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24 Gynecologic Surgery OB.GYN.

NEWS • April 1, 2007

Sentinel-Node Biopsy Defines Risk in Vulvar Ca


BY ROBERT FINN said Dr. van der Zee of the Uni- lymphadenectomy. The remain- Another two of the false neg- The women who underwent
San Francisco Bureau versity Medical Center Gronin- ing sentinel node–negative pa- atives were attributed to techni- only sentinel-node biopsy had
gen (the Netherlands). tients were followed for a medi- cal error, and no explanation one-third the rate of wound
S A N T A M O N I C A , C A L I F. — None of the patients had clin- an of 35 months. could be found for the remaining breakdown and one-quarter the
It’s safe to rely on sentinel-node ically suspicious groin nodes, and During that time, 8% of the three. rate of cellulitis as did those
biopsy for assessing the risk of their sentinel nodes were detect- patients had a local recurrence of Among the 21 sentinel who underwent lymphadenec-
metastasis in women with early- ed with radioactive tracer. their cancer, and 2.9% had a node–negative patients with re- tomy.
stage vulvar cancer, Dr. Ate van Patients whose sentinel- current local disease, the Moreover, the median length
der Zee said at the biennial meet- node biopsies were nega- The 3-year survival rate was median time to recurrence of stay in the hospital was sig-
ing of the International Gyneco- tive did not have full lym- 96.5% among women who were was 21 months, and 4 of nificantly shorter for sentinel
logic Cancer Society. phadenectomies, but the patients died. node–negative women. They
The results of a large, multi- rather were followed up sentinel-node negative, and The 3-year survival rate also had much lower rates of re-
center, observational study indi- closely by an experienced 80.5% among women who were was 96.5% among women current erysipelas and lym-
cate that sentinel-node biopsy physician. who were sentinel-node phedema.
has a sensitivity of 95.4% in pre- Physicians treated the sentinel-node positive. negative, and 80.5% Although he is enthusiastic
dicting whether unifocal vulvar primary tumor with a among women who were about the potential for sentinel-
cancer has metastasized, with a wide local excision in 91% of the groin recurrence. sentinel-node positive. node biopsy in women with vul-
negative predictive value of women, with the remainder re- Of the seven patients who had There was significantly less var cancer, Dr. van der Zee cau-
98.3%. ceiving either radiotherapy or a groin recurrence, two had mul- short-term and long-term mor- tioned that this should be
These data come from a total radical vulvectomy. tifocal disease, and the study pro- bidity among the sentinel performed only by an experi-
of 367 women, median age 66 Overall, 32% of the patients tocol was subsequently amended node–negative women, com- enced team, and preferably
years, with stage T1 or T2 squa- had positive biopsies of sentinel to exclude women with multifo- pared with those who underwent within the context of a clinical
mous cell cancer of the vulva, lymph nodes and went on to cal disease. lymphadenectomy. trial. ■

Preserve Ovarian Function ‘Muscle Welding’ Is Last, Best


With Laparoscopic Detorsion Way to Stem Presacral Bleeding
B Y M I C H E L E G. S U L L I VA N Adnexal torsions have historically been BY MITCHEL L. ZOLER the burned muscle fragment. Contin-
Mid-Atlantic Bureau treated by laparotomy with adnexecto- Philadelphia Bureau ued cautery power is applied until the
my, he said. “Gynecologists were afraid of muscle takes on the appearance of shoe
O R L A N D O — Laparoscopic untwisting sepsis and pulmonary embolism associat- F O R T L A U D E R D A L E , F L A . — Any- leather and becomes a coagulum that
of an adnexal torsion can almost always ed with the torsion. And they were not one who operates in the pelvis should seals the bleeding point.
preserve ovarian function and avoid the that concerned about preserving the ovary know how to manage presacral bleeding A thumbtack may work, but only
need for an adnexectomy, Dr. Kazem because they held the opinion that after because it occasionally happens to most when it’s correctly applied. The tack
Nouri said at a meeting on laparoscopy torsion, the ovary was nonfunctional.” surgeons, Dr. Herand Abcarian said at an must be placed over the bleeding point
and minimally invasive surgery. The introduction of laparoscopic detor- international colorectal disease sympo- and forcefully driven into the anterior
“These days, there is no longer any sion proved that ovarian function can be sium sponsored by the Cleveland Clinic sacral table, causing a crunching of the
question about whether laparoscopy or la- preserved in almost 90% of cases, Dr. Florida. “Muscle welding” is an effective bone. Collapsing the bone is vital for
parotomy is the best way to deal with ad- Nouri said at the meeting sponsored by way to stop presacral venous bleeding stopping flow because it’s the bone drop-
nexal torsion. The answer is laparoscopy,” the Society of Laparoendoscopic Sur- when other steps fail. ping into the sacral plexus that helps
said Dr. Nouri of the General Hospital of geons. In a series of 426 patients at the Mayo block further bleeding. Although place-
Vienna. In addition, the fear of pulmonary em- Clinic, Rochester, Minn., who had surgery ment of a second tack might occasionally
“The question is whether to go with bolism associated with the condition ap- for rectal cancer during the early 1990s, be called for, placing multiple tacks
detorsion or removal of the adnexa,” he pears unfounded. A 1999 review of about 3% had presacral bleeding. Dr. Abcarian’s should be avoided, Dr. Abcarian advised.
said. “In my opinion, detorsion is justified 600 patients treated with either laparo- suggested management sequence is initial When tacks and muscle welding fail to
because even if the ovary appears devas- scopic detorsion or laparotomy with re- tamponade with packing. The patient staunch the flow, packing for several
cularized, function can be preserved in al- section found only two cases of pul- should be put in the reverse Trendelen- days is the last resort. A layer of Silastic
most all cases.” monary embolism, both in women who burg’s position while exposure of the or a piece from a rubber glove is placed
Ovarian torsion most often occurs in underwent laparotomy. bleed is set up, followed by digital pressure over the bleeding, and then the pelvis is
conjunction with a cyst and is seen more Embolism appeared to be associated and then attempted repair with suture, packed tightly to produce tamponade.
frequently in the right ovary than in the with length of hospital stay: One woman clips, cautery, or argon beam. If none of The patient should be stabilized and nor-
left. was hospitalized 3 days before the surgery, these work, a properly placed thumbtack malized for coagulation factors, hemo-
The symptoms include nonspecific ab- and the other, 4 days. can sometimes staunch the flow. globin, and vital functions, and returned
dominal pain, which can have either grad- Laparoscopic detorsion involves careful But muscle welding is almost always ef- to the operating room 3 days later to
ual or sudden onset and may radiate to the manipulation of the adnexa, making sure fective as a last-ditch attempt to stop the have the pack removed and the bleeding
front, back, or groin. Nausea and vomit- to untwist the tissue in the correct direc- bleeding before temporarily packing the assessed. In rare cases when bleeding
ing are present in up to 70% of cases. tion. If there is a cyst, opinions are divid- patient and waiting a few days for the pa- continues, the packing should be redone
The differential diagnosis includes ap- ed on whether to remove it at the time of tient to stabilize. “By far it’s the most suc- and the bleeding reassessed as needed
pendicitis, ectopic pregnancy, pelvic in- the detorsion. cessful method for controlling presacral until it stops.
flammatory disease, diverticulitis, and re- “Reports in the literature mention that bleeding,” said Dr Abcarian, chairman The most common cause of presacral
nal colic. the cystectomy can be complicated by and professor, department of surgery, bleeding is a forceful lifting of the rectum
Torsion is usually diagnosed by ab- edematous tissue, and some advise wait- the University of Illinois at Chicago. from the sacral surface and blunt dissec-
dominal or transvaginal ultrasound. The ing for 3 or 4 weeks before removing the Welding is done by harvesting a 3- to tion of the rectum in a narrow male
classic finding is the “whirlpool sign”—a cyst,” Dr. Nouri said. 4-cm by 1- to 2-cm strip of rectus mus- pelvis. The best way to prevent a pre-
spiraling line that shows the twisted pedi- Other surgeons prefer to remove the cle from the lower abdominal incision, sacral bleed is by appropriately position-
cle. Ultrasound may also show an en- cyst for immediate biopsy. below the midline. The muscle is placed ing the patient, using excellent exposure
largement of the affected ovary and devi- “I have treated eight torsions, and in directly over the bleeding point, held and lighted retractors, and by using
ation of the uterus toward the affected some cases I did the cystectomy later. In there with the tip of a clamp, and treat- sharp—not blunt—dissection.
side. others I thought the ovary looked suspi- ed with a cautery probe turned up to Sometimes it is tempting to simply
“None of these findings has 100% speci- cious, so I performed it right away.” maximum coagulating power. The pull the rectum straight up and out of
ficity and sensitivity, however,” said Dr. An oophorectomy is usually performed clamp should be withdrawn after a few the way, but this can cause a tear. “The
Nouri. “The only way to be 100% sure is only in the case of recurrent torsion, he seconds, once the patch sits firmly on its less blunt dissection, the better,” Dr. Ab-
to do a diagnostic laparoscopy.” said. ■ own, so that the clamp does not stick to carian said. ■