Detection of sentinel lymph nodes in patients with endometrial cancer undergoing robotic-assisted staging: A comparison of colorimetric and fluorescence imaging☆
Highlights
► Fluorescence imaging resulted in improved bilateral detection rate of sentinel lymph nodes in endometrial cancer compared to colorimetric method. ► Colorimetric combined with fluorescence imaging results in 100% bilateral detection of sentinel lymph nodes in patients with endometrial cancer.
Introduction
Lymphatic mapping for assessment of sentinel lymph nodes (SLN) is an accepted practice for breast, melanoma, and vulvar cancers [1], [2], [3] with the primary goal to reduce morbidity of a complete lymphadenectomy. A secondary goal is to improve detection of metastatic disease with pathology protocols that utilize ultra-sectioning of SLN and immunohistochemical (IHC) staining [4]. In 2008, a consensus panel of experts reported that sentinel node assessment in endometrial cancer was worthy of further investigation; however, there was insufficient data to comment on feasibility or benefits [5]. Since then, investigators have reported on their experiences with pelvic lymphatic mapping using colorimetric imaging of blue dyes [isosulfan blue (ISB), patent blue, and methylene blue] and/or radiocolloid mapping with Technetium-99 (Tc-99). Bilateral detection of pelvic lymph nodes is reported in 66 to 86% of cervix and endometrial cancer cases [6], [7], [8], [9]. Furthermore, Roy et al. [9] reported a 7.8% increase in SLN detection utilizing both ISB and Tc-99 compared to ISB alone, achieving a 90.6% bilateral detection rate in patients with cervical cancer. However, radiocolloid mapping suffers from difficulties associated with coordinating injection times in the radiology suite relative to operating times when imaging is desired, variability of operators' ability to interpret the radioactive signal intra-operatively, cost, and patient concerns with injection of radioactive pharmaceuticals.
Recently, other medical dyes that fluoresce in light at the near-infrared (NIR) spectrum (700–900 nm) using laparoscopic imaging systems have been reported for use in lymphatic mapping of gastric, breast, rectal, cervical, and endometrial cancers [10], [11], [12], [13], [14]. Indocyanine green (ICG) is the most clinically useful agent for NIR lymphatic mapping [15], and has been used clinically for two decades with an excellent safety profile. The risk of allergic reactions with ICG has been estimated 1 per 42,000 uses [16]. The da Vinci® NIR fluorescence imaging system is FDA cleared for vascular imaging and is useful for confirming patency of vascular anastamoses in cardiovascular surgery [17]. The robotic NIR system has also been used for partial nephrectomy by revealing photopenic tumor relative to the surrounding normal renal parenchyma [18]. Rossi et al. [14] recently described preliminary results with NIR fluorescence imaging used with robotic-assisted surgery in patients with cervical and endometrial cancers, recommending that a 1 mg dose of ICG was most efficacious for lymphatic mapping.
In this study, we sought to retrospectively compare the ability of fluorescence imaging of ICG and standard colorimetric analysis of ISB dyes for the detection of SLN in small cohort of women with endometrial carcinoma who underwent robotic-assisted lymphadenectomy (RAL). A secondary aim of this study was to investigate the ability of SLN mapping to increase the detection of metastatic disease by comparing SLN ultra-sectioning and IHC to traditional hematoxylin and eosin (H&E) staining results.
Section snippets
Study subjects
The medical records from 35 patients who underwent da Vinci® (Intuitive Surgical, Inc., Sunnyvale, CA) SLN mapping during robotic-assisted hysterectomy and staging lymphadenectomy for the treatment of uterine carcinoma from May to September, 2011 were reviewed. Medical records were reviewed for patient demographics and clinico-pathologic factors including the sites of SLN biopsies and method of identification. An IRB-approved clinical data analysis protocol was used for this study.
SLN mapping procedure
Immediately
Results
The mean age of patients was 63.4 years, BMI 33.1 kg/m2, and 26 (74.6%) of patients had “Mayo Clinic high-risk” features for lymphatic metastasis on final pathologic analysis [19]. The mean lesion size was 4.4 cm. and 63% of tumors were Grade 2 or 3. The mean myometrial depth of invasion was 41% (range 6 to 100%) and lymphovascular space invasion was detected in 37% cases (Table 1). All cases were completed with the robotic-assisted laparoscopic technique previously described [20]. Sixty-three
Discussion
The role of complete pelvic and aortic lymphadenectomy for patients with EC continues to be debated. Retrospective studies from both individual institutions and large national databases suggest that lymphadenectomy may be therapeutic or improve outcomes [21], [22]. However, two randomized clinical trials have called into question routine pelvic and aortic lymphadenectomy because survival outcomes were not improved for patients randomized to the lymphadenectomy arms [23], [24]. These two studies
Conflict of interest statement
Dr. Robert Holloway is a training consultant for Intuitive Surgical, Inc. All other co-authors declare that there are no conflicts of interest associated with this manuscript.
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Presented at Focused Plenary Session at the 43rd Annual Meeting on Women's Cancer® of the Society of Gynecologic Oncology (SGO), March 2012, Austin, TX.