Intraoperative sentinel node identification in early stage cervical cancer using a combination of radiolabeled albumin injection and isosulfan blue dye injection

OBJECTIVES: We investigated the feasibility of sentinel lymph node identification using radioisotopic lymphatic mapping with technetium-99m-labeled human serum albumin and isosulfan blue dye injection in patients undergoing radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer. METHODS: Between September 2000 and October 2002, 25 patients with cervical cancer FIGO stage I (n=24) or stage II (n=1) underwent sentinel lymph node detection with preoperative lymphoscintigraphy (technetium-99m colloid albumin injection around the tumor) and intraoperative lymphatic mapping with blue dye and a handheld or laparoscopic gamma probe. Complete pelvic or paraaortic lymphadenectomy was performed in all cases by open surgery or laparoscopic surgery. RESULTS: In 23 evaluable patients, a total of 51 sentinel lymph nodes were detected by lymphoscintigraphy (mean 2.21 nodes per patient). Intraoperatively, 61 sentinel lymph nodes were identified, with a mean of 2.52 nodes per patient by gamma probe and a mean of 1.94 nodes per patient after isosulfan blue injection. Forty percent of sentinel nodes were found in the interiliac region and 25% in the external iliac area. Microscopic nodal metastases (four nodes) were confirmed in 12% of cases. All these lymph nodes were previously detected as sentinel lymph nodes. The remaining 419 nodes after pelvic lymphadenectomy were histologically negative. CONCLUSIONS: Sentinel lymph node identification with technetium-99m-labeled nanocolloid combined with blue dye injection is feasible and showed a 100% negative predictive value, and potentially identified women in whom lymph node dissection can be avoided.     

Sentinel node detection in cervical cancer with (99m)Tc-phytate

OBJECTIVES: The aim of this study was to investigate the feasibility of sentinel lymph node (SLN) identification using radioisotopic lymphatic mapping with technetium-99 m-labeled phytate in patients undergoing radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer. METHODS: Between July 2001 and February 2003, 56 patients with cervical cancer FIGO stage I (n = 53) or stage II (n = 3) underwent sentinel lymph node detection with preoperative lymphoscintigraphy ((99m)Tc-labeled phytate injected into the uterine cervix, at 3, 6, 9, and 12 o'clock, at a dose of 55-74 MBq in a volume of 0.8 ml) and intraoperative lymphatic mapping with a handheld gamma probe. Radical hysterectomy was aborted in three cases because parametrial invasion was found intraoperatively and we performed only sentinel node resection. The remaining 53 patients underwent radical hysterectomy with complete pelvic lymphadenectomy. Sentinel nodes were detected using a handheld gamma-probe and removed for pathological assessment during the abdominal radical hysterectomy and pelvic lymphadenectomy. RESULTS: One or more sentinel nodes were detected in 52 out of 56 eligible patients (92.8%). A total of 120 SLNs were detected by lymphoscintigraphy (mean 2.27 nodes per patient) and intraoperatively by gamma probe. Forty-four percent of SLNs were found in the external iliac area, 39% in the obturator region, 8.3% in interiliac region, and 6.7% in the common iliac area. Unilateral sentinel nodes were found in thirty-one patients (59%). The remaining 21 patients (41%) had bilateral sentinel nodes. Microscopic nodal metastases were confirmed in 17 (32%) cases. In 10 of these patients, only SLNs had metastases. The 98 sentinel nodes that were negative on hematoxylin and eosin were submitted to cytokeratin immunohistochemical analysis. Five (5.1%) micrometastases were identified with this technique. The sensitivity of the sentinel node was 82.3% (CI 95% = 56.6-96.2) and the negative predictive value was 92.1% (CI 95% = 78.6-98.3). The accuracy of sentinel node in predicting the lymph node status was 94.2%. CONCLUSION: Preoperative lymphoscintigraphy and intraoperative lymphatic mapping with (99m)Tc-labeled phytate are effective in identifying sentinel nodes in patients undergoing radical hysterectomy and to select women in whom lymph node dissection can be avoided.     

Preoperative pelvic lymphoscintigraphy is of limited usefulness for sentinel lymph node detection in cervical cancer

Objectives

To analyze concordance between preoperative lymphoscintigraphy and intraoperative lymphatic mapping (ILM) for sentinel lymph node identification using technetium 99m-labeled-dextran 500 (99m-Tc) and patent blue dye in patients with early cervical cancer undergoing radical hysterectomy and pelvic lymphadenectomy, as well as to evaluate sentinel lymph node (SLN) detection.

Study design

Forty-seven patients underwent surgical treatment for cervical cancer. For SLN identification, 99m-Tc and blue patent were injected into the cervix on the eve and day of surgery, respectively. Preoperative pelvic lymphoscintigraphy was performed in all patients after 99m-Tc injection. Concordance between preoperative lymphoscintigraphy and ILM was evaluated.

Results

Of the 56 patients who underwent preoperative lymphoscintigraphy, 43 (81.13%) had at least one lymph node identified. Bilateral lymph nodes were identified in 21 (37.5%) patients. Sentinel lymph nodes detected on ILM had been previously found on preoperative lymphoscintigraphy in 66.7%, 67.2% and 0% in the right, left and central locations, respectively. In 14 patients (25%), only one lymph node was identified on preoperative lymphoscintigraphy, but more than one sentinel lymph node was detected on intraoperative mapping. In nine (16.1%) patients, lymphoscintigraphy showed only unilateral lymph nodes, but ILM identified bilateral sentinel lymph nodes.

Conclusion

The combination of patent blue and radionuclide techniques produced excellent results for SLN detection in cervical cancer. Preoperative lymphoscintigraphy does not offer any advantage over ILM for SLN identification.     

Lymph node mapping and sentinel node detection in carcinoma of the cervix, endometrium and vulva

OBJECTIVES: Validity of the sentinel node concept in patients with cervical, endometrial and vulvar cancer. MATERIAL AND METHODS: 47 cases of FIGO stage I and II cervical cancer, 33 cases of first clinical stage of endometrial cancer and 37 patients with FIGO stage I and II of vulvar cancer. In cervical and vulvar cancer preoperative lymphoscyntygraphy and intraoperative lymphatic mapping with blue dye and handheld gamma probe were performed. In patients with endometrial cancer intraoperative lymphatic mapping with blue dye injected into the cervix and into the uterine corpus subserously were done. In the last 10 cases radiolabeled nannocolloid were administered and the patients underwent preoperative lymphoscyntygraphy and intraoperative radio detection of sentinel node. Sentinel nodes were labeled as blue, radioactive, or blue/radioactive. RESULTS: In cervical cancer sensitivity of the dye and radiocolloid methods was 94%, specificity 100% and negative predictive value 97%. Out of 33 cases of endometrial cancer sentinel node was identified in 29 (87.87%) patients. None of women with histological negative sentinel node had metastases in the rest of lymph nodes resected. Sentinel node was detected in all cases of vulvar cancer. The status of sentinel nodes were representative for all lymph node resected. CONCLUSIONS: Concept of sentinel node may be applied first of all for vulvar cancer and also for cervical and endometrial cancer.     

Sentinel lymph node detection in patients with endometrial cancer

OBJECTIVE: The purpose of this study was to examine the feasibility of sentinel lymph node (SLN) detection in patients with endometrial cancer using preoperative lymphoscintigraphy and an intraoperative gamma probe. PATIENTS AND METHODS: Between June 2001 and January 2003, 28 consecutive patients with endometrial cancer who were scheduled for total abdominal hysterectomy, bilateral salpingo-oophorectomy, total pelvic lymphadenectomy, and paraaortic lymphadenectomy at Tohoku University School of Medicine underwent sentinel lymph node detection. On the day before surgery, preoperative lymphoscintigraphy was performed by injection of 99m-Technetium ((99m)Tc)-labeled phytate into the endometrium during hysteroscopy. At the time of surgery, a gamma-detecting probe was used to locate radioactive lymph nodes. RESULTS: At least one sentinel node was detected in each of 23 of the 28 patients (82%). The mean number of sentinel nodes detected was 3.1 (range, 1-9). Sentinel nodes could be identified in 21 of 22 patients (95%) whose tumor did not invade more than halfway into the myometrium. Eighteen patients had radioactive nodes in the paraaortic area. Most patients had a sentinel node in one of the following three sites: paraaortic, external iliac, and obturator. The sensitivity and specificity for detecting lymph node metastases were both 100%. CONCLUSION: The combination of preoperative lymphoscintigraphy with intraoperative gamma probe detection may be useful in identifying sentinel nodes in early-stage endometrial cancer.     

Sentinel lymph node detection in early cervical cancer with combination 99mTc phytate and patent blue

OBJECTIVE: The purpose of this study was to examine sentinel lymph node (SLN) detection in patients with early stage cervical cancer using (99m)Tc phytate and patent blue dye and to compare our method with published findings utilizing other radioisotopic tracers. PATIENTS AND METHODS: A total of 20 consecutive patients with cervical cancer scheduled for radical hysterectomy and total pelvic lymphadenectomy at our hospital underwent SLN detection study. The day before surgery, lymphoscintigraphy was performed with injection of 99m-technetium ((99m)Tc)-labeled phytate into the uterine cervix. At surgery, patients underwent lymphatic mapping with a gamma-detecting probe and patent blue injected into the same points as the phytate solution. RESULTS: At least one positive node was detected in 18 patients (90%). A total of 46 sentinel nodes were detected (mean, 2.3; range, 1-5). Most sentinel nodes were in one of the following sites: external iliac (21 nodes), obturator (15 nodes), and parametrial (7 nodes). Eleven (24%) sentinel nodes were detected only through radioactivity and two (4%) were detected only with blue dye. The sensitivity, specificity, and negative predictive value for SLN detection were all 100%. Nine published studies involving 295 patients had a summarized detection rate of 85%. Summarized sensitivity, specificity, and negative predictive value were 93%, 100%, and 99%, respectively. CONCLUSION: Combination of (99m)Tc phytate and patent blue is effective in SLN detection in early stage cervical cancer.     

Total laparoscopic radical hysterectomy with intraoperative sentinel node identification in patients with early invasive cervical cancer

OBJECTIVES: To describe the feasibility and results of total laparoscopic radical hysterectomy with intraoperative sentinel lymph node identification in patients with early cervical cancer. METHODS: Between March 2001 and October 2003, 12 patients with FIGO stage IA(2) (n = 1) or IB(1) (n = 11) cancer of the cervix underwent surgical treatment through the laparoscopic route. All patients underwent a laparoscopic sentinel node identification with preoperative lymphoscintigraphy (technetium-99 m colloid albumin injection around the tumor) and intraoperative lymphatic mapping with isosulfan blue dye and a laparoscopic gamma probe followed by systematic bilateral pelvic lymphadenectomy and laparoscopic type II (n = 5) or type III (n = 7) hysterectomy. RESULTS: A mean of 2.5 sentinel nodes per patient (range 1-4) was detected, with a mean of 2.33 nodes per patient by gamma probe and a mean of 2 per patient after blue injection (combined detection rate 100%). The most frequent localization of the nodes was the interiliac region. Histopathologic examination of sentinel nodes including cytokeratin immunohistochemical analysis did not show metastasis. Microscopic nodal metastases were not found. The mean number of resected pelvic nodes was 18.6 per patient (range 10-28). The operation was performed entirely by laparoscopy in all patients and no case of laparotomy conversion was recorded. The mean duration of operation was 271 min (range 235-300), with a mean blood loss of 445 mL (range 240-800), and a mean length of stay of 5.25 days (range 3-10). No major intraoperative complications occurred. After a median follow-up of 20 months (range 5-34), all patients are free of disease. CONCLUSIONS: This study shows the feasibility of the combination of laparoscopic intraoperative sentinel node mapping and laparoscopic radical surgery in the context of minimally invasive surgery for the management of patients with early cervical cancer.     

Laparoscopic sentinel node mapping in early-stage cervical cancer

OBJECTIVE: We aimed to determine the feasibility and accuracy of sentinel node (SN) mapping and its ability to predict the status of the regional nodal basin. METHODS: From October 2000 to September 2002, 70 patients undergoing radical surgery for early-stage cervical cancer (stage IA, IB, and IIA) were offered lymph node mapping for identification of the sentinel node. All patients underwent SN identification laparoscopically followed by a complete laparoscopic pelvic node and parametrial dissection. The SN mapping was done after intracervical blue dye injection in all cases and was combined with preoperative lymphoscintigraphy following intracervical Tc-99 injection and intraoperative SN detection with a miniaturized laparoscopic gamma probe in 29 cases (42%). RESULTS: The blue dye technique alone (n = 70) identified at least 1 SN in 61 (87%) of the patients. The rate of SN detection by side of dissection was 74%, 70% on the left side and 77% on the right side. Bilateral SN were identified in 60% of cases. In the subgroup of patients who had the combined technique (n = 29), the rate of SN detection increased from 79 to 93% (P = 0.04). The bilateral SN detection rate increased from 55 to 72% when adding lymphoscintigraphy (P = 0.03). In the last 15 cases of the series, the SN detection rate reached 93% (14/15) and this was statistically significant compared to the detection rate of the first 55 cases (P < 0.01). A total of 135 SN were identified, with the majority (88%) being located at three main sites: the external iliac, obturator, and bifurcation. Thirty-six patients (51%) had 2 SN identified, and 16 (24%) had 3 SN or more. Twelve (17%) patients had positive lymph nodes. In those cases, the rate of SN detection per side of dissection in patients with normal appearing nodes at laparoscopy was 75%, whereas it was only 56% in patients with macroscopically involved lymph nodes (P = NS). The false negative rate was 0. The negative predictive value of SN mapping was 100% and the sensitivity was 93% with the combined technique. Two patients had allergic reactions to the blue dye (3%). CONCLUSION: Sentinel node mapping with the combined blue dye technique and lymphoscintigraphy in patients with cervical cancer is laparoscopically feasible and is highly accurate. The detection rate improves significantly with experience and with the use of lymphoscintigraphy.     

Interest of preoperative lymphoscintigraphy on sentinel lymph node identification in patients with breast cancer

Sentinel lymph node biopsy is nowadays an accepted method of staging breast cancer patients. In case of an injection of radioactive colloid, preoperative lymphoscintigraphy is recommended to establish a lymphatic mapping and to predict the number of sentinel lymph nodes identified during surgery. Preoperative lymphoscintigraphy does not decrease the false-negative rate. However, positive preoperative lymphoscintigraphy significantly improves the identification rate of intraoperative sentinel nodes comparing with negative preoperative lymphoscintigraphy. Detecting extra-axillary sentinel lymph nodes, because of its minimal therapeutic consequences, does not appear to be an indication for preoperative lymphoscintigraphy. Given logistics and cost required, preoperative lymphoscintigraphy should be only performed for patients with a high risk of intraoperative failed localization. In case of negative preoperative lymphoscintigraphy, sentinel lymph node biopsy must be tried because sentinel nodes are still identified in the majority of these patients. Another possibility, with important cost and logistic, should consist in performing a later lymphoscintigraphy on the day after radioactive injection to ameliorate sentinel lymph nodes identification.     

Radioguided sentinel lymph node detection in vulvar cancer

Lymph node status is the most important prognostic factor in vulvar cancer. Histologically, sentinel nodes may be representative of the status of the other regional nodes. Identification and histopathologic evaluation of sentinel nodes could then have a significant impact on clinical management and surgery. The aim of this study was to evaluate the feasibility and diagnostic accuracy of sentinel lymph node detection by preoperative lymphoscintigraphy with technetium-99 m-labeled nanocolloid, followed by radioguided intraoperative detection. Nine patients with stage T1, N0, M0, and 11 patients with stage T2, N0, M0 squamous cell carcinoma of the vulva were included in the study. Only three cases had lesions exceeding 3.5 cm in diameter. Sentinel nodes were detected in 100% of cases. A total of 30 inguinofemoral lymphadenectomies were performed, with a mean of 10 surgically removed nodes. Histological examination revealed 17 true negative sentinel nodes, 2 true positive, and 1 false negative. In our case series, sentinel lymph node detection had a 95% diagnostic accuracy, with only one false negative. Based on literature evidence, the sentinel node procedure is feasible and reliable in vulvar cancer; however, the value of sentinel node dissection in the treatment of early-stage vulvar cancer still needs to be confirmed.     

Laparoscopic detection of sentinel lymph nodes followed by lymph node dissection in patients with early stage cervical cancer

OBJECTIVE: The purpose of this study was to investigate the feasibility of sentinel node detection through laparoscopy in patients with early cervical cancer. Furthermore, the results of laparoscopic pelvic lymph node dissection were studied, validated by subsequent laparotomy. METHODS: Twenty-five patients with early stage cervical cancer who planned to undergo a radical hysterectomy and pelvic lymph node dissection received an intracervical injection of technetium-99m colloidal albumin as well as blue dye. With a laparoscopic gamma probe and with visual detection of blue nodes, the sentinel nodes were identified and separately removed via laparoscopy. If frozen sections of the sentinel nodes were negative, a laparoscopic pelvic lymph node dissection, followed by radical hysterectomy via laparotomy, was performed. If the sentinel nodes showed malignant cells on frozen section, only a laparoscopic lymph node dissection was performed. RESULTS: One or more sentinel nodes could be detected via laparoscopy in 25/25 patients (100%). A sentinel node was found bilaterally in 22/25 patients (88%). Histological positive nodes were detected in 10/25 patients (40%). One patient (11%) had two false negative sentinel nodes in the obturator fossa, whereas a positive lymph node was found in the parametrium removed together with the primary tumor. In seven patients (28%), the planned laparotomy and radical hysterectomy were abandoned because of a positive sentinel node. Bulky lymph nodes were removed through laparotomy in one patient, and in six patients only laparoscopic lymph node dissection and transposition of the ovaries were performed. These patients were treated with chemoradiation. In two patients, a micrometastasis in the sentinel node was demonstrated after surgery. Ninety-two percent of all lymph nodes was retrieved via laparoscopy, confirmed by laparotomy. Detection and removal of the sentinel nodes took 55 +/- 17 min. Together with the complete pelvic lymph node dissection, the procedure lasted 200 +/- 53 min. CONCLUSION: Laparoscopic removal of sentinel nodes in cervical cancer is a feasible technique. If radical hysterectomy is aborted in the case of positive lymph nodes, sentinel node detection via laparoscopy, followed by laparoscopic lymph node dissection, prevents potentially harmful and unnecessary surgery.     

Role of sentinel lymph node biopsy procedure in cervical cancer: a critical point of view

OBJECTIVE: To report our experience about the role of sentinel node biopsy in cervical cancer patients while debating provocatory arguments concerning this procedure. METHODS: From June 2001 to February 2003, patients affected by stage IB(1) cervical cancer were submitted to the sentinel node biopsy procedure. Patients were submitted to lymphoscintigraphy and, subsequently, to laparoscopy in order to locate the sentinel lymph node. RESULTS: Thirty-seven patients were enrolled in the study. Sentinel node(s) was(were) identified with preoperative lymphoscintigraphy in 89% of the patients. Intraoperative detection rate was 70%. During surgery in 31% of the patients, sentinel node was detected bilaterally; in 15%, two sentinel nodes on the same side of the lymphatic vessels were detected. The sentinel node was located at the level of superficial common iliac vessels (26%), external iliac vessels (69%), and superficial obturator vessels (49%). In 77% of the patients, the histologic specimen sent by the surgeon as unique sentinel node contained two or more nodes. Metastatic sentinel nodes were found in 23% of the patients. There was no case with a positive nonsentinel node in the presence of a negative sentinel node. CONCLUSION: Sentinel node detection is a feasible procedure in cervical cancer patients. However, a high percentage of patients is found with bilateral and/or more than one sentinel lymph node. Improvements in detection rate and pathological analysis are needed prior to consider the sentinel node biopsy a routine procedure in cervical cancer patients.     

Sentinel node detection in cervical cancer

BACKGROUND: For superficial tumors such as melanoma, breast, and vulvar cancer, sentinel node detection prevents unnecessary extensive lymph node dissections. Sentinel node detection has not yet proved feasible in tumors, such as cervical cancer, that drain to deep pelvic lymph nodes. TECHNIQUE: We injected technetium-99m colloidal albumin around the tumor allowing preoperative lymphscintigraphy and intraoperative gamma probe detection of sentinel nodes. For visual detection, blue dye was injected at the start of surgery. EXPERIENCE: In six of 10 eligible women who had Wertheim-Meigs operations for cervical cancer stage Ib, one or more sentinel nodes could be detected by scintigraphy. Intraoperative gamma probe detection was successful in eight of ten women, whereas visual detection found sentinel nodes in only four. They were found as far as the common iliac level. One woman had positive lymph nodes, of which one was a sentinel node. CONCLUSION: Identification of sentinel nodes using radionuclide is possible in women with cervical cancer and potentially identifies women in whom lymph node dissection can be avoided.     

Intraoperative lymphatic mapping and sentinel lymph node dissection in cervical uterine cancer

Regional lymph node involvement is the most important prognostic indicator in patients with solid tumors. Conventional lymph node dissection has not been shown to affect survical and is often associated with considerable morbidity. Intraoperative lymphatic mapping and sentinel lymph node dissection were therefore designed as a minimally invesive alternative to routine elective lymph node dissection in patients with primary cutaneous melanoma. This study examined whether intraoperative lympatic mapping and sentinel lymph node dissection were accurate in staging patients with cervical cancer.     

Accuracy of sentinel lymph node detection following intra-operative cervical injection for endometrial cancer: A prospective study

Objective

The objective of this study is to evaluate the detection rate and diagnostic accuracy of sentinel lymph node (SLN) mapping using intra-operative cervical injection of filtered 99mTc-sulfur colloid (99mTc-SC) and patent blue in patients with endometrial cancer.

Methods

Prospective evaluation of the first 100 endometrial cancer patients undergoing SLN mapping using cervical injection of patent blue combined with filtered 99mTc-SC in the operating room was done. Patients underwent robotic-assisted lymphatic mapping with frozen section, hysterectomy, BSO, and completion bilateral lymphadenectomy (including para-aortic nodes in grade 2 and 3 tumors).

Results

At least one SLN was detected in 92% of patients; in 66 of these (72%) bilateral SLN were detected, and in 15 cases the SLN was in the para-aortic area. Eleven percent of all patients had lymph node metastases, and 4 of which had pre-operative grade 1 tumor. The SLN was the only positive node in 44% of the cases with positive nodes. Sensitivity was 89% with 1 false negative result, yielding a negative predictive value of 99% (95% CI 93-100). Specificity was 100% (95% CI 94-100), and positive predictive value was 100% (95% CI 60-100). No complications or anaphylactic reactions were noted.

Conclusions

Intra-operative SLN biopsy, using cervical injection of patent blue and filtered 99mTc-SC in endometrial cancer patients is feasible and yields adequate detection rates.     

Sentinel lymph node biopsy in the management of early-stage cervical carcinoma

Objectives

We aimed to determine the sentinel lymph node detection rates, accuracy in predicting the status of lymph node metastasis, and if pathologic ultrastaging improves the detection of micrometastases and isolated tumor cells at the time of primary surgery for cervical cancer.

Methods

A prospective, non-randomized study of women with early-stage (FIGO stage IA1 with lymphovascular space involvement — IIA) cervical carcinoma was conducted from June 2003 to August 2009. All patients underwent an intraoperative intracervical blue dye injection. Patients who underwent a preoperative lymphoscintigraphy received a 99 m Tc sulfur colloid injection in addition. All patients underwent sentinel lymph node (SLN) identification followed by a complete pelvic node and parametrial dissection. SLN were evaluated using our institutional protocol that included pathologic ultrastaging.

Results

SLN mapping was successful in 77 (95%) of 81 patients. A total of 316 SLN were identified, with a median of 3 SLN per patient (range, 0-10 SLN). The majority (85%) of SLN were located at three main sites: the external iliac (35%); internal iliac (30%); and obturator (20%). Positive lymph nodes (LN) were identified in 26 (32%) patients, including 21 patients with positive SLN. Fifteen of 21 patients (71%) had SLN metastasis detected on routine processing. SLN ultrastaging detected metastasis in an additional 6/21 patients (29%). Two patients had grossly positive LN at exploration, and mapping was abandoned. Three of 26 (12%) patients had successful SLN mapping; however, the SLN failed to identify the metastatic LN. Of these 3 false negative cases, 2 patients had a metastatic parametrial node as the only positive LN with multiple negative pelvic nodes including negative SLN. One patient with stage IA1 disease and lymphovascular invasion had unilateral SLN mapping and a metastatic common iliac LN identified on completion lymphadenectomy of the contralateral side that did not map. The 4 (5%) patients with unsuccessful mapping included 1 who had grossly positive nodes identified at the time of laparotomy; the remaining 3 occurred during each surgeon's initial SLN mapping learning phase.

Conclusion

SLN mapping in early-stage cervical carcinoma yields high detection rates. Ultrastaging improves micrometastasis detection. Parametrectomy and side-specific lymphadenectomy (in cases of failed mapping) remain important components of the surgical management of selected cases.     

Sentinel node biopsy helps to diagnose spread of endometrial cancer. A case report

BACKGROUND: The sentinel lymph node (SLN) could improve the staging of endometrial cancer. CASE: In a patient with endometrial cancer, preoperative lymphoscintigraphy showed a highly radioactive SLN in the left external iliac chain and a radioactive SLN in the right external iliac chain and at the promontory. Intraoperative lymphatic mapping using blue dye and a hand-held gamma probe showed the same nodes, as well as a blue node near the vena cava. Selective removal of these nodes allowed detection of a micrometastasis in the left external iliac node. Pelvic node dissection was performed, and a micrometastasis was found in a left non sentinel iliac node. CONCLUSION: The presence in our patient of micrometastases in a SLN and in a non-SLN belonging to the same chain confirms the value of SLN detection for diagnosing tumor spread.     

Change in clinical management of sentinel lymph node location in early stage cervical cancer: the role of SPECT/CT

Objective

The aim of this study was to investigate the feasibility of the sentinel lymph node (SLN) identification with SPECT/CT lymphoscintigraphy imaging in the early stage invasive cervical cancer in patients undergoing radical hysterectomy and pelvic lymphadenectomy.

Methods

Between March 2007 and June 2009, a prospective consecutive study was designed for SLN mapping. Twenty-two patients with cervical cancer FIGO stage IB1 (n = 20) or stage IIA1 (n = 2) underwent SLN identification with preoperative SPECT/CT and planar images (technetium-99 m colloid albumin injection around the tumor) and posterior intraoperative detection with both blue dye and a handheld or laparoscopic gamma probe. Complete pelvic lymphadenectomy was performed in all cases by open (n = 2) or laparoscopic (n = 20) surgery.

Results

In the present series, a total of 35 SLN were detected with planar images and 40 SLN were identified and well located by SPECT/CT lymphoscintigraphy (median 2.0 nodes per patient). In 5/22 patients (22.7%) SPECT/CT procedure improves the number of localized SLN. Intraoperatively, 57 SLNs were identified, with a median of 3 SLNs per patient by gamma probe (a total of 53 hot nodes) and a median of 2 nodes per patient after blue dye injection (a total of 42 blue nodes). Microscopic nodal metastases (eight nodes, corresponding to four patients) were confirmed in 18.18% of cases; all these lymph nodes were previously detected as SLN. The remaining 450 nodes, including SLNs, following complete pelvic lymphadenectomy, were histologically negative.

Conclusions

Sentinel lymph node detection is improved by SPECT/CT imaging because of the increased number of SLN detected and the better tridimensional anatomic location, allowing easier intra-operative detection with gamma probe and showing, in this series, a 100% negative predictive value.     

Value of indocyanine green pelvic lymph node mapping in the surgical approach of cervical cancer

Lymph node metastasis is a significant predictive factor for disease recurrence and survival in cervical cancer patients and relevant for therapeutic strategies. We evaluated the clinical value of indocyanine green (ICG) by measuring the sensitivity and negative predictive value of sentinel lymph node mapping compared with the gold standard of complete lymphadenectomy in detecting lymph node metastases for cervical cancer. We utilized the near-infrared imaging agent ICG to detect tumor-infested lymph nodes in the pelvis analogue to a classical sentinel lymph node procedure by analyzing data from 20 patients who had undergone surgery for cervical cancer at our institution. A laparoscopic lymph node mapping procedure by means of ICG, followed by a complete pelvic lymphadenectomy with or without paraaortic lymphadenectomy was done in all patients. Histological examination identified seven patients with tumor-positive pelvic nodes, whereas mapping with ICG identified only five of these patients. Detection rate of positive nodes by ICG mapping and false negative rate was 71.4% and 28.6%, respectively; bilateral detection rate was 83.3%. One of the two false negative patients additionally suffered from deep infiltrating endometriosis. Our results indicate that ICG can identify the relevant pelvic nodes independent of tumor size, provided bilateral detection is achieved and additional, related diseases are excluded. This trial is registered within the German Clinical Trial Register (DRKS-ID: DRKS00014692).     

Detection of the sentinel lymph node under local anaesthesia in early-stage breast cancer: feasibility study in a series of 78 unselected patients

AIMS: To evaluate the feasibility of excision of the sentinel lymph node under local anaesthesia in early-stage breast cancer. METHODS: Sentinel lymph node detection under local anaesthesia was carried out on all patients presenting with breast cancer at Stage T0, T1 or T2 < 3 cm and N0, M0. The lymph node was mapped using a radioisotope and patent blue dye and lymphoscintigraphy was routinely performed. No premedication was given, and local anaesthesia was carried out with xylocaine. The patients underwent tumorectomy one week later under general anaesthesia, with or without complete axillary dissection, depending on the results of the definitive histopathological examination of the sentinel lymph node. RESULTS: 78 patients underwent this procedure over a period of 20 months. The procedure was successful in 76 out of the 78 patients, with one failure in mapping and one failure in detection (detection rate = 97.4%). The mean time to detection was 21 min (range: 6-45). It was unnecessary to interrupt the procedure due to patient discomfort in any of the cases. One allergic reaction to patent blue dye was noted and required corticosteroid therapy without interruption of the procedure.The time to detection was correlated with the experience of the surgeon carrying of the procedure, the patient's body mass index and the number of labelled lymph nodes found at lymphoscintigraphy. CONCLUSION: We have shown that it is feasible to detect the sentinel lymph node under local anaesthesia in an unselected population. Using this procedure, patients can undergo surgery with the knowledge of their axillary lymph node status while at the same time avoiding the uncertainties of an intraoperative examination of the sentinel lymph node--a source of many false negatives, particularly in the event of micrometastases.