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

Mexican consensus about surgical treatment in early-stage cervicouterine cancer

Introduction

Cervical cancer is a public health problem in our country and worldwide. Less than 25% of cases are diagnosed in the early stages, where survival is more remarkable than 90% at five years. Here, we review surgical treatment in the early stages of cervical cancer.

Methodology

A literature review was carried out in the MEDLINE database. The search was mainly limited to the English language, with priority given to systematic reviews with or without meta-analysis and randomized studies. However, only retrospective or observational evidence was found for some topics.

Results

The standard treatment for early-stage cervical cancer is hysterectomy, and its radical nature will depend on the tumor size, lymphovascular permeation, and tumor-specific prognostic factors. Furthermore, the type of surgery (hysterectomy or trachelectomy) will rely on the patient's desire to preserve fertility. Nodal evaluation is indicated as part of the treatment from stage IAI with PLV. However, the sentinel lymph node is more relevant in the treatment. The incidental finding of cervical cancer after a hysterectomy requires a multidisciplinary evaluation to determine the therapeutic approach. Less radical surgery has been described as oncologically safe in low-risk groups.

Conclusion

Surgical treatment in its early stages has evolved in recent decades, making it more individualized and seeking less morbidity in patients without compromising their survival.

The Sentinel Lymph Node in Treatment Planning: A Narrative Review of Lymph-Flow-Guided Radiotherapy

The sentinel lymph node technique is minimally invasive and used routinely by surgeons, reducing the need for morbid extensive lymph node dissections, which is a significant advantage for cancer staging and treatment decisions. The sentinel lymph node could also help radiation oncologists to identify tumor drainage for each of their patients, leading to a more personalized radiotherapy, instead of a probabilistic irradiation based on delineation atlases. The aim is both to avoid recurrence in unexpected areas and to limit the volume of irradiated healthy tissues. The aim of our study is to evaluate the impact of sentinel lymph node mapping for radiation oncologists. This concept, relying on sentinel lymph node mapping for treatment planning, is known as lymph-flow-guided radiotherapy. We present an up-to-date narrative literature review showing the potential applications of the sentinel lymph node technique for radiotherapy, as well as the limits that need to be addressed before its routine usage.

Lymph Node Mapping for Tumor Micrometastasis

Lymph node mapping for tumor micrometastasis is of great significance for the prevention, prognosis, and treatment of cancer. Currently, the traditional clinical detection methods (computed tomography, magnetic resonance imaging, or positron emission tomography/computed tomography) in clinical lymph node mapping still have some inherent disadvantages, which have prompted the development of various fluorescent probes for lymph node mapping. However, the conventional fluorescent probes such as indocyanine green or methylene blue in lymph node mapping are still accompanied by several problems such as impaired surgical field vision due to dye staining or less accumulation and shorter retention time in the lymph node. In a recent achievement, newly designed nanoparticles are prepared with novel properties that could be attractive for lymph node mapping. In this review, we will provide details on the progress of various nanoparticles for lymph node mapping and emphasize other multivariant properties in different nanoparticles, including strong tumor-targeting affinity and specificity, self-luminescence, and even with the function to kill metastatic cancer cells.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predictive value of sentinel lymph node imaging and biopsy in early cervical cancers: correlation with scintigraphic uptake patterns and histology

AIM

This study was designed to 1) assess the feasibility, standardization of sentinel lymph node imaging (SLNI) and biopsy in early cervical cancers and also to determine the detection rates. 2) To analyze the SLN uptake pattern and correlate the findings with the histological grades of tumor.

MATERIALS AND METHODS

52 early cervical cancer patients underwent same-day Tc sulfur colloid (filtered) SLNI and biopsy with gamma probing. Patients underwent radical hysterectomy, para-aortic and pelvic lymphadenectomy irrespective of sentinel lymph node biopsy (SLNB) findings. We analyzed the colloid transit times, uptake pattern, lymphatic groups involved and histology.

RESULTS

A total of 203 hot nodes (100% detection rate) were detected and harvested. Study showed 100% sensitivity, specificity, and negative predictive value. Internal iliac nodes were predominantly involved. Lymphatic uptake patterns were graded and correlated with tumor histology (Ki index). Transit time was relatively prolonged in patients with aggressive tumors.

CONCLUSION

SLNI and biopsy in early cervical malignancies are feasible with high detection rate. Scintigraphic patterns of nodal uptake were relevant and found to correlate with the tumor histological grades. We found that nonfocal nodal uptake patterns were mainly encountered in patients with tumors having higher Ki index. Immunohistochemistry further facilitated identification of lymph nodal metastases. The visual grading system, implemented in this study provides a good indication of the degree of impairment of lymphatic drainage. Higher visual scintigraphic grade denotes greater lymphatic tumor burden.

The impact of modern preoperative high-dose-rate brachytherapy in early-stage cervical cancer

PURPOSE

To analyze the clinical outcomes and the safety of preoperative high-dose-rate (HDR) image-guided adaptive brachytherapy (IGABT) followed by minimally invasive surgery (MIS) in the multidisciplinary management of early-stage cervical cancer.

METHODS AND MATERIALS

Medical records of all consecutive patients with early-stage cervical cancer treated at our institution between 2012 and 2018 with preoperative IGABT in a multidisciplinary approach were reviewed. Treatment schedule was pelvic node dissection, preoperative IGABT followed 6-8 week later by MIS hysterectomy.

RESULTS

Seventy patients with cervical cancer FIGO stages (IB1 18.6%, IB2 75.7% and IIA1 5.7%) were treated by preoperative HDR brachytherapy. With a median follow-up of 37.4 months [95% confidence interval, 32.1-39.7 months] isolated vaginal vault recurrence was not observed, 3 pelvic relapses were reported (4.3%). None of patients received postoperative radiotherapy (EBRT) or radiochemotherapy. The estimated 3-year local and pelvis relapse free survival for the entire population were respectively 98% [95% confidence interval, 89%-100%] and 90% [80%-96%]. The estimated 3-year disease-free survival (DFS) for the entire population was 88% [77-94%]. The 3-year overall survival (OS) rate was 97% [88%-99%]. Microscopic vaginal resection margin (R1) was observed in one patient ([1].4%). Lymph-vascular space invasion (LVSI) was found found in 6 (8.6%) patients. Forty-eight late complications in 36 patients (51.4%) were observed. Five (7.1%) grade 3 vaginal wound dehiscence toxicities were observed. Urinary and gastrointestinal toxicities were grade 1-2. No grade 4-5 complications were observed.

CONCLUSIONS

Preoperative image-guided adaptive brachytherapy followed by minimally invasive surgery allows high local control, reduces positive surgical margins and rates of lymph-vascular space invasion avoiding adjuvants treatments. Surgical approaches must be discussed with patients including preoperative brachytherapy as a down-staging treatment.

The impact of low-volume metastasis on disease-free survival of women with early-stage cervical cancer

PURPOSE

We aimed to assess the impact of low-volume metastasis (micrometastasis and isolated tumor cells) on disease-free survival (DFS) of women with early-stage cervical cancer.

METHODS

Women with clinically suspected stage 1A-IB2 (FIGO 2018 classification) disease who underwent retroperitoneal nodal staging between October 2010 and April 2018, were retrospectively analyzed. The group of women who had undergone lymphadenectomy and standard node pathologic analysis (H&E group), were compared to the group undergoing sentinel node mapping (SLN) and ultrastaging with or without lymphadenectomy (ultrastaging group). At a median follow-up of 45 months, the DFS curves were analyzed.

RESULTS

Overall, 573 patients were revised (272 in the H&E group and 302 in the ultrastaging group). Eighty-five patients presented lymph node metastasis (32 in H&E, 53 in ultrastaging). Ultrastaging protocol increased the rate of low-volume metastasis by 5.6%. Twenty patients showed exclusive micrometastasis or ITC's. Seventy-three recurrences occurred (35 in H&E, 38 in ultrastaging). Only 1 out of 53 patients in the ultrastaging group (1.9%) presented with micrometastasis recurred. The 3-year disease-free survival was 89% for the H&E group, and 88% for the ultrastaging group, respectively (p = 0.175).

CONCLUSION

Ultrastaging analysis allowed increasing the detection of low volume metastasis in women with early-stage cervical cancer. However, the type of nodal staging did not have an impact on patients' 3-year disease-free survival.