Page 15 - ESGO - Vulvar cancer - Complete report_fxd2

8 Preoperative investigations

8.1 Summary of available scientific evidence

Pathology review: two studies enrolling at least 50 pathology reports of vulvar tissues were LoE 2+
identified. As part of a retrospective pathology report review, Beugeling et al.12 assessed 1 the
impact of pathology review on patient management and 2 the ade quacy of the pathology reports,
with regard to tumour type, infiltration depth, and, for excision biopsies, resection margins on 121
pathology reports from 112 patients. Two discrepancies have been reported 1.7% but the huge
majority of reviewed reports showed no discrepancy 98.3%. In this study, a report stating
histological type and depth of infiltration was considered “adequate”. Using this criterion, 56% of
the original reports and 83% of the review reports were adequate. In the second identified study13,
113 pathology reports were reviewed and 4 major discrepancies were reported.

Results from the 4 other identified studies14-17 are limited by the small number of pathology reports

taken into account. These studies show a rate between 0% and 15.8% for major discrepancy Table 2.

Among the 6 identified studies, it was not possible to estimate how many histology reviews would
be necessary to find one major discrepancy. Half of the authors from the 6 identified studies12,15,16

have expressed doubt concerning the necessity of pathology report review for vulvar cancer.

Accuracy of clinical palpation to assess the lymph nodes status: four studies18-21 assessing the value LoE 2+
of clinical palpation of the groin lymph nodes were identified. But only two studies18,21 have accrued

in excess of 50 patients:

 In a series of 258 patients treated with radical vulvectomy and bilateral groin lymphadenectomy,
Iversen et al.18 reported metastases to the superficial and/or deep inguinal lymph nodes in 100
cases. Only 64 of which were detected by clinical examination. A false positive rate of 15.5%
among the patients with clinically suspicious groin lymph nodes has been reported.

 Podratz et al.21 reported that the preoperative clinical staging efforts were incorrect in 25% of
the cases 56/224 .

Among the 50 patients enrolled in the study published by Piura et al.19, data with respect to both
clinical palpation and histopathologic examination of groin lymph nodes were available in 20 of the
26 patients who had radical vulvectomy and groin lymph node dissection. Authors have noticed that
clinical palpation was not very reliable in detecting groin lymph node metastases. Overdiagnosis and
underdiagnosis were present in 55.5% and 27.3% of patients sensitivity: 57.1%, specificity: 61.5%.

Thirty-nine patients out of the 59 patients enrolled in the fourth identified study20 had
inguinofemoral lymphadenectomy and all except one had bilateral groin node excision. Clinical
findings were compared with histology result to assess test accuracy for a total of 77 groin nodes. In
this study published by Singh et al.20, clinical examination has a sensitivity of 35% and specificity of
94.3%.

Accuracy of MRI to assess the lymph nodes status: as part of a systematic review, Selman et al.22 LoE 1-
compared the accuracy of non-invasive tests to assess the groin node status. One prospective23 and
one retrospective24 studies assessing the value of the MRI have been included in this review for a

total of 60 patients. MRI has a pooled sensitivity and specificity of 86% 95% CI = 0.57 -0.98 and

87% 95% CI = 0.74 -0.95 respectively in predicting the gro in node status.

Three other original studies20,25,26 were identified but only one study25 has accrued in excess of 50 LoE 2+
patients. In a retrospective study published by Bipat et al. 25, 60 patients underwent MRI
examination for preoperative evaluation of lymph nodes. MRI images were read independently and
retrospectively by two radiologists, both unaware of physical examination and surgery findings. Both

 VULVAR CANCER - GUIDELINES 
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