Elsevier

Gynecologic Oncology

Volume 105, Issue 1, April 2007, Pages 189-193
Gynecologic Oncology

Sentinel lymph node biopsy improves staging in early cervical cancer

https://doi.org/10.1016/j.ygyno.2006.11.021Get rights and content

Abstract

Objectives

The main study objective was to describe the distribution of sentinel lymph nodes (SLNs) and the prevalence of SLN micrometastases in patients with early cervical cancer. The secondary objective was to confirm the SLN detection rate and negative predictive value found in our preliminary study.

Patients and methods

We prospectively included 25 patients with early cervical cancer, each of whom received an injection of 120 MBq of technetium-99m for preoperative lymphoscintigraphy and intraoperative node detection using an endoscopic gamma probe. Patent blue dye was injected intraoperatively. SLNs were sought in the pelvic and para-aortic drainage areas. Radical iliac dissection was performed routinely at the end of the procedure. SLNs were examined after hematoxylin–eosin–saffron staining; negative specimens were assessed using immunohistochemistry.

Results

Most (85%) of the SLNs were in the inter-iliac territory. Para-aortic or parametrial SLNs were found respectively in 2 patients and common iliac SLNs in 5 patients. Thus 9/25 patients had additional information due to SLN detection. One metastasis and one micrometastasis were detected in SLNs. No patients had positive non-sentinel nodes with negative SLNs.

Conclusion

SLN detection ensures the identification of SLNs in unusual locations in 36% of patients. SLN disease was found in 8% of our patients. Thus, SLN biopsy improves staging in patients with early cervical cancer. Studies in larger patient populations are needed to evaluate the clinical impact of SLN biopsy.

Introduction

Sentinel lymph node (SLN) detection is widely used as a staging tool in cancer of the breast or vulva [1], [2] and has been suggested more recently in cancer of the cervix [3]. Many studies have established that SLN detection is feasible in patients with early-stage cervical cancer, especially with a laparoscopic approach [4]. When both a radioactive tracer and patent blue dye were used, SLNs were detected in over 85% of patients [5], [6], [7], [8], [9], [10]. In most studies, the mean number of SLNs per patient was two or greater, and the false-negative rate ranged from 0% to 5% [11], [12]. Morbidity rates have been extremely low [4], [5], [6], [7], [8], [9], [10].

The main goal of SLN detection is to improve nodal staging, which largely governs the prognosis of cervical cancer. SLN detection should improve lymphatic mapping in each individual patient by identifying nodes that are located outside the usual dissection field and that may lead to a recurrence if left in place in patients falsely considered as pN0 [13], [14]. SLN biopsy should also improve the detection of nodal micrometastases, which may influence the prognosis [15]. Micrometastasis detection requires sensitive techniques such as immunohistochemistry, which cannot be used on a large number of nodes [2], [16].

The primary objective of this study was to evaluate the contribution of SLN detection and biopsy to lymphatic mapping in patients with early cervical cancer. The secondary objective was to assess the micrometastasis rate. Finally, we sought to confirm the detection rate and negative predictive value (100%) found in our preliminary study [17].

Section snippets

Patients and methods

We prospectively enrolled 25 patients with early cervical cancer (two FIGO stages Ia2, 20 stages Ib1 < 2 cm, and 3 patients who received pre-operative brachytherapy because cervical diameter was initially between 2 and 4 cm). Patients were operated on between January 1, 2003 and March 30, 2006. All histological types were eligible. We did not include patients with clinical parametrial involvement or preoperative imaging study findings consistent with nodal involvement. Neoadjuvant chemotherapy

Results

Mean age of the 25 patients was 51.2 ± 16.4 years (range, 30-85 years). Histology showed squamous cell carcinoma in 22 patients and adenocarcinoma in 3 patients. FIGO stage was Ia2 in 2 (8%) patients and Ib1 in 23 (92%). Lymphoscintigraphy was performed in 23 (92%) patients and endoscopic probe detection in 24 (96%) patients; thus, 2 patients did not undergo lymphoscintigraphy and 1 did not have the radioactive tracer injection, for reasons related to nuclear medicine department maintenance. Blue

Discussion

SLN detection and biopsy in patients with cervical cancer have been under study for more than 5 years [3]. This technique has proved feasible, including during laparoscopic surgery [17]. We investigated potential clinical benefits of SLN detection and biopsy in 25 patients with early-stage cervical cancer.

The mean number and the location of SLNs in our study were consistent with data in the literature. In keeping with previous studies [10], [11], [12], Marnitz et al. found a mean of 3.3 SLNs

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