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Minareci Y, Sozen H, Altinkara Hacioglu B, Yuvanc HO, Topuz S, Salihoglu MY. Sentinel lymph node biopsy with carbon dye in endometrial cancer: a single center, prospective cohort study. Surg Endosc 2024; 38:1608-1616. [PMID: 38291161 PMCID: PMC10881722 DOI: 10.1007/s00464-023-10662-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 12/22/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Many agents have been used for the detection of sentinel lymph nodes in endometrial cancer. Carbon dye, which has a strong staining ability and high contrast due to its dark black color, identifies the lymph nodes efficiently. Our aim was to evaluate the safety and efficacy of carbon dye for the detection of sentinel lymph nodes in endometrial cancer. METHODS We conducted a single-center, prospective, cohort study in 89 patients with early-stage endometrial cancer between September 2021 and August 2022. The procedure was performed under laparoscopy. RESULTS The sensitivity and negative predictive value of the sentinel lymph node biopsy (SLNB) with carbon dye injection were 83.3% and 98.8%, respectively. Mapping identified at least one sentinel lymph node in 84 patients (94.4%) on one pelvic side and at least one sentinel lymph node in 73 patients (82.0%) on each pelvic side out of 89 patients. In addition, no carbon dye-associated allergic reaction was detected. CONCLUSION Carbon dye is a non-allergenic, inexpensive, and effective agent for SLNB with a satisfying sensitivity and a negative predictive value. In addition, both unilateral and bilateral detection rates were sufficient. Accordingly, carbon dye may be a promising tracer and a considerable option, particularly for low-income countries.
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Affiliation(s)
- Yagmur Minareci
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Faculty of Medicine, Istanbul Medical Faculty, Istanbul University, Turgut Ozal Millet Cd, Monoblok Binasi, No:118, Zemin Kat, Jinekolojik Onkoloji Poliklinigi, Capa, Fatih, 34093, Istanbul, Turkey.
| | - Hamdullah Sozen
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Faculty of Medicine, Istanbul Medical Faculty, Istanbul University, Turgut Ozal Millet Cd, Monoblok Binasi, No:118, Zemin Kat, Jinekolojik Onkoloji Poliklinigi, Capa, Fatih, 34093, Istanbul, Turkey
| | | | - Huseyin Oguz Yuvanc
- Department of Gynecology and Obstetrics, Eskisehir City Hospital, Eskisehir, Turkey
| | - Samet Topuz
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Faculty of Medicine, Istanbul Medical Faculty, Istanbul University, Turgut Ozal Millet Cd, Monoblok Binasi, No:118, Zemin Kat, Jinekolojik Onkoloji Poliklinigi, Capa, Fatih, 34093, Istanbul, Turkey
| | - Mehmet Yavuz Salihoglu
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Faculty of Medicine, Istanbul Medical Faculty, Istanbul University, Turgut Ozal Millet Cd, Monoblok Binasi, No:118, Zemin Kat, Jinekolojik Onkoloji Poliklinigi, Capa, Fatih, 34093, Istanbul, Turkey
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Lucas K, Melling N, Giannou AD, Reeh M, Mann O, Hackert T, Izbicki JR, Perez D, Grass JK. Lymphatic Mapping in Colon Cancer Depending on Injection Time and Tracing Agent: A Systematic Review and Meta-Analysis of Prospective Designed Studies. Cancers (Basel) 2023; 15:3196. [PMID: 37370806 PMCID: PMC10296374 DOI: 10.3390/cancers15123196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/08/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
An optimized lymph node yield leads to better survival in colon cancer, but extended lymphadenectomy is not associated with survival benefits. Lymphatic mapping shows several colon cancers feature aberrant drainage pathways inducing local recurrence when not resected. Currently, different protocols exist for lymphatic mapping procedures. This meta-analysis assessed which protocol has the best capacity to detect tumor-draining and possibly metastatic lymph nodes. A systematic review was conducted according to PRISMA guidelines, including prospective trials with in vivo tracer application. The risk of bias was evaluated using the QUADAS-2 tool. Traced lymph nodes, total resected lymph nodes, and aberrant drainage detection rate were analyzed. Fifty-eight studies met the inclusion criteria, of which 42 searched for aberrant drainage. While a preoperative tracer injection significantly increased the traced lymph node rates compared to intraoperative tracing (30.1% (15.4, 47.3) vs. 14.1% (11.9, 16.5), p = 0.03), no effect was shown for the tracer used (p = 0.740) or the application sites comparing submucosal and subserosal injection (22.9% (14.1, 33.1) vs. 14.3% (12.1, 16.8), p = 0.07). Preoperative tracer injection resulted in a significantly higher rate of detected aberrant lymph nodes compared to intraoperative injection (26.3% [95% CI 11.5, 44.0] vs. 2.5% [95% CI 0.8, 4.7], p < 0.001). Analyzing 112 individual patient datasets from eight studies revealed a significant impact on aberrant drainage detection for injection timing, favoring preoperative over intraoperative injection (OR 0.050 [95% CI 0.010-0.176], p < 0.001) while indocyanine green presented itself as the superior tracer (OR 0.127 [95% CI 0.018-0.528], p = 0.012). Optimized lymphatic mapping techniques result in significantly higher detection of aberrant lymphatic drainage patterns and thus enable a personalized approach to reducing local recurrence.
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Affiliation(s)
- Katharina Lucas
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (K.L.); (N.M.); (A.D.G.); (M.R.); (O.M.); (T.H.); (J.R.I.); (D.P.)
- Department of Visceral, Thoracic, Vascular Surgery and Angiology, City Hospital Triemli, Birmensdorferstrasse 497, 8063 Zürich, Switzerland
| | - Nathaniel Melling
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (K.L.); (N.M.); (A.D.G.); (M.R.); (O.M.); (T.H.); (J.R.I.); (D.P.)
| | - Anastasios D. Giannou
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (K.L.); (N.M.); (A.D.G.); (M.R.); (O.M.); (T.H.); (J.R.I.); (D.P.)
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (K.L.); (N.M.); (A.D.G.); (M.R.); (O.M.); (T.H.); (J.R.I.); (D.P.)
| | - Oliver Mann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (K.L.); (N.M.); (A.D.G.); (M.R.); (O.M.); (T.H.); (J.R.I.); (D.P.)
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (K.L.); (N.M.); (A.D.G.); (M.R.); (O.M.); (T.H.); (J.R.I.); (D.P.)
| | - Jakob R. Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (K.L.); (N.M.); (A.D.G.); (M.R.); (O.M.); (T.H.); (J.R.I.); (D.P.)
| | - Daniel Perez
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (K.L.); (N.M.); (A.D.G.); (M.R.); (O.M.); (T.H.); (J.R.I.); (D.P.)
- Department of General and Visceral Surgery, Asklepios Hospital Altona, Paul-Ehrlich-Straße 1, 22763 Hamburg, Germany
| | - Julia K. Grass
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; (K.L.); (N.M.); (A.D.G.); (M.R.); (O.M.); (T.H.); (J.R.I.); (D.P.)
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Weixler B, Ramser M, Warschkow R, Viehl CT, Vaughan-Shaw PG, Zettl A, Kettelhack C, Zuber M. The Value of Sentinel Lymph Node Mapping for the Staging of Node-Negative Colon Cancer: Propensity Score and Mediation Analyses. ANNALS OF SURGERY OPEN 2021; 2:e084. [PMID: 37635823 PMCID: PMC10455289 DOI: 10.1097/as9.0000000000000084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/29/2021] [Indexed: 11/27/2022] Open
Abstract
Objectives Mediation analysis to assess the protective impact of sentinel lymph node (SLN) mapping on prognosis and survival of patients with colon cancer through a more precise evaluation of the lymph node (LN) status. Background Up to 20% of patients with node-negative colon cancer develop disease recurrence. Conventional histopathological LN examination may be limited in describing the real metastatic burden of LN. Methods Data of 312 patients with stage I & II colon cancer was collected prospectively. Patients were either staged using intraoperative SLN mapping with multilevel sectioning and immunohistochemical staining of the SLN or conventional techniques. The value of the SLN mapping for the detection of truly node-negative patients was assessed using Cox regression and mediation analysis. Results SLN mapping was performed in 143 patients. Disease recurrence was observed in 13 (9.1%) patients staged with SLN mapping and in 27 (16%) staged conventionally. Five-year overall survival (OS) rate was 82.7% (95% confidence interval [CI], 76.5-89.4%) with SLN mapping compared with 65.8% (95% CI, 58.8-73.7%). Five-year cancer-specific survival (CSS) was 95.1% (95% CI, 91.3-99.0%) with SLN mapping compared with 92.5% (95% CI, 88.0-97.2%). Node-negative staging with SLN mapping was associated with significantly better OS (hazard ratio [HR], 0.64; 95% CI, 0.56-0.72; P < 0.001) and CSS (HR, 0.49; 95% CI, 0.39-0.61; P < 0.001) in multivariate analysis. Mediation analysis confirmed a direct protective effect of SLN mapping on OS (HR, 0.78; 95% CI, 0.52-0.96; P < 0.01) and disease-free survival (DFS) (HR, 0.75; 95% CI, 0.48-0.89; P < 0.01). Conclusions Staging performed by SLN mapping with multilevel sectioning provides more accurate results than conventional staging. The observed clinically relevant and statistically significant benefit in OS and DFS is explained by a more accurate detection of positive LN by SLN mapping.
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Affiliation(s)
- Benjamin Weixler
- From the Department of General, Visceral and Vascular Surgery, Campus Benjamin Franklin, Charité University of Medicine Berlin, Berlin, Germany
| | - Michaela Ramser
- Department of Surgery, Cantonal Hospital Olten, Olten, Switzerland
| | - Rene Warschkow
- Department of Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Carsten T. Viehl
- Department of Surgery, Hospital Center Biel/Bienne, Biel/Bienne, Switzerland
| | - Peter G. Vaughan-Shaw
- Colorectal Unit, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom
| | - Andreas Zettl
- Viollier AG, Histopathology/Cytology, Basel, Switzerland
| | - Christoph Kettelhack
- Clarunis Visceral Medicine Center, St. Clara Hospital & University Hospital Basel, Basel, Switzerland
| | - Markus Zuber
- Department of Surgery, Cantonal Hospital Olten, Olten, Switzerland
- Clarunis Visceral Medicine Center, St. Clara Hospital & University Hospital Basel, Basel, Switzerland
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Weixler B, Rickenbacher A, Raptis DA, Viehl CT, Guller U, Rueff J, Zettl A, Zuber M. Sentinel Lymph Node Mapping with Isosulfan Blue or Indocyanine Green in Colon Cancer Shows Comparable Results and Identifies Patients with Decreased Survival: A Prospective Single-Center Trial. World J Surg 2018; 41:2378-2386. [PMID: 28508233 DOI: 10.1007/s00268-017-4051-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Sentinel lymph node (SLN) mapping was reported to improve lymph node staging in colon cancer. This study compares isosulfan blue (IB) with indocyanine green (ICG)-based SLN-mapping and assesses the prognostic value of isolated tumor cells (ITC) and micro-metastases in upstaged patients. METHODS A total of 220 stage I-III colon cancer patients were included in this prospective single-center study. In 170 patients, SLN-mapping was performed in vivo with IB and in 50 patients ex vivo with ICG. Three levels of each SLN were stained with H&E. If negative for tumor infiltration, immunostaining for cytokeratin (AE1/3; cytokeratin-19) was performed. RESULTS SLN detection rate for IB and ICG was 100 and 98%, respectively. Accuracy and sensitivity was 88 and 75% for IB, 82 and 64% for ICG, respectively (p = 0.244). Overall, 149 (68%) patients were node negative. In these patients, ITC and micro-metastases were detected in 26% (31/129) with IB and 17% (5/29) with ICG (p = 0.469). Patients with ITC and micro-metastases did show decreased overall survival (hazard ratio = 1.96, p = 0.09) compared to node negative disease. CONCLUSIONS This study demonstrates a high diagnostic accuracy for both the IB and the ICG SLN-mapping. SLN-mapping upstaged a quarter of patients with node negative colon cancer, and the detected ITC and micro-metastases were an independent negative prognostic marker in multivariate analysis.
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Affiliation(s)
- Benjamin Weixler
- Department of Surgery, University Hospital Basel, Basel, Switzerland.,Department of Surgery, Kantonsspital Olten, 4600, Olten, Switzerland
| | - Andreas Rickenbacher
- Department of Surgery, Kantonsspital Olten, 4600, Olten, Switzerland.,Department of Visceral Surgery, University Hospital Zürich, Zurich, Switzerland
| | - Dimitri Aristotle Raptis
- Department of Surgery, Kantonsspital Olten, 4600, Olten, Switzerland.,Department of Visceral Surgery, University Hospital Zürich, Zurich, Switzerland
| | - Carsten T Viehl
- Department of Surgery, Hospital Center Biel, Biel/Bienne, Switzerland
| | - Ulrich Guller
- Division of Oncology/Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,University Clinic for Visceral Surgery and Medicine, Inselspital Berne, University of Berne, Berne, Switzerland
| | - Jessica Rueff
- Department of Surgery, Kantonsspital Olten, 4600, Olten, Switzerland
| | - Andreas Zettl
- Viollier AG, Histopathology/Cytology, Basel, Switzerland
| | - Markus Zuber
- Department of Surgery, Kantonsspital Olten, 4600, Olten, Switzerland.
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Weixler B, Viehl CT, Warschkow R, Guller U, Ramser M, Sauter G, Zuber M. Comparative Analysis of Tumor Cell Dissemination to the Sentinel Lymph Nodes and to the Bone Marrow in Patients With Nonmetastasized Colon Cancer: A Prospective Multicenter Study. JAMA Surg 2017; 152:912-920. [PMID: 28593306 DOI: 10.1001/jamasurg.2017.1514] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Small nodal tumor infiltrates (SNTI; isolated tumor cells and micrometastases) in sentinel lymph nodes and bone marrow micrometastases (BMM) were independently described as prognostic factors in patients with colon cancer. Objective To examine the association between the occurrence of SNTI and BMM as well as their prognostic relevance. Design, Setting, and Participants This prospective study was conducted at 3 university-affiliated institutions in Switzerland between May 2000 and December 2006. Statistical analyses were performed in October 2016. A total of 122 patients with stage I to III colon cancer were included. Follow-up time exceeded 6 years, with no patients lost to follow-up. Interventions Bone marrow aspiration from the iliac crests and in vivo sentinel lymph node mapping were performed during open standard oncological resection. Bone marrow aspirates were stained with the pancytokeratin marker A45-B/B3. All sentinel lymph nodes underwent multilevel sectioning and were stained with hematoxylin-eosin and the pancytokeratin marker AE1/AE3. Main Outcomes and Measures Association of SNTI in sentinel lymph nodes and BMM in patients with stage I to III colon cancer and the prognostic effect on disease-free survival (DFS) and overall survival (OS). Results Of the 122 patients, 63 (51.6%) were female, with a mean (SD) age of 71.2 (11.7) years. Small nodal tumor infiltrates and BMM were found in a total of 21 patients (17.2%) and 46 patients (37.7%), respectively. The occurrence of BMM was not associated with the presence of SNTI by standard correlation (κ, -0.07; 95% CI, -0.29 to 0.14; P = .49) nor by univariate logistic regression analysis (odds ratio, 0.64; 95% CI, 0.22-1.67; P = .37) or multivariate logistic regression analysis (odds ratio, 1.09; 95% CI, 0.34-3.28; P = .88). The presence of SNTI was an independent negative prognostic factor for DFS (hazard ratio [HR], 2.93; 95% CI, 1.24-6.93; P = .02) and OS (HR, 4.04; 95% CI, 1.56-10.45; P = .005), as was BMM (HR, 2.07; 95% CI, 1.06-4.06; P = .04; and HR, 2.68; 95% CI, 1.26-5.70; P = .01; respectively). The combined detection of BMM and SNTI demonstrated the poorest DFS (HR, 6.73; 95% CI, 2.29-19.76; P = .006) and OS (HR, 5.96; 95% CI, 1.66-21.49; P = .03). Conclusions and Relevance This study demonstrates no association between the occurrence of SNTI and BMM in patients with stage I to III colon cancer. However, both SNTI and BMM are independent negative prognostic factors regarding DFS and OS, and the occurrence of both is associated with significantly worse prognosis compared with either one of them. Trial Registration clinicaltrials.gov Identifier: NCT00826579.
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Affiliation(s)
- Benjamin Weixler
- Department of Surgery, University Hospital Basel, Basel, Switzerland.,Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Carsten T Viehl
- Department of Surgery, University Hospital Basel, Basel, Switzerland.,Department of Surgery, Hospital Center Biel, Biel/Bienne, Switzerland
| | - Rene Warschkow
- Department of Surgery, Kantonsspital St Gallen, St Gallen, Switzerland.,Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Guller
- Department of Oncology and Hematology, Cantonal Hospital St Gallen, St Gallen, Switzerland.,University Clinic for Visceral Surgery and Medicine, Inselspital Berne, University of Berne, Berne, Switzerland
| | - Michaela Ramser
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - Guido Sauter
- Department of Pathology, University Hospital Basel, Basel, Switzerland.,Department of Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Zuber
- Department Surgery, Cantonal Hospital Olten, Olten, Switzerland
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