Introduction The surgical management of vulvar cancer has been evolving. Standard inguino-femoral lymphadenectomy (IFL) is associated with significant postoperative morbidity and lymphedema. Current guidelines recommend sentinel lymph node biopsy with Technetium-99m (Tc99) and blue dye. With the introduction of fluorescence in surgery, the use of indocyanine green (ICG) appears to have a role in improving the detection rate of sentinel lymph nodes. We present a case of sentinel lymph node biopsy with Tc-99 and ICG.

Description Sixty-five yo female with a BMI of 47.50 Kg/m2 presented with vulvar biopsy that showed Stage 2b malignant vulvar melanoma. Physical exam showed two black 5-mm lesions in the mons. PET CT scan did not show abnormal groin lymph nodes or distant metastasis. Underwent radical vulvectomy with Bilateral Inguino-femoral sentinel lymph node biopsy with Tc99 and Indocyanine green (ICG). Pre-operative lymphoscintigraphy detected bilateral groin lymph node. During surgery, ICG (25 grams/diluted in 10 ml sterile water) was injected intradermally at the leading edge of the lesion.

Conclusion/Implications Pathology showed one left groin sentinel node with 7 mm metastatic disease. One out of four right groin sentinel node biopsy showed 1 mm disease. All surgical margins were negative for invasive melanoma. The final pathology was pT2a pN2. Sentinel lymph node biopsy with Tc-99 and ICG appears feasible and may increase the detection rate of micrometastasis. ICG is an alternative to blue dye.