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Pelvic Lymph Node Dissection (PLND) in Carcinoma Vulva

Comprehensive Evidence-Based Overview (2021-2026)

1. Historical Context and Evolution

Pelvic lymph node dissection has undergone a dramatic evolution in the surgical management of vulvar cancer. Following the initial reports of Taussig (USA) and Way (UK), radical vulvectomy with en bloc groin dissection including pelvic lymphadenectomy was the standard of care for all operable patients. This was associated with extremely high morbidity, prolonged hospitalization, and significant physical/psychological burden.

Over the past four decades, the paradigm has shifted toward conservative, individualized surgery. The key milestones include:

Individualization of treatment for all patients
Vulvar conservation for unifocal tumors with normal surrounding vulva
Omission of groin dissection for Stage IA (T1a, ≤1 mm invasion)
Elimination of routine pelvic lymphadenectomy - most critical shift
Sentinel lymph node (SLN) procedure replacing full inguinofemoral lymphadenectomy in eligible patients
Separate groin incisions replacing en bloc resection
Preoperative chemoradiation for advanced disease
Postoperative (chemo-)radiation replacing pelvic nodal dissection in groin-positive cases

(Berek & Novak's Gynecology, p. 2438)

2. FIGO Staging - 2021 Revised Classification

Table 1: FIGO 2021 Staging of Vulvar Cancer (Lymph Node-Relevant Stages)

FIGO Stage	TNM	Criteria	5-yr Survival
IA	T1a N0 M0	≤2 cm, stromal invasion ≤1 mm, no nodal metastasis	~98%
IB	T1b N0 M0	>2 cm OR invasion >1 mm, negative nodes	~85%
II	T2 N0 M0	Extension to lower urethra/vagina/anus, negative nodes	~75%
IIIA	T1-2 N1a M0	1-2 LN metastases (<5 mm)	~60%
IIIA	T1-2 N1b M0	1 LN metastasis (≥5 mm)	~60%
IIIB	T1-2 N2a M0	3+ LN metastases (<5 mm)	~40%
IIIB	T1-2 N2b M0	2+ LN metastases (≥5 mm)	~40%
IIIC	T1-2 N2c M0	Positive nodes with extracapsular spread	~30%
IVA	T3 Any N	Invades upper urethra/vagina/bladder/rectum/fixed nodes	~15%
IVB	Any T, Any N, M1	Distant metastasis, including pelvic LN metastasis	<10%

Note: Pelvic lymph node metastasis is classified as Stage IVB (distant metastasis) in FIGO 2021, reflecting its very poor prognosis.

(Virarkar et al., Cancers 2022, PMID: 35565394; Berek & Novak's Gynecology)

3. Lymphatic Drainage and Risk of Pelvic Node Involvement

Lymphatic Pathway in Vulvar Cancer

Vulvar primary tumor
        │
        ▼
Superficial Inguinal Nodes (primary drainage)
        │
        ▼
Deep Inguinal/Femoral Nodes (Cloquet's node = most medial femoral node)
        │
        ▼  (SKIP METASTASIS IS RARE)
External Iliac → Obturator → Internal Iliac Nodes
        │
        ▼
Common Iliac → Para-aortic Nodes

Key principle: Pelvic node involvement is nearly always preceded by inguinofemoral node metastasis. Skip metastasis directly to pelvic nodes, bypassing inguinofemoral nodes, is extremely rare.

4. Incidence of Pelvic Lymph Node Metastasis

Table 2: Risk of Pelvic LN Metastasis by Inguinofemoral Node Status

Inguinofemoral Node Status	Risk of Pelvic LN Metastasis	Management Implication
All nodes negative	<1% (essentially zero)	No pelvic treatment needed
1 small node positive (<5 mm), no ECS	~3-5%	RT may not be needed; monitor
1 large node positive (≥5 mm)	~10-15%	Adjuvant RT to groin and pelvis
2+ nodes positive	~20-25%	Adjuvant RT to groin and pelvis (GOG 37)
3+ nodes positive	~30-40%	High priority for pelvic RT/chemoRT
Extracapsular spread (ECS) present	~35-45%	Adjuvant chemoRT mandatory
Fixed/ulcerated groin nodes	Very high	Primary chemoRT to pelvis + groin
Cloquet's node positive (intraoperative)	~60-80%	Pelvic RT essential; consider debulking

(Berek & Novak's Gynecology, p. 2458; PMC12411818 - Cancer of the Vulva 2025 Update)

5. The Pivotal Trial: GOG Protocol 37 (Homesley et al., 1986)

This remains the cornerstone evidence against routine pelvic lymphadenectomy in vulvar cancer.

Study Design

Population: 114 patients with inguinofemoral node-positive vulvar cancer after radical vulvectomy + bilateral inguinofemoral lymphadenectomy
Randomization: Bilateral pelvic node dissection vs. bilateral groin + pelvic radiotherapy (45-50 Gy, 1.8-2.0 Gy/fx, anterior-posterior photons)

Table 3: GOG 37 Results Summary

Outcome	Pelvic Node Dissection	Groin + Pelvic RT	P-value
2-year Overall Survival	54%	68%	P=0.03
2-year Cancer-Specific Survival	54%	75%	P=0.004
Groin failure rate	24%	5%	Significant
6-year OS (long-term follow-up)	~29%	~51%	HR 0.49, P=0.015

Subset Analysis - Who Benefits Most from RT over Surgery?

Patients with ≥2 positive inguinofemoral nodes
Patients with fixed or ulcerative groin nodes
Both groups showed the most significant survival advantage with RT over surgical pelvic dissection

Conclusion of GOG 37: Adjuvant radiation to the groin and pelvis is superior to pelvic lymph node dissection in node-positive vulvar cancer. Surgical PLND is therefore NOT recommended as standard management.

(NCCN Vulvar Cancer Guidelines v3.2024; JNCCN 22:2, 2024)

6. Current Role of PLND: When Is It Indicated?

Routine pelvic lymphadenectomy has been abandoned. However, targeted pelvic node debulking retains a role in specific scenarios.

Table 4: Current Indications for Pelvic Lymph Node Dissection/Debulking

Indication	Evidence Level	Notes
Bulky/enlarged pelvic nodes on preoperative imaging (CT, PET-CT, MRI)	Level 2B (NCCN); Grade C (ESGO)	Extraperitoneal node debulking BEFORE radiation - bulky nodes cannot be sterilized by RT alone
Cloquet's node positive on intraoperative frozen section	Expert consensus	Historical indication; now largely replaced by preoperative imaging assessment
Clinically suspicious pelvic nodes on PET-CT	Level 2B	Biopsy or resection to alter treatment planning
Residual pelvic nodes after chemoRT (select cases)	Level 2B (NCCN)	GOG data support resection of residual nodes post-chemoRT if no distant metastasis
Pelvic recurrence limited to pelvic nodes	Level 2B	Surgical resection if previously irradiated and resectable

Current Indications in Clinical Practice (NCCN 2024 / ESGO 2023 Aligned):

The main current role of pelvic lymph node surgery is DEBULKING of macroscopic pelvic disease identified on imaging, prior to adjuvant radiation - not systematic dissection.

7. Main Flowchart: Lymph Node Management Algorithm in Vulvar Cancer

┌─────────────────────────────────────────────────────────┐
│                INVASIVE VULVAR CANCER                   │
│           (Stromal invasion > 1 mm, i.e., ≥Stage IB)   │
└───────────────────────────┬─────────────────────────────┘
                            │
              ┌─────────────▼─────────────┐
              │  PREOPERATIVE ASSESSMENT  │
              │  Clinical exam + Imaging  │
              │  (CT/PET-CT/MRI/US groins)│
              └─────────────┬─────────────┘
                            │
         ┌──────────────────┴───────────────────┐
         │                                      │
         ▼                                      ▼
  CLINICALLY/IMAGING                   CLINICALLY SUSPICIOUS
  NEGATIVE NODES                       or FIXED NODES
         │                                      │
         ▼                                      │
  Eligible for SLN?                             │
  • Unifocal tumor                              │
  • Tumor < 4 cm                                │
  • No prior groin surgery                      │
         │                                      │
    YES  │  NO                                  │
    ▼         ▼                                 ▼
SLN BIOPSY   BILATERAL              PRIMARY CHEMORADIATION
(Tc-99m ±   INGUINOFEMORAL          (45 Gy + weekly cisplatin)
 Blue dye   LYMPHADENECTOMY              │
 ± ICG)          │                       │
    │            │                  Consider resection of
    │            │                  residual bulky nodes
    │            │                  post-chemoRT
    │            │
    ├─ SLN NEGATIVE ─────────────────────────────────────────┐
    │  No further node surgery; observe                       │
    │                                                         │
    └─ SLN POSITIVE ──────────────────────────────────────────┤
         │                                                     │
    MICROMETASTASIS              MACROMETASTASIS (>2 mm)       │
    (≤2 mm, no ECS)              OR ECS                        │
         │                           │                         │
         ▼                           ▼                         │
    Inguinofemoral RT            FULL INGUINOFEMORAL            │
    (50 Gy) -                    LYMPHADENECTOMY                │
    GROINSS-V II data            (Complete IFL)                 │
                                     │                         │
                              ┌──────▼─────────────────────────┘
                              │   AFTER IFL: ASSESS NODE STATUS │
                              └──────┬─────────────────────────┘
                                     │
              ┌──────────────────────┴───────────────────────┐
              │                                              │
              ▼                                              ▼
     NODES NEGATIVE                              NODES POSITIVE
     No further treatment                             │
     for nodes                         ┌─────────────┼──────────────┐
                                       │             │              │
                                       ▼             ▼              ▼
                                  1 NODE+        2+ NODES+     ECS PRESENT
                                  No ECS         OR ≥1 LARGE   ANY NUMBER
                                  (<5 mm)        NODE+             │
                                       │             │              │
                                       ▼             ▼              ▼
                               Adjuvant RT    ADJUVANT         ADJUVANT
                               (groin only,   CHEMORADIATION   CHEMORADIATION
                               may omit)      GROIN +          GROIN + PELVIS
                                              PELVIS           (mandatory)
                                              (45-50 Gy)
                                                   │
                                   ┌───────────────▼────────────────┐
                                   │ PRE-RT: IMAGE PELVIC NODES     │
                                   │ CT/PET-CT for pelvic LN status │
                                   └───────────────┬────────────────┘
                                                   │
                           ┌───────────────────────┤
                           │                       │
                           ▼                       ▼
                    PELVIC NODES             BULKY PELVIC NODES
                    NOT ENLARGED             IDENTIFIED ON IMAGING
                    │                              │
                    ▼                              ▼
              Standard pelvic RT          EXTRAPERITONEAL PELVIC
              (included in field)         NODE DEBULKING SURGERY
                                          (PLND - limited)
                                          THEN RT to pelvis
                                          (cannot sterilize
                                           bulky disease with
                                           RT alone)

8. PLND vs. Pelvic Radiotherapy: Key Comparison

Table 5: PLND vs. Adjuvant Pelvic Radiotherapy in Groin Node-Positive Disease

Parameter	Pelvic Lymph Node Dissection	Pelvic Radiotherapy
Overall Survival (GOG 37, 6-yr)	29%	51%
Groin recurrence rate	24%	5%
Morbidity	High (lymphedema, bowel injury)	Moderate (acute GI, lymphedema)
Ability to sterilize bulky nodes	Yes (mechanically)	Limited (>2-3 cm nodes)
Current guideline recommendation	NOT routine; debulking only for bulky nodes	PREFERRED over PLND (GOG 37 evidence)
Best candidates	Bulky/enlarged pelvic nodes on imaging	All node-positive cases without bulky pelvic nodes
Evidence level	Level I (against routine PLND)	Level I (GOG 37 RCT)

9. Sentinel Lymph Node Biopsy - The Modern Paradigm

Table 6: SLN Biopsy in Vulvar Cancer - Evidence Summary

Trial	Year	N	Key Finding
GROINSS-V I	2008	377	SLN feasible; 2.5% groin recurrence in SLN-negative patients; safe in unifocal <4 cm tumors
GOG-173	2012	452	SLN sensitivity 91.7%; false-negative rate 3.7%; acceptable in unifocal <4 cm
GROINSS-V II	2021 (PMID: 34432481)	1,535	RT = safe alternative to IFL for micrometastases (≤2 mm); RT inferior to IFL for macrometastases (>2 mm) - groin recurrence 22% vs 6.9%
Cochrane Review	~2020	2,396 groins	Blue dye + Tc-99m: detection rate 98%, sensitivity 0.95, NPV >95%
GROINSS-V long-term	2022	377	5-yr local recurrence 27.2%; isolated groin recurrence 2.5% (negative SLN)
Gracia et al. (2025) (PMID: 40277771)	2025	Review	SLN valid in unifocal <4 cm; limitations in recurrent disease and larger tumors
Bogani et al. (2026) (PMID: 42172493)	2026	Review	False-negative rate 7-10% in some series (up to 27%); ultrastaging mandatory

SLN Eligibility Criteria (GROINSS-V / ESGO / NCCN Aligned)

✅ ELIGIBLE for SLN biopsy:           ❌ NOT eligible (proceed to IFL):
• Unifocal tumor                       • Multifocal disease
• Tumor diameter < 4 cm               • Tumor ≥ 4 cm
• Stromal invasion > 1 mm             • Clinically/radiologically suspicious nodes
• Clinically negative groin nodes     • Prior groin surgery/lymphadenectomy
• No prior inguinofemoral surgery      • Tumor involving midline structures (controversial)
• Adequate surgical expertise         • Inadequate surgical volume/expertise
• Appropriate infrastructure          • T1a (≤1 mm invasion) - no groin Rx needed

10. Management Based on SLN Findings

Table 7: SLN Result and Subsequent Management (GROINSS-V II Protocol)

SLN Finding	Definition	Recommended Management	Groin Recurrence Rate
Negative	No tumor cells	No further node surgery or RT	~2.5%
Isolated tumor cells (ITC)	≤0.2 mm	Controversial; treat as micrometastasis	~3-4%
Micrometastasis	>0.2 to ≤2 mm	Inguinofemoral RT (50 Gy) - SAFE	~1.6% at 2 yrs
Macrometastasis	>2 mm	Complete IFL + adjuvant RT	~6.9% (IFL) vs 22% (RT alone)
Extracapsular spread	Any size with ECS	Complete IFL + adjuvant chemoRT	High without treatment

11. Post-IFL Node-Positive Management: Indications for Pelvic RT

This is the primary scenario where pelvic nodes are treated (by radiation, with selective surgical debulking).

Table 8: Indications for Pelvic and Groin Irradiation After IFL (Current Consensus)

Indication	Evidence	Recommendation
2 or more positive inguinofemoral nodes	GOG 37 (Level I)	Adjuvant pelvic + groin RT mandatory
Extracapsular spread (ECS)	Multiple retrospective series	Adjuvant pelvic + groin chemoRT mandatory
Fixed or ulcerated groin nodes	GOG 37 subset	Adjuvant pelvic + groin RT
Inadequate dissection (<8-10 nodes removed)	Expert consensus	Adjuvant RT to compensate
1 macrometastasis (≥5 mm)	Retrospective data	Consider adjuvant RT - controversial
1 small metastasis (<5 mm), no ECS	Limited evidence	RT may be omitted; individualize

(PMC12411818 - Cancer of the Vulva 2025 Update; NCCN v3.2024)

12. Prognostic Factors for Pelvic Nodal Involvement

Table 9: Negative Predictors of Survival in Node-Positive Vulvar Cancer

Factor	Impact on Pelvic Node Risk	Impact on Survival
Number of positive inguinofemoral nodes	≥3 nodes: 30-40% pelvic LN risk	Proportional reduction
Size of nodal metastasis	Macrometastasis >>Micrometastasis	Major determinant
Extracapsular spread (ECS)	Markedly increases pelvic involvement	Most important negative predictor
Proportion of node replaced by tumor	Higher replacement = worse prognosis	Significant
Bilateral vs. unilateral involvement	Bilateral = higher stage	Survival reduced
Depth of stromal invasion	>5 mm = 34% node positivity	Risk factor
Tumor size	>4 cm = markedly higher risk	Correlates with nodal positivity

(Berek & Novak's Gynecology, p. 2458)

13. Lymphedema and Morbidity: Why PLND is Avoided

Table 10: Complications of Lymphadenectomy in Vulvar Cancer

Complication	IFL Rate	PLND (additional)	SLN Rate
Lymphedema (chronic)	25-40%	Significantly higher	8-10%
Wound breakdown/infection	20-40%	Additional risk	5-10%
Lymphocyst formation	15-20%	Added risk	5-8%
Deep vein thrombosis	5-10%	Higher	2-5%
Bowel injury	Rare	2-5%	Near zero
Nerve injury (femoral)	2-5%	Higher	Rare
Hernia	Rare	3-5%	None
Perioperative mortality	0.5-1%	Higher in elderly/comorbid	Minimal

(Rahm et al., Eur J Surg Oncol 2022, PMID: 35148915)

14. Special Scenarios

14a. Midline/Central Tumors

Bilateral lymphatic drainage is the norm for lesions involving the clitoris, anterior labia minora, posterior fourchette, or within 2 cm of the midline
Bilateral inguinofemoral lymphadenectomy is required
Higher risk of bilateral nodal involvement (and thus bilateral pelvic involvement)

14b. Locally Advanced Vulvar Cancer (T3 / Clinically Fixed Nodes)

Advanced Vulvar Cancer (T3 / Fixed/Unresectable nodes)
            │
            ▼
Primary Chemoradiation:
- 45 Gy to primary tumor, groins, and pelvis
- Concurrent weekly cisplatin 30-40 mg/m²
- IMRT preferred (generous volumes)
            │
            ▼
Re-evaluate at 6-8 weeks (CT/MRI/PET-CT)
            │
    ┌───────┴──────────────┐
    │                      │
    ▼                      ▼
Resectable residual    Complete response
    │                  (clinical/pathologic)
    ▼                      │
Resect primary +           ▼
Limited groin node     Observation
debulking (NOT full        (biopsy if needed)
lymphadenectomy)

(NCCN Vulvar Cancer v3.2024; Berek & Novak's Gynecology, p. 2454-58)

14c. Recurrent Vulvar Cancer with Pelvic Nodal Involvement (NCCN 2024)

Recurrence with pelvic LN involvement
            │
            ▼
Multiple pelvic nodes / distant metastasis:
→ Systemic therapy ± selective EBRT (if feasible)
→ Palliative/best supportive care
            │
Isolated pelvic LN recurrence (previously irradiated):
→ Resection + systemic therapy (select cases)
            │
Isolated pelvic LN recurrence (no prior RT):
→ EBRT ± concurrent chemotherapy

15. Emerging Evidence and Future Directions

15a. ICG (Indocyanine Green) for SLN Mapping

ICG near-infrared fluorescence is gaining adoption as a complementary or replacement technique for blue dye
Meta-analysis (Chauvet et al., 2024, PMID: 38950735) confirms safety and emerging efficacy in gynecologic oncology
May improve detection rates and reduce allergic reactions from blue dye

15b. iLND (Immune-directed LN Dissection) - Novel Approach

Höckel et al. (Gynecol Oncol, 2026, PMID: 41774944) described peripheral immune network-directed dissection of lymph node regions (iLND) as a novel surgical approach
Aims to better delineate regional lymph node basins based on immune network anatomy
Early-stage investigational work

15c. GROINSS-V III and Future Trials

Active research is focusing on SLN in recurrent vulvar cancer, larger tumors (>4 cm), and optimization of ultrastaging protocols
The role of adjuvant immunotherapy (pembrolizumab) is being explored in node-positive disease

15d. FIGO 2021 vs. 2009 Staging Implications

The 2021 FIGO revision reclassified pelvic LN metastasis as M1 (Stage IVB), emphasizing its very poor prognosis
This change reinforces the clinical importance of preventing pelvic spread through appropriate management of inguinofemoral nodes

16. Summary Flowchart: Role of PLND in 2025/2026

Vulvar Cancer - Decision Point for Pelvic Node Management
═══════════════════════════════════════════════════════════

                     ALL PATIENTS
                          │
         ┌────────────────┼────────────────┐
         │                │                │
         ▼                ▼                ▼
    EARLY STAGE      LOCALLY ADVANCED   RECURRENT
    (I-II, N0)       (III-IVA)          DISEASE
         │                │                │
         ▼                ▼                ▼
   SLN biopsy or     Primary CRT      See recurrence
   IFL ± SLN         (groin+pelvis     algorithm
         │           in field)         above
         │
         ├── ALL NODES NEGATIVE
         │        │
         │        ▼
         │   NO pelvic
         │   treatment needed
         │
         └── NODES POSITIVE (IFL done)
                  │
          ┌───────┴────────┐
          │                │
          ▼                ▼
    1 node+, no ECS    ≥2 nodes+ OR ECS
    (<5 mm)            OR ≥1 large node
          │                │
          ▼                ▼
    Individualize    ADJUVANT CHEMORADIATION
    (RT may not      GROIN + PELVIS
     be needed)      (45-50 Gy + cisplatin)
                          │
                          ▼
               ┌──────────────────────┐
               │ Is there BULKY       │
               │ PELVIC NODE on       │
               │ pre-RT imaging?      │
               └────────┬─────────────┘
                        │
              ┌─────────┴─────────┐
              │                   │
              ▼                   ▼
         YES: Bulky          NO: Microscopic
         pelvic node         pelvic risk only
              │                   │
              ▼                   ▼
     EXTRAPERITONEAL         Pelvis included
     PELVIC NODE             in RT field
     DEBULKING               (no surgery)
     (limited PLND)
     THEN RT
         │
         ▼
THIS IS THE ONLY CURRENT
SURGICAL INDICATION FOR PLND

17. Key Takeaways and Clinical Pearls

#	Key Point
1	Routine pelvic lymphadenectomy is obsolete - abandoned based on GOG 37 evidence
2	Pelvic LN metastasis is Stage IVB (FIGO 2021) - distant metastasis, very poor prognosis
3	PLND is now only indicated for debulking macroscopic pelvic nodes before adjuvant RT
4	For groin node-positive disease, adjuvant RT to pelvis + groins is superior to PLND
5	GOG 37 showed 6-yr OS 51% (RT) vs. 29% (PLND) in groin node-positive patients
6	SLN biopsy has replaced IFL in eligible patients (unifocal, <4 cm, N0 clinically)
7	GROINSS-V II confirms: RT = IFL for micrometastases; IFL superior for macrometastases
8	Adjuvant chemoRT indications: ≥2 positive nodes, extracapsular spread, fixed nodes
9	Groin recurrence is fatal in >90% of cases - the most feared outcome in vulvar cancer
10	ICG is an emerging SLN tracer alongside Tc-99m; blue dye is being phased out at many centers

References

GOG 37 (Homesley et al., Obstet Gynecol 1986) - Foundational RCT: pelvic node dissection vs. RT in groin-positive vulvar cancer
GROINSS-V II (Oonk et al., J Clin Oncol 2021) - [PMID: 34432481] - RT vs. IFL for SLN micrometastases
Cancer of the Vulva: 2025 Update (PMC12411818) - Most current comprehensive review, Int J Gynecol Obstet 2025
NCCN Vulvar Cancer Guidelines v3.2024 - [JNCCN 22:2, 2024]
Vulvar Cancer: 2021 FIGO Staging (Virarkar et al., Cancers 2022) - [PMID: 35565394]
Bogani et al. J Gynecol Oncol 2026 - [PMID: 42172493] - SLN current evidence and future perspectives
Gracia et al. Curr Oncol 2025 - [PMID: 40277771] - Limitations of SLN in vulvar cancer
Penn et al. Curr Treat Options Oncol 2024 - [PMID: 38170388] - SLN evaluation in early-stage vulvar cancer
Rahm et al. Eur J Surg Oncol 2022 - [PMID: 35148915] - Complications of vulvar cancer surgery
Berek & Novak's Gynecology - pp. 2438-2465, Vulvar Cancer chapter

Bottom line: Pelvic lymph node dissection as a routine procedure in vulvar cancer has been superseded by adjuvant radiotherapy (GOG 37) and sentinel node biopsy. Its modern role is narrow - limited to extraperitoneal debulking of macroscopic pelvic nodes identified on pre-treatment imaging before radiotherapy begins, and selected cases of pelvic nodal recurrence. The primary goal of modern management is to prevent pelvic nodal involvement by optimizing inguinofemoral node assessment (SLN or IFL) and delivering adjuvant chemoradiotherapy appropriately when indicated.

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