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Oonk MHM, Planchamp F, Baldwin P, Mahner S, Mirza MR, Fischerová D, Creutzberg CL, Guillot E, Garganese G, Lax S, Redondo A, Sturdza A, Taylor A, Ulrikh E, Vandecaveye V, van der Zee A, Wölber L, Zach D, Zannoni GF, Zapardiel I. European Society of Gynaecological Oncology Guidelines for the Management of Patients with Vulvar Cancer - Update 2023. Int J Gynecol Cancer 2023; 33:1023-1043. [PMID: 37369376 PMCID: PMC10359596 DOI: 10.1136/ijgc-2023-004486] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/20/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) first published in 2017 evidence-based guidelines for the management of patients with vulvar cancer. OBJECTIVE To update the ESGO guidelines based on the new evidence addressing the management of vulvar cancer and to cover new topics in order to provide comprehensive guidelines on all relevant issues of diagnosis and treatment of vulvar cancer. METHODS The ESGO Council nominated an international development group comprised of practicing clinicians who provide care to vulvar cancer patients and have demonstrated leadership through their expertize in clinical care and research, national and international engagement and profile as well as dedication to the topics addressed to serve on the expert panel (18 experts across Europe). To ensure that the statements were evidence-based, new data identified from a systematic search were reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the international development group. Prior to publication, the guidelines were reviewed by 206 international practitioners in cancer care delivery and patient representatives. RESULTS The updated guidelines cover comprehensively diagnosis and referral, staging, pathology, pre-operative investigations, surgical management (local treatment, groin treatment, sentinel lymph node procedure, reconstructive surgery), (chemo)radiotherapy, systemic treatment, treatment of recurrent disease (vulvar, inguinal, pelvic, and distant recurrences), and follow-up. Management algorithms are also defined.
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Affiliation(s)
- Maaike H M Oonk
- University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - Sven Mahner
- University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | | | - Daniela Fischerová
- Charles University First Faculty of Medicine, Prague, Czech Republic
- General University Hospital in Prague, Prague, Czech Republic
| | | | | | - Giorgia Garganese
- Catholic University of the Sacred Heart, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sigurd Lax
- Hospital Graz II, Graz, Austria
- Johannes Kepler Universitat Linz, Linz, Austria
| | | | | | | | - Elena Ulrikh
- Almazov National Medical Research Center, Saint Petersburg, Russian Federation
| | | | - Ate van der Zee
- University Medical Center Groningen, Groningen, The Netherlands
| | - Linn Wölber
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Diana Zach
- Karolinska University Hospital, Stockholm, Sweden
- Karolinska Institutet Eugeniavägen, Stockholm, Sweden
| | - Gian Franco Zannoni
- Catholic University of the Sacred Heart, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Pedrão PG, Guimarães YM, Godoy LR, Possati-Resende JC, Bovo AC, Andrade CEMC, Longatto-Filho A, dos Reis R. Management of Early-Stage Vulvar Cancer. Cancers (Basel) 2022; 14:cancers14174184. [PMID: 36077719 PMCID: PMC9454625 DOI: 10.3390/cancers14174184] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 11/22/2022] Open
Abstract
Simple Summary Vulvar cancer is a rare gynecological malignancy that affects mainly postmenopausal women. Recently, however, an alarming increase in the rates among young women has been observed due to human papillomavirus infection. The standard treatment for vulvar cancer is surgery with or without radiotherapy as adjuvant treatment. In recent decades, sentinel lymph node biopsy has been included as part of the surgical treatment. Thus, our objective was to review and discuss the advances found in the literature about early-stage vulvar cancer. For this, we searched PubMed for publications in the English language. Relevant articles, such as the GROINS-V studies, and the GOG protocols, are presented in this review exhibiting the evolution of early-stage vulvar cancer treatment and the decrease in surgical morbidity rates. Abstract Vulvar cancer is a rare gynecological malignancy since it represents 4% of all cancers of the female genital tract. The most common histological type is squamous cell carcinoma (90%). This type can be classified into two clinicopathological subtypes according to the etiology. The first subtype is associated with persistent human papillomavirus infection and is usually diagnosed in younger women. The second subtype is associated with lichen sclerosus condition, and in most cases is diagnosed in postmenopausal women. Currently, an increase in first subtype cases has been observed, which raised the concern about associated mortality and treatment morbidity among young women. Vulvar cancer treatment depends on histopathology grade and staging, but surgery with or without radiotherapy as adjuvant treatment is considered the gold standard. In recent decades, sentinel lymph node biopsy has been incorporated as part of the treatment. Therefore, we sought to review and discuss the advances documented in the literature about vulvar cancer focusing on the treatment of early-stage disease. Relevant articles, such as the GROINS-V studies and the GOG protocols, are presented in this review. Additionally, we discuss key points such as the evolution of treatment from invasive surgery with high morbidity, to more conservative approaches without compromising oncologic safety; the role of sentinel lymph node mapping in the initial staging, since it reduces the complications caused by inguinofemoral lymphadenectomy; the recurrences rates, since local recurrence is common and curable, however, groin-associated, or distant recurrences have a poor prognosis; and, finally, the long-term follow-up that is essential for all patients.
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Affiliation(s)
- Priscila Grecca Pedrão
- Molecular Oncology Research Center, Barretos Cancer Hospital, São Paulo 14784-400, Brazil
| | | | - Luani Rezende Godoy
- Molecular Oncology Research Center, Barretos Cancer Hospital, São Paulo 14784-400, Brazil
| | | | - Adriane Cristina Bovo
- Department of Prevention Oncology, Barretos Cancer Hospital, Mato Grosso do Sul 79085-040, Brazil
| | - Carlos Eduardo Mattos Cunha Andrade
- Department of Gynecologic Oncology, Barretos Cancer Hospital, São Paulo 14784-400, Brazil
- Barretos School of Health Sciences, Dr. Paulo Prata-FACISB, Barretos, São Paulo 14785-002, Brazil
| | - Adhemar Longatto-Filho
- Molecular Oncology Research Center, Barretos Cancer Hospital, São Paulo 14784-400, Brazil
- Medical Laboratory of Medical Investigation (LIM) 14, Department of Pathology, Medical School, University of São Paulo, São Paulo 01246-903, Brazil
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s—PT Government Associate Laboratory, 4710-057 Braga, Portugal
- ICVS/3B’s—PT Government Associate Laboratory, 4805-017 Guimarães, Portugal
| | - Ricardo dos Reis
- Department of Gynecologic Oncology, Barretos Cancer Hospital, São Paulo 14784-400, Brazil
- Correspondence: ; Tel.: +55-3321-6600 (ext. 7126)
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Madhunarayana B, Rajagopalan Iyer R, Patnaik SC, Raju KVVN, Murthy SS, Kodandapani S, Subramanyeshwar Rao T. ICG-Based Sentinel Lymph Node Biopsy in Endometrioid Endometrial Carcinoma—Results of a Prospective Study from a Single Tertiary Cancer Center of India. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2021. [DOI: 10.1007/s40944-021-00586-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zhou W, Bai Y, Yue Y. Safety and Benefit Of Sentinel Lymph Nodes Biopsy Compared to Regional Lymph Node Dissection in Primary Vulvar Cancer Patients Without Distant Metastasis and Adjacent Organ Invasion: A Retrospective Population Study. Front Oncol 2021; 11:676038. [PMID: 34381709 PMCID: PMC8350928 DOI: 10.3389/fonc.2021.676038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/06/2021] [Indexed: 11/29/2022] Open
Abstract
Background The safety and benefit of sentinel lymph node biopsy (SLNB) compared with regional lymph node dissection (RLND) and no lymph nodes removed (NA) in patients with vulvar squamous cell cancer (VSCC) was not well studied. Methods A retrospective analysis on VSCC patients without distant metastasis and adjacent organ invasion from the Surveillance, Epidemiology, and End Results Program database between 2004 and 2016 was carried out. Within subgroups stratified by negative (LN−) or positive (LN+) regional lymph node findings, inverse probability weighting (IPW) adjusted multivariate Fine-Gray compete risk (CR) model and accelerated failure time (AFT) model was used to investigate the factors associated with and cancer-specific survival (CSS) and overall survival (OS). Results Of the 3,161 VSCC patients treated with surgery, 287 (9.1%) underwent SLNB, 1,716 (54.3%) underwent RLND, and 1,158 (36.6%) had no regional lymph nodes removed. As illustrated by IPW adjusted multivariate regressions, SLNB was significantly associated with prolonged CSS (LN−, adjusted sub-proportional hazard ratio [sHR] = 0.42; 95% confidence interval [CI], 0.19–0.93; P=0.032; LN+, adjusted sHR = 0.29; 95% CI, 0.16–0.54, P<0.001) and OS (LN−, adjusted time ratio [TR] = 1.38; 95% CI, 0.82–2.32; P=0.226; LN+, adjusted TR = 2.68; 95% CI, 1.73–4.14; P<0.001), although the effect of SLNB on OS was not significant within the LN− cohort. Moreover, SLNB led to improved CSS (adjusted sHR = 0.40; 95% CI, 0.23–0.70; P = 0.001) and OS (adjusted TR=1.15, 95% CI 0.76-1.73, P=0.279) compared with NA. Age was a significant prognostic factor of CSS and OS, whereas tumor size, surgery type, and invasion depth were not. Conclusions SLNB leads to significantly prolonged CSS and OS in VSCC surgery patients without distant metastasis and adjacent organ invasion than RLND, except for the similar OS in the LN− cohort. SLNB could be carried out preferentially for VSCC surgery patients without distant metastasis and adjacent organ invasion, irrespective of tumor size, surgery type, invasion depth, and regional lymph nodes metastasis. Further prospective clinical trials are warranted to confirm the findings of this study.
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Affiliation(s)
- Weili Zhou
- Department of General Surgery, Shengjing Hospital, China Medical University, Shenyang, China
| | - Yang Bai
- Department of General Surgery, Shengjing Hospital, China Medical University, Shenyang, China
| | - Yangyang Yue
- Department of Health Management, Shengjing Hospital, China Medical University, Shenyang, China
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Nagar H, Wietek N, Goodall RJ, Hughes W, Schmidt-Hansen M, Morrison J. Sentinel node biopsy for diagnosis of lymph node involvement in endometrial cancer. Cochrane Database Syst Rev 2021; 6:CD013021. [PMID: 34106467 PMCID: PMC8189170 DOI: 10.1002/14651858.cd013021.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Pelvic lymphadenectomy provides prognostic information for those diagnosed with endometrial (womb) cancer and provides information that may influence decisions regarding adjuvant treatment. However, studies have not shown a therapeutic benefit, and lymphadenectomy causes significant morbidity. The technique of sentinel lymph node biopsy (SLNB), allows the first draining node from a cancer to be identified and examined histologically for involvement with cancer cells. SLNB is commonly used in other cancers, including breast and vulval cancer. Different tracers, including colloid labelled with radioactive technetium-99, blue dyes, e.g. patent or methylene blue, and near infra-red fluorescent dyes, e.g. indocyanine green (ICG), have been used singly or in combination for detection of sentinel lymph nodes (SLN). OBJECTIVES To assess the diagnostic accuracy of sentinel lymph node biopsy (SLNB) in the identification of pelvic lymph node involvement in women with endometrial cancer, presumed to be at an early stage prior to surgery, including consideration of the detection rate. SEARCH METHODS We searched MEDLINE (1946 to July 2019), Embase (1974 to July 2019) and the relevant Cochrane trial registers. SELECTION CRITERIA We included studies that evaluated the diagnostic accuracy of tracers for SLN assessment (involving the identification of a SLN plus histological examination) against a reference standard of histological examination of removed pelvic +/- para-aortic lymph nodes following systematic pelvic +/- para-aortic lymphadenectomy (PLND/PPALND) in women with endometrial cancer, where there were sufficient data for the construction of two-by-two tables. DATA COLLECTION AND ANALYSIS Two review authors (a combination of HN, JM, NW, RG, and WH) independently screened titles and abstracts for relevance, classified studies for inclusion/exclusion and extracted data. We assessed the methodological quality of studies using the QUADAS-2 tool. We calculated the detection rate as the arithmetic mean of the total number of SLNs detected out of the total number of women included in the included studies with the woman as the unit of analysis, used univariate meta-analytical methods to estimate pooled sensitivity estimates, and summarised the results using GRADE. MAIN RESULTS The search revealed 6259 unique records after removal of duplicates. After screening 232 studies in full text, we found 73 potentially includable records (for 52 studies), although we were only able to extract 2x2 table data for 33 studies, including 2237 women (46 records) for inclusion in the review, despite writing to trial authors for additional information. We found 11 studies that analysed results for blue dye alone, four studies for technetium-99m alone, 12 studies that used a combination of blue dye and technetium-99m, nine studies that used indocyanine green (ICG) and near infra-red immunofluorescence, and one study that used a combination of ICG and technetium-99m. Overall, the methodological reporting in most of the studies was poor, which resulted in a very large proportion of 'unclear risk of bias' ratings. Overall, the mean SLN detection rate was 86.9% (95% CI 82.9% to 90.8%; 2237 women; 33 studies; moderate-certainty evidence). In studies that reported bilateral detection the mean rate was 65.4% (95% CI 57.8% to 73.0%) . When considered according to which tracer was used, the SLN detection rate ranged from 77.8% (95% CI 70.0% to 85.6%) for blue dye alone (559 women; 11 studies; low-certainty evidence) to 100% for ICG and technetium-99m (32 women; 1 study; very low-certainty evidence). The rates of positive lymph nodes ranged from 5.2% to 34.4% with a mean of 20.1% (95% CI 17.7% to 22.3%). The pooled sensitivity of SLNB was 91.8% (95% CI 86.5% to 95.1%; total 2237 women, of whom 409 had SLN involvement; moderate-certainty evidence). The sensitivity for of SLNB for the different tracers were: blue dye alone 95.2% (95% CI 77.2% to 99.2%; 559 women; 11 studies; low-certainty evidence); Technetium-99m alone 90.5% (95% CI 67.7% to 97.7%; 257 women; 4 studies; low-certainty evidence); technetium-99m and blue dye 91.9% (95% CI 74.4% to 97.8%; 548 women; 12 studies; low-certainty evidence); ICG alone 92.5% (95% CI 81.8% to 97.1%; 953 women; 9 studies; moderate-certainty evidence); ICG and blue dye 90.5% (95% CI 63.2.6% to 98.1%; 215 women; 2 studies; low-certainty evidence); and ICG and technetium-99m 100% (95% CI 63% to 100%; 32 women; 1 study; very low-certainty evidence). Meta-regression analyses found that the sensitivities did not differ between the different tracers used, between studies with a majority of women with FIGO stage 1A versus 1B or above; between studies assessing the pelvic lymph node basin alone versus the pelvic and para-aortic lymph node basin; or between studies that used subserosal alone versus subserosal and cervical injection. It should be noted that a false-positive result cannot occur, as the histological examination of the SLN is unchanged by the results from any additional nodes removed at systematic lymphadenectomy. AUTHORS' CONCLUSIONS The diagnostic test accuracy for SLNB using either ICG alone or a combination of a dye (blue or ICG) and technetium-99m is probably good, with high sensitivity, where a SLN could be detected. Detection rates with ICG or a combination of dye (ICG or blue) and technetium-99m may be higher. The value of a SLNB approach in a treatment pathway, over adjuvant treatment decisions based on uterine factors and molecular profiling, requires examination in a high-quality intervention study.
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Affiliation(s)
- Hans Nagar
- Belfast Health and Social Care Trust, Belfast City Hospital and the Royal Maternity Hospital, Belfast, UK
| | - Nina Wietek
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Richard J Goodall
- Department of Surgery and Cancer , Imperial College London, London, UK
| | - Will Hughes
- Department of Plastic Surgery, Addenbrookes Hospital, Cambridge, UK
| | - Mia Schmidt-Hansen
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, GRACE Centre, Musgrove Park Hospital, Taunton, UK
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Siegenthaler F, Imboden S, Knabben L, Mohr S, Papadia A, Mueller MD. Exploratory Study of the Clinical Value of Near-Infrared Sentinel Lymph Node Mapping With Indocyanine Green in Vulvar Cancer Patients. Front Oncol 2021; 11:652458. [PMID: 33968754 PMCID: PMC8100341 DOI: 10.3389/fonc.2021.652458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/30/2021] [Indexed: 11/25/2022] Open
Abstract
Background This study aimed to evaluate the clinical value of indocyanine green sentinel lymph node (SLN) mapping in patients with vulvar cancer. The conventional procedure of SLN mapping in vulvar cancer includes peritumoral injection of technetium-99m nanocolloid before surgery and intraoperative injection of a blue dye. However, these techniques harbor some limitations. Near-infrared fluorescence imaging with indocyanine green has gained popularity in SLN mapping in different types of cancer. Methods We analyzed retrospectively vulvar cancer patients at our institution between 2013 and 2020 undergoing indocyanine green SLN mapping by applying video telescope operating microscope system technology. Results 64 groins of 34 patients were analyzed. In 53 groins we used technetium-99m nanocolloid, in four patent blue, and in five both techniques, additionally to indocyanine green for SLN detection. In total, 120 SLNs were identified and removed. The SLN detection rate of indocyanine green was comparable to technetium-99m nanocolloid (p=.143) and higher than patent blue (p=.003). The best results were achieved using a combination of ICG and technetium-99m nanocolloid (detection rate of 96.9%). SLN detection rates of indocyanine green were significantly higher in patients with positive lymph nodes (p=.035) and lymphatic space invasion (p=.004) compared to technetium-99m nanocolloid. Conclusion Indocyanine green SLN mapping in vulvar cancer is feasible and safe, with reasonable detection rates. Due to its easy application and few side effects, it offers a sound alternative to the conventional SLN mapping techniques in vulvar cancer. In patients with lymph node metastasis, indocyanine green even outperformed technetium-99m nanocolloid in terms of detection rate.
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Affiliation(s)
- Franziska Siegenthaler
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Sara Imboden
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Laura Knabben
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Stefan Mohr
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Andrea Papadia
- Department of Obstetrics and Gynecology, Ente Ospedaliere Cantonale, University of the Italian Switzerland, Lugano, Switzerland
| | - Michael D Mueller
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, Bern, Switzerland
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Jedryka MA, Klimczak P, Kryszpin M, Matkowski R. Superparamagnetic iron oxide: a novel tracer for sentinel lymph node detection in vulvar cancer. Int J Gynecol Cancer 2020; 30:1280-1284. [PMID: 32675253 DOI: 10.1136/ijgc-2020-001458] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Superparamagnetic techniques for sentinel lymph node (SLNs) biopsy in breast cancer is well recognized but remains novel in the literature in relation to early stage vulvar cancer. The aim of this study was to compare and validate SLN detection using a superparamagnetic iron oxide tracer and a magnetometer probe compared with the standard procedure with a radioisotope (99Tc-technetium 99) and a gamma probe, in patients with vulvar cancer. METHODS Patients were included in the study with squamous vulvar tumors less than 4 cm in diameter and without suspicious groin lymph nodes on preoperative magnetic resonance imaging. Patients must have previously qualified for SLN biopsy with a radiotracer as the standard of care. The primary endpoint was the proportion of successful SLN detection with superparamagnetic iron oxide tracer versus 99Tc. The secondary endpoints were average number of SLNs retrieved per patient, proportion of SLNs detected (nodal detection rate), and proportion of pathologically positive results (malignancy rate) per patient and per node comparing both SLN detection methods. RESULTS A total of 20 patients were included in the study. SLNs were found in all patients with both methods, resulting in similar average distributions (3.1/3.2 SLN per patient). The SLN detection rate per patient was 100% with both techniques. Nodal detection sensitivity was 98.5% for the superparamagnetic technique and 93.8% for the radiotracer. Percentage of metastatic lymph nodes detected was 100% with both tracers. The rate of lymph node positivity was 21.5% (14 lymph nodes with metastases) and for patients 45% (9 patients with nodal metastases). Additionally, SLN tainted brown due to superparamagnetic iron oxide nanoparticles in 19 of 20 patients. CONCLUSIONS The use of superparamagnetic iron oxide tracer in patients with vulvar cancer seems reliable and not inferior to the standard approach with radiotracer.
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Affiliation(s)
- Marcin A Jedryka
- Gynecological Oncology, Wroclaw Medical University, Wroclaw, Dolnoslaskie, Poland .,Oncological Gynecology, Wroclaw Comprehensive Cancer Center, Wroclaw, Dolnoslaskie, Poland
| | - Piotr Klimczak
- Gynecological Oncology, Regional Oncology Centre of Professor Tadeusz Koszarowski in Opole, Opole, Poland
| | - Marcin Kryszpin
- Oncological Gynecology, Wroclaw Comprehensive Cancer Center, Wroclaw, Dolnoslaskie, Poland
| | - Rafal Matkowski
- Oncology, Wroclaw Medical University, Wroclaw, Dolnoslaskie, Poland.,Breast Unit, Wroclaw Comprehensive Cancer Center, Wroclaw, Dolnoslaskie, Poland
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Prader S, du Bois A, Harter P, Breit E, Schneider S, Baert T, Heitz F, Traut A, Ehmann S, Pauly N, Heikaus S, Moka D, Ataseven B. Sentinel lymph node mapping with fluorescent and radioactive tracers in vulvar cancer patients. Arch Gynecol Obstet 2020; 301:729-736. [PMID: 32055954 DOI: 10.1007/s00404-019-05415-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 12/07/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Application of radioactive tracers for sentinel lymph node biopsy (SLNB) in vulvar cancer has been established, however, the use of radioisotopes is expensive and requires complex logistics. This exploratory study evaluated the feasibility of near-infrared fluorescence-based SLNB in comparison to the gold standard using radioactive guidance. METHODS At Evangelische Kliniken Essen-Mitte (Essen, Germany) between 02/2015 and 04/2019, 33 patients with squamous cell vulvar cancer and unifocal tumors (32 midline, 1 lateral) smaller than 4 cm underwent SLNB as part of their routine primary surgical therapy. Radiolabeled nanocolloid technetium 99 (99mTc) was injected preoperatively and indocyanine green (ICG) intraoperatively. Demographic and clinical data were retrieved from patients' records, and descriptive statistics were applied. The detection rate of the ICG fluorescence technique was compared with the standard radioactive approach. RESULTS In patients with midline tumors, bilateral SLNB was attempted. SLNB was feasible in 61/64 (95.3%) groins with 99mTc and in 56/64 (87.5%) with ICG. In total, 125 SLNs were excised; all SLNs were radioactive and 117 (93.6%) also fluorescent. In 8 patients with BMI > 30 kg/m2, SLNB was successful in 14/15 groins (93.3%) with 99mTc and 13/15 groins (86.7%) with ICG. Upon final histology, infiltrated nodes were present in 9/64 (14.1%) groins and 10/125 SLNs; one positive SLN was not detected with ICG. CONCLUSIONS SLNB using ICG is a promising technique, however, the detection rate obtained was slightly lower than with 99mTc. The detection rate increased over time indicating that experience and training may play an important role besides further methodological refinements.
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Affiliation(s)
- Sonia Prader
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte (KEM) gGmbH, Evang. Huyssens-Stiftung Essen-Huttrop, Henricistrasse 92, 45136, Essen, Germany.
| | - Andreas du Bois
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte (KEM) gGmbH, Evang. Huyssens-Stiftung Essen-Huttrop, Henricistrasse 92, 45136, Essen, Germany
| | - Philipp Harter
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte (KEM) gGmbH, Evang. Huyssens-Stiftung Essen-Huttrop, Henricistrasse 92, 45136, Essen, Germany
| | - Elisabeth Breit
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte (KEM) gGmbH, Evang. Huyssens-Stiftung Essen-Huttrop, Henricistrasse 92, 45136, Essen, Germany
- Breast Unit, Evang. Kliniken Essen-Mitte gGmbH, Essen, Germany
| | - Stephanie Schneider
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte (KEM) gGmbH, Evang. Huyssens-Stiftung Essen-Huttrop, Henricistrasse 92, 45136, Essen, Germany
| | - Thais Baert
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte (KEM) gGmbH, Evang. Huyssens-Stiftung Essen-Huttrop, Henricistrasse 92, 45136, Essen, Germany
| | - Florian Heitz
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte (KEM) gGmbH, Evang. Huyssens-Stiftung Essen-Huttrop, Henricistrasse 92, 45136, Essen, Germany
| | - Alexander Traut
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte (KEM) gGmbH, Evang. Huyssens-Stiftung Essen-Huttrop, Henricistrasse 92, 45136, Essen, Germany
| | - Sarah Ehmann
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte (KEM) gGmbH, Evang. Huyssens-Stiftung Essen-Huttrop, Henricistrasse 92, 45136, Essen, Germany
| | - Nina Pauly
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte (KEM) gGmbH, Evang. Huyssens-Stiftung Essen-Huttrop, Henricistrasse 92, 45136, Essen, Germany
| | | | | | - Beyhan Ataseven
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte (KEM) gGmbH, Evang. Huyssens-Stiftung Essen-Huttrop, Henricistrasse 92, 45136, Essen, Germany
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
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Nagar H, Goodall RJ, Lyons TJ, Schmidt-Hansen M, Morrison J. Sentinel node biopsy for diagnosis of lymph node involvement in endometrial cancer. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2018. [DOI: 10.1002/14651858.cd013021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Hans Nagar
- Belfast City Hospital and the Royal Maternity Hospital; Belfast Health and Social Care Trust; Belfast UK
| | | | - Thomas J Lyons
- University of Bristol; School of Medical Sciences; 38 Kings Parade Avenue Bristol UK BS8 2RB
| | - Mia Schmidt-Hansen
- Royal College of Obstetricians and Gynaecologists; National Guideline Alliance; 27 Sussex Pl Regent's Park London UK NW1 4RG
| | - Jo Morrison
- Musgrove Park Hospital; Department of Gynaecological Oncology; Taunton and Somerset NHS Foundation Trust Taunton Somerset UK TA1 5DA
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10
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Gómez-Hidalgo NR, Chen L, Hou JY, Tergas AI, St Clair CM, Ananth CV, Hershman DL, Wright JD. Trends in Sentinel Lymph Node Mapping and Adjuvant Therapy in Endometrial Carcinoma. Cancer Invest 2018; 36:190-198. [PMID: 29565689 DOI: 10.1080/07357907.2018.1449212] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
We analyzed 54,039 women with uterine cancer in the National Cancer Database from 2013 to 2014 including 38,453 (71.2%) who underwent lymphadenectomy, 1929 (3.6%) who underwent sentinel lymph node (SLN) mapping, and 13,657 (25.3%) who did not undergo nodal assessment. SLN mapping increased from 2.8% in 2013 to 4.3% in 2014 (P < 0.001). Patients treated in 2014 and those at community centers were more likely to undergo SLN biopsy, while women with advanced-stage disease, sarcomas, and grade 3 tumors were less likely to undergo SLN mapping (P < 0.05). There was no association between use of SLN biopsy and use of radiation (aRR = 0.92; 95% CI, 0.82-1.05).
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Affiliation(s)
- Natalia R Gómez-Hidalgo
- a Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , USA
| | - Ling Chen
- a Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , USA
| | - June Y Hou
- a Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , USA.,d Herbert Irving Comprehensive Cancer Center , Columbia University College of Physicians and Surgeons , New York , New York , USA.,e New York Presbyterian Hospital , New York , New York , USA
| | - Ana I Tergas
- a Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , USA.,c Department of Epidemiology, Joseph L. Mailman School of Public Health , Columbia University , New York , New York , USA.,d Herbert Irving Comprehensive Cancer Center , Columbia University College of Physicians and Surgeons , New York , New York , USA.,e New York Presbyterian Hospital , New York , New York , USA
| | - Caryn M St Clair
- a Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , USA.,d Herbert Irving Comprehensive Cancer Center , Columbia University College of Physicians and Surgeons , New York , New York , USA.,e New York Presbyterian Hospital , New York , New York , USA
| | - Cande V Ananth
- a Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , USA.,c Department of Epidemiology, Joseph L. Mailman School of Public Health , Columbia University , New York , New York , USA
| | - Dawn L Hershman
- b Department of Medicine , Columbia University College of Physicians and Surgeons , New York , New York , USA.,c Department of Epidemiology, Joseph L. Mailman School of Public Health , Columbia University , New York , New York , USA.,d Herbert Irving Comprehensive Cancer Center , Columbia University College of Physicians and Surgeons , New York , New York , USA.,e New York Presbyterian Hospital , New York , New York , USA
| | - Jason D Wright
- a Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , USA.,d Herbert Irving Comprehensive Cancer Center , Columbia University College of Physicians and Surgeons , New York , New York , USA.,e New York Presbyterian Hospital , New York , New York , USA
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11
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Cham S, Chen L, Burke WM, Hou JY, Tergas AI, Hu JC, Ananth CV, Neugut AI, Hershman DL, Wright JD. Utilization and Outcomes of Sentinel Lymph Node Biopsy for Vulvar Cancer. Obstet Gynecol 2017; 128:754-60. [PMID: 27607871 DOI: 10.1097/aog.0000000000001648] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the use and predictors of sentinel node biopsy in women with vulvar cancer. METHODS The Perspective database, an all-payer database that collects data from more than 500 hospitals, was used to perform a retrospective cohort study of women with vulvar cancer who underwent vulvectomy and lymph node assessment from 2006 to 2015. Multivariable models were used to determine factors associated with sentinel node biopsy. Length of stay and cost were compared between women who underwent sentinel node biopsy and lymphadenectomy. RESULTS Among 2,273 women, sentinel node biopsy was utilized in 618 (27.2%) and 1,655 (72.8%) underwent inguinofemoral lymphadenectomy. Performance of sentinel node biopsy increased from 17.0% (95% confidence interval [CI] 12.0-22.0%) in 2006 to 39.1% (95% CI 27.1-51.0%) in 2015. In a multivariable model, women treated more recently were more likely to have undergone sentinel node biopsy, whereas women with more comorbidities and those treated at rural hospitals were less likely to have undergone the procedure. The median length of stay was shorter for those undergoing sentinel node biopsy (median 2 days, interquartile range 1-3) compared with women who underwent inguinofemoral lymphadenectomy (median 3 days, interquartile range 2-4). The cost of sentinel node biopsy was $7,599 (interquartile range $5,739-9,922) compared with $8,095 (interquartile range $5,917-11,281) for lymphadenectomy. CONCLUSION The use of sentinel node biopsy for vulvar cancer has more than doubled since 2006. Sentinel lymph node biopsy is associated with a shorter hospital stay and decreased cost compared with inguinofemoral lymphadenectomy.
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Affiliation(s)
- Stephanie Cham
- Departments of Obstetrics and Gynecology and Medicine and the Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, the Department of Epidemiology, Mailman School of Public Health, Columbia University, the Department of Urology, Weill Cornell Medical College, and New York Presbyterian Hospital, New York, New York
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12
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Wright JD, Cham S, Chen L, Burke WM, Hou JY, Tergas AI, Desai V, Hu JC, Ananth CV, Neugut AI, Hershman DL. Utilization of sentinel lymph node biopsy for uterine cancer. Am J Obstet Gynecol 2017; 216:594.e1-594.e13. [PMID: 28213057 DOI: 10.1016/j.ajog.2017.02.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 01/24/2017] [Accepted: 02/08/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND To limit the potential short and long-term morbidity of lymphadenectomy, sentinel lymph node biopsy has been proposed for endometrial cancer. The principle of sentinel lymph node biopsy relies on removal of a small number of lymph nodes that are the first drainage basins from a tumor and thus the most likely to harbor tumor cells. While the procedure may reduce morbidity, efficacy data are limited and little is known about how commonly the procedure is performed. OBJECTIVE We examined the patterns and predictors of use of sentinel lymph node biopsy and outcomes of the procedure in women with endometrial cancer who underwent hysterectomy. STUDY DESIGN We used the Perspective database to identify women with uterine cancer who underwent hysterectomy from 2011 through 2015. Billing and charge codes were used to classify women as having undergone lymphadenectomy, sentinel lymph node biopsy, or no nodal assessment. Multivariable models were used to examine clinical, demographic, and hospital characteristics with use of sentinel lymph node biopsy. Length of stay and cost were compared among the different methods of nodal assessment. RESULTS Among 28,362 patients, 9327 (32.9%) did not undergo nodal assessment, 17,669 (62.3%) underwent lymphadenectomy, and 1366 (4.8%) underwent sentinel lymph node biopsy. Sentinel lymph node biopsy was performed in 1.3% (95% confidence interval, 1.0-1.6%) of abdominal hysterectomies, 3.4% (95% confidence interval, 2.7-4.1%) of laparoscopic hysterectomies, and 7.5% (95% confidence interval, 7.0-8.0%) of robotic-assisted hysterectomies. In a multivariable model, more recent year of surgery was associated with performance of sentinel lymph node biopsy. Compared to abdominal hysterectomy, those undergoing laparoscopic (adjusted risk ratio, 2.45; 95% confidence interval, 1.89-3.18) and robotic-assisted (adjusted risk ratio, 2.69; 95% confidence interval, 2.19-3.30) hysterectomy were more likely to undergo sentinel lymph node biopsy. Among women who underwent minimally invasive hysterectomy, length of stay and cost were lower for sentinel lymph node biopsy compared to lymphadenectomy. CONCLUSION The use of sentinel lymph node biopsy for endometrial cancer increased from 2011 through 2015. The increased use was most notable in women who underwent a robotic-assisted hysterectomy.
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13
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Derdelis G, Pergialiotis V, Terzakis E, Koufopoulos N, Martzoukou I, Gakiopoulou C, Lazaris A, Patsouris E. The impact of inguinal lymph node micrometastases in patients with vulvar cancer. Arch Gynecol Obstet 2016; 295:435-438. [PMID: 27832348 DOI: 10.1007/s00404-016-4233-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Inguinofemoral metastases are a major determinant of vulvar cancer relapse. Until today, the impact of micrometastases of inguinal nodes on local recurrence rates of patients with vulvar cancer remains unknown. The purpose of this retrospective study is to evaluate the rates of micrometastases in a series of patients with vulvar cancer treated with radical vulvectomy and inguinofemoral LND and to assess the probability of cancer relapse among this specific category. METHODS We conducted a retrospective observational study on patients with vulvar cancer who attended the gynaecological department of Anticancer Hospital of St. Savvas between January 1989 and January 2007. Ultra-staging of lymph nodes for micrometastases was performed after cutting the remaining specimens with a microtome in multiple slices of 3 μm. Subsequently they were stained with traditional hematoxylin and eosin and CK AE1/AE3 antibodies for immunohistochemichal analysis. RESULTS Ninety-two patients with primary vulvar malignancies were included in the present retrospective study. Ultrastaging of the lymph nodes revealed micrometastases in five patients (5.4%). Neither the duration of the procedure, nor the number of retrieved lymph nodes was directly associated with the presence of micrometastases. The patients were followed up for more than 5 years. Sixteen recurrences (17.4%) occurred during this period. The presence of micrometastases did not influence the recurrence rate (OR 3.57, 95% CI 0.55-23.36, p = 0.184). CONCLUSION Ultrastaging of inguinal nodes does not seem to add any benefit in the prediction of local recurrence rates. Future multicenter studies are needed in the field to corroborate our findings.
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Affiliation(s)
- Grigoris Derdelis
- Third Department of Ob/Gyn, Attikon University Hospital, National and Kapodistrian University of Athens, 66, Dimitriou Gounari Str., 15124, Marousi, Greece.
| | - Vasilios Pergialiotis
- Third Department of Ob/Gyn, Attikon University Hospital, National and Kapodistrian University of Athens, 66, Dimitriou Gounari Str., 15124, Marousi, Greece
| | - Emmanouil Terzakis
- Second Department of Gynaecology, St. Savas Anticancer Hospital, 171 Alexandras Avenue, 11522, Athens, Greece
| | - Nektarios Koufopoulos
- First Histopathology Department, Athens Medical School, Laiko Hospital, Athens, Greece
| | - Ioanna Martzoukou
- First Histopathology Department, Athens Medical School, Laiko Hospital, Athens, Greece
| | - Chara Gakiopoulou
- First Histopathology Department, Athens Medical School, Laiko Hospital, Athens, Greece
| | - Andreas Lazaris
- First Histopathology Department, Athens Medical School, Laiko Hospital, Athens, Greece
| | - Efstratios Patsouris
- First Histopathology Department, Athens Medical School, Laiko Hospital, Athens, Greece
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14
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Chokoeva AA, Tchernev G, Castelli E, Orlando E, Verma SB, Grebe M, Wollina U. Vulvar cancer: a review for dermatologists. Wien Med Wochenschr 2015; 165:164-77. [PMID: 25930015 DOI: 10.1007/s10354-015-0354-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/07/2015] [Indexed: 12/01/2022]
Abstract
Vulvar malignancies are important tumors of the female reproductive system. They represent a serious health issue with an incidence between 2 and 7 per 100,000 and year. We provide a review about most important cancer entities, i.e., melanoma, squamous cell carcinoma, basal cell carcinoma, neuroendocrine cancer, and skin adnexal malignancies.Squamous cell carcinoma is the most common vulvar malignancy that can develop from vulvar intraepithelial neoplasia or de novo. Basal cell carcinoma represents only 2% of all vulvar cancers. Melanoma of the vulva exists in two major types-superficial spreading and acral lentiginous. A special feature is the occurrence of multiple vulvar melanomas. Of the adnexal cancer types Paget's disease and carcinoma are seen more frequently than other adnexal malignancies. The dermatologist should be aware of this problem, since he might be the first to be consulted by patients for vulvar disease. Treatment should be interdisciplinary in close association to gynecologists, oncologists, and radiologists.
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