Laparoscopic identification of sentinel lymph nodes in early stage cervical cancer: prospective study using a combination of patent blue dye injection and technetium radiocolloid injection

OBJECTIVE: To determine the feasibility of intraoperative radioisotopic mapping using an endoscopic gamma probe associated with patent blue dye injection in patients with early stage cervical cancer. METHODS: Between April 2001 and March 2002 a total of 12 patients underwent laparoscopic bilateral pelvic lymphadenectomy (squamous carcinoma in 10 cases, all stage FIGO IB1, and adenocarcinoma in 2 cases, stages IA2 and IB1). Lymphoscintigraphies were performed on the day before surgery to visualize sentinel lymph nodes, 31 +/- 22.5 and 174 +/- 34 min after injection of 200 microCi of technetium 99m rhenium sulfur colloid. The marker was injected at the 3, 6, 9, and 12 o'clock positions. The day of surgery 2 ml of patent blue dye plus 2 ml of physiological serum was injected in the cervix, at the same locations as the radioactive isotope injection. RESULTS: A total of 35 sentinel lymph nodes were detected. Eight sentinel lymph nodes were only detected by color, 8 sentinel lymph nodes were only detected by the endoscopic gamma probe, and 19 sentinel lymph nodes were "hot and dyed." We found 3 metastatic lymph nodes. In one case, bilateral positive sentinel nodes were only detected by the endoscopic gamma probe. Permanent section identified one inframillimetric micrometastasis in a lymph node that was neither blue nor hot intraoperatively (sensitivity = 66%, specificity = 100%, positive predictive value = 100%, negative predictive value = 90%). CONCLUSION: The identification of the sentinel lymph node with blue dye and radioisotope using an endoscopic gamma probe is feasible and improves detection rate. False negatives still occur, but the proportion is low even at the beginning of the learning curve. Isotopic imaging identifies nodes in areas outside the pelvis not routinely sampled in early cervical cancer patients.     

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.     

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 node detection with radiocolloid lymphatic mapping in early invasive cervical cancer

We assessed the feasibility of sentinel lymph node detection using technicium-99 radiocolloid lymphatic mapping for predicting lymph node metastases in early invasive cervical cancer. Thirty patients with cervical cancer (stages IA2-IIA) underwent preoperative lymphoscintigraphy using technicium-99 intracervical injection and intraoperative lymphatic mapping with a handheld gamma probe. After dissection of the sentinel nodes, the standard procedure of pelvic lymph node dissection and radical hysterectomy was performed as usual. The sentinel node detection rate was 100% (30/30). There were seven (23.3%) cases of microscopic lymph node metastases on pathologic analysis. All of them had sentinel node involvement. Therefore, the sensitivity of sentinel node identification for prediction of lymph node metastases was 100%, and no false negative was found. Preoperative lymphoscintigraphy, coupled with intraoperative lymphatic mapping, located the sentinel nodes accurately in our study patients. This sentinel node detection method appears to be feasible for predicting lymph node metastases.     

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.     

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 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.     

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.     

Sentinel node detection with the blue dye technique in early cervical cancer

OBJECTIVE: The aim of this study was to investigate the feasibility of sentinel node detection with the blue dye technique in early cervical cancer. METHODS: In a retrospective study conducted between January 2000 and February 2005, 47 women with early cervical cancer (6 patients FIGO Stage I A, 38 patients FIGO Stage I B, 2 patients FIGO Stage II A, 1 patient FIGO Stage II B) who underwent class II-III radical hysterectomy with pelvic lymphadenectomy were identified. Prior to surgery 1 ml of blue dye (lymphazurin 1%) was injected into the four quadrants of the cervix. RESULTS: The detection rate for sentinel nodes was 83% (39/47 patients). The median number of sentinel lymph nodes per patient was two. Nine patients had positive sentinel nodes. In one patient the sentinel lymph node procedure revealed to be false-negative. Positive predictive value and specificity were both 100%. The sensitivity and negative predictive value were 90% and 97%, respectively. CONCLUSIONS: Sentinel node detection has become a main field of interest in gynecological oncology. Our detection rate and sensitivity rate using the blue dye technique in cervical cancer are comparable to those in previously published data. However, recent data on a combined radioactively labeled albumin and blue dye technique show even more promising results. The clinical validity of the combined techniques must be evaluated prospectively in larger studies.     

Lymphatic mapping and sentinel node biopsy in women with high-risk endometrial cancer

OBJECTIVE: To evaluate fundal injection of blue dye and radiocolloid for lymphatic mapping and sentinel node identification in women with high-risk endometrial cancer. METHODS: At laparotomy, 18 women with high-risk endometrial cancer had isosulfan blue and technitium-99 radiocolloid injected into the uterine fundus subserosally. Sentinel nodes were then identified either by direct observation of blue dye, by radioactive counts using a handheld gamma counter, or by a combination of both methods. The number and location of sentinel node(s) were recorded and compared with the final lymph node specimens after hysterectomy and selective lymphadenectomy. RESULTS: A sentinel node was identified in only 8 (45%) of the cases. Four patients had sentinel nodes only in the pelvis, 2 had sentinel nodes in the pelvis and above the bifurcation of the aorta, and 2 patients had sentinel nodes above the bifurcation of the aorta only. Seven (88%) patients had unilateral drainage of dye and the radiocolloid; the other patient had bilateral drainage. No patients had metastatic disease to sentinel or nonsentinel lymph nodes. CONCLUSIONS: Subserosal fundal injection of blue dye and the radiocolloid is a poor technique for identifying sentinel lymph nodes in patients with high-risk 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.     

Sentinel lymph node biopsy improves staging in early cervical cancer

OBJECTIVES: The main study objective was to describe the distribution of sentinel lymph nodes (SLNs) and the prevalence of SLN micrometastases in patients with early cervical cancer. The secondary objective was to confirm the SLN detection rate and negative predictive value found in our preliminary study. PATIENTS AND METHODS: We prospectively included 25 patients with early cervical cancer, each of whom received an injection of 120 MBq of technetium-99m for preoperative lymphoscintigraphy and intraoperative node detection using an endoscopic gamma probe. Patent blue dye was injected intraoperatively. SLNs were sought in the pelvic and para-aortic drainage areas. Radical iliac dissection was performed routinely at the end of the procedure. SLNs were examined after hematoxylin-eosin-saffron staining; negative specimens were assessed using immunohistochemistry. RESULTS: Most (85%) of the SLNs were in the inter-iliac territory. Para-aortic or parametrial SLNs were found respectively in 2 patients and common iliac SLNs in 5 patients. Thus 9/25 patients had additional information due to SLN detection. One metastasis and one micrometastasis were detected in SLNs. No patients had positive non-sentinel nodes with negative SLNs. CONCLUSION: SLN detection ensures the identification of SLNs in unusual locations in 36% of patients. SLN disease was found in 8% of our patients. Thus, SLN biopsy improves staging in patients with early cervical cancer. Studies in larger patient populations are needed to evaluate the clinical impact of SLN biopsy.     

Sentinel node metastasis in the groin detected by technetium-labeled nannocolloid in a patient with cervical cancer

OBJECTIVE: The aim of this study was to describe the first sentinel groin node metastasis detected by technetium-labeled nanocolloid in a patient with cervical carcinoma. METHOD: Preoperatively, 60 mBq technetium-labeled nannocolloid was injected at 3 and 9 o'clock in the uterine cervix. Sentinel nodes were detected using a handheld and laparoscopic probe (Navigator) and removed for pathological assessment. RESULTS: A 52-year-old diagnosed with FIGO stage IIA squamous cervical carcinoma was referred to our unit. On physical examination a bulky cervical tumor and a 1.5-cm enlarged left inguinal lymph node were found. No other abnormalities were seen on pelvic MRI scan and CT scan of the abdomen and lower pelvis. Preoperative lymphoscintigraphy showed that a left groin node and three nodes located in the right obturator fossa were the sentinel nodes. They were easily detected using, respectively, a hand-held and a laparoscopic probe and removed. As both the inguinal and the obturator lymph nodes contained metastatic deposits, the patient was treated with the combination of chemotherapy and radiotherapy. CONCLUSION: Inguinal lymph nodes can rarely be the sentinel nodes in patients with cancer of the uterine cervix.     

Sentinellymphadenektomie bei Patientinnen mit Zervixkarzinom

Sentinel lymph node biopsy in women with cervical cancer is an object of current clinical research. Blue dye, technetium-labeled colloids, or their combination are used to detect sentinel lymph nodes. Several studies showed that the best results were achieved through the combination of these agents. Beside the rate of detection the negative predictive value is the most important factor to assess the impact of the sentinel lymph node concept. Incorrect application of the agents used to detect sentinel lymph nodes is one reason for failure of detecting sentinel lymph nodes. False negative detections are seen in patients with grossly metastatic lymph nodes. The detection of sentinel lymph nodes in the parametrial tissue close to the cervix is hampered, as the tissue is either intensively colored or the activity of technetium within the cervix does not allow a detection of smaller deposits of activity within the sentinel lymph nodes. Isolated sentinel lymph nodes can be used for special investigations establishing new prognostic markers. Future studies should clarify which group of patients with cervical cancer will benefit most.     

HPV status in sentinel nodes might be a prognostic factor in cervical cancer

OBJECTIVE: Although there have been studies that focused on the correlation between the HPV presence of pelvic lymph nodes and pathological metastasis in patients with cervical cancer, the biologic role of HPV DNA in lymph nodes still remains uncertain. We performed this study to investigate the correlation between the sentinel-node HPV status and pelvic lymph node metastasis in patients with cervical cancer. The patients were followed up for 3 years to evaluate the clinical role of HPV in sentinel nodes as a prognostic factor. METHODS: From August 2001 to July 2003, 57 patients affected by stages IB-IIA cervical cancer had sentinel-node biopsies performed during radical hysterectomy and pelvic and paraaortic lymphadenectomy. Each detected sentinel node was divided into two parts. One part of them was submitted for frozen section examination and the other was submitted for HPV typing by oligonucleotide microarray. After follow-up, we analyzed the outcome of the patients with respect to the influence of sentinel-node HPV. RESULTS: Sentinel nodes were identified in all patients. A total of 79 nodes from 57 patients were detected as sentinel nodes. Metastasis in the sentinel nodes were found in 10 patients (17.6%) by frozen section and 11 patients by pathologic examination. The results of sentinel lymph node frozen biopsy were statistically significant for predicting the metastasis of the pelvic lymph nodes (P<0.05), but showed one false-negative case. HPV DNA was detected in the cervical cancer lesions of 55 patients (96.5%) and 80.0% (44/55) of them were found to have HPV DNA in the sentinel nodes as well. HPV DNA was detected in sentinel nodes of 10 patients among 11 patients with lymph node metastasis. Disease recurred in five patients and one of them did not show pelvic lymph node metastasis at surgery. But, all of these patients had HPV in sentinel nodes. The combination of sentinel-node frozen biopsy and HPV typing showed a negative predictive value of 100% in predicting non-metastasis of lymph node and no recurrence of disease. CONCLUSION: Our results suggested the possibility that sentinel-node HPV typing could play a supportive role to reduce the false-negative rate of the sentinel-node biopsy. All of five patients with recurrence had HPV infection in the sentinel nodes. Absence of HPV in sentinel nodes showed reliable negative predictive value for lymph node metastasis and recurrence. Additional study will be needed to confirm the clinical application of the sentinel-node procedure and to determine whether there is a correlation of HPV status of sentinel nodes to lymph node metastasis and recurrence in cervical cancer patients.     

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 identification and intraoperative lymphatic mapping. First results of a pilot study in patients with endometrial cancer

INTRODUCTION: To minimize the surgical morbidity after lymphadenectomy, sentinel node biopsy (SLNB) has become fundamental in the management of different malignancies. We decided to evaluate sentinel lymph node (SNL) biopsies also in patients with endometrial cancer undergoing hysterectomy with lymphadenectomy. METHODS: In the setting of a prospective study we developed a technique for sentinel node biopsy of ten patients with histologically confirmed endometrial cancer. Prior to surgery 99m Tc Nanocol was injected in the peritumoral region by hysteroscopy. Six hours later lymphoscintigraphy was performed to identify the draining lymph nodes. During surgery we first detected the sentinel lymph node by a hand-held gamma tracer and then removed it. Surgery was completed by the standard therapy of total hysterectomy, bilateral salpingo-oophorectomy and pelvic and/or para-aortic lymphadenectomy. RESULTS: Scintigraphic identification was possible in eight out of ten patients. Intraoperative identification of sentinel lymph nodes was possible in seven out of eight patients. In five patients we found the sentinel lymph nodes in the pelvic region while the other two patients had bilateral sentinel nodes in the pelvic and para-aortic region. Histologically confirmed microscopic tumor metastases of the SLNs and para-aortic lymph nodes were only found in one case. The sentinel lymph nodes from the other six patients were free of tumor and accurately reflected the pathological status. CONCLUSION: The identification of sentinel lymph nodes in endometrial cancer is a practical and safe method. In order to improve this technique as a standard procedure for staging of endometrial cancer further studies with a larger number of patients have to be done.     

Contribution of the sentinel node procedure to tailoring the radicality of hysterectomy for cervical cancer

OBJECTIVE: The required radicality of hysterectomy for women with early-stage cervical cancer is controversial owing to the risk of severe complications. The aim of this study was to determine the contribution of the sentinel node (SN) procedure to tailoring the radicality of hysterectomy in women with cervical cancer. METHODS: Between April 2001 and December 2005, 54 patients with early-stage or locally advanced cervical cancer underwent laparoscopic sentinel node (SN) biopsy based on combined patent blue and radiocolloid detection. Thirty-nine patients with early-stage cervical cancer underwent a laparoscopic SN procedure with complete pelvic lymphadenectomy and radical hysterectomy. Moreover, 15 women with locally advanced cervical cancer underwent an SN procedure with pelvic and para-aortic lymphadenectomy before concurrent neoadjuvant chemoradiotherapy. RESULTS: The SN detection rate was 83.3%. The detection rate was higher in women with early-stage disease (90%) than in women with more advanced disease (66.6%) (p=0.03). At final histology, 14 metastatic SN were found in 11 (21.3%) of the 54 patients. They comprised macrometastases in 6 SN, micrometastases in 5 SN, and isolated tumour cells in 3 SN. Parametrial involvement with negative sentinel nodes was found in 15.1% of cases. The overall sensitivity, specificity, positive and negative predictive values and accuracy of intraoperative imprint cytology were 20%, 100%, 100%, 79.5% and 80.5%, respectively. Among the 39 women with early cervical cancer, five (12.8%) had parametrial involvement. In univariate analysis, parametrial involvement was significantly associated with large tumour size, advanced-stage disease, positive pelvic lymph nodes and lymphovascular space involvement. Parametrial involvement tended to be associated with positive sentinel nodes. CONCLUSION: These results underline the contribution of the SN procedure to evaluating lymph node status. However, intraoperative imprint cytology appeared poorly accurate, and further histological or biological tools are needed to evaluate SN status and, hence, to tailor the radicality of hysterectomy.     

Laparoscopic sentinel lymph nodes identification followed by trachelectomy in early stage cervical cancer

The status of regional lymph nodes is the main prognostic factor in diagnosis and treatment of early stage of the cervical cancer. If the first node that drains a tumor site (sentinel node) is not metastatic, other lymph nodes should also be free of the disease. Detection using blue dye and laparoscopic removal of the sentinel lymph nodes let to avoid radical hysterectomy with pelvic limphadenectomy and it is especially useful in young women who want to preserve fertility. We describe a case of a 33- year old woman with invasive cervical cancer who underwent laparoscopic sentinel lymph nodes detection followed by trachelectomy. Thus histopatological examination confirmed no metastasis in removed sentinel lymph nodes, trachelectomy as a minimally invasive procedure was performed.     

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.