Laparoscopic assessment of the sentinel lymph node in early stage cervical cancer

OBJECTIVE: The aim of this study was to describe a minimally invasive technique enabling us to identify the sentinel lymph node in patients affected by early stage cervical cancer and to report the preliminary data. METHOD: Patent Blue Violet was injected around the tumor. Laparoscopy was undertaken and the blue-dyed lymph nodes (BDLN) were sought. The evidenced BDLN were removed, and then the systematic dissection was carried out. Material. Thirty-five patients were submitted to surgery. A systematic dissection was performed on 69 pelvic sidewalls (no dissection was performed on the second side of the patient for whom we decided to renounce surgery after assessment of the first side). RESULTS: One or more BDLN was evidenced in 59 of 69 dissections. The rate of failure depends on the quantity of injected blue dye. Failure to identify a BDLN depended on the quantity of injected blue dye: 3 of 6 (50%) for 1.5 ml or less, 3 of 18 (17%) for 2 ml, and only 4 of 45 (10%) after injection of 4 ml (P = 0.05). Among the 63 BDLN (in 4 cases 2 BDLN were identified), 53 were located in contact with the external iliac vein, lateral to the inferior vesical artery, and ventral to the origin of the uterine artery, 7 were located close to the origin of one of the collaterals of the internal iliac artery, and 3 were adjacent to the left common iliac vein. One or more positive pelvic lymph nodes was found in 11 pelvic wall dissections done on 8 patients. The BDLN was the positive node or one of them in all cases. CONCLUSION: If the sensitivity of the assessment of the BDLN is confirmed to be 100%, this laparoscopic approach could transform the management of 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.     

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.     

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.     

腹腔镜前哨淋巴结活检在子宫恶性肿瘤中的应用

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

腹腔镜前哨淋巴结活检在子宫恶性肿瘤中的应用

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

Establishing a sentinel lymph node mapping algorithm for the treatment of early cervical cancer

Objective

To establish an algorithm that incorporates sentinel lymph node (SLN) mapping to the surgical treatment of early cervical cancer, ensuring that lymph node (LN) metastases are accurately detected but minimizing the need for complete lymphadenectomy (LND).

Methods

A prospectively maintained database of all patients who underwent SLN procedure followed by a complete bilateral pelvic LND for cervical cancer (FIGO stages IA1 with LVI to IIA) from 03/2003 to 09/2010 was analyzed. The surgical algorithm we evaluated included the following: 1. SLNs are removed and submitted to ultrastaging; 2. any suspicious LN is removed regardless of mapping; 3. if only unilateral mapping is noted, a contralateral side-specific pelvic LND is performed (including inter-iliac nodes); and 4. parametrectomy en bloc with primary tumor resection is done in all cases. We retrospectively applied the algorithm to determine how it would have performed.

Results

One hundred twenty-two patients were included. Median SLN count was 3 and median total LN count was 20. At least one SLN was identified in 93% of cases (114/122), while optimal (bilateral) mapping was achieved in 75% of cases (91/122). SLN correctly diagnosed 21 of 25 patients with nodal spread. When the algorithm was applied, all patients with LN metastasis were detected; with optimal mapping, bilateral pelvic LND could have been avoided in 75% of cases.

Conclusions

In the surgical treatment of early cervical cancer, the algorithm we propose allows for comprehensive detection of all patients with nodal disease and spares complete LND in the majority of cases.     

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.     

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.     

Prognostic significance of low volume sentinel lymph node disease in early-stage cervical cancer

Objective

Evaluate prognostic significance of low volume disease detected in sentinel nodes (SN) of patients with early stages cervical cancer. Although pathologic ultrastaging of SN allows for identification of low volume disease, including micro-metastasis and isolated tumor cells (ITC), in up to 15% of cases, prognostic significance of these findings is unknown.

Methods

A total of 645 records from 8 centers were retrospectively reviewed. Enrolled in our study were patients with early-stage cervical cancer who had undergone surgical treatment including SN biopsy followed by pelvic lymphadenectomy and pathologic ultrastaging of SN.

Results

Macrometastasis, micrometastasis, and ITC were detected by SN ultrastaging in 14.7%, 10.1%, and 4.5% patients respectively. False negativity of SN ultrastaging reached 2.8%. The presence of ITC was not associated with significant risk, both for recurrence free survival and overall survival. Overall survival was significantly reduced in patients with macrometastasis and micrometastasis; hazard ratio for overall survival reached 6.85 (95% CI, 2.59-18.05) and 6.86 (95% CI, 2.09-22.61) respectively. Presence of micrometastasis was an independent prognostic factor for overall survival in a multivariable model.

Conclusion

Presence of micrometastasis in SN in patients with early stage cervical cancer was associated with significant reduction of overall survival, which was equivalent to patients with macrometastasis. No prognostic significance was found for ITC. These data highlight the importance of SN biopsy and pathologic ultrastaging for the management of cervical cancer.     

Cervical and hysteroscopic injection for identification of sentinel lymph node in endometrial cancer

ObjectivesThe aims of our study were to evaluate the possibility of identifying the sentinel lymph node (SLN) in patients with endometrial cancer (EC) and to directly compare two injection techniques, cervical and hysteroscopic injection.MethodsFifty-four patients with endometrial carcinoma, clinical stages I and II, were submitted to complete surgical staging through laparoscopy, as recommended by FIGO in 1988. For the mapping procedure the patients were divided into two groups of injection: the cervical injection group and hysteroscopic injection group. Technetium (Tc) 99m radiocolloid was used as tracer.ResultsIntraoperative detection rate of SLN was 70% in cervical group and 65% in the hysteroscopic group (p = n.s.). In the cervical group, all patients had SLN in the pelvis only and the mean SLN removed was 18 (range 2–26). In the hysteroscopic group, all patients had SNLs in the pelvis and two patients had SLN both in the pelvis and above the bifurcation of the aorta. Mean pelvic SLN removed was 20 (range 8–42).ConclusionsOur data shows that it is possible to identify the SLN in tumours of the endometrium. Both cervical and hysteroscopic techniques are feasible but the hysteroscopic procedure might represent the only method able to highlight the complete lymphatic drainage of the uterus as suggested by the presence of paraaortic positive SLN only in this group.     

Study of lymphatic mapping and sentinel node identification in early stage cervical cancer

OBJECTIVE: The aim of our study was to compare the identification of sentinel lymph nodes (SLN) by blue dye and (99m) Tc; to evaluate detection rate per patient and specific side detection rate (SSDR) of SLN, distribution of SLN and distribution of positive SLN and false negative rate of the methods. PATIENTS AND METHODS: From February 2000 until September 2004, we included 183 women with early stage cervical carcinoma. We evaluated two methods of detection of SLN (100 cases by Patent blue, 83 cases by Patent blue with (99m)Tc). We stratified the group upon the size of the tumor and upon the type of surgical method (laparoscopy, laparotomy). RESULTS: SLN identification increased in cases when we used combination of both methods (Tc + blue dye) SSDR = 93% versus the use of blue dye only SSDR = 71% (OR:5,76, CI 95% -2.9 -11.4, <0.0001). Distribution of 462 SLN-45.0% external iliac artery and vein, 42.6% supraobturator, 4.8 bifurcation and common illiac artery and vein, 4.6% praesacral, 3% medial part of lateral parametrium. Distribution of 44 positive SLN-approximately 38.6% external illiac artery and vein, 45.5% supraobturator, 6.8% bifurcation and common illiac artery and vein, 4.5% praesacral, 4.5% medial part of lateral parametrium. One false negative SN was in presacral area. CONCLUSION: Detection of SLN by combination of (99m)Tc and blue dye was statistically significantly better than blue dye alone. Our study documents high sensitivity, specificity and low false negativity of the method.     

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.     

Axillary lymph node recurrence after sentinel lymph node biopsy for breast cancer

ObjectiveThe aim of this review is to summarize the current knowledge about axillary recurrences after sentinel lymph node (SLN) biopsy for breast cancer.MethodsA Pubmed search for publications (in English or French) related to breast cancer, SLN and axillary recurrence was carried out from 1995 to 2006.ResultsUnder controlled conditions (notably after a learning curve concerning the multidisciplinary team), the SLN procedure proved to be a reliable method for evaluation of axillary nodal status in selected patients with early-stage invasive breast cancer. When the SLN is free of cancer cells, the rate of axillary recurrence varies from 0% to 2% with a follow-up ranging from 14 to 57 months. Recurrence after axillary lymph node dissection is similar. When isolated cancer cells or micrometastases invaded the SLN, the rate of axillary recurrence remains low, but a complete axillary lymph node dissection must be performed to reduce this rate significantly. The use of intraoperative miniaturized gamma cameras could contribute to the optimization of the SLN procedure and to reduce axillary recurrences.