The state of the (sentinel) lymph node and tumour microenvironment in patients with HPV-positive and HPV-negative cancer of the vulva.

Vulvar cancer most frequently occurs in women 65 to 75 years of age.
Squamous cell cancer of the vulva can be developed in at least two ways. In up
to half of all cases, human papilloma virus (HPV) infection appears to have an
important role, and are often found along with areas of vulvar intraepithelial
neoplasia (VIN). The women who have these cancers tend to be younger and are
often smokers.
The second process by which squamous cancer of the vulva might develop does not
involve HPV infection and are usually diagnosed in older women (over age 55).
These women may have lichen sclerosis and may also have the differentiated type
of VIN.
Other types of vulvar cancer comprises adenocarcinoma which may start in the
cells of the Bartholin glands or is found in patients with vulvar Paget disease
and melanoma of the vulva which develops from cells producing pigment in the
skin. This happens usually on sun-exposed areas, but can also start in areas as
the vulva or vagina.
Sentinel lymph nodes are the first lymph nodes that are under the influence of
tumour-derived factors and in which an immune response can be generated by the
activation of naive T and B cells. Thus the state of the sentinel lymph node
microenvironment is critical in the initial decision between activation and
suppression of the immune system by the primary tumour. A better understanding
of the microenvironment of the vulvar sentinel lymph node is therefore critical
for the development of new immunotherapeutic strategies. Also non sentinel
lymph nodes can be influenced in their microenvironment, due to draining tumour
derived factors from the sentinel lymph nodes.

The primary objective of this study is to analyse the microenvironment of the
tumour, (sentinel) lymph nodes (i.e. various T-cell populations, antigen
presenting cells and myeloid-derived suppressor cells) in patients with vulvar
carcinoma.
The secondary objectives of this study are to assess the differences of the
microenvironment in HPV-positive and HPV-negative (sentinel) lymph nodes; the
difference of the microenvironment of tumour-negative and metastatic (sentinel)
lymph nodes.
Exploratory objectives of this study are to analyse the difference in
microenvironment in (sentinel) lymph nodes; and to analyse the difference in
the (sentinel) lymph nodes compared to the primary tumour.

This is an exploratory study to further delineate the microenvironment of
(sentinel) lymph nodes in HPV-positive and HPV-negative vulvar cancer.

The isolation of lymph node cell samples via scrapings of the longitudinal
cutting edges of lymph nodes that are processed for diagnosis may carry a very
small risk for a false-negative diagnosis for the presence of metastases in
lymph nodes because a little bit of lymph node material is removed before the
lymph node is processed according to standard procedures. Notably, a surgically
dissected lymph node is cut through the longitudinal axis as part of the
standard procedures in the department of Pathology. Then the lymph node is
paraffin embedded. From each half only one section is taken for diagnosis. The
section used for diagnosis follows the cutting of several sections, a procedure
which is needed to have an optimal section cut off the embedded lymph node. It
should be appreciated that there is always loss of lymph node material before a
diagnosis can be made. Also in case of a sentinel node procedure only a few
sections are used for diagnosis. This indicates that there will always be a
small risk for a false -negative diagnosis. The department of Pathology
considers the chance of missing a metastasis in a lymph node by introduction of
scraping the cutting edge of the lymph nodes very small, but they cannot
exclude it.

Patiënts will be asked to donate 2x 10 ml blood for further analysis (at two
different timepoints).

Performing a sentinel node procedure extra (only using patent blue), directly
followed by a complete lymph node dissection gives a small chance on an
allergic reaction. This procedure gives no benefit for the patient and is to
determine the difference in microenvironment between sentinel and non-sentinel
lymph nodes.

In case of a lymph node debulking, a small tumour biopsy will be performed on
the surgery room. This carries a small risk of infection/bleeding, but as the
patient will be hospitalized for a couple of days, this can be adequately
monitored and/or treated.