Vulvar Cancer Flashcards
Is sentinel lymph node biopsy safe as a replacement for inguinofemoral lymphadenectomy in women with early vulvar cancer?
GROINSS-V observational study, looked at tumors < 4 cm only, SLN w/ IFLND only if positive, used T99 and blue dye, showed SLN negative groin recurrence rate about 2.5% (typical rate). 2% lymphedema rate with SLN vs. 25% with IFLN.
GOG 173, validation study, SLN mapping w/isosulfan blue (T99 started late), subsequent completion lymphadenectomy. False NPV: 3.7% (<3% groin recurrence for tumors <4cm, 7.4% for tumors 4-6cm).
Note: 41% of GROINSS-V and 23% of GOG-173 +LNs were picked up with ultrastaging! Recurrences will be higher if you don’t do ultrastaging.
173: “SLN should be offered to well-selected patients by well-trained providers.” Many of their recurrences were in surgeons still on their learning curve, first 3-5 cases, GROINSS you had to do 10 cases.
Why is primary chemoradiation an option for inoperable (not amenable to standard radical vulvectomy) stage II and stage III vulvar cancer?
GOG 205 phase 2 looked at former T3 (now stage II and stage III) and T4 patients with inoperable tumor and gave chemoRT 70% completed therapy and 64% with CCR and 50% with CPR…“Patients with an inoperable tumor or lymph nodes benefit from chemoradiation if an operation of lesser scope can ultimately be performed.” GOG 101 was an earlier version of this same study with positive results using cis-FU and radiation and at a lower radiation dose. It was thought that keeping to platinum as with cervical cancer and increasing the dose would get better results, as a fair number of GOG 101 patients had microscopic disease and several recurred in vulva.
http://www.aboutcancer.com/gog_205_vulva.htm
These aren’t the kinds of studies you’re going to get survival data on…I mean I guess you could but it’s 40 people, single arm, what is there to say.
Why are sentinel lymph nodes acceptable in vulvar cancer?
GROINS-V, 2008. Multicenter observation, tumor < 4 cm w/ negative clinical groin, 623 groins, LN mets 26%, OS 3yr was 97% for SLN negative. Lymphedema 2% SLN, 25% full.
After LND and positive nodes are seen but resected, why do we give postoperative radiation?
GOG 88, +LNs without RT had 20% recurrence, with RT 0%, small but closed early.
What set up our current surgical approach, modified radical vulvectomy and IFLND including deep nodes?
GOG 74, study performing modified radical with superficial-only IFLND in T1 patients, 121 patients compared to historical controls. Vulvar recurrence was similar but 7.3% experimental groin recurrence vs. 0% in historical. Got to take those deep nodes, man.
Who are candidates for SLN and how do you perform?
< 4cm, clinically normal nodes, no prior surgery, experience with SLN. “Technique four 0.5 mL 30-100 MBq Tc-99 injections circumferentially primary tumor morning of, following induction of anesthesia, 0.5-1 mL of isosulfan blue injections same manner 5-10 minutes prior to procedure.”
For sentinel nodes, what data is there to guide us on treatment based off our result?
GROINSS-V2, prospective multicenter phase 2 with 1552 patients, < 4cm, all got SLN and if positive radiated, if negative observed. Interim changed due to high groin recurrence for SN > 2mm or extranodal extension - these got IFL and if > 1 met or ENE then radiation as well. End result micros did very well, 2 actual same groin recurrences. That said, it wasn’t built to answer the question of treatment based off number of LNs, it mostly answered that SLN < 2 mm didn’t need IFLN.
