Node count and groin recurrence in early vulvar cancer: A Gynecologic Oncology Group study
Introduction
In an effort to reduce the morbidity of groin dissection, DiSaia et al. described a procedure removing the superficial inguinal nodes [1]. This report limited the operation's application to 20 patients with early vulvar cancer who had primary lesions < 1 cm in size, < 5 mm invasion, and clinical N0/N1 nodes. Removal of superficial inguinal nodes was not associated with relapse in the groin. Berman et al. updated their institutional experience of 50 patients [2]. In these manuscripts, the authors described an operation using an 8 cm incision with removal of all nodal tissue medial to the vessels and above the fascia, from the sartorius to the adductor longus. The femoral vessels were not skeletonized. Approximately 8–10 nodes were removed from each groin. Forty of the fifty patients in the second report had node counts, with a range of 3–30 nodes identified, and a median of 15 nodes per groin. No isolated groin recurrences were observed among those fifty patients.
In a prospective trial, the Gynecologic Oncology Group (GOG) was unable to reproduce these results [3]. Other authors have tried to apply limited groin dissection to a population including more advanced stage patients and have encountered groin recurrences among patients with negative nodes [4], [5] (Table 1). One possible explanation could be that the “superficial” lymph node dissection as described by DiSaia was misinterpreted. This possiblity is not addressed here. Another conclusion could be that these patients had positive nodes which were not resected by the limited procedure. If only a few lymph nodes are plucked from the groin without performing a complete dissection, then positive nodes might not be recognized and left behind.
One approach to address this possibility is to evaluate the completeness of the node dissection by counting lymph nodes in the pathologic specimen. We reviewed the pathology reports for all patients entered on GOG 74 to determine if low node counts correlated with first recurrence in the groin [3]. We proposed to reject the null hypothesis that the number of (negative) lymph nodes sampled from a groin does not correlate with the risk of recurrence in that groin, among patients with early vulvar cancer.
Section snippets
Materials and methods
The GOG conducted a cohort trial for patients with previously untreated, invasive squamous vulvar carcinoma, International Federation of Gynecology and Obstetrics (FIGO) stage I and with lesions < 2 cm in size and < 5 mm in depth. Patients were required to have no lymph-vascular space involvement in the primary lesion and clinically and pathologically negative nodes. There were 155 patients entered who underwent a modified radical hemi-vulvectomy and a superficial, ipsilateral, inguinal lymph
Results
There were 155 patients entered on this study between 1983 and 1989. There were 34 patients who were considered ineligible on review. Pathology review did not confirm eligibility in nine; seven had more advanced disease than the eligibility requirements stipulated; three had insufficient data to determine eligibility; and 15 had a more extensive operation than called for in the protocol. In 14 of these patients, the Gynecologic Oncology Committee review of the operative report indicated that
Discussion
Anatomic studies have confirmed that the deep femoral nodes are consistently situated within the openings in the fascia at the fossa ovalis, and that there are no lymph nodes distal to the inferior margin of the fossa ovalis [10], [11]. Borgno resected 100 groins from 50 female cadavers [10]. In cutting thin sections he did not find any nodes between the femoral vessels, lateral to the femoral artery, or distal to the fossa ovalis. Micheletti examined fetuses and found that cords of dense
Conflict of interest statement
The authors declare that there are no conflicts of interest.
Acknowledgments
This study was supported by a grant from the American Board of Obstetrics and Gynecology/American Association of Obstetricians and Gynecologists Foundation and National Cancer Institute grants to the Gynecologic Oncology Group Administrative Office (CA 27469) and the Gynecologic Oncology Group Statistical and Data Center (CA 37517).
The following Gynecologic Oncology Group member institutions participated in this study: University of Alabama at Birmingham, Oregon Health Sciences University, Duke
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2017, Gynecologic Oncology ReportsCitation Excerpt :The superficial inguinal nodes are usually the first nodes involved, but this does not always appear to be the case (DiSaia et al., 1979; Chu et al., 1981). It is not very clear whether groin lymph node dissections should be complete or limited in patients with vulvar cancer or how many lymph nodes should be dissected (Stehman et al., 2009; van Beekhuizen et al., 2014). Fascia incision and skeletonization of femoral veins are not required for superficial inguinal lymphadenectomy.
Does the count after inguinofemoral lymphadenectomy in vulvar cancer correlate with outcome?
2013, European Journal of Surgical OncologyCitation Excerpt :The node count varies widely, from 1 to 36 per groin.9,10,26,27,30–33 This finding reflects not only the variation in individual anatomy but also differences in surgical techniques and skills and pathologists’ efforts to identify and analyze the LNs within the surgical specimen.27,31 Only 2 studies have examined the prognostic value of the number of resected inguinal LNs in vulvar cancer.
Reliability of sentinel node assay in vulvar cancer: The first Croatian validation trial
2012, Gynecologic OncologyCitation Excerpt :Based on reports, approximately 5% of all carcinomas located on one side of the vulva metastasize to the contralateral lymph nodes only and 15% of unilateral cancers metastasize bilaterally [4,13]. The only prospective study on this subject [42] showed contralateral groin node metastases in 3 of 107 patients (2.8%). Van der Velden [43] found that 19 out of 489 patients (3.9%) with unilateral vulvar tumors and negative ipsilateral lymph nodes had positive contralateral lymph nodes.