What doctors and patients think about false-negative sentinel lymph nodes in vulvar cancer

The sentinel lymph node procedure is a relatively new, minimally-invasive method for the assessment of nodal status in malignancies such as breast cancer, cutaneous melanoma and vulvar cancer. Although highly accurate, this new method is inevitably associated with a certain false-negative rate, possibly leading to worse survival in a small subset of patients. The clinical implementation of the sentinel lymph node procedure is therefore a matter of ongoing debate, especially among doctors. The aim of this study was to assess opinions on the acceptable false-negative rate of the sentinel lymph node procedure in patients with vulvar cancer, who in the past had undergone standard routine radical vulvectomy and complete inguinofemoral lymphadenectomy (and frequently experienced complications), and in gynecologists treating patients with vulvar cancer. Structured questionnaires were sent to both patients and gynecologists. The patients had been treated for vulvar cancer between 1985 and 1993, and were all in complete remission with a median follow-up of 118 months (range: 76-185). Questions to the patients dealt with experienced side-effects of the standard treatment and opinion on the acceptable false-negative rate of the sentinel lymph node procedure. The response rate among patients was 91% (106/117). Forty per cent of the patients experienced one or more infections in the legs (cellulitis) and 49% of the patients still experience either severe pain and/or severe lymphedema in the legs. Sixty-six per cent of the patients preferred complete inguinofemoral lymphadenectomy in preference to a 5% false-negative rate of the sentinel lymph node procedure of 5%. Their preference was not related to age or the side-effects they had experienced. The response rate among gynecologists was 80% (80/100), of whom 60% were willing to accept a 5-20% false-negative rate of the sentinel lymph node procedure. While gynecologists may consider the sentinel lymph node procedure to be a promising diagnostic tool, the majority of vulvar cancer patients, who have undergone complete inguinofemoral lymphadenectomy in the past and have frequently experienced complications, would not advise introduction of this technique because they do not want to take any risk of missing a lymph node metastasis.