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Nodal Metastasis is Highly Consistent in Squamous Cell Carcinoma of the Vulva

Massachusetts General HospitalBoston, MA

To the Editor:We are delighted to see the excellent article by de Hullu et al¹ draw the issue of sentinel node biopsy full circle. In the 1970s, Cabanas² was the first to describe sentinel node biopsy, indeed, describing sentinel node biopsy for penile cancer and reporting very similar findings to de Hullu et al.¹ Although false-negative rates for extended sentinel node dissection in penile cancer has been reported to be as high as 25%,³ Cabanas² like de Hullu et al,¹ reported obligatory drainage of lymph and metastases to a sentinel inguinofemoral node at the superficial epigastric vein: de Hullu’s node above the cibriform fascia over the fossa ovalis. However, it was DiSaia et al⁴ who first defined the importance of this node. In their comprehensive silver mining, de Hullu et al¹ seem to have tripped over, yet missed, the nugget of gold. Because of the predictable lymphatic drainage Hullu et al’s article neatly reconfirms that sentinel node mapping is not necessary.

In a seminal article, Figge et al⁵ provided the first definitive support for more conservative surgery for early-stage carcinoma of the vulva. However, it was salutary that all patients with nodalrecurrence died, perhaps separating this epithelial tumor from malignant melanoma, where at least one study has suggested a survival advantage for lymph node dissection.⁶ In the article by Figge et al,⁵ 60% of patients with lesions larger than 2-cm and positive nodes developed a recurrence. How much bilateral lymph node dissection contributed to cure in the other 40% is unknown and is a tantalizing issue. In the only randomized controlled trial in vulval carcinoma, inadequate radiotherapy resulted in poorer local control and a poorer survival than observed with surgery.⁷

We have changed our treatment policy little in the last 20 years. Hopefully, excision of DiSaia’s node will now spare considerable morbidity for more women. According to the data of Figge et al,⁵ and to our data, two thirds of patients with lesions larder than 2 cm will have a negative DiSaia’s node associated with only a 10% recurrence rate at 5 years.^5,8

REFERENCES

1. de Hullu JA, Hollema H, Piers DA, et al: Sentinel lymph node procedure is highly accurate in squamous cell carcinoma of the vulva. J Clin Oncol 18: 2811-2816, 2000[Abstract/Free Full Text]

2. Cabanas RM: An approach for the treatment of penile carcinoma. Cancer 39: 456-466, 1977[Medline]

3. Pettaway CA, Pisters LL, Dinney CP, et al: Sentinel lymph node dissection for penile carcinoma: The M.D. Anderson Cancer Center experience. J Urol 154: 1999-2003, 1995[Medline]

4. DiSaia PJ, Creasman WT, Rich WM: An alternative approach to early cancer of the vulva. Am J Obstet Gynecol 133: 825-832, 1979[Medline]

5. Figge DC, Tamimi HK, Greer BE: Lymphatic spread in carcinoma of the vulva. Am J Obstet Gynecol 15:152: 387-394, 1985

6. Balch CM, Soong SJ, Bartolucci AA, et al: Efficacy of an elective regional lymph node dissection of 1 to 4 mm thick melanomas for patients 60 years of age and younger. Ann Surg 224: 255-263, 1996[Medline]

7. Keys H: Gynecologic Oncology Group randomized trials of combined technique therapy for vulvar cancer. Cancer 15: 1691-1696, 1993 (suppl 4)

8. Shimm DS, Fuller AF, Orlow EL, et al: Prognostic variables in the treatment of squamous cell carcinoma of the vulva. Gynecol Oncol 24: 343-358, 1986[Medline]

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