Sentinel node biopsy using blue dye and technetium99 in advanced gastric cancer: anatomical drainage and clinical application.

F.A.V Santos,A.J.A Wainstein,H Braga,A.P Drummond-Lage,M.A Cabral,M.A Rodrigues,M.S Pedrosa

doi:10.1590/1414-431x20165341

Abstract

Lymph node metastases are an independent prognosis factor in gastric carcinoma (GC) patients. Radical lymphadenectomy can improve survival but it can also increase surgical morbidity. As a principle, sentinel node (SN) navigation surgery can avoid unnecessary lymphadenectomy without compromising prognosis. In this pilot study, 24 patients with untreated GC were initially screened for SN navigation surgery, of which 12 were eligible. Five patients had T2 tumors, 5 had T3 tumors and 2 had T1 tumors. In 33% of cases, tumor diameter was greater than 5.0 cm. Three hundred and eighty-seven lymph nodes were excised with a median of 32.3 per patient. The SN navigation surgery was feasible in all patients, with a median of 4.5 SNs per patient. The detection success rate was 100%. All the SNs were located in N1 and N2 nodal level. In 70.9% of cases, the SNs were located at lymphatic chains 6 and 7. The SN sensitivity for nodal staging was 91.6%, with 8.3% of false negative. In 4 patients who were initially staged as N0, the SNs were submitted to multisection analyses and immunohistochemistry, confirming the N0 stage, without micrometastases. In one case initially staged as negative for nodal metastases based on SN analyses, metastases in lymph nodes other than SN were found, resulting in a 20% skip metastases incidence. This surgery is a reproducible procedure with 100% detection rate of SN. Tumor size, GC location and obesity were factors that imposed some limitations regarding SN identification. Results from nodal multisection histology and immunohistochemistry analysis did not change initial nodal staging.

Highlights

Gastric carcinoma (GC) remains the 4th most common cancer and the 2nd cause of cancer-related deaths worldwide [1], responsible for more than 738,000 deaths every year [2]
This classification reflects a common situation found in countries like Brazil where the majority of patients have gastric cancer diagnosed at late stages
The average tumor diameter observed in the current study was greater than that reported in the literature on the application of sentinel lymph node (SN) biopsy in gastric cancer [16]

Summary

Introduction

Gastric carcinoma (GC) remains the 4th most common cancer and the 2nd cause of cancer-related deaths worldwide [1], responsible for more than 738,000 deaths every year [2]. Radical lymphadenectomy has been responsible for increased morbidity [3]. Studies concerning tumors like melanoma and breast cancer have used results of radical lymph node dissection more as a marker of prognosis than an opportunity to increase the radicality of surgery and influence overall survival [4,5]. Aiming at decreasing surgical morbidity without compromising surgical outcome, sentinel lymph node (SN) biopsy has been evaluated in patients with GC [6]. Dissection of the SN is the standard of care for patients with melanoma and breast cancer [7]. It is an attractive and promising technique that could benefit patients with cancers of the digestive tract. SN biopsy is associated with a low morbidity and absence of mortality [9]

Objectives

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Conclusion