Sentinel node biopsy for lymph nodal staging of uterine cervix cancer: a systematic review and meta-analysis of the pertinent literature

Survival Impact of Sentinel Lymph Node Biopsy in Patients with Early-Stage Cervical Cancer

To assess whether there were statistically significant differences in terms of overall survival (OS) and progression-free survival (PFS) between pelvic lymphadenectomy (PL) and sentinel lymph node biopsy (SLNB) alone as a nodal assessment method in patients with early-stage cervical cancer (IA1 with ILV to IB2 or IIA1 of the FIGO 2018 classification). A retrospective study was conducted among patients with early-stage cervical cancer who underwent radical surgery with pelvic lymph node assessment at La Paz University Hospital between 2005 and 2022. For nodal staging, either PL, SLNB + PL, or exclusive SLNB were performed, depending on the time period. Kaplan-Meier survival curves were compared between the PL and SLNB groups. Predictors of bilateral sentinel lymph node (SLN) detection were identified with Cox proportional hazard models. Among the 128 patients included, PL ± SLNB was performed in 79 (61.7%) patients and exclusive SLNB in 49 (38.3%) patients. There was no difference between PL and SLNB in OS (log-rank 0.0730) or PFS (log-rank 0.0189). Lower limb lymphedema (LLL) was significantly lower in the SLNB group (p = 0.001). Pelvic nodal assessment with SLNB alone did not worsen survival rates compared with the standard PL in patients with early-stage cervical cancer, and it is associated with a lower rate of LLL.

Benefits of sentinel node detection in cervical cancer

PURPOSE OF REVIEW

Sentinel lymph node biopsy (SLNB) is a widely used technique in other gynaecological tumours but has not yet been implemented as the gold standard technique for nodal staging in cervical cancer. Since the majority of evidence is derived from retrospective studies, this review aims to summarize the most recent evidence on this relevant topic.

RECENT FINDINGS

SLNB has demonstrated to be a well tolerated technique for lymph node staging in early-stage cervical cancer patients with promising future as exclusive lymph node assessment method avoiding full lymphadenectomy. Moreover, it allows ultrastaging and unfrequent drainage identification, which enables the detection of patients at a high risk of recurrence who would otherwise remain unnoticed. When compared with pelvic lymphadenectomy, SLNB is also associated with less intraoperative and postoperative complications, especially in terms of lymphedema formation.

SUMMARY

The available evidence suggests that SLNB offers numerous advantages over the standard pelvic lymphadenectomy reducing morbidity rates and increasing diagnostic accuracy. Three ongoing prospective trials will likely answer the controversies over these questions.

Cervical cancer: a new era

Cervical cancer is a major global health issue, ranking as the fourth most common cancer in women worldwide. Depending on stage, histology, and patient factors, the standard management of cervical cancer is a combination of treatment approaches, including (fertility- or non-fertility-sparing) surgery, radiotherapy, platinum-based chemotherapy, and novel systemic therapies such as bevacizumab, immune checkpoint inhibitors, and antibody-drug conjugates. While ambitious global initiatives seek to eliminate cervical cancer as a public health problem, the management of cervical cancer continues to evolve with major advances in imaging modalities, surgical approaches, identification of histopathological risk factors, radiotherapy techniques, and biomarker-driven personalized therapies. In particular, the introduction of immune checkpoint inhibitors has dramatically altered the treatment of cervical cancer, leading to significant survival benefits in both locally advanced and metastatic/recurrent settings. As the landscape of cervical cancer therapies continues to evolve, the aim of the present review is to provide a comprehensive discussion of the current state and the latest practice-changing updates in cervical cancer.

Molecular image-guided surgery in gynaecological cancer: where do we stand?

PURPOSE

The aim of this review is to give an overview of the current status of molecular image-guided surgery in gynaecological malignancies, from both clinical and technological points of view.

METHODS

A narrative approach was taken to describe the relevant literature, focusing on clinical applications of molecular image-guided surgery in gynaecology, preoperative imaging as surgical roadmap, and intraoperative devices.

RESULTS

The most common clinical application in gynaecology is sentinel node biopsy (SNB). Other promising approaches are receptor-target modalities and occult lesion localisation. Preoperative SPECT/CT and PET/CT permit a roadmap for adequate surgical planning. Intraoperative detection modalities span from 1D probes to 2D portable cameras and 3D freehand imaging.

CONCLUSION

After successful application of radio-guided SNB and SPECT, innovation is leaning towards hybrid modalities, such as hybrid tracer and fusion of imaging approaches including SPECT/CT and PET/CT. Robotic surgery, as well as augmented reality and virtual reality techniques, is leading to application of these innovative technologies to the clinical setting, guiding surgeons towards a precise, personalised, and minimally invasive approach.

Oncologic Outcomes of Patients with Early-Stage Cervical Cancer after Minimally Invasive Radical Hysterectomy and Sentinel Lymph Node Biopsy

Background: The sentinel lymph node is the first node that cancer cells reach when migrating from the primary site. However, oncological outcomes after sentinel lymph node biopsy (SNB) have not been reported for cervical cancer. In this study, oncological outcomes were compared between patients receiving SNB and pelvic lymphadenectomy (PLD) for early-stage cervical cancer. Methods: One hundred and four patients with clinical stage 1A2, 1B1, and 2A1 cervical cancer were included in this study. All patients underwent laparoscopic or robot-assisted radical hysterectomy with SNB or PLD. Fifty-two patients with tumors ≤2 cm underwent SNB. Disease-free survival (DFS) and overall survival (OS) were compared between the groups. Results: The median (interquartile range) tumor size was 12 (7-20) mm in the SNB group and 20 (13-25) mm in the PLD group. Lymph node metastasis occurred in one patient in the SNB group and in nine patients in the PLD group. The median follow-up periods were 42 (24-60) and 82 (19-101) months in the SNB group and PLD group, respectively. The 3-year DFS rates were 100% in SNB and 91.5% in PLD. The 3-year OS was 100% in both groups. Conclusions: SNB was sufficient in cervical cancer patients with tumors ≤2 cm, suggesting that PLD might not be necessary for these patients.

The top 100 most cited articles on fertility-sparing treatments for cervical cancer: A bibliometric analysis

Background

The primary objective of this paper was to assess and analyze the top 100 most cited articles currently cited in studies of fertility-sparing treatments for cervical cancer.

Methods

Searching the Web of Science Core Collection database for the top 100 most cited articles on fertility-sparing treatments for cervical cancer, different aspects of the articles were analyzed, including countries, journals, institutions, authors, keywords and topics.

Results

The search was conducted up to August 2023, and the number of citations for the top 100 articles ranged from 19 to 212. These articles originated from 28 different countries, with Professor Plante, M. from Canada and Professor Sonoda, Y. from the USA having the highest number of articles, both with 10. Professor Plante, M. was the first author of 9 articles and corresponding author of 9 articles. The Memorial Sloan Kettering Cancer Center in the USA published the most articles (21) and received a total of 258 citations. Gynecologic Oncology published 37 of the top 100 articles, with 524 citations and an average of 14.16 citations per article.

Conclusions

The study concludes that the USA has made the most significant contributions to this field based on the number of articles, authors, and institutions. Additionally, keyword clustering and burst analysis revealed the research hotspots and future trends in this area.

Feasibility and Diagnostic Accuracy of Ultrastaging in the Detection of Micrometastases in Sentinel and Non-sentinel Lymph Nodes in Cervical Cancer: A Single-Center Retrospective Study With a Five-Year Follow-Up Period

BACKGROUND

Cervical cancer is the fourth most common cause of malignant tumor-related deaths among women in developing nations. Cervical cancer has been estimated to cause 527.600 new cases and 265.700 deaths globally per year.

OBJECTIVES

This study aimed to evaluate patients with cervical cancer by ultrastaging all the lymph nodes (LN), sentinel LN (SLN) and non-SLN, to increase the sensitivity of the detection of LN metastases and the diagnostic accuracy in cervical cancer with a five-year follow-up.

MATERIALS AND METHODS

This is a retrospective study of 14 cervical cancer cases from 2017 to 2019 at the Municipal Emergency Clinical Hospital of Timisoara, Romania. The cases were selected based on their high risk of LN involvement but negative intraoperative pathologic LN. After re-evaluating all paraffin block biopsy samples from 29 cases, 14 cases were included in the study, which met all criteria for ultrastaging on surgical biopsy samples.

RESULTS

Patients' ages included in the study ranged from 43 to 70 years (median: 57.14 years). According to the International Federation of Gynecology and Obstetrics (FIGO) staging, the majority of the patients were in stage IB: seven cases (50%). The study revealed a positive correlation between patient age and FIGO staging, with Pearson's correlation coefficient of 0.707 and a p-value of less than 0.05, indicating that older patients were more likely to be diagnosed with a higher FIGO stage. The mean follow-up was 34.5 months, and the median follow-up was 36 months (range: 6-60 months). We obtained 167 nodes, with a mean of 11.92 nodes/case. Twenty-one LN were found to be positive with the ultrastaging method. We detected 11 LN with macrometastases (MAC) (52.38%), seven with micrometastasis (MIC) (33.3%), and three with tumor cell islets (14.4%). That would be 13% of newly diagnosed ultrastaging cases as positive nodes. This ultrastaging method detected nodal MIC in eight (57.1%) out of the 14 patients, who initially tested negative for LN involvement using the routine Hematoxylin and Eosin (HE) method. The detection of micrometastases in these patients underscored the superior sensitivity of ultrastaging, which was further highlighted by the subsequent relapse of four (28.57%) out of these eight patients. The study also found no correlation between the FIGO standardization and the number of MIC found in these patients.

CONCLUSIONS

Predicting cervical LN metastasis (LNM) is crucial for improving survival rates and reducing recurrence. Very few small cohort studies used an ultrastaging method to assess non-SLNs; most of them only assessed SLNs. We showed in our study that the ultrastaging method, both in the case of SLN and non-SLN, is superior compared with H&E analysis, with a 13% rate of new positive nodule diagnosis. Metastatic involvement of non-SLN was found in over 50% of all cases (8/14) according to the ultrastaging method. Additionally, our study confirms that the sensitivity of SLN ultrastaging is high for the presence of both MIC and MAC in SLN pelvic LN. As a result, we feel that ultrastaging is the most effective method for SLN analysis in patients with early-stage cervical cancer, and bilateral detection is preferable, significantly reducing false-negative results. The routine use of SLN along with ultrastaging would lead to more accurate surgical staging and better oncological follow-up of cases.

Comparative study using indocyanine green and patent blue dye for sentinel lymph node biopsy in patients with early-stage cervical cancer

BACKGROUND

Lymphatic involvement is the most important prognostic factor in early-stage cervical cancer. Sentinel lymph node biopsy is a viable alternative to systematic lymphadenectomy and may identify metastases more precisely.

OBJECTIVE

To compare two tracers (indocyanine green and patent blue) to detect sentinel nodes.

METHODS

A single-center, retrospective study of women treated due to early-stage cervical cancer (International Federation of Gynecology and Obstetrics 2009 IA1 with lymphovascular invasion, IA2, and IB1). Location and tracer of all detected sentinel nodes had been documented for a prospective, multicenter trial (SENTIX trial). All sentinel nodes were sent to frozen section and final analysis through ultrastaging using a standard protocol.

RESULTS

Overall, 103 patients were included. Bilateral detection rate for indocyanine green (93.2%) was significantly higher than for blue dye (77.7%; p=0.004). Their combined use significantly increased the bilateral detection to 99.0% (p=0.031). While 97.4% of all sentinel nodes were located below the common iliac vessels, no para-aortic nodes were labeled. Simultaneous bilateral detection with both tracers was found in 71.8% of the cases, of which the sentinel nodes were identical in 91.9%. Nine positive nodes were detected among seven patients (6.8%), all marked with indocyanine green while patent blue labeled six. Frozen section failed to detect one of three macrometastases and three of four micrometastases (sensitivity 43%; negative prediction value 96%).

CONCLUSION

Anatomical distribution and topographic localization of the sentinel nodes obtained with these tracers were not different. Indocyanine green provided a significantly higher bilateral detection rate and had superior sensitivity to detect positive nodes compared with patent blue. Combining indocyanine green and blue dye increased the bilateral detection rate significantly.

A machine learning-based prediction model of pelvic lymph node metastasis in women with early-stage cervical cancer

OBJECTIVE

To develop a novel machine learning-based preoperative prediction model for pelvic lymph node metastasis (PLNM) in early-stage cervical cancer by combining the clinical findings and preoperative computerized tomography (CT) of the whole abdomen and pelvis.

METHODS

Patients diagnosed with International Federation of Gynecology and Obstetrics stage IA2-IIA1 squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma of the cervix who had primary radical surgery with bilateral pelvic lymphadenectomy from January 1, 2003 to December 31, 2020, were included. Seven supervised machine learning algorithms, including logistic regression, random forest, support vector machine, adaptive boosting, gradient boosting, extreme gradient boosting, and category boosting, were used to evaluate the risk of PLNM.

RESULTS

PLNM was found in 199 (23.9%) of 832 patients included. Younger age, larger tumor size, higher stage, no prior conization, tumor appearance, adenosquamous histology, and vaginal metastasis as well as the CT findings of larger tumor size, parametrial metastasis, pelvic lymph node enlargement, and vaginal metastasis, were significantly associated with PLNM. The models' predictive performance, including accuracy (89.1%-90.6%), area under the receiver operating characteristics curve (86.9%-91.0%), sensitivity (77.4%-82.4%), specificity (92.1%-94.3%), positive predictive value (77.0%-81.7%), and negative predictive value (93.0%-94.4%), appeared satisfactory and comparable among all the algorithms. After optimizing the model's decision threshold to enhance the sensitivity to at least 95%, the 'highly sensitive' model was obtained with a 2.5%-4.4% false-negative rate of PLNM prediction.

CONCLUSION

We developed prediction models for PLNM in early-stage cervical cancer with promising prediction performance in our setting. Further external validation in other populations is needed with potential clinical applications.

Diagnostic Value of the Sentinel Lymph Node Technique in Patients with Muscle-Invasive Bladder Cancer

BACKGROUND

The optimal limits of the bilateral pelvic lymph node dissection (PLND) template in bladder cancer treatment remain controversial. This study aimed to investigate whether radio-guided sentinel node (SLN) detection is a reliable technique for the perioperative localisation of potential lymphatic metastasis during cystectomy for muscle-invasive bladder cancer (MIBC).

MATERIALS AND METHODS

We studied 54 patients with pT2-pT4 MIBC who underwent cystectomy with extended PLND (ePLND) augmented by the SLN technique. The identification of SLN was performed by preoperative SPECT/CT hybrid lymphoscintigraphy using peritumoral injection of nanocolloid-Tc-99m, followed by intraoperative navigation with a handheld γ-probe. All nodal specimens were collected separately and then fixed in formalin, stained with haematoxylin and eosin, and examined by an experienced uropathologist.

RESULTS

A total of 1414 LNs were resected and examined for the presence of metastases. The mean number of harvested LNs was 26 (range: 11-50) per patient. In 51 of 54 patients, 192 SLNs were resected. In addition, 20/192 (10.4%) SLNs were located outside of the ePLND area. Overall, 72 metastatic LNs (LN+) were found in 22 of 54 patients (40.7%) and in 24/192 SLNs (12.5%). The SLN technique detected LN+ in 14 of 22 (64%) patients. The SLNs were the only sites of metastasis (SLN+ = LN+) in 6 of 22 (27.3%) LN+ patients, including two cases with foci located in the pararectal region. The diagnostic values for the sensitivity, specificity, positive predictive value, and false-negative rate for the SLN technique were 66.66%, 4.16%, 28.57%, and 33.33%, respectively. Extended lymphadenectomy and its combination with the SLN technique enabled the correct assessment in 96.3 and 100% of patients, respectively.

CONCLUSIONS

The combination of ePLND and SLN provides a better pN assessment compared to ePLND alone. Although the SLN technique has restrictions that limit its diagnostic value, its use as an addition to lymphadenectomy allows for the visualisation of nonstandard lymph drainage pathways that may be potential metastatic routes.

Finding the sentinel lymph node in early cervical cancer: When is unusual not uncommon?

OBJECTIVE

To report our institutional experience with sentinel lymph node (SLN) detection using indocyanine green for cervical cancer, in terms of detection rates, detection of SLN at unusual locations, and factors associated with unusual SLN locations. In addition, we performed a systematic review of the literature to identify factors associated with unusual SLN localizations.

METHODS

This is a retrospective cohort study of women with early-stage cervical cancer undergoing sentinel lymph node mapping between 2015 and 2019. Outcome measures were SLN detection rates, detection rates of unusual locations for SLN and risk factors for aberrant lymphatic drainage pathways. In addition, studies evaluating factors associated with unusual SLN locations in cervical cancer were assessed in a systematic review.

RESULTS

A total of 100 patients were included. The unilateral SLN detection rate was 88%, whereas the bilateral detection rate was 75%. In 37% of all patients, SLN were found in unusual locations, and in 10% of patients SLN were solely found in unusual locations. Body mass index (BMI) was associated with finding SLN in unusual locations, with unusual nodes detected in 52% of patients with BMI <25 kg/m² and in 28% of patients with BMI ≥25 kg/m². The systematic review identified three studies, identifying lower BMI, nulliparity and tumor size of >20 mm as factors associated with finding SLN at unusual locations.

CONCLUSION

Aberrant drainage sites represent a significant proportion of SLN detected in cervical cancer. Factors associated with increased rates of unusual nodal locations are a lower BMI, with a possible association with nulliparity and tumor size of >20 mm.

Sentinel node navigation surgery in cervical cancer: a systematic review and metaanalysis

Sentinel node navigation surgery (SNNS) is used in clinical practice for the treatment of cervical cancer. This study aimed to elucidate the appropriate sentinel lymph node (SLN) mapping method and assess the safety and benefits of SNNS. We searched the PubMed, Ichushi, and Cochrane Library databases for randomized controlled trials (RCT) and studies on SLN in cervical cancer from January 2012 to December 2020. Two authors independently assessed study quality and extracted data. We quantitatively analyzed the detection rate, sensitivity/specificity, and complications and reviewed information, including the survival data of SLN biopsy (SLNB) without pelvic lymphadenectomy (PLND). The detection rate of SLN mapping in the unilateral pelvis was median 95.7% and 100% and in the bilateral pelvis was median 80.4% and 90% for technetium-99 m (Tc) with/without blue dye (Tc w/wo BD) and indocyanine green (ICG) alone, respectively. The sensitivity and specificity of each tracer were high; the area under the curve of each tracer was 0.988 (Tc w/wo BD), 0.931 (BD w/wo Tc), 0.966 (ICG), and 0.977 (carbon nanoparticle). Morbidities including lymphedema, neurological symptoms and blood loss were associated with PLND. One RCT and five studies all showed SNNS without systematic PLND does not impair recurrence or survival in early-stage cervical cancer with a tumor size ≤ 2-4 cm. Both Tc w/wo BD and ICG are appropriate SLN tracers. SNNS can reduce the morbidities associated with PLND without affecting disease progression in early-stage cervical cancer.

Clinical Study of Sentinel Lymph Node Detection to Evaluate Pelvic Lymph Node Metastasis to Determine the Prognosis of Patients with Early Cervical Cancer

Objective

Lymph node status is one of the most important prognostic factors for uterine cervical cancer. Sentinel lymph node (SLN) biopsy has emerged as a potential alternative to systematic lymphadenectomy for the lymph node mapping in such patients. However, the SLN metastasis detection via SLN biopsy in early-stage cervical cancer remains controversial. The current study is aimed at investigating the feasibility and accuracy of combined tracer method for localization of SLN in initial stages of cervical cancer and to evaluate the clinical value of SLN biopsy in replacing pelvic lymph node resection.

Methods

We retrospectively reviewed 348 cases who were admitted to the Department of Gynecologic Oncology, Shandong Provincial Cancer Hospital, China, between February 2003 and June 2018 with FIGO stage IA2 to IIA2 cervical cancer and undergone through SLN biopsy. Methylthioninium chloride was injected in combination with ^99mtechnetium-labeled sulfur colloid prior to surgery to these patients. SLNs were identified intraoperatively, excised, and subsequently submitted to fast frozen section. The detection rates, accuracy, sensitivity, coincidence rate, false negative rate, and negative predictive values of these cases were estimated, and the follow-up outcomes were carefully observed. Chi squared test or Fisher's exact test was employed for a comparison of the categorical variables. Univariate and multivariate Cox proportional hazard models were used for estimation of relationships between overall survival (OS) and disease-free survival (DFS) and prognostic factors.

Results

The total detection rate of SLN was 97.1% (338/348), and identification of bilateral SLN was successful in 237 patients (70.1%). The patient's tumor size, FIGO stage, lymph node metastasis, and depth of invasion had statistically significant differences in SLN detection rates. The detection rate had inverse relation with tumors size (>4 cm), invasive depth > 2/3, lymph node positive, late staging, and preoperative radiotherapy. 117 positive SLNs were detected in 73 patients. The negative predictive value, sensitivity, false negative rate, and coincidence rate and were 97.7%, 92.4%, 7.6%, and 95.4%, respectively. In patients whose tumor size were ≦ 4 cm, the false negative rate was 4.55% (2/44), whereas it was 0 in patients with tumor size≦2 cm. The respective 1, 3, and 5-year OS was 100%, 94.8%, and 91.8%, respectively, whereas DFS rate for 1, 3, and 5 years was 96.7%, 92%, and 89.6%, respectively. The lymph node was positive, tumor size, the depth of invasion, and staging were statistically different from the recurrence rate and survival rate of patients (p < 0.05). When tumor metastasis exceeded SLN, the recurrence rate was significantly increased, and survival rate is significantly reduced (p < 0.05, p < 0.01, p < 0.05, respectively).

Conclusions

The identification of SLN combined with ^99mtechnetium-labeled sulfur colloid and methylthioninium chloride has a good accuracy and is safe for the assessment of the status of pelvic nodes in patients with initial stage cervical cancer. Nuclide as a tracer has low dependence on objective conditions and doctors' technology and has a good detection rate. In our study, we believe that SLN biopsy is feasible when the tumor is ≦ 4 cm. Large scale clinical trials are required in China expand the sample size and validate the results of this study.

Methods of Sentinel Lymph Node Detection and Management in Urinary Bladder Cancer—A Narrative Review

Introduction: Detection of lymph node status in bladder cancer significantly impacts clinical decisions regarding its management. There is a wide range of detection modalities for this task, including lymphoscintigraphy, computed tomography, magnetic resonance imaging, single-photon emission computed tomography, positron emission tomography, and fluoroscopy. We aimed to study the pre- and intraoperative detection modalities of sentinel lymph nodes in urinary bladder cancer. Method: This narrative review was performed by searching the PubMed and EMBASE libraries using the following search terms: (“Transitional cell carcinoma of the bladder” OR “urothelial cancer” OR “urinary bladder cancer” OR “bladder cancer”) AND ((“sentinel lymph node”) OR (“lymphatic mapping”) OR (“lymphoscintigraphy”) OR (“lymphangiography”) OR (“lymph node metastases”)). Studies analysing the effectiveness and outcomes of sentinel lymph node detection in bladder cancer were included, while non-English language, duplicates, and non-article studies were excluded. After analysing the libraries and a further manual search of bibliographies, 31 studies were included in this paper. We followed the RAMESES publication standard for narrative reviews to produce this paper. Results: Of the 31 studies included, 7 studies included multiple detection methods; 5 studies included lymphoscintigraphy; 5 studies included computed tomography and/or single-photon emission computed tomography; 5 studies included fluoroscopy; 4 studies included magnetic resonance imaging; and 5 studies included positron emission tomography. Discussion: Anatomical, radioactive, and functional detection modalities have been studied independently and in combination. The consensus is that preoperative detection with imaging helps guide surgical management and intraoperative detection methods help capture any lymph nodes that may have been missed. Each of these types of detection represent their own set of benefits and drawbacks, but there is currently limited evidence to support any change in overall practice to replace conventional staging.

Assessment of ESGO Quality Indicators in Cervical Cancer Surgery: A Real-World Study in a High-Volume Chinese Hospital

The ESGO developed a list of fifteen quality indicators for cervical cancer surgery in order to audit and improve clinical practice in 2020. However, data from the developing countries with high incidence rates of cervical cancer is still lacking. Therefore, we conducted a retrospective study of 7081 cases diagnosed as cervical cancer between 2014 and 2019 in a Chinese single center according to the quality indicators proposed by ESGO. A total of 5952 patients underwent radical procedures, with an average of 992.0 per year. All surgeries were performed or supervised by a certified gynecologic oncologist as surgical qualification grading system has been established. Compared with the low-volume group, patients in the high-volume group (≥15 cases/year) had a shorter hospital stay (P<0.001), more free surgical margins (P=0.031), and less complications (P<0.001), but the 5-year recurrence-free survival and overall survival rates were similar (P>0.05). Treatment was not planned at a multidisciplinary team meeting but with the consultation system. The required preoperative workup was incomplete in 19.7% of patients with pelvic MRI and 45.7% of patients with PET-CT. A total of 1459 (20.6%) patients experienced at least one complication after surgery. The CDC grade IIIb or higher complications occurred in 80 patients, accounting for 5.5% complications. The urological fistula rate within 30 postoperative days were 0.3%. After primary surgical treatment, 97.4% patients had clear vaginal and parametrial margins. After restaging FIGO 2009 to FIGO 2018 system, 14.7% patients with a stage T1b disease were T-upstaged. After a median follow-up of 42 months, recurrence occurred in 448 patients, and 82.1% patients recurred within 2 years. The 2-year RFS rate of patients with pT1b1N0 was 97.3% in 2009 FIGO staging system. Lymph node staging was performed in 99.0% patients with a stage T1 disease. After a primary surgical treatment for a stage pT1b1N0 disease, 28.3% patients received adjuvant chemoradiotherapy. Above all, most of quality indicators reached the targets, except four quality indicators. The quality indicators of ESGO should be popularized and applied in China to guarantee quality of surgery.

Predictors of uncommon location of sentinel nodes in endometrial and cervical cancers

OBJECTIVE

Sentinel node mapping is widely used in the treatment of gynecologic cancers. The current study aimed to identify predictors of uncommon sentinel lymph node (SLN) locations.

METHODS

The current study included women who were operated for endometrial or cervical cancer with attempted sentinel lymph node mapping during surgical staging. Data were collected from electronic charts. The pelvis and the external ilia and obturator basins were common node locations. Para-aortic, pre-sacral, common iliac, internal iliac, and parametrial nodes were considered uncommon locations. We conducted analyses stratified according to common, uncommon, and very uncommon (para-aortic, pre-sacral, parametrial) node location sites.

RESULTS

A total of 304 women were enrolled in the current study; 15.8% had SLN in uncommon locations and 4.3% had very uncommon node locations. Body mass index (BMI) was a negative predictor for uncommon SLN locations (OR 0.88, p = 0.03). The use of either indocyanine green (ICG) or Tc99 & blue dye was an independent predictor for uncommon SLN locations (OR 8.24, p = 0.006). More recent surgeries and the presence of positive nodes were independent predictors for very uncommon node locations (OR 2.13, p = 0.011, and OR 9.3, p = 0.002, respectively).

CONCLUSIONS

BMI, tracer type, surgical year, and positive nodes were independent predictors for uncommon SLN locations. These findings suggest that surgical effort, technique and experience may result in better identification of uncommon SLN locations.

Fertility-Sparing and Less Radical Surgery for Cervical Cancer

PURPOSE OF REVIEW

Patients with early-stage cervical cancer who desire future fertility may be candidates for less radical surgery. We review the literature supporting this approach in early-stage disease.

RECENT FINDINGS

Retrospective data have shown that in carefully selected patients, the risk of parametrial involvement is less than 1%. This has led to interest in moving away from radical surgery towards more conservative approaches. Data from the newly published ConCerv trial, a prospective study evaluating the feasibility of conservative surgery in women with early-stage, low-risk cervical carcinoma, suggest that conservative surgery is feasible and safe in this patient population. Furthermore, neoadjuvant chemotherapy is being assessed as an option to extend fertility-sparing treatment to a larger group of women. Less radical surgery may be appropriate for carefully selected women with early-stage, low-risk cervical cancer, including those desiring future fertility.

Clinical Study of Sentinel Lymph Node Detection Using Photodynamic Eye for Abdominal Radical Trachelectomy

This study aimed to assess the accuracy of predicting pelvic lymph node status using sentinel lymph node (SLN) biopsy with indocyanine green (ICG) and to examine the outcomes of SLN biopsy-guided abdominal radical trachelectomy (ART). Patients with stage IA2-IB2 cervical cancer from January 2009 to January 2021 were included. ICG was injected before ART and SLNs were identified, excised, and assessed intraoperatively using fast-frozen sections. Systemic pelvic lymphadenectomy was subsequently performed. The SLN detection rate, sensitivity, and false-negative rate were determined. Thirty patients desiring fertility preservation were enrolled, of whom 26 successfully completed ART and four underwent radical hysterectomies because of metastatic primary SLNs. Bilateral SLNs were identified in all patients. The sensitivity, false-negative rate, and negative predictive value were 100%, 7.7%, and 92.3%, respectively. Three (12%) patients were lost to follow-up: two relapsed and one died of tumor progression. Of the nine patients who tried to conceive after surgery, four achieved pregnancy and three delivered healthy live infants. In women with early-stage cervical cancer who desired to conserve fertility, SLN mapping with ICG had a very high detection rate, sensitivity, and low false-negative rate. SLN biopsy-guided ART is a feasible and accurate method for assessing pelvic node status.

Repeat injection following sentinel node nonvisualization on lymphoscintigraphy images can decrease axillary dissection rate in breast cancer patients

AIM

Sentinel node biopsy is considered the standard of care in early-stage breast cancer patients. In the current study, we evaluated the effect of radiotracer reinjection in the case of sentinel node nonvisualization on preoperative lymphoscintigraphy.

MATERIALS AND METHODS

Between March 2017 and March 2020, 1850 early-stage breast cancer patients were referred for sentinel node mapping. All patients received a single injected activity of Tc-99m Phytate intradermally in the periareolar area of the index lesion using an insulin syringe. Lymphoscintigraphy images of the patients were done 1-2 h postinjection. Between March 2017 and September 2017, sentinel node nonvisualization was reported to the surgeon, and for the rest of the study period, the patients received another injected activity of the radiotracer, and immediately, other lymphoscintigraphy images were taken (with the same parameters).

RESULTS

A total of 255 patients entered our study. Fifty-five patients were in group I without any reinjection. The remainder of the patients were in group II. In 155 out of 200 patients of group II, a sentinel node could be visualized following reinjection of the radiotracer. The detection rate was 15 out of 45 and 15 out of 55 in group I and patients without sentinel node visualization even after reinjection, respectively. Axilla was involved in 5 out of 40 (12.5%) patients in group I with intraoperative sentinel node mapping failure. On the other hand, axilla was involved in 27 out of 30 (90%) group II patients with sentinel node nonvisualization.

CONCLUSION

Reinjection of the tracer in cases of no sentinel node visualization in lymphoscintigraphy for breast cancer increases the detection rate of sentinel nodes, and therefore a high number of unnecessary axillary lymph node dissections can be avoided.

Sentinel lymph node mapping in early-stage cervical cancer: Meta-analysis

BACKGROUND

The value of sentinel lymph node (SLN) mapping for early-stage cervical cancer remains controversial. Therefore, we collected data to investigate the feasibility and diagnostic accuracy of SLN in patients with early-stage (IA-IIA) cervical cancer.

METHODS

We searched Embase, PubMed, and the Cochrane Library databases issued before June 1, 2020. The sample size of the selected study was at least 10 patients with early-stage (IA-IIA) cervical cancer, the pooled detection rates and the separate detection rate (overall detection rate, bilateral detection rate) using blue dye with Tc, technetium 99 (Tc) and indocyanine green (ICG) technique of early-stage cervical cancer was reported. R-3.6.1 software was used to evaluate pooled detection rate and sensitivity.

RESULTS

Two thousand one hundred sixty-four patients included for analysis in 28 studies ranging from 12 to 405 patients. The combined overall detection rate of SLN mapping was 95% with a 72% pooled bilateral detection rate. The sensitivity of the combined overall detection rate of SLN mapping was 94.99% as well as a sensitivity of 72.43% bilateral detection rate. The overall detection rate of SLN was 96% for blue dye with Tc, 95% for Tc, 98% for ICG technique. The bilateral detection rate of SLN was 76% for blue dye with Tc, 63% for Tc, 85% for ICG technique. The sensitivity of the overall detection rate of SLN mapping was 97.76% as well as a sensitivity of 84.96% bilateral detection rate of ICG technique.

CONCLUSION

In early-stage cervical cancer, overall detection rate of SLN mapping is elevated while bilateral detection rate is lower. The overall detection rate (98%) as well as bilateral rate (85%) of ICG seems to be a better SLN mapping technique among the method of SLN mapping (using blue dye with Tc, Tc or ICG). We believe SLN mapping may be considered contemporary technique which could provide additional benefits over traditional pelvic lymphadenectomy. While promising results in SLN mapping has been found, larger patient samples, including randomized studies, are required at the same time.

Lymph Node Staging with a Combined Protocol of 18F-FDG PET/MRI and Sentinel Node SPECT/CT: A Prospective Study in Patients with FIGO I/II Cervical Carcinoma

Lymph node metastasis (LNM) is present in a minority of patients with early stages of cervical carcinomas. As conventional imaging including PET/CT has shown limited sensitivity, systematic lymphadenectomies are often conducted for staging purposes. Therefore, the aim of this prospective study was to analyze the impact of 18F-FDG PET/MRI in addition to sentinel lymph node (SLN) biopsy on lymph node (LN) status. Methods: Forty-two women with an initial diagnosis of Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) IA-IIB cervical carcinoma were included between March 2016 and April 2019. Each patient underwent preoperative whole-body 18F-FDG PET/MRI and SLN imaging with SPECT/CT after intracervical injection of 99mTc-labeled nanocolloid. Systematic lymphadenectomy and SLN biopsy served as the reference standard. Staging using PET/MRI was performed by nuclear medicine and radiology experts working in consensus. Results: One patient was excluded from surgical staging because of liver metastases newly diagnosed on PET/MRI. The overall prevalence of LNM in the remaining 41 patients was 29.3% (12/41). Five of 12 patients with LNM had solely small metastases with a maximum diameter of 5 mm. The consensus interpretation showed PET/MRI to have a specificity of 100% (29/29; 95% CI, 88.3%-100%) for LNM staging but a low sensitivity, 33.3% (4/12; 95% CI, 12.8%-60.9%). LN size was the most important factor for the detectability of metastases, since only LNMs larger than 5 mm could be identified by PET/MRI (sensitivity, 57.1% for >5 mm and 0% for ≤5 mm). Paraaortic LNM was evaluated accurately in 3 of the 4 patients with paraaortic LN metastasis. SLNs were detectable by SPECT/CT in 82.9% of the patients or 69.0% of the hemipelves. In cases with an undetectable SLN on SPECT/CT, the malignancy rate was considerably higher (31.2% vs. 19.3%). The combination of PET/MRI and SLN SPECT/CT improved the detection of pelvic LNM from 33.3% to 75%. Conclusion:18F-FDG PET/MRI is a highly specific N-staging method and improves LNM detection. Because of the limited sensitivity in frequently occurring small LNMs, PET/MRI should be combined with SLN mapping. The proposed combined protocol helps to decide whether extensive surgical staging is necessary in patients with FIGO I/II cervical cancer.

Sentinel-Lymph-Node Multicenter Trials

Well executed multicenter clinical trials often provide significant evidence and support for, or against, foundational aspects of clinical procedures perceived to improve clinical management of a medical condition. In this review, discussed are reports of multicenter clinical trials designed to investigate sentinel lymph node biopsy procedures in seven types of cancer: breast, melanoma, head and neck, gastric, colon, uterine, and vulvar-with focus on the most recent reports of the hypotheses, objectives, parameters, data, results, implications, and impacts of the included trials. Such trials generally enroll more subjects, in shorter time periods, than do single-center studies. Such studies generally also have greater diversities among investigator practitioners and investigative environments than do single-center studies. The greater number of subjects provides more power to statistical analyses performed in such studies. The more rapid accrual usually results in data being more consistently acquired. The diversities of practitioners and environments may produce results that are more conservative than might be obtained from more "focused" studies; however, diversities in a study often identify implicitly results that are more robust-that is results applicable by more practitioners and applicable in more environments.

A novel 2-deoxy-2-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT)-based nomogram to predict lymph node metastasis in early stage uterine cervical squamous cell cancer

Background

We aimed to establish an effective 2-deoxy-2-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) based nomogram for pelvic lymph node (PLN) metastasis prediction in early-stage uterine cervical squamous cell cancer.

Methods

A predictive model was developed in a cohort that consisted of 351 patients with stage IB-IIA [International Federation of Gynecology and Obstetrics (FIGO) 2009] uterine cervical squamous cell cancer. All patients underwent a preoperative PET/CT scan and subsequent radical surgery between 2010 and 2017, with 241 and 110 patients allotted into training and external validation cohorts. The chi-square (χ²) test and the logistic regression analysis were used to compare the clinical and PET/CT parameters with PLN metastasis. A nomogram was developed and validated by internal and external validation.

Results

In the training cohort, 82 (34.0%) patients had positive PLNs identified in the preoperative PET/CT scan. Among them, 46 (56.1%) were pathologically confirmed. There were 30 (18.9%) PET/CT scan-negative patients found to have PLN metastasis. The χ² test and logistic regression showed that only the squamous cell carcinoma antigen (SCCA) level (P=0.039) and maximum standardized uptake value (SUVmax) of PLN (nSUVmax, P=0.001) were independent predictors for PLN metastasis. A predictive nomogram based on these 2 parameters was developed with a C-index [95% confidence interval (CI)] of 0.854 (0.772-0.937) on internal validation and 0.836 (0.723-0.948) on the external validation. Compared to nSUVmax alone, our nomogram showed elevated sensitivity (70.5%, 73.1% vs. 60.5%), specificity (94.4%, 86.4% vs. 78.2%), and positive predictive value (PPV) (93.9%, 86.4% vs. 56.1%) in both the training and validation cohorts.

Conclusions

We successfully developed a noninvasive and convenient nomogram for preoperative identification of PLN metastasis in early-stage squamous cell cervical cancer.

Histopathologic Validation of the Sentinel Node Technique for Early-Stage Cervical Cancer Patients

BACKGROUND

The sentinel lymph node (SLN) biopsy may be an alternative to systematic lymphadenectomy in early cervical cancer. The SLN biopsy is less morbid and has been shown to have high sensitivity for metastasis detection. However, the sensitivity of the SLN technique might be overevaluated because SLNs are examined with ultra-staging, and non-sentinel nodes usually are examined only with routine techniques. This study aimed to validate the negative predictive value (NPV) of the SLN technique by the ultra-staging of SLNs and non-sentinel nodes (NSLNs).

METHODS

The SENTICOL 1 study data published in 2011 were used. All nodes (i.e., SLNs and NSLNs) were secondarily subjected to ultra-staging. The ultra-staging consisted of sectioning every 200 µm, in addition to immunohistochemistry. Moreover, the positive slides and 10% of the negative slides were reviewed.

RESULTS

The study enrolled 139 patients, and SLNs were detected in 136 (97.8%) of these patiets. Bilateral SLNs were detected in 104 (76.5%) of the 136 patients. A total of 2056 NSLNs were identified (median, 13 NSLNs per patient; range 1-54). Of the 136 patients with SLNs, 23 were shown to have positive SLNs after serial sectioning and immunohistochemical staining. The NSLNs were metastatic in six patients. In the case of bilateral SLN detection, the NPV was 100%, with no false-negatives (FNs).

CONCLUSIONS

The pelvic SLN technique is safe and trustworthy for determining the nodal status of patients with early-stage cervical cancer. In the case of optimal mapping with bilateral detection, the NPV was found to be 100%.

Standard ultrastaging compared to one-step nucleic acid amplification (OSNA) for the detection of sentinel lymph node metastases in early stage cervical cancer

OBJECTIVE

We compared ultrastaging and one-step nucleic acid amplification (OSNA) examination of sentinel lymph nodes in two homogeneous patient populations diagnosed with early stage cervical cancer. The primary aim of our study was to evaluate the rate and type of sentinel lymph node metastases detected by ultrastaging and OSNA assay. Secondary aims were to define the sensitivity and the negative predictive value of sentinel lymph node biopsy assessed with OSNA and ultrastaging and to define the role of sentinel lymph node assessment in predicting non-sentinel lymph node status.

METHODS

Consecutive patients who underwent surgery (radical hysterectomy or trachelectomy or cervical conization) at our institution, between January 2018 and March 2020, were enrolled. All patients had a preoperative diagnosis of early-stage cervical carcinoma (International Federation of Gynecology and Obstetrics (FIGO) 2018 stages IA-IIB) and underwent sentinel lymph node assessment with ultrastaging or OSNA. Patients with advanced FIGO stages and special histology subtypes (other than squamous cell carcinoma, adenocarcinoma or adenosquamous carcinoma) or patients with sentinel lymph nodes analyzed only with hematoxylin and eosin were excluded. Clinical data were compared using the χ² test and Fisher's exact test. A κ coefficient was determined with respect to lymph node assessment. A p value <0.05 was considered statistically significant.

RESULTS

A total of 116 patients were included in this retrospective analysis (53 ultrastaging, 63 OSNA). Overall, 531 and 605 lymph nodes were removed in the ultrastaging and OSNA groups, respectively, and 140 and 129 sentinel lymph nodes were analyzed in the ultrastaging and OSNA groups, respectively. 22 patients had metastatic sentinel lymph nodes: 6 (11.3%) of 53 patients in the ultrastaging group and 16 (25.4%) of 63 patients in the OSNA group. The total amount of positive SLNs was 7 (5%) of 140 in the ultrastaging group and 21 (16.3%) of 129 in the OSNA group, respectively (p=0.0047). Pelvic lymphadenectomy was performed in 26 (49.1%) of 53 patients in the ultrastaging group and in 34 (54%) of 63 patients in the OSNA group due to comorbidities. Metastatic non-sentinel lymph nodes were found in 4 patients: 2 (7.7%) of 26 patients in the ultrastaging group and 2 (5.9%) of 34 patients in the OSNA group, respectively. The total amount of positive pelvic lymph nodes was 3 (0.6%) of 531 in the ultrastaging group and 4 (0.7%) of 605 in the OSNA group (p=0.61). In the OSNA group, only 2 patients with negative sentinel lymph nodes had metastatic disease in the pelvic lymph nodes. By contrast, no patients with OSNA-positive sentinel lymph nodes had metastases in the pelvic lymph nodes. In the ultrastaging group, all patients with negative sentinel lymph nodes did not have metastatic disease in other pelvic lymph nodes.

CONCLUSIONS

OSNA assessment of sentinel lymph nodes was associated with a negative predictive value of 91% but poor reliability in detecting node metastases in non-sentinel pelvic lymph nodes. Of note, the ultrastaging protocol revealed higher sensitivity and more reliability in predicting pelvic non-sentinel lymph node status.

British Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice

Cervix cancer in many countries is declining and screening programmes and immunisation will reduce the incidence in the next few decades. This guideline attempts to cover management of invasive disease reflecting diagnosis and imaging including new imaging and sentinel lymph node biopsies. Smaller volume disease is usually managed surgically whereas advanced disease is treated with (chemo)- radiation. It also includes discussion of fertility sparing procedures. Practices are changing frequently for all aspects of care usually in attempts to reduce complications and improve quality of life. The management of advanced disease is treated by chemotherapy and the use of newer agents is also discussed. Other sections discuss specialist situations such as cancer in pregnancy, rare cervical tumours, late effects and supportive measures and fertility preserving approaches.

Diagnostic criteria of sentinel lymph node micrometastasis or macrometastasis based on tissue rinse liquid-based cytology in gynecological cancer

OBJECTIVE

This study aimed to establish intraoperative diagnostic criteria of sentinel lymph node (SLN) micro-/macrometastasis on the basis of tissue rinse liquid-based cytology (TRLBC) in gynecological cancer.

METHODS

We enrolled 214 patients with gynecological cancer who underwent rapid diagnosis of SLN metastasis on the basis of TRLBC from a total of 490 SLNs. For slides that were classified as positive for atypical cells on cytological inspection, we counted the number of clusters (an atypical cell mass consisted of three or more cells) and the number of single cells (an atypical cell other than clusters). Receiver operating characteristic (ROC) analysis was applied to determine the efficiency of predicting SLN micro-/macrometastasis.

RESULTS

On cytological inspection, 36 slides were classified as positive for atypical cells, while 21 slides (4.3%) were true positive, 15 (3.1%) were false positive, and 454 (92.6%) were true negative. There were no false negative results in this study. The area under the ROC curve for the number of cluster was superior to that for the number of single cells for distinguishing micro-/macrometastasis from negative/isolated tumor cells (0.86 vs. 0.67, P = 0.032). The optimum cut-off value of the number of clusters was 5 for distinguishing these two categories.

CONCLUSIONS

TRLBC is a highly sensitive alternative for detecting SLN metastasis as a rapid intraoperative diagnosis. Counting the number of atypical cell clusters might be useful for distinguishing micro-/macrometastasis from isolated tumor cells.

SPECT-CT visualization and biopsy of sentinel lymph nodes in patients with stage IAB-IIA cervical cancer

OBJECTIVE

To evaluate the diagnostic accuracy of sentinel lymph node (SLN) biopsy and to determine clinical significance of preoperative single-photon emission computed tomography/computed tomography (SPECT-CT).

METHODS

We retrospectively evaluate data and images of 55 women with stage IAB-IIA cervical cancer that underwent sentinel lymph node biopsy and subsequent lymph node dissection. ^99mTc-phytate (300 MBq) was injected submucosally in 4 points and SPECT-CT started 2 h after the injection. All lymph nodes (LN) that accumulated radiocolloids were regarded as sentinel. Next day after the mapping radical hysterectomy with complete pelvic and parametrial LN dissection and SLN biopsy were performed according to the institute protocol.

RESULTS

SPECT-CT identified SLNs in 51 of 55 patients. All SLNs were successfully detected during the surgery. The SLN mapping efficacy was 92.7%. LN metastases were diagnosed in 6/51 (11.8%) cases, including 2 patients with positive SLNs. Sensitivity, negative predictive value (NPV) and false-negative rate for SLN biopsy were as follows: 33.4%, 91.8% and 66.6%. In patients with unilateral SPECT-CT localization of SLNs, LN metastases were identified in 4 (20%) of 20 patients but SLN biopsy was false negative in all cases. In 31 women, SPECT-CT detected SLNs on both sides of the pelvis. In this group, regional LN metastases were diagnosed in 2 patients, and in both cases metastases were detected only in SLNs.

CONCLUSIONS

In women with SPECT-CT visualization of SLNs on both sides of the pelvis, SLN biopsy had high sensitivity and NPV. In patients with unilateral SLN localization, SLN biopsy cannot be used for the prediction of regional LN status.

Sentinel lymph node biopsy in muscle-invasive bladder cancer: single-center experience

OBJECTIVE

In this study, the validity of sentinel node biopsy procedure as our index test was assessed and compared with bilateral pelvic lymphadenectomy for staging and detecting the regional lymph nodes metastasis in patients with muscle-invasive bladder cancer (MIBC).

METHODS

Consecutive series of cases with T1-T4 urothelial MIBC were included. Following the injection of radiotracer, sentinel nodes were sought using a handheld gamma probe and all hot nodes were harvested. Bilateral pelvic lymphadenectomy was done for all patients following sentinel node biopsy. The tumor specimen, sentinel nodes, and excised lymph nodes were evaluated histopathologically. Same as the other midline tumors, detection rate and false negative rates were calculated using patient basis and side basis methods.

RESULTS

By evaluating each patient as a unit of analysis, sentinel nodes were detected in 35 of 41 patients (85%), 13/16 (81%) of the neoadjuvant chemotherapy (NAC) and 22/25 (88%) of the no-neoadjuvant chemotherapy (No-NAC) participants. The false negative rate was 3/7 (42%): 1/3 (33%) for NAC, and 2/4 (50%) for No-NAC patients. By evaluating each hemipelvis as a unit of analysis, sentinel nodes were detected in 53 of 82 hemipelves (65%), 19/32 (66%) of the NAC, and 34/50 (68%) of the No-NAC hemipelves. No false-negative result was found by assessing each hemipelvis as a unit of analysis.

CONCLUSIONS

Sentinel node biopsy is a feasible method for lymph node staging in MIBC, including patients with a history of NAC. To optimize the sensitivity, the decision regarding the lymphadenectomy is best to be based on the pathological status of sentinel node harvested from each hemipelvis separately as the unilateral finding of a sentinel node, does not rule out the possibility of metastatic involvement of contralateral pelvic lymph nodes.

Sentinel lymph node biopsy alone in the management of early cervical carcinoma

OBJECTIVE

Sentinel lymph node (SLN) biopsy aims to assess lymph node status with reduced surgical morbidity. The aim of the study was to determine the accuracy and safety of SLN biopsy in the management of early cervical carcinoma using a double technique (technetium-99m (Tc-99m) nanocolloid and methylene blue dye injection).

METHODS

This was a 10-year study from January 2009 to January 2019 that recruited 103 consecutive women undergoing surgery for early cervical carcinoma, FIGO 2009 stage IA1 (grade 3, and grade 2 with lymphovascular space invasion) to IB1 (<2 cm), at the West Kent Gynaecological Oncology Centre, Maidstone, UK. All patients were given the choice of pelvic node dissection and SLN mapping or SLN only. All patients elected to undergo SLN only. In total 97 patients had SLN mapping performed laparoscopically. We used the combined method (Tc-99m nanocolloid and/or methylene blue dye). All SLN routinely underwent ultrastaging.

RESULTS

At least one SLN was detected in all 103 patients, using at least one of the combined methods (Tc-99m nanocolloid or blue dye). Bilaterally SLN were removed in 85/103 women with an 83% bilateral detection rate. The median SLN count was 2.3 (range 1-6) nodes. Of 103 patients, 7 (6.7%) patients had lymph node involvement. There were no pelvic or para-aortic lymph node recurrences with a median follow-up of 53 (range 8-120) months. The specificity and negative predictive value of a negative SLN was 100%. None of our 103 patients reported lower extremity lymphedema.

CONCLUSION

In carefully selected patients with early cervical carcinoma, SLN biopsy alone appears to be a safe method for lymph node assessment of women undergoing surgical staging. Ultrastaging is an essential part of histologic examination of SLN.

Superparamagnetic iron oxide as a tracer for sentinel lymph node detection in uterine cancer: a pilot study

Sentinel lymph node (SLN) mapping using dye or radioisotopes has been performed in patients with uterine cancer. Superparamagnetic iron oxide (SPIO) can be handled safely and is taken up by lymph nodes (LNs); however, its efficacy in detecting SLNs in uterine cancer remains unknown. This pilot study evaluated the use of SPIO as a tracer for SLN detection in patients with uterine cancer. SPIO was injected into the uterine cervixes of 15 patients with uterine cancer scheduled for pelvic LN dissection. Magnetic resonance imaging (MRI) was performed preoperatively. Five patients also underwent radioisotope injection and single-photon emission computed tomography/computed tomography. Dissected LNs were stained with iron and examined pathologically. Of the radioisotope-positive LNs, 92% were also SPIO/MRI-positive. SPIO/MRI and iron staining were positively correlated. SLNs were identified by iron staining in 93% of cases. Iron staining was strongly positive in two of the five areas of LN metastasis; these were considered SLNs. Staining was negative or very weak in the other three areas and lymph flow disturbance was considered. SPIO and radioisotopes are taken up similarly by SLNs. SPIO/MRI and iron staining may thus be useful for detection of SLNs and diagnosis of LN metastasis in patients with uterine cancer.

Central Pathology Review in SENTIX, A Prospective Observational International Study on Sentinel Lymph Node Biopsy in Patients with Early-Stage Cervical Cancer (ENGOT-CX2)

The quality of pathological assessment is crucial for the safety of patients with cervical cancer if pelvic lymph node dissection is to be replaced by sentinel lymph node (SLN) biopsy. Central pathology review of SLN pathological ultrastaging was conducted in the prospective SENTIX/European Network of Gynaecological Oncological Trial (ENGOT)-CX2 study. All specimens from at least two patients per site were submitted for the central review. For cases with major or critical deviations, the sites were requested to submit all samples from all additional patients for second-round assessment. From the group of 300 patients, samples from 83 cases from 37 sites were reviewed in the first round. Minor, major, critical, and no deviations were identified in 28%, 19%, 14%, and 39% of cases, respectively. Samples from 26 patients were submitted for the second-round review, with only two major deviations found. In conclusion, a high rate of major or critical deviations was identified in the first round of the central pathology review (28% of samples). This reflects a substantial heterogeneity in current practice, despite trial protocol requirements. The importance of the central review conducted prospectively at the early phase of the trial is demonstrated by a substantial improvement of SLN ultrastaging quality in the second-round review.

Pathologic Protocols for Sentinel Lymph Nodes Ultrastaging in Cervical Cancer

CONTEXT.—

Ultrastaging of sentinel lymph nodes (SLNs) is a crucial aspect in the approach to SLN processing. No consensual protocol for pathologic ultrastaging has been approved by international societies to date.

OBJECTIVE.—

To provide a review of the ultrastaging protocol and all its aspects related to the processing of SLNs in patients with cervical cancer.

DATA SOURCES.—

In total, 127 publications reporting data from 9085 cases were identified in the literature. In 24% of studies, the information about SLN processing is entirely missing. No ultrastaging protocol was used in 7% of publications. When described, the differences in all aspects of SLN processing among the studies and institutions are substantial. This includes grossing of the SLN, which is not completely sliced and processed in almost 20% of studies. The reported protocols varied in all aspects of SLN processing, including the thickness of slices (range, 1-5 mm), the number of levels (range, 0-cut out until no tissue left), distance between the levels (range, 40-1000 μm), and number of sections per level (range, 1-5).

CONCLUSIONS.—

We found substantial differences in protocols used for SLN pathologic ultrastaging, which can impact sensitivity for detection of micrometastases and even small macrometastases. Since the involvement of pelvic lymph nodes is the most important negative prognostic factor, such profound discrepancies influence the referral of patients to adjuvant radiotherapy and could potentially cause treatment failure. It is urgent that international societies agree on a consensual protocol before SLN biopsy without pelvic lymphadenectomy is introduced into routine clinical practice.

Does small volume metastatic lymph node disease affect long-term prognosis in early cervical cancer?

INTRODUCTION

As sentinel lymph node biopsy is evolving to an accepted standard of care, clinicians are being faced with more frequent cases of small volume nodal metastatic disease. The objective of this study is to describe the management and to measure the effect on recurrence rates of nodal micrometastasis and isolated tumor cells in patients with early stage cervical cancer at two high-volume centers.

METHODS

We conducted a review of prospectively collected patients with surgically treated cervical cancer who were found to have micrometastasis or isolated tumor cells on ultrastaging of the sentinel lymph node. Our practice is to follow patients for ≥5 years post-operatively either at our center or another cancer center closer to home.

RESULTS

Nineteen patients with small volume nodal disease were identified between 2006 and 2018. Median follow-up was 62 months. Ten (53%) had nodal micrometastatic disease, while nine (47%) had isolated tumor cells detected in the sentinel lymph node. Seven patients (37%) underwent completion pelvic lymphadenectomy and four of them also had para-aortic lymphadenectomy; there were no positive non-sentinel lymph nodes. The majority (74%) received adjuvant treatment, mostly driven by tumor factors. We observed two recurrences. Recurrence-free survival was comparable with historical cohorts of node negative patients, and adjuvant treatment did not seem to impact the recurrence rate (p=0.5).

CONCLUSION

Given the uncertainties around the prognostic significance of small volume nodal disease in cervical cancer, a large proportion of patients receive adjuvant treatment. We found no positive non-sentinel lymph nodes, suggesting that pelvic lymphadenectomy or para-aortic lymphadenectomy may not be of benefit in patients diagnosed with small volume nodal metastases. Recurrence-free survival in this group did not seem to be affected. However, given the small numbers of patients and lack of level 1 evidence, decisions should be individualized in accordance with patient preferences and tumor factors.

[Sentinel lymph node biopsy in early-stage cervical cancer: current state of art]

Lymph node status is the most important prognostic factor of survival in women with early stage cervical cancer. Sentinel lymph node (SLN) biopsy is an accurate method for the assessment of lymph nodal involvement in early-stages cervical cancer and has been increasingly used instead of systematic pelvic lymph node dissection (PLND). Less-radical lymph node dissection decreases the associated morbidity of PLND, especially the risk of lower-leg lymphoedema, which affects severely patient quality of life. SLN biopsy allows nodes ultrastaging and provides supplementary histological information by increasing the detection of tumor low-volume (isolated tumors cells and micrometastases). Moreover, SLN biopsy provides accurate anatomical information on pelvic lymphatic drainage pathway by identifying nodes outside of routine lymphadenectomy areas. Selection of a population at low-risk of nodal metastasis, a minimal training, and simple rules may ensure a low false negative rate. Several studies have shown that SLN mapping in these patients is feasible, with excellent detection rates and sensitivity. Combined detection with technetium-99 and blue dye has been widely used but recently, there has been increasing interest in the use of fluorescent dies such as indocyanine green (ICG) which would improve SLN detection. Although recent international guidelines recommend performing SLN biopsy in addition to PLND, SLN biopsy alone is not the gold-standard yet due to lack of prospective evidence, especially on long-term oncological safety. Some points remain controversial such as the low accuracy of intraoperative SLN status assessment by frozen section and the impact of micrometastasis on prognostic. The prospective randomized clinical trial SENTICOL III will answer to these problematics.

Use of a Sentinel Lymph Node Biopsy Algorithm in a South African Population of Patients With Cervical Cancer and High Prevalence of Human Immunodeficiency Virus Infection

OBJECTIVES

Cervical cancer is common in resource-poor settings with high prevalence of tuberculosis, pelvic inflammatory disease, and human immunodeficiency virus (HIV) infection. There are no data regarding the sentinel lymph node (SLN) algorithm in these high-risk cancer populations. Our objectives were to establish the sensitivity, specificity, positive predictive value, and negative predictive value of the SLN algorithm in cervical cancer and to compare the detection rate of indocyanine green (ICG) versus blue dye versus technetium Tc 99m nanocolloid (Tc).

METHODS

This prospective study was conducted at the University of Pretoria. Tc-nanocolloid tracer, ICG dye, and methylene blue (MB) were used to detect SLNs. Pathological ultrastaging was performed on hematoxylin-eosin- negative nodes.

RESULTS

Results of 72 women were analyzed. The mean age was 47.2 years, 5.5% had a history of tuberculosis, 18.1% had pelvic inflammatory disease, and 65.3% were HIV positive. The SLN detection rate was 65.3%. Detection rate of MB was 56.9%; Tc, 69.4%; ICG, 87.5%; and the combination of MB and Tc, 91.7%. Pelvic nodal metastases occurred in 26.4%. The sensitivity, specificity, negative predictive value, and positive predictive value of SLN biopsy were 85.7%, 100%, 100%, and 98.33%, respectively. The false-negative rate was 14.3%, and it was 0% if the algorithm was applied.

CONCLUSIONS

The SLN algorithm is a feasible option for use in cervical cancer women with a high prevalence of HIV infection. The detection rate is generally lower, but in select subgroups of women, it was comparable to that reported elsewhere. This is the first report of the use of SLN biopsy in a substantial group of HIV-infected women.

Preoperative prediction of pelvic lymph nodes metastasis in early-stage cervical cancer using radiomics nomogram developed based on T2-weighted MRI and diffusion-weighted imaging

OBJECTIVE

To explore an MRI-based radiomics nomogram for preoperatively predicting of pelvic lymph node (PLN) metastasis in patients with early-stage cervical cancer (ECC).

METHODS

Ninety-six patients with ECC were enrolled in this study. All patients underwent T2WI and DWI scans before radical hysterectomy with PLN dissection surgery. Radiomics features extracted from T2WI and DWI were selected by least absolute shrinkage and selection operation regression for further radimoics signature calculation. The discrimination of this radiomics signature for PLN metastasis was then assessed using a support vector machine (SVM) model. Subsequently, a radiomics nomogram was constructed based on the radiomics signature and clinicopathologic risk factors using a multivariable logistic regression method. The performance of the radiomics nomogram for the preoperative prediction of PLN metastasis was evaluated for discrimination and calibration.

RESULTS

The radiomics signatures demonstrated a good discrimination for PLN metastasis. A radiomics signature derived from joint T2WI and DWI yielded higher AUC than the signatures derived from T2WI or DWI alone. The radiomics nomogram integrating the radiomics signature with clinicopathologic risk factors showed a significant improvement over the nomogram based only on clinicopathologic risk factors in the primary cohort(C-index, 0.893 vs. 0.616; P = 4.311×10^-5) and validation cohort(C-index, 0.922 vs. 0.799; P = 3.412 ×10^-2).The calibration curves also showed good agreement.

CONCLUSIONS

The radiomics nomogram based on joint T2WI and DWI demonstrated an improved prediction ability for PLN metastasis in ECC. This noninvasive and convenient tool may be used to facilitate preoperative identification of PLN metastasis in patients with ECC.

Sentinel lymph node mapping using indocyanine green in patients with uterine and cervical neoplasms: restrictions of the method

Purpose

To establish the surgical, demographic and histopathological factors associated with inaccurate sentinel lymph nodes (SLNs) identification using indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging in uterine and cervical neoplasms during both open and laparoscopic surgery.

Methods

We reviewed patients with atypical endometrial hyperplasia (AEH), clinical stage I and II cervical cancer or uterine malignancies who underwent primary surgery with SLN mapping between September 2015 and January 2018. An analysis of patients’ demographics, tumor factors and surgical approach was conducted. Bilateral and overall detection rates were calculated and univariate analysis was performed to estimate factors associated with failed SLN mapping.

Results

A total of 32 patients with uterine and cervical neoplasms were included in the study. The overall detection rate of the SLN was 84% and bilateral detection rate was 75%. There were no statistically relevant differences in overall and bilateral SLN detection rates by BMI, surgical approach or age. Regarding endometrial cancer, there were no differences in SLN detection rates when comparing tumor grade, histology nor myometrial invasion. For SLN detection failure, only the presence of metastatic lymph nodes and lack of surgical experience significantly increased the disability to detect SLNs (p = 0.03, p = 0.04, respectively).

Conclusions

SLN mapping technique using NIR fluorescence imaging with ICG appears to be accurate method in most of the patients with cervical or endometrial carcinoma, regardless of demographic characteristics, tumor-related features and surgical approach. Surgeons’ expertise in that field allows obtaining excellent detection rates.

Combinative evaluation of primary tumor and lymph nodes in predicting pelvic lymphatic metastasis in early-stage cervical cancer: A multiparametric PET-CT study

PURPOSE

The purpose of this study is to investigate the value of combining tumor and pelvic lymph node (PLN) characteristics on PET-CT in predicting PLN metastasis of patients with early-stage cervical cancer, specifically to further reduce the false-negative cases of diagnosis.

METHODS

The [18F] FDG PET-CT imaging data of 394 patients who were newly diagnosed with cervical cancer (FIGO stage, Ia-IIa) were retrospectively studied. We measured size, total lesion glycolysis (TLG) of tumor, metabolic tumor volume (MTV), maximum and mean standardized uptake value (SUVmax, SUVmean) of tumor and lymph node (LN). Diagnostic efficiency was evaluated using receiver operator characteristic (ROC) curve. We also investigated additional CT diagnosis information in PET-negative cases.

RESULTS

Our results indicated both lymph node and tumor parameters were independent risk factors for lymphatic metastasis in early-stage cervical cancer. The diagnosis based on above meaningful parameters, we name it 'combination diagnosis', offered significantly higher predictive value than that based on SUV measurement alone, which the values of AUC were 0.842 and 0.784 respectively (P < 0.05). In PET-negative cases, we also found that tumor TLG, suspicious LN in lymphatic drainage pathway, long/short axis of LN ≤ 2, heterogeneity of LN significantly associated with PLN metastasis. ROC analysis showed combination diagnosis of all these parameters above produced an AUC value of 0.859 (P < 0.05, 95% CI, 0.811-0.899), which was significantly higher than either using tumor TLG alone (AUC = 0.622, Z = 3.919, P < 0.05) or indices derived from CT alone (AUC = 0.727, 0.668, 0.695. Z = 3.620, 5.356, 3.696, P < 0.05).

CONCLUSIONS

We proposed a combination diagnosis method that can better predict PLN metastasis for patients with early-stage cervical cancer. In PET-negative cases, combination diagnosis of TLG of tumor and CT indicators also produced improved prediction by reducing false-negative cases of diagnosis. This combination diagnosis approach has significant implications in cervical cancer patient management and treatment planning.

Impact of micrometastasis or isolated tumor cells on recurrence and survival in patients with early cervical cancer: SENTICOL Trial

Objectives

The aim of this study was to evaluate the impact of micrometastasis and isolated tumor cells on disease recurrence in patients with early-stage cervical cancer.

Methods

We included patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA1 with lymphvascular space invasion, stage IA2, and IB1 who participated in the SENTICOL1 trial. A centralized histologic analysis with re-reading and ultrastaging was performed 3 months after surgery and treatment was not impacted by findings from our study. Patients were followed for 3 years and outcomes were compared according to prognostic factors.

Results

A total of 139 patients were included and 13 recurrences were found. There were two recurrences in patients with positive sentinel lymph node (SLN) (one macrometastases and one micrometastases) and 11 recurrences in patients with negative lymph nodes (sentinel or non-sentinel). Among patients with positive SLN for micrometastases there was only one recurrence. No patient with isolated tumor cells on their lymph nodes experienced a recurrence. There was a significant decrease in disease-free survival in patients aged >50 years (p = 0.01).

Conclusion

Evidence of micrometastasis or isolated tumor cells in the SLN of untreated patients with early cervical cancer in the SENTICOL1 trial did not impact progression-free survival.

Present status of sentinel lymph node biopsy in cervical cancer

Cervical cancer is the fourth most common cancer in women, and seventh overall. This disease represents a medical, economic and social burden. In early FIGO stage patients (IA, IB1 and IIA1), nodal involvement is the most important prognostic factor. Imaging evaluation of nodal metastasis is of limited value. In order to determine lymph node involvement, allow loco-regional control of the disease, define the need for adjuvant radiotherapy and improve survival, standard surgery for early disease is radical hysterectomy with systematic pelvic lymphadenectomy. However, this surgical treatment has risks and complications: longer operative time, larger blood loss, neurovascular or ureteral injury, lower-limb lymphedema, symptomatic lymphocysts, hydronephrosis. A method that allows to define the presence of regional metastasis with less morbidity and equal or greater precision is particularly relevant. The use of the sentinel lymph node biopsy is intended to reach that purpose. The present study reviews recent literature on the role of sentinel lymph node biopsy in cervical cancer, analyzing its indications and contraindications, injection and detection techniques, tracers used, surgical and pathological approaches and its applicability in up-to-date clinical practice.

Pathology Consultation for the Gynecologic Oncologist: What the Surgeon Wants to Know

CONTEXT.—

Clinical management of gynecologic malignancies is often multimodal. Pathologic diagnoses, patient-related factors, and disease-related factors all contribute to clinical decision making.

OBJECTIVE.—

To review the role of surgical pathology in treatment planning among women with gynecologic malignancies.

DATA SOURCES.—

An analysis of relevant literature (PubMed Plus [National Center for Biotechnology Information, Bethesda, Maryland] and Medline [Ovid, New York, New York]) and the authors' clinical practice experience were used.

CONCLUSIONS.—

Pathologic evaluation of gynecologic malignancies with traditional histopathology, assessment of genetic alterations, and identification of tumor biomarkers are critical to traditional treatment planning as well as for ongoing clinical trials.

Selective biopsy of the sentinel node in cancer of cervix: Experience in validation phase

BACKGROUND AND OBJECTIVE

Sentinel lymph node biopsy (SLNB) was created to reduce the morbidity associated with pelvic lymphadenectomy in the early stages of cervical cancer (CC), preserving its prognostic information. The goal is to assess the diagnostic validity of SLNB in CC in initial stages (IA1 with lymphovascular infiltration (LVI) +, IA2, IB1 and IIA1), thus avoiding unnecessary lymphadenectomies in many of the cases.

MATERIAL AND METHOD

From January 2012 to April 2017, 23 patients with initial stages of CC were included in a cross-sectional study to evaluate the effectiveness of the SLNB in CC with a mixed technique of cervical injection of ^99mTc-nanocolloid of albumin and methylene blue, using combined planar lymphoscintigraphy with multimodality SPECT/CT image and subsequent removal of the sentinel node (SN) by laparoscopy.

RESULTS

The detection rate of SLNB with the mixed technique was 95.65%, with a negative predictive value (NPV) of 95.45% and sensitivity (S) of 100% in the case of bilateral drainage. The mean of excised SN was 3 (range 1-5). The bilateral detection rate in laparoscopy was 85.35%. The concordance between SPECT/CT and laparoscopy for the number and bilaterality of the SN using the Pearson coefficient was r = 0.727 and r = 0.833, respectively; p = 0.01. We only found one SN with a deferred result of micrometástasis and one false negative was detected.

CONCLUSIONS

SLNB in CC using a mixed technique has a high detection and bilateral drainage rate, but S is still low if we include cases of unilateral drainage. A greater number of cases and the development of intraoperative ultrastaging could increase the S of the technique and to reduce the number of false negatives.