Unifocal Vulvar SCC <4 cm: Inguinofemoral Management When the Sentinel Lymph Node Procedure Does Not Achieve Its Goals
This protocol applies to patients with a unifocal squamous cell carcinoma of the vulva measuring less than 4 cm, with depth of invasion greater than 1 mm (>T1a), and no clinically suspicious inguinofemoral lymph nodes — the population in which a sentinel lymph node (SLN) procedure is the recommended initial surgical approach.
The preceding treatment line — radical (wide) local excision of the vulvar tumor combined with a sentinel lymph node procedure — aims to achieve histological tumor-free margins and a negative sentinel node. When the SLN is found to contain tumor cells (whether isolated, micrometastatic, or macrometastatic), or when the SLN cannot be identified at all (method failure), the nodal goal of that first step has not been met. This protocol defines the additional management required for the inguinofemoral area under those circumstances.
The appropriate intervention for the inguinofemoral region is determined by the specific SLN result. Depending on whether nodal involvement is absent, limited, or more extensive — or whether the node was locatable at all — the next step involves either targeted radiotherapy to the inguinofemoral area or surgical lymphadenectomy of the affected side. The full decision pathway, indications, and sequencing are set out in the complete protocol.
DOI: 10.1136/ijgc-2023-004486
- A SLN procedure is indicated in all patients with a primary unifocal tumor <4 cm with a depth of invasion >1 mm and no suspicious nodes.
- The SLN procedure is recommended in patients with unifocal cancers of <4 cm, >T1a, without suspicious inguinofemoral nodes [II, B].
- When tumor cells, both metastases and isolated tumor cells, are identified in the SLN, additional treatment to the involved inguinofemoral area is indicated [I, A].
- Inguinofemoral lymphadenectomy can safely be omitted in favor of radiotherapy when micrometastatic disease (≤2 mm) or isolated tumor cells are identified in the metastatic SLN [III, B].
- When macrometastatic (>2 mm) disease is identified in the SLN, inguinofemoral lymphadenectomy of the affected site should be performed [I, A].
- When a SLN is not found (method failure), inguinofemoral lymphadenectomy should be performed [I, A].