Laparoscopic sentinel node mapping in early-stage cervical cancer

Sentinel lymph node biopsy in gynaecological cancers: the importance of micrometastases in cervical cancer

Lymph node metastases is a recognized prognostic factor in women with cervical cancer. However, there is a need for consensual histological definition of micrometastases in this indication which could give rise to a classification system similar to that used in breast cancer. We thus conducted a MEDLINE and EMBASE database analysis to evaluate the concept of micrometastases in cervical cancer. Retrospective studies place the incidence of micrometastasis between 1.5 and 15% depending on the technique used to evaluate lymph node status. Sentinel lymph node biopsy with serial sectioning and immunohistochemical analysis appears to be the most accurate micrometastases detection technique. The value of RT-PCR in micrometastases detection remains to be clarified by further studies. From a clinical view point, few data are available to support the prognostic relevance of micrometastases. However, case control and longitudinal studies have underlined the risk of recurrence in women with micrometastases, raising the issue of a revision of adjuvant therapy indications in this specific population.

Lymphatic mapping and sentinel node biopsy in gynecological cancers: a critical review of the literature

Although it does not have a long history of sentinel node evaluation (SLN) in female genital system cancers, there is a growing number of promising study results, despite the presence of some aspects that need to be considered and developed. It has been most commonly used in vulvar and uterine cervivcal cancer in gynecological oncology. According to these studies, almost all of which are prospective, particularly in cases where Technetium-labeled nanocolloid is used, sentinel node detection rate sensitivity and specificity has been reported to be 100%, except for a few cases. In the studies on cervical cancer, sentinel node detection rates have been reported around 80–86%, a little lower than those in vulva cancer, and negative predictive value has been reported about 99%. It is relatively new in endometrial cancer, where its detection rate varies between 50 and 80%. Studies about vulvar melanoma and vaginal cancers are generally case reports. Although it has not been supported with multicenter randomized and controlled studies including larger case series, study results reported by various centers around the world are harmonious and mutually supportive particularly in vulva cancer, and cervix cancer. Even though it does not seem possible to replace the traditional approaches in these two cancers, it is still a serious alternative for the future. We believe that it is important to increase and support the studies that will strengthen the weaknesses of the method, among which there are detection of micrometastases and increasing detection rates, and render it usable in routine clinical practice.

Advances in Surgical Treatment of Cervical Cancer

Radical hysterectomy has been the standard surgical treatment for cervical cancer, achieving a good survival outcome. However, it is a major operation that has considerable potential long-term morbidity. With good prognosis achieved in most early cervical cancers, there is a trend towards more emphasis on maintaining good quality of life post-treatment. Many women diagnosed with cervical cancer are young, and fertility-sparing surgery such as trachelectomy would preserve their reproductive potential. Minimally invasive surgery, such as laparoscopic radical hysterectomy, can potentially improve post-operative recovery and cosmetic results while maintaining oncological safety. Sentinel lymph nodes assessment can minimize unnecessary systematic pelvic lymphadenectomy. Radicality of the hysterectomy may also be reduced in selected individuals with good prognostic factors, thus minimizing long-term pelvic floor dysfunction. This review aims to give a broad overview of the current status of these new trends in surgical management for cervical cancer.

A prospective study of sentinel lymph node status and parametrial involvement in patients with small tumour volume cervical cancer

OBJECTIVE

The purpose of prospective study is to determine incidence and distribution of pelvic lymph node (LN) involvement, sentinel lymph node (SLN) involvement and pathologic parametrial involvement (PI) in stage Ia2 and small Ib1 cervical cancer. PI is defined as positive parametrial LN or discontinuous malignant cells in parametrium.

METHODS

After radical abdominal hysterectomy, 158 women patients were stratified into two groups based on tumour size: In Group 1 (91 women) tumours were less than 20 mm and less than half of stromal invasion. In Group 2 (67 women) tumours were between 20 and 30 mm and infiltration was not more than 2/3 of cervical stroma.

RESULTS

In Group 1 positive SLN was detected in 11(12.1%) patients; of these, 3 (27.3%) had positive PI. In 80 women with negative SLN PI was not detected. In Group 2 positive SLN was detected in 14 (20.9%) patients: PI was found in four (28.6%) of these 14 patients. No PI was detected in 53 women with negative SLN.

CONCLUSION

No PI was observed in early cervical cancer if SLNs were negative. However, we found PI in 28.0% of women with positive SLN. Statistical analysis revealed that the results were highly significant. Based on our results, radical removal of parametrium in SLN negative patients is questionable.

Frequency and prognostic significance of HPV DNA in sentinel lymph nodes of patients with cervical cancer

BACKGROUND

It has been suggested that histologically undetectable or 'occult' metastases in the lymphatic system could explain some recurrences. HPV DNA screening by means of the polymerase chain reaction (PCR) has been proposed as a method to detect occult metastases. This study was designed to determine the frequency of HPV DNA detection by PCR in sentinel lymph node (SN), and its relation to the clinical characteristics and outcome of women with cervical cancer.

PATIENTS AND METHODS

The primary cervical tumor and SN were tested for HPV DNA by means of PCR in 59 patients.

RESULTS

Fifteen (25.4%) of the 59 women undergoing the SN procedure had an involved SN. HPV DNA was more frequent in positive SN than in negative SN (P < 0.0001). Seven patients had a recurrence, after a mean delay of 17 months (range: 10-26). One of seven patients with a recurrence had an involved SN. HPV DNA was detected in an SN of one of seven patients with recurrence and nine (19.5%) of 46 patients without recurrence (not significant).

CONCLUSION

In women with cervical cancer, HPV DNA screening of sentinel nodes might help to identify patients at risk of lymph node metastases and recurrence.

Where to look for the sentinel lymph node in cervical cancer

OBJECTIVE

The aim of this study was to analyze lymphatic spread to pelvic, parametrial, and paraaortic lymph nodes in patients with cervical cancer.

STUDY DESIGN

We reviewed 619 patients with invasive cervical cancer treated by radical abdominal hysterectomy and systematic pelvic or pelvic and paraaortic lymphadenectomy between 1971 and 2005. The present study included 61 patients with one positive lymph node (10%) and 59 patients with two positive lymph nodes (10%) at any location.

RESULTS

The external iliac (43%) and obturator (26%) regions and the parametrium (21%) were the most commonly involved pelvic lymph node sites with solitary metastases. Isolated metastases to common iliac, presacral (internal iliac), and paraaortic nodes were found in 7%, 1%, and 1% of patients, respectively. Patients with 2 positive nodes had 1 parametrial and 1 pelvic node involved (32%), 2 ipsilateral positive nodes (31%), 1 positive lymph node on both sides of the pelvis (27%), and 2 positive nodes within the parametrium (10%).

CONCLUSIONS

In cervical cancer patients with only 1 positive lymph node, this node is most frequently located within the external iliac and obturator regions and the parametrium. Sentinel node identification should primarily address these lymph node sites. If 1 positive lymph node is found, further metastases are unpredictable within pelvic and parametrial lymph node sites. Paraaortic spread without pelvic node involvement is rare.

Sentinel lymph node detection in early stage uterine cervix carcinoma: A systematic review

OBJECTIVE

The aim of this study was to systematically review the diagnostic performance of Sentinel Node (SN) detection for assessing the nodal status in early stage cervical carcinoma, and to determine which technique (using blue dye, Technetium-99m colloid (99mTc), or the combined method) had the highest success rate in terms of detection rate and sensitivity.

METHODS

A comprehensive computer literature search of English language studies in human subjects on Sentinel Node procedures was performed in MEDLINE and EMBASE databases up to July 2006. For each article two reviewers independently performed a methodological qualitative analysis and data extraction using a standard form. Pooled values of the SN detection rate and pooled sensitivity values of the SN procedure are presented with a 95% confidence interval (95% CI) for the three different SN detection techniques.

RESULTS

We identified 98 articles, and 23 met the inclusion criteria, comprising a total of 842 patients. Ultimately, 12 studies used the combined technique with a sensitivity of 92% (95% CI: 84-98%). Five studies used 99mTc-colloid, with a pooled sensitivity of 92% (95% CI: 79-98%; p=0.71 vs. combined technique), and four used blue dye with a pooled sensitivity of 81% (67-92%, p=0.17 vs. combined technique). The SN detection rate was highest for the combined technique: 97% (95% CI: 95-98%), vs. 84% for blue dye (95% CI: 79-89%; p<0.0001), and 88% (95% CI: 82-92%, p=0.0018) for 99mTc colloid.

CONCLUSION

SN biopsy has the highest SN detection rate when 99mTc is used in combination with blue dye (97%), and a sensitivity of 92%. Hence, according to the present evidence in literature the combination of 99mTc and a blue dye for SN biopsy in patients with early stage cervical cancer is a reliable method to detect lymph node metastases in early stage cervical cancer.

The sentinel concept in patients with cervical cancer

The sentinel concept for patients with early cervical cancer has a high potential for decreasing morbidity and for increasing oncologic safety. The detection rate with technetium-labeling or a combination with blue dye varies between 84% and 92%. Sensitivity and negative predictive value depend on tumor size: the smaller the tumor, the higher the validity of the technique. Detection of circulating tumor cells in the sentinel node using HPVmRNA as marker may have a good prognostic value. Currently the sentinel concept should only be used in clinical studies before its validity has been proved.

Sentinel lymph node procedure followed by laparoscopic pelvic and paraaortic lymphadenectomy in women with IB2-II cervical cancer

OBJECTIVE

To evaluate the contribution of the sentinel node (SN) procedure followed by pelvic and paraaortic lymphadenectomy to determine lymph node status in women with locally advanced cervical cancer.

PATIENTS AND METHODS

A total of 21 women with locally advanced cervical cancer underwent a first laparoscopic SN procedure and pelvic and paraaortic lymphadenectomy followed by concurrent chemoradiotherapy (CCR). Laparoscopic radical hysterectomy was performed after CCR when the pelvic and paraaortic nodes were not involved.

RESULTS

SNs were detected by means of lymphoscintigraphy in 10 women (47.6%) and intra-operatively in 14 women (66.6%). Of the latter 14 patients, 9 (64%) had an involved SN and 1 of the remaining 5 had pelvic non-SN metastases. The SN false-negative rate was 10%. At final histology, 13 of the 21 women (62%) had lymph node metastases. The total number of recovered pelvic non-SNs was 262, and 10 nodes in 8 women were involved. The total number of paraaortic non-SNs was 255, and 2 nodes in 2 women were involved.

CONCLUSION

This study shows the poor correlation between pre-operative lymphoscintigraphy and surgical SN mapping in women with locally advanced cervical cancer. A high proportion of women had SN metastases, underlining the importance of multiple sectioning and immunohistochemical staining of SNs.

Up-to-date management of lymph node metastasis and the role of tailored lymphadenectomy in cervical cancer

Lymph node metastasis (LNM), together with parametrial infiltration and positive surgical margins, is an important prognostic factor in cervical cancer. The incidence of LNM increases with International Federation of Gynecology and Obstetrics (FIGO) stage, with rates being 12%-22% in stage Ib, 10%-27% in stage IIa, and 34%-43% in stage IIb. Radical hysterectomy and pelvic lymphadenectomy are widely used treatments for early-stage (Ib to IIa) cervical cancer, as well as for stage IIb disease, in some European and Asian countries. In several types of cancer, the therapeutic significance of systematic lymphadenectomy has been demonstrated by recent reports showing that a larger number of lymph nodes removed relates to better survival. In cervical cancer, a significant relationship between the number of lymph nodes removed and disease-free survival has been reported in node-positive patients. Preoperative evaluation of nodal status with computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) imaging techniques is not sensitive enough to replace the histological examination of dissected nodes. The sentinel node procedure may be an alternative to systematic lymphadenectomy to reduce treatment-related morbidity, but more work on this is needed. Although the presence of LNM does not change FIGO staging, it will modulate postoperative therapy. Progression-free and overall survivals were significantly improved by the addition of chemotherapy to adjuvant radiotherapy after radical hysterectomy and lymphadenectomy. Adjuvant chemotherapy combined solely with radical hysterectomy and systematic lymphadenectomy may also provide a survival benefit. In conclusion, efforts to establish more tailored surgical strategies, by introducing advanced imaging technologies and molecular diagnostic procedures, are needed for cervical cancer.

Laparoscopic sentinel lymph node mapping for cervix cancer--a detailed evaluation and time analysis

OBJECTIVE

To provide data from a US center on laparoscopic (LSC) approach to sentinel lymph node (SLN) detection in cervix cancer with detailed time analysis.

METHODS

This prospective trial enrolled patients with stage IA2-IIA cervix cancer undergoing primary radical surgery. Tc-99 radiocolloid was injected the morning of surgery, followed by hybrid SPECT/CT lymphoscintigraphy. Blue dye injection occurred just prior to incision. After bilateral LSC SLN detection, all patients received complete LSC pelvic lymphadenectomy. Institutional SLN protocol was followed for frozen section, hematoxylin and eosin, and cytokeratin staining.

RESULTS

Between December 2003 and February 2006, 20 enrolled patients received 9 LSC-assisted radical vaginal hysterectomies, 7 radical abdominal hysterectomies, 2 LSC-assisted radical vaginal trachelectomies, and 2 LSC lymphadenectomies alone (secondary to positive lymph nodes). Mean tumor size was 2.5 cm. Nineteen percent of the 64 SLNs were found in unusual sites, including common iliac (11%), presacral (5%) and para-aortic (3%). The negative predictive value was 100%. The combined technique detected SLNs bilaterally in all patients. If blue dye alone was used, this rate would have dropped to 67.5% and was negatively correlated with elapsed surgical time (-0.7; p=0.002). The ability to visualize blue SLNs remained steady for 30 min and was completely gone by 50 min.

CONCLUSIONS

Laparoscopic SLN mapping can be newly introduced into gynecologic oncology centers with high detection rates and negative predictive values. The visualization of blue dye in SLNs is transient, and this negative time correlation may explain the previously reported inferior detection rates with this technique. CLINICAL TRIAL REGISTRATION.: ClinicalTrials.gov, http://www.clinicaltrials.gov, NCT 00205010.

Laparoscopic Sentinel Node Biopsy in Cervical Cancer Using a Combined Detection: 5–Years Experience

BACKGROUND

To evaluate the feasibility after 5 years experience of a laparoscopic sentinel node (SN) procedure with combined radioisotopic and patent blue labeling in patients with cervical cancer.

METHODS

Sixty-seven patients (median age 48.9 years) with cervical cancer underwent a laparoscopic SN procedure using an endoscopic gamma probe, after both radioactive and patent blue injections. After the procedure, all the patients underwent complete laparoscopic pelvic/para-aortic lymphadenectomy.

RESULTS

At least one SN was identified in 57 patients (85.1%). According to the Stage, the SN identification rate was 91.2% in early-stage cervical cancer and 78.5% in locally advanced cervical cancer. The mean number of SN was 2.3 per patient (range 1-5). A total of 129 SNs were removed. Lymph node metastasis involvement was identified in the 20 SNs (15.5%) from 14 patients (24.6%). Nine of the 14 patients had at least one macrometastases, three patients presented micrometastases in H&S, and two patients presented isolated single cells. Six patients presented a pelvic non-SN involvement including two patients whose SNs were uninvolved. The false-negative SNs rate was 12.5% (two patients out of 16). Both patients have locally advanced cervical cancer.

CONCLUSION

This study confirms that laparoscopic SN detection with a combination of radiocolloid and patent blue is accurate in patients with early cervical cancer to assess pelvic lymph node status.

Sentinel lymph node detection using methylene blue in patients with early stage cervical cancer

OBJECTIVE

To evaluate the feasibility of sentinel lymph node (SLN) detection in patients with cervical cancer using the low-cost methylene blue dye and to optimize the application procedure.

PATIENTS AND METHODS

Patients with stage Ib(1)-IIa cervical cancer and subjected to abdominal radical abdominal hysterectomy and pelvic lymphadenectomy were enrolled. Methylene blue, 2-4 ml, was injected into the cervical peritumoral area in 77 cases (4 ml patent blue in the other four cases) 10-360 min before the incision, and surgically removed lymph nodes were examined for the blue lymph nodes that were considered as SLNs.

RESULTS

High SLN detection rate was successfully achieved when 4 ml of methylene blue was applied (93.9%, 46/49). Bilaterally SLN detection rate was significantly higher (78.1% vs. 47.1% P=0.027) in cases when the timing of application was more than 60 min before surgery than those with timing no more than 30 min. The blue color of methylene blue-stained SLNs sustained both in vivo and ex vivo, compared with the gradually faded blue color of patent blue that detected in 3 of 4 cases unilaterally. In the total of 112 dissected sides, the most common location of SLNs was the obturator basin (65.2%, 73/112), followed by external iliac area (30.4%, 34/112) and internal iliac area (26.8%, 30/112). Three patients who gave false negative results all had enlarged nodes.

CONCLUSION

Methylene blue is an effective tracer to detect SLNs in patients with early stage cervical cancer. The ideal dose and timing of methylene blue application are 4 ml and 60-90 min prior surgery, respectively.

Sentinel lymph nodes in early stage cervical cancer

OBJECTIVES

Lymph node status is the most important prognostic factor in cervical cancer. Sentinel lymph node (SLN) procedures have been purported to reduce peri- and postoperative morbidity and operative time.

METHODS

All patients with surgically managed clinical FIGO stage IA/B1 cervical cancer underwent SLN followed by pelvic lymphadenectomy with technetium+/-lymphazurin from April 2004 to April 2006. 0.1-0.2 mci of filtered sulfur colloid technetium was injected submucosally into 4 quadrants of the exocervix. Lymphazurin (4cc) was only used if technetium was unsuccessful in identifying bilateral sentinel lymph nodes. Serial microsections at 5 microm intervals were performed and stained intraoperatively. Complete pelvic node dissections were performed in all patients.

RESULTS

Forty-two patients underwent SLN, prior to full pelvic lymphadenectomy. Thirty-nine patients were included for the purposes of this study. The incidence in detecting at least one sentinel node was 98% per patient, and 85% per side. Identification of bilateral sentinel lymph nodes was successful in 28 cases (72%). The median number of SLN/side was 2. Three patients were found to have metastatic tumor to lymph nodes. No false negatives were identified. No adverse effects were noted.

CONCLUSIONS

SLN biopsy in cervical cancer is feasible to do, with a low false negative rate. We believe SLN should be evaluated per side and not per patient, that a pelvic lymphadenectomy is otherwise required. By following this protocol, the false negative rate can be minimized. The combined reported FN rate in the literature is 1.8%. If our definition is applied, the majority of reported false negative SLN is not actual false negatives.

Dilution of dye improves parametrial SLN detection in patients with cervical cancer

OBJECTIVE

Aim of this study to improve the detection rate of parametrial sentinel nodes in patients with early cervical cancer by using a new dosage of blue dye in a randomized trial.

METHODS

Standard labelling volume of 4 ml Patent Blue was compared to 2 ml Patent Blue diluted with 8 ml NaCl 0.9% in 60 patients using a randomized protocol. Tc-99 was not applied in any patient. All patients underwent open lymphadenectomy.

RESULTS

In each arm 30 patients were enrolled. Overall detection rate of sentinel nodes was 93.3%. Both groups did not differ with regard to patient's age, BMI, tumor stage, number of lymph nodes harvested, number of sentinel nodes detected and detection rate. Significantly more patients with parametrial sentinel nodes were detected in the diluted protocol (37.0% vs. 10.3%) which is due to the lateral part of the cardinal ligament (29.6% vs. 6.9%).

CONCLUSION

In our study overall detection of sentinel nodes using a dye was high. The diluted solution of Patent Blue led to a higher detection rate of parametrial sentinel nodes. These findings might help explain the discrepancy between the high reported rate of parametrial lymph nodes in anatomical studies compared with the low rates in clinical sentinel series.

Lymphatic mapping and sentinel node biopsy in women with high-risk endometrial cancer

OBJECTIVE

To evaluate fundal injection of blue dye and radiocolloid for lymphatic mapping and sentinel node identification in women with high-risk endometrial cancer.

METHODS

At laparotomy, 18 women with high-risk endometrial cancer had isosulfan blue and technitium-99 radiocolloid injected into the uterine fundus subserosally. Sentinel nodes were then identified either by direct observation of blue dye, by radioactive counts using a handheld gamma counter, or by a combination of both methods. The number and location of sentinel node(s) were recorded and compared with the final lymph node specimens after hysterectomy and selective lymphadenectomy.

RESULTS

A sentinel node was identified in only 8 (45%) of the cases. Four patients had sentinel nodes only in the pelvis, 2 had sentinel nodes in the pelvis and above the bifurcation of the aorta, and 2 patients had sentinel nodes above the bifurcation of the aorta only. Seven (88%) patients had unilateral drainage of dye and the radiocolloid; the other patient had bilateral drainage. No patients had metastatic disease to sentinel or nonsentinel lymph nodes.

CONCLUSIONS

Subserosal fundal injection of blue dye and the radiocolloid is a poor technique for identifying sentinel lymph nodes in patients with high-risk endometrial cancer.

Less radical fertility-sparing surgery than radical trachelectomy in early cervical cancer

The purpose of this pilot study was to determine feasibility and safety of a novel and less radical fertility-preserving surgery; laparoscopic lymphadenectomy with sentinel lymph node identification (SLNI) followed by large cone or simple trachelectomy. Obstetrical and oncologic outcomes were evaluated. Twenty-six patients (6-IA2, 20-IB1) selected on basis of favorable cervical tumor characteristics and the desire to maintain fertility underwent laparoscopic SLNI, frozen section (FS), and a complete pelvic lymphadenectomy as first step of treatment. All of nodes were submitted for microscopic evaluation (sentinel nodes for ultramicrostaging). After a 7-day interval, large cone or simple vaginal trachelectomy was performed in patients with negative nodes. The average of sentinel nodes per side was 1.50 and the average of total nodes was 28.0. Four FS were positive (15.4%). In these cases, Wertheim radical hysterectomy type III was immediately performed. We had no false-negative SLN neither on FS nor on final pathology assessment. Median follow-up was 49 months (18–84). One central recurrence (isthmic part of uterus) was observed 14 months after surgery. This patient was treated with radical chemoradiotherapy, and there was no evidence of the disease 36 months after treatment. Fifteen women planned pregnancy, 11 women became pregnant (15 pregnancies), and 7 women delivered eight children (one in 24 weeks, one in 34 weeks, one in 36 weeks, and five between 37 and 39 weeks). We conclude that lymphatic mapping and SLNI improves safety in this fertility sparing surgery. Large cone or simple trachelectomy combined with laparoscopic pelvic lymphadenectomy can be a feasible method with a high successful pregnancy rate

Negative sentinel lymph node accurately predicts negative status of pelvic lymph nodes in uterine cervix carcinoma

OBJECTIVE

The significance of negative sentinel lymph nodes (SLN) is important in the staging and treatment of melanoma and a few other cancers, but is controversial in uterine cervix carcinoma. Our study was aimed at correlating the SLN status in cervical carcinoma with non-sentinel lymph nodes (non-SLN), in a uniform and well controlled population.

METHODS

This study includes 36 patients with stage I and IIA cervical carcinoma and bilaterally negative SLN on final pathology. SLN were identified using blue dye and radioisotopic techniques. Frozen section examination was performed for all SLN; the rest of the tissue was formalin fixed and paraffin embedded. The protocol used for SLN was also applied for non-SLN. For each block, six 4-micro m thick sections were cut at 40 micro m intervals and stained with H and E; an additional section taken between the 3rd and 4th levels was imunostained using AE1/AE3 cytokeratin.

RESULTS

The mean age for the study population was 39 years (range 25-76); the number of SLN ranged from 2 to 6 (mean 2.7) and the non-SLN from 8 to 49 (mean 23) per case. No metastasis was found in any SLN and non-SLN by step sections and IHC.

CONCLUSION

Our study demonstrates that bilaterally negative SLN on final pathology accurately predict the absence of metastases in non-SLN in cervical carcinoma. If confirmed by larger trials, these results may influence the clinical management of early cervical cancer.

Sentinel node identification in cervical cancer patients undergoing transperitoneal radical hysterectomy: a study of 100 cases

We investigated the feasibility of sentinel lymph node (SN) identification using radioisotopic lymphatic mapping with technetium-99m-labeled nanocolloid and blue-dye injection in 100 patients with early cervical cancer (FIGO stage IB1 in 58, IB2 in 18, and IIA in 24) undergoing radical hysterectomy with pelvic lymphadenectomy. At least one SN was found in 84% on one side and in 66% on both sides. The sentinel detection rates according to the stages were as follows: 96.6% in IB1, 66.7% in IB2, and 62.5% in IIA with at least one SN on one side, and 86.2% in IB1, 38.9% in IB2, and 37.5% in IIA with at least one SN on both sides. Successful identification of at least one SN was less likely in patients with tumors >2 cm (54% of SN) compared with those with tumors </=2 cm (96% of SN). In 15/22 patients, the SNs were the only lymph nodes that were tumor positive. The false-negative rate for the SN procedure was 3% (3/100). In all false-negative SNs, the primary cervical tumor was above 2 cm and there was an isthmus infiltration. SN detection had 86.4% sensitivity (19/22), 100% specificity (66/66), and 95.5% negative predictive value (63/68). The sentinel node detection rate is relatively high and depends on the tumor size and FIGO stage.

The sentinel lymph node: Relevance in gynaecological cancers

AIMS

Sentinel lymph node (SLN) detection is widely practiced in the management of patients with malignant melanoma and beast cancer. Large studies on SLN detection and determination of nodal status have led to changes in the surgical management of the regional lymph nodes in these diseases. More recently attention has focused on other solid cancers, including gynaecological cancers.

METHODS

An extensive literature review of published reports on the SLN in gynaecological cancers was undertaken and the reports were categorised according to the level of evidence provided.

RESULTS

Vulva cancer is the most frequently investigated gynaecological cancer with regard to SLN detection because of its anatomical location and easily accessible nodal basin. Although there are no randomised controlled trials, some data suggest SLN detection in vulval cancer may alter clinical practice and reduce the number of groin lymphadenectomies. The lymphatic drainage of the other gynaecological organs is less predictable, the nodal basin less accessible or less well defined, the techniques not standardised and the evidence for the applicability of SLN detection in the management of these cancers is weak.

CONCLUSION

Sentinel lymph node detection in vulval cancer may reduce the need for radical groin lymphadenectomy and thereby reduce morbidity. SLN detection for other gynaecological cancers has little potential to alter clinical practice.

Topographic distribution of sentinel lymph nodes in patients with cervical cancer

BACKGROUND

Since the introduction of the sentinel concept in cervical cancer in 1999, various studies have been demonstrated the feasibility, detection rate and sensitivity and rate of false-negative sentinel lymph nodes (SLN). There are only limited data regarding the mapping of the removed SLN. A correlation between the localization of SLN and the tumor stage, histology or marker substance has never been investigated.

METHODS

Between 2/2000 and 6/2005, the SLN distribution of 151 patients with histologically confirmed cervical cancer (FIGO stages IA n = 21, IB n = 95, IIA n = 14, IIB n = 18, IIIB n = 2, IVA n = 1), who participated in the ongoing "Uterus 3" sentinel study of the German Association of Gynecologic Oncologists (AGO), was retrospectively analyzed with respect to the histology, tumor stage and detection substance. The tumors comprised mostly of squamous cell carcinomas (75.5%) with a smaller fraction of adenocarcinomas (24.5%).

RESULTS

Altogether, 406 SLN, an average of 2.7 (1-7) SLN per patient, were removed. More than one SLN was detected in 111 patients (73.5%). SLN were found unilaterally in 70 patients (46.4%) und bilaterally in 81 patients (53.6%). SLN sites were paraaortic in 4%, common iliac in 5%, external iliac in 5%, internal iliac in 8%, interiliac in 71% and parametric in 7%. Irrespective of the detection drug applied, most SLN were interiliac (blue 70%, TC 67%, TC and blue 71%). Combined application of technetium and blue dye revealed significantly more SLN in the paraaotic region (P = 0.006). Adenocarcinomas and squamous carcinomas did not differ in the distribution of SLN (P = 0.205). The majority of SLN are interiliac in all tumor stages (FIGO IA 76%, IB 68%, IIA 61%, IIB 83%, III and IV 88%).

CONCLUSIONS

Removal of SLN in the external iliac, interiliac and obturator area enables evaluation of more than 80% of all SLN. The pattern of SLN is independent from histology and tumor stage. Combined use of technetium and blue dye detects sentinels more frequently in the paraaortic region than a single marker.

The sentinel node in gynaecological malignancies

As lymph node metastasis is one of the earliest features of tumour cell spread in most human cancers, assessment of the regional lymph nodes is required for tumour staging, determining prognosis and planning adjuvant therapeutic strategies. However, complete lymph node dissections are frequently associated with significant complications. Conjugating the diagnostic advantages with decreased morbidity, the sentinel node concept represents one of the most recent advances in surgical oncology. In this review we briefly highlight the historical background of the development of the sentinel node concept, the anatomical evidence for applying the sentinel node concept in pelvic gynaecological cancers and the technical aspects of sentinel node detection. We discuss recent studies in vulval, cervical and endometrial cancer.

Low Value of [18F]-Fluoro-2-Deoxy-d-Glucose Positron Emission Tomography in Primary Staging of Early-Stage Cervical Cancer Before Radical Hysterectomy

Purpose

The role of positron emission tomography (PET) with [18F]-fluoro-2-deoxy-d-glucose (FDG) in early-stage cervical cancer is unclear. We aimed to investigate the clinical benefit of FDG-PET in primary staging before radical hysterectomy and pelvic lymphadenectomy (RH-PLND).

Patients and Methods

Patients with untreated stage IA2 to IIA adenocarcinoma (AD) or adenosquamous carcinoma (ASC) or nonbulky (≤ 4 cm) squamous cell carcinoma cervical cancer with magnetic resonance imaging (MRI) –defined negative nodal metastasis were enrolled onto a prospective study with a two-stage design. All patients had a preoperative dual-phase FDG-PET, technetium-99m–sulfur colloid lymphoscintigraphy, and intraoperative sentinel lymph node (LN) detection at RH-PLND. The gold standard of LN metastasis is histologic. A sample size of 120 patients was calculated to fit study aims (diagnostic efficacy of PET and sentinel LN sampling). An interim analysis was performed when 60 patients were accrued, which led to the current report.

Results

There were 36 SCCs, 20 ADs, and four ASCs. Of the 60 patients, 10 (16.7%) had pelvic LN metastases, and one (1.7%) had para-aortic LN (PALN) metastasis histologically. FDG-PET detected the single PALN metastasis (one of one patient) but detected only one (10%) of the 10 pelvic LN metastases. The PET false-negative pelvic LN micrometastases measured a median of 4.0 × 3.0 mm (range, 0.5 × 0.5 to 7 × 6 mm). The second stage of this trial will be continued without PET.

Conclusion

This study shows that dual-phase FDG-PET has little value in primary, nonbulky, stage IA2 to IIA and MRI-defined, LN-negative cervical cancer.

Lymphatic mapping and sentinel node detection in gynecologic malignancies of the lower genital tract

The utility of lymphatic mapping and sentinel lymph node biopsy in malignancies of the female lower genital tract-- vulvar, vaginal, and cervical cancers--is being explored in multiple centers internationally. For patients with these tumors, lymphatic mapping with sentinel lymph node biopsy holds the promise of increasing the identification of microscopically metastatic disease while decreasing the morbidity of complete lymphadenectomy. In this review article we present the published data on mapping techniques and discuss the advantages and pitfalls of these procedures.

Uterus-conserving surgery for invasive cervical cancer

Standard treatment for cervical cancer is either radical hysterectomy or radiotherapy to the pelvis. Either will inevitably compromise fertility, rendering future childbearing impossible. Precise staging and magnetic resonance imaging can indicate the site and location of the tumour. Radical wide local excision of early-stage small tumours can allow conservation of the uterine corpus and the potential for fertility preservation. An isthmic vaginal anastomosis restores continuity of the vaginal canal after insertion of an isthmic cerclage. This will keep the isthmus competent but still allow menstruation. Pelvic lymphadenectomy is performed laparoscopically. This new approach combines current developing minimal access techniques with laparoscopic pelvic sidewall dissection and lymphadenectomy. The bottom or inferior part of a traditional radical vaginal hysterectomy is performed simultaneously. Over 400 cases have been reported with 100 live births. Premature rupture of the membranes is a risk. Delivery is by classical Caesarean section. Fertility rates are good and recurrence rates are low at 4%. This technique appears to be safe in well-selected cases and when performed in centres with suitable experience of radical vaginal surgery and laparoscopic techniques. Obstetric management in high-risk feto-maternal units is necessary in view of the risk of prematurity.

Sentinel node biopsy is reliable in early-stage cervical cancer but not in locally advanced disease

BACKGROUND

Sentinel lymph node (SN) biopsy based on dual labeling with blue dye and radiocolloid can reliably determine lymph node status in early-stage cervical cancer, but few data are available on its accuracy in more advanced disease. We examined the influence of tumor stage on the accuracy of SN biopsy in patients with cervical cancer.

METHODS

Between July 2001 and June 2004, 33 patients (mean age 52 years) with early-stage or locally advanced cervical cancer underwent laparoscopic SN biopsy based on dual labeling with patent blue and radiocolloid. Patients with early-stage cervical cancer (stages IA and IB1, 23 patients) underwent complete laparoscopic pelvic lymphadenectomy after the SN procedure. Patients with locally advanced cervical cancer (stage IB2, IIA or IIB, 10 patients) underwent laparoscopic pelvic and para-aortic lymphadenectomy after SN biopsy and prior neoadjuvant concomitant chemoradiotherapy. The SN identification rates and false-negative rates of patients with early-stage and locally advanced disease were compared.

RESULTS

The mean numbers of SNs identified per patient with early-stage and locally advanced cervical cancer were 2.3 (range 0-4) and 1.9 (range 0-4), respectively. SNs were identified in 86.9% (20/23) of patients with early-stage disease and in 80% (8/10) of patients with locally advanced disease. When analyzed according to the side of dissection, the identification rate was lower, especially in the patients with locally advanced disease (55% compared with 67.4%). The false-negative rate per patient was zero in early-stage disease and 20% (1/5) in locally advanced disease (no significant difference). When the side of dissection was taken into account, the false-negative rate improved to 42.9% (3/7) in patients with locally advanced disease and remained at zero in early-stage disease (P=0.038). Isolated blue dye was taken up in 53.3% of SNs in patients with locally advanced disease, compared with only 6.4% in patients with early-stage disease.

CONCLUSIONS

This study suggests that the SN biopsy technique with dual labeling is less accurate in locally advanced cervical cancer than in early-stage cervical cancer.

Study of lymphatic mapping and sentinel node identification in early stage cervical cancer

OBJECTIVE

The aim of our study was to compare the identification of sentinel lymph nodes (SLN) by blue dye and (99m) Tc; to evaluate detection rate per patient and specific side detection rate (SSDR) of SLN, distribution of SLN and distribution of positive SLN and false negative rate of the methods.

PATIENTS AND METHODS

From February 2000 until September 2004, we included 183 women with early stage cervical carcinoma. We evaluated two methods of detection of SLN (100 cases by Patent blue, 83 cases by Patent blue with (99m)Tc). We stratified the group upon the size of the tumor and upon the type of surgical method (laparoscopy, laparotomy).

RESULTS

SLN identification increased in cases when we used combination of both methods (Tc + blue dye) SSDR = 93% versus the use of blue dye only SSDR = 71% (OR:5,76, CI 95% -2.9 -11.4, <0.0001). Distribution of 462 SLN-45.0% external iliac artery and vein, 42.6% supraobturator, 4.8 bifurcation and common illiac artery and vein, 4.6% praesacral, 3% medial part of lateral parametrium. Distribution of 44 positive SLN-approximately 38.6% external illiac artery and vein, 45.5% supraobturator, 6.8% bifurcation and common illiac artery and vein, 4.5% praesacral, 4.5% medial part of lateral parametrium. One false negative SN was in presacral area.

CONCLUSION

Detection of SLN by combination of (99m)Tc and blue dye was statistically significantly better than blue dye alone. Our study documents high sensitivity, specificity and low false negativity of the method.

Advances in the surgical management of invasive cervical cancer

PURPOSE OF REVIEW

Cervical cancer is the second most frequent cancer in women in the world. Surgery plays a major role, particularly in patients with early-stage disease. This review focuses on the evaluation of important papers published since January 2003 on the management of invasive cervical cancer.

RECENT FINDINGS

Patients are classified as having early-stage (stage IB1) or advanced-stage (stage IB2 or greater) disease. Several papers are devoted to the evaluation of prognostic factors in patients with early-stage disease and negative nodes. Several recurrences after radical trachelectomy have been reported that remind us that strict selection criteria are mandatory for conservative management. The development of sentinel node and laparoscopic procedures has gained momentum. For patients with advanced-stage disease, the place of staging procedures in para-aortic areas or pelvic surgery after chemoradiation therapy continues to be debated and is currently being investigated in randomized studies. Several papers also continue to debate surgical treatment modalities for recurrent disease (the place of laparoscopy and reconstructive surgery).

SUMMARY

Several interesting papers have been published since 2003 about the surgical treatment of cervical cancer. Laparoscopic surgery and the sentinel node procedure have developed considerably, particularly for the surgical management of early-stage disease. The results of ongoing studies are awaited to determine the value of pelvic surgery (after neoadjuvant treatment) in patients with advanced-stage disease.

Pathologisch-anatomische Aufarbeitung und Befundung von Lymphknoten bei gynäkologischen Malignomen

The nodal status is one of the strongest prognostic factors in gynecologic malignancies. Metastatic involvement of regional and distant lymph nodes represents the selection basis for adjuvant therapy in a large number of solid neoplasms. The number of resected lymph nodes is one of the most important parameters in the quality control of the surgical procedure, in particular with respect to radicality. The present paper provides recommendations for gross dissection, laboratory procedures and reporting for lymph node biopsies, lymph node dissections and sentinel lymph node biopsies (SLN) for cancers of the vulva, vagina, uterine cervix, endometrium, Fallopian tubes and the ovaries, submitted for the evaluation of metastatic disease. The pathologic oncology report should include information about the number and size of resected lymph nodes, the number of involved lymph nodes with the maximum size of metastases and the presence of paranodal infiltration. In addition, the detection of isolated tumor cells should be reported, particularly with respect to the detection method (immunostains or molecular methods). In cases of metastatic disease and carcinoma of unknown primary (CUP-syndrome), information should be given regarding the primary tumor.

Radical hysterectomy

The radical hysterectomy is the standard approach for the treatment of women with early cervical cancer. However, it has increasingly been recognized that a more individualized approach to treatment should be taken. In particular, careful pretreatment evaluation should reduce the number of women receiving adjuvant radiotherapy. Laparoscopic lymphadenectomy is an attractive technique that seems likely to reduce the use of dual modality therapy. The laparoscopic approach to the evaluation of lymph nodes in cervical cancer has also allowed the development of the fertility-preserving radical trachelectomy. Outcomes for women with early cervical cancer are generally good, and it therefore becomes increasingly relevant to develop methods of reducing long-term morbidity.

Usefulness of sentinel lymph node detection in early stages of cervical cancer

PURPOSE

Sentinel lymph node (SLN) mapping in combination with surgical biopsy is an emerging technique for use in the early stages of cervical cancer. The purpose of this study was to evaluate the technique in a series of 40 consecutive women with early stage cervical cancer.

METHODS

Forty patients with early stage cervical cancer [FIGO stage IA2 (2), IB1 (34), IB2 (1) or IIA (3)] were referred for radical hysterectomy with pelvic lymphadenectomy. Patients were submitted to preoperative lymphoscintigraphy (four 99mTc-nanocolloid injections around the tumour) and intraoperative SLN detection. Hand-held or laparoscopic gamma probes were used to locate SLNs during surgery.

RESULTS

The mean number of SLNs was 2.5 per patient (interiliac 49%, external iliac 19%). Of the total of 99 SLNs, six, in four women, showed metastases (all 68 non-SLNs removed were negative). In the other 36 patients, all the removed lymph nodes (sentinel and non-sentinel) were negative (0% false negative rate). During the follow-up (median 25 months), only two patients presented distant metastases: one died 6 months after surgery (two of three SLNs positive, both hot and blue), while the second patient is alive 4 years after surgery (lung metastasis, no isotope drainage, negative blue SLN). The survival rate was 95% and disease-free survival, 97%.

CONCLUSION

SLN surgical biopsy based on lymphoscintigraphy and blue dye is a feasible and useful technique to avoid lymph node dissection in the early stages of cervical cancer. It has a high negative predictive value, can be incorporated into clinical routine (laparoscopy or open surgery) and is close to achieving validation in this setting.

Sentinel node detection in cervical cancer with 99mTc-phytate

OBJECTIVES

The aim of this study was to investigate the feasibility of sentinel lymph node (SLN) identification using radioisotopic lymphatic mapping with technetium-99 m-labeled phytate in patients undergoing radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer.

METHODS

Between July 2001 and February 2003, 56 patients with cervical cancer FIGO stage I (n = 53) or stage II (n = 3) underwent sentinel lymph node detection with preoperative lymphoscintigraphy ((99m)Tc-labeled phytate injected into the uterine cervix, at 3, 6, 9, and 12 o'clock, at a dose of 55-74 MBq in a volume of 0.8 ml) and intraoperative lymphatic mapping with a handheld gamma probe. Radical hysterectomy was aborted in three cases because parametrial invasion was found intraoperatively and we performed only sentinel node resection. The remaining 53 patients underwent radical hysterectomy with complete pelvic lymphadenectomy. Sentinel nodes were detected using a handheld gamma-probe and removed for pathological assessment during the abdominal radical hysterectomy and pelvic lymphadenectomy.

RESULTS

One or more sentinel nodes were detected in 52 out of 56 eligible patients (92.8%). A total of 120 SLNs were detected by lymphoscintigraphy (mean 2.27 nodes per patient) and intraoperatively by gamma probe. Forty-four percent of SLNs were found in the external iliac area, 39% in the obturator region, 8.3% in interiliac region, and 6.7% in the common iliac area. Unilateral sentinel nodes were found in thirty-one patients (59%). The remaining 21 patients (41%) had bilateral sentinel nodes. Microscopic nodal metastases were confirmed in 17 (32%) cases. In 10 of these patients, only SLNs had metastases. The 98 sentinel nodes that were negative on hematoxylin and eosin were submitted to cytokeratin immunohistochemical analysis. Five (5.1%) micrometastases were identified with this technique. The sensitivity of the sentinel node was 82.3% (CI 95% = 56.6-96.2) and the negative predictive value was 92.1% (CI 95% = 78.6-98.3). The accuracy of sentinel node in predicting the lymph node status was 94.2%.

CONCLUSION

Preoperative lymphoscintigraphy and intraoperative lymphatic mapping with (99m)Tc-labeled phytate are effective in identifying sentinel nodes in patients undergoing radical hysterectomy and to select women in whom lymph node dissection can be avoided.

Evaluation of patients after extraperitoneal lymph node dissection for cervical cancer

OBJECTIVE

The presence of nodal metastases is an important prognostic factor in patients with cervical cancer. To adjust our therapy to the anatomic extent of the disease, we performed a surgical staging with extraperitoneal lymph node dissection (EPLND). The goal of our study was to evaluate the clinical outcome and side effects of the combined treatment approach of EPLND and either radical hysterectomy in case of early stage cervical cancer (FIGO Ia/b and IIa) and negative nodes, or pelvic radiotherapy/extended field radiotherapy with concomitant chemotherapy in case of positive nodes or advanced stage cervical cancer (FIGO IIb, III, and IVa).

PATIENTS AND METHODS

Fifty-nine patients with primarily diagnosed invasive cervical cancer underwent EPLND. The value of this procedure as a diagnostic tool for evaluating the extent of disease was determined. Additionally, treatment-related complications and clinical outcomes were monitored.

RESULTS

A total of 983 lymph nodes were removed during EPLND (mean 16.7). According to the results of EPLND, radical hysterectomy was abandoned due to histopathologically confirmed lymph node involvement by frozen section in 11 out of 36 patients with early stage cervical cancer (31%). The most common adverse effects directly related to surgery in general (EPLND or combined EPLND and radical hysterectomy) were lymph cysts in seven patients (12%). Only in the group of patients who received EPLND followed by radical hysterectomy, 2 out of 25 patients (8%) developed a severe ileus postoperatively (WHO Grade 3 toxicity). The treatment approach of combined EPLND followed by radio- and chemotherapy was without major complications (WHO Grade 3 or 4 toxicity). After a mean follow up of 28 months (range 6-60), 44 out of 58 patients (one patient lost to follow up) are without evidence of disease (76%), 2 patients have progressive disease (3%), and 12 patients died of their disease (21%). Using Kaplan-Meier analysis, the estimated 5-year overall survival rate for all patients is 64% (SD +/- 9%). Performing the Cox proportional regression analysis, in contrast to clinical FIGO staging (P = 0.24; ns), lymph node involvement was the only significant independent predictor for overall survival (P = 0.04).

CONCLUSION

Our data support the approach of pretherapeutic surgical staging by performing EPLND as a diagnostic tool with a low complication rate. This allows an individualized treatment for cervical cancer patients.

Role of sentinel lymph node biopsy procedure in cervical cancer: a critical point of view

OBJECTIVE

To report our experience about the role of sentinel node biopsy in cervical cancer patients while debating provocatory arguments concerning this procedure.

METHODS

From June 2001 to February 2003, patients affected by stage IB(1) cervical cancer were submitted to the sentinel node biopsy procedure. Patients were submitted to lymphoscintigraphy and, subsequently, to laparoscopy in order to locate the sentinel lymph node.

RESULTS

Thirty-seven patients were enrolled in the study. Sentinel node(s) was(were) identified with preoperative lymphoscintigraphy in 89% of the patients. Intraoperative detection rate was 70%. During surgery in 31% of the patients, sentinel node was detected bilaterally; in 15%, two sentinel nodes on the same side of the lymphatic vessels were detected. The sentinel node was located at the level of superficial common iliac vessels (26%), external iliac vessels (69%), and superficial obturator vessels (49%). In 77% of the patients, the histologic specimen sent by the surgeon as unique sentinel node contained two or more nodes. Metastatic sentinel nodes were found in 23% of the patients. There was no case with a positive nonsentinel node in the presence of a negative sentinel node.

CONCLUSION

Sentinel node detection is a feasible procedure in cervical cancer patients. However, a high percentage of patients is found with bilateral and/or more than one sentinel lymph node. Improvements in detection rate and pathological analysis are needed prior to consider the sentinel node biopsy a routine procedure in cervical cancer patients.

Total laparoscopic radical hysterectomy with intraoperative sentinel node identification in patients with early invasive cervical cancer

OBJECTIVES

To describe the feasibility and results of total laparoscopic radical hysterectomy with intraoperative sentinel lymph node identification in patients with early cervical cancer.

METHODS

Between March 2001 and October 2003, 12 patients with FIGO stage IA(2) (n = 1) or IB(1) (n = 11) cancer of the cervix underwent surgical treatment through the laparoscopic route. All patients underwent a laparoscopic sentinel node identification with preoperative lymphoscintigraphy (technetium-99 m colloid albumin injection around the tumor) and intraoperative lymphatic mapping with isosulfan blue dye and a laparoscopic gamma probe followed by systematic bilateral pelvic lymphadenectomy and laparoscopic type II (n = 5) or type III (n = 7) hysterectomy.

RESULTS

A mean of 2.5 sentinel nodes per patient (range 1-4) was detected, with a mean of 2.33 nodes per patient by gamma probe and a mean of 2 per patient after blue injection (combined detection rate 100%). The most frequent localization of the nodes was the interiliac region. Histopathologic examination of sentinel nodes including cytokeratin immunohistochemical analysis did not show metastasis. Microscopic nodal metastases were not found. The mean number of resected pelvic nodes was 18.6 per patient (range 10-28). The operation was performed entirely by laparoscopy in all patients and no case of laparotomy conversion was recorded. The mean duration of operation was 271 min (range 235-300), with a mean blood loss of 445 mL (range 240-800), and a mean length of stay of 5.25 days (range 3-10). No major intraoperative complications occurred. After a median follow-up of 20 months (range 5-34), all patients are free of disease.

CONCLUSIONS

This study shows the feasibility of the combination of laparoscopic intraoperative sentinel node mapping and laparoscopic radical surgery in the context of minimally invasive surgery for the management of patients with early cervical cancer.

Histopathologic parameters of prognosis in cervical cancer--a review

Apart from clinical stage and lymph node status, acknowledged to be among the most powerful predictors of outcome in cervical cancer, the determination of prognosis and thereby the need for adjuvant therapy in surgically treated patients currently relies on a variety of histopathologic factors. The role of many of these is controversial. This may be because histopathology is genuinely lacking in sensitivity for predicting tumor behavior in vivo. There is, however, wide variation in histopathologic definitions and criteria. This is probably the major reason for both the lack of reproducibility in the reporting of certain factors and in their diminished value in predicting behavior. Tumor type, grade, vascular invasion, pattern of invasion, and depth are all extremely important prognostic indicators when used individually or as a part of a scoring system.

Sentinel lymph node detection in early cervical cancer with combination 99mTc phytate and patent blue

OBJECTIVE

The purpose of this study was to examine sentinel lymph node (SLN) detection in patients with early stage cervical cancer using (99m)Tc phytate and patent blue dye and to compare our method with published findings utilizing other radioisotopic tracers.

PATIENTS AND METHODS

A total of 20 consecutive patients with cervical cancer scheduled for radical hysterectomy and total pelvic lymphadenectomy at our hospital underwent SLN detection study. The day before surgery, lymphoscintigraphy was performed with injection of 99m-technetium ((99m)Tc)-labeled phytate into the uterine cervix. At surgery, patients underwent lymphatic mapping with a gamma-detecting probe and patent blue injected into the same points as the phytate solution.

RESULTS

At least one positive node was detected in 18 patients (90%). A total of 46 sentinel nodes were detected (mean, 2.3; range, 1-5). Most sentinel nodes were in one of the following sites: external iliac (21 nodes), obturator (15 nodes), and parametrial (7 nodes). Eleven (24%) sentinel nodes were detected only through radioactivity and two (4%) were detected only with blue dye. The sensitivity, specificity, and negative predictive value for SLN detection were all 100%. Nine published studies involving 295 patients had a summarized detection rate of 85%. Summarized sensitivity, specificity, and negative predictive value were 93%, 100%, and 99%, respectively.

CONCLUSION

Combination of (99m)Tc phytate and patent blue is effective in SLN detection in early stage cervical cancer.

Vaginal radical trachelectomy: an oncologically safe fertility-preserving surgery. An updated series of 72 cases and review of the literature

OBJECTIVE

To review the oncological results and complication rate of our first consecutive 72 completed cases of vaginal radical trachelectomies (VRT).

METHODS

From October 1991 to October 2003, we have planned 82 VRT in patients with early-stage cervical cancer (stages IA, IB, and IIA). The VRT was preceded by a complete laparoscopic pelvic node dissection and laparoscopic parametrectomy.

RESULTS

The planned procedure was successfully completed in 72 cases and was abandoned in 10 cases (12%) because of either positive nodes discovered at the time of surgery (4), positive endocervical margins (5) or extensive tubal adhesions (1). The median age of the remaining 72 patients was 31 and most (75%) were nulliparous. The majority of the lesions were stage IA2 (32%) or IB1 (60%) and 54% were grade 1. In terms of histology, 58% were squamous and 42% were adenocarcinomas. Vascular space invasion was present in 20% of cases, and 90% of the lesions measured </=2 cm. An average of 32 lymph nodes has been removed laparoscopically. The mean follow-up is 60 months (6-156). The intraoperative complication rate was low (6%) and the postoperative morbidity was also low mainly involving bladder hypotonia (16%) and vulvar edema (12%). There were no bladder or ureteral injuries. The average hospital stay was 3 days. Excluding one patient with a small cell neuroendocrine tumor who rapidly recurred and died, there were two recurrences (2.8%) and one death (1.4%). The actuarial recurrence-free survival is 95%. Tumor size >2 cm was statistically significantly associated with a higher risk of recurrence (P = 0.03). The recurrence-free survival of the nine patients who did not have the planned VRT because of more advanced disease was statistically significantly less (P = 0.003).

CONCLUSION

VRT is an oncologically safe procedure in well-selected patients with early-stage disease. Lesion size >2 cm appears to be associated with a higher risk of recurrence. The morbidity of the procedure is low and it allows fertility preservation.

Value of intraoperative imprint cytology of sentinel nodes in patients with cervical cancer

OBJECTIVE

The purpose of this study was to evaluate intraoperative imprint cytology (IC) for the detection of sentinel node (SN) involvement in patients with cervical cancer.

METHODS

Thirty-six consecutive patients with cervical cancer underwent a laparoscopic SN procedure with intraoperative IC, followed by complete laparoscopic pelvic lymphadenectomy, with or without laparoscopic para-aortic lymphadenectomy. The SN was bisected and both cut surfaces were applied to the surface of glass slides. Permanent sections were stained with H&E and immunohistochemical methods. The IC results were compared with the final histological results.

RESULTS

At least one SN (mean: 2 SN per patient, range: 1-5) was detected in 34 of the 36 patients. Eight patients (22.2%) had a total of 12 metastatic SNs (four macrometastatic, five micrometastatic, and three with isolated tumor cells). No false-negative results of SN biopsy were obtained. Only one metastasis was identified by IC. No false-positive findings were obtained with IC. The overall sensitivity, specificity, accuracy, and positive and negative predictive values of IC were 8.3%, 100%, 85.7%, 100%, and 85.5%, respectively.

CONCLUSION

These results suggest that intraoperative imprint cytology of sentinel nodes is unreliable in patients with cervical cancer.

Surgical and radiographic staging in patients with cervical cancer

PURPOSE OF REVIEW

The most recent data on surgical and radiographic staging in patients with cervical cancer are analysed.

RECENT FINDINGS

Laparoscopic staging of retro and intraperitoneal disease is feasible. Morbidity is low, but the impact on survival has still to be shown. The sentinel lymph node concept is valid in patients with cervical cancer. Sensitivity and negative predictive value, however, have to be improved before the concept can be integrated into clinical practice. The majority of most recent radiographic studies evaluate the value of positron emission tomography. Accuracy of detection of extracervical disease is high and the response to chemoradiation can be measured by positron emission tomography using various scoring systems. Positron emission tomography seems to be the most accurate technique for detecting early recurrence.

SUMMARY

Surgical staging is less invasive by laparoscopy, and radiographic staging becomes more accurate by positron emission tomography. Prospective evaluations have to show the impact of these new techniques on survival of patients diagnosed with cervical cancer.