Bilateral Sentinel Lymph Node Detection Research Articles

Sentinel lymph node detection with indocyanine green and patent blue dye in cervical cancer: A single-centre feasibility study.

Sentinel lymph node (SLN) dissection has been established as standard of care in many tumours. Its use in early cervical cancer is an area of increasing interest and some studies suggest a high detection rate. To explore feasibility of SLN dissection and establish the patient detection rate in women with early cervical cancer. All patients with early cervical cancer, International Federation of Gynaecology and Obstetrics (FIGO) 2018 Stage 1, of any histology who underwent SLN dissection from January 2017 to March 2023 were included. Patients were eligible if they had pelvic confined disease; no suspicious lymph nodes on pre-operative imaging or intra-operatively; tumours <4 cm at the time of surgery and no contra-indications to surgery. Patients were excluded if there was a known allergy to dye or less than six months follow-up data. Sixty-two patients were included in the study and 53% had FIGO stage 1b1 disease. The overall bilateral SLN detection rate was 89%, and the side-specific rate was 94%. Where indocyanine green (ICG) was used alone, the bilateral detection rate was 87% and the side-specific rate was 93%. Where ICG was used with patent blue dye (PTB) the bilateral detection rate was 92% and the side-specific rate was 96%. Where PTB was used alone the bilateral detection rate was 85% and the side-specific rate was 92%. The node positive rate was 6% (7/124) which included isolated tumour cells in four patients. SLN dissection with ICG or PTB is feasible in early-stage cervical cancer.

Predictors of Bilateral SLN Radiocolloid Detection in Endometrial Carcinoma.

Introduction Sentinel lymph node (SLN) mapping is an alternative method to conventional lymphadenectomy for nodal status assessment in patients with stage I/II endometrial carcinoma (EC). This study aimed to analyze the potential predictors of unsuccessful bilateral detection of SLN after the application of radiocolloid in EC. Materials and Methods A prospective, observational, cross-sectional study was performed on 41 patients with EC in preoperative stage I, who underwent SLN mapping after cervical application of 4mCi 99m Tc-SENTI-SCINT. The demographic, clinical, and tumor-related data were obtained from the patient's medical records. Univariate analysis was used to analyze the potential factors associated with an unsuccessful bilateral SLN biopsy. Results The bilateral SLN detection rate of planar lymphoscintigraphy, single photon emission computed tomography/computed tomography, and gamma probe was 29.26, 41.46, and 26.82%, correspondingly. None of the 16 analyzed risk factors showed statistical significance for nonconclusive bilateral SLN biopsy. Conclusion Larger scale studies are needed to determine the exact risk factors for unsuccessful bilateral mapping of the lymphatic drainage after cervical application of the radiotracers. This will eventually lead to improvement in bilateral SLN detection in EC patients, so unilateral lymphadenectomy could be avoided.

Learning curve and factors influencing successful robot-assisted bilateral sentinel lymph node mapping in early-stage cervical cancer: an observational cohort study

ABSTRACT Objectives To evaluate whether a learning curve affects the bilateral sentinel lymph node (SLN) detection in early-stage cervical cancer. Methods All patients with FIGO (2018) stage IA1-IB2 or IIA1 cervical cancer who had undergone robot-assisted SLN mapping performed with a combination of preoperative technetium-99m nanocolloids (including preoperative imaging) and intraoperative blue dye were retrospectively included. Risk-adjusted cumulative sum (RA-CUSUM) analysis was used to determine if a learning curve based on bilateral SLN detection existed in this cohort. Results A total of 227 cervical cancer patients were included. In 98.2% of patients (223/227) at least one SLN was detected. The bilateral SLN detection rate was 87.2% (198/227). Except for age (OR 1.06 per year, 95%CI 1.02–1.09), no significant risk factors for non-bilateral SLN detection were found (e.g., prior conization, BMI or FIGO stage). The RA-CUSUM analysis showed no clear learning phase during the first procedures and cumulative bilateral detection rate remained at least 80% during the entire inclusion period. Conclusions In this single-institution experience, we observed no learning curve affecting robot-assisted SLN mapping using a radiotracer and blue dye in early-stage cervical cancer patients, with stable bilateral detection rates of at least 80% when adhering to a standardized methodology.

Laparoscopic sentinel lymph node mapping with indocyanine green in endometrial cancer: surgeon’s learning curve (cumulative sum analysis)

ObjectivesTo evaluate surgeons’ learning curves for laparoscopic sentinel lymph node biopsy in endometrial cancer.MethodsA prospective observational study was performed at the Oncogynecology Center, Lithuanian University of Health Sciences Hospital, from...

Efficacy and prognosis of robotic surgery with sentinel node navigation surgery in endometrial cancer.

This study aimed to validate the surgical and oncologic outcomes of robotic surgery with sentinel node navigation surgery (SNNS) in endometrial cancer. This study included 130 patients with endometrial cancer, who underwent robotic surgery, including hysterectomy, bilateral salpingo-oophorectomy, and pelvic SNNS at the Department of Obstetrics and Gynecology of Kagoshima University Hospital. Pelvic sentinel lymph nodes (SLNs) were identified using the uterine cervix 99m Technetium-labeled phytate and indocyanine green injections. Surgery-related and survival outcomes were also evaluated. The median operative and console times and volume of blood loss were 204 (range: 101-555) minutes, 152 (range: 70-453) minutes, and 20 (range: 2-620) mL, respectively. The bilateral and unilateral pelvic SLN detection rates were 90.0% (117/130) and 5.4% (7/130), respectively, and the identification rate (the rate at which at least one SLN could be identified on either side) was 95% (124/130). Lower extremity lymphedema occurred in only 1 patient (0.8%), and no pelvic lymphocele occurred. Recurrence occurred in 3 patients (2.3%), and the recurrence site was the abdominal cavity, with dissemination in 2 patients and vaginal stump in one. The 3-year recurrence-free survival and 3-year overall survival rates were 97.1% and 98.9%, respectively. Robotic surgery with SNNS for endometrial cancer showed a high SLN identification rate, low occurrence rates of lower extremity lymphedema and pelvic lymphocele, and excellent oncologic outcomes.

Sentinel Lymph Node Mapping in Presumed Low- and Intermediate-Risk Endometrial Cancer Management (SLIM): A Multicenter, Prospective Cohort Study in The Netherlands.

The aim was to investigate the incidence of sentinel lymph node (SLN) metastases and the contribution of SLN mapping in presumed low- and intermediate-risk endometrial cancer (EC). A multicenter, prospective cohort study in presumed low- and intermediate-risk EC patients was performed. Patients underwent SLN mapping using cervical injections of indocyanine green and a minimally invasive hysterectomy with bilateral salpingo-oophorectomy. The primary outcome was the incidence of SLN metastases, leading to adjusted adjuvant treatment. Secondary outcomes were the SLN detection rate and the occurrence of complications. Descriptive statistics and univariate general linear model analyses were used. A total of 152 patients were enrolled, with overall and bilateral SLN detection rates of 91% and 61%, respectively. At final histology, 78.9% of patients (n = 120) had truly low- and intermediate-risk EC. Macro- and micro-metastases were present in 11.2% (n = 17/152), and three patients had isolated tumor cells (2.0%). Nine patients (5.9%) had addition of adjuvant radiotherapy based on SLN metastases only. In 2.0% of patients with high-risk disease, adjuvant therapy was more limited due to negative SLNs. This study emphasizes the importance of SLN mapping in presumed early-stage, grade 1 and 2 EC, leading to individualized adjuvant management, resulting in less undertreatment and overtreatment.

Can mismatch repair status be added to sentinel lymph node mapping algorithm in endometrioid endometrial cancer?

ObjectiveTo evaluate the relation between mismatch repair (MMR) status and the risk of lymph node metastasis in endometrial cancer, and whether this additional data can be incorporated to current SLN (sentinel lymph node) algorithm. MethodsWe included a series of 332 women that underwent SLN mapping ± systematic lymphadenectomy from January 2013 to December 2021. Protein expressions of MLH1, MSH2, MSH6, PMS2 were examined by immuno-histochemistry and considered MMRd (deficient) when at least one protein was not expressed. ResultsMMRd was noted in 20.8% of cases and correlated to grade 3 (p = 0.018) and presence of lymphovascular space invasion (p = 0.032). Moreover, MMRd was an independent risk factor for lymph node metastasis (OR 2.76, 95% CI 1.36–5.62). Notably, 21.7% (15/69) cases with MMRd had lymph node metastasis compared to 9.5% (25/263) of cases with MMRp (proficient) (p = 0.005). The overall and bilateral SLN detection rates were 91.9% and 75.9%, respectively. Of the 80 (24%) cases of non-bilateral SLN detection, 66.2% had low-grade tumors (G1/G2) and myometrial invasion <50%. Considering MMR status an independent prognostic factor for lymph node metastasis, a systematic lymphadenectomy (side specific or bilateral) would forgo in 53.7% (43/80) of cases with non-bilateral detection, representing 13% (43/332) of all endometroid tumors. ConclusionMMR status was independently related to lymph node metastasis in endometrioid EC. Moreover, MMR status may help to select patients that can forgo systematic lymphadenectomy in case of undetected SLN.

Fluorescent Indocyanine Green versus Technetium-99m and Blue Dye for Bilateral SENTinel Lymph Node Detection in Stage I–IIA Cervical Cancer (FluoreSENT): protocol for a non-inferiority study

IntroductionNowadays, two predominant methods for detecting sentinel lymph nodes (SLNs) in cervical cancer are in use. The most conventional method is a combination of a radiotracer, technetium-99m (99mTc) and blue...

Patient, disease and surgeon predictors of successful bilateral sentinel lymph node mapping for endometrial cancer: A retrospective, multicenter analysis

Objective: Sentinel lymph node mapping is an acceptable standard for lymph node evaluation in patients with endometrial cancer. The purpose of this study was to evaluate the adoption of this technique at two academic institutions, including which patient and disease features are associated with rates of successfully identifying sentinel lymph nodes with fluorescent mapping. In addition, we sought to characterize if and how surgeons experience the technique related to successful bilateral sentinel lymph node mapping. Methods: A retrospective chart review was performed of patients at two academic institutions who underwent sentinel lymph node mapping prior to a minimally invasive hysterectomy for endometrial cancer over the first 30 months during which the technique was adopted at each institution. A modified Poisson regression model was used to determine the relationships between patient, disease, and surgeon factors on outcomes of sentinel lymph node mapping. Results: A total of 460 charts were reviewed. The mean age was 64 and the median body mass index was 34.2. The most disease was stage I (83%), endometrioid (89%), and Grade I (64%). The bilateral sentinel lymph node mapping success rate was 65%, while unilateral or bilateral success occurred in 91% of cases. Sentinel lymph node mapping was significantly more likely to be successful in premenopausal women (RR 1.25; 95% CI 1.07 - 1.46; p = 0.005) and Asian women (RR 1.48; 95% CI 1.3-1.68; p &lt; 0.001). BMI was not significantly predictive of mapping success (RR 1.03; 95% CI 1.00 - 1.07; p = 0.05). Increasing surgeon experience with the technique did predict successful bilateral sentinel lymph node mapping (RR 1.02; 95% CI 1.00 - 1.03; p = 0.02). Conclusion: Premenopausal status and surgeon experience with the technique increases the likelihood of bilateral sentinel lymph node detection for endometrial cancer.

Comparison of radio-isotope method with 99m technetium and near-infrared fluorescent imaging with indocyanine green for sentinel lymph node detection in endometrial cancer.

We aimed to compare the detection rate of pelvic sentinel lymph node between the radio-isotope with 99m technetium (99mTc)-labeled phytate and near-infrared fluorescent imaging with indocyanine green in patients with endometrial cancer. This study included 122 patients who had undergone sentinel lymph node mapping using 99mTc and indocyanine green. In the radio-isotope method, sentinel lymph nodes were detected using uterine cervix 99mTc injections the day before surgery. Following injection, the number and locations of the sentinel lymph nodes were evaluated by lymphoscintigraphy. In addition, indocyanine green was injected into the cervix immediately before surgery. The overall pelvic sentinel lymph node detection rate (at least one pelvic sentinel lymph node detected) was not significantly different between 99mTc (95.9% [117/122]) and indocyanine green (94.3% [115/122]). Similarly, the bilateral sentinel lymph node detection rate was not significantly different between 99mTc (87.7% [107/122]) and indocyanine green (79.5% [97/122]). More than two sentinel lymph nodes per unilateral pelvic lymph node were found in 12.3% (15/122) and 27% (33/122) of cases with 99mTc and indocyanine green, respectively, in the right pelvic side, and 11.5% (14/122) and 32.8% (40/122) of cases with 99mTc and indocyanine green, respectively, in the left pelvic side. indocyanine green showed that there were significantly more than two sentinel lymph nodes in either the left or right pelvic sentinel lymph nodes (P<0.0001). There was a significant difference in the mean number of total pelvic sentinel lymph nodes between 99mTc (2.2) and indocyanine green (2.5) (P=0.028) methods. Although indocyanine green is useful for sentinel lymph node identification, we believe it is better to use it in combination with 99mTc until the surgeon is accustomed to it.

Efficacy of sentinel lymph node mapping in endometrial cancer with low‐ or high‐intermediate risk

This study was aimed to evaluate the efficacy of sentinel lymph node (SLN) mapping using indocyanine green (ICG) in Chinese women with endometrial cancer (EC). Consecutive EC patients undergoing SLN mapping at Obstetrics and Gynecology Hospital of Fudan University were retrospectively reviewed. Overall and bilateral SLN detection rates and SLN locations were presented. Sensitivity, negative predictive value (NPV), and agreement rate were calculated and were compared between patients with low-intermediate (LIR) or high-intermediate risk (HIR). There were 454 patients screened, with SLN mapping with ICG performed in 428 patients and systematic lymphadenectomy performed in 159 patients. Overall and bilateral SLN detection rates were 96.50% and 82.71%, respectively. The sensitivity of SLN mapping was 80.00%, and the NPV was 97.76%. SLNs were most commonly located in obturator and external iliac regions. Efficacy of SLN mapping was higher in LIR patients than in HIR patients, with sensitivities of 100.00% and 75.00% (p > 0.05), NPVs of 100.00% and 90.00% (p = 0.002), and agreement rates of 100.00% and 92.31% (p = 0.007), respectively. SLN mapping with ICG had acceptable diagnostic efficacy in Chinese women with EC, but may cause more missed diagnoses in patients with HIR due to relatively low NPV and agreement rate.

Morbid obesity increases the failure rate of sentinel lymph node mapping for endometrial carcinoma

<h3>Objectives:</h3> Sentinel Lymph Node (SLN) mapping is recommended for patients with endometrial carcinoma to reduce the rate of full lymphadenectomy and its associated morbidity such as lymphedema. Obesity is a risk factor for endometrial carcinoma, and many patients are morbidly obese at the time of diagnosis. The goal of this study is to examine the impact of body mass index (BMI) on the success rate of SLN mapping using indocyanine green (ICG) and near-infrared imaging. <h3>Methods:</h3> A retrospective cohort study was performed of women with endometrial carcinoma undergoing robotic hysterectomy and SLN mapping with ICG between March 2016 and August 2019. Robotic surgery cases were identified from the hospital financial system that were coded with a primary diagnosis of Endometrial Cancer, a procedure of hysterectomy, and a cost code for indocyanine green. A total of 369 cases were identified. A total of 28 cases were excluded because no dye was used or SLN mapping was not attempted due to extent of disease. Preoperative patient characteristics and surgical outcomes including SLN mapping success rate were compared across World Health Organization BMI groups. <h3>Results:</h3> BMI was categorized as normal weight (BMI 18.5 - 24.9, 41 patients), pre-obesity (BMI 25.0 - 29.9, 48 patients), obesity class I (BMI 30.0 - 34.9, 71 patients), obesity class II (BMI 35.0 - 39.9, 70 patients), and obesity class III (BMI ≥40, 111 patients). Across BMI groups, patient age and ASA category were significantly different, with younger ages and higher ASA scores in the higher BMI groups. BMI groups did not differ in the number of prior abdominal surgeries or FIGO Grade. Uterine weight, diameter and procedure time were all significantly different across BMI groups, with higher weights, diameters and procedure times in the higher BMI groups. Estimated blood loss and depth of myometrial invasion were not significantly different. In the cohort, 85% had FIGO Stage 1 disease. For procedures with successful unilateral or bilateral SLN detection, the mean number of lymph nodes removed per side was not significantly different across BMI groups. The overall bilateral SLN mapping success rate for the cohort was 68.9%. However, the bilateral SLN mapping success rate was significantly lower in patients with obesity class III (54.1%) compared with patients who were less obese (76.1%, p<0.01). There was no difference in success rate between lower BMI categories. <h3>Conclusions:</h3> Patients with class III obesity (BMI > 40) have a significantly lower success rate for SLN mapping when compared with all other BMI categories (54.1% vs 76.1%, respectively, p<0.01).

Lymphatic mapping and obesity with sentinel lymph node biopsy in endometrial cancer

<h3>Objectives:</h3> Sentinel lymph node biopsy (SLNB) has emerged as an acceptable alternative to complete pelvic and paraaortic lymph node dissection (PPALND) for patients with clinical stage I endometrial cancer. Several factors are associated with high risk of bilateral SLN detection failure. Our aim is to investigate the effect of obesity on bilateral SLN detection rates. <h3>Methods:</h3> Patients with either clinical stage I endometrial cancer or complex atypical hyperplasia were retrospectively reviewed from September 2016 through February 2020. All patients had undergone either a robot-assisted or laparoscopic hysterectomy with SLNB. Endometrioid, uterine papillary serous (UPSC), malignant mixed mesodermal tumor (MMMT), and clear cell (CC) histologies were included. Indocyanine green was injected into the cervix per our protocol. Patients with suboptimal lymph node mapping or nodes suspicious for metastasis underwent a side specific pelvic lymph node dissection (LND). In addition to SLNB, PPALND was performed for patients with UPSC, MMMT, and CC. Sentinel lymph nodes (SLN) were evaluated using ultra-staging protocols including serial sectioning and cytokeratin staining. The medical record was queried for successful bilateral or unilateral sentinel lymph node detection. Patient demographic data was then collected and analyzed with sentinel lymph node detection rate. <h3>Results:</h3> A total of 97 patients were reviewed and included: 92 had diagnosed endometrial cancer while 5 had complex atypical hyperplasia. Stage were as follows: 81 patients had stage I or II disease, and 8 patients had Stage III disease diagnosed at surgery. At least one SLN was detected 95.9% of cases, with an overall bilateral detection rate of 77.7%. In total, 53 patients classified as obese (25 Class I, 15 Class II and 13 Class III), 24 patients were overweight (BMI 25-29.9) and 20 patients had normal BMI. Unilateral and bilateral detection rates were not independently associated with obesity class. Bilateral SLN detection rates were 76% in normal BMI class and 67%, 83% and 73% for Class I, Class II and Class III obesity respectively; while at least one SLN was detected in 94% of normal BMI class and 92%, 96%, 100% and 92% in overweight weight class, Class I, II and II obesity respectively. <h3>Conclusions:</h3> Patient BMI is an important consideration for preoperative planning and success of bilateral sentinel lymph node mapping. Bilateral detection rates among obese patients are comparable to those of non-obese patients in our cohort. Despite previously reported correlation between BMI and successful bilateral mapping, our results do not demonstrate this relationship and obesity does not appear to be a contraindication to SLNB.

Sentinel lymph node mapping detection and recurrence rates in clinical stage I endometrial cancer

Objectives: The literature suggests that sentinel lymph node biopsy (SLNB) is an acceptable alternative to pelvic and paraaortic lymph node dissection (PPALND) in patients with clinical stage I endometrial cancers. The referenced data is largely published from high-volume specialized institutions and a complete PPALND is still performed by many surgeons at smaller, non-specialized centers. Our aim is to demonstrate that SLNB is feasible, reproducible, and sensitive without affecting cancer-specific outcomes when implemented at a non-specialized center. Methods: A retrospective review of patients with clinical stage I endometrial cancer was performed from September 2016 through February 2020. All patients had undergone either a robot-assisted or laparoscopic hysterectomy with SLNB. Endometrioid, uterine papillary serous (UPSC), malignant mixed mesodermal tumor (MMMT), and clear cell (CC) histologies were included. Indocyanine green was injected into the cervix bilaterally as per a previously described protocol. Paraaortic LND was performed at the discretion of the surgeon. In addition to SLNB, complete PPALND was performed for patients with MMMT, UPSC or CC. Sentinel lymph nodes (SLN) were evaluated using ultra-staging protocols including serial sectioning and cytokeratin staining. The medical record was queried for clinical or radiographic evidence of recurrence. Results: A total of 92 patients were included: 69 stage IA, 12 stage IB, 3 stage II and 8 stage III (2 IIIA, 2 IIIC1, 4 IIIC2). The majority of patients were endometrioid (73%), followed by UPSC (15.0%), MMMT (5.0%) and CC (4%). At least one SLN was detected in 95.4% of cases. The rate of bilateral SLN detection was 74.3% and improved over time from 2017-2019: 70% (2017), 74.4% (2018), 80% (2019). Twenty patients underwent PPALND. Non-SLN were positive in 3 patients, all with high-risk histology. There were no other patients with false-negative SLNB. There have been 3 (3%) recurrences to date; one rectal recurrence, one pelvic side wall and one paraaortic lymph node recurrence. All three patients had detected bilateral SLN which were negative at the time of their initial surgery; all three recurrences were high grade histology. Conclusions: SLNB is a sensitive and specific method for assessing lymph node involvement in patients with clinical stage I endometrial cancers. Our detection and recurrence rates are comparable to the rates reported in the literature and demonstrate that when applied at non-specialized centers this approach is safe and reproducible without affecting cancer-specific outcomes.

Sentinel lymph node detection in endometrial cancer with indocyanine green: laparoscopic versus robotic approach.

The aims of the present study were to assess bilateral sentinel lymph node (SLN) mapping with laparoscopic versus robotic approach, to assess variables affecting bilateral detection rates and to assess survival difference in patients with no/unilateral, compared to bilateral SLN detection. This is a retrospective, single-centre, observational cohort study, including patients with endometrial cancer FIGO stage IA-IVB, treated with minimally invasive primary surgery and undergoing indocyanine green (ICG) injection to detect SLN, between January 2015 and December 2019. Of the 549 included patients, 286 (52.1%) and 263 (47.9%) underwent the laparoscopic and robotic approach respectively. 387 (70.5%) patients had bilateral SLN mapping, 102 (18.6%) and 60 (10.9%) had unilateral and no mapping, respectively. Patients who underwent the robotic approach were older (median 61 versus 64 years, p=0.046) and had a higher BMI (median 26.0 versus 34.8 kg/m2, p<0.001). No difference in any SLN mapping or in SLN bilateral detection was evident between the laparoscopic or robotic approach (p=0.892 and p=0.507 respectively). Patients with bilateral SLN detection in the entire cohort were younger (p<0.001) and had a better 3-year disease-free survival (DFS) compared to patients with no/unilateral SLN mapping (77.0% versus 66.3%, respectively, p=0.036). No 3-year overall survival (OS) difference was reported (p=0.491). SLN mapping and bilateral SLN detection with ICG in endometrial cancer was not different in the laparoscopic and robotic approach, even though patients undergoing the robotic approach were older and more obese. Bilateral SLN detection was associated with improved 3-year DFS, but not with 3-year OS, compared to no and unilateral SLN detection.

Sentinel node mapping in endometrial cancer: Tips and tricks to improve bilateral detection rate. The sentitricks study, a monocentric experience

ObjectiveThe objective of the study is to show some small tricks for bilateral sentinel lymph node (SLN) uptake in endometrial cancer. Materials and methodsEach step of the sentinel lymph node technique was analyzed. The cervix was exposed through the use of vaginal valves and by Martin pliers stapling of the anterior cervical lip. Fifty mg Indocyanine Green (ICG) powder was diluted with 10 ml of physiological solution. The spinal needle was marked at 15 mm with a steri-strip. After 20 min from the administration, in case of no LNS identification, an additional 1 ml in the non-detected side was administered in the superficial cervical area. All cervical injections were made by a single (BR) surgeon experienced in oncological gynecology. ResultsFifty patients undergoing sentinel lymph node research for endometrial cancer. The uptake of at least one side of the sentinel node was 98% (49 cases). Forty-six (92%) patients had bilateral lymph node uptake and 3 patients (6%) had unilateral uptake. Only one patient with pelvic and metastatic aortic lymph nodes had no sentinel nodal uptake. ConclusionsLittle tricks can increase the bilateral uptake of the SLN up to 92%. The reinjection could be a key element for the success of the SLN technique. Experienced surgeons could certainly play a fundamental role in raising bilateral SLN detection. Further prospective randomized studies are needed to achieve the best SLN infiltration strategy.

Anatomic Asymmetry in Sentinel Lymph Node Detection in Endometrial Cancer

To determine whether the concomitant use of indocyanine green (ICG) with technetium-99m-filtered sulfur colloid (Tc99m-FSC) improves bilateral sentinel lymph node (SLN) detection rate in endometrial cancer and whether anatomic concordance of pelvic lymph nodes exists and can be used to predict SLN location in cases of unilateral mapping failure. Retrospective cohort study. Tertiary academic medical center in Holon, Israel. Patients diagnosed with endometrial cancer, who underwent SLN mapping with Tc99m-FSC, ICG, or both, at our center between 2014 and 2019. A total of 111 patients were included in the study. SLN mapping using Tc99m-FSC was performed in 101 (91.9%) patients, and ICG injection was given to 64 (57.6%) patients of whom 55 (49.5%) received both. We compared SLN detection rates (unilateral and bilateral) and anatomic symmetry for each method alone and for a combination of the 2. The overall detection rate for unilateral SLNs was 96.4%; 96.9% with ICG, 93.1% with gamma-probe, and 98.2% by combining both methods. The total bilateral detection rate was 72.1%, with ICG performing better as a single tracer than Tc99m-FSC (75% vs 63.4%, respectively). In 55 women in whom both tracers were used, the bilateral detection rate was significantly higher compared with Tc99m-FSC alone. Symmetric pelvic anatomic concordance of SLN was found in only 35 of 80 patients with bilateral SLN detection (43.8%). The combination of preoperative radioisotope injection and intraoperative ICG administration may yield the best bilateral SLN detection rate. In cases of unilateral mapping failure, one cannot rely on the anatomic location of the ipsilateral SLN detected to harvest the complementary node because the symmetric concordance is poor.

Histopathologic Validation of the Sentinel Node Technique for Early-Stage Cervical Cancer Patients

BackgroundThe sentinel lymph node (SLN) biopsy may be an alternative to systematic lymphadenectomy in early cervical cancer. The SLN biopsy is less morbid and has been shown to have high sensitivity for metastasis detection. However, the sensitivity of the SLN technique might be overevaluated because SLNs are examined with ultra-staging, and non-sentinel nodes usually are examined only with routine techniques. This study aimed to validate the negative predictive value (NPV) of the SLN technique by the ultra-staging of SLNs and non-sentinel nodes (NSLNs).MethodsThe SENTICOL 1 study data published in 2011 were used. All nodes (i.e., SLNs and NSLNs) were secondarily subjected to ultra-staging. The ultra-staging consisted of sectioning every 200 µm, in addition to immunohistochemistry. Moreover, the positive slides and 10% of the negative slides were reviewed.ResultsThe study enrolled 139 patients, and SLNs were detected in 136 (97.8%) of these patiets. Bilateral SLNs were detected in 104 (76.5%) of the 136 patients. A total of 2056 NSLNs were identified (median, 13 NSLNs per patient; range 1–54). Of the 136 patients with SLNs, 23 were shown to have positive SLNs after serial sectioning and immunohistochemical staining. The NSLNs were metastatic in six patients. In the case of bilateral SLN detection, the NPV was 100%, with no false-negatives (FNs).ConclusionsThe pelvic SLN technique is safe and trustworthy for determining the nodal status of patients with early-stage cervical cancer. In the case of optimal mapping with bilateral detection, the NPV was found to be 100%.

Laparoscopic sentinel node mapping with intracervical indocyanine green injection for endometrial cancer: the SENTIFAIL study – a multicentric analysis of predictors of failed mapping

ObjectivesLaparoscopy is commonly used for endometrial cancer treatment, and sentinel lymph node (SLN) mapping has become the standard procedure for nodal assessment. Despite the standardization of the technique, there is...

Sentinel lymph node mapping and intraoperative assessment in a prospective, international, multicentre, observational trial of patients with cervical cancer: The SENTIX trial

BackgroundSENTIX (ENGOT-CX2/CEEGOG-CX1) is an international, multicentre, prospective observational trial evaluating sentinel lymph node (SLN) biopsy without pelvic lymph node dissection in patients with early-stage cervical cancer. We report the final preplanned analysis of the secondary end-points: SLN mapping and outcomes of intraoperative SLN pathology. MethodsForty-seven sites (18 countries) with experience of SLN biopsy participated in SENTIX. We preregistered patients with stage IA1/lymphovascular space invasion-positive to IB2 (4 cm or smaller or 2 cm or smaller for fertility-sparing treatment) cervical cancer without suspicious lymph nodes on imaging before surgery. SLN frozen section assessment and pathological ultrastaging were mandatory. Patients were registered postoperatively if SLN were bilaterally detected in the pelvis, and frozen sections were negative. Trial registration: ClinicalTrials.gov (NCT02494063). ResultsWe analysed data for 395 preregistered patients. Bilateral detection was achieved in 91% (355/395), and it was unaffected by tumour size, tumour stage or body mass index, but it was lower in older patients, in patients who underwent open surgery, and in sites with fewer cases. No SLN were found outside the seven anatomical pelvic regions. Most SLN and positive SLN were localised below the common iliac artery bifurcation. Single positive SLN above the iliac bifurcation were found in 2% of cases. Frozen sections failed to detect 54% of positive lymph nodes (pN1), including 28% of cases with macrometastases and 90% with micrometastases. InterpretationSLN biopsy can achieve high bilateral SLN detection in patients with tumours of 4 cm or smaller. At experienced centres, all SLN were found in the pelvis, and most were located below the iliac vessel bifurcation. SLN frozen section assessment is an unreliable tool for intraoperative triage because it only detects about half of N1 cases.