Sentinel lymph node status in patients with locally advanced cervical cancers and impact of neoadjuvant chemotherapy

Sentinel node navigation surgery in cervical cancer: a systematic review and metaanalysis

Sentinel node navigation surgery (SNNS) is used in clinical practice for the treatment of cervical cancer. This study aimed to elucidate the appropriate sentinel lymph node (SLN) mapping method and assess the safety and benefits of SNNS. We searched the PubMed, Ichushi, and Cochrane Library databases for randomized controlled trials (RCT) and studies on SLN in cervical cancer from January 2012 to December 2020. Two authors independently assessed study quality and extracted data. We quantitatively analyzed the detection rate, sensitivity/specificity, and complications and reviewed information, including the survival data of SLN biopsy (SLNB) without pelvic lymphadenectomy (PLND). The detection rate of SLN mapping in the unilateral pelvis was median 95.7% and 100% and in the bilateral pelvis was median 80.4% and 90% for technetium-99 m (Tc) with/without blue dye (Tc w/wo BD) and indocyanine green (ICG) alone, respectively. The sensitivity and specificity of each tracer were high; the area under the curve of each tracer was 0.988 (Tc w/wo BD), 0.931 (BD w/wo Tc), 0.966 (ICG), and 0.977 (carbon nanoparticle). Morbidities including lymphedema, neurological symptoms and blood loss were associated with PLND. One RCT and five studies all showed SNNS without systematic PLND does not impair recurrence or survival in early-stage cervical cancer with a tumor size ≤ 2-4 cm. Both Tc w/wo BD and ICG are appropriate SLN tracers. SNNS can reduce the morbidities associated with PLND without affecting disease progression in early-stage cervical cancer.

Fertility-Sparing and Less Radical Surgery for Cervical Cancer

PURPOSE OF REVIEW

Patients with early-stage cervical cancer who desire future fertility may be candidates for less radical surgery. We review the literature supporting this approach in early-stage disease.

RECENT FINDINGS

Retrospective data have shown that in carefully selected patients, the risk of parametrial involvement is less than 1%. This has led to interest in moving away from radical surgery towards more conservative approaches. Data from the newly published ConCerv trial, a prospective study evaluating the feasibility of conservative surgery in women with early-stage, low-risk cervical carcinoma, suggest that conservative surgery is feasible and safe in this patient population. Furthermore, neoadjuvant chemotherapy is being assessed as an option to extend fertility-sparing treatment to a larger group of women. Less radical surgery may be appropriate for carefully selected women with early-stage, low-risk cervical cancer, including those desiring future fertility.

Sentinel lymph node mapping with indocyanine green in cervical cancer patients undergoing open radical hysterectomy: a single-institution series

PURPOSE

To assess the rate of bilateral sentinel lymph node (SLN) detection with indocyanine green (ICG), to evaluate the sensitivity and the negative predictive value of cervical cancer patients undergoing open radical hysterectomy; to compare open versus minimally invasive SLN biopsy performance and to assess factors related to no/unilateral SLN mapping.

METHODS

We retrospectively reviewed consecutive patients with FIGO 2018 stage IA1 with lymph-vascular space involvement to IIB and IIIC1p cervical carcinoma who underwent SLN mapping with ICG followed by systematic pelvic lymphadenectomy between 05/2017 and 06/2020. Patients were divided according to surgical approach for statistical analysis.

RESULTS

Eighty-five patients met inclusion criteria. Twenty-seven (31.8%) underwent open and 58 (68.2%) underwent minimally invasive SLN mapping. No difference in any SLN mapping (laparotomy 92.6% and minimally invasive 91.4%) or in SLN bilateral detection (laparotomy 72.0% and minimally invasive 84.9%) (p = 0.850 and p = 0.222, respectively), in median number of SLNs mapped and retrieved (2 in both groups, p = 0.165) and in site of SLN mapping per hemi-pelvis (right side, p = 0273 and left side, p = 0.618) was evident between open and minimally invasive approach. Per-patient sensitivity of SLN biopsy in laparotomy was 83.3% (95% CI 35.9-99.6%) and the negative predictive value was 95.0% (95% CI 76.0-99.1%). No difference in per-patient sensitivity was noted between two approaches (p = 0.300). None of the analyzed variables was associated with no/unilateral SLN mapping.

CONCLUSION

The use of ICG to detect SLN in cervical cancer treated with open surgery allows a bilateral detection, sensitivity and negative predictive value comparable to minimally invasive surgery with potential advantages of ICG compared to other tracers.

Pathologic Protocols for Sentinel Lymph Nodes Ultrastaging in Cervical Cancer

CONTEXT.—

Ultrastaging of sentinel lymph nodes (SLNs) is a crucial aspect in the approach to SLN processing. No consensual protocol for pathologic ultrastaging has been approved by international societies to date.

OBJECTIVE.—

To provide a review of the ultrastaging protocol and all its aspects related to the processing of SLNs in patients with cervical cancer.

DATA SOURCES.—

In total, 127 publications reporting data from 9085 cases were identified in the literature. In 24% of studies, the information about SLN processing is entirely missing. No ultrastaging protocol was used in 7% of publications. When described, the differences in all aspects of SLN processing among the studies and institutions are substantial. This includes grossing of the SLN, which is not completely sliced and processed in almost 20% of studies. The reported protocols varied in all aspects of SLN processing, including the thickness of slices (range, 1-5 mm), the number of levels (range, 0-cut out until no tissue left), distance between the levels (range, 40-1000 μm), and number of sections per level (range, 1-5).

CONCLUSIONS.—

We found substantial differences in protocols used for SLN pathologic ultrastaging, which can impact sensitivity for detection of micrometastases and even small macrometastases. Since the involvement of pelvic lymph nodes is the most important negative prognostic factor, such profound discrepancies influence the referral of patients to adjuvant radiotherapy and could potentially cause treatment failure. It is urgent that international societies agree on a consensual protocol before SLN biopsy without pelvic lymphadenectomy is introduced into routine clinical practice.

A GCIG international survey: clinical practice patterns of sentinel lymph node biopsies in cervical cancer

PURPOSE

To evaluate the practice patterns among centers and physicians worldwide regarding sentinel lymph node biopsies (SLNB) in cervical cancer (CC) patients.

METHOD

A validated 35-item questionnaire regarding SLNB in CC supported by the Gynecologic Cancer Intergroup (GCIG), and sponsored by the North-Eastern German Society of Gynaecologic-Oncology (NOGGO) was sent to all major gynecological cancer societies across the globe for further distribution from October 2015 and continued for a period of 7 months.

RESULTS

One hundred and sixty-one institutions from around the world participated. One hundred and six (66%) of the participants were from university centers and 111 (69%) were gynecologic oncologists. One hundred and fifty-two (97%) performed lymphadenectomy (LNE) and 147 (94%) did so systematically; 97 (60%) used SLNB, due to lower morbidity (73%), reliability (55%) and time-saving (27%). In cases of positive SLNB (pN+), 39% of respondents stopped the operation and sent the patient for chemoradiation (CRT), 45% completed pelvic and paraaortic LNE, whereas 26% went on to perform a radical hysterectomy (RH) and systematic pelvic and paraaortic LNE. In case of negative SLNB (pN0), 39% of institutions still performed a systematic pelvic and paraaortic LNE.

CONCLUSION

In this survey worldwide, SLNB adoption is an encouraging 60%, yet ample differences exist regarding strategy, and to a lower extent the techniques used. Lack of experience is the most common reason SLNB is not performed. Efforts to increase surgical education on SLNB technique and multicenter prospective trials providing evidence-based guidelines are warranted.

A retrospective analysis of cisplatin/carboplatin plus paclitaxel in advanced or recurrent cervical cancer

To compare the efficacy and safety of paclitaxel plus carboplatin (TC) and paclitaxel plus cisplatin (TP) in the treatment of advanced or recurrent cervical cancer, this retrospective study included 116 advanced or recurrent cervical cancer cases treated at Beijing Obstetrics and Gynecology Hospital between June 2002 and June 2014. Of these cases, 52 were treated with TC (TC group) and 64 were treated with TP (TP group). We found that the overall survival and response and disease-control rates were not significantly different between the two groups. The TC group had a markedly lower incidence of Grade III-IV gastrointestinal toxicity reactions and a shorter hospitalisation stay than the TP group. The incidences of Grade III-IV bone marrow suppression and renal toxicity were not significantly different between the TP and TC groups. These findings suggest that TC may be a safe and effective alternative to TP for the treatment of advanced or recurrent cervical cancer. Impact Statement What is already known on this subject: Paclitaxel plus cisplatin (TP) is regarded as the standard regimen for cervical cancer, nevertheless, cisplatin is always associated with nephrotoxicity and requires hydration therapy. Carboplatin is a platinum analogue with milder nephrotoxicity than cisplatin. It is reported that carboplatin may be a viable and less toxic alternative to cisplatin in the management of advanced or recurrent cervical cancer, but another study shows that the therapeutic efficacy of paclitaxel plus carboplatin (TC) is non-inferior to that of TP. What the results of this study add: This study compared the efficacy and safety of TC and TP, and found that the TC and TP groups had similar overall response and disease-control rates and survival, but the TC group was better tolerated with a markedly lower incidence of Grades III-IV gastrointestinal toxicity reactions and had a shorter hospitalisation stay than the TP group. What the implications are of these findings for clinical practice and/or further research: TC may be a safe and effective alternative to TP for the treatment of advanced or recurrent cervical cancer in clinical practice.

Where Are We Going with Sentinel Lymph Node Mapping in Gynecologic Cancers?

PURPOSE OF REVIEW

Sentinel lymph node (SLN) mapping is a standard of care for lymphatic assessment of many early-stage gynecologic malignancies. We review the current data, emphasizing the utility of SLN mapping in the management of gynecologic cancers.

RECENT FINDINGS

Endometrial cancer: recent studies have focused on confirming the safety and efficacy of SLN mapping for high-risk patients. Cervical cancer: the LACC Trial demonstrated reduced survival with minimally invasive surgery, calling into question the validity of prior studies evaluating SLN mapping with a minimally invasive approach. Vulvar cancer: the ongoing GROINS-V-II trial is investigating whether patients with SLN metastasis < 2 mm in diameter can safely undergo adjuvant radiation ± chemotherapy without completion inguinal lymphadenectomy. NCCN guidelines have incorporated SLN mapping as a lymphatic assessment strategy for endometrial, cervical, and vulvar malignancies. SLN mapping appears to reduce morbidity while still maintaining an appropriate detection rate of lymphatic metastasis. Additional clinical trials will further our knowledge of these procedures.

Present status of sentinel lymph node biopsy in cervical cancer

Cervical cancer is the fourth most common cancer in women, and seventh overall. This disease represents a medical, economic and social burden. In early FIGO stage patients (IA, IB1 and IIA1), nodal involvement is the most important prognostic factor. Imaging evaluation of nodal metastasis is of limited value. In order to determine lymph node involvement, allow loco-regional control of the disease, define the need for adjuvant radiotherapy and improve survival, standard surgery for early disease is radical hysterectomy with systematic pelvic lymphadenectomy. However, this surgical treatment has risks and complications: longer operative time, larger blood loss, neurovascular or ureteral injury, lower-limb lymphedema, symptomatic lymphocysts, hydronephrosis. A method that allows to define the presence of regional metastasis with less morbidity and equal or greater precision is particularly relevant. The use of the sentinel lymph node biopsy is intended to reach that purpose. The present study reviews recent literature on the role of sentinel lymph node biopsy in cervical cancer, analyzing its indications and contraindications, injection and detection techniques, tracers used, surgical and pathological approaches and its applicability in up-to-date clinical practice.

Preoperative measurement of serum CA-125 levels: is it useful in the risk assessment of low volume lymph node disease in cervical cancer?

BACKGROUND: Elevated serum cancer antigen 125 (CA-125) is observed in some cervical cancers (CCs). Is the correlation of CA-125 with the presence of nodal events useful in predicting early metastasis to the lymph nodes?

METHODS: The study included 45 patients with CC FIGO (2009) stages IA1-IIA1 and known preoperative CA-125 concentration, surgery treated (05.2011-05.2014). Investigated pretreatment: age (pre-, postmenopausal), histological type, grade, confounding factors - prior cone biopsy, ovarian cyst, endometriosis, liver or colon pathology, concomitant malignancy. LN metastases (LNM) were defined as macro (MAC, >2mm) and/or micrometastases (mic, 0.2 - 2 mm), and LVLND as mic or/and ITC (single CC cells clusters) in LNs. Ultrastaging of all LNs (sentinel and non-sentinel, 4 μm thick slices/150 μm intervals) was performed with hematoxylin and eosin staining and with immunohistochemistry (IHC - AE1/AE3 cytokeratin antibodies). Non-parametrical analysis and receiver operating curve analysis were used to determine correlation between CA-125 and LNM including LVLND.

RESULTS: The median age was 55 (23-71). 806 LNs were extracted. LNM was found in 12, LVLND in 6 patients. LNM but not LVLND was correlated with higher grade (G2-G3, p<0.05). LVLND was positively correlated with premenopausal age (p<0.05) but not with tumor histology or grade. Liver disease only was found to influence CA-125 levels (p=0.064). There were no differences within CA-125 concentration among LVLND, LNM, and node-negative patients groups, however a trend was found between higher CA-125 and lower LVLND risk.

CONCLUSIONS: Elevated levels of CA-125 may be less likely due to LVLND than to LN positivity. Grade is an important feature in prediction of LNM but not LVLND. CA-125 level was found to be not predictive of LNM nor LVLND, as confirmed by ultrastaging.

Sentinel node biopsy for lymph nodal staging of uterine cervix cancer: a systematic review and meta-analysis of the pertinent literature

BACKGROUND

We reviewed the available literature on the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers.

METHODS

MEDLINE and Scopus were searched by using "sentinel AND (cervix OR cervical)" as key words. Studies evaluating the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers were included if enough data could be extracted for calculation of detection rate and/or sensitivity.

RESULTS

Sixty-seven studies were included in the systematic review. Pooled detection rate was 89.2% [95% CI: 86.3-91.6]. Pooled sensitivity was 90% [95% CI: 88-92]. Sentinel node detection rate and sensitivity were related to mapping method (blue dye, radiotracer, or both) and history of pre-operative neoadjuvant chemotherapy. Sensitivity was higher in patients with bilaterally detected pelvic sentinel nodes compared to those with unilateral sentinel nodes. Lymphatic mapping could identify sentinel nodes outside the routine lymphadenectomy limits.

CONCLUSION

Sentinel node mapping is an accurate method for the assessment of lymph nodal involvement in uterine cervical cancers. Selection of a population with small tumor size and lower stage will ensure the lowest false negative rate. Lymphatic mapping can also detect sentinel nodes outside of routine lymphadenectomy areas providing additional histological information which can improve the staging. Further studies are needed to explore the impact of sentinel node mapping in fertility sparing surgery and in patients with history of neoadjuvant chemotherapy.

The EANM clinical and technical guidelines for lymphoscintigraphy and sentinel node localization in gynaecological cancers

The accurate harvesting of a sentinel node in gynaecological cancer (i.e. vaginal, vulvar, cervical, endometrial or ovarian cancer) includes a sequence of procedures with components from different medical specialities (nuclear medicine, radiology, surgical oncology and pathology). These guidelines are divided into sectione entitled: Purpose, Background information and definitions, Clinical indications and contraindications for SLN detection, Procedures (in the nuclear medicine department, in the surgical suite, and for radiation dosimetry), and Issues requiring further clarification. The guidelines were prepared for nuclear medicine physicians. The intention is to offer assistance in optimizing the diagnostic information that can currently be obtained from sentinel lymph node procedures. If specific recommendations given cannot be based on evidence from original scientific studies, referral is made to "general consensus" and similar expressions. The recommendations are designed to assist in the practice of referral to, and the performance, interpretation and reporting of all steps of the sentinel node procedure in the hope of setting state-of-the-art standards for high-quality evaluation of possible metastatic spread to the lymphatic system in gynaecological cancer. The final result has been discussed by a group of distinguished experts from the EANM Oncology Committee and the European Society of Gynaecological Oncology (ESGO). The document has been endorsed by the SNMMI Board.

Current status of sentinel lymph node mapping in the management of cervical cancer

The status of regional lymph nodes is the most important prognostic factor in early cervical cancer patients. Pelvic lymph node dissections are routinely performed as a part of standard surgical treatment. Systematic pelvic lymphadenectomy is associated with short- and long-term morbidities. This review discusses single components of the sentinel lymph node mapping (SLNM) technique and results of the detection of sentinel lymph nodes. SLNM biopsy performed by an experienced team for small volume tumors (<2 cm) has high specific side detection rate, excellent negative-predictive value and high sensitivity. Uncommon lymphatic drainage has been reported in 15% of cervical cancer patients. There is sufficient data now to suggest that SLNM with 99mTc plus blue dye in the hands of a surgeon with extensive experience should prove to be an important part of individualized cervical cancer surgery and increase the safety of less radical or fertility-sparing surgery.

Sentinel lymph node biopsy in uterine cervical cancer patients: ready for clinical use? A review of the literature

Sentinel lymph node biopsy has been widely studied in a number of cancer types. As far as cervical cancer is concerned, this technique has already been used, revealing both positive results and several issues to be solved. The debate on the role of sentinel lymph node biopsy in cervical cancer is still open although most of the studies have already revealed its superiority over complete lymphadenectomy and the best handling possible of the emerging practical problems. Further research should be made in order to standardize this method and include it in the clinical routine.

High false negative rate of frozen section examination of sentinel lymph nodes in patients with cervical cancer

OBJECTIVES

Metastatic involvement of the sentinel nodes (SN) is one of the main prognostic factors in cervical cancer which determines the disease management. The results of intra-operative SN examination would make it possible to triage patients in a one-step protocol. The studies carried out on the subject so far have, however, failed to demonstrate adequate accuracy of frozen section examination (FS) and, moreover, they only involved small cohorts.

METHODS

The study included 225 patients with cervical cancer FIGO IA2-IIB in whom at least one SN has been detected and intra-operatively processed. The prevalence of macrometastases, micrometastases and isolated tumour cells (ITC) in the SN was evaluated and the results of FS and final SN ultrastaging were compared.

RESULTS

Metastatic involvement of the SN was detected by pathologic ultrastaging in 73 cases (32.4%); macrometastases, micrometastases and ITC were found in 48, 17 and 8 patients, respectively. Intra-operative SN assessment established the SN status correctly in as few as 41 cases (56.2%), or in 49 cases (63%) if ITC had been excluded. Final ultrastaging of intra-operatively negative SN confirmed macrometastases, micrometastases, and ITC in additional 8, 18 and 8 patients, respectively. The false negative rate of FS was higher in bigger tumours (>20 cm3) and in the presence of LVSI.

CONCLUSIONS

Frozen section examination of SN is not sufficiently reliable; it has a high false negative rate mainly due to its limited ability to detect micrometastases. A possible solution would be a more detailed intra-operative pathologic processing or two-step surgical management.