Indocyanine green fluorescent image-guided inguinal sentinel lymph node biopsy in vulvar cancer

Article information

Obstet Gynecol Sci. 2022;65(2):223-225

Publication date (electronic) : 2021 December 16

doi : https://doi.org/10.5468/ogs.21335

Young Hwa Kwak, MD^1,2, Yong Jae Lee, MD^1,2, Jung-Yun Lee, MD, PhD^1,2, Eun Ji Nam, MD, PhD^1,2, Sunghoon Kim, MD, PhD^1,2, Young Tae Kim, MD, PhD^1,2, Sang Wun Kim, MD, PhD^1,2

¹Women’s Cancer Center, Yonsei Cancer Center, Seoul, Korea

²Department of Obstetrics and Gynecology, Institute of Women’s Life Medical Science, Yonsei University College of Medicine, Seoul, Korea

Corresponding author: Sang Wun Kim, MD, PhD, Department of Obstetrics and Gynecology, Institute of Women’s Life Medical Science, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea, E-mail: san1@yuhs.ac

Jung-Yun Lee and Young Tae Kim have been an Editorial Board of Obstetrics & Gynecology Science; however, they are not involved in the peer reviewer selection, evaluation, or decision process of this article. Otherwise, no other potential conflicts of interest relevant to this article were reported.

Received 2021 November 08; Accepted 2021 November 17.

Inguinal lymph node status is the most significant prognostic factor in patients with vulvar cancer [1]. The classical gold standard surgical treatment for patients with vulvar cancer is radical vulvectomy and complete inguinofemoral lymphadenectomy. Complete inguinofemoral lymph node dissection results in short- and long-term morbidities, including wound infections, dehiscence, and lymphedema [2]. Several studies have demonstrated that sentinel lymph node (SLN) biopsy significantly reduces complications while avoiding unnecessary lymphadenectomy, and has a low inguinal recurrence rate [3,4].

SLN mapping using indocyanine green (ICG) with near-infrared fluorescence imaging is a promising staging alternative in gynecologic malignancies and has been validated in patients with endometrial and cervical cancers [5,6]. Based on this evidence, this technique has been extended to vulvar cancers. Recently, several studies have shown the feasibility, accuracy, and safety of SLN mapping using ICG with near-infrared fluorescence imaging in vulvar cancer [7,8].

A 40-year-old woman was referred to our hospital for cancer in the left vulva that was diagnosed at another hospital in March 2020. She had no specific medical history other than two induced abortions. The vulvar biopsy specimen was reviewed by a gynecologic pathologist at our institute; adenoid cystic carcinoma was subsequently diagnosed. A baseline study was performed: Pap smear results showed adenoid cystic carcinoma, human papillomavirus genotyping revealed negative findings, and tumor markers were within the normal range. Examination of the vulvar mass lesion by colposcopy revealed an ulcerative and palpable mass, approximately 3 cm in size, in the left vulva. Pelvic contrast-enhanced magnetic resonance imaging showed small ulcerative enhancing lesions of approximately 3.4 cm in the left vagina; these were predicted to be International Federation of Gynecology and Obstetrics (FIGO) stage II. F-18 fluorodeoxyglucose (FDG) positron-emission tomography-computed tomography showed mild FDG uptake in the left vulva area, suggesting postoperative change; however, residual tumors could not be excluded. In both images, there was no evidence of metastasis to the lymph nodes or other organs. Esophagogastroduodenoscopy, colonoscopy, and breast sonography revealed no tumors in the upper gastrointestinal tract, colon, or breast, respectively. Under the diagnosis of vulvar cancer, the patient was scheduled to undergo radical vulvectomy and ICG fluorescent image-guided inguinal SLN biopsy. Approximately 3 mL of ICG (1.25 mg/mL) was directly injected into the vulvar mass for lymphatic drainage mapping. A 4-cm linear incision was made on the left inguinal crease, lymphatic channels were dissected, and an SLN was identified using the 1588 Advanced Imaging Modalities Platform laparoscopic camera (Stryker, Kalamazoo, MI, USA). After removing the left inguinal SLN, the node was sent out for frozen section diagnosis, which revealed few atypical cell clusters. The operation was completed after radical vulvectomy with an adequate resection margin. However, the final pathology result showed metastasis to the left inguinal SLN, indicating vulvar cancer, FIGO stage IIIA. The patient then received radiation therapy to the inguinal area and was monitored for 16 months without recurrence.

The advantages of SLN mapping using ICG with near-infrared fluorescence imaging include easier application, absence of radioactivity, and fewer side effects [8]. In addition, the procedure is less invasive, with little pain and scarring.

SLN biopsy is recommended as the standard treatment for women with early-stage vulvar cancer [9]. Comba et al. [10] showed that videoendoscopic SLN biopsy in vulvar cancer is a feasible procedure, and there may be increased usage of SLNs in early stage vulvar cancer with a videoendoscopic approach. However, this case demonstrated that the use of ICG with near-infrared fluorescence imaging for SLN biopsy is effective even at advanced stages. Gu et al. [11] reported that appropriate adjuvant radiotherapy SLN biopsy alone provided similar long-term survival to inguinofemoral lymphadenectomy for patients with or without sentinel node metastasis.

In conclusion, this video demonstrates that ICG fluorescent image-guided inguinal SLN biopsy using a laparoscopic fluorescence imaging system could be applied in vulvar cancer. Mapping of inguinal SLNs in vulvar cancer patients may help in retaining surgical radicality while minimizing operative complications.