including surgery and primary radiotherapy, for primary squamous cell carcinoma of the vulva and vulvar melanoma. Recent findings The sentinel lymph node procedure is a promising method of staging in patients with early stage squamous cell carcinoma of the vulva and possibly for patients with vulvar melanoma, but its safety still has to be proved. Less radical surgery has led to a higher local and regional recurrence rate. There may be a role for primary radiotherapy of the groin in a selected group of patients. Summary The authors have concluded that the individualization of treatment for vulvar cancer patients has led to a decrease in morbidity but an increase in recurrences. The increase in recurrences does not appear to compromise prognosis, probably because of the lack of power, based on the low incidence of vulvar cancer. The sentinel lymph node procedure and primary radiotherapy are promising methods to reduce the morbidity of treatment but their safety needs to be studied in randomized trials.

Adjuvant radiotherapy in patients with vulvar cancer and one intra capsular lymph node metastasis is not beneficial

AIM OF THE STUDYnThe aim of the study was to analyze the benefit from adjuvant radiotherapy in patients with vulvar cancer and a single positive node without extra capsular spread.nnnMATERIALS AND METHODSnThe study population comprised data of 75 patients with vulvar cancer and one lymph node metastasis. The patients were treated in three different university centers in Amsterdam, Groningen and Rotterdam between 1984 and 2005.nnnRESULTSnOut of 75 patients, 31 (41%) were treated with adjuvant radiotherapy. Both disease-free survival (DFS) and disease-specific survival (DSS) were comparable between the groups who did and who did not receive adjuvant radiotherapy (HR 0.98, 95% CI 0.45-2.14, p=0.97 and HR=1.02, 95% CI 0.42-2.47, p=0.96).nnnCONCLUSIONnWe could not demonstrate any beneficial effect of adjuvant radiotherapy in the group of patients with one intra capsular metastasis.

Groin surgery and the sentinel lymph node

Vulvar cancer is a rare disease. Squamous-cell carcinomas account for 90% of vulvar cancers. The main mode of spread is lymphogenic to the inguinofemoral lymph nodes. Therefore, elective uni- or bilateral inguinofemoral lymphadenectomy is part of the standard treatment in combination with radical (wide) local excision of the vulvar tumour. Lymph drainage studies in relation to the biological behaviour of vulvar cancer are presented, as well as the anatomy and surgery of the groin. The sentinel lymph node procedure is a relatively new method of staging in vulvar cancer which may lead to the omission of inguinofemoral lymphadenectomy in those patients identified as not having inguinofemoral lymph node metastases. The accuracy of this technique appears to be high, but its safety still has to be proven. Moreover, the role of additional histopathological techniques for the examination of the sentinel lymph nodes needs to be established.