573580
research-article2015
SRIXXX10.1177/1553350615573580Surgical InnovationIavazzo and Gkegkes
Letter to the Editor
Sentinel Lymph Node Detection With the Use of Intradermal Microbubbles in Vulvar Cancer
Surgical Innovation 2015, Vol. 22(4) 446–447 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1553350615573580 sri.sagepub.com
Christos Iavazzo, MD, PhD1, and Ioannis D. Gkegkes, MD2 Dear Editor, Vulvar cancer has an incidence of 2.4 new cases per 100 000 persons, corresponding to 0.3% of all new cancer cases in the United States.1 Radical vulvectomy or wide local excision of the tumor and inguinal lymph node dissection is the standard of care for early-stage vulvar cancers. Inguinal lymph node dissection may affect patients’ quality of life, and it is related with significant morbidity such as wound infection or breakdown, lymphocyst, and lymphoedema.2 Sentinel lymph node (SLN) is defined as the first regional node that collects lymph from the lymphatic vessels of the primary tumor.2 The SLN technique is a feasible and suitable alternative while decreased post-biopsy complications as well as the possibility of detection of micrometastases are among its major advantages. The presence of a positive node imposes a complete inguinofemoral dissection including the deep femoral nodes. The safety of the method was shown by the GROningen INternational Study on Sentinel nodes in Vulvar cancer (GROINSS-V).3 The utilization of contrast-enhanced ultrasonography (CEUS) combined with the administration of intravenous contrast is a standard clinical practice, enhancing the image of the tissue vasculature. The method of ultrasound contrast agents is based on the utilization of various dispersions with sulfur hexafluoride gas (SonoVue, Bracco Imaging). The mean diameter of such microbubbles is 2.5 µm, dimension smaller than red blood cells, which leads to the reflection of the ultrasound beam.4 The microbubble technique was recently suggested in the United Kingdom by a Maidstone group in the management of breast cancer for the detection of SLN.4 All the main techniques applied in SLN mapping are simple to apply and relatively economic. However, the contrast substance may pass through the SLN to other regional lymph nodes in both the blue dye method and the radioactive colloid technique as a result of the surgical incision made during the lymph node excision.3 The manipulation of radioactive material such as these mainly utilized in lymphoscintigraphy are difficult both to handle as well as to dispose. Furthermore, the probability of anaphylaxis subsequently to blue dye injection should also not be underestimated, even though it can only be found in
0.9% of the cases.5 Additionally, the local delivery of blue dye may cause skin/fat necrosis or skin tattooing at the injection site, which can last up to a year.5 On the other hand, the microbubble technique is an innovative technique that can be characterized as safe, economic, and noninvasive technique that offers the possibility of a dynamic visualization of the lymphatic system. The CEUS method may represent a valuable technique of identification of the lymphatic drainage of vulvar cancer. This specific technique could also be applied on preoperative ultrasonographic guided biopsy of SLNs. Inguinofemoral dissection even without the necessity of SLN biopsy could be directly performed in patients with known SLN metastasis. The intradermal microbubble method may cause less trauma and architectural disruption to the lymph nodes’ precise sampling. The small duration of the CEUS method (around 30 minutes) is another advantage. Such a method does not cause any discomfort to the patient. The absence of any published complication of the injected microbubble in breast cancer patients renders this technique as relatively safe. Thus, the microbubble technique may represent an alternative for SLN detection in patients with vulvar cancer. As vulvar cancer is a relatively rare tumor, it is suggested that a multicenter study—similar to GROINSS-V study—could be organized with the same inclusion and exclusion criteria in order to clarify the possible role of such a promising technique. Author Contributions CI had the initial idea of the manuscript, both CI and IDG performed the literature search and wrote this article.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
1
The Christie Hospital, Manchester, UK General Hospital of Attica “KAT,” Athens, Greece
2
Corresponding Author: Christos Iavazzo, 38, Seizani Str, Nea Ionia, Athens 14231, Greece. Email:
[email protected]
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Iavazzo and Gkegkes Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. National Cancer Institute, Surveillance, Epidemiology and End Results Program. SEER Stat fact sheets: vulvar cancer. http://seer.cancer.gov/statfacts/html/vulva.html. Accessed February 10, 2014. 2. Ramirez PT, Levenback C. Sentinel nodes in gynecologic malignancies. Curr Opin Oncol. 2001;5:403-407.
3. Oonk MH, van Hemel BM, Hollema H, et al. Size of sentinelnode metastasis and chances of non-sentinel-node involvement and survival in early stage vulvar cancer: results from GROINSS-V, a multicentre observational study. Lancet Oncol. 2010;11:646-652. 4. Cox K, Sever A, Jones S, et al. Validation of a technique using microbubbles and contrast enhanced ultrasound (CEUS) to biopsy sentinel lymph nodes (SLN) in pre-operative breast cancer patients with a normal grey-scale axillary ultrasound. Eur J Surg Oncol. 2013;39:760-765. 5. Reyes F, Noelck M, Valentino C, Grasso-Lebeau L, Lang J. Complications of methylene blue dye in breast surgery: case reports and review of the literature. J Cancer. 2010;8:20-25.
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