Patient Education & Consent
Patient Instructions
Perioperative instructions to the patient vary by provider, institution, and specific procedure performed.
Elements of Informed Consent
The patient should be informed of the risks and benefits of sentinel node dissection compared to routine inguinofemoral lymphadenectomy. Sentinel node biopsy confers minimal short-term complications and a low risk of lymphedema compared to complete inguinal node dissection. The primary risk of sentinel node biopsy is in not performing a complete inguinofemoral lymphadenectomy based on false-negative sentinel node biopsy result. Presently, the preferred surgical method to evaluate the lymph nodes seems to be transition from complete lymphadenectomy to sentinel node dissection. [12]
Pre-Procedure Planning
Surgeons may consider some form of preoperative imaging to rule out grossly involved lymph nodes, the presence of which negates the effectiveness of sentinel node biopsy.
The expert panel statement from the International Sentinel Node Society Meeting in 2008 recommended that sentinel node biopsy procedures for vulvar cancer be performed by a skilled multidisciplinary team. A gynecologic oncologist trained in the procedure, a nuclear medicine specialist, and surgical pathologist familiar with the concept of ultrastaging should be recruited in order to provide the highest likelihood of successful sentinel node dissection.
The expert panel statement recommends that each oncologist perform at least 10 consecutive cases with successful sentinel node identification and no false-negative results with at least 5-10 patients/year before performing the procedure without lymphadenectomy. [12, 13] Oncologists with limited annual exposure to patients with vulvar cancer should consider referral to physicians who care for a high volume of patients who are candidates for sentinel node biopsy. [12]
Equipment
Although the specific technique may vary slightly by provider, the injection of isosulfan blue dye or radiotracer is necessary. Preoperative lymphoscintigraphy and/or an intraoperative gamma probe will be required to identify the sentinel lymph node(s).
Patient Preparation
Anesthesia
Although it is always at the discretion of the anesthesiologist, general endotracheal anesthesia is generally the most appropriate anesthesia for this procedure, given the duration and possible need for complete lymphadenectomy.
Positioning
For both cervical and vulvar sentinel lymph node dissection, dorsal lithotomy is the most appropriate positioning to allow for perineal, inguinal, and abdominal access.
Monitoring & Follow-up
Patients with invasive cervical and vulvar cancers who undergo sentinel lymph node dissection should be monitored closely by a gynecologic oncologist. Most vulvar cancers that recur do so in the first year, but up to 10% of cases recur beyond 5 years after diagnosis, necessitating long-term follow up. [5]
The optimal surveillance strategy has not been established, and clinical practice varies. The Society of Gynecologic Oncologists (SGO) advises follow-up every 6 months for 2 years, then annually for low-risk disease (early stage, treated with surgery alone, no adjuvant therapy). For high-risk disease (advanced stage, treated with primary chemotherapy/radiation or surgery plus adjuvant therapy), follow-up is scheduled every 3 months for the first 2 years, then every 6 months for the subsequent 3 years, then annually. There is no current recommendation for routine use of imaging or cervical/vaginal cytology. [27]
Surveillance for invasive cervical cancer after primary curative therapy is uniformly recommended and is based on the premise that early detection of recurrence may lead to treatments that have lower morbidity and increase survival. SGO guidelines recommend follow-up every 3 months for the first 2 years, every 6 months for the subsequent 3 years, then annually for high-risk disease (advanced stage, treated with primary chemotherapy/radiation or surgery plus adjuvant therapy). For low-risk disease (early stage, treated with surgery alone, no adjuvant therapy), the guidelines recommend follow-up every 6 months for the first 2 years, then annually. They also recommend annual cytology but do not recommend routine imaging as part of surveillance at this time. [27]
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Using the gamma probe to detect a hot spot in the inguinal area.
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Blue-stained afferent lymphatic leading to blue-stained inguinal lymph node.
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Diagram of lymphatic drainage of a lateral lesion. Most lymphatics flow through the superficial inguinal nodes, deep inguinal nodes, and the node of Cloquet to the pelvic lymph node chains. Deep inguinal node findings are positive approximately 3% of the time when superficial inguinal node findings are negative. Lymphatic mapping studies indicate that 13% of cases demonstrate findings consistent with flow to the pelvis that does not involve the node of Cloquet. If the lesion is in the anterior labia minor, then contralateral flow is demonstrated in 67% of cases.
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A specimen from a traditional single-incision radical hysterectomy. Most radical vulvectomies are now performed through 3 incisions, with the groin nodes removed separately from the vulvectomy specimen. (Photograph courtesy of James B. Hall, MD)
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Closure of a large single-incision radical vulvectomy. The complete wound breakdown rate from this procedure is often greater than 50%. (Photograph courtesy of James B. Hall, MD)
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The parietal lymph glands of the pelvis.
