Groin Node Research Articles

The accuracy of intraoperative frozen section examination of sentinel lymph nodes in squamous cell cancer of the vulva

ObjectiveTo assess the diagnostic accuracy of intraoperative pathologic examination of sentinel lymph nodes (SLNs) and patient outcomes in vulva cancer. MethodsThis retrospective study included patients with unifocal, <4 cm, invasive vulvar squamous cell carcinoma and clinically negative groin nodes treated with SLN biopsy from January 2008–March 2020. Intraoperative SLN frozen section and final pathology were compared. If the SLN was negative, inguinal femoral lymphadenectomy (IFLD) was omitted. Recurrence location and groin recurrence free survival (RFS) were assessed. ResultsThe SLN cohort included 173 patients, with 258 groins. On frozen section, there were 36/258 positive and 222 negative groins. On final pathology, there were 39/258 positive: 31 macrometastases, 6 micrometastases, 2 isolated tumor cells (ITCs) and 219 negative groins. The sensitivity, specificity, PPV and NPV for intraoperative detection of metastatic disease, was 89.7% and 99.5%, 97.2% and 98.2%, respectively. There was 1 false positive and 4 false negative frozen section results where final pathology revealed 2 ITCs, 1 micrometastasis and 1 macrometastasis. Based on intraoperative results, thirty patients (17.3%) underwent immediate IFLD.Median follow up was 38.0 (1–137.8) months. The 3-year groin RFS was 91.6% (95% CI 86.2–97.4%) for negative SLNs and 64.6% (95% CI 46.5–89.7%) for positive SLNs on frozen section. Similarly, the 3-year groin RFS was 91.7% (95% CI 86.3–97.4%) for negative, 58.4% (95% CI 38.5–87.7%) for macrometastases and 100% for micrometastases/ITCs on final pathology. ConclusionsIntraoperative assessment of SLNs is accurate to determine need for IFLD and does not compromise patient outcomes in vulvar cancer.

Medial Inguino-Femoral Lymphadenectomy for Vulvar Cancer: An Approach to Decrease Lymphedema without Compromising Survival.

Simple SummaryThis prospective study has demonstrated that if the inguinal nodes medial to the lateral border of the femoral artery and the femoral nodes are negative in patients with vulvar cancer, the chances of having a positive node lateral to the artery are less than 1 in 10,000. About one-third of groin nodes are situated lateral to the femoral artery, so leaving these nodes in situ if the medial nodes are negative should significantly decrease the incidence and severity of lower limb lymphedema, without compromising survival.Background: Lower limb lymphedema is a long-term complication of inguino-femoral lymphadenectomy and is related to the number of lymph nodes removed. Our hypothesis was that lymph nodes lateral to the femoral artery could be left in situ if the medial nodes were negative, thereby decreasing this risk. Methods: We included patients with vulvar cancer of any histological type, even if the cancer extended medially to involve the urethra, anus, or vagina. We excluded patients whose tumor extended (i) laterally onto the thigh, (ii) posteriorly onto the buttocks, or (iii) anteriorly onto the mons pubis. After resection, the inguinal nodes were divided into a medial and a lateral group, based on the lateral border of the femoral artery. Results: Between December 2010 and July 2018, 76 patients underwent some form of groin node dissection, and data were obtained from 112 groins. Approximately one-third of nodes were located lateral to the femoral artery. Positive groin nodes were found in 29 patients (38.2%). All patients with positive nodes had positive nodes medial to the femoral artery. Five patients (6.6%) had positive lateral inguinal nodes. The probability of having a positive lateral node given a negative medial node was estimated to be 0.00002. Conclusion: Provided the medial nodes are negative, medial inguino-femoral lymphadenectomy may suffice and should reduce lower limb lymphedema without compromising survival.

Commentary: Lymph-axiality concept awareness reduces trauma-induced lymphedema (commentary on JPRAS-D-20-01255: Lymph-interpositional-flap transfer (LIFT) based on lymph-axiality concept: simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosis)

Depending on the stage of secondary lymphedema, surgical treatments can be categorized into reconstructive (e.g., lymphovenous bypass and vascularized lymph nodes transfers 1 Cheng M.H. Chen S.C. Henry S.L. et al. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg. 2013; 131: 1286-1298 Google Scholar ) and debulking procedures (e.g., lipoaspiration 2 Brorson H. Svensson H. Liposuction combined with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg. 1998; 102 (discussion 1068): 1058-1067 Google Scholar , modified Charles’ procedures 3 van der Walt J.C. Perks T.J. Zeeman B.J. et al. Modified Charles procedure using negative pressure dressings for primary lymphedema: a functional assessment. Ann Plast Surg. 2009; 62: 669-675 Google Scholar ). Lymph-interpositional-flap transfer (LIFT) based on lymph-axiality concept: Simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosisJournal of Plastic, Reconstructive & Aesthetic SurgeryVol. 74Issue 10PreviewLymphatic system is important to maintain homeostasis. Lymph-axiality concept has been reported, which suggests possibility of lymphatic reconstruction using flap transfer without lymph node or supermicrosurgical lymphatic anastomosis. Full-Text PDF

The Predictive Value of Post-Treatment PET-CT Imaging for Patients With Curable Anal Canal Cancer

<h3>Purpose/Objective(s)</h3> According to 2020 "NCCN" guidelines, post-treatment positron emission tomography (PET) – computed tomography (CT) imaging of the body is <b>not</b> recommended to predict outcomes of patients undergoing curative intent chemoradiation therapy (CRT) for anal canal cancer. This study used PERCIST (Positron Emission tomography Response Criteria In Solid Tumors) to evaluate CRT response and outcomes for our patient population at a single institution. <h3>Materials/Methods</h3> Our "IRB"-approved anal canal database was queried for patients who have undergone CRT, modified "NIGRO" protocol, for carcinoma of the anal canal. The evaluable patient dataset comprised those with both pre- and post-CRT PET-CT imaging of the body. The primary study endpoint was relapse-free survival (RFS) calculated from date of diagnosis to date of first known appearance of disease or death from any cause. Overall survival (OS) was defined using elapsed time between date of diagnosis and date of death and surviving patients were censored using date of last follow-up. Also, the range and median time to first post-CRT PET-CT imaging was determined. RFS and OS were analyzed using Kaplan-Meier method. Complete response rate (CRR) and objective response rate (ORR) were calculated along with 95% confidence intervals using Fisher's exact method. All tests were two-sided, and statistical significance was considered when <i>P</i> < 0.05. <h3>Results</h3> Out of an initial 392 patients in our database registry, 62 had pre/post-CRT PET-CT imaging from June 2008 until May 2020. There were 18 males and 44 females. The median age at diagnosis was 57.7 years (range: 38-84 years). "AJCC" (7^th edition) staging distribution was as follows: 3 Stage I, 13 Stage II, 41 Stage III, and 5 Stage IV. The median total dose of external beam irradiation was 54 Gy (range: 45-60 Gy). Time to post-CRT PET-CT imaging ranged from 0.2 to 27.8 months (mos) [median: 2.9 mos]. Respective PET-response rates regarding primary tumor (N = 62); largest groin node (N = 33); and largest pelvic node (N = 39) were as follows: 31 CR (Complete Response), 26 PR (Partial Response), 5 SD (Stable Disease), and 0 DP (Disease Progression); 30 CR, 3 PR, 0 SD, 0 DP; and 36 CR, 1 PR, 2 SD, 0 DP. Patient follow-up ranged from 6.8 to 114 mos (median: 38.6 mos). At time of last follow-up, there were 53 alive and 9 dead. Estimated 3-year RFS was 72% (95% "CI": 58.2-81.9%). Estimated 3-year OS was 88.8% (95% CI: 76.6-94.9%). Respective CRRs and ORRs for the primary tumor were 50% (95% CI = 37-63%) and 91.9% (95% CI = 82.2-97.3%); for the groin node 48.4% (95% CI = 35.5-61.4%) and 53.2% (95% CI = 40.1-66%); and for the pelvic node 58.1% (95% CI = 44.8-70.5%) and 59.7% (95% CI = 46.4-71.9%). CRRs and ORRs were not significant prognostic factors for either RFS or OS. <h3>Conclusion</h3> After applying PERCIST to our institutional study cohort, the use of post-treatment PET-CT imaging to predict outcomes for this patient population remains unproven.

Creation of a rat lymphedema model using extensive lymph node dissection and circumferential soft tissue resection: Is this a reliable model?

The medical demand for lymphedema treatment is huge since the disease mechanism remains unclear, and management are difficult. Our purpose was to develop a reliable lymphedema model mimicking the clinical scenario and allows a microsurgical approach. Male Lewis rats weighing 400 to 450 g were used to create lymphedema with groin and popliteal lymph node dissection and creation of 5 mm circumferential skin defect (n=6). A skin incision was made and closed primarily for control group (n=5). Evaluation included indocyanine green (ICG) lymphangiography 1 and 2months postoperatively, volume difference between bilateral hindlimbs measured using micro-CT, and the skin was harvested for histological evaluation 2months postoperatively. Larger volume differences present in the lymphedema group (17.50 ± 7.76 vs. 3.73 ± 2.66%, p < .05). ICG lymphangiography indicated dermal backflow only in the lymphedema group. Increased thickness of the epidermis was noted in lymphedema group (28.50 ± 12.61 μm vs. 15.10 ± 5.41 μm, p < .0001). More CD45+ (35.6 ± 26.68 vs. 2.8 ± 4.23 cells/high power field [HPF], p < .0001), CD3+ (38.39 ± 20.17 vs. 9.73 ± 8.62 cells/HPF, p < .0001), and CD4+ cell infiltration (11.7 ± 7.71 vs. 2.0 ± 2.67 cells/HPF, p < .0001) were observed in the lymphedema group. Collagen type I deposition was more in the lymphedema group (0.15 ± 0.06 vs. 0.07 ± 0.03, p < .0005). A rat lymphedema model was successfully established. The model can be applied in lymphedema related research.

Pelvic lymphadenectomy in vulvar cancer and its impact on prognosis and outcome

BackgroundThe value of pelvic lymphadenectomy (LAE) has been subject of discussions since the 1980s. This is mainly due to the fact that the relation between lymph node involvement of the groin and pelvis is poorly understood and therewith the need for pelvic treatment in general.Patients and MethodsN = 514 patients with primary vulvar squamous cell cancer (VSCC) FIGO stage ≥ IB were treated at the University Medical Center Hamburg-Eppendorf between 1996 and 2018. In this analysis, patients with pelvic LAE (n = 21) were analyzed with regard to prognosis and the relation of groin and pelvic lymph node involvement.ResultsThe majority had T1b/T2 tumors (n = 15, 78.9%) with a median diameter of 40 mm (11–110 mm). 17/21 patients showed positive inguinal nodes. Pelvic nodal involvement without groin metastases was not observed. 6/17 node-positive patients with positive groin nodes also had pelvic nodal metastases (35.3%; median number of affected pelvic nodes 2.5 (1–8)). These 6 patients were highly node positive with median 4.5 (2–9) affected groin nodes. With regard to the metastatic spread between groins and pelvis, no contralateral spread was observed. Five recurrences were observed after a median follow-up of 33.5 months. No pelvic recurrences were observed in the pelvic nodal positive group. Patients with pelvic metastasis at first diagnosis had a median progression-free survival of only 9.9 months and overall-survival of 31.1 months.ConclusionA relevant risk for pelvic nodal involvement only seems to be present in highly node-positive disease, therefore pelvic staging (and radiotherapy) is probably unnecessary in the majority of patients with node-positive VSCC.

Clinicopathological Prognostic Factors Influencing Survival Outcomes of Vulvar Cancer.

Background:The prognostic factors for survival in squamous cell carcinoma (SCCA) of vulva cancer such as groin node involvement, postmenopausal status, tumor size, margin status, tumor grade, lymph vascular space invasion (LVSI) were reported in the past. However, with limited data from Southeast - Asian population, the present study was conducted to evaluate the clinicopathological prognostic factors for survival outcomes of this disease after treatment with surgery.Methods:All SCCA vulva cancer patients who underwent surgery between January 2006 and December 2017 were reviewed. The clinicopathological factors were analyzed to identify the prognostic factors for the progression-free survival (PFS) and overall survival (OS) using the Kaplan- Meier method and Cox-Proportional Hazard model. Results:One hundred twenty-five patients were recruited. The independent poor prognostic factors for PFS were groin node-positive and pathologic tumor diameter of more than 25 mm. Whereas postmenopausal status and groin node positive were independent poor prognostic factors for OS. Conclusion:Groin node-positive was the only one independent poor prognostic factor for both PFS and OS. In addition, the tumor diameter longer than 25 mm. was independent poor prognostic factors for PFS while postmenopausal status was independent poor prognostic factors for OS. Special adjuvant treatment for patients with these factors should be further investigated.

Vessel-preserving en-bloc excision of groin recurrence of vulval carcinoma with tensor fasciae latae flap reconstruction in a previously irradiated field

Objectives: Groin node dissection for recurrent vulval cancer in a previously irradiated field presents many surgical challenges - risk of vascular involvement, ill-defined planes and poor tissue quality for closure and healing. Our case demonstrates the feasibility of surgical management and value of flap reconstruction in managing disease relapse in such patients. Methods: We present the surgical approach to recurrent squamous cell carcinoma (SCC) vulva in a patient who has undergone previous radical radiotherapy to the site of relapse. Download : Download high-res image (268KB) Download : Download full-size image Results: In 2019 - a 70 year old lady underwent radical vulvectomy and left gluteal fold flap reconstruction, followed by radical radiotherapy and concomitant cisplatin for stage IIIc SCC vulva. A total of 12 months later, the patient presented with a clinically palpable, fixed left groin swelling. Imaging confirmed an FDG-avid 2.6 x 4.2 centimetre (cm) partially necrotic left inguinal lymph node, engulfing the femoral vessels. The patient was counselled pre-operatively by both gynae-oncology and plastic surgery – offering surgical excision of this single site recurrence, anticipating the need for further flap reconstruction for wound closure. Additional challenges included body mass index (BMI) of over 40 kilograms/metre2 and chronic candida of the abdominal pannus. Joint examination under anaesthetic by gynae-oncology and plastic surgery confirmed no vulval recurrence and no palpable right groin nodes. Left thigh perforator vessels were identified and marked using doppler. An 8.6 x 3.1cm elliptical incision was made around the fixed underlying node; and systematic inguino-femoral lymph node dissection performed using both bipolar scissors and an advanced energy device. An en-bloc specimen measuring 6.6 x 3.1 x 6.1cm was obtained. The femoral artery and vein were identified; and long saphenous vein preserved. Wound closure was achieved by raising an 18 x 8cm tensor fasciae latae (TFL) islanded flap, rotating and anchoring into place. Postoperatively, the patient was managed jointly under gynae-oncology and plastic surgery. Intravenous antibiotics, anti-fungals and thromboprophylaxis were given. The patient was advised to avoid sitting for 2 weeks. Drain outputs were monitored; and drains removed day 14. A small area of wound dehiscence occurred along the inferior border of the groin flap – which was healing well by secondary intention at the time of 4 week post-operative review, without need for further management. Final histopathology confirmed excised metastatic SCC, with a plan for ongoing surveillance arranged. Conclusions: In patients having undergone previous radiotherapy - surgery remains the main therapeutic option for recurrence. Undertaking such surgery, however, in a previously irradiated field - with altered anatomy and compromised perfusion - significantly increases the risk of inadvertent vessel or nerve injury and wound breakdown. We have demonstrated an approach, however, in an obese patient that achieved disease clearance through meticulous dissection, achieving wound closure and healing by incorporating TFL flap reconstruction.

The accuracy of intraoperative frozen section examination of sentinel lymph nodes in squamous cell cancer of the vulva

<h3>Objectives:</h3> To measure the diagnostic accuracy of intraoperative frozen section examination of sentinel lymph nodes (SLN) in vulvar cancer and to describe associated patient outcomes. <h3>Methods:</h3> This retrospective cohort study included patients with invasive squamous cell carcinoma of the vulva who underwent SLN biopsy with intraoperative frozen section at one cancer centre from Jan 2008 - Feb 2020. Exclusion criteria were tumor size >4cm, multifocal tumor, palpable groin lymph nodes and neoadjuvant therapy. The SLN procedure was performed by injection of the primary vulvar tumor or scar with technetium-99m, ICG and/or blue dye. We compared the intraoperative SLN frozen section diagnosis and the paraffin section report for concordance. Recurrence location was described and recurrence free survival (RFS) was compared using the Kaplan-Meier method. <h3>Results:</h3> A total of 173 patients (258 groins) met inclusion and exclusion criteria. On frozen section, there were 36/258 positive groins on frozen section and 222 negative groins. On final pathology, there were 39/258 positive groin nodes: 30 macro-metastases, 7 micro-metastases, 2 isolated tumor cells (ITCs). There were 219 negative groins. The sensitivity and specificity for frozen section detecting any metastatic disease compared to final pathology, was 89.7% and 99.5%, respectively. The positive-predictive value (PPV) was 97.2% and the negative-predictive-value (NPV) was 98.2%. There were 4 cases of false negative frozen section where final pathology revealed two cases of ITCs, 1 micro-metastasis and 1 macro-metastasis. A total of 30 patients (17.3%) underwent a full inguinal femoral lymphadenectomy during the same operation due to the frozen section results and avoided a second operation. A total of 2 patients (1.2%) required a second operation for lymphadenectomy due to false negative results on frozen section. Median (range) follow up was 38.0 (1-137.8) months. Median RFS was 14.9 (3.6 to 98.2) months. There were 46 recurrences in the study population, of which 29 were confined to the vulva, 9 groin recurrences and 8 distant recurrences. Among patients with a negative SLN biopsy on both frozen section and final pathology, there were 10 (3.9 %) groin and/or distant recurrences. A total of 6 nodal recurrences were ipsilateral, 1 was contralateral, 2 were bilateral and 1 recurrence was distant. After exclusion of patients with local recurrence only, the RFS at 3 years was 91.6% (95% CI 86.2-97.4%) for patients with negative SLN on frozen section and 64.6% (95% CI 46.5-89.7%) for positive SLN on frozen section. On final pathology, patients with negative SLN had a 3-year RFS of 91.7% (95% CI 86.3-97.4%), macro-metastases 58.4% (95% CI 38.5-87.7%), and micro-metastases/ITCs was 100%. <h3>Conclusions:</h3> Intraoperative frozen section of SLNs in vulvar cancer is an accurate intraoperative guide to determine if complete inguinal femoral lymphadenectomy should be performed. SLN biopsy reduced the need for a second surgical procedure and does not appear to compromise patient outcomes.

Superficially Invasive Vulvar Squamous Cell Carcinoma: A 37-Year-Long Experience of a Tertiary Referral Center

Simple SummarySuperficially invasive vulvar squamous cell carcinoma (SISCCA) is a rare subgroup of vulvar squamous cell carcinoma with good prognosis and low risk of groin metastasis, however experience reported in the literature is limited. The aim of our retrospective study is to present a large series of SISCCAs and analyze prognostic outcomes. We also described a case of SISCCA from our series with vulvar recurrence and groin metastasis, together with a literature review of this issue. Overall, SISCCA have a good prognosis, irrespective of type of surgical treatment, pathological characteristics, and status of surgical margins. However, patients should enter in accurate long term follow-up, in particular for younger patients and in case of small tumors, as recurrence or re-occurrence may occur even after many years after diagnosis.Superficially, invasive vulvar squamous cell carcinoma (SISCCA) (FIGO stage IA) is a rare subset of vulvar cancer defined as a single lesion measuring ≤2 cm with a depth of invasion of ≤1.0 mm. This is a retrospective study performed on 48 patients with SISCCA, surgically treated between 1981 and 2018 at the S. Anna Hospital, University of Turin, to evaluate pathological characteristics and prognosis of these tumors. Ten patients (21%) recurred: seven (14%) as SISCCA and three (7%) as deeply invasive carcinoma. One case with perineural invasion and groin node metastasis at recurrence. No patient had groin lymph node metastases at initial diagnosis. Site of SISCCA, type of surgery, status of surgical margins, and histopathological features did not differ between recurrent and non-recurrent patients. We observed a non-significant trend towards an increase of recurrences in younger women (median age: 63 years vs. 70 years, p = 0.09), while, surprisingly, smaller tumors (<12 mm) were significantly related to tumor relapse (p = 0.03). Overall, SISCCA has a good long-term prognosis, regardless of the pathological characteristics and the type of surgical treatment. We recommend close follow-up, especially for younger patients and for small tumors, due to the possibility of recurrence or re-occurrence even after years.

Evaluation of Free vascularized groin lymph nodes transfer for treatment of secondary upper limb lymphedema

Abstract Background: Vascularized lymph node flap transfer is a recent approach used for the treatment of breast cancer-related upper limb lymphedema. Objective: This work aims to evaluate the effect of vascularized lymph node transfer in the management of secondary upper extremity lymphedema. Methods: a prospective randomized clinical study was conducted including 30 patients stage II-III breast cancer-related lymphedema (BCRL) between December 2017 till June 2020. 15 patients underwent vascularized groin lymph node flap transfer (group B) using the axilla (n = 7) or distal placement (elbow/wrist) (n = 8) as a recipient site. 15 patients who were selected to undergo conservative therapy were used as controls. Intraoperatively, reverse lymphatic mapping using radioisotope or indocyanine green lymphography was performed to avoid iatrogenic lower extremity lymphatic injury. Outcomes were assessed using change of circumferential differentiation, volume reduction rate, and the change in episodes of cellulitis, pain, heaviness, and limb function. Results: At a mean follow-up of 30.07±2.6 months, the mean improvement of circumferential differentiation of group B (VGLNT) was statistically greater than that of group A (conservative physical therapy) (8.3 ± 2.7 percent versus 2.1 ± 4.6; P < 0.01). The evaluation of each treatment showed a significant reduction of infection rate in group B compared with group A (p < 0.001). Conclusion: Vascularized groin lymph node flap transfer using the axilla or distal forearm as a recipient site is an effective and reliable approach for treating breast cancer-related lymphedema.

Prospective Clinicopathological Study of Penile Cancer Patients : A Single Institution Experience

Background: Carcinoma of the penis is an uncommon malignancy in Western countries but constitutes amajor health problem in many countries in Asia, Africa, and South America, where it may comprise up to10% of all malignancies.Materials and Method: 42 consecutive patients of carcinoma penis were treated from 2013 to 2015. Clinicaland pathological profies were recorded and studied prospectively.Results: 20/42 (48%) patients were of the age group 60 and above. majority of patients belonged to poorsocioeconomic status, 32/42 patients(76.1%). Glans of the penis was the most common site of presentationin 28/42patients(66.6%). The most common symptoms were pus discharge from the penile ulcer in 21patients(50%). 31/42 patients were chronic smoker or tobacco chewer. Inguinal lymph nodes were palpablein 24/42 (57%). The most common complication associated with Groin node dissection was lymphedema in19 patients (45.2%). 12/42 patients had inguinal lymph node metastasis in final histopathological examinationreport. 50 % patients had grade II primary tumor.Conclusion: Incidence of carcinoma penis peaks in the 6thdecade of life. Illiteracy, low socio-economicstatus and phimosis appear to be main predisposing factors for carcinoma of penis. Nodal metastasis wassignificantly associated with factors like T3 and high grade lesions (grade II & III). Complication rate relatedto groin node dissection is high, commonest being lymphedema.

A Novel Technique for Preventive Lymphovenous Anastomosis: Anastomosing a Ligated Lymphatic Vessel

Background:Lymphedema is defined as a chronic condition, caused by lymphostasis. A major part in the Western world consists of iatrogenic lymphedema caused by surgery to the lymph nodes of the axilla or groin. Prophylactic lymphovenous anastomosis (LVA) could be beneficial in the prevention of lymphedema of the extremities. These procedures require experienced supramicrosurgeons and can be time consuming, which might be the reasons why prophylactic LVA has not yet been widely implemented in the treatment of cancer. Due to the small diameter of lymphatic vessels, it remains challenging to identify the lumen, and therefore, anastomoses are prone to back wall stitching. Different inventive procedures have been described making use of stents or monofilament sutures.Methods:In this article, we describe a newly developed and straightforward technique for LVA in 4 patients who underwent an axilla dissection and 1 patient who underwent a dissection of the groin lymph nodes. This latter approach makes use of clipping of the lymphatic vessel during lymph node dissection, and remains ligated during anastomosis. The candidate vein was the V. thoracodorsalis for the axilla and the V. circumflexa superficialis for the groin. We describe the feasibility, average duration, and complications.Results:Performing an end-to-side anastomosis on a clipped lymphatic vessel minimizes the problem of back wall stitching as well as the trouble of finding the lumen due to collapsing of the vessel. The turgor of the lymphatic vessel is maintained and makes anastomosing easy. Average time for LVA was 33.4 minutes and 1 minor complication was seen.Conclusion:We believe that this approach might be of value in popularizing LVA in the treatment or prevention of different conditions such as breast cancer-related lymphedema.

Role of Pelvic Lymph Node Resection in Vulvar Squamous Cell Cancer: A Subset Analysis of the AGO-CaRE-1 Study

BackgroundAs the population at risk for pelvic nodal involvement remains poorly described, the role of pelvic lymphadenectomy (LAE) in vulvar squamous cell cancer (VSCC) has been a matter of discussion for decades.MethodsIn the AGO-CaRE-1 study, 1618 patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB or higher primary VSCC treated at 29 centers in Germany between 1998 and 2008 were documented. In this analysis, only patients with pelvic LAE (n = 70) were analyzed with regard to prognosis and correlation between inguinal and pelvic lymph node involvement.ResultsThe majority of patients had T1b/T2 tumors (n = 47; 67.1%), with a median diameter of 40 mm (2–240 mm); 54/70 patients (77.1%) who received pelvic LAE had positive groin nodes. For 42 of these 54 patients, the number of affected groin nodes had been documented as a median of 3; 14/42 (33.3%) of these patients had histologically confirmed pelvic nodal metastases (median number of affected pelvic nodes 3 [1–12]). In these 14 patients, the median number of affected groin nodes was 7 (1–30), with a groin metastases median maximum diameter of 42.5 mm (12–50). Receiver operating characteristic analysis showed an area under the curve of 0.85, with 83.3% sensitivity and 92.6% specificity for the prediction of pelvic involvement in cases of six or more positive groin nodes. No cases of pelvic nodal involvement without groin metastases were observed. Prognosis in cases of pelvic metastasis was poor, with a median progression-free survival of only 12.5 months.ConclusionFor the majority of node-positive patients with VSCC, pelvic nodal staging appears unnecessary since a relevant risk for pelvic nodal involvement only seems to be present in highly node-positive disease.

Diagnostic performance of preoperative [18F]FDG-PET/CT for lymph node staging in vulvar cancer: a large single-centre study

PurposeThis retrospective study aimed to assess the diagnostic performance of preoperative [18F]FDG-PET/CT in predicting the groin and pelvic lymph node (LN) status in a large single-centre series of vulvar cancer patients.MethodsBetween January 2013 and October 2018, among all consecutive women with proven vulvar cancer submitted to [18F]FDG-PET/CT, 160 patients were included. LNs were analysed by two qualitative methods assessing PET information (defined as visual assessment) and a combination of PET and low-dose CT information (defined as overall assessment), respectively, as well as semi-quantitative analysis (LN-SUVmax). Sensitivity, specificity, accuracy, positive and negative predictive values (PPV and NPV) in predicting the groin and pelvic LN status were calculated in the overall study population; a subset analysis of groin parameters in clinically/ultrasonography negative patients was also performed. Histopathology was the reference standard.ResultsAll patients underwent vulvar and inguinofemoral LN surgery, and 35 pelvic LN surgery. Overall, 338 LN sites (296 groins and 42 pelvic sites) were histologically examined with 30.4% prevalence of metastatic groins and 28.6% for metastatic pelvic sites. In the overall study population, sensitivity (95% confidence interval, CI), specificity (95% CI), accuracy (95% CI), PPV (95% CI) and NPV (95% CI) at the groin level were 85.6% (78.3–92.8), 65.5% (59.0–72.0), 71.6% (66.5–76.8), 52.0% (44.0–60.1) and 91.2% (86.7–95.8) for visual assessment; 78.9% (70.5–87.3), 78.2% (72.5–83.8), 78.4% (73.7–83.1), 61.2% (52.3–70.1) and 89.4% (85.0–93.9) for overall assessment; and 73.3% (64.2–82.5), 85.0% (80.1–89.8), 81.4% (77.0–85.8), 68.0% (58.8–77.3) and 87.9% (83.4–92.5) for semi-quantitative analysis (SUVmax cut-off value 1.89 achieved by ROC analysis). Similar results were observed in the pelvis-based analysis.ConclusionIn this large single-centre series of vulvar cancer patients, [18F]FDG-PET/CT showed good values of sensitivity and NPV in discriminating metastatic from non-metastatic LNs. In routine clinical practice, qualitative analysis is a reliable interpretative criterion making unnecessary commonly used semi-quantitative methods such as SUVmax.

The potential risk of contralateral non-sentinel groin node metastasis in women with early primary vulvar cancer following unilateral sentinel node metastasis: a single center evaluation in University Hospital of D\xfcsseldorf

BackgroundSince the introduction of sentinel node biopsy (SLNB) in unifocal vulvar cancer (diameter of < 4 cm) and unsuspicious groin lymph nodes, the morbidity rate of patients has significantly decreased globally. In contrast to SLNB, bilateral inguinofemoral lymphadenectomy (IFL) has been associated with increased risk of common morbidities. Current guidelines (NCCN, ESGO, RCOG, and German) recommend that in cases of unilaterally positive sentinel lymph node (SLN), bilateral IFL should be performed. However, two recent publications by Woelber et al. and Nica et al. contradict the current guideline, since a significant rate of positive non sentinel lymph nodes in IFL contralaterally was not observed [Woelber et al. 0% (p = 0/28) and Nica et al. 5.3% (p = 1/19)].MethodsA retrospective single-center analysis conducted in the University Hospital of Dusseldorf, evaluating vulvar cancer patients treated with SLNB from 2002 to 2018.Results22.2% of women (n = 4/18) were found to have contralateral IFL groin metastasis after an initial diagnosis of unilateral SLN metastasis. The depth of tumor infiltrating cells correlated significantly and positively with the rate of incidence of groin metastasis (p = 0.0038).ConclusionCurrent guideline for bilateral IFL should remain as the standard management. Therefore, this depth may be taken into account as an indication for bilateral IFL. The management of VC and SLNB should be performed in a high volume center with an experienced team in marking SLN and performing the adequate surgical procedure. Well conducted counseling of the patients outlining advantages but also potential oncological risks of this technique especially concerning rate of groin recurrence is critical.

Indigenous Groin Board Immobilization Reduces Planning Target Volume Margins in Groin Radiotherapy.

Purpose:To quantify the relative motion of pelvic and groin lymph nodes (PLN and GLN) and define indicative margins for image-guided radiotherapy based on bony anatomy for the frog-leg position (FLP) and groin immobilization board (GIB).Materials and Methods:Twenty patients with planning computed tomography (CT) scan and on treatment cone beam CTs (median = 8) for groin and pelvic radiotherapy were included in the study. Of these nine were treated with FLP and eleven with GIB. The PLN and GLN regions on the left and right were outlined in each scan. Systematic and random uncertainties were determined along with correlations between the motions of these regions. The clinical target volume to planning target volume (PTV) margins required to take motion into account was calculated for each immobilization.Results:The mean shifts for PLN and GLN were lesser but not statistically lower using GIB over FLP. There was significant concordance in the vertical, longitudinal and lateral motion of the pelvis and right groin (P = 0.015, 0.09 and 0.049, respectively), pelvis and left groin (P = 0.001, 0.048, and 0.006, respectively) and between left and right groin (P = 0.013, 0.01 and 0.07, respectively) for FLP and not GIB. The PTV margins required by Van Herk and Stroom's formula were reduced from 11 mm and 9 mm to 6 mm and 5 mm for pelvis; 12 mm and 11 mm to 7 mm and 6 mm for groin, respectively, using FLP over GIB.Conclusions:GIB brings concordance in shifts between pelvis and groin and between bilateral groins, thereby reducing the required PTV margins.

Combined deep inferior epigastric artery perforator flap with vascularized groin lymph node transplant for treatment of breast cancer-related lymphedema.

For survivors of breast cancer lymphedema is their greatest survivorship burden. Modern surgical techniques to treat lymphedema are effective at reducing limb volume, symptoms of lymphedema, episodes of cellulitis, and improving patient quality of life. Physiologic procedures, including lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT), restore physiological lymphatic function within the affected extremity. In patients with post-mastectomy breast cancer-related upper extremity lymphedema that desire breast reconstruction, microvascular abdominal flap breast reconstruction can be combined with superficial inguinal (groin) VLNT to provide breast reconstruction and treatment of lymphedema in a single operation. This article reviews the indications, preoperative assessment, surgical technique, outcomes, and tips and pearls for performing this procedure.

The use of preoperative neutrophil-lymphocyte ratio and lymphocyte-monocyte ratio in predicting survival and groin node involvement of patients with squamous cell carcinoma of penis.

Introduction:The association between inflammation and malignancies is being recognized. In this study, we assessed the use of preoperative neutrophil–lymphocyte ratio (NLR) and lymphocyte–monocyte ratio (LMR) in predicting cancer-specific survival (CSS) and inguinal node involvement in patients with carcinoma penis.Methods:Sixty-nine patients operated for squamous cell carcinoma penis with inguinal node dissection between 2012 and 2020 were identified. We recorded the type of surgery (partial/total penectomy), T stage, grade, lymphovascular invasion (LVI), perineural invasion (PNI), pathological status of inguinal nodes and nodal stage (pN1–3), extranodal extension (ENE), and CSS. The hemogram performed within 2 weeks of surgery was used for calculating NLR and LMR.Results:Partial penectomy was the most common surgery (65.22%) and pT2 was the most common stage (53.62%). Grade 2 was seen in 66.67%, LVI in 34.78%, PNI in 37.68%, 52.17% had inguinal node involvement with pN3 being the most common (36.23%), and 36.23% had ENE. Kaplan–Meier analysis revealed that NLR of >3 and the LMR ≤3 indicated an inferior CSS (P = 0.05 and 0.04, respectively). T stage, inguinal node involvement, LVI, pN stage, and ENE were also associated with inferior CSS (P < 0.05). On multivariate analysis, T stage was significantly associated with CSS (P = 0.02). The NLR >3 and LMR ≤3 were also significantly associated with the presence of pathological inguinal node involvement (P = 0.001 and 0.026).Conclusion:NLR and LMR may help in predicting CSS and inguinal node involvement in patients of carcinoma penis.

Perioperative morbidity of Vulval cancer

Introduction: The present study is a retrospective analysis of vulval cancer patients who had been treated with surgery as primary mode. The cases studied were in tertiary care hospital south India of March 2008 to February 2013. Total number of patients was 11. Materials and Methods: The medical records of all patients studied retrospectively with reference to stage of the disease, surgery performed, prophylactic antibiotics, intra-operative and postoperative complications. Results: Among 11 patients 9 were postmenopausal. Ten patients histopathology showed stage 1b cancer for whom simple vulvectomy was performed, one patient had co-existing HGSIL( High Grade Squamous Intraepithelial Lesion) and positive right inguinal nodes, requiring TAH+ BSO+ right groin dissection and posterior colporrhaphy was done in one patient with rectocele. One patient presented with stage 2 disease for which radical vulvectomy with bilateral groin lymph node dissection was carried out. Postoperative radiotherapy was given for 8 patients with tumor positive margins. Conclusion: Even though many modifications in surgical methods of vulval cancer still morbidity is high. Particularly surgical complication of wound infection. This delay will further add up for delay in starting adjuvant treatment. Hence there is a need of further modifications of surgical treatments like minimally invasive approach. A team of oncology surgeons, medical oncologists, radiotherapists is needed to manage this rare cancer. With multidisciplinary approach Surgery for early stage vulval cancer has acceptable morbidity. Keywords: Carcinoma vulva, Saphenous vein, Vulval cancer.