Sentinel lymph node mapping in gynecologic malignancies

A prospective study in the evaluation of quality of life after vulvar cancer surgery

OBJECTIVE

The aim of this study was to prospectively monitor the patients' quality of life (QoL) after vulvar cancer surgery.

DESIGN

The design was prospective clinical study.

SETTING

The study was set in the Department of Obstetrics and Gynecology, 2nd Medical Faculty of the Charles University and University Hospital Motol, Prague, Czech Republic.

METHODS

A group of 36 patients underwent vulvar cancer surgery: 24 patients were subject to inguinofemoral lymphadenectomy (RAD) and 12 to sentinel lymph node biopsy. To evaluate QoL, the European Organisation for Research and Treatment of Cancer, QoL questionnaires (QLQ-C30 and QLQ-CX24) were administered to patients before and 6 and 12 months after surgery.

RESULTS

In patients with vulvar cancer after inguinofemoral lymphadenectomy, increased fatigue and impaired lymphedema were observed. In the group of patients after sentinel lymph node biopsy, none of the QoL variables worsened postoperatively. Comparing both groups 12 months after surgery, the RAD group had significantly worse outcomes in body image and cognitive functioning than the sentinel lymph node biopsy group.Patients in the RAD group, who received adjuvant radiotherapy (n = 13), had worse QoL in symptom experience (P < 0.05) at 6 and 12 months after the surgery than patients without radiotherapy (n = 11).

CONCLUSIONS

Less radical surgery showed objectively better QoL results.

A Prospective Study in Detection of Lower-Limb Lymphedema and Evaluation of Quality of Life After Vulvar Cancer Surgery

Background

Lower-limb lymphedema is one of the most disabling adverse effects of vulvar cancer surgery. Multifrequency Bioelectrical Impedance Analysis (MFBIA) is a modern noninvasive method to detect lymphedema. The first aim of this study was to prospectively determine the prevalence of secondary lower-limb lymphedema after surgical treatment for vulvar cancer using objective methods, circumference measurements and MFBIA technique. The second aim was to compare quality of life (QoL) before and 6 months after vulvar surgery.

Methods

Twenty-nine patients underwent vulvar cancer surgery in our study: 17 underwent inguinofemoral lymphadenectomy (RAD), and 12 underwent sentinel lymph node biopsy (CONS). Patients were examined before and 6 months after vulvar surgery by measuring the circumference of the lower limbs and with MFBIA. A control group of 27 healthy women was also measured. To evaluate QoL, the European Organisation for Research and Treatment of Cancer (EORTC) QoL questionnaires (QLQ-C30 and QLQ-CX24) were administered to patients before and 6 months after surgery.

Results

Using circumference measurement, 9 lymphedemas (31%) were diagnosed: 3 (25%) in the CONS and 6 (37.5%) in the RAD group (P= 0.69). After vulvar surgery, patients in the RAD group reported more fatigue and worsening of physical and role functioning. When comparing both groups, the RAD group had significantly worse parameters in social functioning, fatigue, and dyspnea.

Conclusions

Lower radicality in inguinofemoral lymphadenectomy shows a trend toward lower morbidity and significantly improves QoL. Multifrequency Bioelectrical Impedance Analysis was tested in these patients as a noninvasive, objective method for lymphedema detection. Detection of lymphedema based on subjective evaluations proved to have an unsatisfactory sensitivity. Less radical surgery showed objectively better results in QoL.

Intraoperative multispectral fluorescence imaging for the detection of the sentinel lymph node in cervical cancer: a novel concept

Purpose

Real-time intraoperative near-infrared fluorescence (NIRF) imaging is a promising technique for lymphatic mapping and sentinel lymph node (SLN) detection. The purpose of this technical feasibility pilot study was to evaluate the applicability of NIRF imaging with indocyanin green (ICG) for the detection of the SLN in cervical cancer.

Procedures

In ten patients with early stage cervical cancer, a mixture of patent blue and ICG was injected into the cervix uteri during surgery. Real-time color and fluorescence videos and images were acquired using a custom-made multispectral fluorescence camera system.

Results

Real-time fluorescence lymphatic mapping was observed in vivo in six patients; a total of nine SLNs were detected, of which one (11%) contained metastases. Ex vivo fluorescence imaging revealed the remaining fluorescent signal in 11 of 197 non-sentinel LNs (5%), of which one contained metastatic tumor tissue. None of the non-fluorescent LNs contained metastases.

Conclusions

We conclude that lymphatic mapping and detection of the SLN in cervical cancer using intraoperative NIRF imaging is technically feasible. However, the technique needs to be refined for full applicability in cervical cancer in terms of sensitivity and specificity.

Electronic supplementary material

The online version of this article (doi:10.1007/s11307-010-0425-7) contains supplementary material, which is available to authorized users.

A comprehensive overview of radioguided surgery using gamma detection probe technology

The concept of radioguided surgery, which was first developed some 60 years ago, involves the use of a radiation detection probe system for the intraoperative detection of radionuclides. The use of gamma detection probe technology in radioguided surgery has tremendously expanded and has evolved into what is now considered an established discipline within the practice of surgery, revolutionizing the surgical management of many malignancies, including breast cancer, melanoma, and colorectal cancer, as well as the surgical management of parathyroid disease. The impact of radioguided surgery on the surgical management of cancer patients includes providing vital and real-time information to the surgeon regarding the location and extent of disease, as well as regarding the assessment of surgical resection margins. Additionally, it has allowed the surgeon to minimize the surgical invasiveness of many diagnostic and therapeutic procedures, while still maintaining maximum benefit to the cancer patient. In the current review, we have attempted to comprehensively evaluate the history, technical aspects, and clinical applications of radioguided surgery using gamma detection probe technology.

Staging of gynaecological malignancies by natural orifice transluminal endoscopic surgery (N.O.T.E.S.)

Gynaecological malignancies are most often diagnosed and staged by surgery. With the expanding evidence of efficacy and benefit of neoadjuvant treatments, such tumor confirmation and assessment should be ideally done with the least associated morbidity. Thus sentinel node biopsy has already been proposed for selected indications so that the morbidity associated with formal lymphadenectomy could be avoided in those patients without nodal metastases. The era of natural orifice transluminal endoscopic surgery (N.O.T.E.S.) heralds an operative methodology of 'least invasiveness' that could be useful in gynaecological cancer. In this article, we present an overview of the staging of gynaecological malignancies with a focus on the potential applications and benefits that N.O.T.E.S. may provide in this field. In particular, we believe that performing sentinel lymph node dissection with N.O.T.E.S. could associate the low morbidity rate of the former technique with the minimal invasiveness of the latter one and therefore consolidate the potential of this technique.

Changes in pulse oximetry after patent blue dye injection into the uterine cervix

BACKGROUND

To evaluate changes in pulse oximetry readings in patients with cervical carcinoma after the injection of patent blue dye into the uterine cervix for sentinel lymph node detection.

METHODS

Fifty-six patients underwent radical hysterectomy and bilateral pelvic lymphadenectomy for the treatment of International Federation of Gynecology and Obstetrics stage I or II cervical cancer. Four milliliters of patent blue dye were injected into the cervix. On the eve of surgery, all patients also received an injection of Dextran 500 labeled with technetium 99 m (Tc-99 m Dextran, 600 to 800 muCi) into the cervix and subsequently underwent pelvic lymphoscintigraphy.

RESULTS

Of the 56 patients, 1 (1.79%) had an anaphylactic reaction, and in 13 (23.22%), pulse oximetry readings were <96%. The lowest median pulse oximetry reading in these patients was 87%. Pulse oximetry readings began to decrease between 2 and 10 minutes after patent blue dye injection into the cervix and lasted for approximately 5 minutes. No changes in blood pressure, heart rate, or electrocardiogram were found during the period in which this alteration was recorded by the pulse oximeter.

CONCLUSION

The decrease in pulse oximetry readings after patent blue dye injection into the cervix was associated with larger tumors and tumors that surrounded the external cervical os.

Lymphatic mapping and sentinel node biopsy in gynecological cancers: a critical review of the literature

Although it does not have a long history of sentinel node evaluation (SLN) in female genital system cancers, there is a growing number of promising study results, despite the presence of some aspects that need to be considered and developed. It has been most commonly used in vulvar and uterine cervivcal cancer in gynecological oncology. According to these studies, almost all of which are prospective, particularly in cases where Technetium-labeled nanocolloid is used, sentinel node detection rate sensitivity and specificity has been reported to be 100%, except for a few cases. In the studies on cervical cancer, sentinel node detection rates have been reported around 80–86%, a little lower than those in vulva cancer, and negative predictive value has been reported about 99%. It is relatively new in endometrial cancer, where its detection rate varies between 50 and 80%. Studies about vulvar melanoma and vaginal cancers are generally case reports. Although it has not been supported with multicenter randomized and controlled studies including larger case series, study results reported by various centers around the world are harmonious and mutually supportive particularly in vulva cancer, and cervix cancer. Even though it does not seem possible to replace the traditional approaches in these two cancers, it is still a serious alternative for the future. We believe that it is important to increase and support the studies that will strengthen the weaknesses of the method, among which there are detection of micrometastases and increasing detection rates, and render it usable in routine clinical practice.