Management of the Inguinal Lymph Nodes in Clinically Node Negative cN0 Patients

The timing of lymphadenectomy is of major interest in cNO-patients. There often appears to be a choice between "too late" or "too early" and an evidence-based approach is difficult as the available published studies have a small number of patients, selection biases, and the lack of randomized trials. As mentioned above, current imaging techniques are unreliable in cN0-patients. Several risk-adapted management approaches have been used and advocated during the last decades (Table 9.1). Basically, these management policies can be divided into noninvasive management (surveillance), minimally invasive staging (dynamic sentinel node biopsy / modified inguinal lymphadenectomy), or invasive staging techniques (radical lymphadenectomy). The fact that approximately 20% of the cN0-patients have occult metastases, inguinal lymphadenectomy is an unnecessary procedure in approximately 80% of patients. Furthermore, lymphadenectomy is associated with

Table 9.1 Available management approaches for cN0-patients

Advantages

Disadvantages

Close surveillance

Nomogram

Minimally invasive staging Modified inguinal lymph-

adenectomy (MIL) Dynamic sentinel node biopsy (DSNB)

Risk-adapted lymphadenectomy Elective lymphadenectomy

No unnecessary morbidity in patients without occult metastasis

Patients are pathologically staged with minor morbidity Only pN+ patients suffer from (completion) LND morbidity No occult metastases are missed

Survival disadvantage compared with early dissection in those with initial occult metastasis Some patients develop inoperable inguinal recurrences In some patients metastases are missed (i.e. false-negative) and develop inguinal recurrences Some patients cannot be salvaged hereafter

Unnecessary in 80% of patients and severe short and long-term morbidity risks and prone to a number of complications which will be discussed later. In general, a lymphadenectomy in all cN0 patients (sometimes described as early, prophylactic, or pre-emptive) is not recommended.

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