Sentinel lymph nodes in early stage cervical cancer

https://doi.org/10.1016/j.ygyno.2007.02.008Get rights and content

Abstract

Objectives.

Lymph node status is the most important prognostic factor in cervical cancer. Sentinel lymph node (SLN) procedures have been purported to reduce peri- and postoperative morbidity and operative time.

Methods.

All patients with surgically managed clinical FIGO stage IA/B1 cervical cancer underwent SLN followed by pelvic lymphadenectomy with technetium +/− lymphazurin from April 2004 to April 2006. 0.1–0.2 mci of filtered sulfur colloid technetium was injected submucosally into 4 quadrants of the exocervix. Lymphazurin (4cc) was only used if technetium was unsuccessful in identifying bilateral sentinel lymph nodes. Serial microsections at 5 μm intervals were performed and stained intraoperatively. Complete pelvic node dissections were performed in all patients.

Results.

Forty-two patients underwent SLN, prior to full pelvic lymphadenectomy. Thirty-nine patients were included for the purposes of this study. The incidence in detecting at least one sentinel node was 98% per patient, and 85% per side. Identification of bilateral sentinel lymph nodes was successful in 28 cases (72%). The median number of SLN/side was 2. Three patients were found to have metastatic tumor to lymph nodes. No false negatives were identified. No adverse effects were noted.

Conclusions.

SLN biopsy in cervical cancer is feasible to do, with a low false negative rate. We believe SLN should be evaluated per side and not per patient, that a pelvic lymphadenectomy is otherwise required. By following this protocol, the false negative rate can be minimized. The combined reported FN rate in the literature is 1.8%. If our definition is applied, the majority of reported false negative SLN is not actual false negatives.

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.

Section snippets

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

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