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Quality of life: one study198 investigated quality of life in 62 patients who participated in the LoE 2+
GROINSS-V study. Using the EORTC QLQ-C30 questionnaire, no difference in overall quality of
life was observed between the 35 patients who underwent the SLN-procedure alone and the 27
patients who underwent an inguinofemoral lymphadenectomy. The major difference was the increase
in complaints of lymphoedema of the legs after inguinofemoral lymphadenectomy (p = 0.01).
Patients who underwent inguinofemoral lymphadenectomy also reported more discomfort in groins,
vulva and legs (p = 0.03), and more frequent need to wear stockings (p = 0.003). Patients after the
SLN procedure only were more content with the treatment they had undergone (p = 0.04). Moreover,
no differences in sexual activeness were observed between SLN procedure and inguinofemoral
lymphadenectomy.
Two smaller studies199,200 were also identified. As part of a prospective study enrolling 36 patients LoE 2-
(12 SLN biopsy procedures and 24 inguinofemoral lymphadenectomies), Novackova et al.199
observed an increased fatigue and impaired lymphoedema in patients after inguinofemoral
lymphadenectomy. Among patients who underwent SLN biopsy procedures, none of the quality of
life variables worsened postoperatively. In the second small study (5 SLN biopsy procedures and 10
inguinofemoral lymphadenectomies), Former et al.200 found that inguinofemoral lymphadenectomy
had a negative impact on sexual function.
Preferences of patients/acceptance of the SLN procedure: three identified studies198,201,202 assessed LoE 2+
the preferences of women for SLN procedure versus inguinofemoral lymphadenectomy in the
treatment of vulvar cancer. Acceptance of the SLN procedure depended on the false-negative rate:
Oonk et al.198: when the false-negative rate was stated as 10%, 84% of patients who underwent a
SLN procedure would recommend it, whereas only 48% of the patients who required the
inguinofemoral lymphadenectomy advised it (p = 0.005). These differences were also observed
with a suggested false-negative rate of 1% (97% versus 62%, p = 0.001) and 0.1% (97% versus
71%, p = 0.013).
de Hullu et al.201: sixty-six per cent of the patients who had undergone inguinofemoral
lymphadenectomy would recommend an inguinofemoral lymphadenectomy if the possibility of
missing a lymph node metastasis with the SLN procedure was one out of 80 patients, while this
proportion increased to 84% if the estimated risk was 10 out of 80. Their preference was not
related to age or the side-effects they had experienced. Investigators also assessed the
preferences on the acceptable false-negative rate of the SLN procedure in gynecologists treating
patients with vulvar cancer. Sixty per cent of gynecologists were willing to accept a 5-20%
false-negative rate of the SLN procedure.
Farrell et al.202: if the risk of missing a positive lymph node was higher than 1 in 100, 80% of
patients who had undergone inguinofemoral lymphadenectomy chose inguinofemoral
lymphadenectomy and 15% of patients chose a SLN procedure (5% of patients were unable to
make a decision). An association has been reported between the choice inguinofemoral
lymphadenectomy or SLN procedure and the severity of lymphoedema. Of the 48 women
choosing inguinofemoral lymphadenectomy, 4 reported moderate or severe lymphoedema,
whereas of the 9 women choosing SLN procedure, 3 reported moderate or severe lymphoedema
(p = 0.04). But if the risk of missing a positive lymph node was lower than 1 in 100, almost one
third of the women would prefer sentinel node biopsy.
10.2 Previous initiatives
Four previous initiatives2,3,39,88,203 presenting guidelines on SLN procedure were identified.
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