Conservative Management With Isolated Sentinel Lymph Node Biopsy in Vulvar Cancer Patients.

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Brief Title

Conservative Management With Isolated Sentinel Lymph Node Biopsy in Vulvar Cancer Patients.

Official Title

Conservative Management With Isolated Sentinel Lymph Node Biopsy in Vulvar Cancer Patients With Sentinel Lymph Nodes Determined to be Negative for Metastatic Disease.

Brief Summary

      The purpose of this study is to evaluate a less invasive procedure for the evaluation of the
      inguinal (groin) nodes in patients with a primary squamous cell carcinoma of the vulva. Each
      patient will undergo a sentinel lymph node dissection as well as resection of the primary
      tumor on the vulva. Patients who are determined to have sentinel nodes that are negative for
      metastatic disease will not receive a full groin dissection. Patients who have sentinel lymph
      nodes that contain metastasis will undergo a complete inguinal dissection. The study will
      evaluate the long-term outcomes in patients who receive only a sentinel lymph node dissection
      without a complete dissection. All patients entered onto the study will have a biopsy proven
      squamous cell carcinoma of the vulva. Each patient will be enrolled by a Gynecologic
      Oncologist practicing out of Women & Infants Hospital

Detailed Description

      Conservative Management with Isolated Sentinel Lymph Node Biopsy in Vulvar Cancer Patients
      with Sentinel Lymph Nodes Determined to be Negative for Metastatic Disease.

      Introduction The American Cancer Society estimates there will be 4000 new cases of vulvar
      cancer for the year 2003(1). The majority of these patients will undergo surgical therapy
      with groin node dissection to assess the inguinal nodal chain for evidence of metastatic
      disease. For many years there has been a search for a less radical surgical approach to
      evaluating the inguinal lymphatic basin. The classic approach to vulvar cancer was an en-bloc
      resection of the vulva and groins with a single incision. This approach led to complication
      rates as high as 69% for chronic leg edema and 85 % for wound breakdown(2). In an effort to
      reduce the morbidity of groin node dissections, the triple incision technique was
      introduced(3). A GOG study evaluating limited surgery with wide local excision and
      superficial groin node dissection reported rates of chronic lymphedema of 19% and wound
      infection and or separation of 29%(4). In their report on penile carcinoma the concept of a
      sentinel node as the first group of nodes in the inguinal lymphatic chain was put forth by
      Cabanas et al.(5). Morton and colleagues advanced the technique of sentinel node lymphatic
      mapping in patients with cutaneous melanoma(6). In 1994 Levenback et al, described of the use
      of isosulfan blue dye for the detection of sentinel nodes in the inguinal lymphatic chain(7).
      To date, a number of studies have been performed evaluating the utility of sentinel node
      technology and its application in vulvar malignancies (Table 1)(7-20). For melanoma, the
      sentinel node dissection has become the standard of care for the evaluation of the lymphatic
      basins. Many cancer centers, including Women and Infants' Hospital, use sentinel node
      dissection for the evaluation of axillary nodes in breast cancer patients as their standard
      of care. This technology has decreased the rate of chronic arm edema in breast cancer

      Inguinal node metastasis in patients with squamous cell carcinoma of the vulva is reported to
      be as high as 27%(21). Consequently, a large number of patients may undergo a potentially
      morbid procedure without any gain. Non-invasive methods for the evaluation of the
      inguinofemoral nodes such as CT, MRI and PET scans have not yet been proven reliable.
      Sentinel node biopsy utilizing Tc-99m sulfur colloid and isosulfan blue dye allows for
      evaluation of nodal status in patients with vulvar malignancies through minimally invasive
      surgery. Our study, at Women and Infants' Hospital, employed Tc-99m sulfur colloid and
      isosulfan blue dye to identify sentinel nodes in the inguinal lymphatic chain of patients
      with primary squamous cell carcinoma of the vulva. Twenty nine patients were enrolled and 107
      sentinel nodes were studied with no false negative SLN being reported(22) There are over 175
      patients in the reported literature who have undergone a SLN dissection for the evaluation of
      the inguinal lymphatic basin for metastatic disease. To date there have been no false
      negative SLN reported. We feel the SLN dissection has been proven to be reliable and safe
      procedure both at our institution and others around the world. Further studies need to be
      performed in order to evaluate the use of SLN dissection alone in patients with pathologic
      negative sentinel nodes for metastasis. This study will evaluate the use of sentinel node
      dissection alone and management of these patients who potentially do not need or will benefit
      from a full inguinal node dissection.

      Sentinel Node Concept Sentinel node dissection was first applied for the evaluation of
      inguinal nodal basins in patients with penile cancer(23). The sentinel node concept is based
      on the belief that certain anatomical areas are drained by individual nodal chains with the
      first lymph node in this chain being the sentinel node. It has been shown the sentinel node
      is predictive of the status of the lymphatic basin for the presence of metastatic disease to
      non-sentinel nodes. The use of both lymphazurin blue dye and technetium-99m sulfur colloid
      has been shown to reliably identify sentinel nodes in many cancers such ad melanoma, breast
      and colon. This technology has also been studied in patients with vulvar malignancies and has
      been shown to detect a sentinel node 100% of the time(22). With a limited number of sentinel
      nodes obtained from a lymphatic basin a more complete pathologic evaluation of the lymph node
      can be performed. The use of ultra-staging (serial sectioning) allows for smaller metastasis
      and micrometastasis to be reliably detected. Sentinel lymph node technology will allow for a
      more complete surgical and pathologic evaluation of the inguinal lymphatic basins with a
      potential benefit of avoiding a complete inguinal node dissection for patients with a SLN
      determined to be negative for metastatic disease.

      Study Design

      This is a prospective trial examining conservative management of patients with inguinal
      sentinel nodes that have been deemed negative for metastatic disease in patients with primary
      squamous cell carcinoma of the vulva.

      Number of Patients:

      The goal of this study is to enroll 100 patients over a 5 year period and follow each for a
      total of three years.

      Sentinel Lymph Node Technique:

      Each patient will undergo two intradermal peritumoral injections with a total of 2-3 mCi of
      unfiltered technetium-99m sulfur colloid in a volume of 1cc, within 24 hours prior to
      surgery. These injections will take place in the nuclear medicine suite at Rhode Island
      Hospital under Dr. Richard Noto's supervision. Following the injection of the Tc-99m sulfur
      colloid a lymphoscintigram will be performed to detect the presence of a sentinel node.
      Intra-operatively, 5 to 10 minutes prior to the groin dissection, 3 cc of isosulfan blue dye
      will be injected at the peritumoral edge in a manner and location similar to the Tc-99m
      sulfur colloid injection. An inguinal dissection will then performed before the radical
      excision of the vulvar tumor. Prior to the groin node incision, a hand held collimated gamma
      counter will be used to identify the location of the sentinel node. This area will be marked
      with ink on the skin surface. An inguinal incision will be made and the inguinal lymphatic
      beds will be dissected to identify blue afferent lymphatic tracts and/or blue stained lymph
      nodes. A hand held collimated gamma counter will be used to detect any lymph nodes with
      increased activity, defined as a count greater than 5 % of that at the injection site,
      through the groin incision. Also, any lymph node with a blue lymphatic tract leading to it or
      stained blue will be considered a sentinel node. As well, any lymph node identified with the
      hand held gamma counter as taking up the Tc-99m sulfur colloid will be considered a hot
      sentinel node. Each sentinel node will be evaluated with a 10 second gamma count and labeled
      as hot and blue, hot and non-blue or cold and blue. With completion of the sentinel node
      groin node dissection, the lymphatic beds will be re-scanned with the gamma counter to ensure
      all sentinel nodes have been removed. Once the SLN groin dissection is complete the incision
      will be closed and a full groin dissection will be done at a separate sitting pending the
      pathologic evaluation of the sentinel lymph node. The remainder of the surgery for the
      treatment of the primary tumor will then be completed with a current standard of care
      procedure depending on the size and location of the tumor.

      Pathologic Analysis of Sentinel Lymph Nodes:

      Each sentinel lymph node will be serially sectioned at 2mm intervals parallel to the long
      axis and totally submitted for histologic evaluation in one or more blocks. From each block,
      five slides will be cut at 100 micron intervals and stained with hematoxylin and eosin. A
      parallel slide at each level will be cut and held for batch cytokeratin AE1/AE3
      immunohistochemical staining if negative for metastasis by initial H&E staining. The largest
      dimension of each metastasis will be measured and recorded in order to track the presence of
      micrometastasis defined as a metastatic focus less than 2mm in size.

      Patient Management Protocol:

      Patients enrolled on to the sentinel lymph node protocol will undergo a sentinel lymph node
      dissection as described above followed by a radical excision of the primary tumor. Patients
      with sentinel nodes found to contain metastatic disease from the primary vulvar malignancy
      will under go a complete inguinal lymph node dissection as per standard care. Patients with
      sentinel lymph nodes deemed negative for metastatic disease based on ultra-staging and H&E
      staining will be followed with conservative management (no further groin node dissection).
      Each of these patients will be followed clinically at 3 month intervals for the first three
      years for a total study follow up period of three years. Any patient determined to have a
      groin recurrence will be treated with current standard of care modalities as appropriate for
      their recurrence. Published data documenting a 5-7% unanticipated groin failures in patients
      with negative lymphadenectomies will be used as the comparative outcomes (25).

Study Type


Primary Outcome

Determination of inguinal recurrence rates in patients with negative sentinel lymph node biopsy alone.

Secondary Outcome

 Ability to detect inguinal sentinel nodes in vulvar cancer patients.


Vulvar Cancer


Sentinel Node Biopsy

Study Arms / Comparison Groups

 No intervention
Description:  Patients with negative SLN will be followed on no intervention arm


* Includes publications given by the data provider as well as publications identified by National Clinical Trials Identifier (NCT ID) in Medline.

Recruitment Information

Recruitment Status


Estimated Enrollment


Start Date

August 2003

Completion Date

May 2014

Primary Completion Date

May 2014

Eligibility Criteria

        Inclusion Criteria:

          1. Patient of any age 18 years or over.

          2. Biopsy proven squamous cell carcinoma of the vulva.

          3. Depth of invasion 1mm or greater.

          4. Patients with groins clinically negative for nodal metastasis.

          5. Patients that are candidates for groin dissections.

        Exclusion Criteria:

          1. Any patient below the age of 18

          2. Patients with clinically suspicious groin nodes for metastatic disease.

          3. Patients with non-squamous cell vulvar lesions.

          4. Depth of invasion less than 1mm.

          5. Patients refusing to sign an informed consent form.




18 Years - N/A

Accepts Healthy Volunteers



Richard G Moore, MD, , 

Location Countries

United States

Location Countries

United States

Administrative Informations



Organization ID


Responsible Party

Principal Investigator

Study Sponsor

Women and Infants Hospital of Rhode Island

Study Sponsor

Richard G Moore, MD, Principal Investigator, Women and Infants' Hospital

Verification Date

January 2015