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Factors associated with parametrial involvement in stage IB1 cervical cancer and identification of patients suitable for less radical surgery. Gynecol Oncol 2011; 122:491-4. [DOI: 10.1016/j.ygyno.2011.05.038] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 05/27/2011] [Accepted: 05/31/2011] [Indexed: 11/21/2022]
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152
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Cormier B, Diaz JP, Shih K, Sampson RM, Sonoda Y, Park KJ, Alektiar K, Chi DS, Barakat RR, Abu-Rustum NR. Establishing a sentinel lymph node mapping algorithm for the treatment of early cervical cancer. Gynecol Oncol 2011; 122:275-80. [PMID: 21570713 DOI: 10.1016/j.ygyno.2011.04.023] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 04/15/2011] [Accepted: 04/16/2011] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To establish an algorithm that incorporates sentinel lymph node (SLN) mapping to the surgical treatment of early cervical cancer, ensuring that lymph node (LN) metastases are accurately detected but minimizing the need for complete lymphadenectomy (LND). METHODS A prospectively maintained database of all patients who underwent SLN procedure followed by a complete bilateral pelvic LND for cervical cancer (FIGO stages IA1 with LVI to IIA) from 03/2003 to 09/2010 was analyzed. The surgical algorithm we evaluated included the following: 1. SLNs are removed and submitted to ultrastaging; 2. any suspicious LN is removed regardless of mapping; 3. if only unilateral mapping is noted, a contralateral side-specific pelvic LND is performed (including inter-iliac nodes); and 4. parametrectomy en bloc with primary tumor resection is done in all cases. We retrospectively applied the algorithm to determine how it would have performed. RESULTS One hundred twenty-two patients were included. Median SLN count was 3 and median total LN count was 20. At least one SLN was identified in 93% of cases (114/122), while optimal (bilateral) mapping was achieved in 75% of cases (91/122). SLN correctly diagnosed 21 of 25 patients with nodal spread. When the algorithm was applied, all patients with LN metastasis were detected; with optimal mapping, bilateral pelvic LND could have been avoided in 75% of cases. CONCLUSIONS In the surgical treatment of early cervical cancer, the algorithm we propose allows for comprehensive detection of all patients with nodal disease and spares complete LND in the majority of cases.
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Affiliation(s)
- Beatrice Cormier
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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153
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Ballester M, Dubernard G, Lécuru F, Heitz D, Mathevet P, Marret H, Querleu D, Golfier F, Leblanc E, Rouzier R, Daraï E. Detection rate and diagnostic accuracy of sentinel-node biopsy in early stage endometrial cancer: a prospective multicentre study (SENTI-ENDO). Lancet Oncol 2011; 12:469-76. [PMID: 21489874 DOI: 10.1016/s1470-2045(11)70070-5] [Citation(s) in RCA: 383] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Retrospective single-centre series have shown the feasibility of sentinel lymph-node (SLN) identification in endometrial cancer. We did a prospective, multicentre cohort study to assess the detection rate and diagnostic accuracy of the SLN procedure in predicting the pathological pelvic-node status in patients with early stage endometrial cancer. METHODS Patients with International Federation of Gynecology and Obstetrics (FIGO) stage I-II endometrial cancer had pelvic SLN assessment via cervical dual injection (with technetium and patent blue), and systematic pelvic-node dissection. All lymph nodes were histopathologically examined and SLNs were serial sectioned and examined by immunochemistry. The primary endpoint was estimation of the negative predictive value (NPV) of sentinel-node biopsy per hemipelvis. This is an ongoing study for which recruitment has ended. The study is registered with ClinicalTrials.gov, number NCT00987051. FINDINGS From July 5, 2007, to Aug 4, 2009, 133 patients were enrolled at nine centres in France. No complications occurred after injection of technetium colloid and no anaphylactic reactions were noted after patent blue injection. No surgical complications were reported during SLN biopsy, including procedures that involved conversion to open surgery. At least one SLN was detected in 111 of the 125 eligible patients. 19 of 111 (17%) had pelvic-lymph-node metastases. Five of 111 patients (5%) had an associated SLN in the para-aortic area. Considering the hemipelvis as the unit of analysis, NPV was 100% (95% CI 95-100) and sensitivity 100% (63-100). Considering the patient as the unit of analysis, three patients had false-negative results (two had metastatic nodes in the contralateral pelvic area and one in the para-aortic area), giving an NPV of 97% (95% CI 91-99) and sensitivity of 84% (62-95). All three of these patients had type 2 endometrial cancer. Immunohistochemistry and serial sectioning detected metastases undiagnosed by conventional histology in nine of 111 (8%) patients with detected SLNs, representing nine of the 19 patients (47%) with metastases. SLN biopsy upstaged 10% of patients with low-risk and 15% of those with intermediate-risk endometrial cancer. INTERPRETATION SLN biopsy with cervical dual labelling could be a trade-off between systematic lymphadenectomy and no dissection at all in patients with endometrial cancer of low or intermediate risk. Moreover, our study suggests that SLN biopsy could provide important data to tailor adjuvant therapy. FUNDING Direction Interrégionale de Recherche Clinique, Ile-de-France, Assistance Publique-Hôpitaux de Paris.
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Affiliation(s)
- Marcos Ballester
- Department of Obstetrics and Gynaecology, Tenon University Hospital, Paris, France
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154
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Huchon C, Bats AS, Achouri A, Lefrère-Belda MA, Buénerd A, Bensaid C, Farragi M, Mathevet P, Lécuru F. [Sentinel lymph node procedure and uterine cancers]. ACTA ACUST UNITED AC 2011; 38:760-6. [PMID: 21111648 DOI: 10.1016/j.gyobfe.2010.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2010] [Accepted: 09/28/2010] [Indexed: 11/26/2022]
Abstract
Lymph node metastases in cervical and endometrial cancer are major prognostic factors. Lymph-nodal involvement determines adjuvant therapy. As imagery is not reliable to diagnose lymph node status, pelvic +/- para-aortic lymphadenectomy remains the gold standard. These surgical procedures are, however, responsible for specific morbidity: lymphocele and lymphedema. Sentinel lymph node procedure could avoid lymphadenectomy and their complications in cervical and endometrial cancer with good negative predictive values. We present actual indications, procedure and results of sentinel lymph node procedures in cervical and endometrial cancer.
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Affiliation(s)
- C Huchon
- Service de chirurgie gynécologique et cancérologique, hôpital européen Georges-Pompidou, AP-HP, 20 rue Leblanc, Paris cedex 15, France.
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155
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Lécuru F, Mathevet P, Querleu D, Leblanc E, Morice P, Daraï E, Marret H, Magaud L, Gillaizeau F, Chatellier G, Dargent D. Bilateral negative sentinel nodes accurately predict absence of lymph node metastasis in early cervical cancer: results of the SENTICOL study. J Clin Oncol 2011; 29:1686-91. [PMID: 21444878 DOI: 10.1200/jco.2010.32.0432] [Citation(s) in RCA: 259] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Sentinel lymph node (SLN) biopsy may be used to target lymph node metastases in patients with early cervical cancer. Whether SLN biopsy only is acceptable in the staging and surgical management of early cervical cancer remains unknown. This prospective multicenter study (SENTICOL [Ganglion Sentinelle dans le Cancer du Col]) assessed the sensitivity and negative predictive value (NPV) of SLN biopsy. PATIENTS AND METHODS Adults with cervical carcinoma who met the International Federation of Gynecology and Obstetrics criteria for stage IA1 with lymphovascular space invasion to stage IB1 underwent technetium 99 lymphoscintigraphy and Patent Blue injection followed by laparoscopic lymph node mapping, SLN removal, and lymph node dissection. Only surgeons trained in SLN biopsy in cervical carcinoma participated in the study. SLNs and nonsentinel lymph nodes underwent routine staining. Negative SLNs were subjected to ultrastaging. The reference method was pelvic and/or para-aortic lymphadenectomy with histologic examination of all nodes. RESULTS One hundred forty-five patients were enrolled, and 139 were included in a modified intention-to-diagnose analysis. Intraoperative radioisotope-blue dye mapping detected at least one SLN in 136 patients (97.8%; 95% CI, 93.8% to 99.6%), 23 of whom had true-positive results and two who had false-negative results, yielding 92.0% sensitivity (23 of 25; 95% CI, 74.0% to 99.0%) and 98.2% NPV (111 of 113; 95% CI, 74.0% to 99.0%) for node metastasis detection. No false-negative results were observed in the 104 patients (76.5%) in whom SLN were identified bilaterally. CONCLUSION Combined labeling for node mapping was associated with high rates of SLN detection and with high sensitivity and NPV for metastasis detection. However, SLN biopsy was fully reliable only when SLNs were detected bilaterally.
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Affiliation(s)
- Fabrice Lécuru
- Service de Chirurgie Gynécologique et Cancérologique, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France.
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156
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Abstract
Sentinel lymph node biopsy in cervical cancer is used to reduce the morbidity of a full lymph node dissection while improving the pickup rate of metastatic lymph nodes. The higher detection rate achieved can be explained by the following: the identification of the sentinel lymph node in an aberrant location which would not be routinely included in a systematic pelvic lymph node dissection, the sentinel lymph node is completely excised, and the routine use of ultrastaging. The higher detection rate achieved through sentinel lymph node biopsy can identify additional patients who could potentially benefit from adjuvant therapy therefore, in our view the gold standard of lymph node assessment in early stage cervical cancer has shifted and sentinel lymph node biopsy has taken the place of a complete lymphadenectomy.
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157
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Hertel H. Cervical cancer and the role of lymph node staging cons sentinel concept. Int J Gynecol Cancer 2011; 20:S37-8. [PMID: 21053525 DOI: 10.1111/igc.0b013e3181f7f52b] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine whether the current standard of cervical cancer staging is sentinel lymph node biopsy. METHOD Review of the literature focusing on the significance of the sentinel node concept in patients with cervical cancer. Because of the data on the significance of the intraoperative histopathological assessment of sentinel lymph nodes, the role of micrometastasis in lymph nodes, and the standards of procedure, the sentinel procedure were analyzed. RESULT Sentinel lymph node biopsy alone is currently not a routine procedure for cervical cancer staging. This procedure should be performed only by specialized centers in a study setting. More data on its oncological safety are needed.
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Affiliation(s)
- Hermann Hertel
- Department of Gynecologic Oncology, Medical School Hannover, Hannover, Germany.
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158
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Díaz-Feijoo B, Pérez-Benavente MA, Cabrera-Diaz S, Gil-Moreno A, Roca I, Franco-Camps S, Fernández MS, García-Jiménez A, Xercavins J, Martínez-Palones JM. Change in clinical management of sentinel lymph node location in early stage cervical cancer. Gynecol Oncol 2011; 120:353-7. [DOI: 10.1016/j.ygyno.2010.12.336] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Revised: 12/02/2010] [Accepted: 12/09/2010] [Indexed: 10/18/2022]
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159
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160
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Martínez A, Zerdoud S, Mery E, Bouissou E, Ferron G, Querleu D. Hybrid imaging by SPECT/CT for sentinel lymph node detection in patients with cancer of the uterine cervix. Gynecol Oncol 2010; 119:431-5. [DOI: 10.1016/j.ygyno.2010.08.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 07/28/2010] [Accepted: 08/02/2010] [Indexed: 11/29/2022]
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161
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Shah M, Lewin SN, Deutsch I, Burke WM, Sun X, Herzog TJ, Wright JD. Therapeutic role of lymphadenectomy for cervical cancer. Cancer 2010; 117:310-7. [PMID: 20862747 DOI: 10.1002/cncr.25408] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Revised: 03/26/2010] [Accepted: 03/30/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite the diagnostic value of lymphadenectomy for early-stage cervical cancer, its therapeutic role is unknown. We examined the therapeutic potential of extensive lymphadenectomy in women with early-stage cervical cancer. METHODS Women with stage IA2-IIA cervical cancer who underwent radical hysterectomy with lymphadenectomy in the Surveillance, Epidemiology, and End Results (SEER) database were analyzed. Patients were stratified according to the number of nodes removed. The effect of the extent of lymphadenectomy on overall and cancer-specific survival was examined using multivariable Cox proportional hazards models. Separate analyses were performed for node positive and node negative patients. RESULTS Among 5522 women, 893 (16%) had <10 nodes, 2030 (37%) had 11-20, 1487 (27%) had 21-30 nodes, and 1112 (20%) had >30 nodes removed. Black women, those >65 years of age and those diagnosed later in the study, were less likely to have 10 or more nodes removed (P < .05 for all). Among women with positive lymph nodes, a more extensive lymphadenectomy had no effect on survival (HR = 0.75; 95% CI, 0.47-1.22). For women with negative lymph nodes, a more extensive lymphadenectomy was associated with improved survival. Compared with node negative patients with less than 10 nodes removed, patients with 21-30 nodes removed were 24% (HR = 0.76; 95% CI, 0.53-1.09) less likely to die, whereas those with >30 nodes removed were 37% (HR = 0.64; 95% CI, 0.43-0.96) less likely to die from their tumors. CONCLUSIONS Node negative, early-stage cervical cancer patients who undergo a more extensive lymphadenectomy have an improved survival.
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Affiliation(s)
- Monjri Shah
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
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162
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Favero G, Chiantera V, Oleszczuk A, Gallotta V, Hertel H, Herrmann J, Marnitz S, Köhler C, Schneider A. Invasive cervical cancer during pregnancy: Laparoscopic nodal evaluation before oncologic treatment delay. Gynecol Oncol 2010; 118:123-7. [DOI: 10.1016/j.ygyno.2010.04.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 04/08/2010] [Accepted: 04/14/2010] [Indexed: 10/19/2022]
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163
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Rob L, Halaska M, Robova H. Nerve-sparing and individually tailored surgery for cervical cancer. Lancet Oncol 2010; 11:292-301. [PMID: 20202614 DOI: 10.1016/s1470-2045(09)70191-3] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Cancer of the cervix is the second most common cancer in women worldwide, with about 500,000 new cases and 273,000 deaths reported annually. Ideal surgical management of cervical cancer should reduce early and late morbidity without compromising oncological disease control. Type of surgical radicality in early cervical cancer should be a consequence of exact preoperative and intraoperative assessments of risk factors. During the past 15 years, substantial progress has been made in understanding the neuroanatomy of the autonomic pelvic plexus. This progress has resulted in individually tailored surgery for cervical cancer. The concept of preservation of autonomic nerves during radical hysterectomy has become standard in many oncogynaecological centres. Nerve-sparing radical hysterectomy and individually tailored surgery, in comparison with standard radical hysterectomy, have led to a much improved quality of life. Since 2008, there has been a new classification of radical hysterectomy, which includes nerve-sparing techniques. 5-year survival in early stage cervical cancer is 88-97% and more than 50% of women are younger than 50 years of age. Thus, we must take into consideration the quality of life of these patients. In this Review, we focus on the neuroanatomy of the pelvis and the possible damage of autonomic nerves, and suggest options for the sparing of these nerves during surgery for cervical cancer.
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Affiliation(s)
- Lukas Rob
- Department of Obstetrics Gynaecology, 2nd Medical Faculty, Charles University, Prague, Czech Republic.
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164
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Darlin L, Persson J, Bossmar T, Lindahl B, Kannisto P, Måsbäck A, Borgfeldt C. The sentinel node concept in early cervical cancer performs well in tumors smaller than 2 cm. Gynecol Oncol 2010; 117:266-9. [PMID: 20167355 DOI: 10.1016/j.ygyno.2010.01.035] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 01/14/2010] [Accepted: 01/22/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the sentinel node (SLN) concept for lymphatic mapping in early stage cervical cancer. METHODS 105 women with early stage (1a1-2a) cervical cancer were scheduled for the sentinel node procedure in conjunction with a complete pelvic lymphadenectomy. The day before surgery, 1-1.5 mL 120MBq Tc(99) albumin nanocolloid was injected submucosally at four points around the tumor followed by a lymphoscintigram (LSG) to achieve an overview of the radiotracer uptake. RESULTS During surgery, the overall detection rate (gamma probe) of at least one SLN was 90% (94/105 women) whereas at least one SLN was identified in 94% (61/65 women) with a tumor <or=2 cm. Bilateral SLNs were identified in 62/105 (59%) of the women. Among 18 women with any metastatic lymph node 17 had a metastatic SLN (sensitivity 94%, 95% CI 73-100%). Among 61 women with a tumor <or=2 cm, all five women with any metastatic lymph node also had a metastatic SLN (sensitivity 100%). One woman with a 1.5-cm squamous epithelial carcinoma had metastatic positive SLNs on each side but also one metastatic bulky (>2 cm) node without radiotracer uptake. The negative predictive value for patients with cervical cancers <or=2 cm was 100%. CONCLUSIONS The SLN-technique seems to be an accurate method for identifying lymph node metastases in cervical cancer patients with tumors of 2 cm or smaller. In case of a unilateral SLN only, a complete lymphadenectomy should be performed on the radionegative side. All bulky nodes must be removed.
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Affiliation(s)
- Lotten Darlin
- Department of Obstetrics and Gynecology, University Hospital Lund, SE-221 85 Lund, Sweden
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165
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Abstract
PURPOSE OF REVIEW In early-stage vulvar, cervical and endometrial cancer, lymph node status is the most important prognostic factor. Surgical treatment is aimed at removing the primary tumor and adequately staging the regional lymph nodes. As morbidity of regional lymphadenectomy is high, sentinel node biopsy is a technique with potential for adequate staging with less treatment-related morbidity. This manuscript reviews its current role in vulvar, cervical and endometrial cancer. RECENT FINDINGS In early-stage vulvar cancer, level 3 evidence indicates that it appears to be safe to omit inguinofemoral lymphadenectomy in case of a negative sentinel node. However, false-negative results with fatal consequences do occur and are often attributable to procedural failures. For early-stage cervical cancer, level 3 evidence points to an acceptable false-negative rate of a negative sentinel node; clinical utility and safety remain to be established. The optimal technique of the sentinel node biopsy in endometrial cancer is currently unclear. SUMMARY In early-stage vulvar cancer, data suggest that sentinel node biopsy could be offered as a treatment option instead of routine inguinofemoral lymphadenectomy. However, more (long-term follow-up) data are needed to further appreciate real clinical benefits. It is emphasized that the procedure should be performed by a skilled multidisciplinary team, centralized in oncology centers and preferably within the protection of clinical trials. For cervical cancer, data are promising, but routine application cannot be recommended due to lack of data on clinical utility and safety. For endometrial cancer, studies on the sentinel node biopsy are still in feasibility stage.
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166
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Role of the integrated FDG PET/CT in the surgical management of patients with high risk clinical early stage endometrial cancer: detection of pelvic nodal metastases. Gynecol Oncol 2009; 115:231-5. [PMID: 19695685 DOI: 10.1016/j.ygyno.2009.07.020] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 07/11/2009] [Accepted: 07/15/2009] [Indexed: 12/28/2022]
Abstract
BACKGROUND High risk clinical stage I endometrial cancer (grade 2 and deep myometrial invasion, grade 3 and serous and clear-cell carcinoma) had 10-35% of nodal involvement. Surgical staging is considered reasonable in this setting of women, although unnecessary in 70-90%. The purpose of this study was to determine prospectively the diagnostic accuracy of 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography 18F-FDG PET/CT in the detection of nodal metastases in patients with high risk endometrial cancer. METHODS Eleven women with grade 2 and deep myometrial invasion and 26 with grade 3 endometrial cancer underwent 18F-FDG PET/CT, followed by total hysterectomy, bilateral salpingo-oophorectomy and systematic pelvic lymphadenectomy. Histopathological findings served as the reference standard. Diagnostic performance of 18F-FDG PET/CT in nodal disease detection was reported in terms of accuracy value both in a patient-based and a lesion site-based analysis. RESULTS Pelvic nodes metastases were found at histopathological analysis in 9 of the 37 patients (24.3%). Patient-based sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 18F-FDG PET/CT for detection of nodal disease were 77.8%, 100.0%, 100.0%, 93.1% and 94.4%, respectively. Nodal lesion site-based sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 18F-FDG PET/CT were 66.7%, 99.4%, 90.9%, 97.2% and 96.8%, respectively. CONCLUSION This study shows that 18F-FDG PET/CT is an accurate method for the presurgical evaluation of pelvic nodes metastases. The high negative predictive value may be useful in selecting patients who only may benefit from lymphadenectomy, minimizing operative and surgical complications.
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167
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[Surgical lymph-node evaluation in cervical cancer]. Cancer Radiother 2009; 13:499-502. [PMID: 19660975 DOI: 10.1016/j.canrad.2009.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Accepted: 06/17/2009] [Indexed: 11/24/2022]
Abstract
Lymph-nodal involvement is a major prognostic factor of cervical cancer. Lymph-node status is classically evaluated by lymph-node dissection. This surgical approach has mainly a prognostic interest. The morbidity related to the lymph-node dissection is not nil, so numerous imaging or surgical techniques have been recently developed in order to reduce this morbidity. Currently, even with the progress of the imaging techniques, surgical lymph-node dissection is the standard approach. For the management of early cervical cancer, surgery is usually the sole treatment. In association with a laparoscopic lymph-node dissection, the sentinel node technique is a new approach that gives interesting data: possibility of performing frozen sections on the sentinel nodes in order to improve the management, discovery in an important proportion of cases of abnormal lymphatic pathways that are a potential aetiology of recurrence, and identification of lymph-node micrometastases that seem to be an important independent prognostic factor. In the future, evaluation of only the sentinel nodes may replace the pelvic lymph-node dissection. For advanced cervical cancers, the treatment is based on chemoradiotherapy. The paraaortic lymph-node status is an important prognostic factor that helps for defining the radiotherapy fields. New imaging techniques as PET Scan, may help for the evaluation of paraaortic lymph-node status. If the PET Scan is positive at the paraaortic level, there is no need for paraaortic lymph-node dissection and radiotherapy should be performed with pelvic and abdominal fields. But the false negative rate of the PET Scan is high and laparoscopic paraaortic lymph-node dissection is required in case of negative PET Scan at the paraaortic level.
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168
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Cibula D, Kuzel D, Sláma J, Fischerova D, Dundr P, Freitag P, Zikán M, Pavlista D, Tomancova V. Sentinel node (SLN) biopsy in the management of locally advanced cervical cancer. Gynecol Oncol 2009; 115:46-50. [PMID: 19646741 DOI: 10.1016/j.ygyno.2009.06.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Sentinel lymph node (SLN) biopsy can significantly contribute to the management of locally advanced cervical cancers with high risk of lymph node (LN) positivity. However, low detection rate and sensitivity were reported in larger tumors, albeit on a small number of cases. It was the aim of our study to verify the SLN reliability in large tumors, with modified dye application technique and a careful identification of side-specific lymphatic drainage. METHODS The study involved 44 patients with tumors 3 cm in diameter or larger, stages IB1 to IIA, or selected IIB. In cases where SLN could not be detected, systematic pelvic lymphadenectomy was performed on the respective side. Systematic pelvic lymphadenectomy was performed during the second step radical procedure if not already done. RESULTS Detection rate in the whole cohort reached 77% per patient and 59% bilaterally. No significant difference was found whether a blue dye or a combined method was used (75% vs 80%, and 55% vs 67%). Systematic pelvic lymphadenectomy was performed in cases with undetected SLN unilaterally in 8 and bilaterally in 10 women. A systematic pelvic lymphadenectomy was included in the second step radical procedure in 19 cases and no positive LN were found. There was no case of false-negative SLN result in patients who underwent surgical treatment. CONCLUSION Detection rate in locally advanced cervical cancer could be improved by a careful dye application technique. Low false-negative SLN rate could be achieved if pelvic lymphatic drainage is evaluated on a side-specific principle by performing systematic lymphadenectomy if SLN is not detected.
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Affiliation(s)
- D Cibula
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic.
| | - D Kuzel
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic
| | - J Sláma
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic
| | - D Fischerova
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic
| | - P Dundr
- Department of Pathology, General Teaching Hospital, First Medical School, Charles University, Prague, Czech Republic
| | - P Freitag
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic
| | - M Zikán
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic
| | - D Pavlista
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic
| | - V Tomancova
- Department of Clinical Oncology, General Teaching Hospital, First Medical School, Charles University, Prague, Czech Republic
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Sentinel Lymph Node Biopsy in the Management of Vulvar Carcinoma, Cervical Cancer, and Endometrial Cancer. Oncologist 2009; 14:695-705. [DOI: 10.1634/theoncologist.2009-0075] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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170
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Preoperative pelvic lymphoscintigraphy is of limited usefulness for sentinel lymph node detection in cervical cancer. Eur J Obstet Gynecol Reprod Biol 2009; 145:96-9. [DOI: 10.1016/j.ejogrb.2009.03.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2009] [Revised: 03/13/2009] [Accepted: 03/30/2009] [Indexed: 11/19/2022]
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171
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Gien LT, Covens A. Lymph node assessment in cervical cancer: prognostic and therapeutic implications. J Surg Oncol 2009; 99:242-7. [PMID: 19048600 DOI: 10.1002/jso.21199] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Lymph node status is not part of the staging system for cervical cancer, but provides important information for prognosis and treatment. This article reviews the incidence and patterns of lymph node metastasis, and the issues surrounding surgical assessment of lymph nodes. The preoperative assessment of lymph nodes by imaging, as well as the intraoperative assessment by sentinel nodes will be discussed. Finally, the prognostic and therapeutic implications of lymphadenectomy in cervical cancer will be reviewed.
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Affiliation(s)
- L T Gien
- Division of Gynecologic Oncology, Odette Cancer Centre, Toronto, Ontario, Canada
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172
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Povoski SP, Neff RL, Mojzisik CM, O'Malley DM, Hinkle GH, Hall NC, Murrey DA, Knopp MV, Martin EW. A comprehensive overview of radioguided surgery using gamma detection probe technology. World J Surg Oncol 2009; 7:11. [PMID: 19173715 PMCID: PMC2653072 DOI: 10.1186/1477-7819-7-11] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2008] [Accepted: 01/27/2009] [Indexed: 02/08/2023] Open
Abstract
The concept of radioguided surgery, which was first developed some 60 years ago, involves the use of a radiation detection probe system for the intraoperative detection of radionuclides. The use of gamma detection probe technology in radioguided surgery has tremendously expanded and has evolved into what is now considered an established discipline within the practice of surgery, revolutionizing the surgical management of many malignancies, including breast cancer, melanoma, and colorectal cancer, as well as the surgical management of parathyroid disease. The impact of radioguided surgery on the surgical management of cancer patients includes providing vital and real-time information to the surgeon regarding the location and extent of disease, as well as regarding the assessment of surgical resection margins. Additionally, it has allowed the surgeon to minimize the surgical invasiveness of many diagnostic and therapeutic procedures, while still maintaining maximum benefit to the cancer patient. In the current review, we have attempted to comprehensively evaluate the history, technical aspects, and clinical applications of radioguided surgery using gamma detection probe technology.
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Affiliation(s)
- Stephen P Povoski
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH, 43210, USA
| | - Ryan L Neff
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH, 43210, USA
| | - Cathy M Mojzisik
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH, 43210, USA
- Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
| | - David M O'Malley
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH, 43210, USA
| | - George H Hinkle
- Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
- College of Pharmacy, The Ohio State University, Columbus, OH, 43210, USA
| | - Nathan C Hall
- Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Douglas A Murrey
- Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Michael V Knopp
- Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Edward W Martin
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH, 43210, USA
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173
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van de Lande J, Davelaar EM, von Mensdorff-Pouilly S, Water TJ, Berkhof J, van Baal WM, Kenemans P, Verheijen RH. SCC-Ag, lymph node metastases and sentinel node procedure in early stage squamous cell cervical cancer. Gynecol Oncol 2009; 112:119-25. [DOI: 10.1016/j.ygyno.2008.09.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Revised: 09/25/2008] [Accepted: 09/28/2008] [Indexed: 10/21/2022]
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174
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[Minutes of the working group on gynecopathology and breast pathology. On the occasion of the 92nd Annual Congress of the German Society for Pathology in Berlin]. DER PATHOLOGE 2008; 29 Suppl 2:374-8. [PMID: 18854997 DOI: 10.1007/s00292-008-1075-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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175
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Mechsner S, Weichbrodt M, Riedlinger WFJ, Bartley J, Kaufmann AM, Schneider A, Köhler C. Estrogen and progestogen receptor positive endometriotic lesions and disseminated cells in pelvic sentinel lymph nodes of patients with deep infiltrating rectovaginal endometriosis: a pilot study. Hum Reprod 2008; 23:2202-9. [PMID: 18635532 DOI: 10.1093/humrep/den259] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Deep infiltrating endometriosis (DIE) shows similarities to malignant diseases. A recent study involving DIE patients found endometriosis in mesorectal lymph nodes (LNs) after segmental bowel resection. However, it is unclear whether this observation is a local phenomenon or a sign of systemic disease. Therefore, we conducted a prospective study to investigate the occurrence of endometriosis in pelvic sentinel lymph nodes (SLNs) in patients with DIE. METHODS Fourteen patients underwent primary surgery for symptomatic DIE. Combined vaginal laparoscopic-assisted resection of the rectovaginal septum was performed. Dye was injected into the visible/palpable nodule. SLNs were removed from the iliac region. In order to identify endometriotic cells, immunohistochemical analysis of estrogen and progestogen receptors, CD10 and cytokeratin was performed. RESULTS In 12 out of 14 patients with DIE, SLNs were detected. The localization of the SLN followed the typical LN spread of the upper vagina. In three patients, we could detect typical endometriotic lesions in the LNs. Ten out of 12 (83.3%) SLNs showed disseminated estrogen and/or progestogen positive cells. CONCLUSIONS By using immunohistochemistry, we could demonstrate endometriotic lesions and endometriotic-like cells in pelvic SLNs of patients with DIE suggesting the potential for lymphatic spread of the disease.
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Affiliation(s)
- S Mechsner
- Department of Gynecology, Endometriosis Research Center Charité, Charité, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany.
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176
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Gien LT, Covens A. Quality Control in Sentinel Lymph Node Biopsy in Cervical Cancer. J Clin Oncol 2008; 26:2930-1. [DOI: 10.1200/jco.2008.16.3964] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Lilian T. Gien
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Allan Covens
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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