Abstract
PurposeIndocyanine green (ICG) is frequently used for the detection of the sentinel lymph node (SLN) in gynecology, but it carries the loss of the presurgical SLN mapping provided by [99mTc]-based colloids. Hybrid tracers such as ICG-[99mTc]Tc-albumin nanocolloid combine the benefits of both components. The aim of this study was to evaluate the feasibility and applicability of this hybrid tracer injected by transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR) approach in the detection of SLNs in patients with intermediate- and high-risk EC.MethodsFifty-two patients with intermediate- and high-risk EC underwent SLN biopsy after injection of a hybrid tracer using the TUMIR approach, followed by pelvic and paraaortic lymphadenectomy. SLNs were detected preoperatively by lymphoscintigraphic study and intraoperatively by gamma probe and near-infrared (NIR) optical laparoscopic camera.ResultsPreoperative lymphatic drainage was obtained in 69% and intraoperative detection in 71.4% of patients. A total of 146 SLNs (4.17 SLNs/patient) were biopsied. Pelvic bilateral detection was observed in 57% of the women and paraaortic drainage in 34% of the patients. The radioactive component allowed the detection of SLN in 97.1% of the patients, while the fluorescent component detected 80%. In more than 17% of the patients with intraoperative detection, SLNs were detected only by the radioactive signal. Lymph node metastasis was identified in 14.3% of patients submitted to SLNB. The sensitivity and negative predictive value for metastatic involvement were 100%.ConclusionTUMIR injection of a hybrid tracer in patients with intermediate- and high-risk EC combines the benefits of the radiotracer and the fluorescence methods with a single tracer. The method increases the paraaortic detection rate and allows a potential increase in SLN detection. Notwithstanding, based on our findings, the radioactive component of the hybrid tracer cannot be obviated.
Highlights
Endometrial cancer (EC) is the most frequent gynecological malignancy in high-income countries
Patients with the following criteria were excluded from our study: (1) contraindication for surgical staging; (2) metastatic disease suspected in the preoperative evaluation by computed tomography (CT) or MRI or confirmed histologically; (3) previous surgery or radiotherapy in the pelvic or paraaortic regions
This increase in the detection rate of intraoperative bilateral pelvic sentinel lymph node (SLN) detection could be explained by the hybrid detection provided by this type of tracer since resection of the SLN is facilitated thanks to the visualization of elevated contrast enhancement provided by Indocyanine green (ICG) after having performed the dissection of the fatty lymph tissue guided by the acoustic signal of the gamma detector probe by the radioactive signal
Summary
Endometrial cancer (EC) is the most frequent gynecological malignancy in high-income countries. As in most solid tumors, lymph node infiltration is the most important prognostic factor, and systematic pelvic and paraaortic lymphadenectomy is indicated in high-risk tumors and is considered in those of intermediate risk [1]. The role of systematic lymphadenectomy has recently been questioned because it has a significant associated morbidity and results in an overtreatment of up to 80% of women [2]. Sentinel lymph node biopsy (SLNB) has been developed as an alternative to systematic lymphadenectomy, associated with a low morbidity rate. The guidelines of the National Comprehensive Cancer Network recommend SNLB in patients with low-risk EC [3]. Recent evidence indicates that SLNB achieves a detection rate of 89% and a false negative rate of 11.5% in patients with intermediate- and high-risk EC [4]. Its indication in these women with intermediateand high-risk EC is still under debate
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