The role of sentinel node detection techniques in vulvar and cervical cancer

The sentinel node is the first lymph node that receives the lymph drainage from the primary tumour. The pathological status of the sentinel node should reflect the histopathology of the entire regional lymph drainage area — both vulvar and cervical cancer spread through the lymphatic system. In gynaecological oncology recent studies have confirmed the utility of the sentinel node concept in vulvar and cervical cancer. Three techniques for sentinel node localisation are available. The preoperative lymphoscintigraphy and intraoperative handheld gamma probe detection require the administration of the technetium-99m-labelled colloid around the tumour. The other method is based on the injection of the patent blue dye — during the surgery of the sentinel node because of the dye uptake becomes visible. Following detection, the sentinel lymph node can be removed separately and assessed with ultrastaging and immunohistochemical staining. In the early stages of vulvar and cervical cancer the lymph nodes metastases rate is relatively low — in most cases lymphadenectomy is not necessary. The determination of the regional lymph nodes’ pathological status may limit the extent of the surgical treatment. The sentinel node detection rate is relatively high and depends on the applied technique. This technique may play an important role in the treatment of vulvar and cervical cancer. This paper describes the details of sentinel node identification and reviews the literature

The influence of depth of marker administration on sentinel node detection in cervical cancer

BACKGROUND: Regional lymph node surgical management is an integral part of cervical cancer therapy. In gynaecological oncology, recent studies have confirmed the utility of the sentinel node concept in vulvar and cervical cancer. The method of the marker’s administration is considered to play an important role in sentinel node detection. MATERIAL AND METHODS: 60 patients with cervical cancer (stage IB–IIA) underwent SLN detection during radical abdominal hysterectomy. The patients were randomly divided into two groups: the first group of 30 patients with 0.5–1cm deep marker injection, the second with sub-epithelial marker injection. Gamma-camera scanning, as well as hand-held probe detection was applied. RESULTS: All hot nodes visualised on lymphoscintigraphy were “hot” when using the hand-held gamma probe. Deep marker injection revealed a sentinel node in 27 patients (90%) on both sides, in 3 patients (10%) only on one side. Only 40 (67%) sentinel nodes were blue-stained. Sub-epithelial marker administration revealed a sentinel node on both sides in all 30 patients (100%). In 28 patients (93.3%) the sentinel nodes were radioactive and blue-stained, in one case not-blue stained on either side, in one case blue stained only on one side. CONCLUSIONS: The sentinel node detection rate in cervical cancer is relatively high and depends on the applied technique. The superficial administration of radiocolloid and the blue dye into the cervix provides a higher sentinel node detection rate than deep administration in cervical cancer patients

Evaluation of sentinel node detection in vulvar cancer

BACKGROUND: In vulvar cancer, in a large portion of patients with early stages of the disease, the inguinal lymphadenectomy not only does not influence the overall survival and recurrence rate but may increase the incidence of complications. Sentinel lymph node (SN) detection is a promising technique for detecting groin lymph nodes, which may in future lead to less extensive use of surgical treatment. The aim of the study was to evaluate the feasibility of the sentinel node detection technique in patients with vulvar cancer. MATERIAL AND METHODS: Between the years 2003 and 2005, we performed intraoperative lymphatic mapping on 10 patients with planoepithelial vulvar cancer. In eight cases, vulvar lesion was localized centrally, around the clitoris. The extent of the surgery included radical vulvectomy with bilateral inguinal lymphadenectomy in nine cases and unilateral inguinal lymphadenectomy in one case. For the lymphatic mapping, we employed two detection methods: 99mTc-labelled radiocolloid (activity 35-70 MBq) and blue dye (3-5 ml). Both techniques were used in six cases (60%), blue dye only in three cases and radiocolloid only in one case. RESULTS: In each patient, we detected at least one sentinel lymph node. Sentinel nodes were localized in 14 of 19 operated groins (73.7%); a total of 25 SNs in all. The mean number of SNs for one groin was 1.78. Nodal metastases were found in four cases. In three cases, metastases were detected only in the SN. In one patient, two SNs with metastases were found in one groin and in the contralateral groin (without any SN) there was one unchanged node, which transpired to be metastatic. This can be explained by a complete overgrowth of neoplasm in the lymph node resulting in lymph flow stasis and disabling tracer uptake. In five cases, an SN was found only in one groin ó the first case is described above, in the second case the vulvar tumor was localized laterally, opposite to the groin without any SN. In the remaining three cases, we have used only one method of SN detection. CONCLUSIONS: Lymphatic mapping in vulvar cancer based on the combined detection technique is a highly accurate method after adequate training of the surgeons

Sentinel lymph node detection with the use of SPECT-CT in endometrial cancer – analysis of two cases

On the basis of two cases we discuss the important issues regarding the sentinel lymph node detection biopsy (SLNB) in endometrial cancer with combined cervical administration of the radiocolloid and the subserosal blue dye injection. The first patient (endometrioid adenocarcinoma G2, invasion >50% myometrium) had 4 SLNs detected. Three were both hot and blue (detected on SPECT-CT). The fourth, paraaortic SLN was blue only. None of the lymph nodes contained metatstases. The second patient (endometrioid adenocarcinoma G1, invasion >50% myometrium) had 4 SLNs detected. Three were blue (but two of them had also very low radioactivity). The fourth SLN was hot only. Blue only node contained macrometastasis. In the past patients underwent cervical amputation. Diverse distribution of each tracer confirms the advantages of the combined tracers administration in SLNB. The radiotracer is the crucial component - uptake was present in 6 of 8 SLNs. Although the blue dye is more a complimentary method, its suberosal injection significantly increases the safety of the SLNB procedure. In the first case we have detected blue only SLN in paraaortic region which otherwise would be missed using the cervical approach only. More importantly, in the second case the tracer uptake was very limited due to the previous surgery and the blue dye administration allowed correct SLNs detection (including the metastatic node). Presented clinical cases confirms that the combined cervical and subserosal tracers administration together with preoperative SPECT-CT constitute an optimal SLN detection method and correctly provides information about the regional lymph node status

Kliniczne znaczenie mikroprzerzutów w węzłach chłonnych w raku szyjki macicy

In most cancers of epithelial origin, metastases to the lymph nodes constitute the most important prognostic factor and are predictive of the results of the surgical and adjuvant therapies. Data on the lymph node status allows to design an appropriate treatment plan. Despite advances in gynecologic oncology, the importance of lymph node micrometastases in cervical cancer, especially in nonsentinel lymph nodes which are detected by ultrastaging, has not been fully elucidated. The purpose of the article is to familiarize the reader with the state of current knowledge on cervical cancer micrometastases. The authors attempt to answer the question about the benefits of lymph node assessment in the search for micrometastases in cervical cancer, as well as to address emerging doubts.Przerzuty do węzłów chłonnych większości nowotworów pochodzenia nabłonkowego stanowią najważniejszy czynnik rokowniczy oraz pozwalają przewidzieć wyniki leczenia operacyjnego i adjuwantowego. Informacja o stanie węzłów chłonnych pozwala zaplanować właściwe leczenie. Pomimo postępu w onkologii ginekologicznej wciąż nie zostało ustalone znaczenie, jakie mogą mieć mikroprzerzuty w raku szyjki macicy, a w szczególności mikroprzerzuty znalezione w pozawartowniczych węzłach chłonnych, oceniane metodą ultrastagingu. Celem artykułu jest zapoznanie czytelnika ze stanem aktualnej wiedzy na temat mikroprzerzutów w raku szyjki macicy. Autorzy starają się dać odpowiedź na pytanie o korzyści wynikające z oceny węzłów chłonnych w poszukiwaniu mikroprzerzutów w raku szyjki macicy i omówić wyłaniające się wątpliwości

Mikroprzerzuty w wartowniczym węźle chłonnym u chorych na raka endometrium

Background: Detection of micrometastases in sentinel lymph nodes (SLN) extends our knowledge of lymphatic spread in endometrial cancer, although its clinical significance has not yet been confirmed. Objectives: The aim of study was to determine the incidence of SLN micrometastases and to analyze the association between micrometastases and disease relapse. Material and methods: Fifty-four patients with endometrioid endometrial cancer underwent routine surgical therapy and sentinel lymph node biopsy (SLNB). SLNB was performed using two techniques: cervical injection of 99mTc-labelled albumin or blue dye and fundal injection of blue dye. SLNs were subjected to ultrastaging with immunohistochemistry (AE1/AE3, 150μm). Results: At least one SLN was detected in 51 patients (94.4%) and bilateral SLN detection was achieved in 80.4%. Nodal macrometastases were found in 3 patients (6.3%). SLNB enabled us to detect nodal macrometastases in 2 out of those 3 patients. In the third case, detection of SLN micrometastasis allowed to correctly determine the nodal status, thus avoiding the false negative result of SLNB. In 48 patients with detected 184 SLNs, there were 4 patients (8.3%) with micrometastases and 4 (8.3%) with ITC foci. No significant associations between the presence of risk factors (grade, myometrial invasion, cervical invasion, lymphovascular space invasion) and incidence of micrometastases and/or ITC foci in SLNs were found. Conclusions: Detection of micrometastases may result in lower false-negative rate, thus increasing SLNB safety.Wstęp: Technika identyfikacji węzła wartowniczego (SLNB) pozwala na dokładną ocenę zaawansowania choroby w obrębie układu limfatycznego, jednak kliniczna przydatność tej metody nie została jeszcze jednoznacznie określona. Cel pracy: Celem pracy jest określenie częstości mikroprzerzutów w wartowniczych węzłach chłonnych (SLN) oraz analiza wczesnych wznów u pacjentek z rakiem endometrium. Materiał i metoda: Analizie poddano 54 pacjentki z endometroidalnym rakiem błony śluzowej trzonu macicy, u których wykonano usunięcie macicy z przydatkami, (miedniczą i przyaortalną limfadenektomię u pacjentek wysokiego ryzyka) oraz SLNB z wykorzystaniem dwóch metod detekcji: doszyjkowego podania albuminy znakowanej 99mTc lub błękitu metylenowego oraz podsurowicówkowego podania błękitu metylenowego w obrębie dna macicy. Węzły wartownicze poddano procedurze ultrastaging z wykorzystaniem immunohistochemii (AE1/AE3, odstępy 150 μm). Wyniki: Przynajmniej jeden SLN wykryto w 94,4%, obustronna detekcja SLN wyniosła 80,4%. U 3 pacjentek wykryto makroprzerzuty w węzłach chłonnych (6,3%): w dwóch przypadkach SLNB umożliwiła prawidłowe wykrycie makroprzerzutów; u trzeciej pacjentki po wykonaniu ultrastaging wykryto mikroprzerzuty w SLN (co pozwoliło na właściwą ocenę zaawansowania choroby w układzie limfatycznym i uniknięcie fałszywie negatywnego wyniku SLNB). U 48 pacjentek, u których wykryto SLN w usuniętych 184 SLN stwierdzono 4 mikroprzerzuty (8,3%) oraz 4 ogniska izolowanych komórek nowotworowych (ITC) (8,3%). Nie stwierdzono korelacji pomiędzy czynnikami ryzyka (inwazja podścieliska szyjki, mięśniówki, grade, zajęcie przestrzeni limfatyczno-naczyniowej) a obecnością mikroprzerzutów lub ITC. Wnioski: Detekcja mikroprzerzutów pozwala zmniejszyć częstość występowania przypadków fałszywie ujemnych, a tym samym zwiększyć bezpieczeństwo SLNB

The impact of low volume lymph node metastases and stage migration after pathologic ultrastaging of non-sentinel lymph nodes in early-stage cervical cancer: a study of 54 patients with 4.2 years of follow up

Objectives: To assess the significance of pathologic ultrastaging (PU) of sentinel (SLN) and non-sentinel (nSLN) lymph nodes (LNs) and the influence on cancer staging in patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA2-IB1 cervical cancer. Material and methods: A retrospective study was conducted with 54 patients divided into two equal-sized groups. In test group (n1), at least one SLN/patient was detected with blue dye. All excised LNs in this group were subjected to PU (4 μm slices/150 μm intervals) with hematoxylin-eosin staining and immunohistochemistry (AE1-AE3 antibodies). In none of the control group (n2) was PU performed, but in 2 patients SLN concept was performed. Patients in both groups underwent radical hysterectomy and lymphadenectomy. The effect of PU was expressed in puTNM and compared with both standard pTNM and FIGO systems. The influence of PU on patients’ disease-free survival (DFS) and overall survival (OS) was assessed using Kaplan-Meier curves. Results: In total, 516 LNs were extracted (66 SLNs, 36% bilaterally). Micrometastases (MIC) or isolated tumor cells (ITC) were detected in 34 of the 482 LNs (7.1%), including 16 MICs and 9 ITC in non-SLNs. False negative rates were: 3.7%/side-specific, and 7.4%/both sides. The use of PU resulted in stage change in 2 cases (N and M status change), FIGO stage did not changed. No PU impact on DFS or OS was observed. Conclusions: The risk of TNM stage migration in early cervical cancer is low, is more likely in inattentively evaluated patients, and has indeterminate prognostic and predictive value. Selection of cases with cT ≤ 2 cm and cN0 is sufficient to avoid the risk of improper staging