Laparoscopic sentinel node mapping in early-stage cervical cancer

Laparoscopic sentinel lymph node mapping with indocyanine green in endometrial cancer: surgeon's learning curve (cumulative sum analysis)

OBJECTIVES

To evaluate surgeons' learning curves for laparoscopic sentinel lymph node biopsy in endometrial cancer.

METHODS

A prospective observational study was performed at the Oncogynecology Center, Lithuanian University of Health Sciences Hospital, from March 2018 to October 2022. Participating surgeons had no previous experience of laparoscopic sentinel lymph node biopsy with indocyanine green tracer. Cumulative sum analysis was used to create learning curves for the performance of eight surgeons, based on a specific result over a time period. Two different cumulative sum plots were made for each surgeon: successful bilateral sentinel lymph node mapping and removal of sentinel lymph node specimens containing actual lymphatic tissue.

RESULTS

190 patients were included. The overall rate of sentinel lymph node mapping was 89.5%: successful bilateral mapping was achieved in 134 (70.5%) patients, while in 36 (19%) patients sentinel lymph nodes were mapped unilaterally. The bilateral detection rate significantly improved in later study periods (from 59.3% in the first year to 85.0% in the last year; p=0.03). Analysis of the performance of the surgeons for bilateral sentinel lymph node mapping showed that the cumulative sum plot crossed the H₀ limit line after 13 consecutive successful bilateral sentinel lymph node biopsies, indicating an acceptable level of competence to achieve the bilateral detection rate of at least 75%. This was accomplished by only one surgeon after 30 surgeries. Analysis of the performance of the surgeons for identification and removal of specimens containing histologically confirmed lymphatic tissue showed that the cumulative sum plots crossed the H₀ limit line after six consecutive successful sentinel lymph node removals. This was accomplished by most of the surgeons (5 of 8).

CONCLUSION

At least 30 procedures of indocyanine green traced laparoscopic sentinel lymph node biopsy were needed to reach an acceptable level of competence for a bilateral sentinel lymph node detection rate of at least 75%.

TRIAL REGISTRATION NUMBER

ACTRN12619000979156.

Estimation risk of lymph nodal invasion in patients with early-stage cervical cancer: Cervical cancer application

Introduction

Lymph node status is a major prognostic factor in early-stage cervical cancer. Predicting the risk of lymph node metastasis is essential for optimal therapeutic management. The aim of the study was to develop a web-based application to predict the risk of lymph node metastasis in patients with early-stage (IA1 with positive lymph vascular space invasion, IA2 and IB1) cervical cancer.

Materials and methods

We performed a secondary analysis of data from two prospective multicenter trials, Senticol 1 and 2 pooled together in the training dataset. The histological risk factors were included in a multivariate logistic regression model in order to determine the most suitable prediction model. An internal validation of the chosen prediction model was then carried out by a cross validation of the ‘leave one out cross validation’ type. The prediction model was implemented in an interactive online application of the ‘Shinyapp’ type. Finally, an external validation was performed with a retrospective cohort from L’Hôtel-Dieu de Québec in Canada.

Results

Three hundred twenty-one patients participating in Senticol 1 and 2 were included in our training analysis. Among these patients, 280 did not present lymph node invasion (87.2%), 13 presented isolated tumor cells (4%), 11 presented micrometastases (3.4%) and 17 macrometastases (5.3%). Tumor size, presence of lymph-vascular space invasion and stromal invasion were included in the prediction model. The Receiver Operating Characteristic (ROC) Curve from this model had an area under the curve (AUC) of 0.79 (95% CI [0.69– 0.90]). The AUC from the cross validation was 0.65. The external validation on the Canadian cohort confirmed a good discrimination of the model with an AUC of 0.83.

Discussion

This is the first study of a prediction score for lymph node involvement in early-stage cervical cancer that includes internal and external validation. The web application is a simple, practical, and modern method of using this prediction score to assist in clinical management.

Clinical Study of Sentinel Lymph Node Detection to Evaluate Pelvic Lymph Node Metastasis to Determine the Prognosis of Patients with Early Cervical Cancer

Objective

Lymph node status is one of the most important prognostic factors for uterine cervical cancer. Sentinel lymph node (SLN) biopsy has emerged as a potential alternative to systematic lymphadenectomy for the lymph node mapping in such patients. However, the SLN metastasis detection via SLN biopsy in early-stage cervical cancer remains controversial. The current study is aimed at investigating the feasibility and accuracy of combined tracer method for localization of SLN in initial stages of cervical cancer and to evaluate the clinical value of SLN biopsy in replacing pelvic lymph node resection.

Methods

We retrospectively reviewed 348 cases who were admitted to the Department of Gynecologic Oncology, Shandong Provincial Cancer Hospital, China, between February 2003 and June 2018 with FIGO stage IA2 to IIA2 cervical cancer and undergone through SLN biopsy. Methylthioninium chloride was injected in combination with ^99mtechnetium-labeled sulfur colloid prior to surgery to these patients. SLNs were identified intraoperatively, excised, and subsequently submitted to fast frozen section. The detection rates, accuracy, sensitivity, coincidence rate, false negative rate, and negative predictive values of these cases were estimated, and the follow-up outcomes were carefully observed. Chi squared test or Fisher's exact test was employed for a comparison of the categorical variables. Univariate and multivariate Cox proportional hazard models were used for estimation of relationships between overall survival (OS) and disease-free survival (DFS) and prognostic factors.

Results

The total detection rate of SLN was 97.1% (338/348), and identification of bilateral SLN was successful in 237 patients (70.1%). The patient's tumor size, FIGO stage, lymph node metastasis, and depth of invasion had statistically significant differences in SLN detection rates. The detection rate had inverse relation with tumors size (>4 cm), invasive depth > 2/3, lymph node positive, late staging, and preoperative radiotherapy. 117 positive SLNs were detected in 73 patients. The negative predictive value, sensitivity, false negative rate, and coincidence rate and were 97.7%, 92.4%, 7.6%, and 95.4%, respectively. In patients whose tumor size were ≦ 4 cm, the false negative rate was 4.55% (2/44), whereas it was 0 in patients with tumor size≦2 cm. The respective 1, 3, and 5-year OS was 100%, 94.8%, and 91.8%, respectively, whereas DFS rate for 1, 3, and 5 years was 96.7%, 92%, and 89.6%, respectively. The lymph node was positive, tumor size, the depth of invasion, and staging were statistically different from the recurrence rate and survival rate of patients (p < 0.05). When tumor metastasis exceeded SLN, the recurrence rate was significantly increased, and survival rate is significantly reduced (p < 0.05, p < 0.01, p < 0.05, respectively).

Conclusions

The identification of SLN combined with ^99mtechnetium-labeled sulfur colloid and methylthioninium chloride has a good accuracy and is safe for the assessment of the status of pelvic nodes in patients with initial stage cervical cancer. Nuclide as a tracer has low dependence on objective conditions and doctors' technology and has a good detection rate. In our study, we believe that SLN biopsy is feasible when the tumor is ≦ 4 cm. Large scale clinical trials are required in China expand the sample size and validate the results of this study.

Clinical impact of low-volume lymph node metastases in early-stage cervical cancer: A comprehensive meta-analysis

OBJECTIVE

In order to define the clinical significance of low-volume metastasis, a comprehensive meta-analysis of published data and individual data obtained from articles mentioning micrometastases (MIC) and isolated tumor cells (ITC) in cervical cancer was performed, with a follow up of at least 3 years.

METHODS

We performed a systematic literature review and meta-analysis, following Cochrane's review methods guide and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcome was the disease-free survival (DFS), and the secondary outcome was the overall survival (OS). The hazard ratio (HR) was taken as the measure of the association between the low-volume metastases (MIC+ITC and MIC alone) and DFS or OS; it quantified the hazard of an event in the MIC (+/- ITC) group compared to the hazard in node-negative (N0) patients. A random-effect meta-analysis model using the inverse variance method was selected for pooling. Forest plots were used to display the HRs and risk differences within individual trials and overall.

RESULTS

Eleven articles were finally retained for the meta-analysis. In the analysis of DFS in patients with low-volume metastasis (MIC + ITC), the HR was increased to 2.60 (1.55-4.34) in the case of low-volume metastasis vs. N0. The presence of MICs had a negative prognostic impact, with an HR of 4.10 (2.71-6.20) compared to N0. Moreover, this impact was worse than that of MIC pooled with ITCs. Concerning OS, the meta-analysis shows an HR of 5.65 (2.81-11.39) in the case of low-volume metastases vs. N0. The presence of MICs alone had a negative effect, with an HR of 6.94 (2.56-18.81).

CONCLUSIONS

In conclusion, the presence of MIC seems to be associated with a negative impact on both the DFS and OS and should be treated as MAC.

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.

Sentinel lymph node biopsy in early stage cervical cancer: A meta-analysis

Background

The aim of this study was to determine the specific side detection rate of the sentinel lymph node biopsy and the accuracy in predicting lymph node metastasis in early stage cervical cancer.

Methods

A systematic search of databases was performed from the inception of the databases to 27 June 2020. Studies of cervical cancer patients with FIGO stage FIGO ⅠA~ⅡB, evaluating the sentinel lymph node biopsy with blue dye, technetium 99, combined technique (blue dye with technetium 99) or indocyanine green with a reference standard of systematic pelvis lymph node dissection or clinical follow‐up were included. Stata12.0 and Meta‐Disc 1.4 were used for the meta‐analysis.

Results

Of 2825 articles found, 21 studies (2234 women) were eventually included. Out of 21 studies, 20 met the detection rate evaluation criteria and six were included for sensitivity meta‐analysis. Due to heterogeneity, it was inappropriate to pool all studies. The pooled specific side detection rates were 85% in tumors up to 2 cm, 67% in tumors over 2 cm, 75.2% for blue dye, 74.7% for technetium 99, 84% for combined technique, and 85.5% for indocyanine green. The sentinel lymph node biopsy had a pooled specific side sensitivity of 88%. Adverse effects of sentinel lymph node biopsy appear minimal for most patients and are mainly related to the injection of blue dye.

Conclusions

Sentinel lymph node biopsy using a tracer with a high detection rate and ultrastaging is highly accurate and reliable when limited to seriously selected patients, with satisfactory bilateral lymph node mapping and where enough cases for learning curve optimization exist. Indocyanine green sentinel lymph node mapping seems to be a superior sentinel lymph node mapping technique compared to other methods at present.

British Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice

Cervix cancer in many countries is declining and screening programmes and immunisation will reduce the incidence in the next few decades. This guideline attempts to cover management of invasive disease reflecting diagnosis and imaging including new imaging and sentinel lymph node biopsies. Smaller volume disease is usually managed surgically whereas advanced disease is treated with (chemo)- radiation. It also includes discussion of fertility sparing procedures. Practices are changing frequently for all aspects of care usually in attempts to reduce complications and improve quality of life. The management of advanced disease is treated by chemotherapy and the use of newer agents is also discussed. Other sections discuss specialist situations such as cancer in pregnancy, rare cervical tumours, late effects and supportive measures and fertility preserving approaches.

SPECT-CT visualization and biopsy of sentinel lymph nodes in patients with stage IAB-IIA cervical cancer

OBJECTIVE

To evaluate the diagnostic accuracy of sentinel lymph node (SLN) biopsy and to determine clinical significance of preoperative single-photon emission computed tomography/computed tomography (SPECT-CT).

METHODS

We retrospectively evaluate data and images of 55 women with stage IAB-IIA cervical cancer that underwent sentinel lymph node biopsy and subsequent lymph node dissection. ^99mTc-phytate (300 MBq) was injected submucosally in 4 points and SPECT-CT started 2 h after the injection. All lymph nodes (LN) that accumulated radiocolloids were regarded as sentinel. Next day after the mapping radical hysterectomy with complete pelvic and parametrial LN dissection and SLN biopsy were performed according to the institute protocol.

RESULTS

SPECT-CT identified SLNs in 51 of 55 patients. All SLNs were successfully detected during the surgery. The SLN mapping efficacy was 92.7%. LN metastases were diagnosed in 6/51 (11.8%) cases, including 2 patients with positive SLNs. Sensitivity, negative predictive value (NPV) and false-negative rate for SLN biopsy were as follows: 33.4%, 91.8% and 66.6%. In patients with unilateral SPECT-CT localization of SLNs, LN metastases were identified in 4 (20%) of 20 patients but SLN biopsy was false negative in all cases. In 31 women, SPECT-CT detected SLNs on both sides of the pelvis. In this group, regional LN metastases were diagnosed in 2 patients, and in both cases metastases were detected only in SLNs.

CONCLUSIONS

In women with SPECT-CT visualization of SLNs on both sides of the pelvis, SLN biopsy had high sensitivity and NPV. In patients with unilateral SLN localization, SLN biopsy cannot be used for the prediction of regional LN status.

Diagnostic value of frozen section examination of sentinel lymph nodes in early-stage cervical cancer at the time of ultrastaging

OBJECTIVES

We aimed to assess the diagnostic value of frozen-section pathologic examination (FSE) of sentinel lymph nodes (SLN) in patients with early-stage cervical cancer.

METHODS

Two French prospective multicentric database on SLN biopsy for cervical cancer (SENTICOL I and II) were analysed. Patients with IA to IIA1 2018 FIGO stage, who underwent SLN biopsy with both FSE and ultrastaging examination were included.

RESULTS AND DISCUSSION

Between 2005 and 2012, 313 patients from 25 centers fulfilled the inclusion criteria. Metastatic involvement of SLN was diagnosed in 52 patients (16.6%). Macrometastases, micrometastases and isolated tumor cells (ITCs) were found in 27, 12 and 13 patients respectively. Among the 928 SLNs analysed, FSE identified 23 SLNs with macrometastases in 20 patients and 5 SLNs with micrometastases in 2 patients whereas no ITCs were identified. Ultrastaging of negative SLNs by FSE found macrometastases, micrometastases and ITCs in additional 7, 11 and 17 SLNs. Ultrastaging increased significantly the rate of patients with positive SLN from 7% to 16.6% (p < 0.0001). The sensitivity and the negative predictive value of FSE were 42.3% and 89.7% respectively or 56.4% and 94.1% if ITCs were excluded. False-negative cases were more frequent with tumor size ≥ 20 mm (OR = 4.46, 95%IC = [1.45-13.66], p = 0.01) and preoperative brachytherapy (OR = 4.47, 95%IC = [1.37-14.63], p = 0.01) and less frequent with patients included in higher volume center (>5 patients/year) (OR = 0.09, 95%IC = [0.02-0.51], p = 0.01).

CONCLUSIONS

FSE of SLN had a low sensitivity for detecting micrometastases and ITCs and a high negative predictive value for SLN status. Clinical impact of false-negative cases has to be assessed by further studies.

Noninvasive prediction of lymph node status for patients with early-stage cervical cancer based on radiomics features from ultrasound images

OBJECTIVE

To investigate the feasibility of a noninvasive detection of lymph node metastasis (LNM) for early-stage cervical cancer (ECC) patients with radiomics methods based on the textural features from ultrasound images.

METHODS

One hundred seventy-two ECC patients between January 2014 and September 2018 with pathologically confirmed lymph node status (LNS) and preoperative ultrasound images were retrospectively reviewed. Regions of interest (ROIs) were delineated by a senior radiologist in the ultrasound images. LIFEx was applied to extract textural features for radiomics study. Least absolute shrinkage and selection operator (LASSO) regression was applied for dimension reduction and for selection of key features. A multivariable logistic regression analysis was adopted to build the radiomics signature. The Mann-Whitney U test was applied to investigate the correlation between radiomics and LNS for both training and validation cohorts. Receiver operating characteristic (ROC) curves were applied to evaluate the accuracy of the radiomics prediction models.

RESULTS

A total of 152 radiomics features were extracted from ultrasound images, in which 6 features were significantly associated with LNS (p < 0.05). The radiomics signatures demonstrated a good discrimination between patients with LNM and non-LNM groups. The best radiomics performance model achieved an area under the curve (AUC) of 0.79 (95% confidence interval (CI), 0.71-0.88) in the training cohort and 0.77 (95% CI, 0.65-0.88) in the validation cohort.

CONCLUSIONS

The feasibility of radiomics features from ultrasound images for the prediction of LNM in ECC was investigated. This noninvasive prediction method may be used to facilitate preoperative identification of LNS in patients with ECC.

KEY POINTS

• Few studied had investigated the feasibility of radiomics based on ultrasound images for cervical cancer, even though it is the most common practice for gynecological cancer diagnosis and treatment. • The radiomics signatures based on ultrasound images demonstrated a good discrimination between patients with and without lymph node metastasis with an area under the curve (AUC) of 0.79 and 0.77 in the training and validation cohorts, respectively. • The radiomics model based on preoperative ultrasound images has the potential ability to predict lymph node status noninvasively in patients with early-state cervical cancer, so as to reduce the impact of invasive examination and to optimize the treatment choices.

Role of one-step nucleic acid amplification (OSNA) to detect sentinel lymph node low-volume metastasis in early-stage cervical cancer

INTRODUCTION

Growing evidence in the literature supports the accuracy of sentinel lymph node (SLN) biopsy in early-stage cervical cancer. One-step nucleic acid amplification (OSNA) is a rapid assay able to detect cytokeratin 19-mRNA in SLNs, and it can be used for intra-operative detection of low-volume metastases. The aim of this study was to evaluate the rate of low-volume metastasis in SLNs detected by OSNA in patients with early-stage cervical cancer. Secondary aims were to define the sensitivity and the negative predictive value of SLN biopsy assessed with OSNA.

METHODS

After IRB approval, consecutive patients who underwent surgery for International Federation of Gynecology and Obstetrics stage IA1 with lymph-vascular space involvement to IB1 between November 2017 and July 2019 and had SLN biopsy and pelvic lymphadenectomy were included. SLNs were detected with indocyanine-green cervical injection and sent intra-operatively for OSNA.

RESULTS

Eighteen patients underwent SLN assessment with OSNA and systematic pelvic lymphadenectomy in the study period. Four (22.2%) patients had unilateral and 14 (77.8%) had bilateral mapping. OSNA detected micro-metastasis in 6/18 (33.3%) patients. All micro-metastases were detected in patients with bilateral SLN mapping. The sensitivity and negative predictive value of SLN in detecting lymph node metastasis with OSNA calculated per pelvic sidewall were 85.7% and 96.1%, respectively. The false negative rate in mapped sidewalls was 14.3%.

DISCUSSION

This is the first series entirely processing SLNs for OSNA in early-stage cervical cancer. OSNA is able to intra-operatively detect low-volume metastases in SLNs. Further studies are necessary to confirm the accuracy of this technique and to assess survival implications of low-volume metastases detected by OSNA.

Pathologic Protocols for Sentinel Lymph Nodes Ultrastaging in Cervical Cancer

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.

Risk factors for failure of bilateral sentinel lymph node mapping in early-stage cervical cancer

BACKGROUND

The objective of this study was to determine clinical, tumoral and surgical factors associated with successful bilateral sentinel lymph node mapping (SBM) in early-stage cervical cancer.

METHODS

We performed an ancillary work on the data of two prospective trials on SLN biopsy for FIGO IA-IIA cervical cancer (SENTICOL I & II). Patients having Sentinel lymph node (SLN) mapping for early-stage cervical cancer were included between 2005 and 2012 from 28 French oncologic centers. SLN was detected by a combined labeling technique (blue and isotopic).

RESULTS

405 patients were included for analysis: SLNs were identified on at least one side of the pelvis in 381 patients (94.1%) and bilaterally in 326 patients (80.5%). The mean age was 45.4 years [22-85 years]. Most patients had IB1 pathologic FIGO 2018 stage (81.3%) and squamous cell carcinoma (71%). Surgeries were mainly performed by minimally invasive approach (368 patients - 90.9%). By multivariate analysis, lower SBM rate was significantly associated with Age ≥70 years (ORa = 0.02, 95%CI = [0.001-0.28], p = 0.004), tumor size larger than 20 mm (ORa = 0.46,95%CI = [0.21-0.99], p = 0.048) and Body-mass index higher than 30 kg/m² (ORa = 0.28, 95%CI = [0.12-0.65], p = 0.003). SBM rate was significantly higher in high skills centers (>5patients/year) (ORa = 8.05, 95%CI = [2.06-31.50], p = 0.003) and in SENTICOL II (2009-2012) compared to SENTICOL I (2005-2007) (ORa = 2.6, 95%CI = [1.23-5.51], p = 0.01).

CONCLUSIONS

In early-stage cervical cancer, bilateral SLN detection rates is lower in patients aged more than 70years, patients with BMI≥30 kg/m² and larger tumor ≥20 mm whereas stronger experience of SLN biopsy technique improves bilateral SLN detection.

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

Lymph node status is the most important prognostic factor of survival in women with early stage cervical cancer. Sentinel lymph node (SLN) biopsy is an accurate method for the assessment of lymph nodal involvement in early-stages cervical cancer and has been increasingly used instead of systematic pelvic lymph node dissection (PLND). Less-radical lymph node dissection decreases the associated morbidity of PLND, especially the risk of lower-leg lymphoedema, which affects severely patient quality of life. SLN biopsy allows nodes ultrastaging and provides supplementary histological information by increasing the detection of tumor low-volume (isolated tumors cells and micrometastases). Moreover, SLN biopsy provides accurate anatomical information on pelvic lymphatic drainage pathway by identifying nodes outside of routine lymphadenectomy areas. Selection of a population at low-risk of nodal metastasis, a minimal training, and simple rules may ensure a low false negative rate. Several studies have shown that SLN mapping in these patients is feasible, with excellent detection rates and sensitivity. Combined detection with technetium-99 and blue dye has been widely used but recently, there has been increasing interest in the use of fluorescent dies such as indocyanine green (ICG) which would improve SLN detection. Although recent international guidelines recommend performing SLN biopsy in addition to PLND, SLN biopsy alone is not the gold-standard yet due to lack of prospective evidence, especially on long-term oncological safety. Some points remain controversial such as the low accuracy of intraoperative SLN status assessment by frozen section and the impact of micrometastasis on prognostic. The prospective randomized clinical trial SENTICOL III will answer to these problematics.

Use of a Sentinel Lymph Node Biopsy Algorithm in a South African Population of Patients With Cervical Cancer and High Prevalence of Human Immunodeficiency Virus Infection

OBJECTIVES

Cervical cancer is common in resource-poor settings with high prevalence of tuberculosis, pelvic inflammatory disease, and human immunodeficiency virus (HIV) infection. There are no data regarding the sentinel lymph node (SLN) algorithm in these high-risk cancer populations. Our objectives were to establish the sensitivity, specificity, positive predictive value, and negative predictive value of the SLN algorithm in cervical cancer and to compare the detection rate of indocyanine green (ICG) versus blue dye versus technetium Tc 99m nanocolloid (Tc).

METHODS

This prospective study was conducted at the University of Pretoria. Tc-nanocolloid tracer, ICG dye, and methylene blue (MB) were used to detect SLNs. Pathological ultrastaging was performed on hematoxylin-eosin- negative nodes.

RESULTS

Results of 72 women were analyzed. The mean age was 47.2 years, 5.5% had a history of tuberculosis, 18.1% had pelvic inflammatory disease, and 65.3% were HIV positive. The SLN detection rate was 65.3%. Detection rate of MB was 56.9%; Tc, 69.4%; ICG, 87.5%; and the combination of MB and Tc, 91.7%. Pelvic nodal metastases occurred in 26.4%. The sensitivity, specificity, negative predictive value, and positive predictive value of SLN biopsy were 85.7%, 100%, 100%, and 98.33%, respectively. The false-negative rate was 14.3%, and it was 0% if the algorithm was applied.

CONCLUSIONS

The SLN algorithm is a feasible option for use in cervical cancer women with a high prevalence of HIV infection. The detection rate is generally lower, but in select subgroups of women, it was comparable to that reported elsewhere. This is the first report of the use of SLN biopsy in a substantial group of HIV-infected women.

A GCIG international survey: clinical practice patterns of sentinel lymph node biopsies in cervical cancer

PURPOSE

To evaluate the practice patterns among centers and physicians worldwide regarding sentinel lymph node biopsies (SLNB) in cervical cancer (CC) patients.

METHOD

A validated 35-item questionnaire regarding SLNB in CC supported by the Gynecologic Cancer Intergroup (GCIG), and sponsored by the North-Eastern German Society of Gynaecologic-Oncology (NOGGO) was sent to all major gynecological cancer societies across the globe for further distribution from October 2015 and continued for a period of 7 months.

RESULTS

One hundred and sixty-one institutions from around the world participated. One hundred and six (66%) of the participants were from university centers and 111 (69%) were gynecologic oncologists. One hundred and fifty-two (97%) performed lymphadenectomy (LNE) and 147 (94%) did so systematically; 97 (60%) used SLNB, due to lower morbidity (73%), reliability (55%) and time-saving (27%). In cases of positive SLNB (pN+), 39% of respondents stopped the operation and sent the patient for chemoradiation (CRT), 45% completed pelvic and paraaortic LNE, whereas 26% went on to perform a radical hysterectomy (RH) and systematic pelvic and paraaortic LNE. In case of negative SLNB (pN0), 39% of institutions still performed a systematic pelvic and paraaortic LNE.

CONCLUSION

In this survey worldwide, SLNB adoption is an encouraging 60%, yet ample differences exist regarding strategy, and to a lower extent the techniques used. Lack of experience is the most common reason SLNB is not performed. Efforts to increase surgical education on SLNB technique and multicenter prospective trials providing evidence-based guidelines are warranted.

Less Is More: Minimally Invasive and Quality Surgical Management of Gynecologic Cancer

Surgery is a cornerstone of gynecologic oncology. Minimally invasive techniques have been adopted rapidly, in lieu of open approaches, in cervical and endometrial cancer staging. In addition, nodal assessment has undergone significant changes with the introduction of SLN biopsies. The movement toward less is more has also been seen with perioperative and postoperative care and the advent of ERAS protocols, which attempt to maintain normal physiology with the goal of improving functional recovery. It is imperative that new technology be critically evaluated to ensure that oncologic outcomes are not compromised.

Sentinel lymph node mapping using indocyanine green in patients with uterine and cervical neoplasms: restrictions of the method

Purpose

To establish the surgical, demographic and histopathological factors associated with inaccurate sentinel lymph nodes (SLNs) identification using indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging in uterine and cervical neoplasms during both open and laparoscopic surgery.

Methods

We reviewed patients with atypical endometrial hyperplasia (AEH), clinical stage I and II cervical cancer or uterine malignancies who underwent primary surgery with SLN mapping between September 2015 and January 2018. An analysis of patients’ demographics, tumor factors and surgical approach was conducted. Bilateral and overall detection rates were calculated and univariate analysis was performed to estimate factors associated with failed SLN mapping.

Results

A total of 32 patients with uterine and cervical neoplasms were included in the study. The overall detection rate of the SLN was 84% and bilateral detection rate was 75%. There were no statistically relevant differences in overall and bilateral SLN detection rates by BMI, surgical approach or age. Regarding endometrial cancer, there were no differences in SLN detection rates when comparing tumor grade, histology nor myometrial invasion. For SLN detection failure, only the presence of metastatic lymph nodes and lack of surgical experience significantly increased the disability to detect SLNs (p = 0.03, p = 0.04, respectively).

Conclusions

SLN mapping technique using NIR fluorescence imaging with ICG appears to be accurate method in most of the patients with cervical or endometrial carcinoma, regardless of demographic characteristics, tumor-related features and surgical approach. Surgeons’ expertise in that field allows obtaining excellent detection rates.

Sentinel lymphatic mapping among women with early-stage cervical cancer: A systematic review

The presence of pelvic lymph node metastases is without doubt the most significant prognostic factor that determines recurrences and survival of women with early-stage cervical cancer. To avoid the underdiagnosis of lymph node metastasis, pelvic lymphadenectomy procedure is routinely performed with radical hysterectomy procedure. However, the pelvic lymphadenectomy procedure may not be necessary in most of these women due to the relatively low incidence of pelvic lymph node metastasis. The removal of large numbers of pelvic lymph nodes could also render non-metastatic irreversible damages for these women, including vessel, nerve, or ureteral injuries; formation of lymphocysts; and lymphedema. Over the past decades, the concept of sentinel lymph node biopsy has emerged as a popular and widespread surgical technique for the evaluation of the pelvic lymph node status in gynecologic malignancies. The histological status of sentinel lymph node should be representative for all other lymph nodes in the regional drainage area. If metastasis is non-existent in the sentinel lymph node, the likelihood of metastatic spread in the remaining regional lymph nodes is very low. Further lymphadenectomy is therefore not necessary for a patient with negative sentinel lymph nodes. Since the uterine cervix has several lymphatic drainage pathways, it is a challenging task to assess the distribution pattern of sentinel lymph nodes in women with early-stage cervical cancer. This review article will adapt the methodology proposed in these studies to systematically review sentinel lymphatic mapping among women with early-stage cervical cancer.

Radiomic signature as a predictive factor for lymph node metastasis in early-stage cervical cancer

BACKGROUND

Lymph node metastasis (LNM) is the principal risk factor for poor outcomes in early-stage cervical cancer. Radiomics may offer a noninvasive way for predicting the stage of LNM.

PURPOSE

To evaluate a radiomic signature of LN involvement based on sagittal T₁ contrast-enhanced (CE) and T₂ MRI sequences.

STUDY TYPE

Retrospective.

POPULATION

In all, 143 patients were randomly divided into two primary and validation cohorts with 100 patients in the primary cohort and 43 patients in the validation cohort.

FIELD STRENGTH/SEQUENCE

T₁ CE and T₂ MRI sequences at 3T.

ASSESSMENT

The gold standard of LN status was based on histologic results. A radiologist with 10 years of experience used the ITK-SNAP software for 3D manual segmentation. A senior radiologist with 15 years of experience validated all segmentations. The area under the receiver operating characteristics curve (ROC AUC), classification accuracy, sensitivity, and specificity were used between LNM and non-LNM groups.

STATISTICAL TESTS

A total of 970 radiomic features and seven clinical characteristics were extracted. Minimum redundancy / maximum relevance and support vector machine algorithms were applied to select features and construct a radiomic signature. The Mann-Whitney U-test and the chi-square test were used to test the performance of clinical characteristics and potential prognostic outcomes. The results were used to assess the quantitative discrimination performance of the SVM-based radiomic signature.

RESULTS

The radiomic signatures allowed good discrimination between LNM and non-LNM groups. The ROC AUC was 0.753 (95% confidence interval [CI], 0.656-0.850) in the primary cohort and 0.754 (95% CI, 0584-0.924) in the validation cohort.

DATA CONCLUSIONS

A multiple-sequence MRI radiomic signature can be used as a noninvasive biomarker for preoperative assessment of LN status and potentially influence the therapeutic decision-making in early-stage cervical cancer patients.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:304-310.

Selective biopsy of the sentinel node in cancer of cervix: Experience in validation phase

BACKGROUND AND OBJECTIVE

Sentinel lymph node biopsy (SLNB) was created to reduce the morbidity associated with pelvic lymphadenectomy in the early stages of cervical cancer (CC), preserving its prognostic information. The goal is to assess the diagnostic validity of SLNB in CC in initial stages (IA1 with lymphovascular infiltration (LVI) +, IA2, IB1 and IIA1), thus avoiding unnecessary lymphadenectomies in many of the cases.

MATERIAL AND METHOD

From January 2012 to April 2017, 23 patients with initial stages of CC were included in a cross-sectional study to evaluate the effectiveness of the SLNB in CC with a mixed technique of cervical injection of ^99mTc-nanocolloid of albumin and methylene blue, using combined planar lymphoscintigraphy with multimodality SPECT/CT image and subsequent removal of the sentinel node (SN) by laparoscopy.

RESULTS

The detection rate of SLNB with the mixed technique was 95.65%, with a negative predictive value (NPV) of 95.45% and sensitivity (S) of 100% in the case of bilateral drainage. The mean of excised SN was 3 (range 1-5). The bilateral detection rate in laparoscopy was 85.35%. The concordance between SPECT/CT and laparoscopy for the number and bilaterality of the SN using the Pearson coefficient was r = 0.727 and r = 0.833, respectively; p = 0.01. We only found one SN with a deferred result of micrometástasis and one false negative was detected.

CONCLUSIONS

SLNB in CC using a mixed technique has a high detection and bilateral drainage rate, but S is still low if we include cases of unilateral drainage. A greater number of cases and the development of intraoperative ultrastaging could increase the S of the technique and to reduce the number of false negatives.

Abdominal radical trachelectomy guided by sentinel lymph node biopsy for stage IB1 cervical cancer with tumors >2 cm

Accuracy of prediction of pelvic lymph node status using sentinel lymph node biopsy (SLNB), and outcomes of SLNB-guided abdominal radical trachelectomy (ART) were assessed. Patients with stage IB1 (Figure 2009) cervical cancer and with tumors >2 cm were enrolled. Prior to fertility-sparing surgery 99mTc-labeled phytate was administered. SLNs were intraoperatively identified, excised, and assessed using fast-frozen sections. Systematic bilateral pelvic lymphadenectomy with or without para-aortic lymphadenectomy was subsequently undertaken. The SLN detection rate was 91.8% (45/49 patients); 8.2% (4/49) had radical hysterectomies because of metastatic primary SLNs. All SLNs received routine immunopathological examination to detect micrometastasis. Sensitivity, accuracy, and false negative rates were 100%, 100%, and 0%, respectively. ART was successfully completed in 45 patients (median follow-up, 61 [range, 4-149] months). Three of the 45 (6.7%) were lost to follow-up; two relapsed and one died of tumor progression. Overall 3-year survival and progression-free survival rates were 97.6% and 95.2%, respectively. Of the 19 patients who attempted to conceive after surgery, five achieved pregnancy, and one had a live birth in the third trimester. We concluded that SLNB using 99mTc-labeled phytate can accurately assess pelvic node status. SLNB-guided ART is safe and feasible in patients selected for fertility-sparing procedures.

Sentinel lymph node mapping in gynecological oncology

The intraoperative mapping of sentinel lymph nodes (SLNs) is part of the treatment strategy for a number of types of tumor. To retrospectively compare results from the mapping of pelvic SLNs for gynecological oncology, using distinct dyes, the present review was conducted to determine the clinical significance of SLN mapping for gynecological oncology. In addition, the present study aimed at identifying an improved choice for SLN mapping tracers in clinical application. Each dye exhibits demerits when applied in the clinical environment. The combination of radioisotopes and blue dyes was identified to exhibit the most accurate detection rate of SLN drainage of gynecological oncology. However, contrast agents were unable to identify whether a SLN is positive or negative for metastasis prior to pathologic examination; additional studies are required.

Subserosal uterine injection of blue dye for the identification of the sentinel node in patients with endometrial cancer: a feasibility study

OBJECTIVE

To define the detection rate, sensitivity, and negative predictive value (NPV) of the sentinel node technique in patients with endometrial cancer.

METHODS

Patients with endometrial cancer after informed consent underwent subserosal injection of blue dye during hysterectomy in a tertiary gynae/oncology department between 2010 and 2014. The procedure was performed in all cases by the same team including two gynae/oncologist consultants and one trainee. All relevant perioperative clinicopathological characteristics of the population were recorded prospectively. The identified sentinel nodes were removed separately and a completion bilateral pelvic lymphadenectomy followed in all cases. Simple statistics were used to calculate the sensitivity and NPV of the method on per patient basis.

RESULTS

Fifty-four patients were included in this study. At least one sentinel node was mapped in 46 patients yielding a detection rate of 85.2%. Bilateral detection of sentinel nodes was accomplished in only 31 patients (57.4%). The mean number of sentinel nodes was 2.6 per patient and the commonest site of identification was the external iliac artery and vein area (66%). Six patients (11%) had a positive lymph node, and in five of them, this was the sentinel one yielding a sensitivity of 83.3% and an NPV of 97.5%. The overall detection rate improved significantly after the first 15 cases; however, this was not the case for the bilateral detection rate.

CONCLUSION

Our study is in accordance with previous studies of sentinel node in endometrial cancer and further demonstrates and enhances the confidence in the technique. In the current era of an ongoing debate on whether a systematic lymphadenectomy in patients with endometrial cancer is still necessary, we believe that the sentinel node is an acceptable alternative and should be applied routinely in tertiary centres following a strict algorithm.

Current imaging strategies for the evaluation of uterine cervical cancer

Uterine cervical cancer still remains an important socioeconomic issue because it largely affects women of reproductive age. Prognosis is highly depended on extent of the disease at diagnosis and, therefore, accurate staging is crucial for optimal management. Cervical cancer is clinically staged, according to International Federation of Gynecology and Obstetrics guidelines, but, currently, there is increased use of cross sectional imaging modalities [computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography-CT (PET-CT)] for the study of important prognostic factors like tumor size, parametrial invasion, endocervical extension, pelvic side wall or adjacent/distal organs involvement and lymph node status. Imaging indications also include cervical cancer follow-up, evaluation of tumor response to treatment and selection of suitable candidates for less radical surgeries like radical trachelectomy for fertility preservation. The preferred imaging method for local cervical cancer evaluation is MRI; CT is equally effective for evaluation of extrauterine spread of the disease. PET-CT shows high diagnostic performance for the detection of tumor relapse and metastatic lymph nodes. The aim of this review is to familiarize radiologists with the MRI appearance of cervical carcinoma and to discuss the indications of cross sectional imaging during the course of the disease in patients with cervical carcinoma.

Feasibility and performance of lymphoscintigraphy in sentinel lymph node biopsy for early cervical cancer: results of the prospective multicenter SENTICOL study

Objective

To evaluate feasibility, SLN detection rate, and SLN location of lymphoscintigraphy in sentinel lymph node (SLN) biopsy for early cervical cancer.

Methods

Ancillary analysis of data from the multicenter prospective SENTICOL study (January 2005–June 2007) of patients with early cervical cancer (FIGO stage IA with emboli to IB1) was conducted. Preoperative lymphoscintigraphy was performed after intracervical administration of 60 or 120 MBq of ^99mTc-labeled radiocolloid on the day before (long protocol) or morning of (short protocol) surgery. SLNs were identified intraoperatively using combined radioactivity/patent blue detection. SLNs were sampled electively and routine bilateral pelvic lymphadenectomy was performed by laparoscopy. A centralized review of lymphoscintigraphies was performed to assess feasibility, detection rates, and anatomic SLN location.

Results

Of 139 patients included in the SENTICOL study, 133 received radiocolloid injection, and 131 (98.5 %) underwent preoperative lymphoscintigraphy, with the long protocol in three-fourths of cases. The lymphoscintigraphic detection rate was 87.8 %, with a median of 2 (1–4) SLNs per patient. By multivariate analysis, factors independently associated with lymphoscintigraphic SLN detection were age [odds ratio (OR) 0.91, 95 % confidence interval (95 % CI) 0.87–0.96; P < 0.001], and protocol (long vs. short; OR 8.23, 95 % CI 1.87–36.25; P = 0.005). Bilateral SLN identification by lymphoscintigraphy occurred in 67 % of cases and was independently influenced by age (OR 0.95, 95 % CI 0.92–0.98, P < 0.001) and protocol (OR 5.42, 95 % CI 2.21–13.27; P < 0.001). Although 60.5 % of preoperative SLNs were in the external iliac territory, unusual drainage patterns included the common iliac (19.6 %), para-aortic (10.8 %), and parametrial (6 %) basins.

Conclusions

Our study demonstrates the feasibility and good detection rate of preoperative lymphoscintigraphy, with better detection in younger patients and with the long protocol. The high proportion of SLN basins in unexpected territories is of interest to guide intraoperative detection. Further studies are needed to better evaluate preoperative detection and to assess the contribution of lymphoscintigraphy to intraoperative detection.

Contribution of Lymphoscintigraphy for Sentinel Lymph Node Biopsy in Women with Early Stage Endometrial Cancer: Results of the SENTI-ENDO Study

BACKGROUND

This study was designed to evaluate detection rate and anatomical location of sentinel lymph node (SLN) at lymphoscintigraphy, to compare short and long lymphoscintigraphy protocols, and to correlate lymphoscintigraphic and surgical mapping of SLN in patients with early-stage endometrial cancer (EC).

METHODS

Subanalysis of the prospective multicenter study Senti-endo performed from July 2007 to August 2009. Patients with stage I and II EC received four cervical injections of 0-2 mL of unfiltered technetium sulphur colloid the day before (long protocol) or the morning (short protocol) before surgery. SLN detection used a combined technetium/patent blue labeling technique, and all patients had a systematic bilateral pelvic lymphadenectomy.

RESULTS

A total of 133 patients were enrolled in the study and 118 (94.5 %) underwent a lymphoscintigraphy. Of these 118 patients, 44 (37 %) underwent a short protocol and 66 (56 %) a long protocol (data on lymphoscintigraphy were not available in eight patients). Lymphoscintigraphic detection rate was 74.6 % (34 % for short protocol and 60.2 % for long protocol). No difference in the detection rate was observed according to lymphoscintigraphy protocol (p = 0.22), but a higher number of SLN was noted for the long protocol (p = 0.02). Aberrant drainage was noted on lymphoscintigraphy in 30.5 % of the patients. Paraaortic SLNs were exclusively detected using the long protocol. A poor correlation was noted between short (κ test = 0.24) or long lymphoscintigraphy (κ test = 0.3) protocol and SLN surgical mapping.

CONCLUSIONS

Our study demonstrates that preoperative lymphoscintigraphy allowed a high SLN detection rate and that long lymphoscintigraphy protocol was associated with a higher detection of aberrant drainage especially in the paraaortic area.

Sentinel node biopsy for lymph nodal staging of uterine cervix cancer: a systematic review and meta-analysis of the pertinent literature

BACKGROUND

We reviewed the available literature on the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers.

METHODS

MEDLINE and Scopus were searched by using "sentinel AND (cervix OR cervical)" as key words. Studies evaluating the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers were included if enough data could be extracted for calculation of detection rate and/or sensitivity.

RESULTS

Sixty-seven studies were included in the systematic review. Pooled detection rate was 89.2% [95% CI: 86.3-91.6]. Pooled sensitivity was 90% [95% CI: 88-92]. Sentinel node detection rate and sensitivity were related to mapping method (blue dye, radiotracer, or both) and history of pre-operative neoadjuvant chemotherapy. Sensitivity was higher in patients with bilaterally detected pelvic sentinel nodes compared to those with unilateral sentinel nodes. Lymphatic mapping could identify sentinel nodes outside the routine lymphadenectomy limits.

CONCLUSION

Sentinel node mapping is an accurate method for the assessment of lymph nodal involvement in uterine cervical cancers. Selection of a population with small tumor size and lower stage will ensure the lowest false negative rate. Lymphatic mapping can also detect sentinel nodes outside of routine lymphadenectomy areas providing additional histological information which can improve the staging. Further studies are needed to explore the impact of sentinel node mapping in fertility sparing surgery and in patients with history of neoadjuvant chemotherapy.

Value and advantages of preoperative sentinel lymph node imaging with SPECT/CT in cervical cancer

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.

[Sentinel lymph node in low stage cervical cancers. Current data. Quality assurance. Prospects]

Sentinel node biopsy appears as a promising technique for the assessment of nodal disease in early cervical cancers. Selection of a population with a low risk of nodal metastasis, a minimal training, and simple rules allow a low false negative rate. Sentinel node biopsy provides supplementary information, such as anatomical information (nodes outside of routine lymphadenectomy areas) and histological information (isolated tumors cells and micrometastases).

Identification of biomarkers for lymph node metastasis in early-stage cervical cancer by tissue-based proteomics

Background:

Pelvic lymph node metastasis (PLNM) is the key to determining the treatment and prognosis of early-stage cervical cancer (CC, I–IIst). The aim of this study was to identify biomarkers for PLNM of CC, I–IIst.

Methods:

Two-dimensional fluorescence difference gel electrophoresis and matrix-assisted laser desorption/ionisation-time-of-flight mass spectrometry (MALDI-TOF/TOF MS) were used to identify differentially expressed proteins in primary CC, I–IIst tissue with (n=8) and without (n=10) PLNM. The expression levels of three differential proteins (FABP5, HspB1, and MnSOD) were validated using western blotting and immunohistochemistry. An independent cohort of 105 CC, I–IIst patients was analysed to assess the correlation of FABP5, HspB1, and MnSOD with clinicopathologic factors and clinical outcomes.

Results:

Forty-one differential proteins were identified. Upregulation of FABP5, HspB1, and MnSOD in CC, I–IIst with PLNM was confirmed and was significantly correlated with PLNM. FABP5, HspB1, and MnSOD were significant predictors of PLNM in univariate analysis. FABP5, HspB1, and lymphovascular space invasion (LVSI) were independent predictors of PLNM in multivariate analysis. Survival curves indicated that CC, I–IIst patients with FABP5, HspB1, and MnSOD upregulation had poor prognosis.

Conclusions:

FABP5, HspB1, and MnSOD may be potential biomarkers for PLNM of CC, I–IIst and may have important roles in the pathogenesis of PLNM.

Current status of sentinel lymph node mapping in the management of cervical cancer

The status of regional lymph nodes is the most important prognostic factor in early cervical cancer patients. Pelvic lymph node dissections are routinely performed as a part of standard surgical treatment. Systematic pelvic lymphadenectomy is associated with short- and long-term morbidities. This review discusses single components of the sentinel lymph node mapping (SLNM) technique and results of the detection of sentinel lymph nodes. SLNM biopsy performed by an experienced team for small volume tumors (<2 cm) has high specific side detection rate, excellent negative-predictive value and high sensitivity. Uncommon lymphatic drainage has been reported in 15% of cervical cancer patients. There is sufficient data now to suggest that SLNM with 99mTc plus blue dye in the hands of a surgeon with extensive experience should prove to be an important part of individualized cervical cancer surgery and increase the safety of less radical or fertility-sparing surgery.

Sentinel lymph node biopsy in cervical cancer: A meta-analysis

Sentinel lymph node biopsy (SLNB) is used to determine the pathological status of the first lymph node receiving lymphatic drainage from the primary tumor. The diagnostic value of SLNB for the assessment of the nodal status in patients with cervical cancer has not been determined. Therefore, this meta-analysis was conducted to assess the diagnostic value of SLNB in cervical cancer. A search for related literature was performed using PubMed. Data were analyzed using a random effects model and a subgroup analysis was used to assess the diagnostic value of different practices during the process. A total of 17 studies involving a total of 1,112 patients were included in the analysis. The pooled sentinel lymph node (SLN) detection rate, sensitivity and negative predictive values were 92.2% [95% confidence interval (CI): 88.3-94.8%], 88.8% (95% CI: 85.1-91.7%) and 95.0% (95% CI: 92.8-96.6%), respectively. The subgroup analysis revealed that laparoscopy, tracer combination and immunohistochemistry were associated with a higher SLN detection rate. In conclusion, the SLNB in cervical cancer appears to be of diagnostic value, particularly the procedure with the combination of laparoscopy, combined tracers and immunohistochemistry. However, further studies are required to establish the clinical value of SLNB in cervical cancer.

Accuracy of intraoperative pathological examination of SLN in cervical cancer

OBJECTIVE

Early cervical cancer patients with pelvic lymph node metastasis do not benefit from radical hysterectomy. Assessment of the SLN status is thus crucial before deciding to perform a radical hysterectomy as opposed to aortic dissection only followed by definitive radiation therapy. Accuracy of frozen section of SLN has been questioned and deserves further investigation.

METHODS

Stage IA-IB1 cervical cancer patients who underwent SLN then full pelvic dissection at the Claudius Regaud Cancer Center in Toulouse, France, were included.

RESULTS

At least one SLN was identified in all 94 patients. Bilateral detection rate was 80.8%. Ectopic drainage area was found in 19 patients (20.2%). Sentinel lymph node involvement was found in 11 patients (11.7%). Sensitivity and NPV of frozen section pathological examination for the detection of macrometastatic disease was 100%, sensitivity for the detection of macro and micrometastatic disease, excluding ITC, was 88.9%, and NPV was 98.8%. Micrometastasis and isolated tumor cells (ITC) undetected at frozen section examination were found in 1 patient (1.06%) and 2 lymph nodes (1.24%), and in 2 patients (2.13%) and 2 lymph nodes (1.24%), respectively. Final pathology sensitivity of SLN was 100% for both macro and micrometastatic disease, including ITC.

CONCLUSION

In our institution, intraoperative frozen examination of SLN accurately predicts the status of pelvic lymph nodes and is effective for selecting intraoperatively the group of patients who benefit from radical hysterectomy. In addition, our results suggest that patients with small tumors and bilateral detection of SLN can be spared full pelvic lymphadenectomy.