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

Detection of sentinel nodes for endometrial cancer with robotic assisted fluorescence imaging: cervical versus hysteroscopic injection

OBJECTIVE

Sentinel lymph node (SLN) mapping with indocyanine green (ICG) detected by robotic near infrared (NIR) imaging is a feasible technique. The optimal site of injection (cervical or endometrial) for endometrial cancer has yet to be determined. We prospectively evaluated SLN mapping after cervical and endometrial injections of ICG to compare the detection rates and patterns of nodal distribution.

METHODS

Twenty-nine subjects with endometrial cancer undergoing robotic hysterectomy with lymphadenectomy by a single surgeon received SLN mapping with robotic fluorescence imaging. Seventeen patients received cervical injections of 1 mg of ICG and 12 patients received hysteroscopic endometrial injections of 0.5-mg ICG. Detection rates between the 2 groups were compared using Fisher exact tests. Continuous variables such as operating room times and body mass index were compared using t tests.

RESULTS

The SLN detection rate was 82% (14/17) for cervical and 33% (4/12) for hysteroscopic injection (P = 0.027). Sentinel lymph nodes were seen bilaterally in 57% (8/14) of the cervical injection group and 50% (2/4) of the hysteroscopic group. Para-aortic SLNs were seen in 71% (10/14) of patients who mapped after cervical injection and 75% (3/4) patients who mapped after hysteroscopic injection. There was 1 false-negative SLN in the cervical injection group.

CONCLUSIONS

Cervical ICG injection achieves a higher SLN detection rate and a similar anatomic nodal distribution as hysteroscopic endometrial injection for SLN mapping in patients with endometrial cancer.

Lymph node assessment in endometrial cancer: towards personalized medicine

Endometrial cancer (EC) is the most common malignancy of the female reproductive tract and is increasing in incidence. Lymphovascular invasion and lymph node (LN) status are strong predictive factors of recurrence. Therefore, the determination of the nodal status of patients is mandatory to optimally tailor adjuvant therapies and reduce local and distant recurrences. Imaging modalities do not yet allow accurate lymph node staging; thus pelvic and aortic lymphadenectomies remain standard staging procedures. The clinical data accumulated recently allow us to define low- and high-risk patients based on pre- or peroperative findings that will allow the clinician to stratify the patients for their need of lymphadenectomies. More recently, several groups have been introducing sentinel node mapping with promising results as an alternative to complete lymphadenectomy. Finally, the use of peroperative algorithm for risk determination could improve patient's staging with a reduction of lymphadenectomy-related morbidity.

Evaluation of the sentinel lymph node algorithm with blue dye labeling for early-stage endometrial cancer in a multicentric setting

OBJECTIVES

Sentinel lymph node (SLN) removal may be a midterm between no and full pelvic dissection in early endometrial cancer. Whereas the use of blue dye alone in SLN detection has a poor accuracy, its integration in an SLN algorithm may yield better results and overcome hurdles such as the requirement of nuclear medicine facility.

METHODS

Sixty-six patients with clinical stage I endometrial cancer were prospectively enrolled in a multicentre study between May 2003 and June 2009. Patent blue was injected intraoperatively into the cervix. We retrospectively assessed the accuracy of a previously described SLN algorithm consisting of the following sequence: (1) pelvic node area is inspected for removal of all mapped SLN and (2) excision of every suspicious non-SLN, (3) in the absence of mapping in a hemipelvis, a standard ipsilateral lymphadenectomy is then performed.

RESULTS

Sentinel nodes were identified in 41 patients (62.1%), mostly in interiliac and obturator areas. None was detected in the para-aortic area. Detection was bilateral in 23 cases (56.1%). Seven patients (10.6%) had positive nodes. The false-negative rate was 40% using SLN detection alone. When the algorithm was applied, the false-negative rate was 14.3%. The use of a SLN algorithm would have avoided 53% of lymphadenectomies

CONCLUSION

Our multicentric evaluation validates the use of a SLN algorithm based on blue-only sentinel node mapping in early-stage endometrial cancer. The application of such SLN algorithm should be evaluated in a prospective context and might lead to decrease unnecessary lymphadenectomies.

Is sentinel lymph node dissection an appropriate standard of care for low-stage endometrial cancers? A review of the literature

BACKGROUND/AIMS

To review the literature and compare detection rates, false negative (FN) rates, and negative predictive values (NPVs) of sentinel lymph node (SLN) biopsy in endometrial cancer to those in breast and vulvar cancer. Secondary objectives were to evaluate techniques of SLN biopsy in endometrial cancer.

METHODS

The PubMed database was searched for applicable scientific articles. Detection rates, FN rates, and NPVs were calculated for all studies. Studies were stratified by techniques and compared.

RESULTS

Nineteen articles met criteria for this review. The overall detection rates ranged from 62 to 100%, the FN rate ranged from 0 to 50%, and the NPVs ranged from 95 to 100%. There is no technique that is definitively superior to any other with regard to surgical modality, injectant used, injection site, or pathologic techniques.

CONCLUSIONS

Studies on SLN biopsy in endometrial cancer have a large range of detection rates and FN rates, and larger studies including more patients with metastatic disease are needed for comparison with breast and vulvar cancers. While no techniques are definitively superior to others, minimally invasive surgery, cervical injection, and pathologic analysis utilizing HE staining, immunohistochemistry, and ultrastaging may be clinically advantageous.

Study of the sentinel node in endometrial cancer at early stages: preliminary results

AIM

To investigate the applicability of the sentinel lymph node biopsy technique in early stages of endometrial cancer.

MATERIAL AND METHODS

A prospective study that included consecutive patients with a histological diagnosis of clinical state I endometrial carcinoma was performed. Two doses of 2 mCi (74 MBq) of (99m)Tc-albumin nanocolloid were injected in the uterine cervix, and planar and SPECT-CT images were obtained at one hour, and at 24 hours if no migration of the tracer was observed. Methylene blue dye was also injected into the cervix immediately prior to the surgery. A gamma probe was used during the surgical procedure for sentinel lymph node identification. In all cases, a hysterectomy, double adnexectomy and pelvic lymphadenectomy were performed, carrying out a histological analysis (hematoxylin-eosin) of the sentinel lymph nodes and the lymphadenectomy specimen.

RESULTS

We included 19 patients, with a final diagnoses of endometrioid carcinoma (18 cases) and endometrial stromal sarcoma (1 case). At least one sentinel lymph node was identified in 17 of them (89.5% detection rate). Twenty-nine sentinel lymph nodes were identified during surgery, all of them negative for neoplastic infiltration. No metastatic invasion was found in the pelvic lymphadenectomy specimens as well.

CONCLUSIONS

The sentinel lymph node biopsy technique seems to be a reliable tool in nodal staging of endometrial cancer at early stages, with an acceptable detection rate and high histological correlation. The low prevalence of lymphatic spread in this group of patients and the encouraging results obtained could make the sentinel lymph node an alternative to routine complete lymphadenectomy.

Sentinel lymph node biopsy in endometrial cancer: meta-analysis of 26 studies

OBJECTIVE

The validity of the sentinel lymph node (SLN) procedure for the assessment of nodal status in patients with endometrial cancer is unclear. We aimed to assess the diagnostic performance of this procedure.

METHODS

We searched the PubMed and Embase databases for studies published before June 1, 2011. Eligible studies had a sample size of at least 10 patients, and reported the detection rate and/or sensitivity of the SLN biopsy.

RESULTS

We identified 26 eligible studies, which included 1101 SLN procedures. The overall weighted-mean number of harvested SLNs was 2.6. The detection rate and the sensitivity were 78% (95% confidence interval [CI]=73%-84%) and 93% (95% CI=87%-100%), respectively. Significant between-study heterogeneity was observed in the analysis of the detection rate (I-squared statistic, 80%). The use of pericervical injection was correlated with the increase of the detection rate (P=0.031). The hysteroscopic injection technique was associated with the decrease of the detection rate (P=0.045) and the subserosal injection technique was associated with the decrease of the sensitivity (P=0.049), if they were not combined with other injection techniques. For the detection rate, significant small-study effects were noted (P<0.001).

CONCLUSIONS

Although SLN biopsy has shown good diagnostic performance in endometrial cancer, such performance should be interpreted with caution because of significant small study effects. Current evidence is not yet sufficient to establish the true performance of SLN biopsy in endometrial cancer.

[Current position of the sentinel lymph node procedure in endometrial cancer]

Lymph node status is a major prognostic element in endometrial cancer and affects the choice of adjuvant therapy. The sentinel lymph node (SLN) procedure is proposed as an alternative to lymphadenectomy. This review aims to assess its feasibility. To this end, 19 studies have been analysed. It appears that double detection (colorimetric and isotopic) is better than single detection, independent of injection site. Hysteroscopic injection is technically more difficult, yet can be done near the tumoral lesion. The cervical site does not accurately reflect the lymphatic drainage of the uterine body but is easier to access. SLN detection rate is notably identical between these two injections sites. Lomboaortic detection rate is lower for cervical injections than for endometrial ones. The myometrial site is also difficult to access (intraoperatively), due to same limitations as the hysteroscopic route, and can be deceiving (insufficient detection rate and high false-negative rate). The SLN allows for ultrastadification (micrometastases and isolated tumoral cells) with the development of new pathological techniques (serial sections and immunohistochemistry). Data on SLN in endometrial cancer is very heterogeneous in terms of methodology and populations studied. Despite being well-known, the SLN procedure in endometrial cancer remains in its feasibility stage. Its place in therapeutic strategies needs to be further explored and its potential benefit remains to be confirmed.

Intraoperative lymphatic mapping techniques for endometrial cancer

Endometrial cancer is the most common malignancy of the female genital tract in developed countries. The primary treatment for women with endometrial cancer is surgical, as well as the staging of the pathological spread pattern of this carcinoma outside of the uterus. A complete surgical staging should include both pelvic and para-aortic lymphadenectomy. The vast majority of endometrial cancers are diagnosed at a very early stage owing to the early presentation as abnormal uterine bleeding. In women with early-stage endometrial cancer the systematic pelvic and para-aortic lymphadenectomy may produce additional morbidity without the benefit of appropriate surgical staging. The procedure of sentinel lymph node (SLN) biopsy after lymphatic mapping has been introduced for patients with cancers of various organs in an effort to avoid complete systematic lymphadenectomy whenever possible. In the case of gynecological malignancies, the reliability of the SLN detection procedure has been extensively investigated in vulvar and cervical cancer. This article focuses on the peculiar aspects of intraoperative lymphatic mapping techniques and SLN procedures in endometrial cancer.

Intraoperative sentinel lymph node detection by vital dye through laparoscopy or laparotomy in early endometrial cancer

BACKGROUND AND OBJECTIVES

Recent studies reported the feasibility of intraoperative lymphatic mapping in women with endometrial cancer but none of these studies compared the sentinel lymph nodes (SLNs) detection rates obtainable through laparoscopy or laparotomy. The purpose of this study was to address this issue.

METHODS

Thirty-four patients with clinical stage I-II endometrial cancer were enrolled in this prospective comparative trial. Four milliliters of Patent Blue Violet were injected into the cervix after the induction of general anesthesia. The assessment of SLNs was done in 17 patients through laparoscopy and in 17 patients through laparotomy as first step of systematic pelvic lymphadenectomy. Both SLNs and non-SLNs were evaluated for micrometastases.

RESULTS

The SLNs detection rate was significantly higher (82%) for laparoscopy than for laparotomy (41%; P = 0.008). Pelvic lymph node metastases were present in 6 out of 34 patients (18%) but only 3 (50%) of these patients were correctly identified.

CONCLUSIONS

SLNs detection rate is significantly higher through laparoscopy than through laparotomy after vital dye pericervical injection but intraoperative vital dye pericervical injection is not reliable as part of standard care for predicting lymphatic spread in women with early stage endometrial cancer.

The role of sentinel node biopsy in gynecological cancer: a review

PURPOSE OF REVIEW

In early-stage vulvar, cervical and endometrial cancer, lymph node status is the most important prognostic factor. Surgical treatment is aimed at removing the primary tumor and adequately staging the regional lymph nodes. As morbidity of regional lymphadenectomy is high, sentinel node biopsy is a technique with potential for adequate staging with less treatment-related morbidity. This manuscript reviews its current role in vulvar, cervical and endometrial cancer.

RECENT FINDINGS

In early-stage vulvar cancer, level 3 evidence indicates that it appears to be safe to omit inguinofemoral lymphadenectomy in case of a negative sentinel node. However, false-negative results with fatal consequences do occur and are often attributable to procedural failures. For early-stage cervical cancer, level 3 evidence points to an acceptable false-negative rate of a negative sentinel node; clinical utility and safety remain to be established. The optimal technique of the sentinel node biopsy in endometrial cancer is currently unclear.

SUMMARY

In early-stage vulvar cancer, data suggest that sentinel node biopsy could be offered as a treatment option instead of routine inguinofemoral lymphadenectomy. However, more (long-term follow-up) data are needed to further appreciate real clinical benefits. It is emphasized that the procedure should be performed by a skilled multidisciplinary team, centralized in oncology centers and preferably within the protection of clinical trials. For cervical cancer, data are promising, but routine application cannot be recommended due to lack of data on clinical utility and safety. For endometrial cancer, studies on the sentinel node biopsy are still in feasibility stage.

Role of the integrated FDG PET/CT in the surgical management of patients with high risk clinical early stage endometrial cancer: detection of pelvic nodal metastases

BACKGROUND

High risk clinical stage I endometrial cancer (grade 2 and deep myometrial invasion, grade 3 and serous and clear-cell carcinoma) had 10-35% of nodal involvement. Surgical staging is considered reasonable in this setting of women, although unnecessary in 70-90%. The purpose of this study was to determine prospectively the diagnostic accuracy of 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography 18F-FDG PET/CT in the detection of nodal metastases in patients with high risk endometrial cancer.

METHODS

Eleven women with grade 2 and deep myometrial invasion and 26 with grade 3 endometrial cancer underwent 18F-FDG PET/CT, followed by total hysterectomy, bilateral salpingo-oophorectomy and systematic pelvic lymphadenectomy. Histopathological findings served as the reference standard. Diagnostic performance of 18F-FDG PET/CT in nodal disease detection was reported in terms of accuracy value both in a patient-based and a lesion site-based analysis.

RESULTS

Pelvic nodes metastases were found at histopathological analysis in 9 of the 37 patients (24.3%). Patient-based sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 18F-FDG PET/CT for detection of nodal disease were 77.8%, 100.0%, 100.0%, 93.1% and 94.4%, respectively. Nodal lesion site-based sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 18F-FDG PET/CT were 66.7%, 99.4%, 90.9%, 97.2% and 96.8%, respectively.

CONCLUSION

This study shows that 18F-FDG PET/CT is an accurate method for the presurgical evaluation of pelvic nodes metastases. The high negative predictive value may be useful in selecting patients who only may benefit from lymphadenectomy, minimizing operative and surgical complications.

Endometrial cancer--current state of the art therapies and unmet clinical needs: the role of surgery and preoperative radiographic assessment

Endometrial carcinoma is the fourth most common cancer among women in the United States. Surgical pathologic staging has been the standard of care since 1988, which consists of analysis of collected peritoneal fluid, hysterectomy/oophorectomy, and pelvic and para-aortic lymphadenectomy. In 2005, it was further recommended that essentially all women with endometrial cancer who choose to undergo surgery have pelvic and para-aortic lymph node analysis. Despite this recommendation, there still remains controversy as to whether all patients with endometrial cancer should undergo full lymph node dissection. In this review, we assess the evidence surrounding this controversy and conclude that women with endometrial cancer should undergo complete lymphadenectomy at the time of surgery. Furthermore, we evaluate the evidence regarding laparoscopic surgical staging as a safe and effective alternative to the more invasive traditional laparotomy. Finally, for those patients who a gynecologic oncologist is not readily available to perform a complete lymph node dissection, we evaluate the various imaging studies and their utility as preoperative triage modalities.

How accurate is frozen section histology of pelvic lymph nodes in patients with endometrial cancer?

OBJECTIVE

Recent prospective data support the trend towards systematic retroperitoneal lymphadenectomy in patients with high-risk endometrial cancer. Because para-aortic node involvement in the absence of pelvic node involvement is uncommon, a reliable finding of negative pelvic lymph nodes (PLN) at intraoperative frozen section examination might allow omitting para-aortic dissection. We analyzed the diagnostic accuracy of frozen section examination of PLN in patients with endometrial cancer.

METHODS

We reviewed 131 patients with endometrial cancer who underwent surgery including systematic pelvic lymphadenectomy (n=101) or pelvic and para-aortic lymphadenectomy (n=27). Intraoperative frozen section examination of PLN was performed in 72 (55%) patients. Results of frozen section examination were compared with those of final histopathology and the diagnostic accuracy of frozen section examination of PLN was calculated. One pathologist measured the diameters of PLN metastases retrospectively.

RESULTS

A total of 1063 and 2666 PLN were analyzed by frozen section examination and by final histopathology, respectively. PLN metastases were found in 7 cases (10%) at frozen section examination, and in 17 cases (24%) at final histopathology (false negative rate, 59%). No false positive cases were noted. The mean diameter of all PLN metastases at final histopathology was 4.3 mm, as compared to 9.0 mm for the metastases detected at frozen section analyses. The mean diameter of PLN metastases missed at frozen section examination was 2.0 mm.

CONCLUSION

In this review at a single institution, intraoperative frozen section histology missed nearly two of three endometrial cancer patients with positive nodes. These results do not support tailoring the extent of lymphadenectomy according to the results of frozen section examination.

A comprehensive overview of radioguided surgery using gamma detection probe technology

The concept of radioguided surgery, which was first developed some 60 years ago, involves the use of a radiation detection probe system for the intraoperative detection of radionuclides. The use of gamma detection probe technology in radioguided surgery has tremendously expanded and has evolved into what is now considered an established discipline within the practice of surgery, revolutionizing the surgical management of many malignancies, including breast cancer, melanoma, and colorectal cancer, as well as the surgical management of parathyroid disease. The impact of radioguided surgery on the surgical management of cancer patients includes providing vital and real-time information to the surgeon regarding the location and extent of disease, as well as regarding the assessment of surgical resection margins. Additionally, it has allowed the surgeon to minimize the surgical invasiveness of many diagnostic and therapeutic procedures, while still maintaining maximum benefit to the cancer patient. In the current review, we have attempted to comprehensively evaluate the history, technical aspects, and clinical applications of radioguided surgery using gamma detection probe technology.

Limits of lymphoscintigraphy for sentinel node biopsy in women with endometrial cancer

OBJECTIVE

Lymph node status in endometrial cancer is a major prognostic factor. Sentinel lymph node (SLN) biopsy using radiocolloid and blue dye labeling has emerged as an alternative to systematic lymphadenectomy. This technique requires a preoperative lymphoscintigraphy. The aim of this study was to evaluate the limits of day-before preoperative lymphoscintigraphy to SLN biopsy.

METHODS

Between July 2002 and March 2007, 38 patients with endometrial cancer underwent laparoscopic SLN procedure using radiocolloid and blue dye. Those with early-stage I endometrial cancer (35 patients) underwent a SLN procedure followed by systematic pelvic lymphadenectomy and a hysterectomy with bilateral salpingo-oophorectomy while those with presumed stage IIB on MR imaging (3 patients) underwent a radical hysterectomy. Omentectomy and paraaortic lymphadenectomy were also performed for women with clear cell or serous papillary carcinoma (5 patients). The SLN identification rates and false-negative rates were studied.

RESULTS

The detection rate of lymphoscintigraphy was 84.5% (32/38), with 1.9 nodes per patient. Eight of 17 patients (47%) with unilateral sentinel lymph node on lymphoscintigraphy had bilateral SLNs at surgery and three of 15 patients (20%) with bilateral SLN on lymphoscintigraphy had unilateral SLN at surgery. The correlation was poor (kappa=0.266). When categorized in <2 and > or =2 sentinel nodes, the correlation between lymphoscintigraphic and surgical SLN mapping was moderate (kappa=0.33).

CONCLUSION

Our results demonstrated the low correlation between day-before lymphoscintigraphy and surgical SLN mapping raising issues of its usefulness and cost-effectiveness in routine practice.