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Vemula Venkata VL, Hulikal N, Chowhan AK. Effectiveness of sentinel lymph node biopsy and bilateral pelvic nodal dissection using methylene blue dye in early-stage operable cervical cancer-A prospective study. Cancer Treat Res Commun 2024; 39:100816. [PMID: 38714022 DOI: 10.1016/j.ctarc.2024.100816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/16/2024] [Accepted: 04/24/2024] [Indexed: 05/09/2024]
Abstract
OBJECTIVE To evaluate the effectiveness of methylene blue dye in detecting sentinel lymph nodes (SLNs) in women with early-stage operable (defined as FIGO I-IIA) cervical cancer. It also aims to evaluate procedural challenges and accuracy. METHOD This prospective study, which focused on 20 women with early-stage cervical cancer, was carried out between June 2016 and December 2017. These patients had SLN mapping with methylene blue dye injections and thorough examinations, including imaging. All patients underwent radical hysterectomy and complete bilateral pelvic lymphadenectomy. No additional investigation was done on the lymph node in cases where a metastasis was found in the first H&E-stained segment of the sentinel node. RESULT 20 patients were included in the analysis. The median age of the subjects was 53, and 95 % of them had squamous cell carcinoma. 90 % of the time, the identification of SLNs was effective, and 55 SLNs were found, of which 52.7 % were on the right side of the pelvis and 47.3 % on the left. The obturator group had the most nodes, followed by the external and internal iliac groups in descending order of occurrence. Metastasis was detected in 3 patients, resulting in a sensitivity of 100 % and a specificity of 93.75 % for SLN biopsy. Notably, no false-negative SLNs were found. Complications related to methylene blue usage included urine discoloration in 30 % of patients. CONCLUSION This trial highlights the promising efficacy and safety of methylene blue dye alone for SLN identification in early-stage operable cervical cancer, with a notably higher success rate. Despite limitations like a small sample size, healthcare professionals and researchers can build upon the insights from this study to enhance cervical cancer management.
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Affiliation(s)
- Vijaya Lakshmi Vemula Venkata
- Department of Surgical Oncology, St Johns Medical College and Hospital, Johnnagara, Bengaluru, Karnataka, 560034, India.
| | - Narendra Hulikal
- Department of Surgical Oncology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
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Deng YR, Chen XJ, Xu CQ, Wu QZ, Zhang W, Guo SQ, Li LX. A preoperative nomogram predicting risk of lymph node metastasis for early-stage cervical cancer. BMC Womens Health 2023; 23:568. [PMID: 37924031 PMCID: PMC10623856 DOI: 10.1186/s12905-023-02726-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 10/23/2023] [Indexed: 11/06/2023] Open
Abstract
OBJECTIVE This study aimed to develop a preoperative nomogram based on clinical and pathological characteristics to provide a more individualized and accurate estimation of lymph node metastasis (LNM) in patients with early-stage cervical cancer. METHODS A total of 7,349 early-stage cervical cancer patients with pathologically confirmed between 1988 and 2015 were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. All the patients were divided into training (n = 5,500) and validation (n = 1,849) cohorts randomly. A cohort of 455 patients from multicenter was used for the external validation. We established a multivariate logistic regression model based on preoperative clinicopathological data, from which a nomogram was developed and validated. A predicted probability of LNM < 5% was defined as low risk. RESULTS From multivariate logistic regression analysis, age at diagnosis, histologic subtype, tumor grade, tumor size and FIGO stage were identified as preoperative independent risk factors of LNM. The nomogram incorporating these factors demonstrated good discrimination and calibration (concordance index = 0.723; 95% confidence interval (CI), 0.707-0.738). In the validation cohort, the discrimination accuracy was 0.745 (95% CI, 0.720-0.770) and 0.747 (95% CI, 0.690-0.804), respectively. The nomogram was well calibrated with a high concordance probability. We also established an R-enabled Internet browser for LNM risk assessment, which tool may be convenient for physicians. CONCLUSIONS We developed an effective preoperative nomogram based on clinical and pathological characteristics to predict LNM for early-stage cervical cancer. This model could improve clinical trial design and help physicians to decide whether to perform lymphadenectomy or not.
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Affiliation(s)
- Yuan-Run Deng
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital, Southern Medical University, Tianhe District, 183 Zhongshan Avenue West, Guangzhou, 510630, P. R. China
| | - Xiao-Jing Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, China
| | - Cai-Qiu Xu
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital, Southern Medical University, Tianhe District, 183 Zhongshan Avenue West, Guangzhou, 510630, P. R. China
| | - Qiao-Zhi Wu
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital, Southern Medical University, Tianhe District, 183 Zhongshan Avenue West, Guangzhou, 510630, P. R. China
| | - Wan Zhang
- Department of Radiation Oncology, Affiliated Dongguan People's Hospital, Southern Medical University, Dongguan, 523059, China
| | - Sui-Qun Guo
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital, Southern Medical University, Tianhe District, 183 Zhongshan Avenue West, Guangzhou, 510630, P. R. China.
| | - Li-Xian Li
- Department of Medical Matters, Puning People's Hospital, 30 Liusha Dadao, Puning, 515300, P. R. China.
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Papathemelis T, Scharl A, Anapolski M, C Inwald E, Ignatov A, Ortmann O, Gerken M, Klinkhammer-Schalke M, Scharl S. Value of indocyanine green pelvic lymph node mapping in the surgical approach of cervical cancer. Arch Gynecol Obstet 2020; 301:787-792. [PMID: 32048031 DOI: 10.1007/s00404-020-05457-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 01/27/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Lymph node metastasis is a significant predictive factor for disease recurrence and survival in cervical cancer patients and relevant for therapeutic strategies. We evaluated the clinical value of indocyanine green (ICG) by measuring the sensitivity and negative predictive value of sentinel lymph node mapping compared with the gold standard of complete lymphadenectomy in detecting lymph node metastases for cervical cancer. METHODS We utilized the near-infrared imaging agent ICG to detect tumor-infested lymph nodes in the pelvis analogue to a classical sentinel lymph node procedure by analyzing data from 20 patients who had undergone surgery for cervical cancer at our institution. A laparoscopic lymph node mapping procedure by means of ICG, followed by a complete pelvic lymphadenectomy with or without paraaortic lymphadenectomy was done in all patients. RESULTS Histological examination identified seven patients with tumor-positive pelvic nodes, whereas mapping with ICG identified only five of these patients. Detection rate of positive nodes by ICG mapping and false negative rate was 71.4% and 28.6%, respectively; bilateral detection rate was 83.3%. One of the two false negative patients additionally suffered from deep infiltrating endometriosis. CONCLUSIONS Our results indicate that ICG can identify the relevant pelvic nodes independent of tumor size, provided bilateral detection is achieved and additional, related diseases are excluded. TRIAL REGISTRATION This trial is registered within the German Clinical Trial Register (DRKS-ID: DRKS00014692).
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Affiliation(s)
- Thomas Papathemelis
- Department of Gynecology and Obstetrics, Klinikum St. Marien Amberg, Amberg, Germany.
| | - Anton Scharl
- Department of Gynecology and Obstetrics, Klinikum St. Marien Amberg, Amberg, Germany
| | - Michael Anapolski
- Department Ob/Gyn, University of Witten-Herdecke, KKH Dormagen, Dormagen, Germany
| | - Elisabeth C Inwald
- Department of Gynecology and Obstetrics, University Medical Center, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Atanas Ignatov
- Department of Gynecology and Obstetrics, University Medical Center, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Olaf Ortmann
- Department of Gynecology and Obstetrics, University Medical Center, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Michael Gerken
- Tumor Center, University of Regensburg, Regensburg, Germany
| | | | - Sophia Scharl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München (TUM), Ismaninger Straße 22, 81675, Munich, Germany
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Real-Time Fluorescent Sentinel Lymph Node Mapping with Indocyanine Green in Women with Previous Conization Undergoing Laparoscopic Surgery for Early Invasive Cervical Cancer: Comparison with Radiotracer ± Blue Dye. J Minim Invasive Gynecol 2018; 25:455-460. [DOI: 10.1016/j.jmig.2017.10.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/01/2017] [Accepted: 10/03/2017] [Indexed: 12/12/2022]
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Management of Para-aortic Lymph Node Disease in Patients With Cervical Cancer: What Is the Best Approach? Int J Gynecol Cancer 2018; 27:543-549. [PMID: 28107261 DOI: 10.1097/igc.0000000000000914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Cervical cancer remains a prevalent and deadly disease in low-income countries, especially among young and otherwise healthy women. Multimodality treatment has led to a significant improvement in outcomes for patients with locally advanced disease, and this is mainly because of the incorporation of platinum-based chemoradiotherapy in current treatment protocols. However, locally advanced tumors are associated with a greater risk for para-aortic lymph node (PALN) involvement, which is an important adverse prognostic factor. Most staging techniques have low accuracy for detection of disease in this area, which could lead to understaging and undertreatment. Meanwhile, patients with PALN disease are underrepresented in trials addressing the treatment of advanced cervical cancer and a few studies have been directed at this population. The aim of this review is to analyze the current data regarding staging and treatment of cervical cancer with PALN disease to determine which strategy is best when managing these patients.
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Di Martino G, Crivellaro C, De Ponti E, Bussi B, Papadia A, Zapardiel I, Vizza E, Elisei F, Diestro MD, Locatelli L, Gasparri ML, Di Lorenzo P, Mueller M, Buda A. Indocyanine Green versus Radiotracer with or without Blue Dye for Sentinel Lymph Node Mapping in Stage >IB1 Cervical Cancer (>2 cm). J Minim Invasive Gynecol 2017; 24:954-959. [PMID: 28571944 DOI: 10.1016/j.jmig.2017.05.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/09/2017] [Accepted: 05/10/2017] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE To compare sentinel lymph node (SLN) mapping in women with cervical cancer stage >IB1 (tumor size >2 cm) using indocyanine green (ICG) versus the standard technique using radioisotope technetium 99m radiocolloid (Tc99m) radiotracer with or without blue dye. DESIGN European multicenter, retrospective observational study (Canadian Task Force classification II-2). SETTING Four academic medical centers. PATIENTS Ninety-five women with stage IB1 cervical cancer (>2 cm) who underwent SLN mapping with Tc99m with or without blue dye or ICG and radical hysterectomy. INTERVENTION The detection rate and bilateral mapping rate were compared between ICG and standard Tc99m radiotracer with or without blue dye. Lymphadenectomy was performed, and the false-negative rate was assessed. MEASUREMENTS AND MAIN RESULTS Forty-seven patients underwent SLN mapping with Tc99m with or without blue dye, and 48 did so with ICG. All patients underwent radical hysterectomy with or without bilateral salpingo-oophorectomy between 2008 and 2016. The overall detection rate of SLN mapping was 91.5% for Tc99m with or without blue dye and 100% for ICG. A 91.7% rate of bilateral migration was achieved for ICG, significantly higher than the 66% obtained with Tc99m with or without blue dye (p = .025). Nine of the 23 SLN-positive patients (39.1%) were diagnosed exclusively as a result of the ultrastaging used to identify micrometastases or isolated tumor cells only. CONCLUSIONS In advanced cervical cancer (stage IB1 >2 cm), the detection rate and bilateral migration rate on real-time fluorescent SLN mapping were higher with ICG than with Tc99m radiotracer with or without blue dye. SLN mapping and ultrastaging can provide additional information for nodal staging in advanced cervical cancer. In this setting, ICG is a promising tool for mapping, appearing less affected by higher disease stage compared with traditional methods.
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Affiliation(s)
- Giampaolo Di Martino
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, ASST Monza, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | | | - Elena De Ponti
- Department of Medical Physics, ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Beatrice Bussi
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, ASST Monza, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Andrea Papadia
- Department of Obstetrics and Gynecology, University of Bern, Bern, Switzerland
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital-IdiPAZ, Madrid, Spain
| | - Enrico Vizza
- Department of Oncological Surgery, Gynecologic Oncologic Unit "Regina Elena", National Cancer Institute, Rome, Italy
| | - Federica Elisei
- Tecnomed Foundation, University of Milano-Bicocca, Monza, Italy
| | | | - Luca Locatelli
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, ASST Monza, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | | | - Paolo Di Lorenzo
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, ASST Monza, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Michael Mueller
- Department of Obstetrics and Gynecology, University of Bern, Bern, Switzerland
| | - Alessandro Buda
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, ASST Monza, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.
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Affiliation(s)
- Adriana Bermudez
- Gynecologic Oncology Unit, Buenos Aires University Hospital, Buenos Aires, Argentina
| | - Neerja Bhatla
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Eric Leung
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, Odette Cancer Centre, Toronto, Ontario, Canada
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8
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Affiliation(s)
- Ericka Wiebe
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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9
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Jarruwale P, Huang KG, Benavides DR, Lee CL. Factors related to sentinel node identification in cervical cancer. Gynecol Minim Invasive Ther 2012. [DOI: 10.1016/j.gmit.2012.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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10
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Cibula D, Abu-Rustum NR, Dusek L, Slama J, Zikán M, Zaal A, Sevcik L, Kenter G, Querleu D, Jach R, Bats AS, Dyduch G, Graf P, Klat J, Meijer CJLM, Mery E, Verheijen R, Zweemer RP. Bilateral ultrastaging of sentinel lymph node in cervical cancer: Lowering the false-negative rate and improving the detection of micrometastasis. Gynecol Oncol 2012; 127:462-6. [PMID: 22943880 DOI: 10.1016/j.ygyno.2012.08.035] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 08/22/2012] [Accepted: 08/26/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the sensitivity of sentinel node (SN) ultrastaging and to define parameters that may reduce the overall false-negative rate in women with early-stage cervical cancer. METHODS We analyzed data from a large retrospective multicenter cohort group with FIGO stages IA-IIB cervical cancer in whom at least one SN was identified and systematic pelvic lymphadenectomy was uniformly performed. All who were SN negative by initial evaluation were subjected to ultrastaging. RESULTS In all, 645 patients were evaluable. SN were detected bilaterally in 72% of cases and unilaterally in 28%. Patients with optimal bilateral SN detection were significantly more likely to have any metastasis detected (33.3% vs. 19.2%; P<0.001) as well as micrometastasis detected in their SN (39.6% vs. 11.4%). SN ultrastaging resulted in a low overall false-negative rate of 2.8% (whole group) and an even lower false-negative rate of 1.3% for patients with optimal bilateral mapping. Patients with false-negative SN after ultrastaging had a higher prevalence of LVSI and more frequent unilateral SN detection. Sensitivity of SN ultrastaging was 91% (95% CI: 86%-95%) for the whole group and 97% (95% CI: 91%-99%) in the subgroup with bilateral SN detection. CONCLUSION These data confirm previous observations that optimal bilateral SN detection substantially decreases the false negative rate of SN ultrastaging and increases detection of micrometastasis. In patients with bilateral SN detection, the sensitivity of SN ultrastaging is not reduced in more advanced stages of the disease. SN mapping and ultrastaging should become standard practice in the surgical management of early-stage cervical cancer.
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Affiliation(s)
- David Cibula
- Gynecological Oncology Centre, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic.
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11
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Peres A, Margulies AL, Barranger E. Comment on 'Contribution of pelvic and para-aortic lymphadenectomy with sentinel node biopsy in patients with IB2-IIB cervical cancer'. Br J Cancer 2012; 107:400; author reply 401-2. [PMID: 22677903 PMCID: PMC3394970 DOI: 10.1038/bjc.2012.225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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12
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Place de la chirurgie avant et après radiochimiothérapie des cancers du col localement évolués : à propos de 102 cas. ACTA ACUST UNITED AC 2011; 40:11-21. [DOI: 10.1016/j.jgyn.2010.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Revised: 10/10/2010] [Accepted: 10/18/2010] [Indexed: 11/30/2022]
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13
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Cibula D, Kuzel D, Sláma J, Fischerova D, Dundr P, Freitag P, Zikán M, Pavlista D, Tomancova V. Sentinel node (SLN) biopsy in the management of locally advanced cervical cancer. Gynecol Oncol 2009; 115:46-50. [PMID: 19646741 DOI: 10.1016/j.ygyno.2009.06.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Sentinel lymph node (SLN) biopsy can significantly contribute to the management of locally advanced cervical cancers with high risk of lymph node (LN) positivity. However, low detection rate and sensitivity were reported in larger tumors, albeit on a small number of cases. It was the aim of our study to verify the SLN reliability in large tumors, with modified dye application technique and a careful identification of side-specific lymphatic drainage. METHODS The study involved 44 patients with tumors 3 cm in diameter or larger, stages IB1 to IIA, or selected IIB. In cases where SLN could not be detected, systematic pelvic lymphadenectomy was performed on the respective side. Systematic pelvic lymphadenectomy was performed during the second step radical procedure if not already done. RESULTS Detection rate in the whole cohort reached 77% per patient and 59% bilaterally. No significant difference was found whether a blue dye or a combined method was used (75% vs 80%, and 55% vs 67%). Systematic pelvic lymphadenectomy was performed in cases with undetected SLN unilaterally in 8 and bilaterally in 10 women. A systematic pelvic lymphadenectomy was included in the second step radical procedure in 19 cases and no positive LN were found. There was no case of false-negative SLN result in patients who underwent surgical treatment. CONCLUSION Detection rate in locally advanced cervical cancer could be improved by a careful dye application technique. Low false-negative SLN rate could be achieved if pelvic lymphatic drainage is evaluated on a side-specific principle by performing systematic lymphadenectomy if SLN is not detected.
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Affiliation(s)
- D Cibula
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic.
| | - D Kuzel
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic
| | - J Sláma
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic
| | - D Fischerova
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic
| | - P Dundr
- Department of Pathology, General Teaching Hospital, First Medical School, Charles University, Prague, Czech Republic
| | - P Freitag
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic
| | - M Zikán
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic
| | - D Pavlista
- Oncogynecological Center, Department of Obstetrics and Gynecology, General Teaching Hospital in Prague, First Medical School, Charles University, Apolinarska 18, Prague 2, Czech Republic
| | - V Tomancova
- Department of Clinical Oncology, General Teaching Hospital, First Medical School, Charles University, Prague, Czech Republic
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Delpech Y, Barranger E. [Management of cervical cancer]. ACTA ACUST UNITED AC 2008; 37 Spec No 2:F51-6. [PMID: 19031627 DOI: 10.1016/s0368-2315(08)75573-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Yann Delpech
- Service de gynécologie obstétrique, Hôpital Tenon (AP-HP), Paris
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Dornhöfer N, Höckel M. New developments in the surgical therapy of cervical carcinoma. Ann N Y Acad Sci 2008; 1138:233-52. [PMID: 18837903 DOI: 10.1196/annals.1414.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
For almost a century abdominal radical hysterectomy has been the standard surgical treatment of early-stage macroscopic carcinoma of the uterine cervix. The excessive parametrial resection of the original procedures of Wertheim, Okabayashi, and Meigs has later been "tailored" to tumor extent. Systematic pelvic and eventually periaortic lymph node dissection is performed to identify and treat regional disease. Adjuvant (chemo)radiation therapy is liberally added to improve locoregional tumor control when histopathological risk factors are present. The therapeutic index of the current surgical treatment, particularly if combined with radiation, appears to be inferior to that of primary chemoradiation as an oncologically equivalent therapeutic alternative. Several avenues of new conceptual and technical developments have been used since the 1990s with the goal of improving the therapeutic index. These are: surgical staging, including sentinel node biopsy and nodal debulking; minimal access and recently robotic radical hysterectomy; fertility-preserving surgery; nerve-sparing radical hysterectomy; total mesometrial resection based on developmentally defined surgical anatomy; and supraradical hysterectomy. The superiority of these new developments over the standard treatment remains to be demonstrated by controlled prospective trials. Multimodality therapy including surgery for locally advanced disease represents another area of clinical research. Both neoadjuvant chemotherapy followed by radical surgery, with or without adjuvant radiation, and completion surgery after (chemo)radiation are feasible and have to be compared to primary chemoradiation as the new nonsurgical treatment standard. Surgical treatment of postirradiation persisting or recurrent cervical carcinoma has been traditionally limited to pelvic exenteration for central disease. Applying the principle of developmentally derived anatomical compartments increases R0 resectability. The laterally extended endopelvic resection allows even the extirpation of a subset of visceral pelvic side wall tumors with clear margins. Many questions regarding the indication for these "ultraradical" operations, the surgery of irradiated tissues, and the optimal reconstructive procedures are still open and demand multi-institutional controlled trials to be answered.
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Affiliation(s)
- Nadja Dornhöfer
- Department of Obstetrics and Gynecology, University of Leipzig, Leipzig, Germany
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Ultrastaging improves detection of metastases in sentinel lymph nodes of uterine cervix squamous cell carcinoma. Am J Surg Pathol 2008; 32:1336-43. [PMID: 18670356 DOI: 10.1097/pas.0b013e31816ecfe4] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Extralesional detection and load of human papillomavirus DNA: a possible marker of preclinical tumor spread in cervical cancer. J Low Genit Tract Dis 2008; 12:204-9. [PMID: 18596462 DOI: 10.1097/lgt.0b013e318161429e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Because the interaction between viral DNA products and cellular regulatory mechanisms is the first step leading to cancerous transformation, the detection of its presence in histologically negative lymph nodes may represent a very early biological step in cancer spread. The quantitative estimate may represent and an indirect sign of active cellular replication. MATERIALS AND METHODS Cervical and lymph nodes tissues of 13 cases of invasive cervical cancer were analyzed for human papillomavirus (HPV)-DNA presence and viral load by HPV typing and quantification by real-time polymerase chain reaction. RESULTS HPV-DNA was demonstrated in all tissue samples (primary tumor, positive lymph nodes, negative lymph nodes) with the most prevalence of HPV 16 (61.5%) and single-type infection (69.3%), whereas viral load (mean quantity of DNA copies) is statistically different in negative versus positive lymph nodes (p =.005). CONCLUSIONS Concordance of viral type and lymph nodes viral load may represent as a useful tool in identifying early metastatic risk of tumor spread.
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Gien LT, Covens A. Quality Control in Sentinel Lymph Node Biopsy in Cervical Cancer. J Clin Oncol 2008; 26:2930-1. [DOI: 10.1200/jco.2008.16.3964] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Lilian T. Gien
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Allan Covens
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Bats AS, Lavoué V, Rouzier R, Coutant C, Kerrou K, Daraï E. Limits of Day-Before Lymphoscintigraphy to Localize Sentinel Nodes in Women with Cervical Cancer. Ann Surg Oncol 2008; 15:2173-9. [DOI: 10.1245/s10434-008-9897-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2008] [Revised: 02/27/2008] [Accepted: 03/01/2008] [Indexed: 11/18/2022]
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Daraï E, Rouzier R, Ballester M, Barranger E, Coutant C. Sentinel lymph node biopsy in gynaecological cancers: the importance of micrometastases in cervical cancer. Surg Oncol 2008; 17:227-35. [PMID: 18504122 DOI: 10.1016/j.suronc.2008.04.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- Emile Daraï
- Department of Gynaecology, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, CancerEst, Université Pierre et Marie Curie, Paris 6, France.
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Elghissassi I, M’rabti H, Bensouda Y, Rahhali R, Benjelloun S, Hassan E. Ganglion sentinelle et cancer du col utérin. IMAGERIE DE LA FEMME 2008. [DOI: 10.1016/s1776-9817(08)71696-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Coutant C, Barranger E, Cortez A, Dabit D, Uzan S, Bernaudin JF, Darai E. Frequency and prognostic significance of HPV DNA in sentinel lymph nodes of patients with cervical cancer. Ann Oncol 2007; 18:1513-7. [PMID: 17761707 DOI: 10.1093/annonc/mdm192] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND It has been suggested that histologically undetectable or 'occult' metastases in the lymphatic system could explain some recurrences. HPV DNA screening by means of the polymerase chain reaction (PCR) has been proposed as a method to detect occult metastases. This study was designed to determine the frequency of HPV DNA detection by PCR in sentinel lymph node (SN), and its relation to the clinical characteristics and outcome of women with cervical cancer. PATIENTS AND METHODS The primary cervical tumor and SN were tested for HPV DNA by means of PCR in 59 patients. RESULTS Fifteen (25.4%) of the 59 women undergoing the SN procedure had an involved SN. HPV DNA was more frequent in positive SN than in negative SN (P < 0.0001). Seven patients had a recurrence, after a mean delay of 17 months (range: 10-26). One of seven patients with a recurrence had an involved SN. HPV DNA was detected in an SN of one of seven patients with recurrence and nine (19.5%) of 46 patients without recurrence (not significant). CONCLUSION In women with cervical cancer, HPV DNA screening of sentinel nodes might help to identify patients at risk of lymph node metastases and recurrence.
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Affiliation(s)
- C Coutant
- Department of Histology and Tumor Biology, Hôpital Tenon, Paris, France
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Yildirim Y, Sehirali S, Avci ME, Yilmaz C, Ertopcu K, Tinar S, Duman Y, Sayhan S. Integrated PET/CT for the evaluation of para-aortic nodal metastasis in locally advanced cervical cancer patients with negative conventional CT findings. Gynecol Oncol 2007; 108:154-9. [PMID: 17945337 DOI: 10.1016/j.ygyno.2007.09.011] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2007] [Revised: 09/09/2007] [Accepted: 09/10/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the usefulness of integrated 2-[18F] fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (PET/CT) for the detection of para-aortic nodal status and to test whether PET/CT change management strategy in locally advanced cervical cancer (LACC) patients with negative conventional CT findings. MATERIALS AND METHODS Sixteen locally advanced (FIGO stage IIB-IVA) cervical squamous cancer patients with negative conventional CT findings were eligible to enter this prospective study. All patients underwent firstly PET/CT scans then extraperitoneal surgical exploration for para-aortic lymphadenectomy. Based on histopathologic confirmation, the accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the PET/CT for para-aortic lymph node metastasis were estimated. RESULTS The median age was 48.7 (range 42-67). The accuracy, sensitivity, specificity, PPV and NPV of the PET/CT were 75%, 50%, 83.3%, 50% and 83.3%, respectively. The treatment was modified in four of sixteen (25%) patients; four patients received EFRT in combination with cisplatin chemotherapy instead of standard pelvic field radiotherapy in combination with cisplatin chemotherapy. CONCLUSION Our results, despite our study group is small, suggest that PET/CT is an effective imaging technique in the evaluation of LACC with negative CT findings. It may help planning the management especially selecting radiation field. However, larger controlled studies are needed to recommend PET/CT as an alternative to pre-treatment surgical staging.
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Affiliation(s)
- Y Yildirim
- Department of Gynecologic Oncology, Aegean Obstetrics and Gynecology Training and Research Hospital, Izmir, Turkey.
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Lavoué V, Bats AS, Rouzier R, Coutant C, Barranger E, Daraï E. Sentinel lymph node procedure followed by laparoscopic pelvic and paraaortic lymphadenectomy in women with IB2-II cervical cancer. Ann Surg Oncol 2007; 14:2654-61. [PMID: 17610015 DOI: 10.1245/s10434-007-9493-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2007] [Accepted: 05/17/2007] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the contribution of the sentinel node (SN) procedure followed by pelvic and paraaortic lymphadenectomy to determine lymph node status in women with locally advanced cervical cancer. PATIENTS AND METHODS A total of 21 women with locally advanced cervical cancer underwent a first laparoscopic SN procedure and pelvic and paraaortic lymphadenectomy followed by concurrent chemoradiotherapy (CCR). Laparoscopic radical hysterectomy was performed after CCR when the pelvic and paraaortic nodes were not involved. RESULTS SNs were detected by means of lymphoscintigraphy in 10 women (47.6%) and intra-operatively in 14 women (66.6%). Of the latter 14 patients, 9 (64%) had an involved SN and 1 of the remaining 5 had pelvic non-SN metastases. The SN false-negative rate was 10%. At final histology, 13 of the 21 women (62%) had lymph node metastases. The total number of recovered pelvic non-SNs was 262, and 10 nodes in 8 women were involved. The total number of paraaortic non-SNs was 255, and 2 nodes in 2 women were involved. CONCLUSION This study shows the poor correlation between pre-operative lymphoscintigraphy and surgical SN mapping in women with locally advanced cervical cancer. A high proportion of women had SN metastases, underlining the importance of multiple sectioning and immunohistochemical staining of SNs.
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Affiliation(s)
- Vincent Lavoué
- Service de Gynécologie-Obstétrique, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, CancerEst, Université Pierre et Marie Curie, Paris VI, France
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Biopsie du ganglion sentinelle dans le cancer du col de l'utérus: état de l'art en 2007. ACTA ACUST UNITED AC 2007; 35:516-22. [DOI: 10.1016/j.gyobfe.2007.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2007] [Accepted: 03/07/2007] [Indexed: 01/29/2023]
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26
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Daraï E, David-Montefiore E. Reply. Am J Obstet Gynecol 2007. [DOI: 10.1016/j.ajog.2006.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Frumovitz M, Ramirez PT, Levenback C. Lymphatic mapping and sentinel node detection in gynecologic malignancies of the lower genital tract. Curr Oncol Rep 2005; 7:435-43. [PMID: 16221380 DOI: 10.1007/s11912-005-0008-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The utility of lymphatic mapping and sentinel lymph node biopsy in malignancies of the female lower genital tract-- vulvar, vaginal, and cervical cancers--is being explored in multiple centers internationally. For patients with these tumors, lymphatic mapping with sentinel lymph node biopsy holds the promise of increasing the identification of microscopically metastatic disease while decreasing the morbidity of complete lymphadenectomy. In this review article we present the published data on mapping techniques and discuss the advantages and pitfalls of these procedures.
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Affiliation(s)
- Michael Frumovitz
- Department of Gynecologic Oncology, CPB6.3244, Unit 1362, The University of Texas M.D. Anderson Cancer Center, 1155 Herman Pressler, TX 77030, USA.
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Lejeune FJ. What is the impact of sentinel node biopsy in the management of cancer? Ann Oncol 2005; 16:1217-8. [PMID: 15994175 DOI: 10.1093/annonc/mdi298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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