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Alternatives of the pelvic sentinel lymph node migration pathway in early ovarian cancer: the simplest the best
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  1. Victor Lago1,2,
  2. Marta Arnaez1,
  3. Pablo Padilla-Iserte1,
  4. Alberto Rafael Guijarro-Campillo3,
  5. Luis Matute1,
  6. Marta Gurrea1,
  7. Pilar Bello4 and
  8. Santiago Domingo1
  1. 1Department of Gynecologic Oncology, La Fe University and Polytechnic Hospital, Valencia, Spain
  2. 2Department of Gynecology, CEU Cardenal Herrera University, Valencia, Comunitat Valenciana, Spain
  3. 3Department of Obstetrics and Gynecology, Virgen de la Arrixaca University Hospital, El Palmar, Murcia, Spain
  4. 4Department of Nuclear Medicine, La Fe University and Polytechnic Hospital, Valencia, Spain
  1. Correspondence to Dr Victor Lago, Department of Gynecologic Oncology, La Fe University and Polytechnic Hospital, Valencia, Spain; victor.lago.leal{at}hotmail.com

https://doi.org/10.1136/ijgc-2023-004912

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    The sentinel lymph node technique in apparent early-stage ovarian cancer represents an emerging surgery, with increasing evidence published in recent years.1 Lymphatic migration from the ovary is bidirectional, but after adnexectomy it becomes unidirectional towards the pelvic and aortic field. Although standardization is not fully established, double puncture after adnexectomy and confirmation of malignancy is the most reproducible technique as it can also be applied to re-staging cases.

    In our experience,2 3 there are some concerns regarding the utero-ovarian ligament injection that may lead to difficulties in its reproducibility. The retroperitoneum is usually opened during adnexal tumor resection, which can lead to a spread of the tracer. Even if protective maneuvers (eg, avoid retroperitoneum dissection, acoid leaving a gauze in the pouch of Douglas, sealing the point of injection, peritonization) are used to prevent extravasation of the tracer, the leak may persist, and this impedes localization of the pelvic lymph node.

    Cervix injection for pelvic sentinel lymph node detection is widespread and commonly used in gynecological oncology, which makes reproducibility of this technique more feasible.4 Injections into the cervical and utero-ovarian ligament appear to identify the same pelvic sentinel lymph node, suggesting that the two injection sites are equivalent.

    In this video the migration of a tracer from the cervix and from the utero-ovarian ligament towards the same sentinel node is showed. We present a patient with endometrial cancer (endometrioid G1, International Federation of Gynecology and Obstetrics (FIGO) IA) for whom a pelvic sentinel lymph node technique was proposed after informed consent was obtained for a prospective study carried out in our center (local ethics approval CEIM-IISLAFE 2022-790-1).

    On the day before surgery, 0.5 mL of Tc-99 (6 mCi) was injected into the cervix at 6 and 9 hours. Subsequently, single photon emission CT combined with CT (SPECT-CT) images were acquired to corroborate the migration of the pelvic sentinel node (external iliac).

    A robotic approach was used to perform the pelvic sentinel node technique, hysterectomy, and double adnexectomy. For indocyanine green injection, to reproduce unidirectional migration from the ovary to the pelvis, the utero-ovarian liament is sealed with bipolar energy prior to injection (Figure 1). Then 0.5 mL of indocyanine green diluted to 1.25 mg/mL is injected into the utero-ovarian ligament.

    Figure 1
    Figure 1

    Indocyanine green injection in the utero-ovarian ligament.

    Using a laparoscopic gamma probe, the location of the sentinel lymph node in the external iliac territory is confirmed. Fifteen minutes after the indocyanine green injection, migration to the same sentinel lymph node is visually verified.

    Video 1 Video demonstration of double migration from cervix and utero-ovarian ligament to the same pelvic sentinel lymph node

    Conclusion

    The lymphatic migration pathway of the cervix could be equivalent to that of the utero-ovarian ligament, representing a more reproducible alternative to the utero-ovarian ligament injection technique. Nevertheless, this video represents a case report with preliminary results for a promising technique.

    Data availability statement

    Data are available upon request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by local code: 2022-790-1 CICEIM IISLAFE. Participants gave informed consent to participate in the study before taking part.

    References

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      1. Agusti N,
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      3. Grillo-Ardila C, et al
      . Sentinel lymph node detection in early-stage ovarian cancer: a systematic review and meta-analysis. Int J Gynecol Cancer 2023;33:1493–501. doi:10.1136/ijgc-2023-004572
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      1. Lago V,
      2. Bello P,
      3. Montero B, et al
      . Clinical application of the sentinel lymph node technique in early ovarian cancer: a pilot study. Int J Gynecol Cancer 2019;29:377–81. doi:10.1136/ijgc-2018-000049
      OpenUrlAbstract/FREE Full Text
    3. ↵
      1. Lago V,
      2. Bello P,
      3. Montero B, et al
      . Sentinel lymph node technique in early-stage ovarian cancer (SENTOV): a phase II clinical trial. Int J Gynecol Cancer 2020;30:1390–6. doi:10.1136/ijgc-2020-001289
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      1. Uccella S,
      2. Garzon S,
      3. Bosco M, et al
      . Cervical versus utero-ovarian ligament injection of the tracer for the pelvic sentinel lymph node mapping in gynecologic oncology: a prospective observational study. Gynecol Obstet Invest 2022;87:242–7. doi:10.1159/000525126
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    Footnotes

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    • Contributors All of the authors of the present manuscript declare that there are no conflicts of interest and have actively participated in the work providing input including: (1) Substantial contributions to conception and study design. (2) Drafting of the article. (3) Final approval of the version to be published. We declare we have no conflict of interest. VL and SD are the guarantors.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.