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PURPOSE The Groningen International Study on Sentinel nodes in Vulvar cancer (GROINSS-V)-II investigated whether inguinofemoral radiotherapy is a safe alternative to inguinofemoral lymphadenectomy (IFL) in vulvar cancer patients with a metastatic sentinel node (SN). METHODS GROINSS-V-II was a prospective multicenter phase-II single-arm treatment trial, including patients with early-stage vulvar cancer (diameter < 4 cm) without signs of lymph node involvement at imaging, who had primary surgical treatment (local excision with SN biopsy). Where the SN was involved (metastasis of any size), inguinofemoral radiotherapy was given (50 Gy). The primary end point was isolated groin recurrence rate at 24 months. Stopping rules were defined for the occurrence of groin recurrences. RESULTS From December 2005 until October 2016, 1,535 eligible patients were registered. The SN showed metastasis in 322 (21.0%) patients. In June 2010, with 91 SN-positive patients included, the stopping rule was activated because the isolated groin recurrence rate in this group went above our predefined threshold. Among 10 patients with an isolated groin recurrence, nine had SN metastases > 2 mm and/or extracapsular spread. The protocol was amended so that those with SN macrometastases (> 2 mm) underwent standard of care (IFL), whereas patients with SN micrometastases (≤ 2 mm) continued to receive inguinofemoral radiotherapy. Among 160 patients with SN micrometastases, 126 received inguinofemoral radiotherapy, with an ipsilateral isolated groin recurrence rate at 2 years of 1.6%. Among 162 patients with SN macrometastases, the isolated groin recurrence rate at 2 years was 22% in those who underwent radiotherapy, and 6.9% in those who underwent IFL ( P = .011). Treatment-related morbidity after radiotherapy was less frequent compared with IFL. CONCLUSION Inguinofemoral radiotherapy is a safe alternative for IFL in patients with SN micrometastases, with minimal morbidity. For patients with SN macrometastasis, radiotherapy with a total dose of 50 Gy resulted in more isolated groin recurrences compared with IFL.

Probability of survival of patients with vulvar cancer directly depends on the lymph node status. Surgery of lymph nodes can be performed as radical inguinofemoral lymphadenectomy or in cases with certain conditions as sentinel lymph node surgery. The aim of this study is to obtain an overview of the intervention-related morbidity and quality of life in patients with vulvar carcinoma after lymphadenectomy. Quality of life and morbidity was compared between patients who underwent radical inguinofemoral lymphadenectomy with those who underwent sentinel lymph node surgery. All recorded postoperative complications occur more frequently in the non-sentinel group, Significant difference was shown for the occurrence of lymphedema (p-value = 0.024) and sensitivity loss (p-value = 0.024). Recurrence of disease was more frequent in the non-sentinel group (38 % vs. 20 %, p = 0.621, n.s.) and satisfaction with groin surgery is slightly higher in the sentinel group (94 % vs. 89 %, p = 1.000, n.s.). We could demonstrate a significantly lower morbidity of sentinel lymphadenectomy compared to conventional inguinofemoral lymphadenectomy while maintaining the same oncological safety. The low morbidity of sentinel- lymphadenectomy does not seem to influence the postoperative quality of life significantly. However, recording of the individual burden of lymphadenectomy by questionnaires should be optimized.ZIEL: Die Überlebenswahrscheinlichkeit von Patientinnen mit Vulvakarzinom hängt direkt vom Lymphknotenstatus ab. Die Resektion der Lymphknoten kann als radikale inguinofemorale Lymphadenektomie oder bei Vorliegen bestimmter Voraussetzungen als Sentinel-Lymphadenektomie durchgeführt werden. Ziel dieser Studie ist es, einen Überblick über die interventionelle Morbidität und Lebensqualität bei Patientinnen mit Vulvakarzinom nach Lymphadenektomie zu erhalten. Lebensqualität und Morbidität wurden zwischen Patientinnen, bei denen eine radikale inguinofemorale Lymphadenektomie durchgeführt wurde, und Patientinnen, bei denen eine Sentinel-Lymphknotenchirurgie durchgeführt wurde, verglichen. Alle erfassten postoperativen Komplikationen traten in der Nicht-Sentinel-Gruppe häufiger auf, ein signifikanter Unterschied zeigte sich für das Auftreten von Lymphödemen (p = 0,024) und Sensibilitätsverlust (p = 0,024). Krankheitsrezidive traten in der Nicht-Sentinel-Gruppe häufiger auf (38 % vs. 20 %; p = 0,621, n.s.) und die Zufriedenheit mit dem Eingriff in der Leistenregion war in der Sentinel-Gruppe etwas höher (94 % vs. 89 %; p = 1,000, n.s.). Wir konnten eine signifikant geringere Morbidität der Sentinel-Lymphadenektomie im Vergleich zur konventionellen inguinofemoralen Lymphadenektomie bei gleichbleibender onkologischer Sicherheit nachweisen. Die niedrigere Morbidität bei der Sentinel-Lymphadenektomie hat keinen signifikanten Einfluss auf die postoperative Lebensqualität. Die Erfassung der individuellen Belastung durch die Lymphadenektomie mittels Fragebögen sollte jedoch optimiert werden.

To investigate the impact of a preoperative CT on surgical decision making in primary vulvar squamous cell carcinoma (VSCC) and the accuracy of detecting inguinal lymph node metastases (LNM). Secondly to assess prevalence and consequences of incidental findings and comorbidity using a CT.This population-based study comprised of surgically treated patients with primary VSCC, at a regional tertiary center, using the Swedish Quality Registry for Gynecological Cancer for identification, and medical records were reviewed. Results from the preoperative CT was compared with the histological analysis from the lymphadenectomy in the total cohort and between tumor size4 cm versus ≥4 cm.In total 134 women had undergone CT before sentinel node (SN) biopsy (n = 83) or inguinofemoral lymphadenectomy (IFL) (n = 51). Fiftyone patients (38%) had groin LNM. Accuracy of CT in detecting groin LNM was 76%; sensitivity 43% and specificity 96%. Positive (PPV) and negative predictive values (NPV) were 88% and 73% respectively. In tumors4 cm (n = 87), sensitivity, specificity, PPV and NPV were 17%, 95%, 57% and 75% and in tumors ≥4 cm (n = 47) 67%, 100%, 100% and 69% respectively. CT altered surgical method from SN biopsy to IFL in only two cases. Incidental findings led to extra follow-up resulting in a benign diagnosis in 22 patients and major important findings in five patients.In primary VSCC, a preoperative abdominal-inguinal CT is of limited value for surgical decision making. In tumors4 cm, it may be omitted due to low diagnostic accuracy and disturbing incidental findings.

ObjectiveThe authors present a surgical film for vulvar cancer surgery, which was performed via video endoscopy.MethodsAn 88-yearold woman with squamous cell carcinoma of the vulva and who underwent radical vulvectomy was treated with sentinel lymph node (SLN) and bilateral inguinofemoral lymphadenectomy, which is preferably performed via video endoscopic surgery with a near-infrared fluorescence video endoscopy system. SLN mapping was performed using indocyanine green and near-infrared fluorescence mapping.ResultsSLNs were detected in the left superficial inguinal area. The surgeons performed bilateral inguinofemoral lymphadenectomy.ConclusionNo postoperative early or late complications developed, and the patient was discharged 7 days after surgery. Stage 1B vulvar cancer was identified.

Aim Application of sentinel lymph node biopsy (SLNB) procedure in early-stage vulvar cancer and analysis of results, recurrences and complications. Material and methods 40 patients with vulvar cancer and SLNB between 2008 and 2018 were retrospectively reviewed. During the surgical procedure the inguinofemoral lymph nodes were checked with a gamma probe to identify the sentinel nodes that were removed and referred for intraoperative pathological assessment. Subsequently, long-term patient follow-up was performed with analysis of complications, relapse and mortality. Results 40 patients (mean age: 72 years [47–86]), the overall detection rate per patient was 95% and a total of 129 sentinel lymph nodes (SLNs) were removed (3.22 SLN/patient). In 3 out of 25 patients with lateral tumor lesions drainage was bilateral and in 2 out of 15 with midline lesions drainage was unilateral. On lymphoscintigraphy, 16 out of 40 had bilateral drainage and 24 unilateral. A total of 119 SLN− and 10 SLN+ were obtained, in 8 out of 10 an inguinofemoral lymphadenectomy was performed. In the SLN− group, one case of lymphatic blockage and one false negative were included. In 12 out of 40 patients there were post-surgical complications, 4 of them lymphoedemas. In the median follow-up (40 months), 6 out of 10 with SLN+ (40% mortality) and 7 out of 30 SLN− (16% mortality) had recurrences. Conclusions SLNB in vulvar cancer is the technique of choice for correct staging and locoregional therapy. Correct clinical lymph node staging is important before surgery in order to avoid potential blockage drainages which could induce a false negative SLN.

Despite the introduction of sentinel node biopsy in patients with vulvar cancer, still approximately 50% of all patients have to undergo an inguinofemoral lymphadenectomy. This is associated with a high incidence of postoperative complications, which may be influenced by inguinal drain management. The aim of this study was to investigate the feasibility of a new surgical technique regarding drain management with an inguinoperitoneal drainage. A retrospective analysis of 21 vulvar cancer patients with inguinofemoral lymphadenectomy was conducted. A silicone drain was circularly placed with the perforated end in the groin and the other end in the space of Douglas. The removal after 3 months was performed under local anesthesia. All patients were questioned during clinical follow-up regarding their personal experiences with the procedure, the occurrence of complications, and side effects using a clinical questionnaire. In 100% of the patients, the procedure was feasible. Regarding the number of groin punctures due to lymphocyst formation, 15 (71.4%) patients did not need any intervention and 3 (14.3%) patients needed 1–3 punctures. The patient satisfaction with the internal drainage was ranked as good by 17 (81.0%) patients and as moderate by 1 (4.8%) patient. In 3 (14.3%) patients, information about the number of groin punctures and the patient satisfaction were missing. Inguinoperitoneal drainage after inguinofemoral lymphadenectomy in vulvar cancer patients is feasible and safe and a patient satisfaction of 81% is promising. For definitive conclusions regarding the efficacy of this technique, further investigations and prospective multicenter trials are needed.

Vulvar cancer is rare. The complex inguinofemoral anatomy and the limited number of surgical procedures per year per gynecological oncologist tends to decrease the competency level. This step-by-step, cadaveric educational video was produced to increase understanding of the anatomy and technique of inguinofemoral lymphadenectomy.

Introduction/Background* Lymph node involvement is the most important prognostic factor for recurrence and survival in vulvar cancer. Sentinel lymphonodectomy (SNLD) successfully replaced inguinofemoral lymphadenectomy (IL) in patients with early vulvar cancer. Nevertheless, management of patients in special situations is not well studied or current data are inconclusive. Methodology To assess the current management of diagnostic and surgical procedures with respect to SNLD in early vulvar cancer, a web-based survey was mailed to 612 gynecological departments. Data are presented as frequencies of selected items. Result(s)* A total of 222 hospitals (36.27%) replied the questionnaire. Only 9.5% of hospitals did not offer the SNLD and 79.5% processed the evaluation of sentinel node (SN) by ultrastaging. After detection of isolated tumor cells (ITCs) or micrometastases, IL was performed in 28.1% and 60.5% of hospitals, respectively, and radiation without further surgical intervention was performed in 19.3% and 23.8% of hospitals, respectively. In 50.9% and 15.1% of cases, hospitals would not initiate any further therapy in patients with ITCs and micrometastases, respectively. In vulvar cancer of the midline with unilateral localized positive SN, 49.1% and 48.6% of hospitals performed ipsilateral or bilateral IF, respectively. Repeat SNLD was performed by 16.2% of hospitals. Conclusion* The vast majority of German hospitals are following current guidelines and are offering SNLD in patients with early vulvar cancer. Despite the fact that according to the GROINSS-V-I-study approximately 42% of positive SN were determined by ultrastaging, only 79.5% of German hospitals implemented this procedure. Our findings showed that hospitals would recommend expectant management in patients with ITCs or with micrometastases in 50.9% and 15.1% of cases, but current guidelines do not support this approach. Nevertheless, radiation is a good option in these patients, as shown by preliminary results of the GROINSS-V-II-study. Bilateral IL should be performed in patients with unilateral positive SN, as a SN positivity rate of 22.2% on the contralateral side was described by a current study and understaging of the groins might be fatal. Any deviation from current guidelines, as well as applying the SNLD in special situations, should be individually discussed with each patient.

Introduction/Background* The cornerstone of treatment in early-stage squamous cell carcinoma (SCC) of the vulva is wide local excision with elective uni- or bi-lateral inguinofemoral lymphadenectomy. Methodology Draw a line between the anterior superior iliac spine (ASIS) and pubic tubercle. Measure 3 cm, medial to ASIS to mark the lateral dissection border. Draw a 90-degree line, 6-7 cm down towards the thigh and repeat the same step from the pubic tubercle. Join the two-end point to draw the incision for the groin nodes. Dissect gently the subcutaneous until you reach to superficial fascia (Campers fascia). Incise the fascia gently, lift the fascia and dissect parallel to the lower border of the fascia to separate the superficial inguinal nodes from the subcutaneous tissue. Continue with until you reach the inguinal ligament (upper border of the dissection). Dissect the superficial inguinal lymph nodes off the inguinal ligament starting from the upper edge of the ligament down to the femoral triangle. Lateral circumflex vessels are laterally and the superficial epigastric vessels central & cranial. Dissect the lymph-nodes off the sartorius muscle fascia starting from upper down to the lower border of the triangle. Dissect the lymph nodes off the adductor longus muscle (medial border). Be aware of the superficial external pudendal vessels. Once the borders identified proceed with separating the groin nodes off the femoral triangle floor proceeding from lateral to medial. Identify the great saphenous vein and dissect carefully until the point of insertion with the femoral vein. For the dissection of the deep femoral lymph nodes, gently dissect the fatty tissue starting from the point of junction between great saphenous vein and femoral vein. Follow the femoral vein through the length of fossa ovalis (usually 3 cm). Retract the inguinal ligament cephalad to check for Cloquet’s node. Place the drain on the pelvic floor, using silk suture to fix the drain. Result(s)* Using this step by step technique we minimize the possibility of injuries and offer better healing prognosis with less complications. Conclusion* This is a safe step by step technique minimizing the risks of injuries and complications of inguinofemoral lymphadenectomy.

Purpose: Inguinofemoral lymphadenectomy (IFLD) is associated with very high morbidity. Fibrin sealant patches are used in various surgical procedures to prevent hematomas and lymphoceles. Here, we report a single-institution experience of fibrin sealants after IFLD in vulvar cancer and give an overview of the current literature. Patients and methods: We retrospectively analyzed outcome data on vulvar cancer patients who underwent bilateral IFLD between November 2014 and June 2016 at the University Hospital Basel. A fibrin sealant patch (Tachosil®) was placed in one groin only. Postsurgical fluid collection and complications were compared between both groins; time courses of lymphocele formation were analyzed using a linear mixed-effects regression model. Results: Postsurgical outcome of 11 consecutive patients with bilateral IFLD for vulvar cancer was assessed for a median follow-up of 32 days (range 12-77). Significantly larger lymphoceles were detected over time in the groin with the fibrin sealant patch (median 20 mL vs 5 mL without patch, p=0.002), and more punctures for symptomatic lymphocele were required on this side. The infection rate did not differ between sides. Conclusion: Fibrin sealant patches should not routinely be used for prevention of lymphoceles after IFLD for vulvar cancer. They do not seem to reduce lymph collection, the need for puncture or the infection risk after lymphadenectomy in our experience and according to a general literature review.

Background Vulvar cancer is a rare gynecological malignancy that primarily affects women of postmenopausal age. Treatment is mainly surgical, particularly for vulvar squamous cell carcinoma, the most prevalent histotype. In patients with unifocal tumors with a maximum diameter of Results Two patients diagnosed with vulvar squamous cell carcinoma (FIGO IB stage) underwent bilateral radical vulvectomy, SLN search and removal, and bilateral inguinal lymphadenectomy at the Cannizzaro Hospital Operative Unit of Obstetrics and Gynecology Department (Catania, Italy). Three milliliters of indocyanine green (ICG) 0.5 mg/mL was administered in 3 peritumoral injections under general anesthesia to screen the SLN. The images were acquired using an intraoperative infrared camera system, which allowed intraoperative visualization of the SLN. An SLN was identified for each patient. The lymph nodes examined by the pathologist were negative for metastatic localization of the disease. However, patients underwent bilateral inguinofemoral lymphadenectomy, as this procedure is not currently codified as a gold standard for the detection of SLN in vulvar cancer. All the lymph nodes removed were negative for the localization of vulvar carcinoma metastases. Conclusions The potential of the administration of indocyanine green (ICG) allows the execution of SLN biopsy, avoiding the multiple administrations of radiocolloid in the pre-operative phase, painful for the patient, elimination, and exposure to radioactivity. Therefore, while requiring standardization of the methodology and a large-scale application, this procedure could open a new surgical management perspective in patients with early-stage vulvar cancer.

PURPOSE/OBJECTIVE(S) Inguinofemoral lymphadenectomy (IFL) is a morbid procedure, and studies support the use of sentinel lymph node biopsy (SLNB) as an initial staging procedure for women with early stage operable vulvar cancer. However, in the recently presented GROINSS-V II study, for patients with SLNB metastasis > 2 mm, groin radiotherapy with a total dose of 50 Gy was not a safe alternative to IFL due to an increased number of groin recurrences. Therefore, the management of patients with SLNB-positive groin disease remains controversial. We used the National Cancer Database (NCDB) to examine national trends in the use of SLNB, IFL, and adjuvant therapies in clinically node negative, pathologic node positive (cN-/pN+) vulvar cancer. MATERIALS/METHODS The NCDB was used to identify patients with cN-/pN+ vulvar cancer between 2012 and 2017. Patients with benign histologies, Paget's disease, and melanoma were excluded. Demographic and clinical data were compared with the chi-squared and Wilcoxon rank-sum test. Overall survival (OS) was analyzed with the Kaplan-Meier method and log-rank test. Cox proportional hazards regression modeling was used to determine factors associated with OS. RESULTS A total of 1,715 patients with cN-/pN+ vulvar cancer were identified. Of this group, sentinel lymph node data was recorded for 1,172 patients. The rate of SLNB with or without IFL increased from 10.2% in 2012 to 24.0% in 2017. The rate of patients who had SLNB alone increased from 3.4% to 15.1% and conversely, the rate of IFL +/- SLNB decreased from 96.6% to 84.9% (P < 0.05). The SLNB-alone cohort (n = 126) did not differ from the IFL +/- SLNB (n = 1046) cohort in terms of race, age, tumor size, margin status, treatment at academic vs. community center, income, insurance, and residence in a metropolitan or non-metropolitan area. Rates of adjuvant treatments were similar with radiation therapy utilized in 63.5% and 64.9% of the SLNB-alone and IFL +/- SLNB cohorts, respectively. Rates of adjuvant chemoradiation were 29.4% and 31.1% of the SLNB-alone and IFL +/- SLNB cohorts, respectively. Median follow-up was 29 months. On multivariate analysis, there was no significant difference in OS between patients who received SLNB-alone vs. those who received IFL +/- SLNB (HR:0.92, 95% CI: 0.7-1.3, P = 0.617). CONCLUSION In this large national sample of vulvar cancer patients with cN-/pN+ groin disease, the rate of IFL is decreasing with time as SLNB is becoming more common and a majority receive either adjuvant radiation or chemoradiation. There was no significant difference in OS observed between patients who received SLNB-alone vs. those who received IFL +/- SLNB. Whether the favorable outcomes in the SLNB-alone cohort may be attributed to radiation technique and/or use of chemoradiation warrants further study. AUTHOR DISCLOSURE M. Mokhtech: None. S. Gao: None. M. Kassick: None. G. Menderes: None. S. Damast: None.

Introduction Despite the less frequent use of surgery in patients with vulvar cancer, the high rates of postoperative complications are still a matter of concern. The aim of the present study was to identify risk factors that influence postoperative complications rates in vulvar cancer and identify specific clinical parameters that may influence their incidence. Materials Patients who underwent curative-intent surgery for squamous cell carcinoma of the vulva from 2003 to 2018 were selected. All patient characteristics were analyzed as risk factors for the development of postoperative lymphocele, lymphedema, and wound dehiscence. The patients were followed up for 2 years postoperatively. Results The investigation comprised 121 patients, of whom 18.1% developed wound dehiscence, 17.7% a lymphocele, and 20.4% lymphedema. We found no significant evidence of an association between patient’s characteristics and postoperative complications. The depth of tumor invasion and the appearance of lymph-node metastasis were significantly associated with postoperative complications. Free resection margins of 5 mm or more were associated with a reduced risk of postoperative complications compared to resection margins less than 5 mm. No complications were encountered after sentinel node biopsy (SNB). Complication rates were associated with inguinofemoral lymphadenectomy, but not with the extent of lymphadenectomy. The development of a lymphocele or wound dehiscence may be correlated with the development of long-term lymphedema. Conclusion FIGO stage at diagnosis influences the risk of postoperative complications. The use of SNB minimized postoperative complications. Correlations between the free microscopic resection margin distance and the risk of postoperative wound dehiscence must be investigated further.

Introduction Vulval carcinoma accounts for 3–5% of all gynaecological cancers. The primary treatment of vulval carcinoma is local excision ±inguinofemoral lymphadenectomy. Inguinal node sates is an important prognostic indicator, this makes lymph node assessment important for all cases of vulval carcinoma except the superficially invasive carcinomas. Here we demonstrate our technique of robotic assisted inguinofemoral lymphadenectomy for vulval carcinoma. Description The biggest problem with inguinofemoral lymphadenectomy is short term and long term morbidity associated with the procedure, especially wound complications. Various techniques have been tried to reduce morbidity like separate incisions, sentinel node mapping, saphenous sparing and video endoscopic approach. From December 2014 to March 2020,15 patients of vulval carcinoma underwent 21( 9 unilateral and 6 bilateral) Robotic Assisted Inguinofemoral lymphadenectomy at our institute. Mean age of patients was 59 yrs (32–73). Mean operative time was 69 min and mean blood loss was 40 ml. Mean number of node harvested were13(8–23). There was no conversion. No intraoperative complication was observed. Postoperative superficial wound infection was seen in 2/21 procedures and prolonged seroma aspiration was required in 4/21 procedures. Final histopathology showed metastasis in 4/21 cases.In this video we describe the patient positioning, port placement and technique of the procedure. Conclusions Robotic assisted inguinofemoral lymphadenectomy is safe and feasible with less wound related morbidity than conventional procedure. Need multi institutional study to evaluate long term complications, safety and survival data.

Vulvar cancer being a rare gynecological malignancy, many dilemmas and controversies remain during management of such cases. Radical surgeries are associated with severe postoperative morbidity due to wound-related complications increasing the hospital stay and delaying adjuvant therapies. A case is discussed where wound complications were prevented with the use of flaps. A 58-year-old postmenopausal lady presented with itching in the vulva and a large ulcerative growth on the right side of the vulva. Biopsy from lesion diagnosed to be moderately differentiated squamous cell carcinoma. Triple incision modified radical vulvectomy with bilateral inguinofemoral lymphadenectomy with sartorius transposition was done. There were no postoperative complications. Histopathology showed keratinizing squamous cell carcinoma vulva grade 2, with a tumor-free margin of 7.8 mm, and single lymph node metastasis of ≥ 5 mm. She was advised adjuvant radiotherapy but did not follow up. Five months later, she presented again with an ulcerative lesion in the right groin. It was diagnosed to be skin bridge recurrence. She was managed with wide excision with a reconstruction of the groin wound with vertical rectus abdominis myocutaneous (VRAM) flap. The grafted wound and the donor site both healed well without any complications.. The patient was referred for adjuvant radiotherapy. Histopathology confirmed it to be skin bridge recurrence. Skin bridge recurrences are rare and occur in modified radical vulvectomies with separate groin incisions. Surgical excision of recurrences leaves large wounds that need reconstructive surgeries for management. VRAM flap is a very versatile flap which can be used for reconstruction in genital malignancies.

Objective We aimed to develop a less invasive inguinofemoral lymphadenectomy (IFL) approach for vulvar cancer based on the investigation of the anatomic distribution of sentinel and metastatic nodes. Methods Patients with vulvar cancer treated by surgery between 1995 and 2019 were retrospectively reviewed. A seven-field method was adopted to assign the anatomic locations for lymph nodes removed via IFL or sentinel node biopsy. Only patients with nodal metastasis or sentinel nodes were included. Results A total of 102 patients with eligible data were analyzed. Nodal metastasis was confirmed in 118 groins undergoing IFL; sentinel node detection succeeded in 46 groins. The medial-inguinal field had the highest rate of nodal metastasis involvement (59.3%, 70/118) and sentinel nodes present (73.9%, 34/46). The inferior-femoral field was involved only in one groin with quadruple-field metastases. The lateral-inguinal field was not involved in any groin. Neither the lateral-inguinal nor the inferior-femoral field presented sentinel nodes. Conclusion The lateral-inguinal and inferior-femoral fields of the groins have a low risk of developing nodal metastasis. Therefore, a modified IFL preserving these fields can be established to reduce surgical morbidity without sacrificing its therapeutic effect.

The aim of this study is to review the indications, techniques, and outcomes of sentinel lymph node (SLN) mapping in endometrial, cervical, and vulvar cancers. In endometrial cancer, the prospective FIRES trial showed that the negative predictive value of SLN mapping was 99.6%. Furthermore, multi-institutional retrospective studies comparing SLN mapping to traditional lymphadenectomy have found comparable survival between the two techniques, in both type 1 and type 2 endometrial cancer. In cervical cancer, randomized data from the SENTICOL-2 study has demonstrated significant reduction in postoperative complications without compromising survival with SLN mapping as compared to SLN mapping and pelvic lymphadenectomy. In vulvar cancer, the GROINS-V-II study protocol was amended to mandate inguinofemoral lymphadenectomy in all patients with SLN macrometastasis greater than 2 mm after unacceptably high rates of groin recurrences were observed on interim analysis. SLN mapping is now included in the treatment guidelines of the National Comprehensive Cancer Network guidelines for endometrial, cervical, and vulvar cancer as an acceptable lymphatic assessment technique in select patients. SLN biopsy is a safe and effective alternative to systematic lymphadenectomy for women with early-stage endometrial, cervical, and vulvar cancer. Recent data has validated the excellent sensitivity and negative predictive value of this technique in carefully selected patients, without compromising survival. The use of an algorithm that mandates pathologic ultrastaging on all SLNs, and ipsilateral lymphadenectomy in cases of failed bilateral mapping improves sensitivity and negative predictive value. All suspicious lymph nodes should be resected regardless of the location of the SLN. In patients with vulvar cancer, SLN biopsy is an acceptable standard of care for patients with unifocal tumors, less than 4 cm in largest diameter, and clinically and radiographically negative groin nodes.

Objectives To determine the clinical significance and prognostic value of femoral lymph node metastasis (FLNM) in patients with International Federation of Gynecology and Obstetrics (FIGO) stage III vulvar carcinoma. Methods The medical records of patients with vulvar carcinoma who underwent inguinofemoral lymphadenectomy between 1990 and 2013 were retrospectively reviewed. Results Of 66 patients with stage III vulvar carcinoma, 42 had superficial lymph node metastasis (SLNM) only and 24 had FLNM. Significantly higher rates of extracapsular invasion (P = 0.008), multiple nodal metastasis (P = 0.042), and advanced FIGO substage (P = 0.026) as well as a larger tumor diameter (≥4 cm, P = 0.023) and greater depth of invasion (≥5 mm, P = 0.020) were observed among patients with FLNM compared to those with SLNM only. After a median follow-up of 46 months (range, 6–172 months), 35 patients experienced relapse and 30 died from disease. The 5-year cancer-specific survival (CSS) rates were 70.1% and 30.8% for patients with SLNM only and FLNM, respectively (P = 0.001). In multivariate analysis, only FLNM was found to be an independent risk factor for reduced recurrence-free survival (RFS) and CSS among patients with stage III vulvar cancer (hazard ratio [HR] = 2.277, P = 0.037 for RFS; HR = 2.360, P = 0.042 for CSS). When the FLNM cases were considered together as stage IIIC, significant differences emerged in the RFS (P = 0.002) and CSS (P = 0.004) among the re-divided FIGO substages. Conclusions FLNM represented an unfavorable status of node metastasis with a worse prognosis compared to that of SLNM alone, and this should be considered in a future FIGO staging system for vulvar cancer.

Vulvar cancers, which constitute 5% of all gynecologic cancers, are the fourth most common female genital cancers, preceded by uterine, ovarian and cervical cancers. The treatment methods employed for vulvar cancers have changed over the years, with previously applied radical surgical approaches, such as en bloc resection, being gradually suspended in favor of treatment approaches that require dissection of less tissue. While the removal of less tissue, which today's approaches have focused on, prevents morbidity, this method seems to result in higher risks of recurrence. It is therefore important that the balance between preventing the recurrence of the disease and forefending against postoperative complications and vulvar deformity be properly understood. As a working assumption, if patients with vulvar cancer are diagnosed at an early stage, properly evaluated and administered appropriate treatment, the most positive results can be obtained. This paper aims to highlight this assumption and demonstrate, through the provision of actual data, how to plan the treatment approach for patients who are diagnosed early. Statements extracted from the National Comprehensive Cancer Network (NCCN) Guidelines Version 1.2016 Sub-Committees on vulvar squamous cell carcinoma and articles by the European Society of Gynaecological Oncology (ESGO) regarding Vulvar Cancer Recommendations were used to obtain updated information., Highlights • Radical/wide local excision is an alternative to radical vulvectomy in selected patients. • The aim of the tumor resection should be to achieve the adequate surgical border. • Complete inguinofemoral lymphadenectomy is more advantageous in terms of recurrence. • Recurrence is a particularly problematic feature of vulvar cancer cases. • Saphenous vein preservation is contradictory, preservation is maybe more advantageous.

Background: Inguinofemoral lymphadenectomy (IFL) is part of the surgical treatment of different malignancies of the genital tract and/or the lower limb including vulvar carcinoma, penile carcinoma and melanoma. IFL is associated with morbidity in up to 85% of the patients. The aims of this MAMBO-IC study (Morbidity And Measurement of the Body) are to study the feasibility of using LigaSure for IFL and to assess the differences in the incidence of short-term complications using LigaSure versus conventional IFL randomized within each individual patient.Methods: In this multicenter randomized controlled trial (RCT), women diagnosed with squamous cell carcinoma of the vulva with an indication for bilateral IFL were included. It was randomly assigned for which groin the LigaSure was used; the other groin was treated with conventional IFL (sharp/diathermia). We estimated the incidence of >= 1 complication(s) per groin using logistic regression and compared this between the two surgical methods, adjusting for possible confounders.Results: We included 40 groins of 20 patients. The estimated incidence of >= 1 complication(s) was 29% after LigaSure versus 70% after conventional IFL (risk difference 41% (95% CI 19-62), p Conclusions: This RCT shows that LigaSure for IFL is feasible and associated with significantly less short-term surgical complications compared to conventional IFL. Further studies with a larger sample size are needed to validate our findings. ISRCTN15057626.

Objectives The International Society for the Study of Vulvovaginal Disease (ISSVD) Surgical Oncological Procedure Definitions Committee propose a consistent terminology based on well-defined and reproducible anatomic landmarks that can be used by all who are involved in care of patients with vulvar conditions. Materials and methods The fundamental principles behind the new terminology contained descriptions of the area extension and depth of the surgical procedure. Results Vulvar Surgical Topographic Anatomy LandmarksExtension. The internal border of the vulva is the hymenal ring. The genitocrural folds are the external lateral borders.The vertical line through the clitoris and the anus defines lateral portions of the vulva.The horizontal line from the upper border of the hymenal ring defines anterior and posterior portion of the vulva.Depth. The floor of the vulva is represented by the median perineal fascia or perineal membrane of the urogenital diaphragm.A. Vulvectomy1. Extension: partial/total vulvectomy. Removal of part/entire vulvar/perineal integument independent of the depth.2. Depth: superficial/deep. Removal of the most superficial layer/removal of the vulvar tissue to the superficial aponeurosis of the urogenital diaphragm and/or pubic periosteum.B. Inguinofemoral lymphadenectomy1. Superficial inguinofemoral lymphadenectomy. Removal of the nodes located beside the inguinal ligament and along the great saphenous vein.2. Deep femoral lymphadenectomy. Removal of the nodes below the cribriform lamina and medial to the femoral vein. Conclusions This terminology helps avoid confusion and promote better understanding and exchange of experiences among gynecologic oncologists involved in vulvar carcinoma care.

BackgroundIn squamous cell vulvar cancer, sentinel node biopsy is accepted as standard treatment in well-defined patient groups and has reduced surgical morbidity considerably. Currently, due to the lack of evidence, it cannot be offered to patients with tumors of 4 cm diameter or greater or with multifocal tumors, or in local recurrences.Primary objectiveThis study is primarily a pilot and feasibility trial, aiming to evaluate if the prerequisites concerning detection rate and negative predictive value are satisfactory before the implementation of a multinational trial.Study hypothesisSentinel node biopsy has an acceptable negative predictive value and detection rate in the study cohort.Trial designThis study is planned as a prospective, national, multicenter interventional trial. Participating patients will undergo a sentinel node biopsy in addition to an inguinofemoral lymphadenectomy.Inclusion and exclusion criteriaInclusion criteria: for women in group 1, a primary tumor ≥4 cm in diameter; in group 2, a multifocal primary tumor; in group 3, a local recurrence without previous inguinofemoral lymphadenectomy or radiation to the groins; in group 4, a local recurrence, with previous inguinofemoral lymphadenectomy and/or radiation to the groins.Primary endpointThe primary endpoints are the detection rate and the negative predictive value of the sentinel node procedure.Sample sizeIn each of the four study arms, recruitment of 20–30 patients is planned.Estimated dates for completing recruitment and presenting resultsRecruitment will take place between November 2019 and October 2021. Results will be available in December 2021.Trial registrationThe trial is registered at “ClinicalTrials.gov” (ID: NCT04147780).

Introduction/Background Introduction: GROINSS-V II investigated whether radiotherapy is a safe alternative for inguinofemoral lymphadenectomy (IFL) in vulvar cancer patients with a metastatic sentinel node (SN). Methodology Methods: In GROINSS-V II, a prospective multicentre phase II trial, patients were included with early-stage squamous cell carcinoma (SCC) of the vulva (diameter Results From December 2005 until October 2016, 1552 eligible patients were registered. SN-metastasis occurred in 324/1552 (21%) patients. After 54 months of inclusion the stopping-rule for SN-positive patients was activated; interim analysis showed an increased risk for groin recurrence in case of SN-metastasis >2 mm and/or extranodal extension (ENE). After amendment of the protocol only patients with SN-micrometastasis ≤2 mm received radiotherapy, while those with SN metastasis >2 mm underwent IFL (with radiotherapy if >1 metastasis or ENE). Final analysis after ≥2 years of follow-up revealed six isolated groin recurrences in 157 patients with a SN-micrometastasis (3.8%). Four could not be considered radiotherapy failures: two developed recurrence in the contralateral (SN-negative) groin, two refused radiotherapy. Twenty-eight patients did not get radiotherapy (2 recurrences;7.1%). Among 129 patients who received radiotherapy to the groin(s) only two isolated groin recurrences were diagnosed (1.6%: 95%CI:0–3.8%). The combination of radiotherapy with SN was associated with minimal toxicity: 5/118(4.2%) grade 3 toxicity, no grade 4 or 5 toxicity. In 38/1222 SN-negative patients (3.1%: 95%CI:2.1–4.1%) isolated groin recurrences were diagnosed with clear protocol violations in 6 patients: incomplete treatment of the groin (n=3); primary tumor >4cm (n=1); not all SNs visualized on the lymphoscintigram removed (n=2). After exclusion of these protocol violations an isolated groin recurrence rate of 2.6% (95%CI:1.7–3.5%) was observed. Conclusion Radiotherapy to the groins is a safe alternative for IFL in patients with SN metastasis ≤2 mm, with minimal toxicity. We further established the safety of omitting IFL in patients with SCC of the vulva 2 mm, radiotherapy with a total dose of 50Gy was no safe alternative for IFL; dose escalation and/or chemoradiation should be investigated in these patients. Disclosure Funded by Dutch Cancer Society.

Introduction/Background Lymph node status is the most important prognostic factor in vulvar cancer. Histologically, sentinel nodes may be representative of the status of the other regional nodes. Identification and histopathologic evaluation of sentinel nodes could then have a significant impact on clinical management and surgery. The aim of the study was to assess the sensitivity, negative prognostic value, accuracy and false negativity of the sentinel lymph node (SLN) procedure during 14 years. Methodology From June 2004 to Deceember 2017, 112 patients with vulvar cancer, clinical stages FIGO IA-IB, underwent surgical tretament in onco-gynecologic center of University Hospital Ostrava. Demographic, surgical, and pathologic data on all patients were prospectively entered in a database. Of 86 women with early-stage squamous cell vulvar cancer included in the study, nineteen had lateral lesions and 67 had midline lesions. SLN detection was performed by using a radioactive tracer and blue dye, followed by radical vulvectomy or radical wide excision with uni ⁄bilateral inguinofemoral lymphadenectomy. SLNs were subsequently examined with haematoxylin-eosin and immunohistochemistry. Results Eighty- six patients underwent the SLN procedure by combined method. The detection rate per patient was 97,7%, and side specific detection rate was 88,1%. For 19 patients with lateral lesion the detection rate per patient and side specific detection rate was 100% and for patients with midline tumor 97,0% a 87,0% respectively. In total, fifty-one positive SLNs were detected in thirty-two of 86 patients (37,2%). From a total 51 positive SLNs, micrometastases were found in ten SLNs. We experienced only one case with a false negativity of SLN. Sensitivity, negative predictive value, accuracy and false negativity of SLN detection were 96,9%, 98,1%, 97,7% and 3.1% respectively. Conclusion The SLN biopsy performed by an experienced team during long time period is a accurate method, with high accuracy and low false negativity in patients with early-stage vulvar cancer. Disclosure Nothing to disclose.

Introduction/Background Sentinel lymph node (SLN) biopsy is the recommended staging method for single vulvar tumors, The vulva has an ample lymphatic system and especially for midline tumors (tumors that cross midline), its drainage can be made to both groins. According to international guidelines, bilateral detection of SLN is recomended for midline tumors and, in case of unilateral detection, inguinofemoral lymphadenectomy should be performed on the opposite groin. In an era of de-escalation surgery, should bilateral groin evaluation be mandatory for midline vulvar tumors? Methodology Retrospective observational study (2005–2018) of midline squamous-cell vulvar tumors, fulfilling criteria for SLN biopsy. In our oncology center, we detect SLN by performing lymphocintigraphy and using dual-mapping technique (radioactive tracer and blue-dye). In case of unilateral detection we do not execute contralateral lymphadenectomy. The aim of the study is to evaluate recurrence on the contralateral groin when SLN was negative. To accomplish this, the study-population was divided into two groups, according to SLN biopsy: 1) unilateral; 2) bilateral. Results We included 34 cases with a median follow-up time of 37,5 (1–111) months. During surgery, the detection rate of the SLN was 100% and always in accordance with the previous lymphocintigraphy. Group 1 included 16 cases (47%) and SLN biopsy was negative in 13 cases (81,3%). There were 2 cases of groin recurrence, one of which on the opposite side of the previous SLN. Group 2 included 18 cases (53%) and SLN biopsy was negative in 13 cases (72,2%). There wasn´t any case of groin recurrence. Conclusion SLN biopsy is a feasible staging technique and should be directed by previous lymphocintigraphy. Because vulvar cancer is rare, few cases were described, but our approach does not seem to increase the groin recurrence rate on the non-evaluated side. More studies are needed. Disclosure Nothing to disclose

Introduction/Background Vulvar cancer is rarely seen Methodology This step by step cadaveric educational video was recorded on the left groin. Results Between the anterior superior iliac spine and pubic tubercle the skin incision is performed, 8 cm in length, and 2 cm below and parallel to the inguinal ligament. After the incision, dissection deepens to identify the Camper’s fascia over the Scarpa’s fascia. Identification and preservation of the Camper’s fascia is critical in securing the skin flap and preventing skin necrosis. To dissect the fibrofatty tissue containing the superficial inguinal lymph nodes between the Camper’s fascia and fascia lata; firstly, the fibrofatty tissue is mobilized under the Scarpa’s fascia and dissected 2 cm cephalad to the inguinal ligament where the aponeurosis of external iliac muscle is seen. Afterwards, excision of the lymphatic and fibrofatty tissue is performed from lateral (superficial circumflex iliac vein) to medial (superficial external pudendal vein) and superior to inferior (inferomedial end of inguinal ligament where it intersects with the adductor longus muscle). The fossa ovalis is encountered after resection of superficial inguinal lymph nodes. Medial to the falciform edge of fossa ovalis, dissection of the cribriform fascia will lead to the deep inguinal lymph nodes which are located medial to the femoral vein. Great saphenous vein enters the femoral vein from the opening of fossa ovalis, so a careful dissection is needed while removing the cribriform fascia. Lymphadenectomy is performed towards the apex of femoral triangle, and there is no need to dissect the femoral sheath to excise the deep inguinal nodes completely. Finally, Cloquet’s lymph node which is the most superior of deep inguinal nodes could be resected from the femoral canal under the level of inguinal ligament. Conclusion Proper anatomical knowledge of inguinofemoral anatomy, the superficial fascia structures and deep vessel structures facilitates the inguinofemoral lymphadenectomy procedure. Disclosure Nothing to disclose

Introduction/Background To describe and to analyze the technique steps and anatomical landmarks for the sentinel node biopsy in vulvar cancer. Methodology Surgery remains the cornerstone in the treatment of vulvar cancer. Radical vulvectomy with inguinofemoral lymphadenectomy has been replaced by radical local excision with sentinel node procedure for early disease. Results We perform the sentinel node biopsy using a double method: Tc99 and blue dye. However, the fluorescence substances is a feasible technique. First of all, the injection of Tc 99 is performed the day before the surgery, and during the surgery we inject the blue dye. A 3 cm insicion is performed at the Douglas arcade. A delicate dissection is performed trying to localize tha blue collector or a hot-spot area. At the time that the node is located, it is taken out and correlated with the gamma probe. Conclusion Patients with unifocal disease, tumor size less than 4 cm, and clinically negative groins are candidates to sentinel node procedure. The learning curve of this technique can be improved with a correct knowledge of surgical anatomy of Scarpa´s triangle. The goal of this technique is the less index of morbidity, specially due to lymphedema Disclosure Nothing to disclose

Introduction/Background Management of vulvar cancer requires a tailored approach with the objective of reducing morbidity associated with radical procedures. The compromise of regional lymph nodes remains the most important prognostic factor. The introduction of sentinel lymph node biopsy instead of total lymphadenectomy has drastically reduced the morbidity associated with the surgical procedure without compromising oncological safety. However, for tumours ≥ 4 cm and/or in case of multifocal invasive disease, inguinofemoral lymphadenectomy (IFL) by separate incisions is recommended. Superficial and deep femoral nodes should be removed. The main objective of this video is to review the surgical anatomical landmarks of the inguinofemoral region as well as useful tips of the procedure performed in a university hospital. Methodology We hereby demonstrate the surgical technique of IFL while identifying the major anatomical landmarks in live tissue as well as in cadaveric dissection models. Surgical steps for the dissection of superficial and deep femoral nodes are shown. Special emphasis is placed on guiding the surgeon using still photographs and videos of live tissue and cadaveric dissection to optimize the understanding of the anatomy involved in this procedure. Key components of the surgery, including identification of Scarpa triangle components, vascular structures like the great saphenous vein, and recognition of the fossa ovalis, are shown. Results The material shown in this video allows the identification of the anatomical landmarks and the step by step systematization of the IFL procedure. Conclusion Through the use of still photographs and video, we hereby demonstrate the surgical technique as well as useful tips of IFL for the treatment of vulvar cancer. Disclosure This procedure was performed at Pereira Rossell Hospital, a tertiary referral and educational center in Montevideo, Uruguay. The patient gave consent for the use of the surgery footage for educational purposes.

Introduction/Background For all vulvar cancer patients with tumour diameter greater than 2 cm and more than 1 mm of stromal invasion, inguinofemoral lymphadenectomy is indicated. In this video we present inguinofemoral lymphadenectomy technique with a patient with vulvar squamous cell cancer. Methodology A linear incision made 1 cm above and parallel to the groin crease starting 3 cm distal and medial to the anterior superior iliac spine and ending below the superficial inguinal ring. The borders of the operation are sartorius muscle laterally, adductor longus muscle medially and inguinal ligament superiorly. The inguinofemoral lymph nodes are divided into superficial and deep. The superficial lymph nodes are above the fascia lata and the deep nodes lye below the fascia lata and within the femoral sheath. To remove the superficial nodes, incision is carried through the subcutaneous tissues to the Camper’s fascia. The dissection should not be too close to the skin flaps as flap necrosis may develop. The fascia is incised and grasped with forceps for traction, and the fatty tissue between it and the fascia lata is removed. Usually the dissection is carried from lateral to medial and superior to inferior. Care should be taken to identify and preserve the great saphenous vein, which is superficial to the fascia of the medial thigh. To access the deep nodes, an incision is made through the cribriform fascia. Lymph nodes are always situated medial to the femoral vein in the opening of fossa ovalis. The proximal deep femoral node (node of Cloquet) is removed from the femoral triangle. The incision is closed in layers. Results not applicable Conclusion not applicable Disclosure Nothing to disclose

Objectives To evaluate the feasibility of leaving the surgical vulvar open for secondary healing in situations where primary closure of the vulvar wound is not possible. Methods This is a case control pilot study analyzing 16 women with the diagnosis of squamous-cell carcinoma of the vulva that underwent first to inguinofemoral lymphadenectomy, them to 6 weeks sections of chemotherapy and 25 daily sessions of radiotherapy. After all, excision of the vulvar lesion with free margins was performed, between January 2011 to July of 2017. 12 patients underwent to the primary closure of the wound (control), and in 4 patients, the surgical defect was left open for secondary healing, by the use of hydrofiber (case). Inclusion criteria were a) FIGO-2009 stage II up to IIIC; b) squamous cell carcinoma; c) no evidence of pelvic or extrapelvic disease nor pelvic nodal involvement. Exclusion criteria was pelvic extra pelvic desease, pelvic nodal involment. Results The mean age of the patients at the time of intervention was 62,1. The distribution of the stages was as follows: II, n=6 (37%); IIIA, n=1 (6%), IIIB, n=1 (6%) and IIIC, n=8 (51%). The mean operative time was 45 minutes. Hospital stay was 2 days. Full vulvar healing in the control group occurred after an average of 30 days, and in the case group, 50 days. Conclusions Secondary healing strategy may be an option for the treatment of vulvar cancer in situations of non-extensive surgical wound when primary closure of the wound is not possible.

Contains fulltext : 174767.pdf (Publisher’s version ) (Open Access) INTRODUCTION: Inguinofemoral lymphadenectomy (IFL) is performed in the treatment for vulvar cancer. One or more complications after IFL is reported in up to 85% of the patients. This review presents an overview of surgical techniques and peri- and post-operative care that has been studied in order to reduce the morbidity associated with IFL in vulvar cancer patients. Areas covered: Current knowledge on post-operative complications after different surgical techniques and peri- and post-operative protocols were discussed. A systematic literature review was conducted using MEDLINE, EMBASE and the Cochrane library on 20 February 2017. In order to be eligible for inclusion, studies must report the associated post-operative morbidity per surgical technique, or peri- or post-operative care given after IFL in vulvar cancer patients. Expert commentary: After the implementation of several new surgical techniques, the morbidity after IFL decreased but remains high and clinically meaningful. More research is needed on surgical techniques and peri-or post-operative care to further reduce the complication rates after IFL in vulvar cancer patients.

Summary:. Reconstruction of a defect in the labial area has to be performed by taking account of the shape of the labial area and urogenital function. The gracilis myocutaneous flap and the gluteal fold flap are commonly used reconstructive procedures, but sometimes these flaps are too bulky and cause a deviation of the urination stream and/or deformity of the reconstructed site. In this report, we present our unique method of reconstruction using a contralateral labia majora sharing perforator flap. The patient was a 76-year-old woman who presented with squamous cell carcinoma on the left labia majora. Following radical vulvectomy with 2 cm radial margins and left inguinofemoral lymphadenectomy, an 8 × 6 cm2 defect was created. Primary closure was possible, but there was a risk that it might cause an unfavorable deformity and exposure of the urethral and vaginal vestibule. Part of the contralateral side of the labia was used for a dorsal clitoral artery perforator–based transposition sharing flap. The defect was covered without tension, and the donor site was closed primarily. The postoperative course was good. One year after the operation, deviation of the urination stream and severe asymmetry was not observed. This study shows feasibility of perforator-based labia majora sharing flap for contralateral labia majora defect. Our “like with like” reconstruction provides a good functional outcome and less donor-site morbidity to the patient.

BACKGROUND Lymph node metastases represent the most important negative prognostic predictor in vulvar carcinoma. Therefore, an accurate preoperative assessment of suspicious lymph nodes would be fundamental for a personalized therapy. The aim of this article was to assess the reliability of ultrasound-guided fine-needle aspiration cytology (FNAC) in the preoperative assessment of nodal metastatic disease in 43 patients with vulvar cancer. METHODS In total, 43 FNAC specimens of clinicoradiologically suspicious lymph nodes with corresponding nodal resection specimens were collected from 2016 to 2018 at Catholic University Hospital in Rome. Cytohistologic correlation was performed. Patients were treated with wide local excision of the vulvar mass followed by bilateral inguinofemoral lymphadenectomy and radiotherapy if the tumor involved a lymph node or the vulvar margins. RESULTS Cytologic examination agreed with histology in 37 of 43 cases (86.04%). The authors observed a positive FNAC result in 14 of 20 histologically confirmed metastatic lymph nodes, 6 false-negative cases, and no false-positive results. The sensitivity and specificity of cytological examination were 76.92% and 100%, respectively. All patients with FNAC-positive results showed metastatic disease in other surgically resected inguinofemoral nodes. Eleven of 29 patients (37.9%) with FNAC-negative results also showed metastatic disease in subsequent lymphadenectomy specimens, but the extent of metastases was always

Vulvar cancer accounts for only 5% of all gynecologic cancers with an incidence rate of 2.4 per 100,000 women. The most common histological type of vulvar cancer is vulvar squamous cell carcinoma (VSCC). There are two different types of VSCC with their own associated premalignant lesions. The most common type occurs in elderly women and leads to mostly differentiated keratinizing VSCC in a background of lichen sclerosus and often differentiated vulvar intraepithelial neoplasia. The second type of VSCC consists of mainly nonkeratinizing carcinomas, primarily affecting younger women, and is associated with high-grade squamous intraepithelial lesions. The diagnosis VSCC should be confirmed histologically, preferably by a punch biopsy. The method of treatment for VSCC depends on the extent of the disease. In general, surgery is the first choice of treatment in patients with primary VSCC. The inguinofemoral lymph node status at initial diagnosis reflected in stage is of critical prognostic importance for patients with VSCC. The treatment of VSCC consists of radical local excision of the tumor combined with the sentinel node procedure in patients with early-stage unifocal tumors of less than 4 cm and without clinically suspicious groin lymph nodes. In case of a metastatic sentinel node, a larger or multifocal tumor, or clinically suspicious lymph nodes, an inguinofemoral lymphadenectomy is indicated. There is a limited role for primary radio- and/or chemotherapy. Overall survival for early-stage VSCC patients is good with 75% at 5 years.

Aims The depth of invasion is an important prognostic factor for patients with vulvar squamous cell carcinoma (SCC). The threshold of 1 mm distinguishes between FIGO stages IA and >= IB disease and guides the need for groin surgery. Therefore, high interobserver agreement is crucial. The conventional and the alternative method are described to measure the depth of invasion. The aims of this study were to assess interobserver agreement for classifying the depth of invasion using both methods and to identify pitfalls. Methods and results Fifty slides of vulvar SCC with a depth of invasion approximately 1 mm were selected, digitally scanned and independently assessed by 10 pathologists working in a referral or oncology centre and four pathologists in training. The depth of invasion was measured using both the conventional and alternative method in each slide and categorised into 1 mm. The percentage of agreement and Light's kappa for multi-rater agreement were calculated, and 95% confidence intervals were calculated by bootstrapping (1000 runs). The agreement using the conventional method was moderate (kappa = 0.57, 95% confidence interval = 0.45-0.68). The percentage of agreement among the participating pathologists using the conventional method was 85.0% versus 89.4% using the alternative method. Six pitfalls were identified: disagreement concerning which invasive nest is deepest, recognition of invasive growth and where it starts, curved surface, carcinoma situated on the edge of the tissue block, ulceration and different measurement methods. Conclusions Pathologists reached only moderate agreement in determining the depth of invasion in vulvar SCC, without a notable difference between the two measurement methods.

To evaluate the effect of a collagen-fibrin sealant patch (TachoSil®) in preventing postoperative complications after inguinofemoral lymphadenectomy for vulvar cancer. Double-blind randomized-controlled trial on consecutive patients undergoing bilateral inguinofemoral lymphadenectomy for vulvar cancer. Intraoperatively, inguinofemoral areas were randomized: one was treated with TachoSil®, while the contralateral had standard closure without collagen-fibrin sealant patch. Surgical outcomes, amount of drainage volume, duration of drain placement, and any postoperative complication (vulvar wound dehiscence, inguinal wound dehiscence, cellulitis, lymphangitis, lymphoceles, and hematoma) were recorded. Leg measurements were taken preoperatively and during postoperative follow-up until 6 months to evaluate lymphedema. A total of 19 patients were enrolled and 38 inguinofemoral dissections were performed. There was no significant difference between the investigational and control arm in the amount of drainage volume (p = 0.976), and duration of drain placement (p = 0.793). The postoperative complications, excluding lymphedema, were 10/19 (53%) in investigational arm and 9/19 (47%) in control arm (p = 0.74). At the end of follow-up, the prevalence of grade 1 lymphedema was 44.4% and 50% in investigational and control arm, respectively (p = 0.744); grade 2 and 3 lymphedema had a prevalence of 33.3% in both arms (p = 1). Application of TachoSil® does not seem to improve postoperative lymphorrhagia nor to reduce the incidence of postoperative complications in patients undergoing inguinofemoral lymphadenectomy for vulvar cancer. Considering this point, it would be useful to identify additional strategies in inguinofemoral dissection for the prevention of these complications.

Objective To determine the efficacy of the addition of an ultrasound of the groins in routine follow up of women with vulvar squamous cell carcinoma (SCC) after a negative sentinel lymph node (SLN). Design Prospective single‐centre study. Setting A tertiary expert oncology centre for the treatment of vulvar cancer. Population All women with vulvar SCC with a negative SLN, treated between 2006 and 2014. Methods We prospectively collected data of 139 women with vulvar SCC treated with an SLN procedure. We analysed data of 76 patients with a negative SLN. Three‐monthly follow‐up visits consisted of physical examination combined with an ultrasound of the groins by a radiologist. Main outcome measures The diagnostic value of ultrasound in the follow up of women with vulvar SCC with a negative SLN during the first 2 years after treatment. Results During a routine visit, two asymptomatic isolated groin recurrences were detected. Both patients were treated by inguinofemoral lymphadenectomy and adjuvant radiotherapy and are alive without evidence of disease 39 and 120 months after diagnosis. In total, 348 ultrasounds and 29 fine‐needle aspiration were performed. The sensitivity of ultrasound to detect a groin metastasis was 100% (95% CI 16–100%), and specificity was 92% (95% CI 89–95%). Conclusions Routine follow up including ultrasound of the groin led to early detection of asymptomatic isolated groin recurrences. Further research is necessary to determine the exact role of ultrasound in the follow up of patients with vulvar SCC with a negative SLN. Tweetable abstract Routine follow up including ultrasound of the groin led to early detection of asymptomatic isolated groin recurrences., Tweetable abstract Routine follow up including ultrasound of the groin led to early detection of asymptomatic isolated groin recurrences.

The objective of this study was to study the risk factors, management protocols, and the outcome of vulvar cancer cases over a period of 2 years in a tertiary care hospital. This is a case series of early-stage vulvar cancer in the Department of Surgical Oncology in BL Kapur Superspeciality Hospital from Jan 2016 to date. Five patients with histologically proven diagnosis of early-stage vulvar cancer were included. The mean age for the diagnosis of vulvar cancer was 58 years and the peak incidence was seen in postmenopausal age group. All of the cases were squamous cell carcinomas in stage IB except one which was a basisquamous variant. All cases were treated primarily with surgery and vulvar flap reconstruction. Adjuvant therapy was not given in any case. Cases were followed from 6 months to date, and no recurrence noted. The limitations of the study were rarity of disease and less number of cases. As all the cases in our study were in early stage of disease (stages I and II), surgical treatment in the form of modified radical vulvectomy with B/L inguinofemoral lymph node dissection and oncoplastic procedure was the treatment modality chosen for all the patients.

Inguinofemoral lymphadenectomy (IFL) is included in the standard surgical management of early-stage vulval cancer (VC) but is often accompanied by surgical complications. Efforts have been made to limit the postoperative morbidity by adopting more conservative IFL techniques without compromising the surgical outcomes. Saphenous vein (SV) preservation during IFL for VC appears to reduce the incidence of postoperative complications including lymphedema. To ascertain the efficacy of SV preservation, we aimed to revisit the impact of SV preservation on short-term per groin complications by updating on a previous meta-analysis to further guide current clinical practice.A systematic literature review was conducted to identify studies that reported postoperative complications following IFL with SV preservation and controls (SV ligation during IFL) in VC patients. We included articles in English language and avoided date restrictions. Direct-comparison meta-analysis was performed between the use of SV preservation and SV ligation for the short-term outcomes of lymphedema, cellulitis, and wound dehiscence/breakdown. Fixed- and random-effects models were fitted to calculate the odds ratios (ORs) and 95% confidence intervals (CIs).Five studies were included in the final analysis. Direct-comparison per-groin meta-analysis between SV preservation and SV ligation significantly decreased the odds for developing lymphedema (OR, 0.363; 95% CI, 0.228-0.578; P0.001), cellulitis (OR, 0.481; 95% CI, 0.28-0.825; P = 0.008), and wound dehiscence/breakdown (OR, 0.296; 95% CI, 0.191-0.458; P0.001). When SV sparing was clearly the sole intervention, lymphedema was the only complication in which the positive effect of SV sparing is exerted (OR, 0.28; 95% CI, 0.149-0.526; P0.001).This per groin meta-analysis updates on the current evidence suggesting the SV sparing improves postoperative outcomes following IFL in VC patients. Where sentinel biopsy is not indicated, this risk-reducing strategy should be considered in selected VC patients undergoing IFL until a multicenter randomized controlled trial becomes available.

INTRODUCTION The aim of this study was to compare oncological outcomes and morbidity in patients with early-stage vulvar cancer with negative sentinel lymph node (SLN) biopsy vs negative inguinofemoral lymphadenectomy (IFL). MATERIAL AND METHODS Study with retrospectively collected data in patients with squamous cell vulvar carcinomas ≤ 4 cm without suspected inguinofemoral lymph node metastases. Only patients with negative nodes after histopathology procedure were followed. Patients who underwent only SLN were compared with patients who underwent IFL ± SLN to compare recurrences, survival rates and morbidity. RESULTS Ninety-three patients were eligible for follow up: 42 with negative SLN and 51 with negative IFL ± SLN. The median follow-up period was 60.4 months (range 6.7-160.7). The rate of isolated first groin recurrence was 4.8% in patients with negative SLN and 2.0% in patients with negative IFL ± SLN (P = 0.587) and the rates of first isolated local recurrence were 28.6% and 31.4%, respectively (P = 0.823). Only 1 patient (2.4%) in the group of negative SLN had distant recurrence. The disease-specific survival rate at 5 years was 83.3% in the negative SLN group and 92.2% in the negative IFL ± SLN group (P = 0.214). We observed a higher rate of wound breakdown and infection after IFL than SLN biopsy (17.6% vs 10.6%; P = 0.020) and lymphedema (33.3% vs 0%; P

Objective. In 2008 GROINSS-V-I, the largest validation trial on the sentinel node (SN) procedure in vulvar cancer, showed that application of the SN-procedure in patients with early-stage vulvar cancer is safe. The current study aimed to evaluate long-term follow-up of these patients regarding recurrences and survival. Methods. From2000 until 2006 GROINSS-V-I included 377 patientswith unifocal squamous cell carcinoma of the vulva (T1

Inguinal lymph node (LN) metastasis is a crucial prognostic factor in vulva carcinoma. The aim of this study was to determine the prognostic value of the number of resected LNs in patients with vulvar carcinoma on recurrence rates. This retrospective study includes patients with vulvar squamous cell carcinoma who underwent inguinofemoral lymphadenectomy (IFL) between 1998 and 2011. Dissected groins were stratified by the number of removed lymph nodes (

Background: We aimed to determine the frequency of early and late complications following groin surgery for vulvar cancer and analyze possible risk factors. Materials and Methods: This retrospective cohort study included 99 women who underwent for vulvar cancer. The early (≤1 month) complications were wound infection, breakdown and lymphocyst and late (>1 month) complications were lower limb lymphedema, incontinence and erysipelas. The risk factors for developing each of the complications were analyzed with regression analysis. Results: In the entire cohort, 29 (29.3%) women experienced early and 12 (12.1%) had late complications. Wound complications including infection and breakdown were the leading early complications (23.2%). In the multivariate analysis, both obesity (body mass index ≥30 kg/m2 ) and advanced age (≥65 years) were found as independent predictive factors for early complications. Obese women of advanced age had 6.32 times more risk of experiencing any of the early complications, when compared to non-obese and young women (55.6% vs 8.7%). The most common late complication was lower limb lymphedema (10.1%) that was more frequently seen in young women. However, neither age nor lymph node count were significantly associated with the occurrence of lower limb lymphedema. Conclusions: More than 40% of the women suffered from postoperative complications after inguinofemoral lymphadenectomy in the current study. While advanced age and obesity were the significant predictors for any of the early complications, there was no identified risk factor for lower limb lymphedema.

Two prospective, multicenter clinical trials have demonstrated the feasibility and reproducibility of sentinel lymph node (SLN) biopsy as part of the standard management of early-stage vulvar carcinoma. On the basis of the results of these trials, many gynecologic oncologists have incorporated SLN biopsy for vulvar cancer into their practice. Studies have further shown that SLN biopsy is associated with better quality of life than full lymphadenectomy, is more cost-effective than full lymphadenectomy, and improved pathologic evaluation. A large observational study is currently evaluating the outcomes of patients with early-stage vulvar cancer according to the results of their SLN biopsy and the approach to their care; this study may confirm that full inguinofemoral lymphadenectomy is no longer necessary in most patients with this disease. Here, we review the published data supporting SLN biopsy as part of the standard of care for women with early-stage vulvar cancer and discuss future considerations for the management of this disease. (C) 2015 Elsevier Inc. All rights reserved.

AimThe aim of this study was to evaluate if the lymph node count from inguinofemoral lymphadenectomy impacted the risk of isolated groin recurrence in patients with node-negative squamous cell vulvar cancer.Materials and MethodsThis is a retrospective cohort study of women with squamous cell vulvar cancer (stage IB–II according to the 2009 Revised International Federation of Gynecology and Obstetrics staging system) who underwent primary radical vulvar surgery and groin lymphadenectomy between January 2005 and December 2014. Patients' sociodemographic characteristics, the disease characteristics, the number of nodes removed from each groin, and the oncologic outcome were evaluated. A cutoff value of at least 6 nodes removed from each groin was used to define the adequacy of inguinofemoral dissection.ResultsSeventy-six patients, fulfilling the study inclusion criteria, were considered. The mean number of nodes removed (bilaterally) was 14.5 (±5.3, SD), with a range of 2 to 29 nodes. Thirty-three women (43.4%) had less than 6 nodes removed from each groin. In the whole study cohort, 4 cases of isolated groin recurrence (5.3%) were detected, and all these recurrences developed in patients with less than 6 nodes removed. Considering the demographic, clinical, and histopathological characteristics potentially related to the risk of groin recurrence, only the number of nodes removed showed a significant correlation.ConclusionsWomen treated for vulvar cancer in which less than 6 nodes are removed from each groin are at higher risk of groin recurrence.

ObjectiveThe aim of this study was to prospectively monitor the patients’ quality of life (QoL) after vulvar cancer surgery.DesignThe design was prospective clinical study.SettingThe study was set in the Department of Obstetrics and Gynecology, 2nd Medical Faculty of the Charles University and University Hospital Motol, Prague, Czech Republic.MethodsA group of 36 patients underwent vulvar cancer surgery: 24 patients were subject to inguinofemoral lymphadenectomy (RAD) and 12 to sentinel lymph node biopsy. To evaluate QoL, the European Organisation for Research and Treatment of Cancer, QoL questionnaires (QLQ-C30 and QLQ-CX24) were administered to patients before and 6 and 12 months after surgery.ResultsIn patients with vulvar cancer after inguinofemoral lymphadenectomy, increased fatigue and impaired lymphedema were observed. In the group of patients after sentinel lymph node biopsy, none of the QoL variables worsened postoperatively. Comparing both groups 12 months after surgery, the RAD group had significantly worse outcomes in body image and cognitive functioning than the sentinel lymph node biopsy group.Patients in the RAD group, who received adjuvant radiotherapy (n = 13), had worse QoL in symptom experience (P < 0.05) at 6 and 12 months after the surgery than patients without radiotherapy (n = 11).ConclusionsLess radical surgery showed objectively better QoL results.

ObjectiveSentinel lymph node biopsy has been widely adopted in the surgical management of women with early-stage vulvar cancer, but many patients require inguinofemoral lymphadenectomy (IFL). Following IFL, many surgeons drain the groin to prevent lymphocyst formation despite a lack of evidence to support this practice. Our objective was to investigate whether groin drains after IFL are associated with reduced postoperative morbidity in women undergoing surgery for vulvar cancer.MethodsA retrospective cohort study of women diagnosed as having primary vulvar cancer who underwent vulvectomy/radical local excision and unilateral or bilateral IFL was conducted. Cases were ascertained from the weekly outcome reports of a statewide tertiary gynecologic oncology tumor board. Data including postoperative outcomes were abstracted from medical records. Patients were stratified into 1 of 2 groups according to whether a groin drain had been used.ResultsSeventy-one patients were included. Inguinal drains were used in 48 patients (67.6%) and 23 patients (32.4%) did not have their groin wound(s) drained. The most common postoperative complications recorded were wound infection (59.2%), groin lymphocyst (32.4%), and cellulitis (25.4%). The mean length of hospital admission was 11.5 days (2–40 days). Compared with patients in whom inguinal drains were placed, those in the “no drain” group had a significantly lower incidence of postoperative groin cellulitis (8.7% vs 25.4% P = 0.039). No significant differences were observed between patients in the “drain” and “no drain” groups in lymphocyst formation, wound infection, return to the operating room, duration of hospital stay, readmission post-discharge, and lower-limb lymphedema.ConclusionsIn this study of patients undergoing inguinofemoral dissection for primary vulvar cancer, postoperative cellulitis occurred less frequently in patients without an inguinal drain. The incidence of other postoperative complications was no different whether or not a groin drain was used. Prospective studies may be warranted.

Lymph node metastasis has been shown to represent the most significant prognostic factor in vulvar carcinoma. Because only 25% to 35% of patients with early stage disease have lymph node metastases, a significant 65% to 75% possibly do not benefit from elective inguinofemoral lymphadenectomy considering the related morbidities of wound infection, breakdown, and lower limb lymphedema. This review article aims to present and summarize the evidence available with regard to sentinel lymph node (SLN)-guided management of vulvar carcinoma.A literature search was performed in MEDLINE resources using the subject headings "vulvar neoplasms," "sentinel lymph node," "sentinel lymph node biopsy," and "lymphatic metastasis." This search returned 886 articles that were published through January 2017. Prospective studies investigating sentinel node identification techniques and their impact on vulvar cancer management and prognosis were considered. Case reports were excluded from the review.Technetium-99-m-labeled nanocolloid with or without blue dye and more recently indocyanine green fluorescence have been the main techniques used for SLN identification in vulvar carcinoma. Radioisotope and near-infrared techniques have been shown to be superior to blue dye particularly with midline lesions that drain bilaterally or that drain directly to a deep pelvic node. Patients with a small unifocal primary tumor (4 cm) and no obvious preoperative metastasis have been shown to have low groin recurrence rates and excellent disease-specific survival rates with minimal treatment-related morbidity when undergoing SLN biopsy-guided management.Sentinel lymph node biopsy-guided management seems to be safe when restricted to International Federation of Gynecology and Obstetrics IB to II cases where tumors are unifocal, less than 4 cm in size, and when there is no evidence of lymph node metastasis on clinical/radiological assessment. This reduces operative morbidity in this cohort of patients.

Objective: To evaluate the patients with non-squamous cell type of vulvar cancer who were treated in our clinic within 21 years. Materials and Methods: We assessed the data of 14 patients who were treated for non-squamous cancer of the vulva between January 1992 and August 2013. The age of patients, histopathological diagnosis of the tumor, tumor size, tumor location, medical or surgical treatment, response to the treatment, recurrence, and survival rates were analyzed. Results: The mean age of the patients was 53 years. The main complaint was vulvar pruritus (71%). Mean tumor size was 2.4 cm (range: 0.5-6 cm). In 65% of cases, the tumor was localized in the labia majora. The histopathologic diagnosis of the patients was as follows: malignant melanoma in 5 patients, basal cell carcinoma in 5 patients, mucinous type adenocarcinoma in 2 patients, apocrine gland carcinoma in one patients, and malign peripheral nerve sheath tumor in 1 patient. For 11 patients, surgery was the primary treatment. Radical vulvectomy and bilateral inguinofemoral lymphadenectomy were performed in 8 patients. Local excision alone without lymphadenectomy was performed in other 3 patients. Five of eight patients (62.5%), who undergone radical surgery, had lymph node metastases. Of these 5 patients, two had bilateral lymph node metastasis. Mean follow-up time was 49.2 months (range 12 to 72 months). Eight (57.1%) patients had suffered first recurrence. In those patients, the mean time to recurrence was 19.5 months (range, 6-48 months). Conclusion: Non-squamous cell vulvar cancer is a rare disease and comprises a heterogeneous group of tumors. Malignant melanoma is the most aggressive one. Multicenter prospective studies are necessary in order to standardize the treatment of these rare tumors.