Sentinel lymph node biopsy in vulvar cancer: current evidence, limitations, and future perspectives

Vulvar cancer is a rare gynecologic malignancy in which regional lymph node status represents the most powerful prognostic factor and a key determinant of therapeutic strategy. For the past 60 years, bilateral inguinofemoral lymphadenectomy was the standard approach for staging and disease control. Although effective, this procedure was associated with substantial morbidity, including wound complications, chronic lower limb lymphedema, and long-term impairment of quality of life. In the past 20 years, sentinel lymph node (SLN) mapping has emerged as a less invasive alternative for selected patients with unifocal, clinically node-negative vulvar tumors less than 4 cm in diameter. Large prospective trials, such as GROINSS-V and GOG-173, demonstrated that sentinel node biopsy is feasible, safe, and significantly reduces postoperative morbidity while maintaining excellent oncologic outcomes in appropriately selected patients. Nevertheless, concerns persist regarding false-negative results, reported in up to 7%-10% of cases in some series, with anecdotal reports of rates up to 27%. Undetected nodal disease represents a missed opportunity for cure, and most patients with an isolated groin recurrence ultimately succumb to their disease. Therefore, the potential benefits of morbidity reduction must be carefully balanced against the risk of undertreatment. This review summarizes the historical evolution of groin management in vulvar cancer, critically appraises the current evidence supporting SLN mapping, and discusses its clinical limitations, patient preferences, and implications for practice. Emphasis is placed on surgical expertise, the importance of ultrastaging, structured surveillance, and ongoing prospective research to achieve the best survival with the lowest morbidity.