Indocyanine green fluorescent image-guided inguinal sentinel node biopsy for vulvar cancer: criteria and intraoperative challenges

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Obstet Gynecol Sci. 2022;65(5):483-484
Publication date (electronic) : 2022 June 10
doi :
1Gynaecological Oncology Department, Metaxa Cancer Hospital, Piraeus, Greece
2Third Department of Obstetrics and Gynaecology, National and Kapodistrian University of Athens Medical School, Attikon Hospital, Athens, Greece
3Athens Colorectal Laboratory, Athens, Greece
4Department of Colorectal Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
Corresponding author: Ioannis D. Gkegkes, MD, PhD, Department of Colorectal Surgery, Royal Devon and Exeter NHS Foundation Trust, 17c James House, Residential Village, Bovemoors Lane, Exeter EX2 5DS, UK, E-mail:
Received 2022 January 16; Accepted 2022 April 25.

We read with great interest the article entitled “Indocyanine green fluorescent image-guided inguinal sentinel lymph node biopsy in vulvar cancer.” by Kwak et al. [1].

We would like to congratulate the authors for their excellent surgical technique. The method was applied in a patient with a 3 cm sized palpable vulval mass, and the final histology revealed a vulval adenoid cystic carcinoma with positive sentinel lymph node (International Federation of Obstetrics and Gynecology stage IIIa). Based on the findings of GROINSS-V study and GOG-173 trial [2,3], inguinofemoral lymphadenectomy could be omitted in the case of a negative sentinel lymph node biopsy. Adenoid cystic carcinoma of the vulva is rarely reported; however, it is described as slowly progressing with late and distant recurrences [4,5].

We would like to ask the authors if frozen sections are used in their center, and what protocol is followed in the case of a positive frozen section. Do they complete an inguinofemoral lymphadenectomy? We would also like to highlight that currently, a new Swedish clinical trial is trying to clarify whether such an approach can be offered in non-squamous cell vulvar cancers, tumors >4 cm in diameter, multifocal tumors, or local recurrences [6].

A recent systematic review revealed that the diagnostic value of indocyanine green fluorescent guided biopsy is equal to that of other techniques, e.g., blue dye or technetium-99 m techniques [7].

Once again, we would like to thank the authors for their contribution.


Conflict of interest

No potential conflict of interest relevant to this article was reported.

Ethical approval

This study does not require approval of the Institutional Review Board because no patient data is contained in this article.

Patient consent

Written informed consent and the use of images from patients are not required for the publication.

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