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Sentinel lymph node mapping with fluorescent and radioactive tracers in vulvar cancer patients



Application of radioactive tracers for sentinel lymph node biopsy (SLNB) in vulvar cancer has been established, however, the use of radioisotopes is expensive and requires complex logistics. This exploratory study evaluated the feasibility of near-infrared fluorescence-based SLNB in comparison to the gold standard using radioactive guidance.


At Evangelische Kliniken Essen-Mitte (Essen, Germany) between 02/2015 and 04/2019, 33 patients with squamous cell vulvar cancer and unifocal tumors (32 midline, 1 lateral) smaller than 4 cm underwent SLNB as part of their routine primary surgical therapy. Radiolabeled nanocolloid technetium 99 (99mTc) was injected preoperatively and indocyanine green (ICG) intraoperatively. Demographic and clinical data were retrieved from patients’ records, and descriptive statistics were applied. The detection rate of the ICG fluorescence technique was compared with the standard radioactive approach.


In patients with midline tumors, bilateral SLNB was attempted. SLNB was feasible in 61/64 (95.3%) groins with 99mTc and in 56/64 (87.5%) with ICG. In total, 125 SLNs were excised; all SLNs were radioactive and 117 (93.6%) also fluorescent. In 8 patients with BMI > 30 kg/m2, SLNB was successful in 14/15 groins (93.3%) with 99mTc and 13/15 groins (86.7%) with ICG. Upon final histology, infiltrated nodes were present in 9/64 (14.1%) groins and 10/125 SLNs; one positive SLN was not detected with ICG.


SLNB using ICG is a promising technique, however, the detection rate obtained was slightly lower than with 99mTc. The detection rate increased over time indicating that experience and training may play an important role besides further methodological refinements.

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  1. 1.

    Rogers LJ, Cuello MA (2018) Cancer of the vulva. Int J Gynecol Obstet 143:4–13.

  2. 2.

    Gadducci A, Tana R, Barsotti C et al (2012) Clinico-pathological and biological prognostic variables in squamous cell carcinoma of the vulva. Crit Rev Oncol Hematol 83:71–83.

  3. 3.

    Meads C, Sutton AJ, Rosenthal AN et al (2014) Sentinel lymph node biopsy in vulval cancer: systematic review and meta-analysis. Br J Cancer 110:2837–2846.

  4. 4.

    Robison K, Fiascone S, Moore R (2014) Vulvar cancer and sentinel lymph nodes: a new standard of care? Expert Rev Anticancer Ther 14:975–977.

  5. 5.

    Soliman AA, Heubner M, Kimmig R, Wimberger P (2012) Morbidity of inguinofemoral lymphadenectomy in vulval cancer. Sci World J 2012:1–4.

  6. 6.

    de Hullu JA, van der Zee AGJ (2006) Surgery and radiotherapy in vulvar cancer. Crit Rev Oncol Hematol 60:38–58.

  7. 7.

    Rottmann M, Beck T, Burges A et al (2016) Trends in surgery and outcomes of squamous cell vulvar cancer patients over a 16-year period (1998–2013): a population-based analysis. J Cancer Res Clin Oncol 142:1331–1341.

  8. 8.

    Lawrie TA, Patel A, Martin-Hirsch PP et al (2014) Sentinel node assessment for diagnosis of groin lymph node involvement in vulval cancer. Cochrane Database Syst Rev.

  9. 9.

    Fujisawa Y, Nakamura Y, Kawachi Y, Otsuka F (2012) Indocyanine green fluorescence-navigated sentinel node biopsy showed higher sensitivity than the radioisotope or blue dye method, which may help to reduce false-negative cases in skin cancer. J Surg Oncol 106:41–45.

  10. 10.

    Hackethal A, Hirschburger M, Eicker SO et al (2018) Role of indocyanine green in fluorescence imaging with near-infrared light to identify sentinel lymph nodes, lymphatic vessels and pathways prior to surgery—a critical evaluation of options. Geburtshilfe Frauenheilkd 78:54–62.

  11. 11.

    Crane LMA, Themelis G, Arts HJG et al (2011) Intraoperative near-infrared fluorescence imaging for sentinel lymph node detection in vulvar cancer: first clinical results. Gynecol Oncol 120:291–295.

  12. 12.

    Hutteman M, van der Vorst JR, Gaarenstroom KN et al (2012) Optimization of near-infrared fluorescent sentinel lymph node mapping for vulvar cancer. Am J Obstet Gynecol 206:89.e1–5.

  13. 13.

    Schaafsma BE, Verbeek FPR, Peters AAW et al (2013) Near-infrared fluorescence sentinel lymph node biopsy in vulvar cancer: a randomised comparison of lymphatic tracers. BJOG 120:758–764.

  14. 14.

    Laios A, Volpi D, Tullis IDC et al (2015) A prospective pilot study of detection of sentinel lymph nodes in gynaecological cancers using a novel near infrared fluorescence imaging system. BMC Res Notes 8:608.

  15. 15.

    Mathéron HM, van den Berg NS, Brouwer OR et al (2013) Multimodal surgical guidance towards the sentinel node in vulvar cancer. Gynecol Oncol 131:720–725.

  16. 16.

    Verbeek FPR, Tummers QRJG, Rietbergen DDD et al (2015) Sentinel lymph node biopsy in vulvar cancer using combined radioactive and fluorescence guidance. Int J Gynecol Cancer 25:1086–1093.

  17. 17.

    Leitao MM, Jewell E, Gardner GJ et al (2015) Sentinel lymph node mapping in patients with vulvar malignancies using indocyanine green and near-infrared imaging: preliminary detection rate experience. Gynecol Oncol 137:100.

  18. 18.

    Soergel P, Hertel H, Nacke AK et al (2017) Sentinel lymphadenectomy in vulvar cancer using near-infrared fluorescence from indocyanine green compared with technetium 99m nanocolloid. Int J Gynecol Cancer 27:805–812.

  19. 19.

    Schnürch HG, Ackermann S, Alt CD et al (2016) Diagnosis, therapy and follow-up care of vulvar cancer and its precursors. guideline of the DGGG and DKG (S2k-level, AWMF registry number 015/059, November 2015). Geburtshilfe Frauenheilkd 76:1035–1049.

  20. 20.

    Oonk MHM, Planchamp F, Baldwin P et al (2017) European society of gynaecological oncology guidelines for the management of patients with vulvar cancer. Int J Gynecol Cancer 27:832–837.

  21. 21.

    KleinJan GH, van Werkhoven E, van den Berg NS et al (2018) The best of both worlds: a hybrid approach for optimal pre- and intraoperative identification of sentinel lymph nodes. Eur J Nucl Med Mol Imaging 45:1915–1925.

  22. 22.

    Marshall MV, Rasmussen JC, Tan I-C et al (2010) Near-infrared fluorescence imaging in humans with indocyanine green: a review and update. Open Surg Oncol J 2:12–25.

  23. 23.

    Zhou J, Zhang W-W, Chen X-T et al (2018) Trends and outcomes of sentinel lymph node biopsy in early-stage vulvar squamous cell carcinoma: a population-based study. J Cancer 9:1951–1957.

  24. 24.

    Oonk MH, van Hemel BM, Hollema H et al (2010) Size of sentinel-node 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 11:646–652.

  25. 25.

    Oonk MHM, Hollema H, van der Zee AGJ (2015) Sentinel node biopsy in vulvar cancer: implications for staging. Best Pract Res Clin Obstet Gynaecol 29:812–821.

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This study was not supported by any funding.

Author information

SP, AdB, PH, BA: protocol and project development, data collection and management, data analysis and interpretation, manuscript writing and editing. EB: data collection and management, data analysis and interpretation, manuscript writing and editing. SS, FH, TB: data analysis and interpretation, manuscript writing and editing. AT: data collection and management.

Correspondence to Sonia Prader.

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The authors declare that they have no conflict of interest regarding the submitted work.

Ethical approval

This retrospective analysis was approved by the Ärztekammer Nordrhein (Germany).

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All patients provided written informed consent for sentinel lymph node detection by both modalities and data analysis.

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Prader, S., du Bois, A., Harter, P. et al. Sentinel lymph node mapping with fluorescent and radioactive tracers in vulvar cancer patients. Arch Gynecol Obstet (2020).

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  • Vulvar cancer
  • Sentinel lymph node
  • Indocyanine green
  • Near-infrared fluorescence