Page 27 - ESGO - Vulvar cancer - Complete report_fxd2
P. 27
Impact of training and experience of the surgeon on the diagnostic accuracy: Several LoE 4
authors118,120,145,173,174 have suggested surgeons should perform at least 10 successful SLN biopsy
procedures followed by complete inguinofemoral lymph node dissection without any false-negative
results prior to performing SLN biopsy alone. In order to keep the experience at a high level, van der
Zee et al.145 proposed that an exposure of at least five to 10 patients per year per surgeon should be
regarded as a minimum figure, requiring potentially centralization of early-stage vulvar cancer
treatment in oncology centres.
As part of a prospective study enrolling 52 patients, Levenback et al.142 reported that the number of LoE 2+
cases in which the sentinel node is not identified or in which there is a false-negative sentinel node
decreases with experience. Indeed, a sentinel node could not be identified in 4 of the 25 (16%)
patients and 13 of the 36 (36%) groins dissected, compared with 2 of the 27 (7%) of patients treated
and 6 of the 40 (15%) groins dissected during the first two years of the study (p = 0.034).
Recurrence and survival rates following SLN procedure: in the GROINSS-V170, five-year disease- LoE 2++
specific survival for patients with positive sentinel nodes was 64.9% when identified by routine
pathology versus 92.1% when identified by ultrastaging (p < 0.0001). The update of the GROINSS-
V-I175 (377 patients) highlighted that on the long-term a significant proportion of patients will
develop a local recurrence, regardless of sentinel node status and that these local recurrences may
occur even a long time after primary treatment. This prospective study also showed that long-term
survival is very good for patients with early-stage vulvar cancer and a negative sentinel node. After a
median follow-up of 105 months, Te Grootenhuis et al.175 reported an overall local recurrence rate of
24.6% at 5 years and 36.4% at 10 years for sentinel node negative patients, and 33.2% and 46.4% for
sentinel node positive patients, respectively (p = 0.03). Disease-specific 10-year survival was 91%
for sentinel node negative patients compared to 65% for sentinel node positive patients (p < 0.0001).
Overall 5- and 10-year survival was also better for sentinel node negative patients (5y-OS: 81.2%
versus 61.3%, 10y-OS: 68.6% versus 43.6%, p < 0.0001).
As part of a health technology assessment comparing SLN biopsy and inguinal lymph node
dissection (ILND), Reade et al.176 reported from 11 studies93,96,113,114,117,132,145-147,177,178 enrolling 591
patients a groin recurrence rate after a negative SLN biopsy of 3.6% (range 0 to 22%). It should be
noted that follow-up in these studies was variable, but in most was at least two years. A recurrence
rate after ILND of 4.3% was also reported (13 studies46,66-68,179-187 enrolling 1,077 patients). It should
be noted that, in general, there was longer follow-up in these studies than in the studies of SLN
biopsy.
Multivariate analyses performed from the surveillance, epidemiology, and end results database on LoE 2-
1,094 patients188 showed that SLN biopsy was not significantly associated with an excess risk of
mortality or recurrence after adjustment for age, ethnicity, stage, grade, and lymph node status (data
not shown).
Complication rates & clinical parameters: Reade et al.176 compared also complication rates between LoE 2++
SLN biopsy (6 studies113,117,120,145,146,178, 532 patients) and ILND (27 studies46,66,68,73-
,76,78,82,85,117,120,145,178,179,182,183,186,189-197 2,135 patients). Wound infection, wound breakdown,
lymphocysts, and chronic lymphoedema after SLN biopsy were 4.4%, 9.5%, 3.8%, and 1.5%,
respectively. The rate of groin wound infection after ILND across all studies was 30.7%, groin
wound breakdown occurred in 23.2%, and lymphocysts occurred in 15.5%. Chronic lymphoedeman
occurred in 22.9% accros all studies.
In a retrospective study enrolling 128 patients, Brammen et al.171 reported also a higher presence of LoE 2+
lymph cysts after ILND compared to SLN biopsy (OR = 3.4 (95% CI = 1.1-10.6), p = 0.02). In
addition, three original studies145,171,178 reported significantly higher operation time, hospital stay or
duration of inguinal drainage after ILND (Table 6).
VULVAR CANCER - GUIDELINES
27
