Abstract
ObjectiveIn cervical cancer, sentinel lymph nodes (SLNs) are processed according to the pathological ultrastaging protocol. According to current guidelines, immunohistochemistry with pancytokeratin antibodies is performed in addition to step sectioning with hematoxylin and eosin (H&E), aiding the detection of low volume disease (micrometastasis and isolated tumor cells (ITC)). We studied the added clinical value, and costs, of routine immunohistochemistry (IHC). MethodsWe retrospectively included all FIGO stage IA-IIA1 cervical cancer patients who had undergone SLN procedures at UMC Utrecht from 2008 to 2020. Pathological data were derived from the Dutch Pathology Registry (PALGA) including SLN tumor status and number of slides stained with IHC. ResultsIn total 234 cervical cancer patients were included. In the 516 surgically resected SLN specimens, 630 SLNs were discovered by the pathologist. Hereof, 579 SLNs from 211 patients were routinely processed with IHC. IHC identified three patients with micrometastasis and five patients with ITC undetected with H&E staining. Thereby, IHC significantly increased the number of patients with low volume disease from 11 (5.3%) to 19 patients (9.1%) (p = 0.04). To achieve this, 3791 slides were stained with IHC at an estimated additional cost of €94,775. In 1.4% (95% CI 0.3%–4.3%) of patients routine use of IHC adjusted the adjuvant treatment. ConclusionsRoutine use of IHC increases detection of low volume disease in cervical cancer SLNs compared to step sectioning with H&E alone by nearly 4%, with an impact on therapeutic strategy-decisions in about 1% of patients. In view of the high associated costs, cost-effectiveness of routine IHC is questionable.
Highlights
Lymph node involvement is the strongest prognostic factor for survival in cervical cancer and impacts therapeutic strategy for patients [1]
Ultrastaging increases the probability of finding low volume disease, defined as either micrometastasis or isolated tumor cells (
We aim to evaluate the added value of IHC in terms of detection of low volume disease in cervical cancer in relation to its costs and clinical impact
Summary
Lymph node involvement is the strongest prognostic factor for survival in cervical cancer and impacts therapeutic strategy for patients [1]. To assess nodal stage accurately and efficiently, the sentinel lymph node (SLN) procedure in cervical cancer has emerged [2,3]. This procedure maps lymphatic drainage from the primary tumor by injecting a tracer in the cervix. Evidence on the impact of low volume disease on survival of patients is limited and controversial, due to the low incidence of both low volume disease in SLNs and recurrence [3,7,8]. Clinical evidence indicates that the presence of isolated tumor cells (ITC) in SLNs is not prognostically associated with reduced survival [1,7,9,10]. Finding ITC does not necessarily impact therapeutic strategy whereas finding micrometastases does and usually adjuvant chemoradiation will be given [11]
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