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Uterine fundus indocyanine green injection for sentinel lymph node biopsy in endometrial cancer patients with limited access to cervical injection
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  1. Nicolò Bizzarri1,
  2. Giuseppe Parisi1,
  3. Stefano Di Berardino1,
  4. Laura Naccarato1,
  5. Giovanni Scambia1,2 and
  6. Francesco Fanfani1,2
    1. 1UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
    2. 2Università Cattolica del Sacro Cuore, Rome, Italy
    1. Correspondence to Dr Nicolò Bizzarri, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; nicolo.bizzarri{at}yahoo.com

    https://doi.org/10.1136/ijgc-2023-005086

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      Different studies have demonstrated that cervical injection of indocyanine green (ICG) provides accurate bilateral detection of sentinel lymph node (SLN) mapping in apparent early-stage endometrial cancer.1 2 Nevertheless, in some patients, as in case of severe vaginal stenosis, it is not possible to have access to the cervix. In these clinical situations the injection of the tracer in the uterine fundus can be considered. Moreover, a few authors have proposed uterine fundus as injection site for SLN detection in endometrial cancer showing that this approach might allow a high rate of aortic detection, potentially identifying a non-negligible percentage of isolated aortic metastases.3–5 The aim of this educational video (Video 1) was to show how to perform uterine fundus injection of ICG in case the cervical injection is not feasible.

      Video 1 –

      We report the case of a 76-year-old patient diagnosed with an apparent uterine-confined grade 2 endometrioid endometrial cancer. A transvaginal ultrasound showed a 39mm a hyperechoic endometrial mass. The operation was performed with robotic-assisted laparoscopy and included total hysterectomy, bilateral salpingo-oophorectomy and bilateral SLNs biopsy.

      The cervical ICG injection was not feasible due to the severe stenosis of the superior third of vagina. An attempt to inject the cervix was performed but was not successful as the cervix could not be seen at vaginal examination. For this reason, transcutaneous injection of 1 ml of ICG was performed in the uterine fundus with transcutaneous spinal needle (Figure 1). A careful study of tumor location on the pre-operative ultrasound scan was performed identifying tumor-free uterine wall to allow a safe injection with no risk of tumor spillage. After this injection bilateral external iliac SLNs were identified and removed. Ultrastaging protocol was performed. With this video we demonstrated the uterine fundus to be an alternative site of ICG injection of the tracer in case cervix is not accessible.

      Figure 1
      Figure 1

      Transcutaneous injection of indocyanine green in the uterine fundus with a spinal needle.

      Data availability statement

      Data are available upon request.

      Ethics statements

      Patient consent for publication

      Ethics approval

      This study involves human participants but Policlinico Agostino Gemelli IRCCS exempted this study. Participants gave informed consent to participate in the study before taking part.

      References

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        . Near-infrared fluorescence for detection of sentinel lymph nodes in women with cervical and uterine cancers (FILM): a randomised, phase 3, multicentre, non-inferiority trial. Lancet Oncol 2018;19:1394–403. doi:10.1016/S1470-2045(18)30448-0
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        . Hysteroscopic versus cervical injection for sentinel node detection in endometrial cancer: a multicenter prospective randomised controlled trial from the multicenter Italian trials in ovarian cancer (MITO). Eur J Cancer 2020;140:1–10. doi:10.1016/j.ejca.2020.08.030
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        3. Jaunarena I, et al
        . Sentinel node biopsy in endometrial cancer with dual cervical and fundal indocyanine green injection. Int J Gynecol Cancer 2018;28:139–44. doi:10.1097/IGC.0000000000001151
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        1. Wang Q,
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        3. Wang L, et al
        . The efficiency of a combined injection technique for sentinel lymph node mapping in intermediate-high-risk endometrial cancer. J Surg Oncol 2021;124:1551–60. doi:10.1002/jso.26666
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        1. Ruiz R,
        2. Gorostidi M,
        3. Jaunarena I, et al
        . Maximizing sentinel node detection in endometrial cancer with dual cervical and transcervical fundal indocyanine green injection: 5-year single-center prospective study. Eur J Obstet Gynecol Reprod Biol 2021;261:59–64. doi:10.1016/j.ejogrb.2021.04.015
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      Footnotes

      • Twitter @Giuseppe83005492, @frafanfani

      • Contributors NB: guarantor. NB, FF: study design. GP, SDB, LN: video preparation and editing. GS: supervision. NB: writing manuscript. FF, GS: editing manuscript. All authors: revise and edit manuscript.

      • 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.