Surgery For Inguinal Lymph Node Disease

Inguinal lymph nodes are usually included in the RT field when anal SCCa patients are treated with CRT. Lee et al. reported on the University of Florida experience with elective inguinal lymph node RT in 164 patients with pelvic malignancies at risk for inguinal nodal metastases (30). Primary sites included the anal canal, distal rectum, and the distal genitourinary (GU) tract. In 148 patients, both groins were clinically negative; 16 patients had unilateral clinical lymphadenopa-thy. The authors reported a 96% inguinal lymph node control rate and minimal complications, with a follow-up of at least two years. They concluded that elective inguinal RT is effective and safe in patients with pelvic malignancies who are at risk for inguinal nodal disease.

Conversely, Gerard et al. advocated a selective approach in the management of inguinal nodal disease, based on their retrospective analysis of 270 patients with anal SCCa treated with RT in Lyon over a 16-year period (31). No routine groin RT was performed. Patients with metastatic inguinal lymph nodes were treated with inguinal dissection and postoperative RT. Synchronous inguinal metastases were observed in 10% of patients (n=27; the rate was 16% for patients with T3-T4 lesions); the five-year overall survival rate in this subgroup was 54%. Metachronous inguinal metastases were seen in 19 patients (8%), and the five-year overall survival rate of these patients was 41%. The authors noted that, when the primary tumor was clearly located on a single lateral side of the anal canal, the nodal metastases always involved the ipsilateral groin (36 of 36 synchronous or metachronous tumors).

From the same group, Bobin et al. recently published a series on 35 patients with clinically N0 cancers of the anal canal who underwent sentinel inguinal lymph node (SILN) biopsy (32). Of this group, 33 had SCCa and 2 had anal melanomas. The SILN was positive in seven cases with SCCa, and in both melanomas. After 18 months of follow-up, the SILN negative cases showed no evidence of inguinal nodal disease. The authors suggested that SILN biopsy can be used to stage anal canal cancers, in order to avoid unnecessary prophylactic inguinal lymph node RT.

MSKCC patients with anal SCCa treated with CRT routinely receive bilateral groin RT. For persistent or recurrent isolated inguinal lymph node disease, we perform selective lymph-adenectomy (Fig. 2). The literature on this approach is scarce. An older report by Greenall et al. on 67 patients with recurrent SCCa tumors of the anal canal suggested that patients with

Radiation Therapy Groins
FIGURE 2 This CT image demonstrates a large recurrent metastatic left inguinal lymph node in an HIV-positive patient with squamous-cell carcinoma of the anus, initially treated with radiation therapy. Abbreviation: CT, computed tomography.

recurrence in the inguinal lymph nodes have relatively good prognosis (55% five-year survival after lymphadenectomy), and recommended treatment with groin dissection (33). In our institution's study by Akbari et al., five patients had isolated inguinal nodal recurrence and underwent inguinal lymph node dissection, with good results (24). Three patients remained free of disease, one died of distant recurrence, and another had local nodal recurrence.

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