Laparoscopic Sentinel Node Procedure for Cervical Cancer: Impact of Neoadjuvant Chemoradiotherapy

Background: SN detection based on combined blue dye and radiocolloid labeling can reliably show lymph node status in cervical cancer, but the influence of prior neoadjuvant chemoradiotherapy has not yet been reported. The aim of this study was to evaluate the effect of neoadjuvant chemoradiotherapy on the accuracy of a dual-labeling laparoscopic sentinel node (SN) procedure in patients with cervical cancer.Methods: Between July 2001 and June 2003, 26 patients (mean age, 50.3 years) with cervical cancer underwent a laparoscopic SN procedure based on dual labeling with patent blue and radiocolloid. After the SN procedure, all the patients underwent complete laparoscopic pelvic lymphadenectomy and laparoscopic radical hysterectomy (n = 19), the Schauta-Amreich operation (n = 5), or trachelectomy (n = 2). The results of the SN procedure were compared between 11 patients who received neoadjuvant chemoradiotherapy and 15 patients who did not receive neoadjuvant treatment.Results: The SN identification rates were 100% in the 11 patients who underwent neoadjuvant chemoradiotherapy and 93.3% in the 15 patients who did not receive adjuvant therapy. A total of 59 SNs were removed. Eight SNs (13.6%) from five patients (19.2%) were found to be metastatic at the final histological assessment. Three SN involvements were detected by hematoxylin and eosin staining of the SN. Immunohistochemical studies identified five metastatic SNs in three patients. There were no false-negative SN results.Conclusions: This study suggests that SN detection with a combination of radiocolloid and patent blue is feasible and accurate in patients with cervical cancer undergoing neoadjuvant chemoradiotherapy or primary surgery. The combination of laparoscopy and the SN procedure permits minimally invasive management of cervical cancer.     

Laparoscopic sentinel node mapping using combined detection for endometrial cancer: a study of 33 cases--is it a promising technique?

Background

To evaluate the feasibility of a laparoscopic sentinel node (SN) procedure based on combined method in patients with endometrial cancer.

Methods

Thirty-three patients (median age 66.1 years) with endometrial cancer of apparent stage I or stage II underwent a laparoscopic SN procedure based on combined radiocolloid and patent blue injected pericervically. After the SN procedure, all the patients underwent laparoscopic bilateral pelvic lymphadenectomy.

Results

SNs were identified in only 27 patients (81.8%). The mean number of SNs was 2.5 per patient (range 1-5). Only 18 patients (54.5%) had an identified bilateral SN. The most common site of the SNs was the medial external iliac region (67.6%). Fourteen SNs (19.7%) from 8 patients (24.2%) were found to be metastatic at the final histological assessment. No false-negative SN results were observed.

Conclusions

A SN procedure based on a combined detection and laparoscopic approach is feasible in patients with early endometrial cancer. However, because of a low rate of bilateral and global SN detections and problems of injection site using pericervical injection of radiocolloid and blue dye, alternative methods should be explored. Pericervical injections should be avoided.     

Laparoscopic Sentinel Node Biopsy in Cervical Cancer Using a Combined Detection: 5–Years Experience

Background To evaluate the feasibility after 5 years experience of a laparoscopic sentinel node (SN) procedure with combined radioisotopic and patent blue labeling in patients with cervical cancer. Methods Sixty-seven patients (median age 48.9 years) with cervical cancer underwent a laparoscopic SN procedure using an endoscopic gamma probe, after both radioactive and patent blue injections. After the procedure, all the patients underwent complete laparoscopic pelvic/para-aortic lymphadenectomy. Results At least one SN was identified in 57 patients (85.1%). According to the Stage, the SN identification rate was 91.2% in early-stage cervical cancer and 78.5% in locally advanced cervical cancer. The mean number of SN was 2.3 per patient (range 1–5). A total of 129 SNs were removed. Lymph node metastasis involvement was identified in the 20 SNs (15.5%) from 14 patients (24.6%). Nine of the 14 patients had at least one macrometastases, three patients presented micrometastases in H&S, and two patients presented isolated single cells. Six patients presented a pelvic non-SN involvement including two patients whose SNs were uninvolved. The false-negative SNs rate was 12.5% (two patients out of 16). Both patients have locally advanced cervical cancer. Conclusion This study confirms that laparoscopic SN detection with a combination of radiocolloid and patent blue is accurate in patients with early cervical cancer to assess pelvic lymph node status.     

Limits of Day-Before Lymphoscintigraphy to Localize Sentinel Nodes in Women with Cervical Cancer

Background  Lymph node status in cervical cancer is a major prognostic factor. Sentinel lymph node (SN) biopsy using radiocolloid and blue dye labeling and preoperative lymphoscintigraphy has emerged as a potential alternative to systematic lymphadenectomy. The aim of this study was to evaluate the contribution of preoperative lymphoscintigraphy to SN biopsy. Methods  Between April 2001 and December 2005, 71 of 77 patients with cervical cancer (38 patients with stages IA or IB1, and 39 patients with stage IB2, IIA or IIB) underwent laparoscopic SN procedure using radiocolloid and blue dye with day-before lymphoscintigraphy. The SN identification rates and false-negative rates were studied. Results  Seventy patients underwent a combined technique and the last patient a radiocolloid technique alone due to blue dye allergic reaction. Detection rate of lymphoscintigraphy was 84.5% (60/71), with 1.4 sentinel nodes per patient. Three of 11 patients (27.3%) with no SN on lymphoscintigraphy had at least one SN during surgery. Sixteen of 27 patients (59.3%) with solitary SN on lymphoscintigraphy had multiple SNs. Nine of 35 patients (25.7%) with unilateral SNs on lymphoscintigraphy had bilateral SNs at surgery (kappa = 0.44 [0.19–0.64]). When categorized into <2 and ≥2 sentinel nodes, the correlation between lymphoscintigraphic and surgical detection was poor (kappa = 0.05 [0.0–0.18]). Conclusions  SN biopsy is a feasible and accurate method to stage early cervical cancer. However, day-before lymphoscintigraphy is poorly correlated to surgical SN mapping.     

Sentinel node mapping during laparoscopic distal gastrectomy for gastric cancer

Background The goal of this study was to evaluate the feasibility and accuracy of sentinel node (SN) mapping with endoscopic submucosal blue dye injection during laparoscopic distal gastrectomy for gastric cancer. Methods Thirty-four patients affected by gastric adenocarcinoma without gross clinical serosal invasion and distant metastasis were prospectively enrolled. At the start of the surgery, 2 ml of 2% patent blue was endoscopically injected into the submucosal layer at four points around the site of the primary tumor. Sentinel nodes were defined as nodes that were stained by the blue dye within 5–10 min after the dye injection. After identification and removal of sentinel lymph nodes, each patient underwent laparoscopic distal gastrectomy with D1 (n = 2) or D2 (n = 32) lymphadenectomy. Results Of the 34 patients, 14 had positive nodules (41%). SNs were detectable as blue nodes in 27 (80%) of 34 patients. The mean number of dissected lymph nodes per patient was 31 ± 10 (range = 16–64) and the mean number of blue nodes was 1.5 (range = 1–4). Only five (sensitivity 36%) of 14 N(+) patients had at least one metastatic lymph node among the SNs identified. In these 14 patients the sentinel node was traced in 12 cases. Sentinel node status diagnosed the lymph node status with 74% accuracy. In early gastric cancer (n = 18), three patients had lymph node metastasis. These early gastric cancer patients with nodal metastases had at least one metastatic lymph node among the SNs identified (sensitivity 100%). Conclusions Blue dye SN mapping during laparoscopic distal gastrectomy seems to be a feasible and accurate diagnostic tool for detecting lymph node metastasis in patients with early-stage gastric cancer in which the accuracy of the method was 100%. However, in more advanced gastric cancer the results are not satisfactory. Validation of this method requires further studies on technical issues, including selection of the tracers.     

Localizing the sentinel node in cutaneous melanoma: Gamma probe detection versus blue dye

Background: Sentinel node (SN) biopsy can be used to select patients with melanoma for therapeutic lymphadenectomy. We investigated the value of two methods to locate the SN: patent blue dye (PBD) and gamma probe detection of^99mTc-nanocolloid. Methods: One hundred ten patients with cutaneous melanoma were studied. Lymphoscintigraphy with^99mTc-nanocolloid was performed to determine the position of the SN. Before operation, PBD was injected at the same site as the radiopharmaceutical. When a blue node was identified intraoperatively, its radioactivity level was measured with the probe. In the absence of blue coloration, the probe was used to trace the SN. Results: Scintigrams visualized a total of 219 SNs in 141 basins. Eight SNs were not explored. One SN was not found. The remaining 210 and 27 additional intraoperatively identified SNs were excised. From the total of 237 removed SNs, 200 (84%) were found using PBD only. All 37 nodes that were not found with the PBD were localized with the probe so that the probe combined with PBD identified 99.5% of all SNs. In 23 patients the SN contained tumor. In three patients the SN was false-negative for metastasis. Conclusion: The gamma probe together with PBD can identify more SNs (99.5%) than lymphatic mapping with PBD alone (84%).Presented at the 49th Annual Cancer Symposium of The Society of Surgical Oncology, Atlanta, Georgia, March 21–24, 1996.     

A Hybrid Radioactive and Fluorescent Tracer for Sentinel Node Biopsy in Penile Carcinoma as a Potential Replacement for Blue Dye

Background

Sentinel node (SN) biopsy in penile cancer is typically performed using a combination of radiocolloid and blue dye. Recently, the hybrid radioactive and fluorescent tracer indocyanine green (ICG)-^99mTc-nanocolloid was developed to combine the beneficial properties of both radio-guidance and fluorescence imaging.

Objective

To explore the added value of SN biopsy using ICG-^99mTc-nanocolloid in patients with penile carcinoma.

Design, setting, and participants

Sixty-five patients with penile squamous cell carcinoma were prospectively included (January 2011 to December 2012). Preoperative SN mapping was performed using lymphoscintigraphy and single-proton emission computed tomography supplemented with computed tomography (SPECT/CT) after peritumoural injection of ICG-^99mTc-nanocolloid. During surgery, SNs were initially approached using a gamma probe, followed by patent blue dye and/or fluorescence imaging. A portable gamma camera was used to confirm excision of all SNs.

Surgical procedure

Patients underwent SN biopsy of the cN0 groin and treatment of the primary tumour.

Outcome measurements and statistical analysis

The number and location of preoperatively identified SNs were documented. Intraoperative SN identification rates using radio- and/or fluorescence guidance were assessed and compared with blue dye. Statistical evaluation was performed using a two-sample test for equality of proportions with continuity correction.

Results and limitations

Preoperative imaging after injection of ICG-^99mTc-nanocolloid enabled SN identification in all patients (a total of 183 SNs dispersed over 119 groins). Intraoperatively, all SNs identified by preoperative SN mapping were localised using combined radio-, fluorescence-, and blue dye guidance. Fluorescence imaging enabled visualisation of 96.8% of SNs, while only 55.7% was stained by blue dye (p < 0.0001). The tissue penetration of the fluorescent signal, and the rapid flow of blue dye limited the detection sensitivity. A tumour-positive SN was found in seven patients.

Conclusions

ICG-^99mTc-nanocolloid allows for both preoperative SN mapping and combined radio- and fluorescence-guided SN biopsy in penile carcinoma patients and significantly improves optical SN detection compared with blue dye.     

Use of the Sentinel Node Procedure to Stage Endometrial Cancer

Background Lymph node status is a major prognostic factor and a criterion for adjuvant therapy in endometrial cancer. The sentinel lymph node (SN) procedure has emerged as a possible alternative to systematic lymphadenectomy. The aims of this study were to determine the detection rate and the false-negative rate of the SN procedure, and its contribution to the staging of women with endometrial cancer. Methods Forty-six patients with endometrial cancer underwent the sentinel node procedure followed by pelvic lymphadenectomy. SNs were detected with a dual or single labelling method in 39 and 7 cases, respectively. All SNs were analysed by both hematoxylin and eosin (H&E) staining and immunochemistry. Results SNs were identified in 40 patients (87%), whose mean number of SN was 2.6 (range 1–5). The SN detection rate was significantly lower with the single label than with the dual label (p = 0.01). Ten women (25%) had a positive SN on final histology (i.e. there were no false negatives). A correlation was observed between lymph node involvement and both histological grade (p = 0.01) and lymphovascular space involvement (p = 0.001). The stage predicted by magnetic resonance (MR) imaging correlated poorly with the Federation International of Gynaecology and Obstetrics (FIGO) stage. Among the ten women with a positive SN, three of the four women with a grade 1 tumour at biopsy had grade 2–3 disease on final histology. Seven of the ten women with a positive SN underwent external pelvic radiotherapy, based solely on their SN involvement. Conclusion The SN procedure can reliably determine lymph node status in women with endometrial cancer. Given the limited capacity of MR imaging to detect myometrial invasion, and of biopsy to determine histological grade, our results support the systematic use of the SN procedure in women with endometrial cancer, including those with presumed early-stage disease and/or well-differentiated tumours.     

Laparoscopic Lymphatic Mapping and Sentinel Node Biopsies for Early-stage Gastric Cancer: The Cause of False Negativity

Sentinel node (SN) biopsies might be useful for performing minimally invasive surgery without interrupting surgical curability. This study examined the cause of false negativity during laparoscopic lymphatic mapping and SN biopsies for early-stage gastric cancer. Thirty-seven patients with gastric cancer (preoperative stage T1-2 or N0) who underwent laparoscopic lymph node mapping and SN biopsies between March 2001 and June 2004 were enrolled in this study. The tracer, patent blue and technecium-99m-labeled tin colloid, was injected endoscopically. Blue-stained or radioactive nodes were defined as SNs. Gastrectomy with lymphadenectomy was performed then the results of the SN biopsies were compared with the final diagnosis of the removed lymph nodes in permanent sections. Sentinel nodes were successfully identified in 35 patients (94.6%), and they were positive in 3 of 4 patients with metastatic lymph nodes; sensitivity was 75% and specificity was 100%. Sentinel node status could therefore be used to diagnose lymph node status with 97.1% accuracy. Of 6 SNs with metastasis, 5 showed radioactivity, and only 2 were blue stained. In the false negative case, a radioactive SN with metastasis in the right paracardial region was missed during laparoscopic mapping. An error in laparoscopic intracorporeal detection of the radioactive node with metastasis occurred because we could not eliminate the shine-through effect. We found that during laparoscopic SN mapping there is a high risk of false negativity with SNs located in the right paracardial region. To apply laparoscopic SN mapping to early-stage gastric cancer patients, the shine-through effect must be eliminated because radiotracers are essential for this method.     

Lymphatic mapping and sentinel node biopsy during laparoscopic gastrectomy for early cancer

BACKGROUND/AIMS: Intraoperative lymphatic mapping and sentinel node (SN) biopsy can potentially be combined with minimally invasive surgery, but there are few reports of laparoscopic lymphatic mapping for gastrointestinal cancer. We examined the feasibility and accuracy of laparoscopic lymphatic mapping in predicting lymph node status in patients with gastric cancer. METHODS: Seventeen patients with gastric cancer invading the mucosal or submucosal layers (T1) underwent laparoscopic gastrectomy with lymphatic mapping between March 2001 and May 2002. The day before surgery, a technetium-99m-labelled tin colloid solution was injected endoscopically around the tumor. Immediately after the pneumoperitoneum, patent blue was injected. Gastrectomy was performed in all patients, and blue-stained or radioactive nodes were defined as SNs. Fresh SNs were immediately processed for frozen-section examination by hematoxylin-eosin (H and E) and immunohistochemical (IHC) staining. All non-SNs harvested from resected specimens were subjected to histological examination with H and E. RESULTS: SNs were detected in all patients by combination of the two kinds of tracers. Three patients had lymph node metastases in their final examination, and SNs in these 3 were operatively diagnosed as positive by H and E or IHC staining. Lymphatic mapping and SN biopsy under laparoscopic surgery were performed with 100% accuracy. CONCLUSION: Our preliminary study shows the feasibility of intraoperative lymphatic mapping in laparoscopic gastrectomy for T1 gastric cancer.     

Laparoscopic Local Resection Based on Sentinel Node Evaluation for Early Gastric Cancer: A Preliminary Report

We previously reported that lymphatic mapping using isosulfan blue can be used to identify sentinel nodes (SNs). This study was undertaken to evaluate the feasibility of using the SN technique in treating early gastric cancer and to explore its usefulness for minimal invasive surgery. Twenty-three patients with early gastric cancer who underwent SN biopsy were retrospectively evaluated. Based on SN evaluation, individualized surgery was performed in five patients with T1N0M0 gastric cancer. When pathological examination of frozen sections revealed metastasis in SNs, we performed a standard D2 gastrectomy. Laparoscopic local resection was applied when the SN biopsy was negative. Our results showed that the success rate with SN biopsy in early gastric cancer was 100%, as were the accuracy, sensitivity, and specificity. All five patients with early gastric cancer had SNs negative for metastases both by frozen section and by postoperative pathology. Thus, all these patients underwent laparoscopic local resection without extended lymphadenectomy. We conclude that SN biopsy is a useful tool to individualize the operative procedure, and laparoscopic local resection can be safely performed using SN guidance in selected patients with early gastric cancer.     

Evaluation of Fluorodeoxyglucose Positron Emission Tomography in the Detection of Axillary Lymph Node Metastases in Patients With Early-Stage Breast Cancer

Background: The aim of this study was to assess the capacity of positron emission tomography (PET) with fluorodeoxyglucose (FDG) to determine axillary lymph node status in patients with breast cancer undergoing sentinel node (SN) biopsy.Methods: Thirty-two patients with breast cancer and clinically negative axillary nodes were recruited. All patients underwent FDG-PET before SN biopsy. After SN biopsy, all patients underwent complete axillary lymph node (ALN) dissection.Results: The SNs were identified in all patients. Fourteen patients (43.8%) had metastatic SNs (macrometastatic in seven, micrometastatic in six, and isolated tumor cells in one). The false-negative rate of SN biopsy was 6.6% (1 in 15). FDG-PET identified lymph node metastases in 3 of the 14 patients with positive SNs. The overall sensitivity, specificity, and positive and negative predictive values of FDG-PET in the diagnosis of axillary metastasis were 20%, 100%, 100%, and 58.6%, respectively. No false-positive findings were obtained with FDG-PET.Conclusions: This study demonstrates the limitations of FDG-PET in the detection of ALN metastases in patients with early breast cancer. In contrast, FDG-PET seems to be a specific method for staging the axilla in breast cancer. SN biopsy can be avoided in patients with positive FDG-PET, in whom complete ALN dissection should be the primary procedure.     

A New Radiocolloid for Sentinel Node Detection in Breast Cancer

Background:The optimal radioactive tracer and technique for sentinel lymph node localization in breast cancer is yet to be determined. The dilemma of small particle size with dispersion to second echelon nodes versus failure of migration of larger radiocolloids needs to be resolved. A new radiocolloid preparation with particle size under 0.1 micron was developed with excellent primary/post lymphatic entrapment ratio.Objective:To assess the feasibility of a new ^99mTc radiocolloid cysteine-rhenium colloid in sentinel lymph node (SLN) localization for breast cancer.Methods:Forty-seven patients with newly diagnosed T1 or T2 breast cancer underwent injection of ^99mTc-labeled cysteine-rhenium colloid followed by lymphoscintigraphy. Same day SLN biopsy with patent blue dye and intraoperative gamma probe to identify SLNs were performed.Results:SLN mapping and intraoperative localization were successful in 46/47 (98%) of patients. The blue dye radioactive tracer concordance was 94%. There was one false-negative in a patient with a nonpalpable tumor that underwent ultrasound-guided peritumoral radiocolloid injection.Conclusions:^99mTc-cysteine-rhenium colloid is highly effective in identifying SLNs. It has the advantage of smaller particle size than sulfur colloid with easier lymphatic migration. It has a more neutral pH with less pain on injection and does not require filtration, thereby minimizing radiation exposure to technologists.Presented at the 53rd Annual Meeting of the Society of Surgical Oncology, New Orleans, Louisiana, March 16–19, 2000     

Localization of the Sentinel Node of the Upper Outer Breast Quadrant in the Axillary Quadrants

Background

Sentinel node (SN) biopsy is associated with much less morbidity than axillary dissection. In patients with early breast cancer, lymphatic mapping and SN biopsy accurately stage the axillary nodes. Both currently available lymphatic mapping agents, radiocolloid and blue dye, have some limitations that may make perioperative or preoperative SN identification difficult. In such cases, exact knowledge of the topography of the axilla and the most probable location of the SN may be crucial.

Methods

In 12 fresh female cadavers with no history of breast carcinoma, injections of patent blue dye were used to visualize the SNs in the axillary quadrants and their lymphatic collectors from the upper outer quadrant of the breast, which is the most common location of breast cancer. The axilla was divided into quadrants with regard to the intersection of the thoracoepigastric vein and the third intercostobrachial nerve.

Results

All SNs were located within a circle of 2-cm radius of this intersection in the fatty tissue at the clavipectoral fascia. In most cases, the SN was located in the fatty tissue near the clavipectoral fascia in the lower ventral quadrant of the axilla (n = 14, 58%). In seven cases (29%), the SN was located in the upper ventral quadrant, in two cases (8%) in the upper dorsal quadrant, and in one case in the lower dorsal quadrant.

Conclusions

The results of this anatomical study may facilitate SN biopsy in patients with breast cancer.     

Validation of Lymphatic Mapping in Colorectal Cancer: In Vivo, Ex Vivo, and Laparoscopic Techniques

Background:The use of lymphatic mapping (LM) is being investigated to improve the staging of colorectal cancer (CRC) and thereby identify patients who might benefit from adjuvant chemotherapy. This study evaluated in vivo, laparoscopic, and ex vivo approaches for the ultrastaging of CRC.Methods:Seventy-five CRC patients were enrolled in a study of LM with peritumoral injection of isosulfan blue dye. LM was undertaken during open colon resection (OCR) in 64 patients, during laparoscopic colon resection (LCR) in 9 patients, and after specimen removal (ex vivo) in 2 patients. Ex vivo LM was also undertaken in 6 patients after unsuccessful in vivo LM. All nodes were examined by hematoxylin and eosin (H&E) staining; in addition, sentinel lymph nodes (SNs) were multisectioned and examined by immunohistochemical staining with cytokeratin (CK-IHC).Results:At least one SN was identified in 72 patients (96%). In vivo LM identified SNs in 56 of 64 (88%) patients undergoing OCR and in 9 of 9 (100%) patients undergoing LCR. Ex vivo LM was undertaken as the initial mapping procedure in 2 cases of intraperitoneal colon cancer and after in vivo LM had failed in 6 cases of extraperitoneal rectal carcinoma; an SN was identified in 7 of the 8 cases. Focused examination of the SN correctly predicted nodal status in 53 of 56 OCR cases, 9 of 9 LCR cases, and 6 of 7 ex vivo cases. Multiple sections and CK-IHC identified occult micrometastases in 13 patients (17%), representing 10 OCR, 1 LCR, and 2 ex vivo cases.Conclusions:LM of drainage from a primary CRC can be accurately performed in vivo during OCR or LCR. Ex vivo LM can be applied when in vivo techniques are unsuccessful and may be useful for rectal tumors. During LCR, colonoscopic injection can be used to mark the primary tumor and define the lymphatic drainage so that adequate resection margins are obtained. These LM techniques improve staging accuracy in CRC.Presented at the 53rd Annual Meeting of the Society of Surgical Oncology, New Orleans, Louisiana, March 16-19, 2000     

Sentinel node mapping in high risk endometrial cancer after laparoscopic supracervical hysterectomy with morcellation

INTRODUCTIONOccult endometrial cancer after supracervical hysterectomy is very uncommon. Even if optimal management of those rare cases is still unproven, to guide the need for further therapies, restaging should be recommended in this situation.PRESENTATION OF CASEWe report of a 60-year old woman with occult high risk endometrial cancer after supracervical hysterectomy with morcellation. We describe the feasibility of laparoscopic intraoperative sentinel node identification with cervical stump removing to restage the suspicious early stage high risk endometrial cancer.DISCUSSIONIn high risk endometrial cancer surgical restaging is important, considering that 10–35% of cases can present pelvic nodal metastasis. To reduce the treatment related morbidity maintaining the benefit of surgical staging, with a negative preoperative PET/CT, we performed a laparoscopic SN mapping with cervical stump removing.CONCLUSIONThis report highlight the fact that SN mapping with cervical injection is a feasible and safe technique also without the uterine corpus after supracervical hysterectomy with morcellation.     

Laparoscopic pelvic lymphadenectomy in the surgical treatment of endometrial cancer: results of a multicenter study.

OBJECTIVE: To analyze the results and determine the contribution of laparoscopic pelvic lymphadenectomy in the surgical treatment of women with endometrial cancer and compare with the open technique. METHODS: A prospective multicenter study was carried out on 120 women who underwent laparoscopic surgery (96 women) and open procedures (24 women) for endometrial cancer between April 1996 and March 2000. RESULTS: Four patients whose laparoscopic surgery was completed by laparotomy were excluded from the study. The other 92 laparoscopic procedures were successfully completed. Laparoscopically assisted surgical staging (LASS) was performed based on the grade of the tumor and the depth of myometrial invasion. Sixty-seven of the patients underwent hysterectomy, bilateral salpingooophorectomy (BSO), and pelvic lymphadenectomy, and 25 women also had para-aortic lymph node sampling dissection. Eleven of these patients had positive pelvic or para-aortic nodes. The mean operating time for the laparoscopic procedure was significantly longer (173.8 min, P < 0.0001) than the time for the open procedure (135.0 min). The rate of complications was similar in both groups. The recovery time was significantly reduced (P < 0.0001). CONCLUSION: The laparoscopic approach to hysterectomy and lymphadenectomy for early stage endometrial carcinoma is an attractive alternative to the abdominal surgical approach. The advantages of laparoscopically assisted surgical staging are patient related. Because the abdominal incision is avoided, the recovery time is reduced. Laparoscopic pelvic lymph node dissection is a procedure that is appropriate, when applicable.     

Interim Results of Sentinel Node Biopsy during Laparoscopic Gastrectomy: Possible Role in Function-Preserving Surgery for Early Cancer

Introduction Intraoperative detection of sentinel nodes (SNs) has been used clinically to predict regional lymph node (LN) metastasis in patients with breast cancer and malignant melanoma. Intraoperative lymphatic mapping and SN biopsy can potentially be combined with minimally invasive surgery. However, few reports have demonstrated the validity of SN biopsy during laparoscopic gastrectomy. The aim of this study was to investigate the feasibility and accuracy of laparoscopic lymphatic mapping in predicting LN status in patients with gastric cancer. Methods A total of 35 patients with gastric cancer diagnosed preoperatively as T1, N0 were enrolled. Endoscopic injection of technetium-99m-radiolabeled tin colloid was completed 16 hours before surgery, and radioactive SNs were identified with a gamma probe intraoperatively. Isosulfan blue dye was injected endoscopically during the operation. Laparoscopy-assisted gastrectomy with LN dissection was performed. All resected LNs were evaluated by routine pathology examination. Results SNs were detected in 33 (94.3%) of 35 patients. The mean number of SNs was 3.9, and the diagnostic accuracy according to SN status was 97.0% (32/33), as one patient with a false-negative result was observed. The patient with the false-negative specimen was finally diagnosed as having advanced gastric cancer with invasion into the proper muscular layer and severe lymphatic vessel invasion, causing destruction of normal lymphatic flow by the tumor. Conclusions Radio-guided SN mapping during laparoscopic gastrectomy is an accurate diagnostic tool for detecting lymph node metastasis in patients with early-stage gastric cancer. Validation of this method requires further studies on technical issues, including indications, tracers, methods of lymph node retrieval, and diagnostic modalities of metastasis.     

Dermal Versus Intraparenchymal Lymphoscintigraphy of the Breast

Background and Objective: Dermal and intraparenchymal (IP) injections of radiocolloid have been used for lymphoscintigraphic identification of the sentinel node (SN) in breast cancer. Because of our institutes extensive experience with dermal and IP lymphoscintigraphy for melanoma and breast cancer, we compared patterns of lymphatic migration after both types of injections to identify any differences in drainage patterns or SN identification.Methods: Lymphoscintigrams (n = 31) after dermal injections in 30 patients with primary cutaneous melanoma on the breast were compared with lymphoscintigrams after IP injections in 97 consecutive patients with breast cancer. In each case, 400 Ci of filtered ^99mTc-sulfur colloid was injected in four quadrants around the tumor or in the biopsy cavity. All lymphoscintigrams were reviewed for patterns of migration and SN location.Results: Five of 31 (16%) dermal injections demonstrated bilateral axillary migration (n = 3) or a suprasternal SN (n = 2), neither of which was found with IP injections. Conversely, 3 of 97 (3%) IP injections demonstrated direct supraclavicular (n = 2) or costal margin (n = 1) nodes (P = .006), neither of which was found with dermal injections. Low axillary SNs were noted after 26 (84%) dermal and 93 (96%) IP injections (P = .037). The incidence of extra-axillary SNs was 26% (8 of 31) in the dermal group but only 5% (5 of 97) in the IP group (P = .0027).Conclusion: There is a significant difference in lymphatic drainage and SN localization between dermal and IP lymphoscintigraphy. This finding has implications for injection techniques when lymphatic mapping of the SN is undertaken to stage a breast carcinoma.Presented at the Society of Surgical Oncology Annual Meeting, New Orleans, Louisiana, March 16–19, 2010434_2001_Article_241.     

Sentinel lymph node procedure followed by laparoscopic pelvic and paraaortic lymphadenectomy in women with <Emphasis Type="Underline">IB2-II</Emphasis> cervical cancer

Objective To evaluate the contribution of the sentinel node (SN) procedure followed by pelvic and paraaortic lymphadenectomy to determine lymph node status in women with locally advanced cervical cancer. Patients and methods A total of 21 women with locally advanced cervical cancer underwent a first laparoscopic SN procedure and pelvic and paraaortic lymphadenectomy followed by concurrent chemoradiotherapy (CCR). Laparoscopic radical hysterectomy was performed after CCR when the pelvic and paraaortic nodes were not involved. Results SNs were detected by means of lymphoscintigraphy in 10 women (47.6%) and intra-operatively in 14 women (66.6%). Of the latter 14 patients, 9 (64%) had an involved SN and 1 of the remaining 5 had pelvic non-SN metastases. The SN false-negative rate was 10%. At final histology, 13 of the 21 women (62%) had lymph node metastases. The total number of recovered pelvic non-SNs was 262, and 10 nodes in 8 women were involved. The total number of paraaortic non-SNs was 255, and 2 nodes in 2 women were involved. Conclusion This study shows the poor correlation between pre-operative lymphoscintigraphy and surgical SN mapping in women with locally advanced cervical cancer. A high proportion of women had SN metastases, underlining the importance of multiple sectioning and immunohistochemical staining of SNs.