Sentinel node detection in a patient with recurrent endometrial cancer initially treated by hysterectomy and radiotherapy

Multicenter Validation Study of the Sentinel Lymph Node Concept in Cervical Cancer: AGO Study Group

Purpose

Single-institution case series have demonstrated the feasibility of the sentinel concept in cervical cancer. However, the diagnostic accuracy remains to be validated. We evaluated detection rate and diagnostic accuracy to predict the histopathologic pelvic nodal status in patients with cervical cancer of all stages.

Patients and Methods

In a hypothesis-based, prospective, multicenter cohort study, patients underwent lymph node detection after labeling with technetium, patent blue, or both. After systematic pelvic and, if indicated, para-aortic node dissection, all lymph nodes were histopathologically examined. Detection rate, sensitivity, and negative predictive value (NPV) were calculated.

Results

According to the protocol, 590 patients were eligible. Detection rate of pelvic sentinel nodes was 88.6% (95% CI, 85.8% to 91.1%) and was significantly higher for the combination of technetium and patent blue (93.5%; 95% CI, 90.3% to 96.0%). Of 106 patients with pelvic lymph node metastases, 82 had pelvic sentinel node metastases. The overall sensitivity was 77.4% (95% CI, 68.2% to 85.0%), which was lower than 90%, the predefined noninferiority margin (P < .001). Sensitivity in women with tumors ≤ 20 mm (90.9%), with bilateral detection (87.2%), or with both substances applied (80.3%) was higher compared with the total population. The overall NPV was 94.3% (95% CI, 91.6% to 96.4%) and was higher in patients with tumors ≤ 20 mm (99.1%; 95% CI, 96.6% to 100%) compared with patients with tumors more than 20 mm (88.5%; 95% CI, 82.9% to 92.8%; P < .001).

Conclusion

In our cohort (all stages), sensitivity of the sentinel concept was low. However, patients with tumor diameter ≤ 20 mm may profit from this concept.

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.

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.