Sentinel lymph node biopsy based on anatomical landmarks and locoregional mapping of inguinofemoral sentinel lymph nodes in women with vulval cancer: an operative technique

Abstract

Inguinal lymph node involvement is the most robust predictor of mortality in vulval cancer and sentinel lymph node (SLN) biopsy is a safe diagnostic modality. We describe a technique based on anatomical landmarks. Our aims are (1) to describe the territorial mapping of SLNs, (2) to evaluate the associated complication rate vis-à-vis those reported in the literature, and (3) to assess its accuracy in detecting SLNs. Data from women who underwent groin SLN biopsies for vulval cancer at a single cancer centre were prospectively collected. All subjects met the GROINSS-V eligibility criteria. The location of the SLN relative to the saphenous vein was recorded. All women were followed up and early and late complications were recorded. The recurrence rate at the time of the census was calculated. A total of 71 groins in 44 women were included. The SLN was primarily located over Cloquet’s node (85.2%). The incidence of early wound cellulitis and dehiscence were 2.8% and 11.3% while lymphocysts were present in 11.3% of groins. The negative nodal recurrence rate was 1.7%. Results showed that this reproducible technique allows access to 96.7% of SLNs, including both deep and superficial SLNs whilst minimising the need for extensive dissection and complications associated with overharvesting of lymph nodes.

IMPACT STATEMENT

• What is already known on this subject? Inguinal sentinel lymph node (SLN) biopsy in women with vulval cancer is often construed as a challenging skill to master and the success rate of SLN detection is dependent on the experience and skill of the surgeon. A review of the literature has revealed that whilst studies have largely concentrated on the efficacy of different intraoperative detection modalities or histopathological protocols, the literature describing a standardised surgical technique remains deficient.

• What do the results of this study add? Our technique offers multiple advantages: our incision, albeit small, allows the operator to gain access to 96.7% of inguinal SLNs and facilitates access to both deep and superficial SLNs regardless of patients’ body mass index, minimises the need for extensive dissection and hence reduces the incidence of complications associated with overharvesting of lymph nodes such as lymphoedema or lymphocysts, particularly in obese women. Our local figures also support the safety of this operative technique (negative nodal recurrence rate 1.7%) and compare favourably with those from the GROINSS-V study.

• What are the implications of these findings for clinical practice and/or further research? We describe a reproducible technique based on anatomical landmarks and an appreciation of the territorial mapping of inguinal SLN to optimise the chances of identifying the inguinal SLN in women with vulval cancer while circumventing the sequelae often attributed to this procedure.

Keywords:

• Vulva
• cancer
• sentinel
• surgery
• Cloquet
• detection

Acknowledgement

The authors would like to thank all women who have participated in this study.

Ethics statement

This study was undertaken in line with our institution’s Clinical Information and Audit Department regulations. Ethical approval was not required. All patient data were anonymised. Written consent was obtained for photographs.

Author contribution

The authors confirm contribution to the paper as follows: study conception and planning: JY; data collection, analysis and interpretation of results: FLK, MS; draft manuscript preparation: FLK. All authors reviewed the results and approved the final version of the manuscript.

Disclosure of interests

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.