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Comparative study using indocyanine green and patent blue dye for sentinel lymph node biopsy in patients with early-stage cervical cancer
  1. Benedikt Wess1,
  2. Christhardt Kohler2,3,
  3. Andrea Plaikner3,
  4. Samer El-Safadi4,
  5. Thilo Schwandner4,
  6. Ivo Meinhold-Heerlein1 and
  7. Giovanni Favero1,4
    1. 1University Hospitals Giessen and Marburg Campus Giessen, Giessen, Hessen, Germany
    2. 2Department of Gynecology, University of Cologne, Koln, Germany
    3. 3Department of Special Operative and Oncologic Gynecology, Asklepios-Clinic Hamburg-Altona, Asklepios Hospital Group, Hamburg, Germany
    4. 4Asklepios Hospital Lich, Lich, Germany
    1. Correspondence to Dr Benedikt Wess, University Hospitals Giessen and Marburg Campus Giessen, Giessen, Hessen, Germany; benedikt.wess{at}


    Background Lymphatic involvement is the most important prognostic factor in early-stage cervical cancer. Sentinel lymph node biopsy is a viable alternative to systematic lymphadenectomy and may identify metastases more precisely.

    Objective To compare two tracers (indocyanine green and patent blue) to detect sentinel nodes.

    Methods A single-center, retrospective study of women treated due to early-stage cervical cancer (International Federation of Gynecology and Obstetrics 2009 IA1 with lymphovascular invasion, IA2, and IB1). Location and tracer of all detected sentinel nodes had been documented for a prospective, multicenter trial (SENTIX trial). All sentinel nodes were sent to frozen section and final analysis through ultrastaging using a standard protocol.

    Results Overall, 103 patients were included. Bilateral detection rate for indocyanine green (93.2%) was significantly higher than for blue dye (77.7%; p=0.004). Their combined use significantly increased the bilateral detection to 99.0% (p=0.031). While 97.4% of all sentinel nodes were located below the common iliac vessels, no para-aortic nodes were labeled. Simultaneous bilateral detection with both tracers was found in 71.8% of the cases, of which the sentinel nodes were identical in 91.9%. Nine positive nodes were detected among seven patients (6.8%), all marked with indocyanine green while patent blue labeled six. Frozen section failed to detect one of three macrometastases and three of four micrometastases (sensitivity 43%; negative prediction value 96%).

    Conclusion Anatomical distribution and topographic localization of the sentinel nodes obtained with these tracers were not different. Indocyanine green provided a significantly higher bilateral detection rate and had superior sensitivity to detect positive nodes compared with patent blue. Combining indocyanine green and blue dye increased the bilateral detection rate significantly.

    • Sentinel Lymph Node
    • Cervical Cancer
    • Cervix Uteri
    • Surgical Oncology

    Data availability statement

    Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

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    Data availability statement

    Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

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    • Contributors CK, AP, and GF peformed all the surgeries of the patients at Asklepios-Clinic Hamburg Altona analyzed in this study. IM-H and GF guided all the work of this study performed by BW (planning the study, collecting all patients' data, writing and proofreading of this manuscript). Furthermore, GF supervised all work related to this publication as the guarantor. AP helped to collect all patients' data (health records, pathology reports, surgery documentations, and doctors' reports). TS and SE-S contributed to analysis of the patients' data.

    • 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.