Sentinel lymph node procedure and uterine cancers

Lymph node metastases in cervical and endometrial cancer are major prognostic factors. Lymph-nodal involvement determines adjuvant therapy. As imagery is not reliable to diagnose lymph node status, pelvic +/- para-aortic lymphadenectomy remains the gold standard. These surgical procedures are, however, responsible for specific morbidity: lymphocele and lymphedema. Sentinel lymph node procedure could avoid lymphadenectomy and their complications in cervical and endometrial cancer with good negative predictive values. We present actual indications, procedure and results of sentinel lymph node procedures in cervical and endometrial cancer.     

Paraaortic lymph node radiotherapy in cancer of the uterine corpus

From 1973 through 1982, 48 women received 4500 to 5075 rads to the paraaortic lymph nodes as part of their primary management for cancer of the uterine corpus. One patient developed severe enteric morbidity. Five-year survival rates were 52% in the total group, 57% in clinically staged patients, and 47% in surgically staged patients. Patients with surgically confirmed pelvic lymphatic spread had a five-year survival rate of 67%. Patients with surgically confirmed paraaortic spread alone or pelvic and paraaortic spread had five-year survival rates of 47 and 43%, respectively. Eighty-eight percent of recurrences were outside of the radiation portals. In contradistinction to much of the last decade's literature, radiation therapy has salvaged a substantial fraction of patients with nodal metastases, and morbidity rates have been acceptable.     

腹腔镜前哨淋巴结活检在子宫恶性肿瘤中的应用

前哨淋巴结（SLN）是肿瘤转移的第一站，SLN检测技术在临床上的应用，对恶性肿瘤的外科治疗有重要指导意义。其在恶性黑色素瘤和乳腺癌中已成功应用，在子宫恶性肿瘤中的应用尚处在研究阶段。多项研究表明．SLN活检在早期子宫恶性肿瘤中是可行的，总结文献，SLN最常见于髂内外和闭孔区。联合放射性胶体和染料法可提高腹腔镜下SLN活检的检出率，放化疗、肿瘤体积、宫颈锥切手术史可影响其检出率。腹腔镜下SLN活检术野清晰、创伤小、并发症少，安全可行，可使患者得到更合理的个体化治疗，提高肿瘤治愈率、患者的生存率和生存质量。将是SLN活检手术的必然选择。     

腹腔镜前哨淋巴结活检在子宫恶性肿瘤中的应用

前哨淋巴结(SLN)是肿瘤转移的第一站,SIN检测技术在临床上的应用,对恶性肿瘤的外科治疗有重要指导意义.其在恶性黑色素瘤和乳腺癌中已成功应用,在子宫恶性肿瘤中的应用尚处在研究阶段.多项研究表明,SIN活检在早期子宫恶性肿瘤中是可行的,总结文献,SIN最常见于髂内外和闭孔区.联合放射性胶体和染料法可提高腹腔镜下SIN活检的检出率,放化疗、肿瘤体积、宫颈锥切手术史可影响其检出率.腹腔镜下SIN活检术野清晰、创伤小、并发症少,安全可行,可使患者得到更合理的个体化治疗,提高肿瘤治愈率、患者的生存率和生存质量.将是SIN活检手术的必然选择.     

Villoglandular papillary adenocarcinoma of the uterine cervix with bulky lymph node metastases

A patient with stage IIb cervical adenocarcinoma underwent Wertheim hysterectomy with pelvic lymphadenectomy and bilateral adenexectomy followed by radiotherapy. Review of histologic sections diagnosed villoglandular papillary adenocarcinoma (VGPA) with metastatic lymph nodes. The patient has been disease-free for 17 years. This patient is the third case of VGPA with lymph node metastasis ever reported.     

Embryonal rhabdomyosarcoma of the uterine corpus and cervix

Embryonal rhabdomyosarcomas of the uterus and cervix are rare tumors with a very poor prognosis historically. Adjuvant multidrug chemotherapy combined with local radiation therapy and/or surgery has resulted in markedly improved survival rates. Six patients with embryonal rhabdomyosarcoma of the uterus/cervix are reported, with a compilation of 28 additional patients from the literature. Nineteen of 24 patients (79%) treated with combination therapy were alive and well 4-147+ months (median 61 months) after diagnosis. The six cases from USC Medical Center and affiliated hospitals are all well 17-144 months (mean 95 months) after diagnosis. Analysis of the collected series indicates that extent of disease is an important prognostic factor. Adjuvant chemotherapy with vincristine, actinomycin D, and cyclophosphamide (VAC) improves survival. Initial therapy for embryonal rhabdomyosarcoma confined to the uterus/cervix should include radical hysterectomy, pelvic lymphadenectomy, and adjuvant chemotherapy with VAC. Pelvic radiotherapy should be employed for involved surgical margins or positive nodes. Advanced disease managed initially with chemotherapy and radiotherapy may allow subsequent curative extirpative surgery.     

Tumor size and lymph node metastases in squamous cell carcinoma of the uterine cervix.

Tumor size was accurately measured in 684 patients who had surgical treatment of cervical carcinoma after a small biopsy and received no preoperative radiotherapy. Frequency of lymph node metastases increased as five different tumor size parameters went up, depth of tumor invasion being of particular importance. When micrometastases, macrometastases, and tumor cell emboli were considered, a correlation was statistically verifiable for micrometastases and macrometastases. Such correlations could not be determined for tumor cell emboli. They are to be regarded as a random event.     

Negative sentinel lymph node accurately predicts negative status of pelvic lymph nodes in uterine cervix carcinoma

OBJECTIVE: The significance of negative sentinel lymph nodes (SLN) is important in the staging and treatment of melanoma and a few other cancers, but is controversial in uterine cervix carcinoma. Our study was aimed at correlating the SLN status in cervical carcinoma with non-sentinel lymph nodes (non-SLN), in a uniform and well controlled population. METHODS: This study includes 36 patients with stage I and IIA cervical carcinoma and bilaterally negative SLN on final pathology. SLN were identified using blue dye and radioisotopic techniques. Frozen section examination was performed for all SLN; the rest of the tissue was formalin fixed and paraffin embedded. The protocol used for SLN was also applied for non-SLN. For each block, six 4-micro m thick sections were cut at 40 micro m intervals and stained with H and E; an additional section taken between the 3rd and 4th levels was imunostained using AE1/AE3 cytokeratin. RESULTS: The mean age for the study population was 39 years (range 25-76); the number of SLN ranged from 2 to 6 (mean 2.7) and the non-SLN from 8 to 49 (mean 23) per case. No metastasis was found in any SLN and non-SLN by step sections and IHC. CONCLUSION: Our study demonstrates that bilaterally negative SLN on final pathology accurately predict the absence of metastases in non-SLN in cervical carcinoma. If confirmed by larger trials, these results may influence the clinical management of early cervical cancer.     

子宫颈癌盆腔淋巴结转移的CT评价

的诊断标准时,计算CT检查的敏感度和特异度分别为62.0%和93.5%;以盆腔CT影像上单侧淋巴结清晰且最大直径≥15 mm或有中心性坏死为淋巴结CT阳性的诊断标准时,敏感度和特异度分别为33.8%和99.0%.结论 螺旋CT检查对诊断宫颈癌盆腔淋巴结转移特异度较高,以淋巴结最大直径≥10 mm为诊断标准时敏感度较高.     

Adenocarcinoma of the uterine cervix: histologic variables associated with lymph node metastasis and survival

One hundred and two patients were treated for primary adenocarcinoma of the uterine cervix over a ten-year period from 1973 to 1982. Of these, 51 patients underwent initial surgical management that included a pelvic and para-aortic lymphadenectomy with a radical hysterectomy or a surgical staging operation. Clinical lesion size, grade, and depth of stromal invasion were correlated with lymph node metastasis and survival. The incidence of positive lymph nodes was 14.6% for stage I and 40.0% for stage II. Positive lymph nodes were documented in none of 15 patients with lesions smaller than 2 cm, 16.7% (five of 30) with 2 to 4 cm, and 82.3% (five of six) with larger than 4 cm; 5.3% of grade 1 tumors, 11.1% of grade 2, and 50.0% of grade 3. There were no lymph node metastases (zero of six) in patients with a tumor that had a depth invasion of less than 2 mm, whereas positive nodes were found in 11.1% (two of 18) patients with 2 to 5 mm of invasion, 28.6% (two of seven) with 5 to 10 mm, and 57.1% (four of seven) with greater than 10 mm of invasion. Five-year survival was 82.9% for stage I and 42.9% for stage II patients; 91.7% with negative lymph nodes, and 10% with positive nodes (P less than .0001). The size of the primary tumor (P less than .0001), tumor grade (P less than .05), and depth of invasion (P less than .05) correlated with patient survival.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prospective evaluation of FDG-PET for detecting pelvic and para-aortic lymph node metastasis in uterine corpus cancer

OBJECTIVES: To estimate the sensitivity and specificity of positron emission tomography (PET) with 2-[(18)F]fluoro-2-deoxy-d-glucose (FDG) for detecting pelvic and para-aortic lymph node metastasis in patients with uterine corpus carcinoma before surgical staging. METHODS: Patients with newly diagnosed FIGO grade 2 or 3 endometrioid, papillary serous, or clear cell adenocarcinoma or uterine corpus sarcoma scheduled for surgical staging, including bilateral pelvic and para-aortic lymphadenectomy, were eligible. PET was performed within 30 days of surgery and interpreted independently by two nuclear medicine physicians. The imaging, operative, and pathologic findings for each patient and each nodal site were compared, and the sensitivity and specificity of FDG-PET in predicting nodal metastasis were determined. RESULTS: Twenty patients underwent FDG-PET before surgical staging. One patient found to have ovarian carcinoma on final pathology was excluded. Of the 19 primary intrauterine tumors, 16 (84%) exhibited increased FDG uptake. One patient did not undergo lymphadenectomy; her chest CT was suspicious for metastatic disease and FDG-PET showed uptake in multiple nodal and pulmonary foci. Metastatic disease was confirmed by percutaneous nodal biopsy. A total of three pathologically positive nodes were found in 2 of the 18 patients (11%). FDG-PET predicted that 3 patients would have positive lymph nodes (2 true positive and 1 false positive). Analyzed by lymph node regions, FDG-PET had 60% sensitivity and 98% specificity. The sensitivity and specificity by individual patient were 67% and 94%, respectively. CONCLUSIONS: FDG-PET is only moderately sensitive in predicting lymph node metastasis pre-operatively in patients with endometrial cancer. This imaging modality should not replace lymphadenectomy, but may be helpful for patients in whom lymphadenectomy cannot be, or was not, performed.     

Sentinel lymph node detection in early stage uterine cervix carcinoma: a systematic review

OBJECTIVE: The aim of this study was to systematically review the diagnostic performance of Sentinel Node (SN) detection for assessing the nodal status in early stage cervical carcinoma, and to determine which technique (using blue dye, Technetium-99m colloid (99mTc), or the combined method) had the highest success rate in terms of detection rate and sensitivity. METHODS: A comprehensive computer literature search of English language studies in human subjects on Sentinel Node procedures was performed in MEDLINE and EMBASE databases up to July 2006. For each article two reviewers independently performed a methodological qualitative analysis and data extraction using a standard form. Pooled values of the SN detection rate and pooled sensitivity values of the SN procedure are presented with a 95% confidence interval (95% CI) for the three different SN detection techniques. RESULTS: We identified 98 articles, and 23 met the inclusion criteria, comprising a total of 842 patients. Ultimately, 12 studies used the combined technique with a sensitivity of 92% (95% CI: 84-98%). Five studies used 99mTc-colloid, with a pooled sensitivity of 92% (95% CI: 79-98%; p=0.71 vs. combined technique), and four used blue dye with a pooled sensitivity of 81% (67-92%, p=0.17 vs. combined technique). The SN detection rate was highest for the combined technique: 97% (95% CI: 95-98%), vs. 84% for blue dye (95% CI: 79-89%; p<0.0001), and 88% (95% CI: 82-92%, p=0.0018) for 99mTc colloid. CONCLUSION: SN biopsy has the highest SN detection rate when 99mTc is used in combination with blue dye (97%), and a sensitivity of 92%. Hence, according to the present evidence in literature the combination of 99mTc and a blue dye for SN biopsy in patients with early stage cervical cancer is a reliable method to detect lymph node metastases in early stage cervical cancer.     

Para-aortic lymph node irradiation for carcinoma of the uterine cervix using split course technique.

Twenty women with previously untreated cervical cancer received radical irradiation to the para-aortic lymph nodes and pelvis. Ninety percent received 6000 rads to the para-aortic nodes and pelvis in 8 weeks using split course technique. The mortality from complications of therapy, without evidence of recurrence, was 25%. Forty percent of the women were dead from recurrent cervical cancer (4–23M), and even with this short follow-up only 35% were surviving NED (6–29M). Methods for improving future trials of irradiation to the para-aortic nodes are discussed.     

Lymph node metastasis and lymph vascular space invasion in microinvasive squamous cell carcinoma of the uterine cervix

The objective of this study was to determine whether the depth of invasion was related to lymph vascular space invasion (LVSI) and lymph node metastasis and whether there was a correlation between LVSI and lymph node metastasis in stage IA cervical cancer. The medical records, including surgical notes and pathologic reports, of 202 patients with microinvasive squamous cell carcinoma of the uterine cervix were reviewed retrospectively. There was a positive correlation between the depth of invasion and the LVSI, and the incidence of lymph node metastasis was slightly higher than those reported hitherto for stage IA1 cervical cancer, especially in the depth of invasion of 1-3 mm group. However, among four patients with lymph node metastasis, only two patients had positive LVSI. There was no definite correlation between LVSI and lymph node metastasis. LVSI could not identify the patients with high risk for lymph node metastasis.     

Occult supraclavicular lymph node metastasis identified by FDG-PET in patients with carcinoma of the uterine cervix

PURPOSE: The objective was to evaluate the frequency and prognostic significance of occult supraclavicular lymph node metastases identified by 2-[(18)F]fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET) in patients with cervical carcinoma. PATIENTS AND METHODS: Between March 1998 and January 2002, 186 patients with a new diagnosis of cervical cancer underwent whole-body FDG-PET before therapy. Fourteen patients had abnormal FDG uptake in left supraclavicular lymph nodes without palpable disease. All 14 patients underwent sonographically guided fine-needle aspiration of the left supraclavicular lymph nodes. One patient refused therapy, 6 were treated with palliative intent, and 7 received definitive irradiation and concurrent chemotherapy. Survival was calculated by the Kaplan-Meier method. RESULTS: The overall frequency of FDG-positive left supraclavicular lymph nodes was 8% (14/186). Metastasis was pathologically confirmed in all 14 patients. Therefore, the positive predictive value of abnormal FDG uptake in left supraclavicular lymph nodes was 100%. Nineteen percent of all patients (35/186) had abnormal FDG uptake in para-aortic lymph nodes. The frequency of positive FDG uptake in the left supraclavicular lymph nodes was 40% (14/35) in those with para-aortic lymph node uptake and 15% in those with stage IIIb disease. The median overall survival was 7.5 months. At last follow-up, 11 patients were dead and 3 were alive with disease. All patients developed metastatic disease, most commonly to bone and lung. CONCLUSION: The positive predictive value of abnormal FDG uptake in left supraclavicular lymph nodes was 100%. Prognosis for these patients was dismal despite aggressive therapy.