Sentinel lymph nodes in early stage cervical cancer
Introduction
Early stage cervical cancer is diagnosed clinically according to the current FIGO staging. Despite the fact that FIGO staging does not include metastasis to lymph nodes, lymph node spread is one of the most important prognostic factors for survival [1], [2], [3]. Pelvic lymphadenectomy remains the gold standard technique in assessing normal sized pelvic lymph nodes. However, lymphocysts (detected by ultrasonography) occur in up to 20%, and lymphedema has been described in up to 10–15% of patients [4]. Importantly, many investigators believe the incidence may be higher but current methods to measure and define lymphedema are imprecise, and those that are precise are clinically impractical. Retrospective studies are notoriously poor at documenting indices of morbidity, and prospective studies to date have not specifically evaluated these issues.
In recent years, the concept and technique of identifying sentinel lymph node (SLN) have been applied to select cancers [5], [6], [7], [8], [9], [10]. Early reports in melanoma and breast cancer have shown that SLN procedures are safe when performed in experienced hands [6], [7], [8].
The clinical benefits of SLN biopsy have been demonstrated in breast cancer. Morbidity and quality of life assessment studies in breast cancer have shown that axillary SLN procedures reduce the relative risks of lymphedema and sensory loss [7] (5% vs. 13%, RR of 0.37) vs. standard lymphadenectomy. Drain usage, length of hospital stay, and time to resumption of normal day-to-day activities after surgery were statistically significantly lower in the SLN biopsy group (all P < .001), and axillary operative time was reduced (P = .055). Overall patient-recorded quality of life and arm functioning scores were statistically significantly better in the SLN biopsy group throughout (all P ≤ .003). These benefits were seen with no increase in anxiety levels in the SLN biopsy group (P > .05). To date no such randomized trials exist for SLN procedures in cervical cancer.
Other theoretical benefits of SLN procedures include: decreased nerve, great vessel, and ureteral injuries, reduced blood loss and operative time, increased identification of metastatic lymph nodes through ultrastaging, and identification of alternate lymphatic drainage sites [11].
The aim of our study was to assess the feasibility, efficacy, and accuracy in the SLN procedure in cervix cancer, and to compare it to the results reported by others.
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Materials and methods
Since the introduction of SLN biopsies on our service in April 2004 until April 2006, all patients with surgically managed clinical FIGO stage IA/B1 cervical cancer underwent SLN detection followed by pelvic lymphadenectomy and radical hysterectomy or radical trachelectomy. Demographic, surgical, and pathological data on these patients have been prospectively entered in a database. Forty-two patients underwent the SLN procedure. Three patients were excluded for further review. In 2 patients,
Results
The patient and tumor characteristics are summarized in Table 1. The average age at diagnosis was 38 (range 20–67) years. Twenty-two patients (56%) underwent laparoscopic radical hysterectomy, 15 patients (38%) underwent radical vaginal trachelectomy, and 2 patients (5%) underwent abdominal radical hysterectomy. The majority of patients (59%) were stage IB1. Histology was evenly divided between squamous cell (49%) and adenocarcinoma (46%). Two patients (5%) had adenosquamous histology.
The
Discussion
Since the introduction of the SLN concept in cervical cancer, several studies have reported their findings (Table 4). In various series the combined technique of using a radioactively labeled carrier and blue dye have the highest detection rates. In total we identified 824 patients who underwent SLN procedure, with an 84% detection rate (detection of at least one SLN per patient). Considering some earlier reports used only blue dye with a much lower yield, most current reports have detection
References (33)
- et al.
Multivariate analysis of the prognostic factors and outcomes in early cervical cancer patients undergoing radical hysterectomy
Gynecol. Oncol.
(2004) Sentinel-node mapping for staging of colorectal cancer
Lancet Oncol.
(2006)- et al.
Lymph node mapping and sentinel node detection in patients with cervical carcinoma: a 2-year experience
Gynecol. Oncol.
(2005) - et al.
Sentinel lymph node detection in patients with cervical cancer
Gynecol. Oncol.
(2001) - et al.
Sentinel node detection in cervical cancer with (99m)Tc-phytate
Gynecol. Oncol.
(2005) - et al.
Laparoscopic identification of sentinel lymph nodes in early stage cervical cancer: prospective study using a combination of patent blue dye injection and technetium radiocolloid injection
Gynecol. Oncol.
(2003) - et al.
Laparoscopic detection of sentinel lymph nodes followed by lymph node dissection in patients with early stage cervical cancer
Gynecol. Oncol.
(2003) - et al.
How important is removal of the parametrium at surgery for carcinoma of the cervix?
Gynecol. Oncol.
(2002) - et al.
Occult lymph node metastases in early stage vulvar carcinoma patients
Gynecol. Oncol.
(2005) - et al.
Study of lymphatic mapping and sentinel node identification in early stage cervical cancer
Gynecol. Oncol.
(2005)
Sentinel lymph node detection in early cervical cancer with combination 99mTc phytate and patent blue
Gynecol. Oncol.
Laparoscopic sentinel node mapping in early-stage cervical cancer
Gynecol. Oncol.
Intraoperative sentinel node identification in early stage cervical cancer using a combination of radiolabeled albumin injection and isosulfan blue dye injection
Gynecol. Oncol.
Role of sentinel lymph node biopsy procedure in cervical cancer: a critical point of view
Gynecol. Oncol.
Carcinoma of the cervix treated with radiation therapy: I. A multi-variate analysis of prognostic variables in the Gynecologic Oncology Group
Cancer
Multivariate analysis of histopathologic prognostic factors for invasive cervical cancer treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy
Acta Obstet. Gynecol. Scand.
Cited by (97)
Sentinel lymph node biopsy in early-stage cervical cancer: current state of art
2020, Bulletin du CancerThe clinical implication of lymph nodes micrometastases and isolated tumor cells in patients with cervical cancer: A systematic review
2019, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :Injection of blue dye and/or radiolabeled colloid into the uterine cervix permits identification of one or more SLNs in the majority of patients. The status of the SLNs accurately predicts the status of the remaining pelvic and paraaortic LNs [6,7]. Rob et al. in a review of 1811 patients who underwent lymphatic mapping and SLN detection as part of their cervical cancer treatment reported a sensitivity for metastatic disease of 93 percent and a sensitivity of 100 percent in tumors limited to ≤2 cm in size [8].
Sentinel lymphatic mapping among women with early-stage cervical cancer: A systematic review
2018, Taiwanese Journal of Obstetrics and GynecologyThe Application of Sentinel Lymph Node Biopsy in Cervical Cancer
2018, Principles of Gynecologic Oncology SurgeryImplementing a Cervical Sentinel Lymph Node Biopsy Program: Quality Improvement in Gynaecologic Oncology
2017, Journal of Obstetrics and Gynaecology CanadaCan sentinel lymph node biopsy replace pelvic lymphadenectomy for early cervical cancer?
2017, Gynecologic Oncology