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Raimondo D, Raffone A, Aguzzi A, Bertoldo L, Seracchioli R. Role of sentinel lymph node biopsy with indocyanine green and site of injection in endometrial cancer. Curr Opin Oncol 2024; 36:383-390. [PMID: 39106403 DOI: 10.1097/cco.0000000000001075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2024]
Abstract
PURPOSE OF REVIEW The aim of the present narrative review is to summarize the state of art on sentinel lymph node biopsy (SLNB) in endometrial cancer, with a special focus on indocyanine green (ICG) as adopted tracer. RECENT FINDINGS Over the years, the surgical nodal staging in patients with endometrial cancer has been intensively investigated. Traditionally, systematic pelvic and para-aortic lymphadenectomy represented the gold standard surgical treatment to assess nodal involvement of the tumor. Through the last two decades, SLNB has gradually replaced lymphadenectomy as a more targeted procedure. A great heterogeneity of tracers and injection techniques have been proposed to perform SLNB. However, no universally accepted recommendations are still available. SUMMARY SLNB has nowadays almost replaced pelvic lymphadenectomy in low-risk endometrial cancers, offering a better safety profile while being related to a comparable nodal involvement sensitivity. Currently, ICG is considered to be the most used tracer among others. Different injection sites have been proposed, with different detection features. While ICG cervical injection is nowadays the suggested technique for SLNB, noncervical injection techniques, such as hysteroscopic and combined procedures, seem to have a better accuracy in para-aortic nodal assessment, which have a role in high-risk endometrial cancers.
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Affiliation(s)
- Diego Raimondo
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna
| | - Antonio Raffone
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Alberto Aguzzi
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna
| | - Linda Bertoldo
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna
| | - Renato Seracchioli
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna
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Jankowski P, Findeklee S, Georgescu MT, Sima RM, Nigdelis MP, Solomayer EF, Klamminger GG, Hamoud BH. The Therapy of Vulvar Carcinoma-Evaluation of Surgical Options in a Retrospective Monocentric Study. Life (Basel) 2023; 13:1973. [PMID: 37895358 PMCID: PMC10608767 DOI: 10.3390/life13101973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/21/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
(1) Background: Surgical-oncological treatment methods are continuously put to the test in times of evidence-based medicine-notably, a constant reevaluation remains key, especially for tumor entities with increasing incidence such as vulvar carcinoma. (2) Methods: In order to determine the postoperative clinical course of different methods of vulvar excision (vulvectomy, hemivulvectomy) as well as inguinal lymph node removal (lymphadenectomy, sentinel lymph node biopsy) with regard to postoperative wound-healingprocess, perioperative hemorrhage, and re-resection rates, we retrospectively analyzed surgical, morphological and laboratory data of 76 patients with a pathological diagnosed vulvar cancer. (3) Results: Analysis of our data from a single center revealed a comparable perioperative clinical course regardless of the chosen method of vulvar excision and inguinal lymph node removal. (4) Conclusions: Thus, our results emphasize the current multimodality in surgical therapy of vulvar carcinoma, in which consideration of known prognostic factors together with the individual patient's clinical situation allow guideline-based therapy aimed at maximizing surgical safety.
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Affiliation(s)
- Peter Jankowski
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany
| | - Sebastian Findeklee
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany
| | - Mihai-Teodor Georgescu
- Department of Oncology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- “Prof. Dr. Alexandru Trestioreanu” Oncology Institute, 022328 Bucharest, Romania
| | - Romina Marina Sima
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- The “Bucur” Maternity, ‘Saint John’ Hospital, 040294 Bucharest, Romania
| | - Meletios P. Nigdelis
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Papageorgiou General Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece
| | - Erich-Franz Solomayer
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany
| | - Gilbert Georg Klamminger
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany
| | - Bashar Haj Hamoud
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, 66421 Homburg, Germany
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Cabezas Palacios MN, García Pineda V, Gracia Segovia M, Diestro Tejeda MD, Hernández Gutiérrez A, Zapardiel Gutiérrez I. Utility of indocyanine green as a single tracer for sentinel node biopsy in endometrial cancer. J Obstet Gynaecol Res 2021; 48:222-229. [PMID: 34698419 DOI: 10.1111/jog.15071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/01/2021] [Accepted: 10/06/2021] [Indexed: 11/26/2022]
Abstract
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.
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Taran FA, Jung L, Waldschmidt J, Huwer SI, Juhasz-Böss I. Status of Sentinel Lymph Node Biopsy in Endometrial Cancer. Geburtshilfe Frauenheilkd 2021; 81:562-573. [PMID: 34035551 PMCID: PMC8137276 DOI: 10.1055/a-1228-6189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 03/01/2021] [Indexed: 11/26/2022] Open
Abstract
The role of lymphadenectomy in surgical staging remains one of the biggest controversies in the management of endometrial cancer. The concept of sentinel lymph node biopsy in endometrial cancer has been evaluated for a number of years, with promising sensitivity rates and negative predictive values. The possibility of adequate staging while avoiding systematic lymphadenectomy leads to a significant reduction in the rate of peri- and postoperative morbidity. Nevertheless, the status of sentinel lymph node biopsy in endometrial cancer has not yet been fully elucidated and is variously assessed internationally. According to current European guidelines and recommendations, sentinel lymph node biopsy in endometrial cancer should be performed only in the context of clinical studies. In this review article, the developments of the past decade are explored concisely. In addition, current data regarding the technical aspects, accuracy and prognostic relevance of sentinel lymph
node biopsy are explained and evaluated critically.
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Affiliation(s)
- Florin Andrei Taran
- Klinik für Frauenheilkunde, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Lisa Jung
- Klinik für Frauenheilkunde, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Julia Waldschmidt
- Klinik für Frauenheilkunde, Universitätsklinikum Freiburg, Freiburg, Germany
| | | | - Ingolf Juhasz-Böss
- Klinik für Frauenheilkunde, Universitätsklinikum Freiburg, Freiburg, Germany
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Gezer Ş, Duman Öztürk S, Hekimsoy T, Vural Ç, İşgören S, Yücesoy İ, Çorakçı A. Cervical versus endometrial injection for sentinel lymph node detection in endometrial cancer: a randomized clinical trial. Int J Gynecol Cancer 2020; 30:325-331. [PMID: 32029429 DOI: 10.1136/ijgc-2019-000860] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 01/08/2020] [Accepted: 01/13/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the relationship between pelvic/para-aortic sentinel lymph node status and two different injection sites of 99m-technetium (99mTc)-labeled phytate in patients with endometrial cancer. METHODS This was a randomized controlled trial involving 81 patients with endometrial cancer. In the cervical group (n=40), injections of 99mTc were performed at the 3 and 9 o'clock positions of the uterine cervix. In the endometrial group (n=41), 99mTc was injected into the fundal endometrium using a transcervical catheter. Sentinel lymph nodes were detected through pre-operative lymphoscintigraphy and intra-operatively using a handheld gamma probe. All patients underwent complete pelvic and para-aortic lymphadenectomy procedures. Pathologic ultra-staging was performed with immunostaining for cytokeratin in sentinel lymph nodes after routine hematoxylin and eosin histological examinations. The primary endpoint was the estimation of detection rates, sensitivity, false-negative rates, negative predictive value, and analysis of the distribution of pelvic and para-aortic sentinel lymph nodes. RESULTS The rate of detection of at least one sentinel lymph node, sensitivity, and the negative predictive value was 80%, 66.6%, 96.6% for the cervical group and 85%, 66.6%, 96.9% for the endometrial group, respectively. False-negative sentinel lymph nodes were detected in one patient from each group . There was no significant difference between the groups in terms of total sentinel lymph node count, sentinel pelvic lymph node count, and pelvic bilaterality, but the para-aortic sentinel lymph node count was significantly higher in the endometrial group (p<0.001). Ultra-staging examination of the pelvic sentinel lymph nodes revealed isolated tumor cells in one patient from each group. CONCLUSION Transcervical endometrial tracer injection in endometrial cancer revealed similar pelvic but significantly higher para-aortic sentinel lymph node detection.
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Affiliation(s)
- Şener Gezer
- Department of Obstetrics and Gynecology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Seda Duman Öztürk
- Department of Pathology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Turkay Hekimsoy
- Department of Nuclear Medicine, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Çiğdem Vural
- Department of Pathology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Serkan İşgören
- Department of Nuclear Medicine, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - İzzet Yücesoy
- Department of Obstetrics and Gynecology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Aydın Çorakçı
- Department of Obstetrics and Gynecology, Kocaeli University School of Medicine, Kocaeli, Turkey
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Singh V, Chaudhary A, Modi KB, Singh LS, Roy L, Dougall P, Makkar G, Abrari A, Chaturvedi H. A Prospective Study of Role of Sentinel Lymph Node Biopsy in Low-Risk/Intermediate-Risk Early-Stage Endometrial Carcinoma Using Dual-Dye and Dual-Site and Injection Technique. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2019. [DOI: 10.1007/s40944-019-0262-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Sentinel lymph node mapping using indocyanine green in patients with uterine and cervical neoplasms: restrictions of the method. Arch Gynecol Obstet 2019; 299:1373-1384. [PMID: 30762108 PMCID: PMC6475506 DOI: 10.1007/s00404-019-05063-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 01/22/2019] [Indexed: 02/06/2023]
Abstract
Purpose To establish the surgical, demographic and histopathological factors associated with inaccurate sentinel lymph nodes (SLNs) identification using indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging in uterine and cervical neoplasms during both open and laparoscopic surgery. Methods We reviewed patients with atypical endometrial hyperplasia (AEH), clinical stage I and II cervical cancer or uterine malignancies who underwent primary surgery with SLN mapping between September 2015 and January 2018. An analysis of patients’ demographics, tumor factors and surgical approach was conducted. Bilateral and overall detection rates were calculated and univariate analysis was performed to estimate factors associated with failed SLN mapping. Results A total of 32 patients with uterine and cervical neoplasms were included in the study. The overall detection rate of the SLN was 84% and bilateral detection rate was 75%. There were no statistically relevant differences in overall and bilateral SLN detection rates by BMI, surgical approach or age. Regarding endometrial cancer, there were no differences in SLN detection rates when comparing tumor grade, histology nor myometrial invasion. For SLN detection failure, only the presence of metastatic lymph nodes and lack of surgical experience significantly increased the disability to detect SLNs (p = 0.03, p = 0.04, respectively). Conclusions SLN mapping technique using NIR fluorescence imaging with ICG appears to be accurate method in most of the patients with cervical or endometrial carcinoma, regardless of demographic characteristics, tumor-related features and surgical approach. Surgeons’ expertise in that field allows obtaining excellent detection rates.
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Saito T, Tabata T, Ikushima H, Yanai H, Tashiro H, Niikura H, Minaguchi T, Muramatsu T, Baba T, Yamagami W, Ariyoshi K, Ushijima K, Mikami M, Nagase S, Kaneuchi M, Yaegashi N, Udagawa Y, Katabuchi H. Japan Society of Gynecologic Oncology guidelines 2015 for the treatment of vulvar cancer and vaginal cancer. Int J Clin Oncol 2018; 23:201-234. [PMID: 29159773 PMCID: PMC5882649 DOI: 10.1007/s10147-017-1193-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/05/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Vulvar cancer and vaginal cancer are relatively rare tumors, and there had been no established treatment principles or guidelines to treat these rare tumors in Japan. The first version of the Japan Society of Gynecologic Oncology (JSGO) guidelines for the treatment of vulvar cancer and vaginal cancer was published in 2015 in Japanese. OBJECTIVE The JSGO committee decided to publish the English version of the JSGO guidelines worldwide, and hope it will be a useful guide to physicians in a similar situation as in Japan. METHODS The guideline was created according to the basic principles in creating the guidelines of JSGO. RESULTS The guidelines consist of five chapters and five algorithms. Prior to the first chapter, basic items are described including staging classification and history, classification of histology, and definition of the methods of surgery, radiation, and chemotherapy to give the reader a better understanding of the contents of the guidelines for these rare tumors. The first chapter gives an overview of the guidelines, including the basic policy of the guidelines. The second chapter discusses vulvar cancer, the third chapter discusses vaginal cancer, and the fourth chapter discusses vulvar Paget's disease and malignant melanoma. Each chapter includes clinical questions, recommendations, backgrounds, objectives, explanations, and references. The fifth chapter provides supplemental data for the drugs that are mentioned in the explanation of clinical questions. CONCLUSION Overall, the objective of these guidelines is to clearly delineate the standard of care for vulvar and vaginal cancer with the goal of ensuring a high standard of care for all women diagnosed with these rare diseases.
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Affiliation(s)
- Toshiaki Saito
- Gynecology Service, National Kyushu Cancer Center, Fukuoka, Japan
| | - Tsutomu Tabata
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Mie University, Mie, Japan
| | - Hitoshi Ikushima
- Department of Therapeutic Radiology, Tokushima University, Tokushima, Japan
| | - Hiroyuki Yanai
- Department of Diagnostic Pathology, Okayama University Hospital, Okayama, Japan
| | - Hironori Tashiro
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hitoshi Niikura
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takeo Minaguchi
- Department of Obstetrics and Gynecology, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Toshinari Muramatsu
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Kanagawa, Japan
| | - Tsukasa Baba
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Wataru Yamagami
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Kazuya Ariyoshi
- Gynecology Service, National Kyushu Cancer Center, Fukuoka, Japan
| | - Kimio Ushijima
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Mikio Mikami
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Kanagawa, Japan
| | - Satoru Nagase
- Department of Obstetrics and Gynecology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Masanori Kaneuchi
- Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Medicine, Nagasaki, Japan
| | - Nobuo Yaegashi
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Udagawa
- Department of Obstetrics and Gynecology, Fujita Health University School of Medicine, Aichi, Japan
| | - Hidetaka Katabuchi
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan.
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Du J, Li Y, Wang Q, Batchu N, Zou J, Sun C, Lv S, Song Q, Li Q. Sentinel lymph node mapping in gynecological oncology. Oncol Lett 2017; 14:7669-7675. [PMID: 29344213 PMCID: PMC5755034 DOI: 10.3892/ol.2017.7219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 05/18/2017] [Indexed: 01/02/2023] Open
Abstract
The intraoperative mapping of sentinel lymph nodes (SLNs) is part of the treatment strategy for a number of types of tumor. To retrospectively compare results from the mapping of pelvic SLNs for gynecological oncology, using distinct dyes, the present review was conducted to determine the clinical significance of SLN mapping for gynecological oncology. In addition, the present study aimed at identifying an improved choice for SLN mapping tracers in clinical application. Each dye exhibits demerits when applied in the clinical environment. The combination of radioisotopes and blue dyes was identified to exhibit the most accurate detection rate of SLN drainage of gynecological oncology. However, contrast agents were unable to identify whether a SLN is positive or negative for metastasis prior to pathologic examination; additional studies are required.
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Affiliation(s)
- Jiang Du
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Yaling Li
- Gongzhuling Health Workers High School, Gongzhuling, Jilin 136100, P.R. China
| | - Qing Wang
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Nasra Batchu
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Junkai Zou
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Chao Sun
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Shulan Lv
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Qing Song
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China.,Cardiovascular Research Institute, Morehouse School of Medicine, Atlanta, Georgia 30310, USA.,Big Data Center, First Affiliated Hospital, Xi'an Jiatong University, Xi'an, Shaanxi 710061, P.R. China
| | - Qiling Li
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China.,Big Data Center, First Affiliated Hospital, Xi'an Jiatong University, Xi'an, Shaanxi 710061, P.R. China
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How J, Boldeanu I, Lau S, Salvador S, How E, Gotlieb R, Abitbol J, Halder A, Amajoud Z, Probst S, Brin S, Gotlieb W. Unexpected locations of sentinel lymph nodes in endometrial cancer. Gynecol Oncol 2017; 147:18-23. [PMID: 28716308 DOI: 10.1016/j.ygyno.2017.07.125] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 12/15/2022]
Abstract
INTRODUCTION To evaluate the anatomical location of sentinel lymph nodes (SLN) following intra-operative cervical injection in endometrial cancer. METHODS All consecutive patients with endometrial cancer undergoing sentinel lymph node mapping were included in this prospective study following intra-operative cervical injection of tracers. Areas of SLN detection distribution were mapped. RESULTS Among 436 patients undergoing SLN mapping, there were 1095 SLNs removed, and 7.9% of these SLNs found in 13.1% of patients, were detected in areas not routinely harvested during a standard lymph node dissection. These included the internal iliac vein, parametrial, and pre-sacral areas. The SLN was the only positive node in 46.1% (15/36) of cases with successful mapping and completion lymphadenectomy, including 3 cases where the sentinel node in the atypical location was the only node with metastatic disease. CONCLUSION SLN mapping using intra-operative cervical injection is capable to map out areas not typically included in a standard lymphadenectomy. The sentinel node is the most relevant lymph node to analyze and may enable to discover metastatic disease in unusual areas.
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Affiliation(s)
- Jeffrey How
- Division of Gynecologic Oncology, Segal Cancer Center, Jewish General Hospital, McGill University, Montreal, Quebec H2T 1E2, Canada
| | - Irina Boldeanu
- Division of Gynecologic Oncology, Segal Cancer Center, Jewish General Hospital, McGill University, Montreal, Quebec H2T 1E2, Canada
| | - Susie Lau
- Division of Gynecologic Oncology, Segal Cancer Center, Jewish General Hospital, McGill University, Montreal, Quebec H2T 1E2, Canada
| | - Shannon Salvador
- Division of Gynecologic Oncology, Segal Cancer Center, Jewish General Hospital, McGill University, Montreal, Quebec H2T 1E2, Canada
| | - Emily How
- Division of Gynecologic Oncology, Segal Cancer Center, Jewish General Hospital, McGill University, Montreal, Quebec H2T 1E2, Canada
| | - Raphael Gotlieb
- Division of Gynecologic Oncology, Segal Cancer Center, Jewish General Hospital, McGill University, Montreal, Quebec H2T 1E2, Canada; Division of Experimental Surgery, Faculty of Medicine, McGill University, Montreal, Quebec H2T 1E2, Canada
| | - Jeremie Abitbol
- Division of Gynecologic Oncology, Segal Cancer Center, Jewish General Hospital, McGill University, Montreal, Quebec H2T 1E2, Canada; Division of Experimental Medicine, Faculty of Medicine, McGill University, Montreal, Quebec H2T 1E2, Canada
| | - Ajay Halder
- Division of Gynecologic Oncology, Segal Cancer Center, Jewish General Hospital, McGill University, Montreal, Quebec H2T 1E2, Canada
| | - Zainab Amajoud
- Division of Gynecologic Oncology, Segal Cancer Center, Jewish General Hospital, McGill University, Montreal, Quebec H2T 1E2, Canada
| | - Stephan Probst
- Department of Nuclear Medicine, Segal Cancer Center, Jewish General Hospital, McGill University, Montreal, Quebec H2T 1E2, Canada
| | - Sonya Brin
- Division of Gynecologic Oncology, Segal Cancer Center, Jewish General Hospital, McGill University, Montreal, Quebec H2T 1E2, Canada
| | - Walter Gotlieb
- Division of Gynecologic Oncology, Segal Cancer Center, Jewish General Hospital, McGill University, Montreal, Quebec H2T 1E2, Canada.
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Schiavone MB, Scelzo C, Straight C, Zhou Q, Alektiar KM, Makker V, Soslow RA, Iasonos A, Leitao MM, Abu-Rustum NR. Survival of Patients with Serous Uterine Carcinoma Undergoing Sentinel Lymph Node Mapping. Ann Surg Oncol 2017; 24:1965-1971. [PMID: 28258415 DOI: 10.1245/s10434-017-5816-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of this study was to determine progression-free survival (PFS) in patients with serous uterine carcinoma undergoing sentinel lymph node (SLN) mapping compared with patients undergoing standard lymphadenectomy. METHODS We retrospectively reviewed all uterine cancer patients treated at our institution from 2005 to 2015. Patients were separated into two cohorts: those who underwent SLN mapping at the time of staging (SLN) and those who underwent routine lymphadenectomy (the non-SLN group). SLN mapping was performed according to institutional protocol, incorporating a surgical algorithm and pathologic ultrastaging. RESULTS Overall, 248 patients were identified-153 SLN mappings and 95 routine lymphadenectomies (pelvic and/or paraaortic lymph node dissection). No significant difference in age or body mass index was observed between the groups (p = 0.08 and p = 0.9, respectively). Minimally invasive surgery was utilized in 117/153 (77%) SLN patients and 30/95 (32%) non-SLN patients (p = <0.001). Stage distribution for the SLN and non-SLN cohorts demonstrated 106/153 (69%) and 59/95 (62%) patients with stage I/II disease, respectively, and 47/153 (31%) and 36/95 (38%) patients with stage III/IV disease, respectively (p = 0.3). The median number of nodes removed was 12 (range, 1-50) in the SLN cohort versus 21 (range, 1-75) in the non-SLN cohort (p = <0.001). Adjuvant chemotherapy alone or with radiation therapy was administered in 122/153 (80%) SLN patients and 79/95 (83%) non-SLN patients; radiotherapy alone was administered in 12/153 (8%) SLN patients and 7/95 (7%) non-SLN patients (p = 0.8). At a median follow-up of 40 months, the 2-year PFS rates were 77% (95% confidence interval [CI], 68-83%) in the SLN group and 71% (95% CI, 61-79%) in the non-SLN group (p = 0.3). CONCLUSIONS Incorporation of the SLN mapping algorithm into the staging of uterine serous cancer is feasible and does not appear to compromise prognosis. PFS in patients with uterine serous carcinoma undergoing SLN mapping, followed by adjuvant therapy, was similar to PFS in patients undergoing standard lymphadenectomy and adjuvant therapy.
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Affiliation(s)
- Maria B Schiavone
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chiara Scelzo
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Celeste Straight
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Qin Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kaled M Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vicky Makker
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Robert A Soslow
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mario M Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA.
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Lax SF, Tamussino KF, Lang PF. [Metastatic mechanisms of uterine malignancies and therapeutic consequences]. DER PATHOLOGE 2016; 37:549-556. [PMID: 27757531 DOI: 10.1007/s00292-016-0243-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Malignancies of the uterus metastasize by direct invasion of neighboring structures, lymphatically or hematogenously. Endometrial and cervical cancers lymphatically spread to the pelvic and para-aortic lymph nodes. For endometrial cancer the depth of myometrial invasion, lymphosvascular space involvement (LVSI) and a microcystic, elongated and fragmented (MELF) glandular invasion pattern are predictors for lymph node metastases. Metastases to the pelvic lymph nodes occur in approximately 10 % of endometrial cancer patients and in 30 % of these cases the para-aortic lymph nodes are also involved. Sentinel lymph node biopsy is possible for clinical stage I endometrial cancer and early stages of cervical cancer but is not yet routine. The presence of LVSI is considered to be the strongest predictor of distant metastases, particularly if assessed by immunohistochemistry with antibodies against factor VIII-related antigen or CD31. Endometrioid and clear cell carcinomas can hematogenously metastasize to the lungs, bones, liver and brain and can rarely be manifested as a solitary metastasis. In contrast, serous carcinomas can show extensive peritoneal spread. To date molecular biomarkers cannot predict the occurrence of distant metastasis. Overexpression of P53, p16 and L1CAM have been identified as negative prognostic factors and are associated with the prognostically unfavorable serous tumor type. The metastatic spread of squamous cell cervical cancer is strongly associated with tumor volume. Microinvasive carcinomas have a very low rate of parametrial and lymph node involvement and do not require radical hysterectomy. In contrast, lymph node metastases occur in up to 50 % of bulky stages IB and II cervical cancers. Distant metastases can occur in the lungs, liver, bones and brain. Molecular biomarkers have not been shown to predict metastatic spread. In well-differentiated adenocarcinoma of the cervix the pattern of invasion is strongly predictive for the presence of lymph node metastases, irrespective of tumor size and depth of invasion.
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Affiliation(s)
- S F Lax
- Institut für Pathologie, LKH Graz Süd-West, Standort West, Akademisches Lehrkrankenhaus der Medizinischen Universität Graz, Göstingerstrasse 22, 8020, Graz, Österreich.
| | - K F Tamussino
- Klinische Abteilung für Gynäkologie, Universitätsklinik für Frauenheilkunde, LKH-Universitätsklinikum Graz, Graz, Österreich
| | - P F Lang
- Gynäkologische Abteilung, Krankenhaus der Barmherzigen Brüder, Graz, Österreich
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Indocyanine green and infrared fluorescence in detection of sentinel lymph nodes in endometrial and cervical cancer staging - a systematic review. Eur J Obstet Gynecol Reprod Biol 2016; 206:213-219. [PMID: 27750179 DOI: 10.1016/j.ejogrb.2016.09.027] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 09/19/2016] [Accepted: 09/22/2016] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Sentinel lymph node (SLN) mapping for endometrial (EC) and cervical cancers (CC) is a current technique that could provide benefits over traditional lymphadenectomy. Near-infrared (NIR) fluorescence imaging is a promising technique to perform this procedure. We conducted a systematic review of the evidence regarding the technique and the effectiveness of indocyanine green (ICG) during SLN biopsy, using robotic and laparoscopic assisted surgery and laparotomy. MATERIALS AND METHODS We conducted a computer literature search for published English language studies in humans using PubMed since January 2010 up to May 2015. The initial search came up with 17 articles, of which 10 articles used ICG as tracer in SLN biopsy in EC and CC. RESULTS 422 patients were included in 10 studies, ranging from 1 to 227 patients. The main surgical approach used in ICG SLN biopsy was robotic-assisted surgery in 368 patients. Laparotomy was performed in 39 patients and laparoscopy in 15. The detection rate in SLN mapping using ICG ranged from 78% to 100% for cervical injection and from 33% to 100% for hysteroscopic injection. Sensitivity and negative predictive value (NPV) vary from 50% to 100% and 88% to 100%, respectively. The most common site of injection was the cervix (two quadrants); this technique is correlated with a high detection rate (ranging from 78% to 95%). The cervical submucosal and stromal injections were the most frequent sites used. No complications related to ICG administration were described. CONCLUSIONS NIR fluorescence imaging using ICG is performed in robotic-assisted surgery in laparoscopy and in laparotomy, being a feasible, safe, time-efficient and seemingly reliable method for lymphatic mapping in early stage of CC and EC. Although it has promising results in SLN mapping, randomized studies, with larger patient samples, are needed.
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Laparoscopic sentinel lymph node detection after hysteroscopic injection of technetium-99 in patients with endometrial cancer. Int J Gynecol Cancer 2015; 25:423-30. [PMID: 25695546 DOI: 10.1097/igc.0000000000000387] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Endometrial cancer (EC) has an increasing incidence worldwide. Despite the unequivocal prognostic importance of nodal status, systematic lymphadenectomy is associated to elevated morbidity. Sentinel lymph node (SLN) biopsy is designed to avoid extensive nodal dissection and provide crucial oncologic information. The goal of this prospective study was to determine the feasibility, safety, and accuracy of laparoscopic SLN biopsy in EC obtained through hysteroscopic injection of technetium-99 (Tc-99). METHODS From January 2008 to December 2012, a total of 42 women with EC were included in the study. We injected 20 mBq of Tc-99 hysteroscopically underneath the tumor minutes before definitive surgery. Thereafter, laparoscopic SLN identification /biopsy followed by pelvic and para-aortic lymphadenectomy, hysterectomy, and bilateral salpingo-oophorectomy were executed. RESULTS The total number of removed nodes was 970. The detection rate of the method was 73% (31/42). Among the 70 isolated SLNs, 35% (24) were exclusively identified in the para-aortic area. Fourteen patients (45%) had SLN only in the pelvic region, whereas 11 (35%) had SLN in both pelvic and para-aortic areas and 6 women (20%) had isolated para-aortic SNL. Nodal metastases were histologically confirmed in 9 patients (22%), and SLN was identified in 7 of 9 patients (78%). Although the obtained specificity was 100% and the negative predictive value was 89%, the sensitivity was only 58% (false-negative rate of 42%). CONCLUSIONS We could demonstrate that endoscopic SLN biopsy obtained through hysteroscopic injection of Tc-99 is a feasible and safe method. Despite the restricted number of included patients in this series, the obtained sensitivity and false-negative rates raise some questions about the real accuracy of the procedure in EC. Larger validation trials requiring quality pelvic and para-aortic lymphadenectomy are essential to correctly evaluate the method.
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Stabile C, Gunn A, Sonoda Y, Carter J. Emotional and sexual concerns in women undergoing pelvic surgery and associated treatment for gynecologic cancer. Transl Androl Urol 2015; 4:169-85. [PMID: 26816823 PMCID: PMC4708131 DOI: 10.3978/j.issn.2223-4683.2015.04.03] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 03/20/2015] [Indexed: 12/29/2022] Open
Abstract
The surgical management of gynecologic cancer can cause short- and long-term effects on sexuality, emotional well being, reproductive function, and overall quality of life (QoL). Fortunately, innovative approaches developed over the past several decades have improved oncologic outcomes and reduced treatment sequelae; however, these side effects of treatment are still prevalent. In this article, we provide an overview of the various standard-of-care pelvic surgeries and multimodality cancer treatments (chemotherapy and radiation therapy) by anatomic site and highlight the potential emotional and sexual consequences that can influence cancer survivorship and QoL. Potential screening tools that can be used in clinical practice to identify some of these concerns and treatment side effects and possible solutions are also provided. These screening tools include brief assessments that can be used in the clinical care setting to assist in the identification of problematic issues throughout the continuum of care. This optimizes quality of care, and ultimately, QoL in these women. Prospective clinical trials with gynecologic oncology populations should include patient-reported outcomes to identify subgroups at risk for difficulties during and following treatment for early intervention.
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Levinson KL, Auer M, Escobar PF. Evolving technologies in robotic surgery for minimally invasive treatment of gynecologic cancers. Expert Rev Med Devices 2014; 10:603-10. [DOI: 10.1586/17434440.2013.827509] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abu-Rustum NR. Update on sentinel node mapping in uterine cancer: 10-year experience at Memorial Sloan-Kettering Cancer Center. J Obstet Gynaecol Res 2013; 40:327-34. [DOI: 10.1111/jog.12227] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Nadeem R. Abu-Rustum
- Gynecology Service, Department of Surgery; Memorial Sloan-Kettering Cancer Center; New York USA
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Han G, Lim D, Leitao MM, Abu-Rustum NR, Soslow RA. Histological features associated with occult lymph node metastasis in FIGO clinical stage I, grade I endometrioid carcinoma. Histopathology 2013; 64:389-98. [PMID: 24215212 DOI: 10.1111/his.12254] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 08/09/2013] [Indexed: 11/26/2022]
Abstract
AIMS Lymph node involvement affects prognosis/treatment in endometrial carcinoma patients. We assessed various histological features associated with nodal metastasis in patients with grade I, stage I endometrial endometrioid carcinoma (EEC). METHODS AND RESULTS Eighteen stage I EECs with occult positive lymph nodes and 36 controls were assessed for depth of myoinvasion; microcystic, elongated and fragmented (MELF) pattern of myometrial invasion; lymphovascular invasion (LVI); and epithelial metaplasia. Nodal metastases were subclassified as isolated tumour cells (ITCs; ≤0.2 mm), micrometastasis (>0.2 mm and <2 mm), or macrometastasis (≥2 mm). Node-positive cases had significantly higher rates of LVI (P < 0.001) and MELF invasion (P = 0.003) on univariate analysis. Only LVI was associated significantly with nodal metastasis on multivariate analysis (P = 0.002). Tumours with MELF invasion demonstrated reduced E-cadherin expression. Macrometastases were identified in seven cases (39%) with or without micrometastasis/ITCs. Eight (44%) contained only ITCs. Eleven (61%) had histiocyte-like nodal metastases. Biopsy material from four of six (67%) and five of 17 (29%) cases with and without nodal metastasis showed detached eosinophilic tumour cell buds. Of the former, three were associated with histiocyte-like nodal metastases - a feature absent in biopsies without tumour budding. CONCLUSIONS Lymph nodes from grade I EEC exhibiting cellular budding or LVI should be examined for occult metastases, especially in the form of histiocyte-like cells.
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Affiliation(s)
- Guangming Han
- Department of Pathology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Levinson KL, Escobar PF. Is sentinel lymph node dissection an appropriate standard of care for low-stage endometrial cancers? A review of the literature. Gynecol Obstet Invest 2013; 76:139-50. [PMID: 23942330 DOI: 10.1159/000353897] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 06/19/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS To review the literature and compare detection rates, false negative (FN) rates, and negative predictive values (NPVs) of sentinel lymph node (SLN) biopsy in endometrial cancer to those in breast and vulvar cancer. Secondary objectives were to evaluate techniques of SLN biopsy in endometrial cancer. METHODS The PubMed database was searched for applicable scientific articles. Detection rates, FN rates, and NPVs were calculated for all studies. Studies were stratified by techniques and compared. RESULTS Nineteen articles met criteria for this review. The overall detection rates ranged from 62 to 100%, the FN rate ranged from 0 to 50%, and the NPVs ranged from 95 to 100%. There is no technique that is definitively superior to any other with regard to surgical modality, injectant used, injection site, or pathologic techniques. CONCLUSIONS Studies on SLN biopsy in endometrial cancer have a large range of detection rates and FN rates, and larger studies including more patients with metastatic disease are needed for comparison with breast and vulvar cancers. While no techniques are definitively superior to others, minimally invasive surgery, cervical injection, and pathologic analysis utilizing HE staining, immunohistochemistry, and ultrastaging may be clinically advantageous.
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Carter J, Stabile C, Gunn A, Sonoda Y. The physical consequences of gynecologic cancer surgery and their impact on sexual, emotional, and quality of life issues. J Sex Med 2013; 10 Suppl 1:21-34. [PMID: 23387909 DOI: 10.1111/jsm.12002] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Surgical management of gynecologic cancer can cause short- and long-term effects on sexuality, reproductive function, and overall quality of life (QOL) (e.g., sexual dysfunction, infertility, lymphedema). However, innovative approaches developed over the past several decades have improved oncologic outcomes and reduced treatment sequelae. AIM To provide an overview of the standards of care and major advancements in gynecologic cancer surgery, with a focus on their direct physical impact, as well as emotional, sexual, and QOL issues. This overview will aid researchers and clinicians in the conceptualization of future clinical care strategies and interventions to improve sexual/vaginal/reproductive health and QOL in gynecologic cancer patients. MAIN OUTCOME MEASURES Comprehensive overview of the literature on gynecologic oncology surgery. METHODS Conceptual framework for this overview follows the current standards of care and recent surgical approaches to treat gynecologic cancer, with a brief overview describing primary management objectives and the physical, sexual, and emotional impact on patients. Extensive literature support is provided. RESULTS The type and radicality of surgical treatment for gynecologic cancer can influence sexual function and play a significant role in QOL. Psychological, sexual, and QOL outcomes improve as surgical procedures continue to evolve. Procedures for fertility preservation, laparoscopy, sentinel lymph node mapping, and robotic and risk-reducing surgery have advanced the field while reducing treatment sequelae. Nevertheless, interventions that address sexual and vaginal health issues are limited. CONCLUSIONS It is imperative to consider QOL and sexuality during the treatment decision-making process. New advances in detection and treatment exist; however, psycho-educational interventions and greater patient-physician communication to address sexual and vaginal health concerns are warranted. Large, prospective clinical trials including patient-reported outcomes are needed in gynecologic oncology populations to identify subgroups at risk. Future study designs need clearly defined samples to gain insight about sexual morbidity and foster the development of targeted interventions.
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Affiliation(s)
- Jeanne Carter
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Gogineni A, Caunt M, Crow A, Lee CV, Fuh G, van Bruggen N, Ye W, Weimer RM. Inhibition of VEGF-C modulates distal lymphatic remodeling and secondary metastasis. PLoS One 2013; 8:e68755. [PMID: 23874750 PMCID: PMC3712991 DOI: 10.1371/journal.pone.0068755] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 06/04/2013] [Indexed: 12/26/2022] Open
Abstract
Tumor-associated lymphatics are postulated to provide a transit route for disseminating metastatic cells. This notion is supported by preclinical findings that inhibition of pro-lymphangiogenic signaling during tumor development reduces cell spread to sentinel lymph nodes (SLNs). However, it is unclear how lymphatics downstream of SLNs contribute to metastatic spread into distal organs, or if modulating distal lymph transport impacts disease progression. Utilizing murine models of metastasis, longitudinal in vivo imaging of lymph transport, and function blocking antibodies against two VEGF family members, we provide evidence that distal lymphatics undergo disease course-dependent up-regulation of lymph transport coincidental with structural remodeling. Inhibition of VEGF-C activity with antibodies against VEGF-C or NRP2 prevented these disease-associated changes. Furthermore, utilizing a novel model of adjuvant treatment, we demonstrate that antagonism of VEGF-C or NRP2 decreases post SLN metastasis. These data support a potential therapeutic strategy for inhibiting distant metastatic dissemination via targeting tumor-associated lymphatic remodeling.
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Affiliation(s)
- Alvin Gogineni
- Department of Biomedical Imaging, Genentech Inc., South San Francisco, California, United States of America
| | - Maresa Caunt
- Department of Molecular Biology, Genentech Inc., South San Francisco, California, United States of America
| | - Ailey Crow
- Department of Molecular Biology, Genentech Inc., South San Francisco, California, United States of America
| | - Chingwei V. Lee
- Department of Antibody Engineering, Genentech Inc., South San Francisco, California, United States of America
| | - Germaine Fuh
- Department of Antibody Engineering, Genentech Inc., South San Francisco, California, United States of America
| | - Nicholas van Bruggen
- Department of Biomedical Imaging, Genentech Inc., South San Francisco, California, United States of America
| | - Weilan Ye
- Department of Molecular Biology, Genentech Inc., South San Francisco, California, United States of America
| | - Robby M. Weimer
- Department of Biomedical Imaging, Genentech Inc., South San Francisco, California, United States of America
- * E-mail:
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Contemporary quality of life issues affecting gynecologic cancer survivors. Hematol Oncol Clin North Am 2011; 26:169-94. [PMID: 22244668 DOI: 10.1016/j.hoc.2011.11.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Regardless of cancer origin or age of onset, the disease and its treatment can produce short- and long-term sequelae (ie, sexual dysfunction, infertility, or lymphedema) that adversely affect quality of life (QOL). This article outlines the primary contemporary issues or concerns that may affect QOL and offers strategies to offset or mitigate QOL disruption. These contemporary issues are identified within the domains of sexual functioning, reproductive issues, lymphedema, and the contribution of health-related QOL in influential gynecologic cancer clinical trials.
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Rossi EC, Ivanova A, Boggess JF. Robotically assisted fluorescence-guided lymph node mapping with ICG for gynecologic malignancies: a feasibility study. Gynecol Oncol 2011; 124:78-82. [PMID: 21996262 DOI: 10.1016/j.ygyno.2011.09.025] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 09/09/2011] [Accepted: 09/17/2011] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Traditional techniques of sentinel lymph node (SLN) mapping for endometrial and cervical cancer present challenges which may be overcome with newer technologies such as near infrared (NIR) imaging of the fluorescent dye Indocyanine green (ICG). We performed a feasibility and dose-finding study to define the dose of ICG required to identify pelvic and para-aortic sentinel lymph nodes with robotically assisted endoscopic NIR imaging after cervical injection. METHODS 20 subjects with cervical or endometrial carcinoma were prospectively enrolled for SLN mapping. ICG was injected into the cervical stroma at 3 o'clock and 9 o'clock Data was collected for the number of nodes identified, the location of SLN's, the duration of procedure and the pathology characteristics of the SLN's compared to the non-sentinel lymph nodes. RESULTS 20 subjects received cervical injection with at least one SLN observed in 17 subjects. 15 of the 17 subjects who received 1mg injections of ICG mapped a SLN for an observed detection rate of 88% (95% CI is (64%,99%)). A median of 4.5 SLN's was identified per patient. Three patients had lymphatic metastases, one of whom had a positive SLN. No adverse events were identified. CONCLUSIONS A 1mg cervical injection of ICG identified a SLN in 88% of patients (95% CI is (64%, 99%)). Robotically assisted fluorescence imaging is a feasible, safe, time efficient and reliable method for lymphatic mapping in early stage cervical and endometrial cancer.
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Affiliation(s)
- Emma C Rossi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, USA.
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Frimer M, Khoury-Collado F, Murray MP, Barakat RR, Abu-Rustum NR. Micrometastasis of endometrial cancer to sentinel lymph nodes: Is it an artifact of uterine manipulation? Gynecol Oncol 2010; 119:496-9. [DOI: 10.1016/j.ygyno.2010.08.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Revised: 08/25/2010] [Accepted: 08/28/2010] [Indexed: 10/19/2022]
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Crane LMA, Themelis G, Buddingh KT, Buddingh T, Harlaar NJ, Pleijhuis RG, Sarantopoulos A, van der Zee AGJ, Ntziachristos V, van Dam GM. Multispectral real-time fluorescence imaging for intraoperative detection of the sentinel lymph node in gynecologic oncology. J Vis Exp 2010:2225. [PMID: 21048667 PMCID: PMC3185642 DOI: 10.3791/2225] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases. Surgical treatment most often combines radical excision of the tumor with a full lymphadenectomy in the drainage area of the tumor. However, removal of lymph nodes is associated with increased morbidity due to infection, wound breakdown and lymphedema. As an alternative, the sentinel lymph node procedure (SLN) was developed several decades ago to detect the first draining lymph node from the tumor. In case of lymphogenic dissemination, the SLN is the first lymph node that is affected (Figure 1). Hence, if the SLN does not contain metastases, downstream lymph nodes will also be free from tumor metastases and need not to be removed. The SLN procedure is part of the treatment for many tumor types, like breast cancer and melanoma, but also for cancer of the vulva and cervix. The current standard methodology for SLN-detection is by peritumoral injection of radiocolloid one day prior to surgery, and a colored dye intraoperatively. Disadvantages of the procedure in cervical and vulvar cancer are multiple injections in the genital area, leading to increased psychological distress for the patient, and the use of radioactive colloid. Multispectral fluorescence imaging is an emerging imaging modality that can be applied intraoperatively without the need for injection of radiocolloid. For intraoperative fluorescence imaging, two components are needed: a fluorescent agent and a quantitative optical system for intraoperative imaging. As a fluorophore we have used indocyanine green (ICG). ICG has been used for many decades to assess cardiac function, cerebral perfusion and liver perfusion. It is an inert drug with a safe pharmaco-biological profile. When excited at around 750 nm, it emits light in the near-infrared spectrum around 800 nm. A custom-made multispectral fluorescence imaging camera system was used. The aim of this video article is to demonstrate the detection of the SLN using intraoperative fluorescence imaging in patients with cervical and vulvar cancer. Fluorescence imaging is used in conjunction with the standard procedure, consisting of radiocolloid and a blue dye. In the future, intraoperative fluorescence imaging might replace the current method and is also easily transferable to other indications like breast cancer and melanoma.
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Affiliation(s)
- Lucia M A Crane
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen
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