Ultrasound‐guided FNA cytology of groin lymph nodes improves the management of squamous cell carcinoma of the vulva: Results from a comparative cytohistological study

Abstract

Background Lymph node metastases represent the most important negative prognostic predictor in vulvar carcinoma. Therefore, an accurate preoperative assessment of suspicious lymph nodes would be fundamental for a personalized therapy. The aim of this article was to assess the reliability of ultrasound‐guided fine‐needle aspiration cytology (FNAC) in the preoperative assessment of nodal metastatic disease in 43 patients with vulvar cancer. Methods In total, 43 FNAC specimens of clinicoradiologically suspicious lymph nodes with corresponding nodal resection specimens were collected from 2016 to 2018 at Catholic University Hospital in Rome. Cytohistologic correlation was performed. Patients were treated with wide local excision of the vulvar mass followed by bilateral inguinofemoral lymphadenectomy and radiotherapy if the tumor involved a lymph node or the vulvar margins. Results Cytologic examination agreed with histology in 37 of 43 cases (86.04%). The authors observed a positive FNAC result in 14 of 20 histologically confirmed metastatic lymph nodes, 6 false‐negative cases, and no false‐positive results. The sensitivity and specificity of cytological examination were 76.92% and 100%, respectively. All patients with FNAC‐positive results showed metastatic disease in other surgically resected inguinofemoral nodes. Eleven of 29 patients (37.9%) with FNAC‐negative results also showed metastatic disease in subsequent lymphadenectomy specimens, but the extent of metastases was always <1 cm (range, 0.1‐0.6 cm). Conclusions FNAC of suspicious lymph nodes represents a useful tool in the management of patients with vulvar cancer. A positive result enables the surgeon to immediately perform a bilateral inguinofemoral lymphadenectomy thus avoiding an unnecessary sentinel lymph node sampling. Finally, FNAC can also predict the presence and extent of metastatic disease in other surgically resected inguinofemoral lymph nodes.

Diagnostic performance of preoperative [18F]FDG-PET/CT for lymph node staging in vulvar cancer: a large single-centre study

“…Surgery varies from the minimally invasive sentinel node biopsy (SNB) to the more demolitive radical lymphadenectomy, which is often followed by lymphedema of the lower limbs [8]. LN assessment is mainly performed by ultrasonography with or without cytological evaluation of suspicious LNs and computed tomography (CT) [9][10][11][12]. Positron emission tomography/CT with [ 18 F]fluorodeoxyglucose ([ 18 F]FDG-PET/CT) has been included in the National Comprehensive Cancer Network guidelines for vulvar cancer since 2016 and is recommended for T2 or larger tumours or when metastases are suspected [4].…”

Real‐time ultrasound virtual navigation in 3D PET/CT volumes for superficial lymph‐node evaluation: innovative fusion examination

“…Between January 2017 and May 2019, we evaluated consecutive patients affected by gynecological or breast cancer, including those with a new diagnosis, those with residual disease after neoadjuvant treatment and those with suspicion of recurrence. Inclusion criteria for fusion imaging analysis were: increased 18 F-FDG uptake in at least one inguinal or axillary lymph node on PET/CT scan; and availability of an ultrasound scan examining the same lymph nodes.…”

“…The physicians were blinded to clinical information and, if they disagreed regarding lymph-node status, they discussed until reaching a consensus [26][27][28][29] . Their evaluation was limited to visual analysis of 18 F-FDG uptake by the superficial lymph nodes. Lymph nodes were considered clearly normal on PET/CT scan if they presented no 18 F-FDG uptake, had short-axis diameter < 5 mm and were elliptical in shape, with an identifiable fatty hilum on coregistered low-dose CT.…”

“…Their evaluation was limited to visual analysis of 18 F-FDG uptake by the superficial lymph nodes. Lymph nodes were considered clearly normal on PET/CT scan if they presented no 18 F-FDG uptake, had short-axis diameter < 5 mm and were elliptical in shape, with an identifiable fatty hilum on coregistered low-dose CT. They were considered inflammatory if they showed 18 F-FDG uptake higher than background level and lower than liver activity, with any short-axis diameter, elliptical shape and presence of the fatty hilum on coregistered low-dose CT.…”

Modern treatment of vulvar cancer

“…Fine needle biopsy and cytological verification follow if lymph node involvement is suspected. 10,11 Other imaging methods have proven to be less reliable compared to ultrasound. 12,13 In the absence of a reliable method for detecting inguino-femoral lymph node involvement, inguino-femoral lymphadenectomy was part of the standard treatment of vulvar cancer.…”