Page 16 - ESGO - Vulvar cancer - Complete report_fxd2

observers detected 12 of the 23 positive groin nodes sensitivity: 52%. Of the 96 negative nodes, 14
and 11 were scored as positive by the observers specificity: 85% and 89% respectively. Singh et
al.20 39 patients, 77 groin nodes reported consistent results with those described by Selman et al.22.
MRI correctly identified metastatic nodal disease in 18 of the 21 positive groins and among the 56
negative groin nodes, 46 nodes were correctly identified on MRI, leading to a sensitivity of 85.7%
and a specificity of 82.1%.

It should to be noted that the used MRI criterion for groin lymph node metastasis prediction varied
between the studies short -axis diameter of the node24,25, short axis/long axis ratio, contour, and
signal intensity20,23. Kataoka et al.26 used several criteria for evaluation of lymph node metastases of
49 patients 36 primary and 13 recurrent). A short axis/long axis ratio ≥ 0.75 was described as the
most relevant criterion for diagnosis of groin lymph node metastasis in groin-by-groin analysis
sensitivity: 86.7% and specificity: 81.3%. The presence of necrosis within a lymph node showed
the highest specificity 87.5%, bu t lower sensitivity 40.0%. Furthermore, MRI accurately
classified 31 out of 36 primary cancers accuracy: 86%. The addition of contrast -enhanced MRI did
not change the accuracy of the size category of primary cancers accuracy: 85%.

Accuracy of PET to assess the lymph nodes status: Selman et al.22 pooled results of two prospective LoE 1-
studies27,28 to assess the value of PET in the determination of groin nodes status 75 patients. PET

has a pooled sensitivity and specificity of 71% 95% CI = 50 -86 and 72% 95% CI = 59 -82

respectively.

One small original study29 was also identified 20 patients. Of the 12 positive nodes, 6 were scored LoE 3
as positive sensi tivity: 50% and all the 8 negative nodes were correctly identified specificity:
100%.

Accuracy of Ultrasound to assess the lymph nodes status: four prospective studies30-33 assessing the LoE 2+
value of ultrasound have been included in the systematic review published by Selman et al.22.
However, a pooled analysis could not be performed due to the difference between studies in
techniques used to discriminate positive and negative groin nodes. Combining the results of another
study34 identified and independently of the test parameters used for ultrasound, the results showed
sensitivity and specificity ranging from 45% to 100% and from 58% to 96% respectively

Table 3. Moskovic et al.30 combined ultrasound with ultrasound-guided fine-needle aspiration

cytology FNAC to improve accuracy. This combi ned technique could accurately predict nodal
status in the majority of cases. Falsely negative cytology occurred when the metastatic focus was ≤ 3
mm two false -negative results out of 40 groins. Hall et al.31, who extended the study of Moskovic
et al.30 to 44 patients, reported that the combination of ultrasound and FNAC provides a sensitive

and specific tool for preoperative assessment sensitivity = 93%, specificity = 100%.

Accuracy of CT to assess the lymph nodes status: no literature is available on the diagnostic value of LoE 4

CT for detection of inguinofemoral lymph node metastases in patients with vulvar cancer. The only
experience with CT in patients with vulvar cancer is the measurement of the distance in centimetres
between the skin and the underlying inguinofemoral lymph nodes for planning of groin radiation35,36.

8.2 Previous initiatives

Seven previous initiatives1-4,37-39 presenting guidelines on preoperative investigations were identified.

8.3 Development group comments

Size of the lesion, distance to the midline and palpation of the lymph nodes all determine the choice for primary
treatment. Involvement of clitoris, anus, and/or urethra often means that these structures will need to be radically
excised together with the primary tumour. Such information is important for treatment planning and informing
the patient. In case of clitoral/anal/urethral involvement, primary radiochemotherapy might be an alternative.

 VULVAR CANCER - GUIDELINES 
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