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Weissinger M, Bala L, Brucker SY, Kommoss S, Hoffmann S, Seith F, Nikolaou K, la Fougère C, Walter CB, Dittmann H. Additional Value of FDG-PET/MRI Complementary to Sentinel Lymphonodectomy for Minimal Invasive Lymph Node Staging in Patients with Endometrial Cancer: A Prospective Study. Diagnostics (Basel) 2024; 14:376. [PMID: 38396415 PMCID: PMC10887690 DOI: 10.3390/diagnostics14040376] [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: 01/03/2024] [Revised: 02/04/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Lymph node metastases (LNM) are rare in early-stage endometrial cancer, but a diagnostic systematic lymphadenectomy (LNE) is often performed to achieve reliable N-staging. Therefore, this prospective study aimed to evaluate the benefit of [18F]-Fluorodeoxyglucose (FDG) PET/MRI complementary to SPECT/CT guided sentinel lymphonodectomy (SLNE) for a less invasive N-staging Methods: 79 patients underwent a whole-body FDG-PET/MRI, SLN mapping with 99mTc-Nanocolloid SPECT/CT and indocyanine green (ICG) fluoroscopy followed by LNE which served as ground truth. RESULTS FDG-PET/MRI was highly specific in N-staging (97.2%) but revealed limited sensitivity (66.7%) due to missed micrometastases. In contrast, bilateral SLN mapping failed more often in patients with macrometastases. The combination of SLN mapping and FDG-PET/MRI increased the sensitivity from 66.7% to 77.8%. Additional SLN labeling with dye (ICG) revealed a complete SLN mapping in 80% (8/10) of patients with failed or incomplete SLN detection in SPECT/CT, reducing the need for diagnostic systematic LNE up to 87%. FDG-PET/MRI detected para-aortic LNM in three out of four cases and a liver metastasis. CONCLUSIONS The combination of FDG-PET/MRI and SLNE can reduce the need for diagnostic systematic LNE by up to 87%. PET/MRI complements the SLN technique particularly in the detection of para-aortic LNM and occasional distant metastases.
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Affiliation(s)
- Matthias Weissinger
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, 72076 Tuebingen, Germany
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, 72076 Tuebingen, Germany (C.l.F.); (H.D.)
| | - Lidia Bala
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, 72076 Tuebingen, Germany (C.l.F.); (H.D.)
| | - Sara Yvonne Brucker
- Department of Women’s Health, University Hospital Tuebingen, 72076 Tuebingen, Germany; (S.Y.B.)
| | - Stefan Kommoss
- Department of Women’s Health, University Hospital Tuebingen, 72076 Tuebingen, Germany; (S.Y.B.)
- Gynecologic Oncology, Diakonie-Hospital Schwäbisch Hall, 74523 Schwäbisch Hall, Germany
| | - Sascha Hoffmann
- Department of Women’s Health, University Hospital Tuebingen, 72076 Tuebingen, Germany; (S.Y.B.)
| | - Ferdinand Seith
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, 72076 Tuebingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, 72076 Tuebingen, Germany
- Image-Guided and Functionally Instructed Tumor Therapies (iFIT)-Cluster of Excellence, Eberhard Karls University, 72076 Tuebingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tuebingen, 72076 Tuebingen, Germany
| | - Christian la Fougère
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, 72076 Tuebingen, Germany (C.l.F.); (H.D.)
- Image-Guided and Functionally Instructed Tumor Therapies (iFIT)-Cluster of Excellence, Eberhard Karls University, 72076 Tuebingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tuebingen, 72076 Tuebingen, Germany
| | | | - Helmut Dittmann
- Department of Nuclear Medicine and Clinical Molecular Imaging, University Hospital Tuebingen, 72076 Tuebingen, Germany (C.l.F.); (H.D.)
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Uterine allograft removal by total laparoscopic hysterectomy after successful cesarean delivery in a living-donor uterus recipient with uterovaginal agenesis (MRKHS). Arch Gynecol Obstet 2023; 307:827-840. [PMID: 36342536 PMCID: PMC9984324 DOI: 10.1007/s00404-022-06796-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/15/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE To limit the burden of long-term immunosuppression (IS) after uterus transplantation (UTx), removal of the uterine allograft is indicated after maximum two pregnancies. Hitherto this has required graft hysterectomy by laparotomy. Our objective was to demonstrate, as a proof of concept, the feasibility of less traumatic transplantectomy by total laparoscopic hysterectomy (TLH). PATIENT A 37-year-old woman with uterovaginal agenesis due to Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) who had undergone neovaginoplasty at age 19 years prior to living-donor (LD) UTx in 10/2019 at age 35 years gave birth to a healthy boy by primary cesarean section in 06/2021. During pregnancy, she developed impaired renal function, with bilateral hydronephrosis, necessitating early allograft removal in 09/2021 to prevent chronic kidney disease, particularly during a potential second pregnancy. METHODS Transplantectomy by TLH essentially followed standard TLH procedures. We paid meticulous attention to removing as much donor tissue as possible to prevent postoperative complications from residual donor tissue after stopping IS, as well as long-term vascular damage. RESULTS TLH was performed successfully without the need to convert to open surgery. Surgical time was 90 min with minimal blood loss. No major complications occurred intra- or postoperatively and during the subsequent 9-month follow-up period. Kidney function normalized. CONCLUSIONS To our knowledge, we report the first successful TLH-based removal of a uterine allograft in a primipara after LD UTx, thus demonstrating the feasibility of TLH in uterus recipients with MRKHS.
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Crivellaro C, Baratto L, Dolci C, De Ponti E, Magni S, Elisei F, Papadia A, Buda A. Sentinel node biopsy in endometrial cancer: an update. Clin Transl Imaging 2018. [DOI: 10.1007/s40336-018-0268-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Pericervical Injection of 99mTc-Nanocolloid Is Superior to Peritumoral Injection for Sentinel Lymph Node Detection of Endometrial Cancer in SPECT/CT. Clin Nucl Med 2017; 41:927-932. [PMID: 27749429 DOI: 10.1097/rlu.0000000000001414] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Scintigraphic mapping of sentinel lymph node (SLN) is increasingly performed in patients with endometrial carcinoma although its routine clinical use is still under investigation. The purpose of this study was to compare preoperative SLN detection by means of SPECT/CT using pericervical (PC) versus hysteroscopic peritumoral (PT) injection. PATIENTS AND METHODS One hundred forty consecutive patients with endometrial carcinoma who underwent surgery and preoperative SLN SPECT/CT with Tc-nanocolloid were included. Seventy women received hysteroscopic injection at 3 PT sites, and 70 women received PC injection at 3-, 6-, 9-, and 12-o'clock positions. Each patient underwent SPECT/CT followed by modified radical hysterectomy with lymphadenectomy on the day after. Histopathological results were collected for validation. RESULTS Three hundred thirty-four SLNs were detected by SPECT/CT in 106 patients (mean, 3.15; range, 1-9). The detection rate after PC nanocolloid injection was 83% versus 69% after PT injection (Pearson χ test, P = 0.049). However, PT application resulted in a higher rate of para-aortic SLNs (PC: 60% vs PT: 38% of positive scans, P = 0.02). SPECT/CT yielded an overall sensitivity of 70% for the SLN detection in women with lymph node metastases with 3 false-negative cases. Failure to detect SLN was mostly associated with uptake in the reticuloendothelial system (liver, spleen, and bone marrow) or peritoneal diffusion in both cohorts. Negative scans after PT application often showed a minor to even failing injection depot. CONCLUSIONS Pericervical injection leads to a significantly better detection rate of SLN on SPECT/CT while reducing invasiveness of the injection procedure. Failure to detect SLN seems to be associated with major venous drainage.
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Sentinel-node mapping in endometrial cancer patients: comparing SPECT/CT, gamma-probe and dye. Ann Nucl Med 2016; 31:93-99. [PMID: 27815812 DOI: 10.1007/s12149-016-1137-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 10/13/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The aim of this study was to compare preoperative SPECT/CT with gamma-probe and methylene blue-dye (MBD) in the identification of sentinel lymph node (SLN) in early stage endometrial cancer. METHODS 40 stage-I EC patients (66.7 ± 9.7 years) underwent preoperative lymphoscintigraphy. After about 3 h from Tc-99m-albumin nanocolloid cervical injection, all patients underwent SPECT/CT study. MBD was injected into the cervix just before surgery under general anesthesia. All patients underwent SLN biopsy, hysterectomy, bilateral salpingo-oophorectomy, and radical regional lymphadenectomy. SPECT/CT findings were compared to those of gamma-probe and MBD techniques. RESULTS In 2 patients no nodal migration was observed, neither with MBD nor radiotracer. Detection rate of at least one SLN was 90% (36/40 patients) with SPECT/CT, 88% (35/40) intra-operatively with gamma-probe and 80% (32/40) with MBD. Only in 7/40 patients a bilateral migration was obtained with all considered modalities. In particular, bilateral detection was achieved in 26 patients with SPECT/CT, in 24 with gamma-probe and in 10 patients with MBD. The concordance site between SPECT/CT and intraoperative gamma-probe was 73% (29/40 patients: 2 without migration, 21 bilateral and 6 monolateral SLNs); while concordance site with MBD was found in 40% (16/40: 8 bilateral, 6 monolateral SLNs, 2 without SLNs). Overall, 628 LNs were dissected (mean 18 LNs per patient). The median number of SLNs removed was 2 (mean 2.5 per patient). Out of 91 SLNs: 43 were "hot and blue (HB)", 10 were blue only and 38 were hot only. LN metastases rate was 16%: 9/90 SLNs (7 HB, 2 hot only) were positive for metastases in 6 patients. Four non-SLNs were found positive in 3 patients, and all presented concomitant positive SLNs. False negative rate was 0%. CONCLUSIONS SPECT/CT had the highest detection rate and achieved the highest rate of bilateral mapping, compared to gamma-probe and MDB. SPECT/CT had moderate concordance with gamma-probe, and it can help the intraoperative detection of SLNs providing important information about their anatomic location.
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Ehrisman J, Secord AA, Berchuck A, Lee PS, Di Santo N, Lopez-Acevedo M, Broadwater G, Valea FA, Havrilesky LJ. Performance of sentinel lymph node biopsy in high-risk endometrial cancer. Gynecol Oncol Rep 2016; 17:69-71. [PMID: 27453926 PMCID: PMC4941561 DOI: 10.1016/j.gore.2016.04.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 04/11/2016] [Accepted: 04/16/2016] [Indexed: 11/30/2022] Open
Abstract
Objective To determine the rate and performance of sentinel lymph node (SLN) mapping among women with high-risk endometrial cancers. Methods Patients diagnosed between 2012 and 2015 with uterine cancer of grade 3 endometrioid, clear cell, serous or carcinosarcoma histology and who underwent SLN mapping prior to full pelvic lymph node dissection were included. Subjects underwent methylene blue or ICG injection for laparoscopic (N = 16) or robotic-assisted laparoscopic (N = 20) staging. Outcomes included SLN mapping rates, SLN and non-SLN positive rates, false negative SLN algorithm rate, and the negative predictive value (NPV) of the SLN algorithm. Fisher's exact test was used to compare mapping and node positivity rates. Results 9/36 (25%) patients with high-risk uterine cancer had at least one metastatic lymph node identified. Successful mapping occurred in 30/36 (83%) patients. SLN mapped to pelvic nodes bilaterally in 20 (56%), unilaterally in 9 (25%), and aortic nodes only in 1 (3%). Malignancy was identified in 14/95 (15%) of all sentinel nodes and 12/775 (1.5%) of all non-sentinel nodes (p < 0.001). The false negative rate of SLN mapping alone was 2/26 (7.7%); the NPV was 92.3%. When the SLN algorithm was applied retrospectively the false negative rate was 0/31 (0%); the NPV was 100%. Conclusion SLN mapping rates for high-risk cancers are slightly lower than in prior reports of lower risk cancers. The NPV of the SLN mapping alone is 92% and rises to 100% when the SLN algorithm is applied. Such results are acceptable and consistent with larger subsets of lower risk endometrial cancers.
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Affiliation(s)
- Jessie Ehrisman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States; Duke Cancer Institute, Durham, NC, United States
| | - Andrew Berchuck
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States; Duke Cancer Institute, Durham, NC, United States
| | - Paula S Lee
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States; Duke Cancer Institute, Durham, NC, United States
| | - Nicola Di Santo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States
| | - Micael Lopez-Acevedo
- Department of Obstetrics & Gynecology, George Washington University Hospital, Washington DC, United States
| | - Gloria Broadwater
- Biostatistics, Duke University Medical Center, Durham, NC, United States
| | - Fidel A Valea
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States; Duke Cancer Institute, Durham, NC, United States
| | - Laura J Havrilesky
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, United States; Duke Cancer Institute, Durham, NC, United States
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Rimbach S, Neis K, Solomayer E, Ulrich U, Wallwiener D. Current and Future Status of Laparoscopy in Gynecologic Oncology. Geburtshilfe Frauenheilkd 2014; 74:852-859. [PMID: 25278627 PMCID: PMC4175127 DOI: 10.1055/s-0034-1383075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 08/22/2014] [Accepted: 08/22/2014] [Indexed: 12/27/2022] Open
Abstract
Laparoscopy is playing an increasingly important role in gynecologic oncology. The benefits of minimally invasive surgery for oncology patients and the quality of this treatment are well documented. Outcomes and quality of minimally invasive surgical procedures to treat cervical cancer were evaluated based on retrospective and case-control studies; outcomes and quality after minimally invasive treatment für early-stage low-risk endometrial cancer were also assessed in prospective randomized studies. If indicated, laparoscopic lymphadenectomy is both technically feasible and oncologically safe. Adipose patients in particular benefit from minimally invasive procedures, where feasible. The potential role of laparoscopy in neoadjuvant therapy for ovarian cancer and in surgery for early-stage ovarian carcinoma is still controversially discussed and is currently being assessed in further studies. Using a minimally invasive approach in gynecologic oncology procedures demands strict adherence to oncological principles and requires considerable surgical skill.
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Affiliation(s)
- S. Rimbach
- Gynäkologie und Geburtshilfe, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - K. Neis
- Praxis Frauenärzte am Staden, Saarbrücken
| | - E. Solomayer
- Gynäkologie und Geburtshilfe, Univ.-klinik des Saarlandes, Homburg/Saar
| | - U. Ulrich
- Gynäkologie und Geburtshilfe, Martin-Luther-Krankenhaus, Berlin
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