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Nagar H, Wietek N, Goodall RJ, Hughes W, Schmidt-Hansen M, Morrison J. Sentinel node biopsy for diagnosis of lymph node involvement in endometrial cancer. Cochrane Database Syst Rev 2021; 6:CD013021. [PMID: 34106467 PMCID: PMC8189170 DOI: 10.1002/14651858.cd013021.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Pelvic lymphadenectomy provides prognostic information for those diagnosed with endometrial (womb) cancer and provides information that may influence decisions regarding adjuvant treatment. However, studies have not shown a therapeutic benefit, and lymphadenectomy causes significant morbidity. The technique of sentinel lymph node biopsy (SLNB), allows the first draining node from a cancer to be identified and examined histologically for involvement with cancer cells. SLNB is commonly used in other cancers, including breast and vulval cancer. Different tracers, including colloid labelled with radioactive technetium-99, blue dyes, e.g. patent or methylene blue, and near infra-red fluorescent dyes, e.g. indocyanine green (ICG), have been used singly or in combination for detection of sentinel lymph nodes (SLN). OBJECTIVES To assess the diagnostic accuracy of sentinel lymph node biopsy (SLNB) in the identification of pelvic lymph node involvement in women with endometrial cancer, presumed to be at an early stage prior to surgery, including consideration of the detection rate. SEARCH METHODS We searched MEDLINE (1946 to July 2019), Embase (1974 to July 2019) and the relevant Cochrane trial registers. SELECTION CRITERIA We included studies that evaluated the diagnostic accuracy of tracers for SLN assessment (involving the identification of a SLN plus histological examination) against a reference standard of histological examination of removed pelvic +/- para-aortic lymph nodes following systematic pelvic +/- para-aortic lymphadenectomy (PLND/PPALND) in women with endometrial cancer, where there were sufficient data for the construction of two-by-two tables. DATA COLLECTION AND ANALYSIS Two review authors (a combination of HN, JM, NW, RG, and WH) independently screened titles and abstracts for relevance, classified studies for inclusion/exclusion and extracted data. We assessed the methodological quality of studies using the QUADAS-2 tool. We calculated the detection rate as the arithmetic mean of the total number of SLNs detected out of the total number of women included in the included studies with the woman as the unit of analysis, used univariate meta-analytical methods to estimate pooled sensitivity estimates, and summarised the results using GRADE. MAIN RESULTS The search revealed 6259 unique records after removal of duplicates. After screening 232 studies in full text, we found 73 potentially includable records (for 52 studies), although we were only able to extract 2x2 table data for 33 studies, including 2237 women (46 records) for inclusion in the review, despite writing to trial authors for additional information. We found 11 studies that analysed results for blue dye alone, four studies for technetium-99m alone, 12 studies that used a combination of blue dye and technetium-99m, nine studies that used indocyanine green (ICG) and near infra-red immunofluorescence, and one study that used a combination of ICG and technetium-99m. Overall, the methodological reporting in most of the studies was poor, which resulted in a very large proportion of 'unclear risk of bias' ratings. Overall, the mean SLN detection rate was 86.9% (95% CI 82.9% to 90.8%; 2237 women; 33 studies; moderate-certainty evidence). In studies that reported bilateral detection the mean rate was 65.4% (95% CI 57.8% to 73.0%) . When considered according to which tracer was used, the SLN detection rate ranged from 77.8% (95% CI 70.0% to 85.6%) for blue dye alone (559 women; 11 studies; low-certainty evidence) to 100% for ICG and technetium-99m (32 women; 1 study; very low-certainty evidence). The rates of positive lymph nodes ranged from 5.2% to 34.4% with a mean of 20.1% (95% CI 17.7% to 22.3%). The pooled sensitivity of SLNB was 91.8% (95% CI 86.5% to 95.1%; total 2237 women, of whom 409 had SLN involvement; moderate-certainty evidence). The sensitivity for of SLNB for the different tracers were: blue dye alone 95.2% (95% CI 77.2% to 99.2%; 559 women; 11 studies; low-certainty evidence); Technetium-99m alone 90.5% (95% CI 67.7% to 97.7%; 257 women; 4 studies; low-certainty evidence); technetium-99m and blue dye 91.9% (95% CI 74.4% to 97.8%; 548 women; 12 studies; low-certainty evidence); ICG alone 92.5% (95% CI 81.8% to 97.1%; 953 women; 9 studies; moderate-certainty evidence); ICG and blue dye 90.5% (95% CI 63.2.6% to 98.1%; 215 women; 2 studies; low-certainty evidence); and ICG and technetium-99m 100% (95% CI 63% to 100%; 32 women; 1 study; very low-certainty evidence). Meta-regression analyses found that the sensitivities did not differ between the different tracers used, between studies with a majority of women with FIGO stage 1A versus 1B or above; between studies assessing the pelvic lymph node basin alone versus the pelvic and para-aortic lymph node basin; or between studies that used subserosal alone versus subserosal and cervical injection. It should be noted that a false-positive result cannot occur, as the histological examination of the SLN is unchanged by the results from any additional nodes removed at systematic lymphadenectomy. AUTHORS' CONCLUSIONS The diagnostic test accuracy for SLNB using either ICG alone or a combination of a dye (blue or ICG) and technetium-99m is probably good, with high sensitivity, where a SLN could be detected. Detection rates with ICG or a combination of dye (ICG or blue) and technetium-99m may be higher. The value of a SLNB approach in a treatment pathway, over adjuvant treatment decisions based on uterine factors and molecular profiling, requires examination in a high-quality intervention study.
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Affiliation(s)
- Hans Nagar
- Belfast Health and Social Care Trust, Belfast City Hospital and the Royal Maternity Hospital, Belfast, UK
| | - Nina Wietek
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Richard J Goodall
- Department of Surgery and Cancer , Imperial College London, London, UK
| | - Will Hughes
- Department of Plastic Surgery, Addenbrookes Hospital, Cambridge, UK
| | - Mia Schmidt-Hansen
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, GRACE Centre, Musgrove Park Hospital, Taunton, UK
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Dundr P, Cibula D, Němejcová K, Tichá I, Bártů M, Jakša R. Pathologic Protocols for Sentinel Lymph Nodes Ultrastaging in Cervical Cancer. Arch Pathol Lab Med 2019; 144:1011-1020. [PMID: 31869245 DOI: 10.5858/arpa.2019-0249-ra] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Ultrastaging of sentinel lymph nodes (SLNs) is a crucial aspect in the approach to SLN processing. No consensual protocol for pathologic ultrastaging has been approved by international societies to date. OBJECTIVE.— To provide a review of the ultrastaging protocol and all its aspects related to the processing of SLNs in patients with cervical cancer. DATA SOURCES.— In total, 127 publications reporting data from 9085 cases were identified in the literature. In 24% of studies, the information about SLN processing is entirely missing. No ultrastaging protocol was used in 7% of publications. When described, the differences in all aspects of SLN processing among the studies and institutions are substantial. This includes grossing of the SLN, which is not completely sliced and processed in almost 20% of studies. The reported protocols varied in all aspects of SLN processing, including the thickness of slices (range, 1-5 mm), the number of levels (range, 0-cut out until no tissue left), distance between the levels (range, 40-1000 μm), and number of sections per level (range, 1-5). CONCLUSIONS.— We found substantial differences in protocols used for SLN pathologic ultrastaging, which can impact sensitivity for detection of micrometastases and even small macrometastases. Since the involvement of pelvic lymph nodes is the most important negative prognostic factor, such profound discrepancies influence the referral of patients to adjuvant radiotherapy and could potentially cause treatment failure. It is urgent that international societies agree on a consensual protocol before SLN biopsy without pelvic lymphadenectomy is introduced into routine clinical practice.
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Affiliation(s)
- Pavel Dundr
- From Institute of Pathology (Drs Dundr, Němejcová, Tichá, Bártů, and Jakša) and Gynecologic Oncology Center, Department of Obstetrics and Gynecology (Dr Cibula), First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - David Cibula
- From Institute of Pathology (Drs Dundr, Němejcová, Tichá, Bártů, and Jakša) and Gynecologic Oncology Center, Department of Obstetrics and Gynecology (Dr Cibula), First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Kristýna Němejcová
- From Institute of Pathology (Drs Dundr, Němejcová, Tichá, Bártů, and Jakša) and Gynecologic Oncology Center, Department of Obstetrics and Gynecology (Dr Cibula), First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Ivana Tichá
- From Institute of Pathology (Drs Dundr, Němejcová, Tichá, Bártů, and Jakša) and Gynecologic Oncology Center, Department of Obstetrics and Gynecology (Dr Cibula), First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Michaela Bártů
- From Institute of Pathology (Drs Dundr, Němejcová, Tichá, Bártů, and Jakša) and Gynecologic Oncology Center, Department of Obstetrics and Gynecology (Dr Cibula), First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Radek Jakša
- From Institute of Pathology (Drs Dundr, Němejcová, Tichá, Bártů, and Jakša) and Gynecologic Oncology Center, Department of Obstetrics and Gynecology (Dr Cibula), First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
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Skanjeti A, Dhomps A, Paschetta C, Tordo J, Giammarile F. Sentinel Node Mapping in Gynecologic Cancers: A Comprehensive Review. Semin Nucl Med 2019; 49:521-533. [DOI: 10.1053/j.semnuclmed.2019.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Scambia G, Nero C, Uccella S, Vizza E, Ghezzi F, Cosentino F, Chiantera V, Fagotti A. Sentinel-node biopsy in early stage ovarian cancer: a prospective multicentre study (SELLY). Int J Gynecol Cancer 2019; 29:1437-1439. [PMID: 31601646 DOI: 10.1136/ijgc-2019-000886] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Systematic para-aortic and bilateral pelvic lymphadenectomy is included in the standard comprehensive surgical staging in presumed early epithelial ovarian cancer. No prospective randomized evidence suggests it has potential therapeutic value, and related morbidity is not negligible. PRIMARY OBJECTIVES To assess sensitivity, safety, and feasibility of the sentinel lymph node technique in identifying the presence of lymph node metastases in patients with early stage epithelial ovarian cancer. STUDY HYPOTHESIS Sentinel lymph node detection with indocyanine green can accurately predict nodal status in a cohort of women with early stage epithelial ovarian cancer. TRIAL DESIGN The SELLY trial is a prospective phase II interventional multicenter study. MAJOR INCLUSION/EXCLUSION CRITERIA Inclusion criteria: Eastern Cooperative Oncology Group 0-1, apparent International Federation of Gynecology and Obstetrics (FIGO) stage I-II, histologically proven epithelial ovarian cancer. EXCLUSION CRITERIA evidence of carcinomatosis, mucinous only at definitive histology. ENDPOINTS Primary endpoint is sensitivity (true positive rate). Secondary endpoints include safety (complications rate of the procedure) and feasibility. SAMPLE SIZE Assuming a sensitivity of 98.5% in predicting positive sentinel lymph nodes at histology, a pathological lymph node prevalence of 14.2%, a precision of estimate (ie, the maximum marginal error) d=5%, and a type I error α=0.05, a sample size of 160 patients is needed to test the general hypothesis (ie, to answer whether sentinel lymph nodes identified with indocyanine green can accurately predict nodal status at histology of patients with apparently early epithelial ovarian cancer). Assuming a drop-out rate of 10%, a total of 176 patients will be enrolled in the study. ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS The accrual should be completed by December 2020 and results should be presented by March 2021. TRIAL REGISTRATION The trial is registered at clinicaltrials.gov (NCT03563781).
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Affiliation(s)
- Giovanni Scambia
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Camilla Nero
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Stefano Uccella
- Nuovo Ospedale degli Infermi Dipartimento di Oncologia di Biella, Ponderano, Italy
| | | | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Francesco Cosentino
- Catholic University of the Sacred Heart Campobasso Campus, Campobasso, Italy
| | - Vito Chiantera
- Department of Gynecologic Oncology, ARNAS Civico Di Cristina Benfratelli, Palermo, Italy
- Department of Gynecologic Oncology, University of Palermo, Palermo, Italy
| | - Anna Fagotti
- Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Università Cattolica del Sacro Cuore, Roma, Italy
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Sentinel-node biopsy in early-stage ovarian cancer: preliminary results of a prospective multicentre study (SELLY). Am J Obstet Gynecol 2019; 221:324.e1-324.e10. [PMID: 31082385 DOI: 10.1016/j.ajog.2019.05.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/01/2019] [Accepted: 05/06/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Systematic paraaortic and bilateral pelvic lymphadenectomy is the standard of a comprehensive surgical staging in presumed early epithelial ovarian cancer, but no prospective randomized evidence suggests a possible therapeutic value. Moreover, this procedure is associated with potential severe morbidity. The Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective study designed to test whether sentinel node detection can accurately predict nodal status in a cohort of women with early epithelial ovarian cancer. OBJECTIVES We here present the results of the first part of the Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial, regarding the feasibility of the sentinel lymph node technique and the preliminary findings regarding its safety and accuracy. STUDY DESIGN The Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective, phase II, single-arm study included patients with presumed stages I-II epithelial ovarian cancer planned for immediate or delayed minimally invasive comprehensive staging. The ovarian pedicle is injected with 2 mL of a 1.25 mg/mL indocyanine green solution. The pelvic and lumboaortic retroperitoneum is then accessed and inspected to identify and remove sentinel nodes. After sentinel node procedure, staging is completed including systematic pelvic and paraaortic lymphadenectomy. Assuming a sensitivity of 98.5% in predicting positive sentinel lymph nodes at histology, a pathological lymph node prevalence of 14.2%, a precision of estimate (ie, the maximum marginal error) d = 5%, a type I error α = 0.05, a sample size of 160 patients is needed to test the general hypothesis. Here we present the preliminary results on the first 31 patients enrolled. RESULTS Thirty-one patients were included. Sentinel node was identified in 21 patients (detection rate, 67.7%). The detection rate was significantly higher in women undergoing immediate vs delayed staging (88.9% vs 41.7%, P = .003). Four patients had positive nodes. In all the patients with lymphatic dissemination, a positive sentinel node was identified (sensitivity, 100%; false-negative rate, 0%; negative predictive value, 100%). One (3.2%) intra- and 2 (6.5%) postoperative grade I complications occurred. CONCLUSION Our data show that the detection of sentinel node in early epithelial ovarian cancer is low when patients are submitted to delayed-staging surgery. However, sentinel node procedure is feasible and has the potential to provide reliable and useful information on nodal status and may allow the avoidance of systematic lymphadenectomy in the majority of patients.
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Lago V, Bello P, Montero B, Matute L, Padilla-Iserte P, Lopez S, Agudelo M, Domingo S. Clinical application of the sentinel lymph node technique in early ovarian cancer: a pilot study. Int J Gynecol Cancer 2018; 29:377-381. [DOI: 10.1136/ijgc-2018-000049] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/20/2018] [Accepted: 10/04/2018] [Indexed: 11/03/2022] Open
Abstract
IntroductionThere is limited evidence favoring the use of the sentinel lymph node technique in ovarian cancer, and no standardized approach has been studied. The objective of the present pilot study is to determine the feasibility of the sentinel lymph node technique by applying a clinical algorithm.MethodsPatients with confirmed ovarian cancer were included. 99mTc and indocyanine green were injected into the ovarian and infundubulo-pelvic ligament stump. A gamma probe and near-infrared fluorescence imaging were used for sentinel lymph node detection.ResultsThe sentinel lymph node technique was performed in ten patients with a detection rate in the pelvic and/or para-aortic region of 100%. The tracer distribution rates of sentinel lymph nodes in the pelvic and para-aortic regions were 87.5% and 70%, respectively.ConclusionThe detection of sentinel lymph nodes in early-stage ovarian cancer appears to be achievable. Based on these results, a clinical trial entitled SENTOV (SENtinel lymph node Technique in OVarian cancer) will be performed.
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Rodríguez-Trujillo A, Fusté P, Paredes P, Mensión E, Agustí N, Gil-Ibáñez B, Del Pino M, González-Bosquet E, Torné A. Long-term oncological outcomes of patients with negative sentinel lymph node in vulvar cancer. Comparative study with conventional lymphadenectomy. Acta Obstet Gynecol Scand 2018; 97:1427-1437. [PMID: 30063814 DOI: 10.1111/aogs.13431] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The aim of this study was to compare oncological outcomes and morbidity in patients with early-stage vulvar cancer with negative sentinel lymph node (SLN) biopsy vs negative inguinofemoral lymphadenectomy (IFL). MATERIAL AND METHODS Study with retrospectively collected data in patients with squamous cell vulvar carcinomas ≤ 4 cm without suspected inguinofemoral lymph node metastases. Only patients with negative nodes after histopathology procedure were followed. Patients who underwent only SLN were compared with patients who underwent IFL ± SLN to compare recurrences, survival rates and morbidity. RESULTS Ninety-three patients were eligible for follow up: 42 with negative SLN and 51 with negative IFL ± SLN. The median follow-up period was 60.4 months (range 6.7-160.7). The rate of isolated first groin recurrence was 4.8% in patients with negative SLN and 2.0% in patients with negative IFL ± SLN (P = 0.587) and the rates of first isolated local recurrence were 28.6% and 31.4%, respectively (P = 0.823). Only 1 patient (2.4%) in the group of negative SLN had distant recurrence. The disease-specific survival rate at 5 years was 83.3% in the negative SLN group and 92.2% in the negative IFL ± SLN group (P = 0.214). We observed a higher rate of wound breakdown and infection after IFL than SLN biopsy (17.6% vs 10.6%; P = 0.020) and lymphedema (33.3% vs 0%; P < 0.001). CONCLUSIONS We report in the same population of patients with early-stage vulvar cancer that SLN biopsy does not have significantly higher rates of groin recurrences or lower survival rates compared with IFL. Moreover, the SLN procedure has less morbidity, which should encourage gynecologists to abandon IFL.
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Affiliation(s)
- Adriano Rodríguez-Trujillo
- Section of Gynecologic Oncology, Clinical Institute of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clínic, Biomedical Research Institute August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Pere Fusté
- Section of Gynecologic Oncology, Clinical Institute of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clínic, Biomedical Research Institute August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Pilar Paredes
- Department of Nuclear Medicine, Hospital Clínic, Biomedical Research Institute August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Eduard Mensión
- Section of Gynecologic Oncology, Clinical Institute of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clínic, Biomedical Research Institute August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Núria Agustí
- Section of Gynecologic Oncology, Clinical Institute of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clínic, Biomedical Research Institute August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Blanca Gil-Ibáñez
- Section of Gynecologic Oncology, Clinical Institute of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clínic, Biomedical Research Institute August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Marta Del Pino
- Section of Gynecologic Oncology, Clinical Institute of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clínic, Biomedical Research Institute August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | | | - Aureli Torné
- Section of Gynecologic Oncology, Clinical Institute of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clínic, Biomedical Research Institute August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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Abstract
Background: Cervical cancer is the second most common type of cancer among women. Effective screening programs can help
cancer detection in early phases and reduce death. Metastasis to lymph nodes is one of the most prognostic factors in patients who
underwent surgery. Also, a positive result from pathology report alert oncologist as a cause of death. Sentinel lymph node biopsy has
been widely studied and clinically used for many types of cancer.
Methods: Two techniques exist for detecting sentinel node in cervical cancer, which are Blue dye and gamma probe with radioactive
isotope (99mTc). Moreover, lymphoscintigraphy has many advantages over the stain method. Detecting the sentinel node is performed
via laparoscopy or laparotomy; former method is better and more accurate.
Results: Various researchers have focused on this method and its positive results; its superiority against full lymphadenectomy has
been declared in previous studies. Moreover, the role of sentinel lymph nodes biopsy in cervical cancer is still being extensively studied.
Sentinel lymph nodes (SLN) method has a higher accuracy level to detect metastasis.
Conclusion: Hence, it can be considered as a more appropriate alternative for pelvic lymph node dissection (PLND), which is a
standard technique. Altering the method to a standard clinical method needs in-depth researches and studies.
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Cigna E, Gradilone A, Ribuffo D, Gazzaniga P, Fino P, Sorvillo V, Scuderi N. Morbidity of Selective Lymph Node Biopsy for Melanoma: Meta-Analysis of Complications. TUMORI JOURNAL 2018; 98:94-8. [DOI: 10.1177/030089161209800113] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Aim Intraoperative lymphatic mapping and selective lymph node biopsy is accepted worldwide as the standard procedure for staging regional lymph nodes of 1–4 mm thick melanomas, as well as for other neoplasms. Although it is often stated that selective lymph node biopsy is a minimally invasive procedure associated with few complications, few data exist concerning the morbidity associated with the procedure. The present analysis was performed to evaluate the morbidity associated with selective lymph node biopsy in a long-term follow-up. Materials and Methods The study provides a review of 437 selective lymph node biopsies on 269 patients, operated on between the 1994 and the 2009, for the lymph node biopsy of head and neck, groin, axilla, upper and lower limbs and nodal basins. Patients’ history and follow-up were reviewed for 2 weeks after surgery, every 3 months for the first 2 years, every 4 months during the third year, and every 6 months subsequently, and postoperative morbidity was evaluated. Results After sentinel node biopsy, 14 patients developed one of the following complications: hematoma, 1 case (0.30%); lymphedema, 1 case (0.30%); seroma, 2 cases (0.61%); wound infection, 6 cases (1.83%); keloid scar, 2 cases (0.61%); and postoperative pain, 2 cases (0.61%). The total complication rate was 4.26%. Conclusions Selective lymph node biopsy for melanoma, as for other tumors, in respect to radical lymphadenectomy, is not a complications-free procedure but is usually not severe.
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Affiliation(s)
- Emanuele Cigna
- Department of Plastic and Reconstructive Surgery, Sapienza University of Rome
| | - Angela Gradilone
- Department of Experimental Medicine, Sapienza University of Rome
| | - Diego Ribuffo
- Unit of Plastic Surgery, Cagliari University Hospital, Monserrato, Italy
| | - Paola Gazzaniga
- Department of Experimental Medicine, Sapienza University of Rome
| | - Pasquale Fino
- Department of Plastic and Reconstructive Surgery, Sapienza University of Rome
| | - Valentina Sorvillo
- Department of Plastic and Reconstructive Surgery, Sapienza University of Rome
| | - Nicolò Scuderi
- Department of Plastic and Reconstructive Surgery, Sapienza University of Rome
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Speth SC, Kruitwagen RF, Kleppe M, Pooters IN, Van Gorp T, Slangen BF, Brans B. Comparison of Intraoperative γ-Probe Imaging and Postoperative SPECT/CT in Detection of Sentinel Nodes Related to the Ovary. J Nucl Med 2016; 58:243-245. [DOI: 10.2967/jnumed.116.183426] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 09/14/2016] [Indexed: 11/16/2022] Open
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The sentinel node approach in gynaecological malignancies. Clin Transl Imaging 2016; 4:411-420. [PMID: 27738629 PMCID: PMC5037154 DOI: 10.1007/s40336-016-0187-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 05/23/2016] [Indexed: 12/11/2022]
Abstract
This review discusses the state-of-the-art of sentinel lymph node mapping in gynaecological malignancies, including cervical cancer, endometrial cancer, and vulvar cancer, with an emphasis on new technological advances. For this objective, PubMed/MEDLINE was searched for relevant studies about the sentinel lymph node procedure in gynaecology. In particular, the use of preoperative lymphatic mapping with lymphoscintigraphy and single photon emission tomography/computed tomography (SPECT/CT) was identified in 18 studies. Other recent advances as hybrid tracers (e.g. ICG-99mTc-nanocolloid) and intraoperative tools (portable γ-camera and 3D navigation devices) appear to also represent a useful guide for the surgeon during the operation. Concerning vulvar and cervical cancers, the sentinel lymph node procedure has been incorporated to the current guidelines in Europe and North America, whereas for endometrial cancer it is considered investigative.
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Hoogendam JP, Veldhuis WB, Hobbelink MGG, Verheijen RHM, van den Bosch MAAJ, Zweemer RP. 99mTc SPECT/CT Versus Planar Lymphoscintigraphy for Preoperative Sentinel Lymph Node Detection in Cervical Cancer: A Systematic Review and Metaanalysis. J Nucl Med 2015; 56:675-80. [PMID: 25858041 DOI: 10.2967/jnumed.114.152439] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 03/16/2015] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED We aimed to compare SPECT/CT and lymphoscintigraphy on overall and bilateral sentinel lymph node (SLN) detection in cervical cancer patients. METHODS A systematic search was performed on August 1, 2014, in PubMed, Embase, Scopus, and the Cochrane library. The syntax was based on synonyms of the terms cervical cancer, SPECT/CT, and lymphoscintigraphy. Retrieved articles were screened on their title/abstract and considered eligible when an SLN procedure was performed using both imaging modalities and if detection results were reported. Two independent reviewers assessed all included studies on methodologic quality using QUADAS-2. Studies were pooled on their odds ratios (ORs) with a random-effects model. RESULTS The search yielded 962 unique articles, of which 8 were ultimately included. The studies were recent retrospective or prospective cohort studies of limited size (n = 7-51) but sufficient methodologic quality. The median overall detection (≥1 SLN in a patient) was 98.6% for SPECT/CT (range, 92.2%-100.0%) and 85.3% for lymphoscintigraphy (range, 70.0%-100.0%). This corresponded to a pooled overall SLN detection OR of 2.5 (95% CI, 1.2-5.3) in favor of SPECT/CT. The reported median bilateral detection (≥1 SLN in each hemipelvis) was 69.0% for SPECT/CT (range, 62.7%-79.3%) and 66.7% for lymphoscintigraphy (range, 56.9%-75.8%), yielding a pooled OR of 1.2 (95% CI, 0.7-2.1). No significant difference in the number of visualized SLNs was observed at a pooled ratio of 1.2 (95% CI, 0.9-1.6). CONCLUSION In cervical cancer patients, preoperative SLN imaging with SPECT/CT results in superior overall SLN detection in comparison with planar lymphoscintigraphy.
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Affiliation(s)
- Jacob P Hoogendam
- Department of Gynaecological Oncology, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | - Wouter B Veldhuis
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Monique G G Hobbelink
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - René H M Verheijen
- Department of Gynaecological Oncology, University Medical Center Utrecht, Utrecht, The Netherlands; and
| | | | - Ronald P Zweemer
- Department of Gynaecological Oncology, University Medical Center Utrecht, Utrecht, The Netherlands; and
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13
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Kleppe M, Brans B, Van Gorp T, Slangen BF, Kruse AJ, Pooters IN, Lotz MG, Van de Vijver KK, Kruitwagen RF. The Detection of Sentinel Nodes in Ovarian Cancer: A Feasibility Study. J Nucl Med 2014; 55:1799-804. [DOI: 10.2967/jnumed.114.144329] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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14
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Value and advantages of preoperative sentinel lymph node imaging with SPECT/CT in cervical cancer. Int J Gynecol Cancer 2014; 24:295-302. [PMID: 24401983 DOI: 10.1097/igc.0000000000000032] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Precise detection of sentinel lymph nodes (SLNs) seems to be a crucial factor for optimized treatment of cervical cancer. We assess the use of single photon emission computed tomography combined with computed tomography (SPECT/CT) as an alternative to lymphoscintigraphy (LSG) for preoperative identification of SLN. METHODS This study was performed in a prospective, unicentric setting. Patients with cervical carcinoma were scheduled for surgery and additional SLN labeling by peritumoral injection of 10 MBq technetium-99m-nanocolloid and patent blue. Thirty minutes after injection, LSG and SPECT/CT were carried out. We evaluated the number of SLNs detected intraoperatively in LSG and SPECT/CT and the histologic findings of SLN and non-SLN. Subsequently, we determined the impact of these results on the therapeutic approach. RESULTS This represents the largest study about SPECT/CT for SLN detection in cervical cancer so far. Between August 2008 and March 2013, 59 cervical cancer patients underwent intraoperative SLN detection. In addition, 51 of these patients underwent preoperative LSG and SPECT/CT. Imaging with SPECT/CT detected singular SLN at significantly higher rate (47/51, 92.2%) than that with planar LSG (43/51, 84.3%, P = 0.044). Furthermore, SPECT/CT performed better than LSG regarding the total number of detected SLN (SPECT/CT median, 3 [0-18]; LSG median, 2 [0-15]) and detection rates per pelvic side (SPECT/CT 76.9%, LSG 69.2%, P < 0.01). Whenever SLN detection succeeded, histologic evaluation of SLN correctly predicted the lymph node status per patient's side. Using this type of diagnostic approach for lymph node staging, we reached sensitivity of 100% and negative predictive value of 100% at a rate of false-negative results of 0% even in tumors larger than 4 cm. CONCLUSIONS Single photon emission computed tomography combined with computed tomography imaging leads to improved rates of SLN detection and better anatomic correlation compared with planar LSG. Thus, intraoperative detection of SLN can be improved by preoperative SPECT/CT imaging. This enhances the clinical value of SLN technique and improves the oncologic safety of SLN concept.
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15
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Handgraaf HJM, Verbeek FPR, Tummers QRJG, Boogerd LSF, van de Velde CJH, Vahrmeijer AL, Gaarenstroom KN. Real-time near-infrared fluorescence guided surgery in gynecologic oncology: a review of the current state of the art. Gynecol Oncol 2014; 135:606-13. [PMID: 25124160 DOI: 10.1016/j.ygyno.2014.08.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 08/01/2014] [Accepted: 08/04/2014] [Indexed: 12/19/2022]
Abstract
Near-infrared (NIR) fluorescence imaging has emerged as a promising complimentary technique for intraoperative visualization of tumor tissue, lymph nodes and vital structures. In this review, the current applications and future opportunities of NIR fluorescence imaging in gynecologic oncology are summarized. Several studies indicate that intraoperative sentinel lymph node identification in vulvar cancer using NIR fluorescence imaging outperforms blue dye staining and provides real-time intraoperative imaging of sentinel lymph nodes. NIR fluorescence imaging can penetrate through several millimeters of tissue, revealing structures just below the tissue surface. Hereby, iatrogenic damage to vital structures, such as the ureter or nerves may be avoided by identification using NIR fluorescence imaging. Tumor-targeted probes are currently being developed and have the potential to improve surgical outcomes of cytoreductive and staging procedures, in particular in ovarian cancer. Research in the near future will be necessary to determine whether this technology has additional value in order to facilitate the surgical procedure, reduce morbidity and improve disease-free and overall survival.
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Affiliation(s)
| | - Floris P R Verbeek
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Leonora S F Boogerd
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Katja N Gaarenstroom
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
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16
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Giammarile F, Bozkurt MF, Cibula D, Pahisa J, Oyen WJ, Paredes P, Olmos RV, Sicart SV. The EANM clinical and technical guidelines for lymphoscintigraphy and sentinel node localization in gynaecological cancers. Eur J Nucl Med Mol Imaging 2014; 41:1463-77. [PMID: 24609929 DOI: 10.1007/s00259-014-2732-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 02/14/2014] [Indexed: 02/06/2023]
Abstract
The accurate harvesting of a sentinel node in gynaecological cancer (i.e. vaginal, vulvar, cervical, endometrial or ovarian cancer) includes a sequence of procedures with components from different medical specialities (nuclear medicine, radiology, surgical oncology and pathology). These guidelines are divided into sectione entitled: Purpose, Background information and definitions, Clinical indications and contraindications for SLN detection, Procedures (in the nuclear medicine department, in the surgical suite, and for radiation dosimetry), and Issues requiring further clarification. The guidelines were prepared for nuclear medicine physicians. The intention is to offer assistance in optimizing the diagnostic information that can currently be obtained from sentinel lymph node procedures. If specific recommendations given cannot be based on evidence from original scientific studies, referral is made to "general consensus" and similar expressions. The recommendations are designed to assist in the practice of referral to, and the performance, interpretation and reporting of all steps of the sentinel node procedure in the hope of setting state-of-the-art standards for high-quality evaluation of possible metastatic spread to the lymphatic system in gynaecological cancer. The final result has been discussed by a group of distinguished experts from the EANM Oncology Committee and the European Society of Gynaecological Oncology (ESGO). The document has been endorsed by the SNMMI Board.
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Affiliation(s)
- Francesco Giammarile
- Médecine Nucléaire, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon and EMR HCL/UCBL, Faculté de Médecine, Université Claude Bernard, Lyon 1, Villeurbanne, France,
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17
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Sentinel lymph node biopsy in uterine cervical cancer patients: ready for clinical use? A review of the literature. ISRN SURGERY 2014; 2014:841618. [PMID: 24527233 PMCID: PMC3914400 DOI: 10.1155/2014/841618] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 12/11/2013] [Indexed: 11/18/2022]
Abstract
Sentinel lymph node biopsy has been widely studied in a number of cancer types. As far as cervical cancer is concerned, this technique has already been used, revealing both positive results and several issues to be solved. The debate on the role of sentinel lymph node biopsy in cervical cancer is still open although most of the studies have already revealed its superiority over complete lymphadenectomy and the best handling possible of the emerging practical problems. Further research should be made in order to standardize this method and include it in the clinical routine.
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18
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Underwood M, Yap JKW, Elattar A, Ganesan R, Notghi A, Crockett C, Luesley DM. The use of sentinel node sampling in vulval cancer. J OBSTET GYNAECOL 2013; 33:892-7. [DOI: 10.3109/01443615.2013.834301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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19
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Hoogendam JP, Hobbelink MG, Veldhuis WB, Verheijen RH, van Diest PJ, Zweemer RP. Preoperative sentinel node mapping with 99mTc-nanocolloid SPECT–CT significantly reduces the intraoperative sentinel node retrieval time in robot assisted laparoscopic cervical cancer surgery. Gynecol Oncol 2013; 129:389-94. [DOI: 10.1016/j.ygyno.2013.02.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 02/11/2013] [Accepted: 02/13/2013] [Indexed: 02/06/2023]
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20
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Amso NN, Shayeb AG. Intraoperative imaging. Best Pract Res Clin Obstet Gynaecol 2013; 27:323-38. [PMID: 23587767 DOI: 10.1016/j.bpobgyn.2013.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 02/20/2013] [Indexed: 11/24/2022]
Abstract
Intraoperative image is a rapidly expanding field encompassing many applications that use a multitude of technologies. Some of the these applications have been in use for many years and are firmly embedded in, and indispensable to, clinical practice (e.g. the use of X-ray to locate foreign bodies during surgery or oocyte retrieval under ultrasound guidance. In others, the application may have been in use in one discipline but not yet fully explored in another. Examples include the use of intraoperative ultrasound with or without contrast enhancement for the detection of hepatic metastases not identified preoperatively, and the effect of such additional information on the ultimate operative procedure. Intraoperative identification of sentinel lymph nodes has been explored in many specialties to a varying extent, with the aim of fine tuning and avoiding unnecessary surgery. In both these instances, we do not know the long-term effect of these interventions on patient survival or quality of life. In this chapter, we will explore the available evidence on these applications and current advances in the new technology in general, with a specific focus on gynaecology.
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Affiliation(s)
- Nazar N Amso
- Cardiff University, School of Medicine, Heath Park, Cardiff CF14 4XW, UK.
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21
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Kleppe M, Van Gorp T, Slangen BFM, Kruse AJ, Brans B, Pooters INA, Van de Vijver KK, Kruitwagen RFPM. Sentinel node in ovarian cancer: study protocol for a phase 1 study. Trials 2013; 14:47. [PMID: 23414057 PMCID: PMC3577513 DOI: 10.1186/1745-6215-14-47] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 02/01/2013] [Indexed: 11/18/2022] Open
Abstract
Background The concept of sentinel lymph node surgery is to determine whether the cancer has spread to the very first lymph node or sentinel node. If the sentinel node does not contain cancer, then there is a high likelihood that the cancer has not spread to other lymph nodes. The sentinel node technique has been proven to be effective in different types of cancer. In this study we want to determine whether a sentinel node procedure in patients with ovarian cancer is feasible when the tracers are injected into the ovarian ligaments. Methods/Design Patients with a high likelihood of having an ovarian malignancy in whom a median laparotomy and a frozen section analysis is planned and patients with endometrial cancer in whom a staging laparotomy is planned will be included. Before starting the surgical staging procedure, blue dye and radioactive colloid will be injected into the ligamentum ovarii proprium and the ligamentum infundibulo-pelvicum. In the analysis we calculate the percentage of patients in whom it is feasible to identify sentinel nodes. Other study parameters are the anatomical localization of the sentinel node(s) and the incidence of false negative lymph nodes. Trial registration Approval number: NL40323.068.12 Name: Medical Ethical Committee Maastricht University Hospital, University of Maastricht Affiliation: Maastricht University Hospital Board Chair Name: Medisch Ethische Commissie azM/UM
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Affiliation(s)
- Marjolein Kleppe
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, PO Box 5800 6202 AZ, Maastricht, The Netherlands
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Sentinel Lymph Node Biopsy in Vulvar Cancer: A Health Technology Assessment for the Canadian Health Care Context. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2012; 34:1053-1065. [DOI: 10.1016/s1701-2163(16)35435-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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23
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Jarruwale P, Huang KG, Benavides DR, Lee CL. Factors related to sentinel node identification in cervical cancer. Gynecol Minim Invasive Ther 2012. [DOI: 10.1016/j.gmit.2012.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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24
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Tsai YJ, Shueng PW, Chan SC, Chuang WY, Shiau YC, Hsu CH. Uterine cervical melanoma presenting with rapid progression detected by PET/CT. Acta Radiol Short Rep 2012; 1:10.1258_arsr.2012.120026. [PMID: 23986839 PMCID: PMC3738348 DOI: 10.1258/arsr.2012.120026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 04/30/2012] [Indexed: 02/03/2023] Open
Abstract
Malignant melanoma of the uterine cervix is a rare extracutaneous melanoma which develops aggressively and is associated with a bleak prognosis. To our knowledge, no prior published reports have discussed the role of 18F-FDG positron emission tomography/computed tomography (PET/CT) in managing this disease. Our case study involved a 66-year-old woman with a malignant melanoma of the uterine cervix. The patient received PET/CT that identified metastases and lesions which had not been detected from her MRI. Serial PET/CT elucidated that the disease was initially limited to the pelvis, but then metastasized to the abdominal para-aortic lymph nodes, followed by extensive metastases to the brain, lungs, breast, supraclavicular, neck, and other abdominal lymph nodes, as observed at 6-month follow-up. PET/CT was used to complement conventional anatomic imaging modalities, and provided a novel modality for whole body screening. Visualization of the metabolic activity of indeterminate lesions may help in staging, re-staging, treatment planning, and prognostic prediction for patients with this rare disease.
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Affiliation(s)
- Ya-Ju Tsai
- Department of Nuclear Medicine, Taipei Medical University Hospital , Taipei ; Department of Nuclear Medicine, Far Eastern Memorial Hospital , Taipei
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25
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Sentinel Lymph Node in Nonmelanoma Skin Cancer. ACTAS DERMO-SIFILIOGRAFICAS 2011. [DOI: 10.1016/j.adengl.2011.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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26
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Salguero-Fernández I, Rios-Buceta L, Jaén-Olasolo P. Ganglio centinela en cáncer de piel no melanoma. ACTAS DERMO-SIFILIOGRAFICAS 2011; 102:589-98. [DOI: 10.1016/j.ad.2011.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Revised: 04/28/2011] [Accepted: 05/26/2011] [Indexed: 12/12/2022] Open
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Sziller P, Langmár Z. [Novel laparoscopic techniques in gynecologic surgery]. Orv Hetil 2011; 152:785-92. [PMID: 21540151 DOI: 10.1556/oh.2011.29118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The practice of gynecologic surgery has been revolutionized by laparoscopic techniques in the past decades. Nowadays minimal invasive procedures are feasible and safe standard options in the management of most benign and malignant gynecologic diseases. Natural orifices transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been developed in an attempt to further reduce the morbidity and scarring with minimal invasive procedures. These techniques share a common conception that a reduction in the number of transcutaneous points of access may benefit patients in terms of port-related complications, risk of hernia formation, recovery time, pain and cosmetics by potentially performing scarless surgery. The development of LESS has been facilitated by the concept of scarless surgical procedures. Increasing experience revealed by recent publications have allowed for the expansion of NOTES and LESS techniques in the gynecologic surgery. Almost all laparoscopic procedures can be performed by acquiring these concepts. Although these surgical methods are feasible and safe, certain technical problems (e.g. loss of triangulation, problems of visualization, ergonomic considerations) has yet to be solved and several questions must be answered before LESS and NOTES could gain widespread acceptance as single procedures. Despite successful technical developments these methods remain investigational approaches and refinement of indications as well as further development of instrumentation are expected to define its area of future application.
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Affiliation(s)
- Péter Sziller
- Semmelweis Egyetem, Általános Orvostudományi Kar, II. Szülészeti és Nőgyógyászati Klinika Budapest.
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Mais V, Cirronis MG, Piras B, Silvetti E, Cossu E, Melis GB. Intraoperative lymphatic mapping techniques for endometrial cancer. Expert Rev Anticancer Ther 2011; 11:83-93. [DOI: 10.1586/era.10.181] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
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29
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Crane LMA, Themelis G, Buddingh KT, Buddingh T, Harlaar NJ, Pleijhuis RG, Sarantopoulos A, van der Zee AGJ, Ntziachristos V, van Dam GM. Multispectral real-time fluorescence imaging for intraoperative detection of the sentinel lymph node in gynecologic oncology. J Vis Exp 2010:2225. [PMID: 21048667 PMCID: PMC3185642 DOI: 10.3791/2225] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases. Surgical treatment most often combines radical excision of the tumor with a full lymphadenectomy in the drainage area of the tumor. However, removal of lymph nodes is associated with increased morbidity due to infection, wound breakdown and lymphedema. As an alternative, the sentinel lymph node procedure (SLN) was developed several decades ago to detect the first draining lymph node from the tumor. In case of lymphogenic dissemination, the SLN is the first lymph node that is affected (Figure 1). Hence, if the SLN does not contain metastases, downstream lymph nodes will also be free from tumor metastases and need not to be removed. The SLN procedure is part of the treatment for many tumor types, like breast cancer and melanoma, but also for cancer of the vulva and cervix. The current standard methodology for SLN-detection is by peritumoral injection of radiocolloid one day prior to surgery, and a colored dye intraoperatively. Disadvantages of the procedure in cervical and vulvar cancer are multiple injections in the genital area, leading to increased psychological distress for the patient, and the use of radioactive colloid. Multispectral fluorescence imaging is an emerging imaging modality that can be applied intraoperatively without the need for injection of radiocolloid. For intraoperative fluorescence imaging, two components are needed: a fluorescent agent and a quantitative optical system for intraoperative imaging. As a fluorophore we have used indocyanine green (ICG). ICG has been used for many decades to assess cardiac function, cerebral perfusion and liver perfusion. It is an inert drug with a safe pharmaco-biological profile. When excited at around 750 nm, it emits light in the near-infrared spectrum around 800 nm. A custom-made multispectral fluorescence imaging camera system was used. The aim of this video article is to demonstrate the detection of the SLN using intraoperative fluorescence imaging in patients with cervical and vulvar cancer. Fluorescence imaging is used in conjunction with the standard procedure, consisting of radiocolloid and a blue dye. In the future, intraoperative fluorescence imaging might replace the current method and is also easily transferable to other indications like breast cancer and melanoma.
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Affiliation(s)
- Lucia M A Crane
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen
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30
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Vermeeren L, Meinhardt W, Bex A, van der Poel HG, Vogel WV, Hoefnagel CA, Horenblas S, Valdés Olmos RA. Paraaortic sentinel lymph nodes: toward optimal detection and intraoperative localization using SPECT/CT and intraoperative real-time imaging. J Nucl Med 2010; 51:376-82. [PMID: 20150260 DOI: 10.2967/jnumed.109.071779] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED Paraaortic sentinel node biopsy may be a challenging procedure because the sentinel nodes are located retroperitoneally in close proximity to vital structures. The purpose of this study was to describe and evaluate the value of preoperative SPECT/CT for lymphatic mapping, and a portable gamma-camera for intraoperative radioguidance, in patients with paraaortic sentinel nodes. METHODS We evaluated our practice in 18 patients, who were treated at The Netherlands Cancer Institute with sentinel lymphadenectomy for different urologic malignancies and showed paraaortic drainage on preoperative images. After intratumoral injection of (99m)Tc-nanocolloid, the patients underwent sequential planar lymphoscintigraphy, hybrid SPECT/CT, and sentinel lymphadenectomy. Intraoperative node detection and localization were guided by a laparoscopic gamma-probe and a portable gamma-camera. This gamma-camera was set to display both the (99m)Tc signal and the (125)I-seed signal. This (125)I seed was placed on top of the gamma-probe, functioning as a pointer on screen, thus enabling real-time sentinel node localization with the gamma-camera. RESULTS In 16 patients with midabdominal drainage on planar images and in 2 patients with nonvisualization on planar images, SPECT/CT showed clear localization of paraaortic sentinel nodes in relation to the abdominal vessels. Five patients underwent open surgery, and 13 patients underwent laparoscopy. The paraaortic sentinel nodes were successfully localized and removed in 15 patients with the help of the portable gamma-camera and gamma-probe and in 3 patients with the gamma-probe only. In 1 patient, the paraaortic sentinel node showed a metastasis. CONCLUSION If retroperitoneal drainage is expected, SPECT/CT provides good detection and clear localization of sentinel nodes in relation to anatomic structures. Detection and removal of paraaortic sentinel nodes by means of a laparoscopic gamma-probe and real-time imaging with a portable gamma-camera is a successful method with high intraoperative detection rates.
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Affiliation(s)
- Lenka Vermeeren
- Department of Nuclear Medicine, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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