Vulval Surgery in Invasive Vulval Cancer


Despite this, unilateral inguinofemoral lymphadenectomy can be reasonably employed in the presence of a well lateralised early tumour with clinically negative nodes, perhaps today with histologically negative sentinel node. However, it must not be forgotten that women developing recurrent disease in an undissected groin will have a very high mortality rate.29,32–36


Total Inguinofemoral Lymphadenectomy with Preservation of Femoral Fascia


When groin dissection is indicated, total or radical inguinofemoral lymphadenectomy must be carried out. This means the removal of all superficial and deep lymph nodes of Scarpa’s triangle. Despite many variations of the Way-Taussig radical inguinofemoral lymphadenectomy, the common denominator in all of these surgical procedures is the belief that to achieve total removal of the groin lymph nodes, a femoral fascia or fascia lata excision with skeletonisation of the femoral vessels is crucial. However, this technique, as demonstrated by Borgno et al.,37


conflicts with the


anatomical data on the topographic position of the deep femoral nodes. These nodes are always situated within the opening of the fossa ovalis, medial to the femoral vein. No lymph nodes are present distal to the lower margin of the fossa ovalis, lateral to the femoral vein or beneath the femoral fascia. Total removal of the groin lymph nodes can therefore be performed without removing the femoral fascia.


In accordance with these findings, Micheletti et al.38 demonstrated that


preservation of the femoral fascia was as effective as the more aggressive Way-Taussig radical inguinofemoral lymphadenectomy. Over time, the knowledge gained about groin anatomy through embryological and anatomical studies39,40


(early stages) is that the incidence of inguinofemoral lymph node metastases is


For this reason, removal of the


inguinofemoral lymph nodes could be spared in approximately 70% of these women.


show that SLND could be reliable and safe in early disease, giving a low (2.3%) false-negative rate. It will certainly become a useful conservative surgical option in selected cases, but at this time more studies are needed to accurately determine the false-negative rate of the procedure due to the high mortality rate from recurrence in patients with an undissected groin.


The results of a recent large, prospective, multicentre, international study47


This technique requires specialist equipment, a multidisciplinary team (medical physicists and nuclear medicine physicians) and a learning curve for the surgeon. As a consequence, SLND should still be considered an experimental procedure that should not be routinely employed by general surgeons outside referral centres.


Locally Advanced Lesions


In the presence of a locally advanced vulval carcinoma, which can be defined as any lesion involving the proximal urethra, anus, rectovaginal septum or rectum, it is advisable for the woman to be examined by some or all of the following specialists: urologist, abdominal surgeon, plastic-reconstructive surgeon and radiation therapist. Case selection and individualised management is mandatory, taking into account not only the extent of the lesion but also the general medical condition and performance status of the patient.


led Micheletti et al. to publish


a description of the fundamental steps of their surgical technique of total inguinofemoral lymphadenectomy with preservation of the femoral fascia.41


This paper included the results in terms of survival rate and decreased complications related to groin dissection.


This surgical procedure, based on sparing normal tissues and structures while removing all the inguinal and femoral lymph nodes, represents an alternative, oncologically sound and surgically more conservative technique. It can reduce some of the major complications related to the anatomically aggressive and mutilating Way-Taussig operation.


Sentinel Lymph-node Dissection


The sentinel node can be defined as any lymph node receiving lymphatic flow directly from the primary tumour. As a consequence, the histology of the sentinel lymph node(s) (SLNs) should provide information about the status of all other nodes within the lymphatic region.


SLNs can be identified by intradermal peritumoral injection around the primary vulval lesion of vital dyes (methylene, isosulfan or patent blue) either alone42 nanocolloid.43,44


or in combination with technetium-labelled


Vital dyes must be injected when the patient is on the operating table. Technetium-labelled nanocolloid is injected the day before the operation. A dynamic pre-operative lymphoscintigraphy assists and directs the surgeon in localising the true SLN(s) through a hand-held gamma detection camera.


The rationale behind SLN dissection (SLND) in the management of invasive vulval carcinoma with clinically negative groin nodes


EUROPEAN OBSTETRICS & GYNAECOLOGY


When possible (in women with resectable lesions and negative or microscopically positive inguinofemoral lymph nodes), the first option should be ultraradical surgery. This consists of radical vulvectomy and bilateral total or radical inguinofemoral lymphadenectomy, combined with partial or total pelvic exenteration.48


After surgery, radiotheraphy


can be administered to prevent local recurrences in patients with involved or close surgical margins.49


Other management options are


radiotherapy alone, occasionally combined with chemotherapy, in non-resectable lesions, and pre-operative radiotherapy alone or integrated with chemotherapy to render the patient operable.


The range of responsiveness to the various treatment modalities and combinations reported in the literature do not allow identification of the best or a superior regimen. The only common finding is the extensive local or general morbidity of these integrated treatments.


Positive Inguinofemoral and/or Pelvic Lymph Nodes


In the past, all patients with clinically or histologically positive inguinofemoral lymph nodes underwent pelvic lymphadenectomy. After the results of the prospective Gynecologic Oncology Group study were published in 1986,50 be preferred to pelvic surgery.


groin and pelvic radiation started to


Today a distinction is made when planning cancer management between the number of positive nodes11


and the type of metastasis.51–53


Patients with one inguinofemoral lymph-node micrometastasis (diameter ≤5mm) can avoid radiotherapy. Patients with two or more inguinofemoral lymph node micrometastases, one macrometastasis (diameter ≥5mm) or extracapsular spread should receive bilateral groin and pelvic radiation.


49


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