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© 2001 American Society for Clinical Oncology
Nodal Metastasis Is Highly Consistent in Squamous Cell Carcinoma of the VulvaMassachusetts 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 nodal recurrence 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 larger 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 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 Onco l24: 343-358, 1986
ResponseUniversity Hospital GroningenGroningen, the Netherlands In Reply:Drs Penson and Fuller suggest that sentinel lymph node biopsy is not necessary in vulvar cancer because of the consistent localization of the sentinel lymph node. Instead of sentinel lymph node identification, they therefore suggest standard removal of a limited number of superficial inguinofemoral lymph nodes (so-called DiSaia’s nodes). We would like to make some remarks on their suggestion.
(1) Although there is consistency in the localization of the sentinel lymph nodes, the radioactivity and blue dye are very helpful in identification of these sentinel lymph nodes, especially in obese patients. (2) DiSaia’s nodes comprise 8 to 10 lymph nodes, whereas we only remove one to two sentinel lymph nodes in our procedure, which at least makes a difference in the size of the incision, frequency of postoperative lymphocysts, and probably also in the risk of lymph edema. (3) The recurrence rate, especially in the groin, is another important issue. It is generally accepted that the majority of local recurrences are curable, whereas most patients with a groin recurrence will die of disease. (4) Preoperative lymposcintigram shows uni- or bilateral lymph flow and is, therefore, helpful in making the decision to perform either unilateral or bilateral sentinel lymph node biopsy (and in case of positive sentinel lymph nodes subsequent inguinofemoral lymphadenectomy). Penson and Fuller suggest that it is possible to define a group of patients who are at low risk of developing lymph node metastases based on tumor characteristics. However, until now, omission of inguinofemoral lymphadenectomy was only possible in patients with vulvar cancer with depth of invasion In conclusion, although we agree with Penson and Fuller that removal of DiSaia’s nodes is an appropriate technique in some patients, we are convinced that our sentinel lymph node biopsy technique is superior, especially for obese patients, and is the most accurate minimally invasive procedure for nodal staging with the lowest risk of complications.
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Copyright © 2001 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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1 mm because of the negligible risk of lymph node metastases. 
