Review Article
Sentinel Lymph Node Evaluation in Women with Cervical Cancer

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Abstract

Lymph node status is the most important prognosticator of survival in women with early stage cervical cancer. Thus many patients with cervical cancer will undergo pelvic lymphadenectomy as part of the treatment. This procedure is associated with substantial morbidity. Use of the sentinel lymph node technique in women with cervical cancer has the potential to decrease this morbidity. Multiple studies have suggested that sentinel lymph node mapping in these patients is feasible, with excellent detection rates and sensitivity. This review examines the current body of literature about sentinel lymph node biopsy in women with cervical cancer.

Section snippets

Mapping Techniques

Use of blue dye alone was the first technique described for sentinel lymph node identification in patients with cervical cancer [7]. For this procedure, isosulfan blue, methylene blue, or patent blue is injected into the cervix immediately after general anesthesia is obtained. Intraoperatively, the dye is visualized with the naked eye. Two injection techniques have been described: injection of dye into each quadrant of the cervix and superficial and deep injections at the 3- and 9-o'clock

Sentinel Node Studies

Multiple single-institution studies have reported their experience with sentinel lymph node biopsy in patients with cervical cancer (Table 2). Although the types of tracer used in each of these studies varied widely, almost all described excellent negative predictive values, ranging from 88% to 100% 8, 9, 10, 11, 15, 16, 17. However, sensitivity seems to be more inconsistent. For example, Marchiolè et al [10] reported their experience with 29 patients with cervical cancer undergoing sentinel

Location of Sentinel Lymph Nodes

In cervical cancer, the sentinel lymph nodes are most commonly located along the internal or external iliac nodal basin. In their retrospective evaluation of 151 women undergoing sentinel lymph node evaluation for cervical cancer, Marnitz et al [35] found that 71% of sentinel nodes were interiliac, 8% were internal iliac, 5% were external iliac, and 5% were common iliac. In the previously described SENTICOL Study, 85.3% of all sentinel nodes were external, internal, or common iliac nodes [36].

Preoperative Imaging of Sentinel Nodes

Lymphoscintigraphy is a nuclear medicine scan in which the lymph node basin is imaged after injection of radiocolloid in an attempt to identify the sentinel lymph nodes preoperatively. This method is most useful in malignant lesions such as melanoma, in which lymphatic drainage is unpredictable. However, when its usefulness has been evaluated in cervical cancer, lymphoscintigraphy has consistently been found to have little clinical value. In their study of 50 women with cervical cancer who

Near-Infrared Fluorescence Imaging for Identification of Sentinel Nodes

Most studies that evaluated intraoperative mapping of sentinel nodes in cervical cancer have used blue dye, radiocolloid, or both to localize the nodes. However, there are limitations to the use of these tracers. For example, radiocolloid use exposes patients to radiation. Near-infrared fluorescence imaging with indocyanine green (ICG) may help overcome these challenges. Similar to other tracers, ICG is injected intracervically in the operating room. The surgeon can then detect the sentinel

Role of Frozen Section

Lymph node metastases in women undergoing surgical management for cervical cancer is an indication to abort the procedure. In these cases, patients typically receive chemoradiation therapy rather than undergoing radical surgery. For this reason, frozen section evaluation of sentinel lymph nodes has typically been used in these patients. Multiple studies have found that the accuracy of intraoperative frozen section evaluation is substantially limited by its inability to detect micrometastases

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    The authors declare no conflicts of interest.

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