Feasibility and safety of the sentinel lymph node procedure for early vulval cancer in a low-resource high HIV-prevalence setting: a pilot study

Abstract

Background: The Groningen International Study on Sentinel Nodes in Vulval cancer (GROINSS-V) showed that if a sentinel lymph node (SLN) is negative, the risk of groin relapse due to a false negative finding is less than 3%. The SLN procedure (SLNP) is the standard of care in the management of early vulval squamous cell carcinoma (SCC). We aimed to evaluate the feasibility and safety of the SLNP in a low-resource setting with a high prevalence of HIV and human papillomavirus (HPV)-associated vulval SCC.

Methods: Between August 2012 and August 2016, women with early vulval SCC managed at Groote Schuur Hospital (GSH), Cape Town, South Africa, who fit the criteria, were offered the SLNP. For quality control, full inguinofemoral lymphadenectomy (IFL) was also done in the first 10 patients.

Results: In our setting, 40% of women with vulval SCC are HIV-infected and there is a predominance of HPV-associated vulval SCC, consequently, only 10.4% (10/96) of women were suitable for the SLNP. Most patients have multifocal tumours and/or enlarged groin nodes. Women with HIV and SCC presented at a younger age than those who were HIV-negative and had more SLN, which were expensive to ultra-stage.

Conclusion: At GSH, multifocal vulval SCC arising in vulval high-grade intraepithelial lesion (VHSIL) in HIV-infected women is relatively common. The main resource issue was the ultrastaging cost. However, more significant limiting factors to safely performing the SLNP were the multifocality of the disease, as well as enlarged (mainly reactive) groin lymph nodes, which could not be distinguished from metastases preoperatively. As a result, relatively few of our patients are suitable for the SLNP, so maintenance of skills is a concern.