Abstract
ObjectivesWe aimed to assess the diagnostic value of frozen-section pathologic examination (FSE) of sentinel lymph nodes (SLN) in patients with early-stage cervical cancer. MethodsTwo French prospective multicentric database on SLN biopsy for cervical cancer (SENTICOL I and II) were analysed. Patients with IA to IIA1 2018 FIGO stage, who underwent SLN biopsy with both FSE and ultrastaging examination were included. Results and discussionBetween 2005 and 2012, 313 patients from 25 centers fulfilled the inclusion criteria. Metastatic involvement of SLN was diagnosed in 52 patients (16.6%). Macrometastases, micrometastases and isolated tumor cells (ITCs) were found in 27, 12 and 13 patients respectively. Among the 928 SLNs analysed, FSE identified 23 SLNs with macrometastases in 20 patients and 5 SLNs with micrometastases in 2 patients whereas no ITCs were identified. Ultrastaging of negative SLNs by FSE found macrometastases, micrometastases and ITCs in additional 7, 11 and 17 SLNs. Ultrastaging increased significantly the rate of patients with positive SLN from 7% to 16.6% (p < 0.0001).The sensitivity and the negative predictive value of FSE were 42.3% and 89.7% respectively or 56.4% and 94.1% if ITCs were excluded. False-negative cases were more frequent with tumor size ≥ 20 mm (OR = 4.46, 95%IC = [1.45–13.66], p = 0.01) and preoperative brachytherapy (OR = 4.47, 95%IC = [1.37–14.63], p = 0.01) and less frequent with patients included in higher volume center (>5 patients/year) (OR = 0.09, 95%IC = [0.02–0.51], p = 0.01). ConclusionsFSE of SLN had a low sensitivity for detecting micrometastases and ITCs and a high negative predictive value for SLN status. Clinical impact of false-negative cases has to be assessed by further studies.
Highlights
Lymph node involvement is the main prognosis factor in early-stage cervical cancer [1,2] and lymph node status has been recently incorporated into the 2018 current International Federation of Gynecology and Obstetrics (FIGO) [3]
Seven patients had another associated malignancy, 24 patients (5.8%) had bilateral Sentinel lymph node (SLN) detection failure and SLNs were not submitted to frozen section pathologic examination (FSE) in 68 patients
Frozen section examination had a sensitivity of 42.3%, a negative predictive value of 89.7% and a proportion of FN of 57.7% compared to definitive pathologic examination
Summary
Lymph node involvement is the main prognosis factor in early-stage cervical cancer [1,2] and lymph node status has been recently incorporated into the 2018 current International Federation of Gynecology and Obstetrics (FIGO) [3]. Lymph node status is crucial to determine the best therapeutic strategy for patients with early-stage cervical cancer, since positive pelvic node may require para-aortic lymphadenectomy and chemoradiotherapy rather than radical surgery. According to the 2019 NCCN guidelines, radical hysterectomy should be associated with pelvic lymph node dissection and optional para-aortic lymphadenectomy for IB1 and IIA1 2018 FIGO stage [5]. Para-aortic lymphadenectomy at least up to inferior mesenteric artery should be performed only in case of positive pelvic nodes detected intraoperatively according to the ESGO/ESRO/ESP guidelines [6]. SLN biopsy alone is not recommended without systematic pelvic lymphadenectomy for lymph node staging for IB1 stage according to the ESGO/ESRO/ESP guidelines [6] whereas SLN biopsy could be considered for these cases according to the 2019 NCCN guidelines [5]. Performing frozen section of grossly normal nodes is questionnable and clinical relevance by focusing on macroscopic suspicious nodes has to be determined [10]
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