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Consensus on surgical technique for sentinel lymph node dissection in cervical cancer
  1. Nicolò Bizzarri1,
  2. Andreas Obermair2,
  3. Heng-Cheng Hsu3,
  4. Enrique Chacon4,
  5. Anna Collins5,
  6. Irina Tsibulak6,
  7. Alex Mutombo7,
  8. Nadeem R Abu-Rustum8,
  9. Vincent Balaya9,
  10. Alessandro Buda10,
  11. David Cibula11,
  12. Allan Covens12,
  13. Francesco Fanfani1,
  14. Gwenaël Ferron13,
  15. Michael Frumovitz14,
  16. Benedetta Guani15,
  17. Roman Kocian11,
  18. Christhardt Kohler16,17,
  19. Eric Leblanc18,
  20. Fabrice Lecuru19,
  21. Mario M Leitao Jr8,
  22. Patrice Mathevet20,
  23. Michael D Mueller21,
  24. Andrea Papadia22,23,
  25. Rene Pareja24,25,
  26. Marie Plante26,
  27. Denis Querleu1,
  28. Giovanni Scambia1,
  29. Edward Tanner27,
  30. Ignacio Zapardiel28,
  31. Jaime R Garcia29 and
  32. Pedro T Ramirez30
    1. 1 UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
    2. 2 Queensland Centre for Gynaecological Cancer Research, Faculty of Medicine, Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
    3. 3 Obstetrics and Gynaecology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
    4. 4 Gynaecologic Oncology, Universidad de Navarra, Pamplona, Spain
    5. 5 Obstetrics and Gynaecology, Derby Hospitals NHS Foundation Trust, Derby, UK
    6. 6 Department of Obstetrics and Gynaecology, Medical University of Innsbruck, Innsbruck, Austria
    7. 7 Gynaecology and Obstetrics, University of Kinshasa, Kinshasa, Congo (Democratic Republic of the)
    8. 8 Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
    9. 9 Department of Obstetrics and Gynaecology, Felix Guyon Hospital, CHU Nord Réunion, France
    10. 10 Gynaecologic Oncology, Ospedale Michele e Pietro Ferrero, Verduno, Italy
    11. 11 Department of Obstetrics and Gynecology, Charles University, First Faculty of Medicine, Prague, Czech Republic
    12. 12 Gynecologic Oncology, Toronto Sunnybrook Regional Cancer Center, Toronto, Ontario, Canada
    13. 13 Department of Surgical Oncology, Institut Claudius Regaud Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
    14. 14 Department of Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
    15. 15 Department of Obstetrics and Gynaecology, Fribourg Hospitals, Fribourg, Switzerland
    16. 16 Department of Gynaecology, University of Cologne, Koln, Germany
    17. 17 Department of Special Operative and Oncologic Gynaecology, Asklepios-Clinic Hamburg-Altona, Asklepios Hospital Group, Hamburg, Germany
    18. 18 Department of Surgical Oncology, Centre Oscar Lambret, Lille, France
    19. 19 Breast, Gynaecology, and Reconstructive Surgery Unit, Institute Curie, Paris, France
    20. 20 Centre Hospitalier Universitaire Vaudois Departement de gynecologie-obstetrique et genetique medicale, Lausanne, Switzerland
    21. 21 Gynaecology and Gynaecological Oncology, Inselspital University Hospital Berne Department of Gynaecology, Bern, Switzerland
    22. 22 Department of Gynaecology and Obstetrics, Ente Ospedaliero Cantonale, Lugano, Switzerland
    23. 23 Università della Svizzera italiana, Lugano, Switzerland
    24. 24 Department of Gynaecology, Gynaecologic Oncology, Clinica Astorga, Medellin, Colombia
    25. 25 Instituto Nacional de Cancerología, Bogotá, Colombia
    26. 26 Laval University, Quebec City, Quebec, Canada
    27. 27 Department of Obstetrics and Gynecology, Northwestern University, Evanston, Illinois, USA
    28. 28 Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
    29. 29 Department of Academic Analytics and Technology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
    30. 30 Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas, USA
    1. Correspondence to Dr Nicolò Bizzarri, UOC Ginecologia Oncologica, Dipartimento di scienze della salute della donna, del bambino e di sanità pubblica, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy; nicolo.bizzarri{at}


    Objective The purpose of this study was to establish a consensus on the surgical technique for sentinel lymph node (SLN) dissection in cervical cancer.

    Methods A 26 question survey was emailed to international expert gynecological oncology surgeons. A two-step modified Delphi method was used to establish consensus. After a first round of online survey, the questions were amended and a second round, along with semistructured interviews was performed. Consensus was defined using a 70% cut-off for agreement.

    Results Twenty-five of 38 (65.8%) experts responded to the first and second rounds of the online survey. Agreement ≥70% was reached for 13 (50.0%) questions in the first round and for 15 (57.7%) in the final round. Consensus agreement identified 15 recommended, three optional, and five not recommended steps. Experts agreed on the following recommended procedures: use of indocyanine green as a tracer; superficial (with or without deep) injection at 3 and 9 o’clock; injection at the margins of uninvolved mucosa avoiding vaginal fornices; grasping the cervix with forceps only in part of the cervix is free of tumor; use of a minimally invasive approach for SLN biopsy in the case of simple trachelectomy/conization; identification of the ureter, obliterated umbilical artery, and external iliac vessels before SLN excision; commencing the dissection at the level of the uterine artery and continuing laterally; and completing dissection in one hemi-pelvis before proceeding to the contralateral side. Consensus was also reached in recommending against injection at 6 and 12 o’clock, and injection directly into the tumor in cases of the tumor completely replacing the cervix; against removal of nodes through port without protective maneuvers; absence of an ultrastaging protocol; and against modifying tracer concentration at the time of re-injection after mapping failure.

    Conclusion Recommended, optional, and not recommended steps of SLN dissection in cervical cancer have been identified based on consensus among international experts. These represent a surgical guide that may be used by surgeons in clinical trials and for quality assurance in routine practice.

    • Cervical Cancer
    • Sentinel Lymph Node
    • Laparoscopes

    Data availability statement

    Data are available upon reasonable request.

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    • Contributors NB, PTR, AO, H-CH, EC, AC, IT, and AMB: designed the study and methodology. NB, H-CH, EC, AC, IT, and AMB: conducted semi-structured interviews. JRG: software and technology. NB and PTR: wrote the original manuscript. NRA-R, VB, AB, DC, ACov, FF, GF, MF, BG, RK, CK, EL, FRL, ML, PM, MDM, AP, RP, MP, DQ, GS, ET, IZ, NB, and PTR: data collection and international experts. NB, PTR, AO, and H-CH: reviewing and editing. All authors: revised and approved manuscript. NB: guarantor.

    • Funding NRA-R is supported in part by a National Cancer Institute/National Institutes of Health Cancer Center Support grant (P30 CA008748).

    • Competing interests None declared.

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

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.