Sentinel node procedure in Ib cervical cancer: a preliminary series

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.

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.

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.

Sentinel-lymph-node procedures in early stage cervical cancer: a systematic review and meta-analysis

We performed a meta-analysis to assess the accuracy of sentinel-lymph-node (SLN) procedures for the assessment of nodal metastases in patients with early stage cervical cancer. Studies of SLN procedures for detecting nodal metastases in patients with early stage cervical cancer were systematically searched in MEDLINE and EMBASE between January 1, 2000 and August 30, 2013. We identified 49 eligible studies, which included 2,476 SLN procedures. The mean overall weighted-detection rate was 0.93 (95 % CI 0.92–0.94), at a pooled sensitivity of 0.88 (95 % CI 0.84–0.90) with limited heterogeneity (χ² = 80.57, degrees of freedom = 47, p = 0.002). Subgroup analysis of sensitivity and the rate of detection of different tracer techniques and surgery methods used in conjunction with an SLN procedures were as follows: studies using combined techniques, 0.88 (95 % CI 0.84–0.91) and 0.97 (95 % CI 0.96–0.98); studies using metastable technetium-99, 0.87 (95 % CI 0.78–0.93) and 0.90 (95 % CI 0.87–0.93); studies using blue dye, 0.87 (95 % CI 0.79–0.93) and 0.87 (95 % CI 0.84–0.90); studies using laparotomy, 0.86 (95 % CI 0.80–0.90) and 0.87 (95 % CI 0.83–0.91); studies using laparoscopy, 0.90 (95 % CI 0.86–0.94) and 0.93 (95 % CI 0.90–0.96); and studies using robot-assisted surgery, 0.84 (95 % CI 0.72–0.92) and 0.92 (95 % CI 0.88–0.95). We concluded that the SLN procedure performs well diagnostically for the assessment of nodal metastases in patients with early stage cervical cancer.

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.

Detection of sentinel lymph nodes in minimally invasive surgery using indocyanine green and near-infrared fluorescence imaging for uterine and cervical malignancies

OBJECTIVES

Our primary objective was to assess the detection rate of sentinel lymph nodes (SLNs) using indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging for uterine and cervical malignancies.

METHODS

NIR fluorescence imaging for the robotic platform was obtained at our institution in 12/2011. We identified all cases planned for SLN mapping using fluorescence imaging from 12/2011-4/2013. Intracervical ICG was the fluorophobe in all cases. Four cc (1.25mg/mL) of ICG was injected into the cervix alone divided into the 3- and 9-o'clock positions, with 1 cc deep into the stroma and 1 cc submucosally before initiating laparoscopic entry. Blue dye was concurrently injected in some cases.

RESULTS

Two hundred twenty-seven cases were performed. Median age was 60 years (range, 28-90 years). Median BMI was 30.2 kg/m(2) (range, 18-60 kg/m(2)). The median SLN count was 3 (range, 1-23). An SLN was identified in 216 cases (95%), with bilateral pelvic mapping in 179 (79%). An aortic SLN was identified in 21 (10%) of the 216 mapped cases. When ICG alone was used to map cases, 188/197 patients mapped, for a 95% detection rate compared to 93% (28/30) in cases in which both dyes were used (P=NS). Bilateral mapping was seen in 156/197 (79%) ICG-only cases and 23/30 (77%) ICG and blue dye cases (P=NS).

CONCLUSIONS

NIR fluorescence imaging with intracervical ICG injection using the robotic platform has a high bilateral SLN detection rate and appears favorable to using blue dye alone and/or other modalities. Combined use of ICG and blue dye appears unnecessary.

Unusual localizations of sentinel lymph nodes in early stage cervical cancer: a review

OBJECTIVE

The aim of this study was to systematically determine the frequency of unusual localizations of sentinel lymph node in patients with early stage cervical cancer.

METHODS

We performed a comprehensive computer literature search of English and French language studies in human subjects on sentinel node procedures in PUBMED database up to December 2010. For each article two reviewers independently performed data extraction using a standard form to determine the route of unusual lymphatic spread of sentinel procedures in cervical cancer.

RESULTS

According to our search, 83.7% of detected sentinel lymph nodes in patients with cervical cancer were in expected localizations (i.e., external iliac, obturator, internal iliac or interiliac). The unusual localizations were: 6.6% in the common iliac chain, 4.31% parametrial, 1.26% sacral, 2% in the lower para-aortic area and 0.07% in the inguinal chain.

CONCLUSION

The unusual localizations of sentinel lymph nodes impose to the gynecologic surgeons to be able to perform lymph node dissection in all the territories potentially affected.

Ultrastaging of lymph node in uterine cancers

Background

Lymph node status is an important prognostic factor and a criterion for adjuvant therapy in uterine cancers. While detection of micrometastases by ultrastaging techniques is correlated to prognosis in several other cancers, this remains a matter of debate for uterine cancers. The objective of this review on sentinel nodes (SN) in uterine cancers was to determine the contribution of ultrastaging to detect micrometastases.

Methods

Review of the English literature on SN procedure in cervical and endometrial cancers and histological techniques including hematoxylin and eosin (H&E) staining, serial sectioning, immunohistochemistry (IHC) and molecular techniques to detect micrometastases.

Results

In both cervical and endometrial cancers, H&E and IHC appeared insufficient to detect micrometastases. In cervical cancer, using H&E, serial sectioning and IHC, the rate of macrometastases varied between 7.1% and 36.3% with a mean value of 25.8%. The percentage of women with micrometastases ranged from 0% and 47.4% with a mean value of 28.3%. In endometrial cancer, the rate of macrometastases varied from 0% to 22%. Using H&E, serial sectioning and IHC, the rate of micrometastases varied from 0% to 15% with a mean value of 5.8%. In both cervical and endometrial cancers, data on the contribution of molecular techniques to detect micrometastases are insufficient to clarify their role in SN ultrastaging.

Conclusion

In uterine cancers, H&E, serial sectioning and IHC appears the best histological combined technique to detect micrometastases. Although accumulating data have proved the relation between the risk of recurrence and the presence of micrometastases, their clinical implications on indications for adjuvant therapy has to be clarified.

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.

Ultrastaging improves detection of metastases in sentinel lymph nodes of uterine cervix squamous cell carcinoma

The technique of sentinel lymph node (SLN) detection is increasingly being applied in patients with uterine cervix carcinoma. This study presents the pathologic findings of SLNs in 48 such patients. The institutional pathology files were searched for all patients with a diagnosis of cervical squamous cell carcinoma who had SLNs reported. Patient age, follow-up, tumor size, presence/absence of lymphatic invasion, number and status of SLNs and non-SLNs, location of SLNs, and size of metastases in SLNs were recorded. All SLNs were sectioned in 2-mm slices perpendicular to the long axis and submitted entirely for microscopic examination. For all SLNs negative on the initial hematoxylin and eosin (H&E) stained slides, an ultrastaging protocol was performed consisting of 5 sets of slides at 40-mum intervals (1 H&E slide+2 unstained slides), representing an additional 5 intervals. Lymph nodes negative by the additional H&E intervals had immunohistochemistry for cytokeratin performed on 1 unstained slide. Forty-eight patients ranging from 25 to 62 years of age had a total of 208 SLNs removed. Fifteen (31%) patients had positive SLNs with 1 to 5 positive SLNs per case. The metastasis size ranged from a single cell to 27 mm. Twelve patients had metastasis detected by routine processing in 23 SLNs, whereas ultrastaging detected metastases in 3 SLNs of 3 additional patients. In 2 patients with metastasis detected by ultrastaging, the metastasis was detected by wide H&E intervals (level 2 for 1 patient; level 3 for 1 patient); in 1 patient, the metastasis was detected only by immunohistochemistry and consisted of a single cell. Of the 15 patients with positive SLNs, 3 patients had a total of 6 positive non-SLNs. All of the patients with a positive SLN are currently living. Thirty-three (69%) patients had negative SLNs. Of these, 1 patient had a single positive non-SLN for a false negative rate of 6.25%. Negative SLN predicts negative non-SLN. For most patients with a positive SLN, the SLN will be the only metastasis detected; a minority of patients with a positive SLN may have a positive non-SLN.

Sentinel lymph node biopsy in gynaecological cancers: the importance of micrometastases in cervical cancer

Lymph node metastases is a recognized prognostic factor in women with cervical cancer. However, there is a need for consensual histological definition of micrometastases in this indication which could give rise to a classification system similar to that used in breast cancer. We thus conducted a MEDLINE and EMBASE database analysis to evaluate the concept of micrometastases in cervical cancer. Retrospective studies place the incidence of micrometastasis between 1.5 and 15% depending on the technique used to evaluate lymph node status. Sentinel lymph node biopsy with serial sectioning and immunohistochemical analysis appears to be the most accurate micrometastases detection technique. The value of RT-PCR in micrometastases detection remains to be clarified by further studies. From a clinical view point, few data are available to support the prognostic relevance of micrometastases. However, case control and longitudinal studies have underlined the risk of recurrence in women with micrometastases, raising the issue of a revision of adjuvant therapy indications in this specific population.

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.

Advances in Surgical Treatment of Cervical Cancer

Radical hysterectomy has been the standard surgical treatment for cervical cancer, achieving a good survival outcome. However, it is a major operation that has considerable potential long-term morbidity. With good prognosis achieved in most early cervical cancers, there is a trend towards more emphasis on maintaining good quality of life post-treatment. Many women diagnosed with cervical cancer are young, and fertility-sparing surgery such as trachelectomy would preserve their reproductive potential. Minimally invasive surgery, such as laparoscopic radical hysterectomy, can potentially improve post-operative recovery and cosmetic results while maintaining oncological safety. Sentinel lymph nodes assessment can minimize unnecessary systematic pelvic lymphadenectomy. Radicality of the hysterectomy may also be reduced in selected individuals with good prognostic factors, thus minimizing long-term pelvic floor dysfunction. This review aims to give a broad overview of the current status of these new trends in surgical management for cervical cancer.

Sentinel lymph node detection in early stage uterine cervix carcinoma: A systematic review

OBJECTIVE

The aim of this study was to systematically review the diagnostic performance of Sentinel Node (SN) detection for assessing the nodal status in early stage cervical carcinoma, and to determine which technique (using blue dye, Technetium-99m colloid (99mTc), or the combined method) had the highest success rate in terms of detection rate and sensitivity.

METHODS

A comprehensive computer literature search of English language studies in human subjects on Sentinel Node procedures was performed in MEDLINE and EMBASE databases up to July 2006. For each article two reviewers independently performed a methodological qualitative analysis and data extraction using a standard form. Pooled values of the SN detection rate and pooled sensitivity values of the SN procedure are presented with a 95% confidence interval (95% CI) for the three different SN detection techniques.

RESULTS

We identified 98 articles, and 23 met the inclusion criteria, comprising a total of 842 patients. Ultimately, 12 studies used the combined technique with a sensitivity of 92% (95% CI: 84-98%). Five studies used 99mTc-colloid, with a pooled sensitivity of 92% (95% CI: 79-98%; p=0.71 vs. combined technique), and four used blue dye with a pooled sensitivity of 81% (67-92%, p=0.17 vs. combined technique). The SN detection rate was highest for the combined technique: 97% (95% CI: 95-98%), vs. 84% for blue dye (95% CI: 79-89%; p<0.0001), and 88% (95% CI: 82-92%, p=0.0018) for 99mTc colloid.

CONCLUSION

SN biopsy has the highest SN detection rate when 99mTc is used in combination with blue dye (97%), and a sensitivity of 92%. Hence, according to the present evidence in literature the combination of 99mTc and a blue dye for SN biopsy in patients with early stage cervical cancer is a reliable method to detect lymph node metastases in early stage cervical cancer.

The sentinel concept in patients with cervical cancer

The sentinel concept for patients with early cervical cancer has a high potential for decreasing morbidity and for increasing oncologic safety. The detection rate with technetium-labeling or a combination with blue dye varies between 84% and 92%. Sensitivity and negative predictive value depend on tumor size: the smaller the tumor, the higher the validity of the technique. Detection of circulating tumor cells in the sentinel node using HPVmRNA as marker may have a good prognostic value. Currently the sentinel concept should only be used in clinical studies before its validity has been proved.

Laparoscopic sentinel lymph node mapping for cervix cancer--a detailed evaluation and time analysis

OBJECTIVE

To provide data from a US center on laparoscopic (LSC) approach to sentinel lymph node (SLN) detection in cervix cancer with detailed time analysis.

METHODS

This prospective trial enrolled patients with stage IA2-IIA cervix cancer undergoing primary radical surgery. Tc-99 radiocolloid was injected the morning of surgery, followed by hybrid SPECT/CT lymphoscintigraphy. Blue dye injection occurred just prior to incision. After bilateral LSC SLN detection, all patients received complete LSC pelvic lymphadenectomy. Institutional SLN protocol was followed for frozen section, hematoxylin and eosin, and cytokeratin staining.

RESULTS

Between December 2003 and February 2006, 20 enrolled patients received 9 LSC-assisted radical vaginal hysterectomies, 7 radical abdominal hysterectomies, 2 LSC-assisted radical vaginal trachelectomies, and 2 LSC lymphadenectomies alone (secondary to positive lymph nodes). Mean tumor size was 2.5 cm. Nineteen percent of the 64 SLNs were found in unusual sites, including common iliac (11%), presacral (5%) and para-aortic (3%). The negative predictive value was 100%. The combined technique detected SLNs bilaterally in all patients. If blue dye alone was used, this rate would have dropped to 67.5% and was negatively correlated with elapsed surgical time (-0.7; p=0.002). The ability to visualize blue SLNs remained steady for 30 min and was completely gone by 50 min.

CONCLUSIONS

Laparoscopic SLN mapping can be newly introduced into gynecologic oncology centers with high detection rates and negative predictive values. The visualization of blue dye in SLNs is transient, and this negative time correlation may explain the previously reported inferior detection rates with this technique. CLINICAL TRIAL REGISTRATION.: ClinicalTrials.gov, http://www.clinicaltrials.gov, NCT 00205010.

Laparoscopic Sentinel Node Biopsy in Cervical Cancer Using a Combined Detection: 5–Years Experience

BACKGROUND

To evaluate the feasibility after 5 years experience of a laparoscopic sentinel node (SN) procedure with combined radioisotopic and patent blue labeling in patients with cervical cancer.

METHODS

Sixty-seven patients (median age 48.9 years) with cervical cancer underwent a laparoscopic SN procedure using an endoscopic gamma probe, after both radioactive and patent blue injections. After the procedure, all the patients underwent complete laparoscopic pelvic/para-aortic lymphadenectomy.

RESULTS

At least one SN was identified in 57 patients (85.1%). According to the Stage, the SN identification rate was 91.2% in early-stage cervical cancer and 78.5% in locally advanced cervical cancer. The mean number of SN was 2.3 per patient (range 1-5). A total of 129 SNs were removed. Lymph node metastasis involvement was identified in the 20 SNs (15.5%) from 14 patients (24.6%). Nine of the 14 patients had at least one macrometastases, three patients presented micrometastases in H&S, and two patients presented isolated single cells. Six patients presented a pelvic non-SN involvement including two patients whose SNs were uninvolved. The false-negative SNs rate was 12.5% (two patients out of 16). Both patients have locally advanced cervical cancer.

CONCLUSION

This study confirms that laparoscopic SN detection with a combination of radiocolloid and patent blue is accurate in patients with early cervical cancer to assess pelvic lymph node status.

Sentinel lymph node detection using methylene blue in patients with early stage cervical cancer

OBJECTIVE

To evaluate the feasibility of sentinel lymph node (SLN) detection in patients with cervical cancer using the low-cost methylene blue dye and to optimize the application procedure.

PATIENTS AND METHODS

Patients with stage Ib(1)-IIa cervical cancer and subjected to abdominal radical abdominal hysterectomy and pelvic lymphadenectomy were enrolled. Methylene blue, 2-4 ml, was injected into the cervical peritumoral area in 77 cases (4 ml patent blue in the other four cases) 10-360 min before the incision, and surgically removed lymph nodes were examined for the blue lymph nodes that were considered as SLNs.

RESULTS

High SLN detection rate was successfully achieved when 4 ml of methylene blue was applied (93.9%, 46/49). Bilaterally SLN detection rate was significantly higher (78.1% vs. 47.1% P=0.027) in cases when the timing of application was more than 60 min before surgery than those with timing no more than 30 min. The blue color of methylene blue-stained SLNs sustained both in vivo and ex vivo, compared with the gradually faded blue color of patent blue that detected in 3 of 4 cases unilaterally. In the total of 112 dissected sides, the most common location of SLNs was the obturator basin (65.2%, 73/112), followed by external iliac area (30.4%, 34/112) and internal iliac area (26.8%, 30/112). Three patients who gave false negative results all had enlarged nodes.

CONCLUSION

Methylene blue is an effective tracer to detect SLNs in patients with early stage cervical cancer. The ideal dose and timing of methylene blue application are 4 ml and 60-90 min prior surgery, respectively.

Dilution of dye improves parametrial SLN detection in patients with cervical cancer

OBJECTIVE

Aim of this study to improve the detection rate of parametrial sentinel nodes in patients with early cervical cancer by using a new dosage of blue dye in a randomized trial.

METHODS

Standard labelling volume of 4 ml Patent Blue was compared to 2 ml Patent Blue diluted with 8 ml NaCl 0.9% in 60 patients using a randomized protocol. Tc-99 was not applied in any patient. All patients underwent open lymphadenectomy.

RESULTS

In each arm 30 patients were enrolled. Overall detection rate of sentinel nodes was 93.3%. Both groups did not differ with regard to patient's age, BMI, tumor stage, number of lymph nodes harvested, number of sentinel nodes detected and detection rate. Significantly more patients with parametrial sentinel nodes were detected in the diluted protocol (37.0% vs. 10.3%) which is due to the lateral part of the cardinal ligament (29.6% vs. 6.9%).

CONCLUSION

In our study overall detection of sentinel nodes using a dye was high. The diluted solution of Patent Blue led to a higher detection rate of parametrial sentinel nodes. These findings might help explain the discrepancy between the high reported rate of parametrial lymph nodes in anatomical studies compared with the low rates in clinical sentinel series.

Negative sentinel lymph node accurately predicts negative status of pelvic lymph nodes in uterine cervix carcinoma

OBJECTIVE

The significance of negative sentinel lymph nodes (SLN) is important in the staging and treatment of melanoma and a few other cancers, but is controversial in uterine cervix carcinoma. Our study was aimed at correlating the SLN status in cervical carcinoma with non-sentinel lymph nodes (non-SLN), in a uniform and well controlled population.

METHODS

This study includes 36 patients with stage I and IIA cervical carcinoma and bilaterally negative SLN on final pathology. SLN were identified using blue dye and radioisotopic techniques. Frozen section examination was performed for all SLN; the rest of the tissue was formalin fixed and paraffin embedded. The protocol used for SLN was also applied for non-SLN. For each block, six 4-micro m thick sections were cut at 40 micro m intervals and stained with H and E; an additional section taken between the 3rd and 4th levels was imunostained using AE1/AE3 cytokeratin.

RESULTS

The mean age for the study population was 39 years (range 25-76); the number of SLN ranged from 2 to 6 (mean 2.7) and the non-SLN from 8 to 49 (mean 23) per case. No metastasis was found in any SLN and non-SLN by step sections and IHC.

CONCLUSION

Our study demonstrates that bilaterally negative SLN on final pathology accurately predict the absence of metastases in non-SLN in cervical carcinoma. If confirmed by larger trials, these results may influence the clinical management of early cervical cancer.

The sentinel lymph node: Relevance in gynaecological cancers

AIMS

Sentinel lymph node (SLN) detection is widely practiced in the management of patients with malignant melanoma and beast cancer. Large studies on SLN detection and determination of nodal status have led to changes in the surgical management of the regional lymph nodes in these diseases. More recently attention has focused on other solid cancers, including gynaecological cancers.

METHODS

An extensive literature review of published reports on the SLN in gynaecological cancers was undertaken and the reports were categorised according to the level of evidence provided.

RESULTS

Vulva cancer is the most frequently investigated gynaecological cancer with regard to SLN detection because of its anatomical location and easily accessible nodal basin. Although there are no randomised controlled trials, some data suggest SLN detection in vulval cancer may alter clinical practice and reduce the number of groin lymphadenectomies. The lymphatic drainage of the other gynaecological organs is less predictable, the nodal basin less accessible or less well defined, the techniques not standardised and the evidence for the applicability of SLN detection in the management of these cancers is weak.

CONCLUSION

Sentinel lymph node detection in vulval cancer may reduce the need for radical groin lymphadenectomy and thereby reduce morbidity. SLN detection for other gynaecological cancers has little potential to alter clinical practice.

Topographic distribution of sentinel lymph nodes in patients with cervical cancer

BACKGROUND

Since the introduction of the sentinel concept in cervical cancer in 1999, various studies have been demonstrated the feasibility, detection rate and sensitivity and rate of false-negative sentinel lymph nodes (SLN). There are only limited data regarding the mapping of the removed SLN. A correlation between the localization of SLN and the tumor stage, histology or marker substance has never been investigated.

METHODS

Between 2/2000 and 6/2005, the SLN distribution of 151 patients with histologically confirmed cervical cancer (FIGO stages IA n = 21, IB n = 95, IIA n = 14, IIB n = 18, IIIB n = 2, IVA n = 1), who participated in the ongoing "Uterus 3" sentinel study of the German Association of Gynecologic Oncologists (AGO), was retrospectively analyzed with respect to the histology, tumor stage and detection substance. The tumors comprised mostly of squamous cell carcinomas (75.5%) with a smaller fraction of adenocarcinomas (24.5%).

RESULTS

Altogether, 406 SLN, an average of 2.7 (1-7) SLN per patient, were removed. More than one SLN was detected in 111 patients (73.5%). SLN were found unilaterally in 70 patients (46.4%) und bilaterally in 81 patients (53.6%). SLN sites were paraaortic in 4%, common iliac in 5%, external iliac in 5%, internal iliac in 8%, interiliac in 71% and parametric in 7%. Irrespective of the detection drug applied, most SLN were interiliac (blue 70%, TC 67%, TC and blue 71%). Combined application of technetium and blue dye revealed significantly more SLN in the paraaotic region (P = 0.006). Adenocarcinomas and squamous carcinomas did not differ in the distribution of SLN (P = 0.205). The majority of SLN are interiliac in all tumor stages (FIGO IA 76%, IB 68%, IIA 61%, IIB 83%, III and IV 88%).

CONCLUSIONS

Removal of SLN in the external iliac, interiliac and obturator area enables evaluation of more than 80% of all SLN. The pattern of SLN is independent from histology and tumor stage. Combined use of technetium and blue dye detects sentinels more frequently in the paraaortic region than a single marker.

The sentinel node in gynaecological malignancies

As lymph node metastasis is one of the earliest features of tumour cell spread in most human cancers, assessment of the regional lymph nodes is required for tumour staging, determining prognosis and planning adjuvant therapeutic strategies. However, complete lymph node dissections are frequently associated with significant complications. Conjugating the diagnostic advantages with decreased morbidity, the sentinel node concept represents one of the most recent advances in surgical oncology. In this review we briefly highlight the historical background of the development of the sentinel node concept, the anatomical evidence for applying the sentinel node concept in pelvic gynaecological cancers and the technical aspects of sentinel node detection. We discuss recent studies in vulval, cervical and endometrial cancer.

Sentinel lymph node in carcinoma of the anal canal: a review

AIMS

To review the studies investigating the efficacy of the sentinel lymph node (SLN) procedure in anal canal carcinoma and to evaluate its potential role in guiding a more selective approach for patients with the malignancy.

METHODS

A literature search in the PubMed database was preformed using the key words "sentinel lymph node" and "anal cancer". All indexed original articles (except case reports) on the SLN procedure in cancer of the anal canal were analysed.

RESULTS

There are five published series to date. Eighty-four patients were studied. Rates of SLN detection and removal ranged from 66 to 100% of patients investigated. Nodal metastases were found in 7.1 to 42% of cases. No serious complications were reported.

CONCLUSIONS

The technique has proven to be safe and effective in sampling inguinal SLNs. The detection of occult metastases in clinically unsuspicious nodes represents an important improvement in the process of staging these patients, which has not been possible with any other method of diagnosis. Although SLN procedure is still in an early phase of investigation in this type of cancer, it emerges as an objective method to guide individual therapeutic decisions.

Sentinel node biopsy is reliable in early-stage cervical cancer but not in locally advanced disease

BACKGROUND

Sentinel lymph node (SN) biopsy based on dual labeling with blue dye and radiocolloid can reliably determine lymph node status in early-stage cervical cancer, but few data are available on its accuracy in more advanced disease. We examined the influence of tumor stage on the accuracy of SN biopsy in patients with cervical cancer.

METHODS

Between July 2001 and June 2004, 33 patients (mean age 52 years) with early-stage or locally advanced cervical cancer underwent laparoscopic SN biopsy based on dual labeling with patent blue and radiocolloid. Patients with early-stage cervical cancer (stages IA and IB1, 23 patients) underwent complete laparoscopic pelvic lymphadenectomy after the SN procedure. Patients with locally advanced cervical cancer (stage IB2, IIA or IIB, 10 patients) underwent laparoscopic pelvic and para-aortic lymphadenectomy after SN biopsy and prior neoadjuvant concomitant chemoradiotherapy. The SN identification rates and false-negative rates of patients with early-stage and locally advanced disease were compared.

RESULTS

The mean numbers of SNs identified per patient with early-stage and locally advanced cervical cancer were 2.3 (range 0-4) and 1.9 (range 0-4), respectively. SNs were identified in 86.9% (20/23) of patients with early-stage disease and in 80% (8/10) of patients with locally advanced disease. When analyzed according to the side of dissection, the identification rate was lower, especially in the patients with locally advanced disease (55% compared with 67.4%). The false-negative rate per patient was zero in early-stage disease and 20% (1/5) in locally advanced disease (no significant difference). When the side of dissection was taken into account, the false-negative rate improved to 42.9% (3/7) in patients with locally advanced disease and remained at zero in early-stage disease (P=0.038). Isolated blue dye was taken up in 53.3% of SNs in patients with locally advanced disease, compared with only 6.4% in patients with early-stage disease.

CONCLUSIONS

This study suggests that the SN biopsy technique with dual labeling is less accurate in locally advanced cervical cancer than in early-stage cervical cancer.

Usefulness of sentinel lymph node detection in early stages of cervical cancer

PURPOSE

Sentinel lymph node (SLN) mapping in combination with surgical biopsy is an emerging technique for use in the early stages of cervical cancer. The purpose of this study was to evaluate the technique in a series of 40 consecutive women with early stage cervical cancer.

METHODS

Forty patients with early stage cervical cancer [FIGO stage IA2 (2), IB1 (34), IB2 (1) or IIA (3)] were referred for radical hysterectomy with pelvic lymphadenectomy. Patients were submitted to preoperative lymphoscintigraphy (four 99mTc-nanocolloid injections around the tumour) and intraoperative SLN detection. Hand-held or laparoscopic gamma probes were used to locate SLNs during surgery.

RESULTS

The mean number of SLNs was 2.5 per patient (interiliac 49%, external iliac 19%). Of the total of 99 SLNs, six, in four women, showed metastases (all 68 non-SLNs removed were negative). In the other 36 patients, all the removed lymph nodes (sentinel and non-sentinel) were negative (0% false negative rate). During the follow-up (median 25 months), only two patients presented distant metastases: one died 6 months after surgery (two of three SLNs positive, both hot and blue), while the second patient is alive 4 years after surgery (lung metastasis, no isotope drainage, negative blue SLN). The survival rate was 95% and disease-free survival, 97%.

CONCLUSION

SLN surgical biopsy based on lymphoscintigraphy and blue dye is a feasible and useful technique to avoid lymph node dissection in the early stages of cervical cancer. It has a high negative predictive value, can be incorporated into clinical routine (laparoscopy or open surgery) and is close to achieving validation in this setting.

Sentinel node detection in cervical cancer with 99mTc-phytate

OBJECTIVES

The aim of this study was to investigate the feasibility of sentinel lymph node (SLN) identification using radioisotopic lymphatic mapping with technetium-99 m-labeled phytate in patients undergoing radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer.

METHODS

Between July 2001 and February 2003, 56 patients with cervical cancer FIGO stage I (n = 53) or stage II (n = 3) underwent sentinel lymph node detection with preoperative lymphoscintigraphy ((99m)Tc-labeled phytate injected into the uterine cervix, at 3, 6, 9, and 12 o'clock, at a dose of 55-74 MBq in a volume of 0.8 ml) and intraoperative lymphatic mapping with a handheld gamma probe. Radical hysterectomy was aborted in three cases because parametrial invasion was found intraoperatively and we performed only sentinel node resection. The remaining 53 patients underwent radical hysterectomy with complete pelvic lymphadenectomy. Sentinel nodes were detected using a handheld gamma-probe and removed for pathological assessment during the abdominal radical hysterectomy and pelvic lymphadenectomy.

RESULTS

One or more sentinel nodes were detected in 52 out of 56 eligible patients (92.8%). A total of 120 SLNs were detected by lymphoscintigraphy (mean 2.27 nodes per patient) and intraoperatively by gamma probe. Forty-four percent of SLNs were found in the external iliac area, 39% in the obturator region, 8.3% in interiliac region, and 6.7% in the common iliac area. Unilateral sentinel nodes were found in thirty-one patients (59%). The remaining 21 patients (41%) had bilateral sentinel nodes. Microscopic nodal metastases were confirmed in 17 (32%) cases. In 10 of these patients, only SLNs had metastases. The 98 sentinel nodes that were negative on hematoxylin and eosin were submitted to cytokeratin immunohistochemical analysis. Five (5.1%) micrometastases were identified with this technique. The sensitivity of the sentinel node was 82.3% (CI 95% = 56.6-96.2) and the negative predictive value was 92.1% (CI 95% = 78.6-98.3). The accuracy of sentinel node in predicting the lymph node status was 94.2%.

CONCLUSION

Preoperative lymphoscintigraphy and intraoperative lymphatic mapping with (99m)Tc-labeled phytate are effective in identifying sentinel nodes in patients undergoing radical hysterectomy and to select women in whom lymph node dissection can be avoided.

Sentinel node detection with radiocolloid lymphatic mapping in early invasive cervical cancer

We assessed the feasibility of sentinel lymph node detection using technicium-99 radiocolloid lymphatic mapping for predicting lymph node metastases in early invasive cervical cancer. Thirty patients with cervical cancer (stages IA2-IIA) underwent preoperative lymphoscintigraphy using technicium-99 intracervical injection and intraoperative lymphatic mapping with a handheld gamma probe. After dissection of the sentinel nodes, the standard procedure of pelvic lymph node dissection and radical hysterectomy was performed as usual. The sentinel node detection rate was 100% (30/30). There were seven (23.3%) cases of microscopic lymph node metastases on pathologic analysis. All of them had sentinel node involvement. Therefore, the sensitivity of sentinel node identification for prediction of lymph node metastases was 100%, and no false negative was found. Preoperative lymphoscintigraphy, coupled with intraoperative lymphatic mapping, located the sentinel nodes accurately in our study patients. This sentinel node detection method appears to be feasible for predicting lymph node metastases.

Role of sentinel lymph node biopsy procedure in cervical cancer: a critical point of view

OBJECTIVE

To report our experience about the role of sentinel node biopsy in cervical cancer patients while debating provocatory arguments concerning this procedure.

METHODS

From June 2001 to February 2003, patients affected by stage IB(1) cervical cancer were submitted to the sentinel node biopsy procedure. Patients were submitted to lymphoscintigraphy and, subsequently, to laparoscopy in order to locate the sentinel lymph node.

RESULTS

Thirty-seven patients were enrolled in the study. Sentinel node(s) was(were) identified with preoperative lymphoscintigraphy in 89% of the patients. Intraoperative detection rate was 70%. During surgery in 31% of the patients, sentinel node was detected bilaterally; in 15%, two sentinel nodes on the same side of the lymphatic vessels were detected. The sentinel node was located at the level of superficial common iliac vessels (26%), external iliac vessels (69%), and superficial obturator vessels (49%). In 77% of the patients, the histologic specimen sent by the surgeon as unique sentinel node contained two or more nodes. Metastatic sentinel nodes were found in 23% of the patients. There was no case with a positive nonsentinel node in the presence of a negative sentinel node.

CONCLUSION

Sentinel node detection is a feasible procedure in cervical cancer patients. However, a high percentage of patients is found with bilateral and/or more than one sentinel lymph node. Improvements in detection rate and pathological analysis are needed prior to consider the sentinel node biopsy a routine procedure in cervical cancer patients.

Histopathologic parameters of prognosis in cervical cancer--a review

Apart from clinical stage and lymph node status, acknowledged to be among the most powerful predictors of outcome in cervical cancer, the determination of prognosis and thereby the need for adjuvant therapy in surgically treated patients currently relies on a variety of histopathologic factors. The role of many of these is controversial. This may be because histopathology is genuinely lacking in sensitivity for predicting tumor behavior in vivo. There is, however, wide variation in histopathologic definitions and criteria. This is probably the major reason for both the lack of reproducibility in the reporting of certain factors and in their diminished value in predicting behavior. Tumor type, grade, vascular invasion, pattern of invasion, and depth are all extremely important prognostic indicators when used individually or as a part of a scoring system.

Sentinel lymph node detection in early cervical cancer with combination 99mTc phytate and patent blue

OBJECTIVE

The purpose of this study was to examine sentinel lymph node (SLN) detection in patients with early stage cervical cancer using (99m)Tc phytate and patent blue dye and to compare our method with published findings utilizing other radioisotopic tracers.

PATIENTS AND METHODS

A total of 20 consecutive patients with cervical cancer scheduled for radical hysterectomy and total pelvic lymphadenectomy at our hospital underwent SLN detection study. The day before surgery, lymphoscintigraphy was performed with injection of 99m-technetium ((99m)Tc)-labeled phytate into the uterine cervix. At surgery, patients underwent lymphatic mapping with a gamma-detecting probe and patent blue injected into the same points as the phytate solution.

RESULTS

At least one positive node was detected in 18 patients (90%). A total of 46 sentinel nodes were detected (mean, 2.3; range, 1-5). Most sentinel nodes were in one of the following sites: external iliac (21 nodes), obturator (15 nodes), and parametrial (7 nodes). Eleven (24%) sentinel nodes were detected only through radioactivity and two (4%) were detected only with blue dye. The sensitivity, specificity, and negative predictive value for SLN detection were all 100%. Nine published studies involving 295 patients had a summarized detection rate of 85%. Summarized sensitivity, specificity, and negative predictive value were 93%, 100%, and 99%, respectively.

CONCLUSION

Combination of (99m)Tc phytate and patent blue is effective in SLN detection in early stage cervical cancer.

The sentinel node in cervical cancer: scintigraphy and laparoscopic gamma probe-guided biopsy

The sentinel node (SN) procedure has been proven to be a valuable technique in the staging and treatment of a number of solid tumours. We evaluated the feasibility of SN biopsy with a laparoscopic gamma probe and dye guidance in 34 patients with clinically localised cervical cancer. After peritumoural injection of 140 MBq 99mTc colloidal albumin, dynamic and late static images were obtained. Just before the laparoscopic procedure, blue dye was injected. Blue and radioactive lymph nodes were excised followed by a regular lymphadenectomy. Lymphoscintigraphy revealed 70 SNs in 50 basins during dynamic imaging and 83 SNs in 63 basins at late imaging. SNs were visualised in 97% of the patients, bilaterally in 30 and unilaterally in three. Seventy-four of the 105 radioactive lymph nodes that were excised laparoscopically were considered to be SNs, 53 being blue as well, and were sent for frozen section. Nine foci that had been seen on scintigraphy could not be found either intraoperatively or in the remaining lymphadenectomy specimen. Four blue nodes were excised in three of five basins that had shown no foci during scintigraphy. In 17 basins of 12 patients, tumour-positive lymph nodes were found. In one of them a micrometastasis was found in the hysterectomy specimen while the lymphadenectomy did not contain any metastases (sensitivity 92%). Based on SN histology, the treatment was altered in nine patients (26%). We conclude that laparoscopic SN biopsy is feasible in cervical cancer and may result in custom-designed treatment strategies with a reduction in morbidity.

Laparoscopic sentinel node procedure using a combination of patent blue and radiocolloid in women with endometrial cancer

BACKGROUND

We assessed the feasibility of a laparoscopic sentinel node (SN) procedure based on the combined use of radiocolloid and patent blue labeling in patients with endometrial cancer.

METHODS

Seventeen patients (median age, 69 years) with endometrial cancer of stage I (16 patients) or stage II (1 patient) underwent a laparoscopic SN procedure based on combined radiocolloid and patent blue injected pericervically. After the SN procedure, all patients underwent complete laparoscopic pelvic lymphadenectomy and either laparoscopically assisted vaginal hysterectomy (16 patients) or laparoscopic radical hysterectomy (1 patient).

RESULTS

SNs (mean number per patient, 2.6; range, 1-4) were identified in 16 (94.1%) of the 17 patients. Macrometastases were detected in three SNs from two patients by hematoxylin and eosin staining. In three other patients, immunohistochemical analysis identified six micrometastatic SNs and one SN containing isolated tumor cells. No false-negative SN results were observed.

CONCLUSIONS

An SN procedure based on a combination of radiocolloid and patent blue is feasible in patients with early endometrial cancer. Combined use of laparoscopy and this SN procedure permits minimally invasive management of endometrial cancer.

Lymphatic mapping for gynecologic malignancies

In gynecologic malignancies, regional lymph node status is a major prognostic factor and a decision criterion for adjuvant therapy. This is the basis for lymphadenectomy. The sentinel node (SN) procedure has emerged as an alternative to systematic lymphadenectomy in various cancers, reducing treatment-related morbidity. In melanoma and breast cancer, SN biopsy is the standard procedure for determining nodal stage. Use of the SN procedure is also well established in vulvar cancer. In small series, combined SN detection based on blue dye and radiocolloid was suitable for the evaluation of lymph node status in cervical cancer. Although some investigators have reported the feasibility of the SN procedure in endometrial cancer, further studies and standardization are required before its routine use can be recommended.

Sentinel lymph node biopsy is not accurate in predicting lymph node status for patients with cervical carcinoma

BACKGROUND

The authors evaluated the accuracy of sentinel lymph node biopsy in predicting lymph node status for patients with early cervical carcinoma. In particular, the authors set out to determine the false-negative rate associated with sentinel lymph node biopsy in this setting.

METHODS

Twenty-nine consecutive patients with early cervical carcinoma who were treated with pelvic laparoscopic lymphadenectomy and radical surgery underwent sentinel lymph node biopsy following lymphatic mapping with patent blue dye. All sentinel and nonsentinel lymph nodes were evaluated for micrometastases via multilevel sectioning followed by immunohistochemical staining.

RESULTS

At least one sentinel lymph node was identified for each patient. On routine pathologic evaluation, 3 patients (10%) were found to have positive lymph nodes. Among the remaining 26 patients, multilevel sectioning in conjunction with immunohistochemical analysis identified 5 patients (19%) who had micrometastases in the pelvic lymph nodes. Two of these five patients had micrometastases in a sentinel lymph node; however, the more notable finding was that the other three patients had micrometastases in nonsentinel pelvic lymph nodes despite having negative findings on sentinel lymph node biopsy. Thus, the negative predictive value of sentinel lymph node biopsy in the current study was 87.5%.

CONCLUSIONS

Multilevel sectioning followed by cytokeratin immunohistochemistry may identify additional patients who have lymph node micrometastases; in the current study, this technique identified cases in which micrometastases were present in nonsentinel lymph nodes even when sentinel lymph nodes were found to be negative for disease on biopsy. This high false-negative rate associated with sentinel lymph node biopsy, raises questions regarding the validity of the sentinel lymph node concept in cervical carcinoma.

Current research directions for locally advanced cervix cancer

Chemoradiotherapy with either weekly doses of cisplatin or the combination of 5-fluorouracil and cisplatin has become the standard of therapy for patients with locally advanced cervix cancer. Recently reported studies that are directed at improvements in radiation treatment planning, improved tissue oxygenation, and neoadjuvant chemotherapy are likely to lead to improvements in therapy. Nonsurgical preoperative staging with positron emission tomography and sentinel lymph node evaluation could result in effective surgical staging, or even nonsurgical staging, more accurate radiation treatment planning, and improved local and systemic control with a reduction in short-term and long-term morbidity in the treatment of locally advanced cervix cancer. Well-designed, randomized, prospective clinical trials are needed for a more thorough evaluation of these preliminary findings and to set research directions for the next several years.

Laparoscopic Sentinel Node Procedure for Cervical Cancer: Impact of Neoadjuvant Chemoradiotherapy

BACKGROUND

SN detection based on combined blue dye and radiocolloid labeling can reliably show lymph node status in cervical cancer, but the influence of prior neoadjuvant chemoradiotherapy has not yet been reported. The aim of this study was to evaluate the effect of neoadjuvant chemoradiotherapy on the accuracy of a dual-labeling laparoscopic sentinel node (SN) procedure in patients with cervical cancer.

METHODS

Between July 2001 and June 2003, 26 patients (mean age, 50.3 years) with cervical cancer underwent a laparoscopic SN procedure based on dual labeling with patent blue and radiocolloid. After the SN procedure, all the patients underwent complete laparoscopic pelvic lymphadenectomy and laparoscopic radical hysterectomy (n=19), the Schauta-Amreich operation (n=5), or trachelectomy (n=2). The results of the SN procedure were compared between 11 patients who received neoadjuvant chemoradiotherapy and 15 patients who did not receive neoadjuvant treatment.

RESULTS

The SN identification rates were 100% in the 11 patients who underwent neoadjuvant chemoradiotherapy and 93.3% in the 15 patients who did not receive adjuvant therapy. A total of 59 SNs were removed. Eight SNs (13.6%) from five patients (19.2%) were found to be metastatic at the final histological assessment. Three SN involvements were detected by hematoxylin and eosin staining of the SN. Immunohistochemical studies identified five metastatic SNs in three patients. There were no false-negative SN results.

CONCLUSIONS

This study suggests that SN detection with a combination of radiocolloid and patent blue is feasible and accurate in patients with cervical cancer undergoing neoadjuvant chemoradiotherapy or primary surgery. The combination of laparoscopy and the SN procedure permits minimally invasive management of cervical cancer.

Intraoperative sentinel node identification in early stage cervical cancer using a combination of radiolabeled albumin injection and isosulfan blue dye injection

OBJECTIVES

We investigated the feasibility of sentinel lymph node identification using radioisotopic lymphatic mapping with technetium-99m-labeled human serum albumin and isosulfan blue dye injection in patients undergoing radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer.

METHODS

Between September 2000 and October 2002, 25 patients with cervical cancer FIGO stage I (n=24) or stage II (n=1) underwent sentinel lymph node detection with preoperative lymphoscintigraphy (technetium-99m colloid albumin injection around the tumor) and intraoperative lymphatic mapping with blue dye and a handheld or laparoscopic gamma probe. Complete pelvic or paraaortic lymphadenectomy was performed in all cases by open surgery or laparoscopic surgery.

RESULTS

In 23 evaluable patients, a total of 51 sentinel lymph nodes were detected by lymphoscintigraphy (mean 2.21 nodes per patient). Intraoperatively, 61 sentinel lymph nodes were identified, with a mean of 2.52 nodes per patient by gamma probe and a mean of 1.94 nodes per patient after isosulfan blue injection. Forty percent of sentinel nodes were found in the interiliac region and 25% in the external iliac area. Microscopic nodal metastases (four nodes) were confirmed in 12% of cases. All these lymph nodes were previously detected as sentinel lymph nodes. The remaining 419 nodes after pelvic lymphadenectomy were histologically negative.

CONCLUSIONS

Sentinel lymph node identification with technetium-99m-labeled nanocolloid combined with blue dye injection is feasible and showed a 100% negative predictive value, and potentially identified women in whom lymph node dissection can be avoided.

Surgical and radiographic staging in patients with cervical cancer

PURPOSE OF REVIEW

The most recent data on surgical and radiographic staging in patients with cervical cancer are analysed.

RECENT FINDINGS

Laparoscopic staging of retro and intraperitoneal disease is feasible. Morbidity is low, but the impact on survival has still to be shown. The sentinel lymph node concept is valid in patients with cervical cancer. Sensitivity and negative predictive value, however, have to be improved before the concept can be integrated into clinical practice. The majority of most recent radiographic studies evaluate the value of positron emission tomography. Accuracy of detection of extracervical disease is high and the response to chemoradiation can be measured by positron emission tomography using various scoring systems. Positron emission tomography seems to be the most accurate technique for detecting early recurrence.

SUMMARY

Surgical staging is less invasive by laparoscopy, and radiographic staging becomes more accurate by positron emission tomography. Prospective evaluations have to show the impact of these new techniques on survival of patients diagnosed with cervical cancer.

The use of sentinel lymph nodes in gynaecological malignancies

PURPOSE OF REVIEW

Lymphatic mapping and sentinel node biopsy represent one of the most revolutionary advances in oncological surgery in recent years. In this review, the current state of sentinel node detection in gynaecological cancers and its use in vulvar and cervical cancer are assessed.

RECENT FINDINGS

Since the recent clinical application of sentinel node biopsy for melanomas and breast cancer, there has been extensive research on the implementation of this technique to most solid neoplasias. Studies on the feasibility of sentinel node biopsy in vulvar cancer have shown that the status of the sentinel node is an accurate predictor of the status of inguinal nodes. The clinical implementation of the procedure requires validation and is under investigation. In the last two years, several pilot studies on the feasibility of lymphatic mapping/sentinel node biopsy in cervical cancer have yielded promising results. There is minimal experience of its use in endometrial cancer. Detailed pathological study of a sentinel node biopsy with ultrastaging and immunohistochemical or polymerase chain reaction analyses can identify lymph node micrometastasis that conventional methods would identify as negative for metastatic disease. The best histopathological procedure for sentinel node biopsy, the clinical significance of micrometastases, and the appropriate management of such micrometastases are currently under investigation.

SUMMARY

Sentinel node biopsy is one of the main research interests in gynaecological oncological surgery. At present there are not enough data to permit modification of current treatment protocols. Large and multi-institutional trials are required in order to define the implementation of sentinel node biopsy in clinical practice with the objective of achieving safer and more conservative surgery.

Laparoscopic sentinel node mapping in early-stage cervical cancer

OBJECTIVE

We aimed to determine the feasibility and accuracy of sentinel node (SN) mapping and its ability to predict the status of the regional nodal basin.

METHODS

From October 2000 to September 2002, 70 patients undergoing radical surgery for early-stage cervical cancer (stage IA, IB, and IIA) were offered lymph node mapping for identification of the sentinel node. All patients underwent SN identification laparoscopically followed by a complete laparoscopic pelvic node and parametrial dissection. The SN mapping was done after intracervical blue dye injection in all cases and was combined with preoperative lymphoscintigraphy following intracervical Tc-99 injection and intraoperative SN detection with a miniaturized laparoscopic gamma probe in 29 cases (42%).

RESULTS

The blue dye technique alone (n = 70) identified at least 1 SN in 61 (87%) of the patients. The rate of SN detection by side of dissection was 74%, 70% on the left side and 77% on the right side. Bilateral SN were identified in 60% of cases. In the subgroup of patients who had the combined technique (n = 29), the rate of SN detection increased from 79 to 93% (P = 0.04). The bilateral SN detection rate increased from 55 to 72% when adding lymphoscintigraphy (P = 0.03). In the last 15 cases of the series, the SN detection rate reached 93% (14/15) and this was statistically significant compared to the detection rate of the first 55 cases (P < 0.01). A total of 135 SN were identified, with the majority (88%) being located at three main sites: the external iliac, obturator, and bifurcation. Thirty-six patients (51%) had 2 SN identified, and 16 (24%) had 3 SN or more. Twelve (17%) patients had positive lymph nodes. In those cases, the rate of SN detection per side of dissection in patients with normal appearing nodes at laparoscopy was 75%, whereas it was only 56% in patients with macroscopically involved lymph nodes (P = NS). The false negative rate was 0. The negative predictive value of SN mapping was 100% and the sensitivity was 93% with the combined technique. Two patients had allergic reactions to the blue dye (3%).

CONCLUSION

Sentinel node mapping with the combined blue dye technique and lymphoscintigraphy in patients with cervical cancer is laparoscopically feasible and is highly accurate. The detection rate improves significantly with experience and with the use of lymphoscintigraphy.