Sentinel Node Mapping in Cervical and Endometrial Cancer: Indocyanine Green Versus Other Conventional Dyes-A Meta-Analysis

Research progress of indocyanine green fluorescence technology in gynecological applications

Indocyanine green is a near-infrared fluorescent dye which is widely used in various fields of surgery and gynecology. It is currently mainly used to detect various malignant tumors, sentinel lymph nodes, endometriosis lesions, ureter or intestinal occlusion, vaginal perfusion, uterine arterial blood perfusion, pelvic nerve, uterine niche, lymphatic edema, metastatic lesion shadow, and so on, providing new methods for decision-making during surgery. This article elaborates the application progress of indocyanine green fluorescence technology in gynecology.

Comparative study using indocyanine green and patent blue dye for sentinel lymph node biopsy in patients with early-stage cervical cancer

BACKGROUND

Lymphatic involvement is the most important prognostic factor in early-stage cervical cancer. Sentinel lymph node biopsy is a viable alternative to systematic lymphadenectomy and may identify metastases more precisely.

OBJECTIVE

To compare two tracers (indocyanine green and patent blue) to detect sentinel nodes.

METHODS

A single-center, retrospective study of women treated due to early-stage cervical cancer (International Federation of Gynecology and Obstetrics 2009 IA1 with lymphovascular invasion, IA2, and IB1). Location and tracer of all detected sentinel nodes had been documented for a prospective, multicenter trial (SENTIX trial). All sentinel nodes were sent to frozen section and final analysis through ultrastaging using a standard protocol.

RESULTS

Overall, 103 patients were included. Bilateral detection rate for indocyanine green (93.2%) was significantly higher than for blue dye (77.7%; p=0.004). Their combined use significantly increased the bilateral detection to 99.0% (p=0.031). While 97.4% of all sentinel nodes were located below the common iliac vessels, no para-aortic nodes were labeled. Simultaneous bilateral detection with both tracers was found in 71.8% of the cases, of which the sentinel nodes were identical in 91.9%. Nine positive nodes were detected among seven patients (6.8%), all marked with indocyanine green while patent blue labeled six. Frozen section failed to detect one of three macrometastases and three of four micrometastases (sensitivity 43%; negative prediction value 96%).

CONCLUSION

Anatomical distribution and topographic localization of the sentinel nodes obtained with these tracers were not different. Indocyanine green provided a significantly higher bilateral detection rate and had superior sensitivity to detect positive nodes compared with patent blue. Combining indocyanine green and blue dye increased the bilateral detection rate significantly.

A machine learning-based prediction model of pelvic lymph node metastasis in women with early-stage cervical cancer

OBJECTIVE

To develop a novel machine learning-based preoperative prediction model for pelvic lymph node metastasis (PLNM) in early-stage cervical cancer by combining the clinical findings and preoperative computerized tomography (CT) of the whole abdomen and pelvis.

METHODS

Patients diagnosed with International Federation of Gynecology and Obstetrics stage IA2-IIA1 squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma of the cervix who had primary radical surgery with bilateral pelvic lymphadenectomy from January 1, 2003 to December 31, 2020, were included. Seven supervised machine learning algorithms, including logistic regression, random forest, support vector machine, adaptive boosting, gradient boosting, extreme gradient boosting, and category boosting, were used to evaluate the risk of PLNM.

RESULTS

PLNM was found in 199 (23.9%) of 832 patients included. Younger age, larger tumor size, higher stage, no prior conization, tumor appearance, adenosquamous histology, and vaginal metastasis as well as the CT findings of larger tumor size, parametrial metastasis, pelvic lymph node enlargement, and vaginal metastasis, were significantly associated with PLNM. The models' predictive performance, including accuracy (89.1%-90.6%), area under the receiver operating characteristics curve (86.9%-91.0%), sensitivity (77.4%-82.4%), specificity (92.1%-94.3%), positive predictive value (77.0%-81.7%), and negative predictive value (93.0%-94.4%), appeared satisfactory and comparable among all the algorithms. After optimizing the model's decision threshold to enhance the sensitivity to at least 95%, the 'highly sensitive' model was obtained with a 2.5%-4.4% false-negative rate of PLNM prediction.

CONCLUSION

We developed prediction models for PLNM in early-stage cervical cancer with promising prediction performance in our setting. Further external validation in other populations is needed with potential clinical applications.

Current applications of indocyanine green (ICG) in abdominal, gynecologic and urologic surgery: a meta-review and quality analysis with use of the AMSTAR 2 instrument

BACKGROUND

Indocyanine green (ICG) is an injectable fluorochrome that has recently gained popularity as a means of assisting intraoperative visualization during laparoscopic and robotic surgery. Many systematic reviews and meta-analyses have been published. We conducted a meta-review to synthesize the findings of these studies.

METHODS

PubMed and Embase were searched to identify systematic reviews and meta-analyses coping with the uses of ICG in abdominal operations, including Metabolic Bariatric Surgery, Cholecystectomy, Colorectal, Esophageal, Gastric, Hepato-Pancreato-Biliary, Obstetrics and Gynecology (OG), Pediatric Surgery, Surgical Oncology, Urology, (abdominal) Vascular Surgery, Adrenal and Splenic Surgery, and Interdisciplinary tasks, until September 2023. We submitted the retrieved meta-analyses to qualitative analysis based on the AMSTAR 2 instrument.

RESULTS

We identified 116 studies, 41 systematic reviews (SRs) and 75 meta-analyses (MAs), spanning 2013-2023. The most thoroughly investigated (sub)specialties were Colorectal (6 SRs, 25 MAs), OG (9 SRs, 15 MAs), and HPB (4 SRs, 12 MAs). Interestingly, there was high heterogeneity regarding the administered ICG doses, routes, and timing. The use of ICG offered a clear benefit regarding anastomotic leak prevention, particularly after colorectal and esophageal surgery. There was no clear benefit regarding sentinel node detection after OG. According to the AMSTAR 2 tool, most meta-analyses ranked as "critically low" (34.7%) or "low" (58.7%) quality. There were only five meta-analyses (6.7%) that qualified as "moderate" quality, whereas there were no "high" quality reviews.

CONCLUSIONS

Regardless of the abundance of pertinent literature and reviews, surgeons should be cautious when interpreting their results on ICG use in abdominal surgery. Future reviews should focus on ensuring methodological vigor; establishing clear protocols of ICG dose, route of administration, and timing; and improving reporting quality. Other sources of data (e.g., registries) and novel methods of data analysis (e.g., machine learning) might also contribute to an enhanced role of ICG as a decision-making tool in surgery.

Recent management of endometrial cancer: a narrative review of the literature

Endometrial cancer is a common female gynecological neoplasia and its incidence rate has increased in the past years. Due to its predominant symptoms, most women will present uterine bleeding. It is usually diagnosed at an early stage and surgery has an important role in the treatment plan. The prognosis and quality of life of these patients can be quite favorable, if proper treatment is offered by surgeons. Traditionally, more invasive approaches and procedures were offered to these patients, but recent data suggest that more conservative and minimal invasive choices can be adopted in the treatment algorithm. Minimal invasive surgery, such as laparoscopy and robotic surgery, should be considered as an acceptable alternative, compared to laparotomy with less comorbidities and similar oncological and survival outcomes. Furthermore, sentinel lymph node biopsy has emerged in the surgical staging of endometrial cancer, in order to replace comprehensive lymphadenectomy. It is associated with less intra- and postoperative complications, while preliminary data show no difference in survival rates. However, sentinel lymph node biopsy should be offered within a strict algorithm, to avoid residual metastatic disease. The aim of this review is to analyze all the available data for the application of minimal invasive surgery in early endometrial cancer and especially the role of sentinel lymph node biopsy.

Sentinel Lymph Node Staging in Early-Stage Cervical Cancer: A Comprehensive Review

Cervical cancer (CC) continues to be a significant global public health concern, even with preventive measures in place. In women with early-stage CC, the status of lymph nodes is of paramount importance, not only for the final prognosis but also for determining the best therapeutic strategy. According to main international guidelines, pelvic full lymphadenectomy (PLND) is recommended for lymph node staging. However, in these early stages of CC, sentinel lymph node biopsy (SLNB) has emerged as a precise technique for evaluating lymph node involvement, improving its morbidity profile. We performed a literature review through PubMed articles about progress on the application of SLNB in women with early-stage CC focusing on the comparison with PET/CT and PLND in terms of oncological outcomes and diagnostic accuracy. While the superiority of SLNB is clear compared to radiologic modalities, it demonstrates no clear oncologic inferiority over PLND, given the higher detection rate of positive lymph nodes and predominance of no lymph node recurrences. However, due to a lack of prospective evidence, particularly concerning long-term oncological safety, SLNB is not the current gold standard. With careful patient selection and adherence to straightforward protocols, a low false-negative rate can be ensured. The aim of the ongoing prospective trials is to address these issues.

Biomimetic nanoplatform with selectively positioned indocyanine green for accurate sentinel lymph node imaging

The status of draining lymph nodes (LNs) is critical for determining the treatment and prognosis of cancer that spreads through the lymphatic system. Indocyanine green (ICG) fluorescence imaging has been widely used in sentinel LN (SLN) biopsy technology and has shown favorable effects. However, this too has its own limitations, such as fluorescence instability and diffusion imaging. In this study, we developed macrophage cell membrane-camouflaged ICG-loaded biomimetic nanoparticles (M@F127-ICG) for accurate SLN imaging. ICG selectively positioned at the hydrophobic-hydrophilic interfaces of pluronic F127 micelles protected itself from quenching in aqueous solution, thereby maintaining fluorescence stability and improving fluorescence intensity. In addition, to further improve the aggregation in SLN, the micellar surface was coated with a layer of biomimetic macrophage cell membrane to target LN-resident macrophages. In vivo fluorescence imaging demonstrated that M@F127-ICG significantly enhanced the fluorescence signal and improved the imaging efficiency of SLN. Thus, selectively positioning ICG in the biomimetic nanoplatform enhanced the fluorescence intensity and stability, providing a novel tracer for timely and accurate SLN imaging.

A Fluorescent and Magnetic Hybrid Tracer for Improved Sentinel Lymphadenectomy in Prostate Cancer Patients

In prostate cancer, sentinel lymph node dissection (sLND) offers a personalized procedure with staging ability which is at least equivalent to extended LND while inducing lower morbidity. A bimodal fluorescent-radioactive approach was introduced to improve sentinel LN (SLN) detection. We present the first in-human case series on exploring the use of a fluorescent-magnetic hybrid tracer in a radiation-free sLND procedure. Superparamagnetic iron oxide nanoparticles and indocyanine green were administered simultaneously in five prostate cancer patients scheduled for extended LND, sLND and radical prostatectomy. In situ and ex vivo fluorescence and magnetic signals were documented for each LN sample detected via a laparoscopic fluorescence imaging and magnetometer system. Fluorescence and magnetic activity could be detected in all patients. Overall, 19 lymph node spots could be detected in situ, 14 of which were fluorescently active and 18 of which were magnetically active. In two patients, no fluorescent LNs could be detected in situ. The separation of the LN samples resulted in a total number of 30 SLNs resected. Ex vivo measurements confirmed fluorescence in all but two magnetically active SLNs. One LN detected in situ with both modalities was subsequently shown to contain a metastasis. This study provides the first promising results of a bimodal, radiation-free sLND, combining the advantages of both the magnetic and fluorescence approaches.

Hysteroscopic endometrial tumor localization and sentinel lymph node mapping. An upgrade of the hysteroscopic role in endometrial cancer patients

INTRODUCTION

Given the growing interest in sentinel node mapping (SLN) biopsy in Endometrial Cancer (EC) patients, many efforts have been made to maximize the SLN bilateral detection rate. However, at present, no previous research assessed the potential correlation between primary EC location in the uterine cavity and SLN mapping. In this context, this study aims to investigate the possible role of intrauterine EC hysteroscopic localization in predicting SLN nodal placement.

MATERIALS AND METHODS

EC patients surgically treated from January 2017 to December 2021 were retrospectively analyzed. All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and SLN mapping. During hysteroscopy, the location of the neoplastic lesion was described as follows: uterine fundus (comprising the most cranial portion of the uterine cavity up to the tubal ostium including the cornual areas), corpus uteri (from the tubal ostium to the inner uterine orifice), and diffuse (when the tumor invades more than 50% of the uterine cavity).

RESULTS

Three hundred ninety patients met the inclusion criteria. The tumor pattern diffused to the whole uterine cavity was statistically associated with SLN uptake on common iliac lymph nodes (OR 2.4, 95%CI 1-5.8, p = 0.05). Patients'age is an independent factor associated with SLN failure (OR: 0.95, 95%CI 0.93-0.98, p < 0.001).

CONCLUSIONS

The study showed a statistically significant association between EC hysteroscopically spread throughout the whole uterine cavity and SLN uptake at the common iliac lymph nodes. Furthermore, patient age negatively affected the SLN detection rate.

Emerging Treatment Options for Cervical Dysplasia and Early Cervical Cancer

DISCUSSION

of treatment strategies for cervical cancer precursors, review of medical therapies and emerging therapeutics for treatment of cervical cancers, and updates on new approaches to treating early-stage cervical cancers.

Robotic para-aortic sentinel lymph node mapping in endometrial, cervical, and ovarian cancer

The concept of pelvic sentinel lymph node mapping has been well-investigated in endometrial and cervical cancer. A variety of tracers have been used including blue dye, technetium-99-m (Tc-99 m), and fluorescent tracer indocyanine green. Pelvic sentinel lymph node mapping has shown its safety, efficacy, and diagnostic accuracy, with high sensitivity and negative predictive value of more than 90%, in retrospective cohort studies as well as in prospective trials for robotic surgery. The concept of pelvic sentinel lymph node biopsy has been incorporated in several international guidelines in early-stage endometrial cancer and a subgroup of early-stage cervical cancer, although survival data are still needed to confirm its standard use. The application of para-aortic sentinel lymph node mapping is still in a development phase, but its detection rate and diagnostic accuracy seem to be promising in initial studies. Here, an overview is given of the recent developments in the different methodologies used for identifying para-aortic sentinel lymph nodes in endometrial, cervical, and ovarian cancer.

The lymphatic system of the uterine cervix: towards a more precise definition of the drainage routes

PURPOSE

Lymph node involvement in cancer of the uterine cervix is a major independent prognostic factor for overall survival. The aim of our study was to examine the lymphatic drainage regions of the different parts of the uterine cervix.

METHODS

An anatomical study of fresh cadavers was conducted by injecting patent blue in the anterior or posterior lip of the uterine cervix and dissecting drainage regions. Furthermore, a retrospective radiological and pathological studies were conducted on patients who were treated for early-stage cancer of the uterine cervix with lymph node involvement. Radiological analysis of pre-therapeutic MRIs and/or pathological analysis of surgical specimens showed the precise location of the tumour. A correlation between the anatomy of the primary lesion site and the lymphatic area involved was established.

RESULTS

We administered 15 cadaveric injections: 8 in the anterior lip of the uterine cervix and 7 in the posterior one. For 100% of the anterior lip injections, lymphatic drainage was bilateral ileo-obturator (n = 8/8) combined with bilateral parametrial drainage. For the posterior injections, there was never any ileo-obturator drainage, and 6 of the 7 (75%) posterior injections drained in the posterior uterine serosa. Concerning the clinical study, we included 21 patients. We observed a non-significant tendency towards bilateral lymph node involvement when the tumour of the anterior lip.

CONCLUSION

Physiological lymphatic drainage of the uterine cervix presents anatomical specificities, depending on the structure studied, anterior or posterior lip of the cervix. Better knowledge of these specificities should allow personalized surgery for each patient.

Blue dye single labelling for colorimetric sentinel lymph node mapping in early endometrial cancer: A feasibility study

Background

Surgical staging in endometrial cancer includes a systematic lymphadenectomy with significant morbidity, although its therapeutic role is unclear. Sentinel lymph node (SLN) study is a less morbid alternative to identify nodes most likely to be metastatic, permitting selective removal and thus reducing morbidity without compromising oncological safety. This study was done using blue dye single labelling to study the feasibility and utility in identifying SLN in early disease.

Methods

Twenty-two patients of early-stage low-risk disease during surgical staging underwent cervical injection of methylene blue, SLN mapping, and sampling as per the standard algorithm, followed by a systematic lymphadenectomy in all cases. SLN were submitted separately for ultrastaging (US).

Results

Twenty patients underwent the procedure, and SLN could be identified in 18 patients with an overall mapping rate of 90% with a bilateral mapping rate of 70%, and a negative mapping rate of 10%. 57 SLN were identified along with two suspicious non-sentinel nodes and 11 were metastatic on US with a sensitivity of 66.7% and NPV of 87.5%. All patients with metastatic nodes, however, could be identified by applying the standard SLN algorithm for sampling.

Conclusion

SLN mapping algorithm with blue dye single labelling in early endometrial cancer, by identifying LN most likely to be metastatic enabling their selective removal may help avoid routine lymphadenectomies without compromising oncological safety. The procedure is simple and can be practiced at all centres and can also aid pathologists by pinpointing the likely metastatic nodes after a selective or complete lymphadenectomy.

Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology

Adenocarcinoma of the endometrium (also known as endometrial cancer, or more broadly as uterine cancer or carcinoma of the uterine corpus) is the most common malignancy of the female genital tract in the United States. It is estimated that 65,950 new uterine cancer cases will have occurred in 2022, with 12,550 deaths resulting from the disease. Endometrial carcinoma includes pure endometrioid cancer and carcinomas with high-risk endometrial histology (including uterine serous carcinoma, clear cell carcinoma, carcinosarcoma [also known as malignant mixed Müllerian tumor], and undifferentiated/dedifferentiated carcinoma). Stromal or mesenchymal sarcomas are uncommon subtypes accounting for approximately 3% of all uterine cancers. This selection from the NCCN Guidelines for Uterine Neoplasms focuses on the diagnosis, staging, and management of pure endometrioid carcinoma. The complete version of the NCCN Guidelines for Uterine Neoplasms is available online at NCCN.org.

Personalized Sentinel Node Mapping in Endometrial Cancer by the Indocyanine Green Implementation as Single Tracer: A Case Control Study

The main objective was to analyze the rate of bilateral sentinel lymph node (SLN) detection in endometrial cancer using indocyanine green (ICG) as a unique tracer compared to Technetium99 + ICG. As secondary objectives, we analyzed the drainage pattern and factors that might affect the oncological outcomes. A case-control ambispective study was carried out on consecutive patients at our center. Data on the SLN biopsy with ICG collected prospectively were compared to retrospective data on the use of a double-tracer technique including Technetium99 + ICG. In total, 194 patients were enrolled and assigned to both groups, in which the group with both tracers (controls) included 107 (54.9%) patients and the ICG-alone group (cases) included 87 (45.1%) patients. The rate of bilateral drainage was significantly higher in the ICG group (98.9% vs. 89.7%; p = 0.013). The median number of nodes retrieved was higher in the control group (three vs. two nodes; p < 0.01). We did not find survival differences associated with the tracer used (p = 0.85). We showed significant differences in terms of disease-free survival regarding the SLN location (p < 0.01), and obturator fossa retrieved nodes showed better prognosis compared to external iliac. The use of ICG as a single tracer for SLN detection in endometrial cancer patients seemed to obtain higher rates of bilateral detection with similar oncological outcomes.

Albumin-based nanoparticle for dual-modality imaging of the lymphatic system

The lymphatic system is a complex network of lymphatic vessels, lymph nodes, and lymphoid organs. The current understanding of the basic mechanism and framework of the lymphatic system is relatively limited and not ideal for exploring the function of the lymphatic system, diagnosing lymphatic system diseases, and controlling tumor metastasis. Imaging modalities for evaluating lymphatic system diseases mainly include lymphatic angiography, reactive dye lymphatic angiography, radionuclide lymphatic angiography, computed tomography, and ultrasonography. However, these are insufficient for clinical diagnosis. Some novel imaging methods, such as magnetic resonance imaging, positron emission computed tomography, single-photon emission computed tomography, contrast-enhanced ultrasonography, and near-infrared imaging with agents such as cyanine dyes, can reveal lymphatic system information more accurately and in detail. We fabricated an albumin-based fluorescent probe for dual-modality imaging of the lymphatic system. A near-infrared cyanine dye, IR-780, was absorbed into bovine serum albumin (BSA), which was covalently linked to a molecule of diethylenetriaminepentaacetic acid to chelate gadolinium Gd3+. The fabricated IR-780@BSA@Gd3+ nanocomposite demonstrates strong fluorescence and high near-infrared absorption and can be used as a T1 contrast agent for magnetic resonance imaging. In vivo dual-modality fluorescence and magnetic resonance imaging showed that IR-780@BSA@Gd3+ rapidly returned to the heart through the lymphatic circulation after it was injected into the toe webs of mice, facilitating good lymphatic imaging. The successful fabrication of the new IR-780@BSA@Gd3+ nanocomposite will facilitate the study of the mechanism and morphological structure of the lymphatic system.

Applications and Safety of Sentinel Lymph Node Biopsy in Endometrial Cancer

Lymph node status is important in predicting the prognosis and guiding adjuvant treatment in endometrial cancer. However, previous studies showed that systematic lymphadenectomy conferred no therapeutic values in clinically early-stage endometrial cancer but might lead to substantial morbidity and impact on the quality of life of the patients. The sentinel lymph node is the first lymph node that tumor cells drain to, and sentinel lymph node biopsy has emerged as an acceptable alternative to full lymphadenectomy in both low-risk and high-risk endometrial cancer. Evidence has demonstrated a high detection rate, sensitivity and negative predictive value of sentinel lymph node biopsy. It can also reduce surgical morbidity and improve the detection of lymph node metastases compared with systematic lymphadenectomy. This review summarizes the current techniques of sentinel lymph node mapping, the applications and oncological outcomes of sentinel lymph node biopsy in low-risk and high-risk endometrial cancer, and the management of isolated tumor cells in sentinel lymph nodes. We also illustrate a revised sentinel lymph node biopsy algorithm and advocate to repeat the tracer injection and explore the presacral and paraaortic areas if sentinel lymph nodes are not found in the hemipelvis.

Fluorescent Indocyanine Green versus Technetium-99m and Blue Dye for Bilateral SENTinel Lymph Node Detection in Stage I-IIA Cervical Cancer (FluoreSENT): protocol for a non-inferiority study

INTRODUCTION

Nowadays, two predominant methods for detecting sentinel lymph nodes (SLNs) in cervical cancer are in use. The most conventional method is a combination of a radiotracer, technetium-99m (^99mTc) and blue dye. More recently, another method for SLN mapping using indocyanine green (ICG) is becoming widely accepted. ICG is a fluorescent dye, visualised intraoperatively with near-infrared (NIR) fluorescence imaging, providing real-time visual navigation. The presumed advantages of ICG over ^99mTc, that is, being cheaper, non-radioactive and logistically more attractive, are only valuable if its detection rate proves to be at least non-inferior. Before omitting the well-functioning and evidence-based combined approach of ^99mTc and blue dye, we aim to provide prospective evidence on the non-inferiority of ICG with NIR fluorescence imaging.

METHODS AND ANALYSIS

We initiated a prospective non-inferiority study with a paired comparison of both SLN methods in a single sample of 101 patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA-IB2 or IIA1 cervical cancer receiving primary surgical treatment. All patients undergo SLN mapping with ICG and NIR fluorescence imaging in adjunct to mapping with ^99mTc (including single photon emission computed tomography with X-ray computed tomography (SPECT/CT)) and blue dye. Surgeons start SLN detection with ICG while being blinded for the preoperative outcome of SPECT/CT to avoid biased detection with ICG. Primary endpoint of this study is bilateral SLN detection rate of both methods (ie, detection of at least one SLN in each hemipelvis). Since we compare strategies for SLN mapping that are already applied in current daily practice for different types of cancer, no additional risks or burdens are expected from these study procedures.

ETHICS AND DISSEMINATION

The current study is approved by the Medical Ethics Research Committee Utrecht (reference number 21-014). Findings arising from this study will be disseminated in peer-reviewed journals, academic conferences and through patient organisations.

TRIAL REGISTRATION NUMBER

NL9011 and EudraCT 2020-005134-15.

Management of Early-Stage Vulvar Cancer

Simple Summary

Vulvar cancer is a rare gynecological malignancy that affects mainly postmenopausal women. Recently, however, an alarming increase in the rates among young women has been observed due to human papillomavirus infection. The standard treatment for vulvar cancer is surgery with or without radiotherapy as adjuvant treatment. In recent decades, sentinel lymph node biopsy has been included as part of the surgical treatment. Thus, our objective was to review and discuss the advances found in the literature about early-stage vulvar cancer. For this, we searched PubMed for publications in the English language. Relevant articles, such as the GROINS-V studies, and the GOG protocols, are presented in this review exhibiting the evolution of early-stage vulvar cancer treatment and the decrease in surgical morbidity rates.

Abstract

Vulvar cancer is a rare gynecological malignancy since it represents 4% of all cancers of the female genital tract. The most common histological type is squamous cell carcinoma (90%). This type can be classified into two clinicopathological subtypes according to the etiology. The first subtype is associated with persistent human papillomavirus infection and is usually diagnosed in younger women. The second subtype is associated with lichen sclerosus condition, and in most cases is diagnosed in postmenopausal women. Currently, an increase in first subtype cases has been observed, which raised the concern about associated mortality and treatment morbidity among young women. Vulvar cancer treatment depends on histopathology grade and staging, but surgery with or without radiotherapy as adjuvant treatment is considered the gold standard. In recent decades, sentinel lymph node biopsy has been incorporated as part of the treatment. Therefore, we sought to review and discuss the advances documented in the literature about vulvar cancer focusing on the treatment of early-stage disease. Relevant articles, such as the GROINS-V studies and the GOG protocols, are presented in this review. Additionally, we discuss key points such as the evolution of treatment from invasive surgery with high morbidity, to more conservative approaches without compromising oncologic safety; the role of sentinel lymph node mapping in the initial staging, since it reduces the complications caused by inguinofemoral lymphadenectomy; the recurrences rates, since local recurrence is common and curable, however, groin-associated, or distant recurrences have a poor prognosis; and, finally, the long-term follow-up that is essential for all patients.

Sentinel Lymph Node Biopsy in Endometrial Cancer - A Systematic Review and Quality Assessment of Meta-Analyses

OBJECTIVE

 To assess the quality of recent meta-analyses reviewing the diagnostic utility of sentinel node biopsy in endometrial cancer.

METHODS

 With the MeSH terms endometrial neoplasms and sentinel lymph node biopsy, PubMed and Embase databases were searched on October 21, 2020, and again on November 10, 2021, with meta-analysis and publication date filters set to since 2015. The articles included were classified with the A Measurement Tool to Assess Systematic Reviews (AMSTAR 2) assessment tool.

RESULTS

 The database searches found 17, 7 of which, after the screening, were selected for full review by the author, finally extracting six meta-analyzes for quality analysis. The rating with the AMSTAR 2 assessment tool found that overall confidence in their results was critically low.

CONCLUSION

 This study found that the quality of recent meta-analyses on the utility of the staging of endometrial cancer with sentinel node biopsy, evaluated by the AMSTAR 2 assessment tool, is classified as critically low, and, therefore, these meta-analyses are not reliable in the summary of their studies.

The added value of SLN mapping with indocyanine green in low- and intermediate-risk endometrial cancer management: a systematic review and meta-analysis

OBJECTIVE

The aim of this study was to assess the SLN detection rate in presumed early stage, low- and intermediate-risk endometrial cancers, the incidence of SLN metastases, and the negative predictive value of SLN mapping performed with indocyanine green (ICG).

METHODS

A systematic review with meta-analyses was conducted. Study inclusion criteria were A) low- and intermediate-risk endometrial cancer, B) the use of ICG per cervical injection; C) a minimum of twenty included patients per study. To assess the negative predictive value of SLN mapping, D) a subsequent lymphadenectomy was an additional inclusion criterion.

RESULTS

Fourteen studies were selected, involving 2,117 patients. The overall and bilateral SLN detection rates were 95.6% (95% confidence interval [CI]=92.4%-97.9%) and 76.5% (95% CI=68.1%-84.0%), respectively. The incidence of SLN metastases was 9.6% (95% CI=5.1%-15.2%) in patients with grade 1-2 endometrial cancer and 11.8% (95% CI=8.1%-16.1%) in patients with grade 1-3 endometrial cancer. The negative predictive value of SLN mapping was 100% (95% CI=98.8%-100%) in studies that included grade 1-2 endometrial cancer and 99.2% (95% CI=97.9%-99.9%) in studies that also included grade 3.

CONCLUSION

SLN mapping with ICG is feasible with a high detection rate and negative predictive value in low- and intermediate-risk endometrial cancers. Given the incidence of SLN metastases is approximately 10% in those patients, SLN mapping may lead to stage shifting with potential therapeutic consequences. Given the high negative predictive value with SLN mapping, routine lymphadenectomy should be omitted in low- and intermediate-risk endometrial cancer.

Feasibility of a drop-in γ-probe for radioguided sentinel lymph detection in early-stage cervical cancer

Background

Minimally invasive radioguided sentinel lymph node (SLN) procedures, increasingly performed with robot-assisted laparoscopy, can benefit from using a drop-in γ-probe instead of the conventional rigid laparoscopic γ-probe. We evaluated the safety and feasibility of a tethered drop-in γ-probe system for SLN detection in patients with early-stage cervical cancer.

Methods

Ten patients with FIGO stage IA – IB2 or IIA1 cervical cancer scheduled for robot-assisted laparoscopic SLN procedure were included. All patients underwent preoperative 240 MBq technetium-99m nanocolloid (^99mTc) injection and SPECT/CT imaging. Intraoperatively the tethered drop-in γ-probe SENSEI® (Lightpoint Medical Ltd, Chesham, UK) was used for probe guided SLN detection, subsequently confirmed by the standard rigid laparoscopic γ-probe. Sentinel lymph node detection rates and anatomical SLN location were assessed. Surgeon questionnaires were used to assess usability.

Results

In all patients at least one SLN was successfully resected under guidance of the drop-in γ-probe (overall detection rate: 100%). Bilateral SLN detection rate with the drop-in γ-probe was 80%. Of the two patients with unilateral SLN detection only, one presented with an atypical SLN location at the aortic bifurcation that was detected only on SPECT/CT. The other patient had failed unilateral ^99mTc uptake. Combined use of preoperative SPECT/CT and drop-in γ-probe resulted in a bilateral detection rate of 90%. Similar to the drop-in γ-probe, overall and bilateral SLN detection rate of the rigid γ-probe was 100% and 80%, respectively. No significant discrepancy existed between the count rate of the drop-in and rigid laparoscopic γ-probe (p = 0.69). In total 21 SLN’s were detected with the drop-in γ-probes including all three tumor positive nodes. Because of wristed articulation of the robotic tissue grasper and possibility of autonomous probe control by the surgeon, maneuverability and control with the drop-in γ-probe were highly rated in surgeon questionnaires. No adverse events related to the intervention occurred.

Conclusions

Sentinel lymph node detection with a drop-in γ-probe is safe and feasible in patients with early-stage cervical cancer. Use of the drop-in γ-probe enhances maneuverability and surgical autonomy during robot-assisted SLN detection.

Trial registration Netherlands Trial Registry, NL9358. Registered 23 March 2021, https://www.trialregister.nl/trial/9358.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13550-022-00907-w.

Comparison of Different Near-Infrared Technologies to Detect Sentinel Lymph Node in Uterine Cancer: A Prospective Comparative Cohort Study

OBJECTIVES

Sentinel lymph node biopsy is considered a crucial step in endometrial cancer staging. Cervical injection has become the most favored technique and indocyanine green has been demonstrated to be more accurate than other tracers. Different near-infrared camera systems are currently being used to detect indocyanine green in sentinel lymph nodes and have been compared in different patients. The present study aimed to determine the number and site of sentinel lymph nodes detected in the same patients with two different near-infrared technologies.

METHODS

This is a prospective, single-center, observational, non-sponsored study. Patients with presumed uterine-confined endometrial cancer were prospectively enrolled. After cervical injection, two different near-infrared cameras were used to detect sentinel lymph nodes at the same time: Olympus, Tokyo, Japan-considered the standard (SNIR); and Medtronic, Minneapolis, MN, USA with VISION SENSE^® which is a new laser near-infrared (LNIR) fluorescence laparoscope. The two cameras were alternatively switched on to detect sentinel lymph nodes in the same patients.

RESULTS

Seventy-four consecutive patients were included in the study. Most of the patients were diagnosed with endometrioid histology (62, 83.8%), FIGO stage IA (48, 64.9%), grade 2 (43, 58.1%), and underwent surgery with laparoscopic approach (70, 94.0%). The bilateral detection rate was 56/74 (75.7%) with SNIR and 63/74 (85.1%) with LNIR (p = 0.214). The total number of sentinel lymph nodes identified in the left hemipelvis was 65 and 70 with SNIR and LNIR, respectively; while in the right hemipelvis, there were 74 and 76, respectively. The median number of sentinel lymph nodes identified with SNIR and LNIR was 2 (range, 0-4) and 2 (range, 0-4), respectively (p = 0.370). No difference in site of sentinel lymph node detection was evident between the two technologies (p = 0.994). Twelve patients (16.2%) had sentinel lymph node metastasis: in all cases metastatic sentinel lymph nodes were detected both with Olympus and LNIR.

CONCLUSIONS

No difference in bilateral detection rate and number or site of sentinel lymph node detection was evident comparing two different technologies of near-infrared camera for ICG detection in endometrial cancer patients. No difference in sentinel lymph node metastases identification was detected between the two technologies.

Lymph Node Mapping for Tumor Micrometastasis

Lymph node mapping for tumor micrometastasis is of great significance for the prevention, prognosis, and treatment of cancer. Currently, the traditional clinical detection methods (computed tomography, magnetic resonance imaging, or positron emission tomography/computed tomography) in clinical lymph node mapping still have some inherent disadvantages, which have prompted the development of various fluorescent probes for lymph node mapping. However, the conventional fluorescent probes such as indocyanine green or methylene blue in lymph node mapping are still accompanied by several problems such as impaired surgical field vision due to dye staining or less accumulation and shorter retention time in the lymph node. In a recent achievement, newly designed nanoparticles are prepared with novel properties that could be attractive for lymph node mapping. In this review, we will provide details on the progress of various nanoparticles for lymph node mapping and emphasize other multivariant properties in different nanoparticles, including strong tumor-targeting affinity and specificity, self-luminescence, and even with the function to kill metastatic cancer cells.

Identification and Biopsy of Sentinel Lymph Node in Early-Stage Cervical Carcinoma: Diagnostic Accuracy and Clinical Utility

Background Due to the subsequent complications of pelvic lymphadenectomy in patients with early-stage cervical cancer, the sentinel lymph node (SLN) technique has been increasingly employed. This study aimed to investigate the detectability of SLN using methylene blue and explore the diagnostic accuracy of SLN biopsy. Methodology A study was conducted from September 2015 to August 2018 and included 90 women with cervical cancer, FIGO (International Federation of Gynecology and Obstetrics-2009) stage IA1-IIA1. Methylene blue was injected intracervically. Any detected dyed nodes were sent for frozen section biopsy, followed by bilateral pelvic lymphadenectomy. The predictive ability of SLN was evaluated in statistical terms after comparison of intraoperative biopsy and final histopathology. Results The sensitivity, specificity, false-negative rate, positive predictive value, and negative predictive value (NPV) were 55.6%, 95.1%, 4.9%, 55.6%, and 95.1%, respectively. The SLN performance in patients with tumor size ≤2.2 cm, negative lymphovascular space involvement, and depth of stromal invasion ≤5 mm was superior (sensitivity 100%, specificity 93.5%, NPV 100%). Conclusions The SLN technique with blue dye alone is a feasible and adequate alternative to systematic lymphadenectomy in early-stage cervical cancer in selected patients, given that a strict algorithm is applied.

Sentinel Lymph Node Biopsy in Surgical Staging for High-Risk Groups of Endometrial Carcinoma Patients

BACKGROUND

In endometrial carcinoma (EC) patients, sentinel lymph node (SLN) biopsy has shown the potential to reduce post-operative morbidity and long-term complications, and to improve the detection of low-volume metastasis through ultrastaging. However, while it has shown high sensitivity and feasibility in low-risk EC patient groups, its role in high-risk groups is still unclear.

AIM

To assess the role of SLN biopsy through the cervical injection of indocyanine green (ICG) in high-risk groups of early-stage EC patients.

MATERIALS AND METHODS

Seven electronic databases were searched from their inception to February 2021 for studies that allowed data extraction about detection rate and accuracy of SLN biopsy through the cervical injection of ICG in high-risk groups of early-stage EC patients. We calculated pooled sensitivity, false negative (FN) rate, detection rate of SLN per hemipelvis (DRh), detection rate of SLN per patients (DRp), and bilateral detection rate of SLN (DRb), with 95% confidence interval (CI).

RESULTS

Five observational cohort studies (three prospective and two retrospective) assessing 578 high risk EC patients were included. SLN biopsy sensitivity in detecting EC metastasis was 0.90 (95% CI: 0.03-0.95). FN rate was 2.8% (95% CI: 0.6-11.6%). DRh was 88.4% (95% CI: 86-90.5%), DRp was 96.6% (95% CI: 94.7-97.8%), and DRb was 80% (95% CI: 75.4-83.9).

CONCLUSION

SLN biopsy through ICG cervical injection may be routinely adopted instead of systematic pelvic and para-aortic lymphadenectomy in surgical staging for high-risk groups of early-stage EC patients, as well as in low-risk groups.

Sentinel Lymph Node Biopsy in Endometrial Cancer: Dual Injection, Dual Tracer—A Multidisciplinary Exhaustive Approach to Nodal Staging

Simple Summary

Since clinical guidelines accepted the utilization of sentinel lymph node (SLN) in apparent uterine-confined endometrial cancer (EC), many centers have already used it as a standard staging surgery. The most widely accepted tracer is ICG alone, but several studies comment on the importance of surgeon experience in order not to lose sensitivity in the first 30-40 cases. This is a prospective, observational single-center trial designed to improve SLN detection rate specially during learning curve. The application of dual tracer (indocyanine green (ICG) and Technetium99 (Tc99) injected separately) helps us to reach a very good overall and bilateral SLN pelvic detection rate in early-stage endometrial cancer patients. Dual injection (cervical and fundal) improves para-aortic SLN detection rate.

Abstract

Introduction: Sentinel lymph node (SLN) has recently been introduced as a standard staging technique in endometrial cancer (EC). There are some issues regarding team experience and para-aortic detection. Objective: to report the accuracy of SLN detection in EC with a dual tracer (ICG and Tc99) and dual injection site (cervix and fundus) during the learning curve. Methods: A prospective, observational single-center trial including 48 patients diagnosed with early-stage EC. Dual intracervical tracer (Tc99 and ICG) was injected at different times. High-risk patients had a second fundus injection with both tracers. Results: the detection rates were as follows: 100% (48/48) overall for SLNs; 98% (47/48) overall for pelvic SLNs; 89.5% (43/48) for bilateral SLNs; and 2% (1/48) for isolated para-aortic SLNs. In high-risk patients, the para-aortic overall DR was 66.7% (22/33); 60.7% (17/28) with ICG and 51.5% (17/33) with Tc99 (p = 0.048)). Overall rate of lymph node involvement was 14.6% (7/48). Macroscopic pelvic metastasis was found in four patients (8.3%) and microscopic in one case (2%). No metastasis was found in any para-aortic SLNs. Half of the patients with positive pelvic SLNs had positive para-aortic nodes. In high-risk patients, when para-aortic SLNs mapped failed, 36.4% (4/11) had positive nodes in para-aortic lymphadenectomy. The sensitivity and negative predictive value (NPV) of SLN pelvic detection was 100%. Conclusions: Multidisciplinary exhaustive approach gives a suitable accuracy of SLN during learning curve. Dual injection (cervical and fundal) with dual tracer (ICG and Tc99) offers good overall detection rates and increases para-aortic SLN detection.

Diagnosis, Therapy and Follow-up of Cervical Cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF Registry No. 032/033OL, May 2021) – Part 1 with Recommendations on Epidemiology, Screening, Diagnostics and Therapy

Aim This update of the interdisciplinary S3 guideline on the Diagnosis, Therapy and Follow-up of Cervical Cancer (AWMF Registry No. 032/033OL) was published in March 2021. This updated guideline was funded by German Cancer Aid (Deutsche Krebshilfe) as part of the German Guideline Program in Oncology. The guideline was coordinated by the German Society of Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and the Working Group on Gynecological Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie, AGO) of the German Cancer Society (Deutsche Krebsgesellschaft, DKG).

Method The process of updating the S3 guideline dating from 2014 was based on an appraisal of the available evidence using the criteria of evidence-based medicine, adaptations of existing evidence-based national and international guidelines or – if evidence was lacking – on a consensus of the specialists involved in compiling the update. After an initial review of the current literature was carried out according to a prescribed algorithm, several areas were identified which, in contrast to the predecessor version from September 2014, required new recommendations or statements which took account of more recently published literature and the appraisal of the new evidence.

Recommendations The short version of this guideline consists of recommendations and statements on the epidemiology, screening, diagnostic workup and therapy of patients with cervical cancer. The most important new aspects included in this updated guideline include the newly published FIGO classification of 2018, the radical open surgery approach for cervical cancers up to FIGO stage IB1, and use of the sentinel lymph node technique for tumors ≤ 2 cm. Other changes include the use of PET-CT, new options in radiotherapy (e.g., intensity-modulated radiotherapy, image-guided adaptive brachytherapy), and drug therapies to treat recurrence or metastasis.

Diagnostic accuracy of sentinel node biopsy in non-endometrioid, high-grade and/or deep myoinvasive endometrial cancer: A Turkish gynecologic oncology group study (TRSGO-SLN-006)

INTRODUCTION

This study aimed to evaluate the diagnostic accuracy of the sentinel lymph node (SLN) mapping algorithm in high-risk endometrial cancer patients.

METHODS

Two hundred forty-four patients with non-endometrioid histology, grade 3 endometrioid tumors and/or tumors with deep myometrial invasion were enrolled in this retrospective, multicentric study. After removal of SLNs, all patients underwent pelvic ± paraaortic lymphadenectomy. Operations were performed via laparotomy, laparoscopy or robotic surgery. Indocyanine green (ICG) and methylene blue (MB) were used as tracers. SLN detection rate, sensitivity, negative predictive value (NPV) and false-negative rate (FNR) were calculated.

RESULTS

Surgeries were performed via laparotomy in 132 (54.1%) patients and 152 (62.3%) underwent both bilateral pelvic and paraaortic lymphadenectomy. At least 1 SLN was detected in 222 (91%) patients. Fifty-five (22.5%) patients had lymphatic metastasis and 45 patients had at least 1 metastatic SLN. Lymphatic metastases were detected by side-specific lymphadenectomy in 8 patients and 2 patients had isolated paraaortic metastasis. Overall sensitivity, NPV and FNR of SLN biopsy were 81.8%, 95% and 18.2%, respectively. By applying SLN algorithm steps, sensitivity and NPV improved to 96.4% and 98.9%, respectively. For grade 3 tumors, sensitivity, NPV and FNR of the SLN algorithm were 97.1%, 98.9% and 2.9%.

CONCLUSION

SLN algorithm had high diagnostic accuracy in high-risk endometrial cancer. All pelvic metastases were detected by the SLN algorithm and the isolated paraaortic metastasis rate was ignorable. But long-term survival studies are necessary before this approach becomes standard of care.

Detection of the sentinel lymph node with hybrid tracer (ICG-[99mTc]Tc-albumin nanocolloid) in intermediate- and high-risk endometrial cancer: a feasibility study

PURPOSE

Indocyanine green (ICG) is frequently used for the detection of the sentinel lymph node (SLN) in gynecology, but it carries the loss of the presurgical SLN mapping provided by [^99mTc]-based colloids. Hybrid tracers such as ICG-[^99mTc]Tc-albumin nanocolloid combine the benefits of both components. The aim of this study was to evaluate the feasibility and applicability of this hybrid tracer injected by transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR) approach in the detection of SLNs in patients with intermediate- and high-risk EC.

METHODS

Fifty-two patients with intermediate- and high-risk EC underwent SLN biopsy after injection of a hybrid tracer using the TUMIR approach, followed by pelvic and paraaortic lymphadenectomy. SLNs were detected preoperatively by lymphoscintigraphic study and intraoperatively by gamma probe and near-infrared (NIR) optical laparoscopic camera.

RESULTS

Preoperative lymphatic drainage was obtained in 69% and intraoperative detection in 71.4% of patients. A total of 146 SLNs (4.17 SLNs/patient) were biopsied. Pelvic bilateral detection was observed in 57% of the women and paraaortic drainage in 34% of the patients. The radioactive component allowed the detection of SLN in 97.1% of the patients, while the fluorescent component detected 80%. In more than 17% of the patients with intraoperative detection, SLNs were detected only by the radioactive signal. Lymph node metastasis was identified in 14.3% of patients submitted to SLNB. The sensitivity and negative predictive value for metastatic involvement were 100%.

CONCLUSION

TUMIR injection of a hybrid tracer in patients with intermediate- and high-risk EC combines the benefits of the radiotracer and the fluorescence methods with a single tracer. The method increases the paraaortic detection rate and allows a potential increase in SLN detection. Notwithstanding, based on our findings, the radioactive component of the hybrid tracer cannot be obviated.

Clinical Study of Sentinel Lymph Node Detection Using Photodynamic Eye for Abdominal Radical Trachelectomy

This study aimed to assess the accuracy of predicting pelvic lymph node status using sentinel lymph node (SLN) biopsy with indocyanine green (ICG) and to examine the outcomes of SLN biopsy-guided abdominal radical trachelectomy (ART). Patients with stage IA2-IB2 cervical cancer from January 2009 to January 2021 were included. ICG was injected before ART and SLNs were identified, excised, and assessed intraoperatively using fast-frozen sections. Systemic pelvic lymphadenectomy was subsequently performed. The SLN detection rate, sensitivity, and false-negative rate were determined. Thirty patients desiring fertility preservation were enrolled, of whom 26 successfully completed ART and four underwent radical hysterectomies because of metastatic primary SLNs. Bilateral SLNs were identified in all patients. The sensitivity, false-negative rate, and negative predictive value were 100%, 7.7%, and 92.3%, respectively. Three (12%) patients were lost to follow-up: two relapsed and one died of tumor progression. Of the nine patients who tried to conceive after surgery, four achieved pregnancy and three delivered healthy live infants. In women with early-stage cervical cancer who desired to conserve fertility, SLN mapping with ICG had a very high detection rate, sensitivity, and low false-negative rate. SLN biopsy-guided ART is a feasible and accurate method for assessing pelvic node status.

Comparison of radio-isotope method with 99m technetium and near-infrared fluorescent imaging with indocyanine green for sentinel lymph node detection in endometrial cancer

BACKGROUND

We aimed to compare the detection rate of pelvic sentinel lymph node between the radio-isotope with 99m technetium (99mTc)-labeled phytate and near-infrared fluorescent imaging with indocyanine green in patients with endometrial cancer.

METHODS

This study included 122 patients who had undergone sentinel lymph node mapping using 99mTc and indocyanine green. In the radio-isotope method, sentinel lymph nodes were detected using uterine cervix 99mTc injections the day before surgery. Following injection, the number and locations of the sentinel lymph nodes were evaluated by lymphoscintigraphy. In addition, indocyanine green was injected into the cervix immediately before surgery.

RESULTS

The overall pelvic sentinel lymph node detection rate (at least one pelvic sentinel lymph node detected) was not significantly different between 99mTc (95.9% [117/122]) and indocyanine green (94.3% [115/122]). Similarly, the bilateral sentinel lymph node detection rate was not significantly different between 99mTc (87.7% [107/122]) and indocyanine green (79.5% [97/122]). More than two sentinel lymph nodes per unilateral pelvic lymph node were found in 12.3% (15/122) and 27% (33/122) of cases with 99mTc and indocyanine green, respectively, in the right pelvic side, and 11.5% (14/122) and 32.8% (40/122) of cases with 99mTc and indocyanine green, respectively, in the left pelvic side. indocyanine green showed that there were significantly more than two sentinel lymph nodes in either the left or right pelvic sentinel lymph nodes (P < 0.0001). There was a significant difference in the mean number of total pelvic sentinel lymph nodes between 99mTc (2.2) and indocyanine green (2.5) (P = 0.028) methods.

CONCLUSION

Although indocyanine green is useful for sentinel lymph node identification, we believe it is better to use it in combination with 99mTc until the surgeon is accustomed to it.

Utility of indocyanine green as a single tracer for sentinel node biopsy in endometrial cancer

AIM

Our study aims to investigate the safety and effectiveness of sentinel lymph node biopsy using indocyanine green (ICG) for the surgical staging of early-stage endometrial cancer in comparison to technetium-99 m use.

METHODS

We conducted an observational retrospective study with patients diagnosed of endometrial cancer and FIGO stages I-II. All participants were injected technetium-99m the day prior to the surgery and underwent lymphoscintigraphy along with single-photon emission computed tomography. In addition, all patients were administered intraoperatively ICG injection to detect sentinel lymph node biopsy. The surgical staging was then completed according to the European Society for Medical Oncology preoperative risk category. Data obtained from the analysis of technetium-99m detection was compared to ICG detection.

RESULTS

A total of 53 women with endometrial cancer were included in the study, 49 (92.5%) of them showed drainage preoperatively in the single-photon emission computed tomography and/or lymphoscintigraphy. The intraoperative bilateral detection rate for technetium-99 m was 26 (49.1%) patients compared to 40 (75.5%) patients with ICG (p = 0.013). We observed a 42.5% increase in the mean number of lymph nodes retrieved by ICG compared to technetium-99m (2.85 vs 2,0 nodes; p = 0.002). We intraoperatively identified 164 lymph nodes, 104 (63.4%) located in both obturator areas and external iliac vessels.

CONCLUSION

The use of ICG for the performance of sentinel node biopsy in patients with endometrial cancer seems safe and could be superior to technetium-99 m, since it offers a higher bilateral detection rate and nodal retrieval, resulting in the possibility to perform safely less full staging lymphadenectomies.

Long-term oncological safety of sentinel lymph node biopsy in early-stage cervical cancer: A post-hoc analysis of SENTICOL I and SENTICOL II cohorts

OBJECTIVES

To compare oncologic outcomes of patients with early-stage cervical cancer and negative nodes who underwent sentinel lymph node biopsy alone (SLNB) versus pelvic lymphadenectomy (PL).

METHODS

An ancillary analysis of two prospective multicentric trials on SLN biopsy for cervical cancer (SENTICOL I and II) was conducted. Only patients with early-stage cervical cancer (IA to IIA FIGO stage), bilateral detection of SLN, negative SLN after ultrastaging and negative non-SLN after final pathologic examination were included. Risk-factors of recurrence and disease-specific mortality were determined by Cox proportional hazard models.

RESULTS

Between January 2005 and July 2012, 259 node-negative patients were analyzed: 87 in the SLNB group and 172 in the PL group. The median follow-up was 47 months [4-127]. During the follow-up, 21 patients (8.1%) experienced recurrences, including 4 nodal recurrences (1.9%), and 9 patients (3.5%) died of cervical cancer. Disease-free survival (DFS) and disease-specific survival (DSS) were similar between SLNB and PL groups, 85.1% vs. 80.4%, p = 0.24 and 90.8% vs. 97.2%, p = 0.22 respectively. By Cox multivariate analysis, SLNB compared to PL was not associated with DFS (HR = 1.78, 95%CI = [0.71-4.46], p = 0.22) neither with DSS (HR = 3.02, 95%CI = [0.69-13.18], p = 0.14). Only pathologic risk level according to the Sedlis criteria was an independent predictor of DFS and DSS.

CONCLUSIONS

Omitting full pelvic lymphadenectomy for patients with bilateral negative SLN does not seem to be associated with an increased risk of recurrence in this series. Survival non-inferiority needs to be confirmed by prospective trials.

Comprehensive Review of Fluorescence Applications in Gynecology

Since the introduction of indocyanine green (ICG) as a fluorophore in near-infrared imaging, fluorescence visualization has become an essential tool in many fields of surgery. In the field of gynecology, recent new applications have been proposed and found their place in clinical practice. Different applications in gynecology were investigated, subcategorized, and overviewed concerning surgical applications and available dyes. Specific applications in which fluorescence-guided surgery was implemented in gynecology are described in this manuscript—namely, sentinel node biopsy, mesometrium visualization, angiography of different organs, safety issues in pregnant women, ureters visualization, detection of peritoneal metastases, targeted fluorophores for cancer detection, fluorescent contamination hysterectomy, lymphography for lower limb lymphedema prevention, tumor margin detection, endometriosis, and metastases mapping. With evolving technology, further innovative research on the new applications of fluorescence visualization in cancer surgery may help to establish these techniques as standards of high-quality surgery in gynecology. However, more investigations are necessary in order to assess if these innovative tools can also be effective to improve patient outcomes and quality of life in different gynecologic malignancies.

Sentinel Lymph Node Mapping in Endometrial Cancer: A Comprehensive Review

Endometrial cancer (EC) is known as a common gynecological malignancy. The incidence rate is on the increase annually. Lymph node status plays a crucial role in evaluating the prognosis and selecting adjuvant therapy. Currently, the patients with high-risk (not comply with any of the following: (1) well-differentiated or moderately differentiated, pathological grade G1 or G2; (2) myometrial invasion< 1/2; (3) tumor diameter < 2 cm are commonly recommended for a systematic lymphadenectomy (LAD). However, conventional LAD shows high complication incidence and uncertain survival benefits. Sentinel lymph node (SLN) refers to the first lymph node that is passed by the lymphatic metastasis of the primary malignant tumor through the regional lymphatic drainage pathway and can indicate the involvement of lymph nodes across the drainage area. Mounting evidence has demonstrated a high detection rate (DR), sensitivity, and negative predictive value (NPV) in patients with early-stage lower risk EC using sentinel lymph node mapping (SLNM) with pathologic ultra-staging. Meanwhile, SLNM did not compromise the patient’s progression-free survival (PFS) and overall survival (OS) with low operative complications. However, the application of SLNM in early-stage high-risk EC patients remains controversial. As revealed by the recent studies, SLNM may also be feasible, effective, and safe in high-risk patients. This review aims at making a systematic description of the progress made in the application of SLNM in the treatment of EC and the relevant controversies, including the application of SLNM in high-risk patients.

Sentinel node biopsy for diagnosis of lymph node involvement in endometrial cancer

BACKGROUND

Pelvic lymphadenectomy provides prognostic information for those diagnosed with endometrial (womb) cancer and provides information that may influence decisions regarding adjuvant treatment. However, studies have not shown a therapeutic benefit, and lymphadenectomy causes significant morbidity. The technique of sentinel lymph node biopsy (SLNB), allows the first draining node from a cancer to be identified and examined histologically for involvement with cancer cells. SLNB is commonly used in other cancers, including breast and vulval cancer. Different tracers, including colloid labelled with radioactive technetium-99, blue dyes, e.g. patent or methylene blue, and near infra-red fluorescent dyes, e.g. indocyanine green (ICG), have been used singly or in combination for detection of sentinel lymph nodes (SLN).

OBJECTIVES

To assess the diagnostic accuracy of sentinel lymph node biopsy (SLNB) in the identification of pelvic lymph node involvement in women with endometrial cancer, presumed to be at an early stage prior to surgery, including consideration of the detection rate.

SEARCH METHODS

We searched MEDLINE (1946 to July 2019), Embase (1974 to July 2019) and the relevant Cochrane trial registers.

SELECTION CRITERIA

We included studies that evaluated the diagnostic accuracy of tracers for SLN assessment (involving the identification of a SLN plus histological examination) against a reference standard of histological examination of removed pelvic +/- para-aortic lymph nodes following systematic pelvic +/- para-aortic lymphadenectomy (PLND/PPALND) in women with endometrial cancer, where there were sufficient data for the construction of two-by-two tables.

DATA COLLECTION AND ANALYSIS

Two review authors (a combination of HN, JM, NW, RG, and WH) independently screened titles and abstracts for relevance, classified studies for inclusion/exclusion and extracted data. We assessed the methodological quality of studies using the QUADAS-2 tool. We calculated the detection rate as the arithmetic mean of the total number of SLNs detected out of the total number of women included in the included studies with the woman as the unit of analysis, used univariate meta-analytical methods to estimate pooled sensitivity estimates, and summarised the results using GRADE.

MAIN RESULTS

The search revealed 6259 unique records after removal of duplicates. After screening 232 studies in full text, we found 73 potentially includable records (for 52 studies), although we were only able to extract 2x2 table data for 33 studies, including 2237 women (46 records) for inclusion in the review, despite writing to trial authors for additional information. We found 11 studies that analysed results for blue dye alone, four studies for technetium-99m alone, 12 studies that used a combination of blue dye and technetium-99m, nine studies that used indocyanine green (ICG) and near infra-red immunofluorescence, and one study that used a combination of ICG and technetium-99m. Overall, the methodological reporting in most of the studies was poor, which resulted in a very large proportion of 'unclear risk of bias' ratings. Overall, the mean SLN detection rate was 86.9% (95% CI 82.9% to 90.8%; 2237 women; 33 studies; moderate-certainty evidence). In studies that reported bilateral detection the mean rate was 65.4% (95% CI 57.8% to 73.0%) . When considered according to which tracer was used, the SLN detection rate ranged from 77.8% (95% CI 70.0% to 85.6%) for blue dye alone (559 women; 11 studies; low-certainty evidence) to 100% for ICG and technetium-99m (32 women; 1 study; very low-certainty evidence). The rates of positive lymph nodes ranged from 5.2% to 34.4% with a mean of 20.1% (95% CI 17.7% to 22.3%). The pooled sensitivity of SLNB was 91.8% (95% CI 86.5% to 95.1%; total 2237 women, of whom 409 had SLN involvement; moderate-certainty evidence). The sensitivity for of SLNB for the different tracers were: blue dye alone 95.2% (95% CI 77.2% to 99.2%; 559 women; 11 studies; low-certainty evidence); Technetium-99m alone 90.5% (95% CI 67.7% to 97.7%; 257 women; 4 studies; low-certainty evidence); technetium-99m and blue dye 91.9% (95% CI 74.4% to 97.8%; 548 women; 12 studies; low-certainty evidence); ICG alone 92.5% (95% CI 81.8% to 97.1%; 953 women; 9 studies; moderate-certainty evidence); ICG and blue dye 90.5% (95% CI 63.2.6% to 98.1%; 215 women; 2 studies; low-certainty evidence); and ICG and technetium-99m 100% (95% CI 63% to 100%; 32 women; 1 study; very low-certainty evidence). Meta-regression analyses found that the sensitivities did not differ between the different tracers used, between studies with a majority of women with FIGO stage 1A versus 1B or above; between studies assessing the pelvic lymph node basin alone versus the pelvic and para-aortic lymph node basin; or between studies that used subserosal alone versus subserosal and cervical injection. It should be noted that a false-positive result cannot occur, as the histological examination of the SLN is unchanged by the results from any additional nodes removed at systematic lymphadenectomy.

AUTHORS' CONCLUSIONS

The diagnostic test accuracy for SLNB using either ICG alone or a combination of a dye (blue or ICG) and technetium-99m is probably good, with high sensitivity, where a SLN could be detected. Detection rates with ICG or a combination of dye (ICG or blue) and technetium-99m may be higher. The value of a SLNB approach in a treatment pathway, over adjuvant treatment decisions based on uterine factors and molecular profiling, requires examination in a high-quality intervention study.

Indocyanine green versus technetium-99m with blue dye for sentinel lymph node detection in early-stage cervical cancer: A systematic review and meta-analysis

Background

The fluorescent dye indocyanine green (ICG) has emerged as a promising tracer for intraoperative detection of sentinel lymph nodes (SLNs) in early‐stage cervical cancer. Although researchers suggest the SLN detection of ICG is equal to the more conventional combined approach of a radiotracer and blue dye, no consensus has been reached.

Aims

We aimed to assess the differences in overall and bilateral SLN detection rates with ICG versus the combined approach, the radiotracer technetium‐99m (^99mTc) with blue dye.

Methods and Results

We searched MEDLINE, Embase, and the Cochrane Library from inception to January 1, 2020 and included studies reporting on a comparison of SLN detection with ICG versus ^99mTc with blue dye in early‐stage cervical cancer. The overall and bilateral detection rates were pooled with random‐effects meta‐analyses.

From 118 studies retrieved seven studies (one cross‐sectional; six retrospective cohorts) were included, encompassing 589 patients. No significant differences were found in the pooled overall SLN detection rate of ICG versus ^99mTc with blue dye. Meta‐analyses of all studies showed ICG to result in a higher bilateral SLN detection rate than ^99mTc with blue dye; 90.3% (95%CI, 79.8‐100.0%) with ICG versus 73.5% (95%CI, 66.4‐80.6%) with 99mTc with blue dye. This resulted in a significant and clinically relevant risk difference of 16.6% (95%CI, 5.3‐28.0%). With sensitivity analysis, the risk difference of the bilateral detection rate maintained in favor of ICG but was no longer significant (13.2%, 95%CI −0.8‐27.3%).

Conclusion

ICG appears to provide higher bilateral SLN detection rates compared to ^99mTc with blue dye in patients with early‐stage cervical cancer. However, in adherence with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines, the quality of evidence is too low to provide strong recommendations and directly omit the combined approach of ^99mTc with blue dye.

Application of near-infrared fluorescent cholangiography using indocyanine green in laparoscopic cholecystectomy

OBJECTIVE

Near-infrared fluorescence cholangiography (NIRF-C) can help to identify the bile duct during laparoscopic cholecystectomy. This retrospective study was performed to investigate the effect of NIRF-C in laparoscopic cholecystectomy.

METHODS

Consecutive patients who underwent NIRF-C-assisted laparoscopic cholecystectomy (n = 34) or conventional laparoscopic cholecystectomy (n = 36) were enrolled in this study. Identification of biliary structures, the operation time, intraoperative blood loss, and postoperative complications were analyzed.

RESULTS

Laparoscopic cholecystectomy was completed in all patients without conversion to laparotomy. The median operation time and intraoperative blood loss were not significantly different between the two groups. No intraoperative injuries or postoperative complications occurred in either group. In the NIRF-C group, the visualization rate of the cystic duct, common bile duct, and common hepatic duct prior to dissection was 91%, 79%, and 53%, respectively. The success rate of cholangiography was 100% in the NIRF-C group. NIRF-C was more effective for visualizing biliary structures in patients with a BMI of <25 than >25 kg/m².

CONCLUSIONS

NIRF-C is a safe and effective technique that enables real-time identification of the biliary anatomy during laparoscopic cholecystectomy. NIRF-C helps to improve the efficiency of dissection.

Exploratory Study of the Clinical Value of Near-Infrared Sentinel Lymph Node Mapping With Indocyanine Green in Vulvar Cancer Patients

Background

This study aimed to evaluate the clinical value of indocyanine green sentinel lymph node (SLN) mapping in patients with vulvar cancer. The conventional procedure of SLN mapping in vulvar cancer includes peritumoral injection of technetium-99m nanocolloid before surgery and intraoperative injection of a blue dye. However, these techniques harbor some limitations. Near-infrared fluorescence imaging with indocyanine green has gained popularity in SLN mapping in different types of cancer.

Methods

We analyzed retrospectively vulvar cancer patients at our institution between 2013 and 2020 undergoing indocyanine green SLN mapping by applying video telescope operating microscope system technology.

Results

64 groins of 34 patients were analyzed. In 53 groins we used technetium-99m nanocolloid, in four patent blue, and in five both techniques, additionally to indocyanine green for SLN detection. In total, 120 SLNs were identified and removed. The SLN detection rate of indocyanine green was comparable to technetium-99m nanocolloid (p=.143) and higher than patent blue (p=.003). The best results were achieved using a combination of ICG and technetium-99m nanocolloid (detection rate of 96.9%). SLN detection rates of indocyanine green were significantly higher in patients with positive lymph nodes (p=.035) and lymphatic space invasion (p=.004) compared to technetium-99m nanocolloid.

Conclusion

Indocyanine green SLN mapping in vulvar cancer is feasible and safe, with reasonable detection rates. Due to its easy application and few side effects, it offers a sound alternative to the conventional SLN mapping techniques in vulvar cancer. In patients with lymph node metastasis, indocyanine green even outperformed technetium-99m nanocolloid in terms of detection rate.

Sentinel Lymph Node Biopsy Is Feasible in Cervical Cancer Laparoscopic Surgery: A Single-Center Retrospective Cohort Study

Methods

A total of 100 cervical cancer patients undergoing laparoscopic surgery with SLN biopsy were included. Indocyanine green, carbon nanoparticles (CNPs), and a combination of both were used during surgeries. Detection rates, sensitivity, negative predictive value (NPV) of SLN biopsy, and related factors were analyzed.

Results

The overall and bilateral SLN detection rates were 92% (92/100) and 74% (74/100), respectively. Combined tracers had higher bilateral SLN detection rates than CNPs alone (p=0.005). Menopause and lymph node metastasis were associated with lower overall and bilateral SLN detection rates (p < 0.05). SLN biopsy sensitivity and NPV for lymph node metastasis in patients with at least one detected SLN were 81.8% (9/11) and 97.3% (72/74), respectively. Among those with bilateral detected SLNs, higher sensitivity and NPV of 87.5% (7/8) and 98.3% (57/58) were observed, respectively. SLN algorithm can ensure that all patients with lymph node metastasis are detected by SLN biopsy.

Conclusion

SLN biopsy appears to be safe and effective for specific cervical cancer patients with high detection rates and NPV in laparoscopic surgery, especially for those with detected bilateral SLNs and undergoing the SLN algorithm. Selecting suitable patients for SLN mapping has prospects for clinical application.

Fluorescence-guided cancer surgery-A new paradigm

Fluorescence-guided surgery is an emerging and promising operative adjunct to assist the surgeon in various aspects of oncosurgery, ranging from assessing perfusion, identification, and characterization of tumors and peritoneal metastases, mapping of lymph nodes/leaks, and assistance for fluorescence-guided surgery (FGS). This study aims to provide an overview of principles, currently available dyes, platforms, and surgical applications and summarizes the available literature on the utility of FGS with a focus on abdomino-thoracic malignancies.

Survey of the clinical practice pattern of using sentinel lymph node biopsy in patients with gynecological cancers in Japan: the Japan Society of Gynecologic Oncology study

BACKGROUND

Sentinel lymph node (SN) biopsy is essential for evaluating survival and minimal treatment-related morbidity associated with cervical, endometrial, and vulvar cancer in Japan. As such, our aim in this study was to evaluate the current practice pattern of using SN biopsy for cervical, endometrial, and vulvar cancer in Japan.

METHODS

We deployed a 47-question survey on the use of SN biopsy for gynecological cancers to 216 gynecological oncology training facilities. The survey included information on the use of SN biopsy for uterine (cervical and endometrial) and vulvar cancers; details on the type, timing, and concentration of tracers used; surgical approach used for SN biopsy; method of biopsy and pathological examination; and facilities' experience with clinical research on SN biopsy.

RESULTS

The response rate was 84% (181/216), with 40 facilities (22%) having experience in SN biopsy for gynecological cancers, 34 (85%) for uterine cancers, and 15 (37%) for vulvar cancers. Radioisotope, indocyanine green (ICG), and blue dyes were available for the detection of uterine cancers in 21 (52%), 25 (62%), and 19 (48%) facilities and for vulvar cancers in 9 (22%), 3 (7%), and 11 (27%) facilities, respectively. Thirty-four facilities (85%) used intraoperative frozen section procedure for diagnosis when possible, with 24 (71%) of these facilities using 2-mm specimen cuts. Diagnosis included pathological examination (85%), immunostaining (57%), and one-step nucleic acid amplification (5%).

CONCLUSION

Increasing research evidence, providing insurance coverage for radioisotope tracers, and increasing the availability of training are expected to increase the use of SN biopsy in Japan.

Comparison of SPECT-CT with intraoperative mapping in cervical and uterine malignancies

INTRODUCTION

The objective was to evaluate whether hybrid imaging combining single photon emission tomography with computed tomography (SPECT/CT) provides additional clinical value for dectection of sentinel lymph nodes (SLNs) compared with intraoperative combined mapping in uterine and cervical malignancies.

METHODS

This was a retrospective study of prospectively collected data from patients with stages IA-IB2 cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2018) or stage I endometrial cancer, who underwent preoperative SPECT/CT for SLN detection. All included patients had dual injection of technetium-99m (^99mTc) with patent blue or indocyanine green.

RESULTS

A total of 171 patients were included with 468 SLNs detected during surgery: 146/171 patients (85.4%) had both radiotracer and blue injection whereas 25/171 patients (14.6%) had radiotracer and indocyanine green injected. The overall detection rate was 95.3%. The detection rate of SLN mapping was 74.9% for SPECT/CT, 90.6% for ^99mTc, 91.8% for blue dye, and 100% for indocyanine green. Bilateral drainage was found in 140 patients (81.9%), detected by ^99mTc in 105 patients (61.4%), by blue in 99 patients (67.3%), by indocyanine green in 23 patients (92%), and by SPECT/CT in 62 patients (36.4%). Atypical SLN locations were identified by SPECT/CT in 64 patients (37.4%), by 99mTc in 28 patients (16.4%), by blue in 17 patients (9.9%), and by indocyanine green in 8 patients (4.7%). Sensitivity and negative predictive value of SLN biopsy to detect lymph node metastasis using dual injection of different intraoperative combined techniques were 88.9% and 97.5%, respectively.

CONCLUSION

SPECT/CT enhanced topographic delineation of SLN and more accurately identified drainage to atypical locations. Fluorescent SLN mapping using indocyanine green offered the highest SLN detection rate. When indocyanine green was used, SPECT/CT did not increase SLN detection, and did not add further information to improve lymph node localization and removal.

Relevance of sentinel lymph node biopsy in early endometrial cancer: A series of 249 cases

OBJECTIVE

We aimed to evaluate the impact of the sentinel lymph node (SLN) biopsy on adjuvant therapy, recurrence and survival in early endometrial cancer (EC).

STUDY DESIGN

We retrospectively included all patients who underwent SLN biopsy for EC between February 2007 and March 2018.

RESULTS

Of the 249 EC patients included, the overall SLN detection rate was 91 %. SLNs were positive in 36 (14.4 %) cases. Nine of the 13 preoperative low-risk patients with positive SLNs were re-operated and 22 % presented positive non-SLNs. No second surgery was required for the 10 patients upstaged to intermediate risk after negative SLN biopsy. Nine of the 11 preoperative intermediate-risk patients with positive SLNs were re-operated and 33 % presented positive non-SLNs. Eleven of the 24 preoperative high-risk patients with negative SLNs were re-operated and 27 % presented positive non-SLNs. For the whole population, 3-year overall survival was 99 % (CI 95 % (97-1)) and 3-year recurrence-free survival (RFS) was 92 % (CI 95 % (0.87-0.95)).

CONCLUSION

Our study supports the feasibility of the SLN procedure for assessing risk recurrence in patients with early-stage EC. SLN biopsy should lead to major reductions in secondary staging and better adaptation of adjuvant therapy.

Anatomic Asymmetry in Sentinel Lymph Node Detection in Endometrial Cancer

STUDY OBJECTIVE

To determine whether the concomitant use of indocyanine green (ICG) with technetium-99m-filtered sulfur colloid (Tc99m-FSC) improves bilateral sentinel lymph node (SLN) detection rate in endometrial cancer and whether anatomic concordance of pelvic lymph nodes exists and can be used to predict SLN location in cases of unilateral mapping failure.

DESIGN

Retrospective cohort study.

SETTING

Tertiary academic medical center in Holon, Israel.

PATIENTS

Patients diagnosed with endometrial cancer, who underwent SLN mapping with Tc99m-FSC, ICG, or both, at our center between 2014 and 2019.

INTERVENTIONS

A total of 111 patients were included in the study. SLN mapping using Tc99m-FSC was performed in 101 (91.9%) patients, and ICG injection was given to 64 (57.6%) patients of whom 55 (49.5%) received both. We compared SLN detection rates (unilateral and bilateral) and anatomic symmetry for each method alone and for a combination of the 2.

MEASUREMENTS AND MAIN RESULTS

The overall detection rate for unilateral SLNs was 96.4%; 96.9% with ICG, 93.1% with gamma-probe, and 98.2% by combining both methods. The total bilateral detection rate was 72.1%, with ICG performing better as a single tracer than Tc99m-FSC (75% vs 63.4%, respectively). In 55 women in whom both tracers were used, the bilateral detection rate was significantly higher compared with Tc99m-FSC alone. Symmetric pelvic anatomic concordance of SLN was found in only 35 of 80 patients with bilateral SLN detection (43.8%).

CONCLUSION

The combination of preoperative radioisotope injection and intraoperative ICG administration may yield the best bilateral SLN detection rate. In cases of unilateral mapping failure, one cannot rely on the anatomic location of the ipsilateral SLN detected to harvest the complementary node because the symmetric concordance is poor.

Sentinel lymph node biopsy in endometrial cancer: state of the art

Endometrial cancer (EC) is the most common gynecological neoplasm in developed countries. In literature, there are discordant data regarding the therapeutic value of systematic lymphadenectomy whereas the importance of lymph node status for determining prognosis and the need for adjuvant treatment is undoubted. Given the low risk of lymph-node metastases in the apparent early-stage disease and the significant surgical and postoperative risks when performing a complete pelvic lymphadenectomy, the surgical approach in these patients is controversial, ranging from no nodal evaluation to comprehensive pelvic and aortic lymphadenectomy. The recent introduction of sentinel node mapping represents the mid-way between the execution and omission of node dissection in EC patients. Indeed, the sentinel node mapping has rapidly emerged as an alternative to complete lymphadenectomy to reduce morbidity. In the present review, we discuss the role of sentinel node mapping in the surgical management of EC evaluating all aspects of this procedure.