Lymphatic mapping and sentinel node identification in patients with cervix cancer undergoing radical hysterectomy and pelvic lymphadenectomy

Detecting Atypical Sentinel Lymph Nodes in Early-Stage Cervical Cancer Using a Standardized Technique with a Hybrid Tracer

BACKGROUND

Since October 2018, lymph node status has become part of the FIGO staging, given that it is one of the most important prognostic factors among women with CC. The aim was to determine the rate of atypical lymphatic drainage in patients with clinical early-stage cervical cancer using a hybrid tracer (ICG-99mTc nanocolloid).

METHODOLOGY

A prospective, observational, single-centre study conducted at Son Espases University Hospital between January 2019 and October 2023. Patients with clinical early-stage CC who underwent SLN mapping were included. External iliac and obturator nodes were defined as common locations. Para-aortic, common iliac, presacral, internal iliac, and parametrial nodes were defined as atypical locations.

RESULTS

Thirty-nine cases of CC were included. The overall SLN detection rate was 97.4%, with 89.5% bilaterally. Positive nodes were found in 21.1% of patients. Atypical lymphatic drainage was present in 8 out of 38 (21.1%) patients. Of all the SLNs biopsied (146), 10.3% corresponded to an atypical zone. SLN in the atypical area had a higher proportion of metastasis than the usual area (37.5% vs. 16.7%; p = 0.327).

CONCLUSIONS

SLN biopsy can detect unusual drainage in a significant proportion of patients. Atypical lymph nodes have a higher percentage of metastasis, which consequently improves staging and tailoring therapy. SLN mapping performed via a standardized surgical technique using a hybrid tracer (ICG-99mTc) could help in the identification of the "true SLN".

Mexican consensus about surgical treatment in early-stage cervicouterine cancer

Introduction

Cervical cancer is a public health problem in our country and worldwide. Less than 25% of cases are diagnosed in the early stages, where survival is more remarkable than 90% at five years. Here, we review surgical treatment in the early stages of cervical cancer.

Methodology

A literature review was carried out in the MEDLINE database. The search was mainly limited to the English language, with priority given to systematic reviews with or without meta-analysis and randomized studies. However, only retrospective or observational evidence was found for some topics.

Results

The standard treatment for early-stage cervical cancer is hysterectomy, and its radical nature will depend on the tumor size, lymphovascular permeation, and tumor-specific prognostic factors. Furthermore, the type of surgery (hysterectomy or trachelectomy) will rely on the patient's desire to preserve fertility. Nodal evaluation is indicated as part of the treatment from stage IAI with PLV. However, the sentinel lymph node is more relevant in the treatment. The incidental finding of cervical cancer after a hysterectomy requires a multidisciplinary evaluation to determine the therapeutic approach. Less radical surgery has been described as oncologically safe in low-risk groups.

Conclusion

Surgical treatment in its early stages has evolved in recent decades, making it more individualized and seeking less morbidity in patients without compromising their survival.

Surgical Treatment for Early Cervical Cancer in the HPV Era: State of the Art

Cervical cancer (CC) is the fourth most common cancer among women worldwide. The aim of this study is to focus on the state of the art of CC prevention, early diagnosis, and treatment and, within the latter, the role of surgery in the various stages of the disease with a focus on the impact of the LACC study (Laparoscopic Approach to Cervical Cancer trial) on the scientific debate and clinical practice. We have discussed the controversial application of minimally invasive surgery (MIS) for tumors < 2 cm and the possibility of fertility-sparing surgery on young women desirous of pregnancy. This analysis provides support for surgeons in the choice of better management, including patients with a desire for offspring and the need for sentinel node biopsy (SNB) rather than pelvic lymphadenectomy for tumors < 4 cm, and without suspicious lymph nodes' involvement on imaging. Vaccines and early diagnosis of pre-cancerous lesions are the most effective public health tool to tackle cervical cancer worldwide.

Multidimensional outlook on the pathophysiology of cervical cancer invasion and metastasis

Cervical cancer being one of the primary causes of high mortality rates among women is an area of concern, especially with ineffective treatment strategies. Extensive studies are carried out to understand various aspects of cervical cancer initiation, development and progression; however, invasive cervical squamous cell carcinoma has poor outcomes. Moreover, the advanced stages of cervical cancer may involve lymphatic circulation with a high risk of tumor recurrence at distant metastatic sites. Dysregulation of the cervical microbiome by human papillomavirus (HPV) together with immune response modulation and the occurrence of novel mutations that trigger genomic instability causes malignant transformation at the cervix. In this review, we focus on the major risk factors as well as the functionally altered signaling pathways promoting the transformation of cervical intraepithelial neoplasia into invasive squamous cell carcinoma. We further elucidate genetic and epigenetic variations to highlight the complexity of causal factors of cervical cancer as well as the metastatic potential due to the changes in immune response, epigenetic regulation, DNA repair capacity, and cell cycle progression. Our bioinformatics analysis on metastatic and non-metastatic cervical cancer datasets identified various significantly and differentially expressed genes as well as the downregulation of potential tumor suppressor microRNA miR-28-5p. Thus, a comprehensive understanding of the genomic landscape in invasive and metastatic cervical cancer will help in stratifying the patient groups and designing potential therapeutic strategies.

Sentinel lymphatic mapping for gynecologic malignancies

PURPOSE OF REVIEW

To summarize the latest data in Gynecologic Oncology for the use of sentinel lymphatic mapping in vulvar, uterine, and cervical cancers.

RECENT FINDINGS

To decrease morbidity and improve detection of lymphatic metastasis, lymphatic mapping with sentinel lymph node biopsy is emerging as standard of care over conventional systemic lymphadenectomy in the surgical management of gynecologic malignancies.

SUMMARY

Sentinel lymph node mapping with biopsy is one of the most significant advances in cancer surgery. The presence of nodal metastasis is not only a prognostic factor for recurrence and survival in patients with gynecologic malignancies, but also guides assessment for adjuvant treatment. This review article discusses the most recent clinical updates in sentinel lymph node mapping, dissection, and management in vulvar cancer, endometrial cancer, and cervical cancer.

Management of Early-Stage Cervical Cancer: A Literature Review

Simple Summary

Despite being a preventable disease, cervical cancer still causes morbidity and deaths worldwide. In the early stages (FIGO IA1 with lymph-vascular space invasion-IIA1), the disease is highly curable. The primary treatment for early-stage cervical cancer is radical hysterectomy with pelvic lymphadenectomy. This surgical treatment has changed during the past decades, and we aimed to review and discuss the advances in the literature. We performed a literature review through PubMed focusing on English articles about the topic of surgical management of early-stage cervical cancer. The emergent topics considered here are the FIGO 2018 staging system update, conservative management for selected patients, sentinel lymph node mapping, fertility preservation, surgical approach, and management of tumors up to 2 cm. These topics show an evolvement to a more tailored treatment to prevent morbidity and assure oncologic safety.

Abstract

Cervical cancer (CC) remains a public health issue worldwide despite preventive measures. Surgical treatment in the early-stage CC has evolved during the last decades. Our aim was to review the advances in the literature and summarize the ongoing studies on this topic. To this end, we conducted a literature review through PubMed focusing on English-language articles on the surgical management of early-stage CC. The emergent topics considered here are the FIGO 2018 staging system update, conservative management with less radical procedures for selected patients, lymph node staging, fertility preservation, preferred surgical approach, management of tumors up to 2 cm, and prognosis. In terms of updating FIGO, we highlight the inclusion of lymph node status on staging and the possibility of imaging. Regarding the preferred surgical approach, we emphasize the LACC trial impact worldwide in favor of open surgery; however, we discuss the controversial application of this for tumors < 2 cm. In summary, all topics show a tendency to provide patients with tailored treatment that avoids morbidity while maintaining oncologic safety, which is already possible in high-income countries. We believe that efforts should focus on making this a reality for low-income countries as well.

Cancer of the cervix uteri: 2021 update

Since the publication of the 2018 FIGO Cancer Report, giant strides have been made in the global effort to reduce the burden of cervical cancer, with the World Health Organization (WHO) rolling out a global strategy for cervical cancer elimination, aiming for implementation by 2030. In over 130 countries, including low- and middle-income countries, HPV vaccination is now included in the national program. Screening has seen major advances with wider implementation of HPV testing. These interventions will take a few years to show their impact. Meanwhile, over half a million new cases are added each year. FIGO's revised staging of cervical cancer (2018) has been widely implemented and retrospective analyses of data based on the new staging have been published. Minimally invasive surgery has been shown to be disadvantageous in women with cervical cancer. This chapter discusses the management of cervical cancer based on the stage of disease, including attention to palliation and quality of life issues.

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

Background

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

Methods

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

Results

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

Conclusions

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

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.

Retrospective analysis for predictors of parametrial involvement in IB cervical cancer

AIM

The use of less radical surgery for early stage cervical cancer has often been discussed. To better determine eligible candidates for less radical surgery, we investigated the risk factors for parametrial involvement (PI).

METHODS

The study included 193 patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB cervical cancer who were treated with radical hysterectomy and pelvic lymphadenectomy between 2008 and 2014. The patients were divided into two groups according to whether or not the parametrium was involved pathologically. The two groups were compared with regards to clinical and histopathological variables.

RESULTS

Univariate analysis showed that International Federation of Gynecology and Obstetrics stage, clinical tumor size, depth of stromal invasion, lymphovascular space invasion and pelvic lymph node metastasis were significantly associated with PI (P < 0.05 each). Multivariate analysis showed pelvic lymph node metastasis was an independent risk factor for PI (odds ratio, 10.70; [95% confidence interval, 3.02-48.08]; P = 0.0006). All patients with clinical tumor size less than or equal to 2 cm and negative for pelvic lymph node metastasis had no PI.

CONCLUSION

Cervical cancer with the tumor less than or equal to 2 cm and negative for pelvic lymph node metastasis seldom has PI. These patients are good candidates for less radical surgery.

Cancer of the cervix uteri

Since the publication of the last FIGO Cancer Report there have been giant strides in the global effort to reduce the burden of cervical cancer, with WHO announcing a call for elimination. In over 80 countries, including LMICs, HPV vaccination is now included in the national program. Screening has also seen major advances with implementation of HPV testing on a larger scale. However, these interventions will take a few years to show their impact. Meanwhile, over half a million new cases are added each year. Recent developments in imaging and increased use of minimally invasive surgery have changed the paradigm for management of these cases. The FIGO Gynecologic Oncology Committee has revised the staging system based on these advances. This chapter discusses the management of cervical cancer based on the stage of disease, including attention to palliation and quality of life issues.

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

BACKGROUND

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

PURPOSE

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

STUDY TYPE

Retrospective.

POPULATION

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

FIELD STRENGTH/SEQUENCE

T₁ CE and T₂ MRI sequences at 3T.

ASSESSMENT

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

STATISTICAL TESTS

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

RESULTS

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

DATA CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Identification of a low risk population for parametrial invasion in patients with early-stage cervical cancer

Background

Recent studies have challenged radical procedures for less extensive surgery in selected patients with early-stage cervical cancer at low risk of parametrial invasion. Our objective was to identify a subgroup of patients at low risk of parametrial invasion among women having undergone surgical treatment.

Methods

Data of 1447 patients with cervical cancer treated between 1996 and 2016 were extracted from maintained databases of 10 French University hospitals. Patients with early-stage (IA2–IIA) disease treated by radical surgery including hysterectomy and trachelectomy, were selected for further analysis. The Kaplan–Meier method was used to estimate the survival distribution. A Cox proportional hazards model including all the parameters statistically significant in univariate analysis, was used to account for the influence of multiple variables.

Results

Out of the 263 patients included for analysis, on final pathology analysis 28 (10.6%) had parametrial invasion and 235 (89.4%) did not. Factors significantly associated with parametrial invasion on multivariate analysis were: age > 65 years, tumor > 30 mm in diameter measured by MRI, lymphovascular space invasion (LVSI) on pathologic analysis. Among the 235 patients with negative pelvic lymph nodes, parametrial disease was seen in only 7.6% compared with 30.8% of those with positive pelvic nodes (p < 0.001). In a subgroup of patients presenting tumors < 30 mm, negative pelvic status and no LVSI, the risk of parametrial invasion fell to 0.6% (1/173 patients).

Conclusion

Our analysis suggests that there is a subgroup of patients at very low risk of parametrial invasion, potentially eligible for less radical procedures.

Electronic supplementary material

The online version of this article (10.1186/s12967-018-1531-6) contains supplementary material, which is available to authorized users.

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

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

Sentinel lymph node in cervical cancer

Background: Cervical cancer is the second most common type of cancer among women. Effective screening programs can help cancer detection in early phases and reduce death. Metastasis to lymph nodes is one of the most prognostic factors in patients who underwent surgery. Also, a positive result from pathology report alert oncologist as a cause of death. Sentinel lymph node biopsy has been widely studied and clinically used for many types of cancer.

Methods: Two techniques exist for detecting sentinel node in cervical cancer, which are Blue dye and gamma probe with radioactive isotope (99mTc). Moreover, lymphoscintigraphy has many advantages over the stain method. Detecting the sentinel node is performed via laparoscopy or laparotomy; former method is better and more accurate.

Results: Various researchers have focused on this method and its positive results; its superiority against full lymphadenectomy has been declared in previous studies. Moreover, the role of sentinel lymph nodes biopsy in cervical cancer is still being extensively studied. Sentinel lymph nodes (SLN) method has a higher accuracy level to detect metastasis.

Conclusion: Hence, it can be considered as a more appropriate alternative for pelvic lymph node dissection (PLND), which is a standard technique. Altering the method to a standard clinical method needs in-depth researches and studies.

Can We Define the Risk of Lymph Node Metastasis in Early-Stage Cervical Cancer Patients? A Large-Scale, Retrospective Study

BACKGROUND

Sentinel lymph node (SLN) biopsy has emerged as one of the most appreciated techniques for reducing the rate of complete lymph node dissection (LND) performed in patients with early-stage cervical cancer (ECC). However, its performances are still a matter of debate and, to improve them, international guidelines recommend performing at least unilateral LND in case of SLN mapping. In a prior study, we identified a group of patients without evidence of lymph node metastasis (LNM). Our objective is to define a precise risk of LNM for each ECC patient in order to significantly tailor surgery for ECC.

METHODS

Clinical and pathological data of ECC patients were retrospectively collected by eight Italian institutions. Chi-square test or Fisher's exact test along with logistic regression analysis was used to determine the association of each variable between patients with or without LNM. Results of logistic regression have been used as a basis to calculate the probability to harboring LNM.

RESULTS

A total of 463 ECC patients were identified. No LNM was detected among the 161 (34.8%) patients who met the criteria and were defined as Very Low Risk. In the other 302 patients, the precise risk of LNM was calculated, and it was <1% in 31 (10.3%) patients.

CONCLUSIONS

Defining the precise risk of LNM could lead to proper selection of patients in whom any lymph nodal procedure, including SLN, could be avoided.

Indocyanine Green versus Radiotracer with or without Blue Dye for Sentinel Lymph Node Mapping in Stage >IB1 Cervical Cancer (>2 cm)

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 (Tc99^m) 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 Tc99^m with or without blue dye or ICG and radical hysterectomy.

INTERVENTION

The detection rate and bilateral mapping rate were compared between ICG and standard Tc99^m 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 Tc99^m 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 Tc99^m 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 Tc99^m 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 Tc99^m 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.

Sensitivity and negative predictive value for sentinel lymph node biopsy in women with early-stage cervical cancer

OBJECTIVE

The role of sentinel lymph node (SLN) biopsy alone for staging of early-stage cervical cancer remains controversial. We aimed to determine the validity of this technique in women with early-stage cervical cancer.

METHODS

We retrospectively reviewed women with early-stage cervical cancer who underwent SLN mapping followed by complete pelvic lymphadenectomy as part of initial surgical management from August 1997 through October 2015. All modes of surgical approach were included. Lymphatic mapping was performed using blue dye, technetium-99m sulfur colloid (Tc-99), and/or indocyanine green (ICG). We determined SLN detection rates, sensitivity and negative predictive value.

RESULTS

One hundred eighty-eight patients were included, and 35 (19%) had lymph node metastases. At least one SLN was identified in 170 patients (90%), and bilateral SLNs were identified in 117 patients (62%). The majority of SLNs (83%) were found in the pelvis. There was no difference in detection rates between mapping agents, surgical approach, patients with and without prior conization or between patients with tumors <2cm and ≥2cm. The detection rate for bilateral SLNs was significantly lower in women with body mass index (BMI)>30kg/m² than in women with lower BMI (p=0.03). Metastatic disease in sentinel nodes was detected by H&E staining in 78% of cases and required ultrastaging/immunohistochemistry in 22% of cases. Only one patient had a false-negative result, yielding a sensitivity of 96.4% (95% CI 79.8%-99.8%) and negative predictive value of 99.3% (95% CI 95.6%-100%). The false-negative rate was 3.6%.

CONCLUSIONS

In these women with early-stage cervical cancer, SLN biopsy had very high sensitivity and negative predictive value. We believe it is time to change the standard of care for women with early-stage cervical cancer to SLN biopsy only.

Resection of Sentinel Lymph Nodes by an Extraperitoneal Minilaparoscopic Approach Using Indocyanine Green for Uterine Malignancies

Background. The sentinel lymph node (SLN) concept might minimize surgical aggressiveness in cervical and endometrial malignancies. The aim of the study was to test the feasibility and reliability of minilaparoscopic extraperitoneal SLN excision after indocyanine green (ICG) cervical injection using a high-definition near infrared (NIR) imaging system in an in vivo porcine model. The same procedure was performed using conventional laparoscopic instruments and both outcomes were compared. Methods. Twenty-four animals were equally and randomly divided into a minilaparoscopic group (group A) and a 5-mm conventional laparoscopic group (group B). A high-definition NIR imaging system and a 30° ICG endoscope were used. First, ICG (0.5 mL) was injected in the paracervical region. The SLN coloring time was recorded. An extraperitoneal approach to the SLN was executed with the same CO2 retropneumoperitoneum pressures (10 mm Hg). In both groups, the times for SLN localization and excision, as well as complications, were registered. Finally, a laparotomy was then done to evaluate whether any stained SLN still remained. The same surgical team performed all experiments. Results. SLNs were identified and extraperitoneally excised in all animals without major complications. The SLN localization varied between animals from external iliac to preaortic regions. The surgical times were shorter with minilaparoscopy (39.3 ± 13 minutes) than with conventional 5-mm instruments (51.3 ± 14.17 minutes; P = .042). In group B, one stained SLN remained and was only detected by laparotomy. Conclusions. We confirmed the feasibility and reliability of extraperitoneal minilaparoscopic approach for identification, dissection, and excision of SLN using an NIR imaging system and ICG.

Beyond sentinel node algorithm. Toward a more tailored surgery for cervical cancer patients

Nowadays cervical cancer is frequently diagnosed at early stage. For these patients lymph node metastasis (LNM) is considered the most important prognostic factor. During the last decade many efforts have been made to reduce rate of complications associated with lymphadenectomy (LND). A great interest has arisen in sentinel lymph node (SLN) biopsy as a technique able to decrease number of LND performed and, at the same time, to assess lymph nodal status. High diagnostic performances have been reached thanks to SLN surgical algorithm. However, despite the efforts, about 25% of these patients undergo at least unilateral LND to meet NCCN recommendations. Data of women with International Federation of Gynecology and Obstetrics stage IA1‐IB1/IIA1 cervical carcinoma were retrospectively collected by six Italian institutions. All patients underwent complete preoperative staging workup and were primarily treated by radical hysterectomy and pelvic bilateral LND. A total of 368 patients with early‐stage cervical cancer were identified. Among them 333 (90.5%) showed no suspicious enlarged nodes at the preoperative magnetic resonance imaging (MRI). In this subset, tumor diameter ≥20 mm was the only independent predictor of LN status (P = 0.003). None of the 106 patients with negative MRI nodal assessment, with squamous and adenosquamous histotype and a tumor diameter less than 2 cm had LNM. Based on these results we propose a new modified SLN surgical algorithm that could safely reduce LND performed in patients with very low‐risk early‐stage cervical cancer.

Incidence of metastasis in circumflex iliac nodes distal to the external iliac nodes in cervical cancer

OBJECTIVE

A causal relationship between removal of circumflex iliac nodes distal to the external iliac nodes (CINDEIN) and lower leg edema has been recently suggested. The aim of this study was to elucidate the incidence of CINDEIN metastasis in cervical cancer.

METHODS

A retrospective chart review was carried out for 531 patients with cervical cancer who underwent lymph node dissection between 1993 and 2014. CINDEIN metastasis was pathologically identified by microscopic investigation. After 2007, sentinel lymph node biopsy was performed selectively in patients with non-bulky cervical cancer. The sentinel node was identified using (99m)Tc-phytate and by scanning the pelvic cavity with a γ probe.

RESULTS

Two hundred and ninety-seven patients (55.9%) underwent CINDEIN dissection and 234 (44.1%) did not. The percentage of International Federation of Gynecology and Obstetrics stage IIb to IV (42.4% vs. 23.5%, p<0.001) was significantly higher in patients who underwent CINDEIN dissection than those who did not. CINDEIN metastasis was identified in 1.9% overall and in 3.4% of patients who underwent CINDEIN dissection. For patients with stage Ia to IIa disease, CINDEIN metastasis was identified in 0.6% overall and in 1.2% of patients who underwent CINDEIN dissection. Of 115 patients with sentinel node mapping, only one (0.9%) had CINDEIN detected as a sentinel node. In this case, the other three lymph nodes were concurrently detected as sentinel lymph nodes.

CONCLUSION

CINDEIN dissection can be eliminated in patients with stage Ia to IIa disease. CINDEIN might not be regional lymph nodes in cervical cancer.

Cervical cancer with a rare umbilical metastases in prior surgical site

•

We describe the case of an unusual port-site cervical cancer metastasis.

•

We perform a review of the current published literature of port-site metastases.

•

We demonstrate that our patient’s case is unlike others previously described.

Introduction

Port-site metastasis of cervical cancer is a relatively rare occurrence, and has been reported in the published literature as a pre-terminal event.

Presentation of case

We present the case of a 52-year-old female who was diagnosed with cervical cancer after presenting to our institution’s hospital with urinary symptoms not relieved by multiple treatments with antibiotics. To fully evaluate the extent of disease, positron emission tomography-computed tomography imaging was obtained, showing an area of mildly increased fluorodeoxyglucose uptake in her umbilicus. While undergoing external-beam radiotherapy treatment for her cervical cancer, she began to experience pain in the umbilicus associated with a mass. A biopsy was taken, revealing metastatic cervical cancer at the site of a previous port-site incision for a cholecystectomy that the patient underwent 18 months before the finding.

Discussion

Port-site metastasis have been reported following kidney, bladder, and colon cancer resections, with reports of cervical cancer cases being exceedingly rare. Several hypotheses have emerged as potential explanations for port-site metastasis.

Conclusion

To our knowledge, this represents the first reported case of a port-site metastasis to an incision site created for an unrelated laparoscopic surgery, performed well in advance of the diagnosis of 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.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Uterine lymphangiography: comparison of two methods for locating the medial iliac lymph node

Different methods for lymphatic mapping in dogs, such as infusing tissues with vital dyes or radioactive substances, have been studied, aiming at the early detection of lymph node metastasis. Thus, one could anticipate therapeutic measures and, consequently, prolong the survival and improve the quality of life of the patients. The objectives of this experiment were to locate the nodes responsible for draining the uterine body and horns and to try to establish the relationship between the uterus and the medial iliac lymph nodes to contribute to the early diagnosis and prognosis of uterine disorders. We studied 15 female dogs divided into two groups (5 dead and 10 intraoperative ovariohysterectomy bitches). The dye used was patent blue V (Patent Bleu V®). It was observed that the iliac lymph node chain receives much of the uterine (horns) drainage. This method should be considered for safer studies of uterine sanity. This information suggests that evaluating these lymph nodes will allow correlating changes in their physiological status with uterine pathologies.

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

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

Sentinel lymph node biopsy in uterine cervical cancer patients: ready for clinical use? A review of the literature

Sentinel lymph node biopsy has been widely studied in a number of cancer types. As far as cervical cancer is concerned, this technique has already been used, revealing both positive results and several issues to be solved. The debate on the role of sentinel lymph node biopsy in cervical cancer is still open although most of the studies have already revealed its superiority over complete lymphadenectomy and the best handling possible of the emerging practical problems. Further research should be made in order to standardize this method and include it in the clinical routine.

Utility of SPECT/CT in Sentinel Lymph Node Detection in a Case of Vulvar Carcinoma

Minimally invasive sentinel node biopsy is associated with significantly less morbidity and has been evaluated in several studies in patients with gynecologic malignancies. Accurate identification of the sentinel lymph nodes is possible in most of the patients. Hybrid SPECT/CT is a newer modality which has been shown to improve the localization of the suspicious lesions and also provide anatomical information of the involved lymph nodes. We report the utility of hybrid SPECT/CT in localization of sentinel lymph node in a case of vulvar cancer and its impact on patient management.

Conflict of interest:None declared.

Sentinel lymph node evaluation in women with cervical cancer

Lymph node status is the most important prognosticator of survival in women with early stage cervical cancer. Thus many patients with cervical cancer will undergo pelvic lymphadenectomy as part of the treatment. This procedure is associated with substantial morbidity. Use of the sentinel lymph node technique in women with cervical cancer has the potential to decrease this morbidity. Multiple studies have suggested that sentinel lymph node mapping in these patients is feasible, with excellent detection rates and sensitivity. This review examines the current body of literature about sentinel lymph node biopsy in women with cervical cancer.

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

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

"Triple injection" lymphatic mapping technique to determine if parametrial nodes are the true sentinel lymph nodes in women with cervical cancer

OBJECTIVES

Lymphatic mapping studies in women with cervical cancer typically identify sentinel nodes (SLNs) in the pelvis and not the parametrium. We added India ink as a mapping agent to determine whether this would allow us to pathologically identify sentinel parametrial nodes and to test our hypothesis that the parametrial nodes are the true SLNs in women with cervical cancer.

METHODS

We performed lymphatic mapping and SLN biopsy in 20 women with early-stage cervical cancer undergoing radical hysterectomy or trachelectomy using a "triple injection" technique with blue dye, radiocolloid, and India ink. Pathologic processing of parametrium and nodal tissue was then performed to identify India ink in specimens.

RESULTS

On pathology review, 15 (75%) patients had a parametrial node identified, and 9 patients (45%) had bilateral parametrial nodes identified; the median number of parametrial nodes identified was 2 (range, 0-7). India ink was seen in at least 1 parametrial node in 13 (87%) of the 15 patients with a parametrial node identified pathologically. Of the 9 patients with bilateral parametrial nodes identified pathologically, only 5 (54%) had bilateral parametrial nodes containing India ink. India ink was found in 26 (44%) of 59 SLNs and only 1 (0.3%) of 289 non-SLNs. In 5 patients, India ink was seen in a SLN on the same side of the pelvis where a parametrial node was identified but not microscopically black.

CONCLUSIONS

There appears to be direct drainage of cervical lesions to pelvic nodal basins bypassing small parametrial nodes. Parametrial nodes, therefore, may not always be the SLNs in women with cervical cancer.

Detection of Sentinel Lymph Nodes in Gynecologic Tumours by Planar Scintigraphy and SPECT/CT

Objective: Assess the role of planar lymphoscintigraphy and fusion imaging of SPECT/CT in sentinel lymph node (SLN) detection in patients with gynecologic tumours.

Material and Methods: Planar scintigraphy and hybrid modality SPECT/CT were performed in 64 consecutive women with gynecologic tumours (mean age 53.6 with range 30-77 years): 36 pts with cervical cancer (Group A), 21 pts with endometrial cancer (Group B), 7 pts with vulvar carcinoma (Group C). Planar and SPECT/CT images were interpreted separately by two nuclear medicine physicians. Efficacy of these two techniques to image SLN were compared.

Results: Planar scintigraphy did not image SLN in 7 patients (10.9%), SPECT/CT was negative in 4 patients (6.3%). In 35 (54.7%) patients the number of SLNs captured on SPECT/CT was higher than on planar imaging. Differences in detection of SLN between planar and SPECT/CT imaging in the group of all 64 patients are statistically significant (p<0.05). Three foci of uptake (1.7% from totally visible 177 foci on planar images) in 2 patients interpreted on planar images as hot LNs were found to be false positive non-nodal sites of uptake when further assessed on SPECT/CT. SPECT/CT showed the exact anatomical location of all visualised sentinel nodes.

Conclusion: In some patients with gynecologic cancers SPECT/CT improves detection of sentinel lymph nodes. It can image nodes not visible on planar scintigrams, exclude false positive uptake and exactly localise pelvic and paraaortal SLNs. It improves anatomic localization of SLNs.

Conflict of interest:None declared.

Anatomic distribution of [(18)F] fluorodeoxyglucose-avid lymph nodes in patients with cervical cancer

PURPOSE

Current information about the anatomic distribution of lymph node (LN) metastases from cervical cancer is not precise enough for optimal treatment planning for highly conformal radiation therapy. To accurately define the anatomic distribution of these LN metastases, we mapped [(18)F] fluorodeoxyglucose positron emission tomography (FDG PET)-positive LNs from 50 women with cervical cancer.

METHODS AND MATERIALS

Records of patients with cervical cancer treated from 2006 to 2010 who had pretreatment PET/computed tomography (CT) scans available were retrospectively reviewed. Forty-one consecutive patients (group 1) with FDG-avid LNs were identified; because there were few positive paraortic LNs in group 1, 9 additional patients (group 2) with positive paraortic LNs were added. Involved LNs were contoured on individual PET/CT images, mapped to a template CT scan by deformable image registration, and edited as necessary by a diagnostic radiologist and radiation oncologists to most accurately represent the location on the original PET/CT scan.

RESULTS

We identified 190 FDG-avid LNs, 122 in group 1 and 68 in group 2. The highest concentrations of FDG-avid nodes were in the external iliac, common iliac, and paraortic regions. The anatomic distribution of the 122 positive LNs in group 1 was as follows: external iliac, 78 (63.9%); common iliac, 21 (17.2%); paraortic, 9 (7.4%); internal iliac, 8 (6.6%); presacral, 2 (1.6%); perirectal, 2 (1.6%); and medial inguinal, 2 (1.6%). Twelve pelvic LNs were not fully covered when the clinical target volume was defined according to Radiation Therapy Oncology Group guidelines for intensity modulated radiation therapy for cervical cancer.

CONCLUSIONS

Our findings clarify nodal volumes at risk and can be used to improve target definition in conformal radiation therapy for cervical cancer. Our findings suggest several areas that may not be adequately covered by contours described in available atlases.

Optimization of near-infrared fluorescent sentinel lymph node mapping in cervical cancer patients

OBJECTIVE

In early cervical cancer, a total pelvic lymphadenectomy is the standard of care, even though most patients have negative nodes and thus undergo lymphadenectomy unnecessarily. Although the value of sentinel lymph node (SLN) mapping in early-stage cervical cancer has not yet been established, near-infrared (NIR) fluorescence imaging is a promising technique to perform this procedure. Near-infrared fluorescence imaging is based on invisible NIR light and can provide high sensitivity, high-resolution, and real-time image guidance during surgery.

METHODS

Clinical trial subjects were 9 consecutive cervical cancer patients undergoing total pelvic lymphadenectomy. Before surgery, 1.6 mL of indocyanine green adsorbed to human serum albumin (ICG:HSA) was injected transvaginally and submucosally in 4 quadrants around the tumor. Patients were allocated to 500-, 750-, or 1000-μM ICG:HSA concentration groups. The Mini-FLARE imaging system was used for NIR fluorescence detection and quantitation.

RESULTS

Sentinel lymph nodes were identified in all 9 patients. An average of 3.4 ± 1.2 SLNs was identified per patient. No differences in signal to background of the SLNs between the 500-, 750-, and 1000-μM dose groups were found (P = 0.73). In 2 patients, tumor-positive lymph nodes were found. In both patients, tumor-positive lymph nodes confirmed by pathology were also NIR fluorescent.

CONCLUSIONS

This study demonstrated preliminary feasibility to successfully detect SLNs in cervical cancer patients using ICG:HSA and the Mini-FLARE imaging system. When considering safety, cost-effectiveness, and pharmacy preferences, an ICG:HSA concentration of 500 μM was optimal for SLN mapping in cervical cancer patients.

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

Purpose

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

Procedures

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

Results

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

Conclusions

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

Electronic supplementary material

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

Impact of nodal status and tumor burden in sentinel lymph nodes on the clinical outcomes of cancer patients

The validation of sentinel lymph node (SLN) concept in melanoma and breast cancer has established a new paradigm in cancer metastasis that, in general, cancer cells spread in a orderly fashion from the primary site to the SLNs in the regional nodal basin and then to the distant sites. In this review article, we examine the development of SLN concept in penile carcinoma, melanoma and breast carcinoma and its application to other solid cancers with emphasis of the relationship between micrometastasis in SLNs and clinical outcomes.

Establishing a sentinel lymph node mapping algorithm for the treatment of early cervical cancer

OBJECTIVE

To establish an algorithm that incorporates sentinel lymph node (SLN) mapping to the surgical treatment of early cervical cancer, ensuring that lymph node (LN) metastases are accurately detected but minimizing the need for complete lymphadenectomy (LND).

METHODS

A prospectively maintained database of all patients who underwent SLN procedure followed by a complete bilateral pelvic LND for cervical cancer (FIGO stages IA1 with LVI to IIA) from 03/2003 to 09/2010 was analyzed. The surgical algorithm we evaluated included the following: 1. SLNs are removed and submitted to ultrastaging; 2. any suspicious LN is removed regardless of mapping; 3. if only unilateral mapping is noted, a contralateral side-specific pelvic LND is performed (including inter-iliac nodes); and 4. parametrectomy en bloc with primary tumor resection is done in all cases. We retrospectively applied the algorithm to determine how it would have performed.

RESULTS

One hundred twenty-two patients were included. Median SLN count was 3 and median total LN count was 20. At least one SLN was identified in 93% of cases (114/122), while optimal (bilateral) mapping was achieved in 75% of cases (91/122). SLN correctly diagnosed 21 of 25 patients with nodal spread. When the algorithm was applied, all patients with LN metastasis were detected; with optimal mapping, bilateral pelvic LND could have been avoided in 75% of cases.

CONCLUSIONS

In the surgical treatment of early cervical cancer, the algorithm we propose allows for comprehensive detection of all patients with nodal disease and spares complete LND in the majority of cases.

Bilateral negative sentinel nodes accurately predict absence of lymph node metastasis in early cervical cancer: results of the SENTICOL study

PURPOSE

Sentinel lymph node (SLN) biopsy may be used to target lymph node metastases in patients with early cervical cancer. Whether SLN biopsy only is acceptable in the staging and surgical management of early cervical cancer remains unknown. This prospective multicenter study (SENTICOL [Ganglion Sentinelle dans le Cancer du Col]) assessed the sensitivity and negative predictive value (NPV) of SLN biopsy.

PATIENTS AND METHODS

Adults with cervical carcinoma who met the International Federation of Gynecology and Obstetrics criteria for stage IA1 with lymphovascular space invasion to stage IB1 underwent technetium 99 lymphoscintigraphy and Patent Blue injection followed by laparoscopic lymph node mapping, SLN removal, and lymph node dissection. Only surgeons trained in SLN biopsy in cervical carcinoma participated in the study. SLNs and nonsentinel lymph nodes underwent routine staining. Negative SLNs were subjected to ultrastaging. The reference method was pelvic and/or para-aortic lymphadenectomy with histologic examination of all nodes.

RESULTS

One hundred forty-five patients were enrolled, and 139 were included in a modified intention-to-diagnose analysis. Intraoperative radioisotope-blue dye mapping detected at least one SLN in 136 patients (97.8%; 95% CI, 93.8% to 99.6%), 23 of whom had true-positive results and two who had false-negative results, yielding 92.0% sensitivity (23 of 25; 95% CI, 74.0% to 99.0%) and 98.2% NPV (111 of 113; 95% CI, 74.0% to 99.0%) for node metastasis detection. No false-negative results were observed in the 104 patients (76.5%) in whom SLN were identified bilaterally.

CONCLUSION

Combined labeling for node mapping was associated with high rates of SLN detection and with high sensitivity and NPV for metastasis detection. However, SLN biopsy was fully reliable only when SLNs were detected bilaterally.

Role of sentinel lymph node biopsy in cervical cancer: pro

Sentinel lymph node biopsy in cervical cancer is used to reduce the morbidity of a full lymph node dissection while improving the pickup rate of metastatic lymph nodes. The higher detection rate achieved can be explained by the following: the identification of the sentinel lymph node in an aberrant location which would not be routinely included in a systematic pelvic lymph node dissection, the sentinel lymph node is completely excised, and the routine use of ultrastaging. The higher detection rate achieved through sentinel lymph node biopsy can identify additional patients who could potentially benefit from adjuvant therapy therefore, in our view the gold standard of lymph node assessment in early stage cervical cancer has shifted and sentinel lymph node biopsy has taken the place of a complete lymphadenectomy.