Bilateral Sentinel Lymph Node Research Articles

Sensitivity and negative predictive value for sentinel lymph node biopsy in women with early-stage cervical cancer

ObjectiveThe role of sentinel lymph node (SLN) biopsy alone for staging of early-stage cervical cancer remains controversial. We aimed to determine the validity of this technique in women with early-stage cervical cancer. MethodsWe retrospectively reviewed women with early-stage cervical cancer who underwent SLN mapping followed by complete pelvic lymphadenectomy as part of initial surgical management from August 1997 through October 2015. All modes of surgical approach were included. Lymphatic mapping was performed using blue dye, technetium-99m sulfur colloid (Tc-99), and/or indocyanine green (ICG). We determined SLN detection rates, sensitivity and negative predictive value. ResultsOne hundred eighty-eight patients were included, and 35 (19%) had lymph node metastases. At least one SLN was identified in 170 patients (90%), and bilateral SLNs were identified in 117 patients (62%). The majority of SLNs (83%) were found in the pelvis. There was no difference in detection rates between mapping agents, surgical approach, patients with and without prior conization or between patients with tumors <2cm and ≥2cm. The detection rate for bilateral SLNs was significantly lower in women with body mass index (BMI)>30kg/m2 than in women with lower BMI (p=0.03). Metastatic disease in sentinel nodes was detected by H&E staining in 78% of cases and required ultrastaging/immunohistochemistry in 22% of cases. Only one patient had a false-negative result, yielding a sensitivity of 96.4% (95% CI 79.8%–99.8%) and negative predictive value of 99.3% (95% CI 95.6%–100%). The false-negative rate was 3.6%. ConclusionsIn these women with early-stage cervical cancer, SLN biopsy had very high sensitivity and negative predictive value. We believe it is time to change the standard of care for women with early-stage cervical cancer to SLN biopsy only.

The management of contralateral axillary sentinel lymph nodes detected by lymphoscintigraphy in a patient of breast cancer that had never undergone breast related medical treatment

In breast cancer, lymphoscintigraphy-based sentinel lymph node biopsy examinations usually show lymphatic drainage to the ipsilateral axilla, and sometimes to the extra-axillary regions. Drainage to the contralateral axilla is rarely observed in patients that have never undergone any medical treatment involving their breasts. We experienced a case of breast cancer in which bilateral sentinel lymph nodes were detected by lymphoscintigraphy in a patient that had never undergone any medical treatment involving her breasts. Here, we report a rare case and review the clinical and pathological features of several reported cases. In addition, we discuss the necessity of subjecting contralateral sentinel lymph nodes to a biopsy examination.

Sentinel lymph node mapping in patients with stage I endometrial carcinoma: a focus on bilateral mapping identification by comparing radiotracer Tc99m with blue dye versus indocyanine green fluorescent dye.

The aim of this study was to compare technetium radiocolloid (Tc99m)+blue dye (BD) versus Indocyanine green (ICG) fluorescent dye in terms of the overall detection rate and bilateral sentinel lymph node (SLN) mapping in patients with endometrial carcinoma. Patients from five European centers with apparently confined clinical stage I endometrial cancer were reviewed. A comparison was made between women who received SLN mapping with pelvic and/or aortic lymphadenectomy (LND), and women who underwent SLN algorithm (SA), was also performed between the two groups. Three hundred and forty-two (342) women were involved (147 in the Tc99m+BD group and 195 in the ICG group). The overall detection rate of SLN biopsy was 97.3% (143/147) for women in the Tc99m+BD group and 96.9% (189/195) for women in the ICG group (p=0.547). The bilateral mapping rate for ICG was 84.1%-significantly higher with respect to the 73.5% obtained with Tc99m+BD (p=0.007). No differences in overall sensitivity (OS) and overall false negative rate (FNR) were seen between LND and SA (p value=0.311), whereas the negative predictive value (NPV) was in favor of SA group (p value=0.030). In this study, fluorescent mapping using ICG resulted equivalent to the standard combined radiocolloid and BD, but real-time SLN mapping achieves a higher bilateral detection rate. The added value that this fast emerging technology promises to give certainly warrants future studies to further consolidate the advantages there are over the standard technique.

Indocyanine green fluorescence imaging of lymph nodes during robotic-assisted laparoscopic operation for endometrial cancer. A prospective validation study using a sentinel lymph node surgical algorithm

ObjectiveA sentinel lymph node (SLN) strategy may have particular value in endometrial cancer (EC) because a therapeutic effect of lymphadenectomy per se is unproven. The aim was to evaluate indocyanine green (ICG) and near-infrared (NIR) fluorescence mapping using a surgical algorithm. MethodsFrom November 2012 through December 2015, women with apparently early stage EC underwent robot-assisted laparoscopic hysterectomy including ICG fluorescence SLN mapping following the Memorial Sloane Kettering Cancer Center (MSKCC) surgical algorithm. ResultsAmong 108 patients included, ≥1 SLNs was identified in 104 (96%), bilaterally in 84 (78%) and unilaterally in 20 patients (18%). Four patients failed SLN mapping. All SLN-positive patients had pelvic SLNs. Median number of nodes were 4.0 and 6.0 (p<0.001), when SLNs only and SLNs plus non-SLNs were removed, respectively. Lymph node metastases were detected in 17 patients (16%). One patient who failed SLN mapping had a non-SLN metastasis. The remaining 16 patients had metastases in SLNs, 12 in SLNs only and four in both SLNs and non-SLNs. Routine pathology detected 75% of patients with cancer positive SLNs while 25% were based on extended pathology. Lymph node metastases were found among 9% with low-, 11% with intermediate- and 32% with high-risk profiles, respectively. ConclusionsWe have reproduced the high total and bilateral SLN mapping using cervical ICG injection and NIR fluorescence. Practical application of the MSKCC algorithm allowed high lymph node metastasis detection in combination with a low extent of lymph node removal.

Can sentinel lymph node biopsy replace pelvic lymphadenectomy for early cervical cancer?

ObjectiveEvaluate recurrence-free survival (RFS) and short-term morbidity in patients with early cervical cancer who undergo bilateral pelvic lymphadenectomy (BPLND) versus bilateral sentinel lymph node biopsy only (BSLNB) at primary surgery. MethodsAll patients with pathologically confirmed node negative stage IA/IB cervical cancer managed with BPLND or BSLNB were identified in the University of Toronto's prospective cervical cancer database from May 1984–June 2015. Groups were compared with Wilcoxon rank-sum, Chi-square, and Fisher's exact tests. Predictors of RFS were identified with Cox proportional hazard models. Kaplan-Meier survival curves were compared. Statistical significance was p<0.05. Results1188 node negative patients were identified, BPLND-1078; BSLNB-110. There was no difference between BPLND and BSLNB in 2 and 5year RFS (95% vs 97% and 92% vs 93% respectively), tumor size, histology, invasion depth, intra-operative complications or short-term morbidity. BPLND was associated with increased surgical time (2.8 vs 2.0h, p<0.001), blood loss (500mL vs 100mL, p<0.001), transfusion (23% vs 0%, p<0.001) and post-operative infection (11% vs 0%, p=0.001). Age, surgery date, stage, LVSI, and radicality of surgery differed between groups. Controlling for age, stage, LVSI, invasion depth and histology, there was no significant difference in RFS between groups. Only invasion depth, LVSI and histology were predictors of RFS. ConclusionA negative BSLNB is not associated with a difference in RFS compared to a negative BPLND. Short-term morbidity may be reduced, however due to the long study period, changes in demographics and surgery may contribute to differences noted.

Reducing overtreatment: A comparison of lymph node assessment strategies for endometrial cancer

ObjectivesTo compare the utility of three lymph node (LN) assessment strategies to identify lymphatic metastases while minimizing complete lymphadenectomy rates in women with low-grade endometrial cancer (EC).Methods: Using our institutional standard protocol (SP), patients with complex atypical hyperplasia (CAH) or grade 1/2 EC underwent sentinel lymph node (SLN) mapping, hysterectomy, and intraoperative frozen section (FS). Lymphadenectomy was performed if high-risk uterine features were identified on FS. Utilizing SP data, two alternative strategies were applied: a Universal FS Strategy (UFS), omitting SLN mapping and performing lymphadenectomy based on FS results, and a SLN-Restrictive FS Strategy (SLN-RFS) in which FS and lymphadenectomy are performed only if bilateral SLN mapping fails. ResultsOf 114 patients managed on the SP, SLNs were identified in 86%, with lymphatic metastases detected in eight patients. Six patients recurred after a median follow up of 15months. Most (83%) developed in those who had a negative systematic lymphadenectomy (n=4; mean LNs: 18) or no lymphadenectomy indication. When applying the alternative lymphatic assessment strategies, the SLN-RFS approach would theoretically result in lower lymphadenectomy rates compared to both the SP and the alternative UFS strategies (9.2% versus 36.8% and 36.8%, respectively; p=0.004), without a reduction in detection of LN metastases (8/8 versus 8/8 and 5/8, respectively). ConclusionIn this modeling analysis, an operative strategy omitting universal frozen section and restricting its use to cases with failed SLN mapping may result in lower lymphadenectomy rates and reduce the risk of overtreatment without compromising oncologic outcome for patients with EC.

Endometrial and cervical cancer patients with multiple sentinel lymph nodes at laparoscopic ICG mapping: How many are enough?

The adoption of a sentinel lymph node (SLN) algorithm and the presence of high bilateral detection rates have been associated with increased accuracy of SLN mapping in cervical and endometrial cancer patients. In this context, the significance of the number of SLNs removed has not yet been investigated. The aim of this study was to evaluate (a) whether or not a higher SLN removal count is associated with a reduced false-negative rate and (b) which clinical factors correlate with the number of SLNs removed. Patients with cervical or endometrial cancer who underwent SLN mapping with bilateral SLN detection followed by lymphadenectomy were evaluated retrospectively. On the basis of the mean number of the SLNs removed, the patients were divided in two groups: Group 1 included patients with up to 3 SLNs removed and Group 2 included patients with more than 3 SLNs removed. Factors predicting a higher SLN count were evaluated using univariate and multivariate analysis. Eighty-four patients met the inclusion criteria. The two groups consisted of 42 patients each and differed only by the median SLN count. Two endometrial cancer patients in Group 1 had false-negative pelvic SLNs and isolated para-aortic metastases; no false-negative SLNs were recorded in Group 2 (p=n.s.). The results of multivariate analysis indicted that the number of SLNs removed was influenced only in cases where the operating surgeon had performed more than 20 laparoscopic ICG SLN mappings. A higher SLN count does not seem to increase the accuracy of SLN mapping in cervical and endometrial cancer patients.

Sentinel node mapping in endometrial cancer: A Brazilian cancer center experience

Objectives: The role of sentinel lymph node (SLN) mapping in endometrial cancer is still in debate. Our aim was to determine the detection rate, sensitivity, and negative predictive value of SLN mapping in low- and high-risk (grade 3, serous, clear cell, deep invasion, or angiolymphatic invasion) endometrial cancer. Methods: We analyzed a series of 91 patients treated at AC Camargo Cancer Center from January 2013 to August 2015 who underwent SLN mapping with cervical injection of blue dye. Forty-nine (53.8%) patients had low-risk tumors and no further lymph node dissection (LND) or only pelvic LND. Forty-two (46.2%) patients had high-risk tumors and received pelvic ± para-aortic LND. Results: Median age was 59.7 years (range, 37-84 years). Median body mass index (BMI) was 28.1 (range, 18-54). Twenty-one patients (23.1%) had open surgeries and 70 underwent (76.9%) minimally invasive surgeries. Thirty-two patients (36.8%) had pelvic LND, and 27 (28.2%) pelvic + para-aortic LND. The rate of SLN detection was 79.1% overall, and bilateral in 50.5% of cases. The median SLN detected was 2 per patient (range, 1-8). Sixteen patients (18.2%) had histologic grade 3, 17 (18.7%) had angiolymphatic invasion, 8 (8.8%) had serous/clear cell histology, and 22 (24.2%) had deep myometrial invasion. Notably, endometrial cancer was diagnosed after subtotal hysterectomy in 3 cases, and bilateral SLN was detected in all. BMI, age, open surgery, blue dye volume (2 vs 4 mL), and first 30 cases did not influence the detection rate. Four patients (4.4%) had technical difficulty with cervical injection, and in this situation, SLN was detected in only 1 (25%) case. No positive node was found in low-risk cases. In high-risk cases, 4 patients had only SLN with no further LND for medical reasons. In the high-risk group, at least 1 SLN was found in 34 (81%) patients and was positive in 8 (23.5%) cases. Two (5.8%) cases had isolated tumor cells, 1 (2.9%) had micrometastasis, and 5 had (14.7%) macrometastasis. Notably, 3 (37.5%) of 8 SLN metastases were found only on immunohistochemistry. Only 1 patient had false-negative SLNs, with ipsilateral pelvic and para-aortic non–sentinel positive nodes. The sensitivity was 88.9%, negative predictive value was 97.4%, and false-negative rate was 11.1%. Two (25%) patients with positive SLN had also other pelvic and para-aortic positive non-SLN. Conclusions: Our data suggest that SLN mapping is a safe and accurate technique for high-risk tumors, and increases metastatic detection rate by 8.7% in high-risk tumors.

The Risk of Contralateral Non-sentinel Metastasis in Patients with Primary Vulvar Cancer and Unilaterally Positive Sentinel Node.

In patients with primary vulvar cancer and bilateral sentinel lymph node (SLN) biopsy, bilateral complete inguino-femoral lymphadenectomy (LAE) is recommended, even in cases with only unilaterally positive SLN by most guidelines. The risk of contralateral non-SLN metastasis is unclear. All patients with primary vulvar cancer receiving an SLN dissection with radioactive tracer±blue dye at the University Medical Center Hamburg-Eppendorf between 2001 and 2013 were retrospectively evaluated. Median follow-up was 33months. A total of 140 patients were included; 124 with bilateral and 16 with unilateral SLN dissection. A median number of two SLNs (range 1-7) per groin were dissected. Overall, 53 (53/140, 37.9%) patients received a complete inguino-femoral LAE, 41 of whom (77.4%) had previously presented with a positive SLN (33 unilaterally, 8 bilaterally). Of the 33 patients with unilaterally positive SLN, 28 (84.9%) underwent complete bilateral inguino-femoral LAE despite a contralateral negative SLN. Of these patients, none presented a contralateral non-SLN metastasis (0/28, 0%) in full dissection; however, one developed groin recurrence in the initially SLN-negative, fully dissected groin after 19months (1/28, 3.6%). In case of bilateral SLN biopsy for clinically node-negative disease and only unilaterally positive SLN, the risk for contralateral non-SLN metastases appears to be low. These data support the omission of contralateral LAE to reduce surgical morbidity.

Laparoscopic Indocyanine Green Sentinel Lymph Node Mapping in Endometrial Cancer.

BackgroundIn endometrial cancer (EMCA), indocyanine green (ICG) sentinel lymph node (SLN) mapping has been reported, mainly in conjunction with robotic surgery.ObjectiveWe aimed to evaluate detection rates, sensitivity, and false negative (FN) rate of laparoscopic ICG SLN mapping in EMCA, and to evaluate differences in surgical outcomes between patients subjected to SLN biopsy only versus lymphadenectomy.MethodsA retrospective analysis of EMCA patients undergoing ICG SLN mapping ± pelvic (PLND) and/or para-aortic lymphadenectomy (PALND) was performed. Detection rates were calculated for the entire cohort. Sensitivity and FN rates were calculated for patients undergoing lymphadenectomy after SLN mapping, and surgical outcome was compared among patients undergoing SLN mapping only versus lymphadenectomy.ResultsOf 75 patients, 33 underwent SLN mapping and 42 underwent SLN mapping followed by PLND/PALND. Overall and bilateral detection rates were 96 % (72/75) and 88 % (66/75), respectively, and the median number of removed SLNs, pelvic non-SLNs (NSLN) and para-aortic NSLNs was 3, 27, and 19, respectively. With a FN rate of 8.3 %, only one patient had bilateral FN SLNs and a metastatic para-aortal NSLN. Estimated blood loss (EBL) and operative (OR) time were significantly lower in patients undergoing SLN mapping only. No differences in complication rates between patients undergoing SLN mapping only and patients undergoing lymphadenectomy were recorded.ConclusionsLaparoscopic ICG SLN mapping has excellent overall and bilateral detection rates and a low FN rate. Compared with lymphadenectomy, SLN biopsy is associated with significantly lower EBL and shorter OR time.

Location of Sentinel Lymph Node in Cervical Carcinoma and Factors Associated With Unilateral Detection.

The aims of this study were to assess locality of the sentinel lymph node (SLN) in cervical carcinoma and examine factors affecting bilateral SLN detection. This was a retrospective review of SLN data (anatomical location, count and laterality) in patients with early-stage cervical cancer (International Federation of Gynecology and Obstetrics stage IA1 with lymphovascular space invasion to stage IIA) using intraoperative gamma probe and blue dye. The preoperative single-photon emission computed tomography with computed tomography was used to detect laterality, number of the SLNs, and rare locations. Patients were treated between January 2005 to January 2015 at the West Kent Gynaecological Oncology Centre, Maidstone Hospital, Maidstone, United Kingdom. A total of 132 women were investigated. The most common SLN location was the external iliac (38.6%) followed by obturator (25.3%) and internal iliac (23.6%) regions. A small percentage was identified in presacral (1.4%) and para-aortic regions (0.7%). Older age (P = 0.01) and an elevated body mass index (P = 0.03) were associated with decreased SLN count by preoperative single-photon emission computed tomography with computed tomography, and only age affected SLN count by gamma probe (P = 0.01). Initial surgery, large loop excision of the transformation zone, or cone biopsy of the cervix had no effect on SLN count. There was no difference observed in bilateral detection with respect to surgical approach (open: n = 48/laparoscopic: n = 84). However, older age was independently associated with a decrease in bilateral SLN detection (P = 0.003). In these patients who underwent unilateral full pelvic lymphadenectomy, all the nonsentinel nodes were negative. The majority of SLNs were located in the external iliac, obturator, and internal iliac regions. Both older age and an elevated body mass index were associated with a reduced SLN count. Unilateral detection of SLN was independently associated with older age, which may be due to sclerosis in the lymphatic vessels or reduced perfusion in the pelvis in these women. If no SLN is detected on one side, the consensus is to perform a full pelvic lymphadenectomy on that side of the pelvis.

Sentinel Lymph Node Mapping With Near-Infrared Fluorescent Imaging Using Indocyanine Green: A New Tool for Laparoscopic Platform in Patients With Endometrial and Cervical Cancer

Indocyanine green (ICG) represents a feasible alternative to the more traditional methods of sentinel lymph node (SLN) mapping, and interest in this promising tracer is growing. This report outlines our experience with ICG in a minimally invasive laparoscopic approach in women with endometrial cancer and cervical cancer using the Storz SPIES ICG near-infrared fluorescence imaging technology. A total of 49 patients with clinical stage I endometrial cancer (n = 40) or stage I cervical cancer (n = 9) were retrospectively reviewed. All patients had undergone simple or radical laparoscopic hysterectomy with pelvic and/or aortic lymphadenectomy and SLN mapping by means of an intracervical injection of ICG dye at the 3 o'clock and 9 o'clock locations after the induction of general anesthesia. The detection rate of ICG was 100% (49 of 49). The rate of bilateral SLN detection was 86% (42 of 49). Positive lymph nodes were found in 6 patients (12%), with at least 1 positive SLN. The sensitivity and negative predictive value of SLN detection were 100%. All procedures were successfully completed without conversion to open laparotomy, and no intraoperative or postoperative complications occurred. In our preliminary experience, ICG showed a high overall detection rate, and bilateral mapping appears to be a feasible alternative to the more traditional methods of SLN mapping in patients with endometrial cancer and cervical cancer. Laparoscopic SLN mapping with ICG appears to be safe, easy, and reproducible, with a positive impact on patient management.

Sentinel Lymph Node Mapping in Gynecologic Cancers

Sentinel lymph node (SLN) mapping has emerged as a promising alternative to comprehensive surgical staging of endometrial, cervical, and vulvar cancers. For cervical and endometrial cancer, cervical injection of indocyanin green dye and/or radiocolloid has resulted in high rates of bilateral SLN identification. Although feasible and safe, prospective trials have not yet clearly determined the false negative rate of SLN mapping for cervical and endometrial cancers. For this reason, SLN mapping has not yet achieved widespread acceptance. In vulvar cancer, prospective trials have demonstrated the safety of SLN mapping and, in many centers, have led to the substitution of SLN mapping for completion lymphadenectomy without compromising long-term outcomes. Further study will hopefully determine whether SLN mapping can replace lymphadenectomy in a greater proportion of patients with gynecologic cancers.

Factors associated with successful bilateral sentinel lymph node mapping in endometrial cancer

ObjectiveAs our understanding of sentinel lymph node (SLN) mapping for endometrial cancer (EC) evolves, tailoring the technique to individual patients at high risk for failed mapping may result in a higher rate of successful bilateral mapping (SBM). The study objective is to identify patient, tumor, and surgeon factors associated with successful SBM in patients with EC and complex atypical hyperplasia (CAH). MethodsFrom September 2012 to November 2014, women with EC or CAH underwent SLN mapping via cervical injection followed by robot-assisted total laparoscopic hysterectomy (RA-TLH) at a tertiary care academic center. Completion lymphadenectomy and ultrastaging were performed according to an institutional protocol. Patient demographics, tumor and surgeon/intraoperative variables were prospectively collected and analyzed. Univariate and multivariate analyses were performed evaluating factors known or hypothesized to impact the rate of successful lymphatic mapping. ResultsRA-TLH and SLN mapping was performed in 111 women; 93 had EC and 18 had CAH. Eighty women had low grade and 31 had high grade disease. Overall, at least one SLN was identified in 85.6% of patients with SBM in 62.2% of patients. Dye choice (indocyanine green versus isosulfan blue), odds ratio (OR: 4.5), body mass index (OR: 0.95), and clinically enlarged lymph nodes (OR: 0.24) were associated with SBM rate on multivariate analyses. The use of indocyanine green dye was particularly beneficial in patients with a body mass index greater than 30. ConclusionInjection dye, BMI, and clinically enlarged lymph nodes are important considerations when performing sentinel lymph node mapping for EC.

Availability of tissue rinse liquid-based cytology for the rapid diagnosis of sentinel lymph node metastasis and improved bilateral detection by photodynamic eye camera.

On sentinel lymph node navigation surgery for early invasive cervical cancers, to gain high sensitivity and specificity, the sentinel nodes should be detected bilaterally and pathological diagnosis should be sensitive to detect micrometastasis. To improve these problems, we tried tissue rinse liquid-based cytology and the photodynamic eye. From 2005 to 2013, 102 patients with Stage Ib1 uterine cervical cancer were subjected to sentinel lymph node navigation surgery with Technetium-99 m colloid and blue dye. For the recent 11 patients with whom bilateral sentinel node detection was not available, the photodynamic eye was selectively examined. The detected sentinel node was cut along the minor axis into 2 mm slices, soaked in 10 ml CytoRich red and then subjected to tissue rinse liquid-based cytology at the time of surgery. With the accumulation of 102 Ib1 patients subjected to sentinel lymph node navigation surgery, the bilateral sentinel node detection rate was 67.7%. The photodynamic eye was examined for the recent 11 patients who did not have bilateral signals. Out of the 11, 10 patients obtained bilateral signals successfully. During the period of examining the photodynamic eye, a total of 34 patients were subjected to sentinel lymph node navigation surgery. Thus, the overall bilateral detection rate increased to 97% in this subset. Two hundred and five lymph nodes were available as sentinel nodes. The sensitivity of tissue rinse liquid-based cytology was 91.7%, and the specificity was 100%. False positivity was 0% and false negativity was 8.3%. Detection failure was observed only with one micrometastasis and one case of isolated tumor cells. Combination of photodynamic eye detection and tissue rinse liquid-based cytology pathology can be a promising method for more rewarding sentinel node detection.

The risk of contralateral non sentinel metastasis in patients with primary vulvar cancer and unilaterally positive sentinel node.

Background In patients with primary vulvar cancer and bilateral sentinel lymph node (SLN) biopsy, bilateral complete inguino-femoral lymphadenectomy (LAE) is recommended, even in cases with only unilaterally positive SLN by most guidelines. The risk of contralateral non-SLN metastasis is unclear.

99mTc SPECT/CT Versus Planar Lymphoscintigraphy for Preoperative Sentinel Lymph Node Detection in Cervical Cancer: A Systematic Review and Metaanalysis.

We aimed to compare SPECT/CT and lymphoscintigraphy on overall and bilateral sentinel lymph node (SLN) detection in cervical cancer patients. A systematic search was performed on August 1, 2014, in PubMed, Embase, Scopus, and the Cochrane library. The syntax was based on synonyms of the terms cervical cancer, SPECT/CT, and lymphoscintigraphy. Retrieved articles were screened on their title/abstract and considered eligible when an SLN procedure was performed using both imaging modalities and if detection results were reported. Two independent reviewers assessed all included studies on methodologic quality using QUADAS-2. Studies were pooled on their odds ratios (ORs) with a random-effects model. The search yielded 962 unique articles, of which 8 were ultimately included. The studies were recent retrospective or prospective cohort studies of limited size (n = 7-51) but sufficient methodologic quality. The median overall detection (≥1 SLN in a patient) was 98.6% for SPECT/CT (range, 92.2%-100.0%) and 85.3% for lymphoscintigraphy (range, 70.0%-100.0%). This corresponded to a pooled overall SLN detection OR of 2.5 (95% CI, 1.2-5.3) in favor of SPECT/CT. The reported median bilateral detection (≥1 SLN in each hemipelvis) was 69.0% for SPECT/CT (range, 62.7%-79.3%) and 66.7% for lymphoscintigraphy (range, 56.9%-75.8%), yielding a pooled OR of 1.2 (95% CI, 0.7-2.1). No significant difference in the number of visualized SLNs was observed at a pooled ratio of 1.2 (95% CI, 0.9-1.6). In cervical cancer patients, preoperative SLN imaging with SPECT/CT results in superior overall SLN detection in comparison with planar lymphoscintigraphy.

Mechanical morcellation of a solid ovarian mass in a pneumo-bag

Objectives: We present a case of a 32-year-old patient who previously underwent simple hysterectomy and bilateral pelvic sentinel lymph node biopsy for epidermoid carcinoma of the cervix. Pathology showed a 5-mm residual tumor at the cervix and the patient was referred for laparoscopic radical nerve-sparing parametrectomy and bilateral pelvic lymphadenectomy. Methods: This video shows the complete technique of the surgery, including patient and team positioning, trocar placement, and step-bystep dissection of planes, vessels, nerves, and other pelvic structures. Snapshots of the surgery with all relevant anatomic structures identified are shown during the video. Conclusions: This didactic surgical film demonstrates that parametrectomy, when systematically performed, is a reliable procedure with minimal complications.

Full thickness skin graft for McIndoe neovagina to treat vaginal agenesis in Mayer–Rokitansky–Küster–Hauser syndrome

Objectives: We present a case of a 32-year-old patient who previously underwent simple hysterectomy and bilateral pelvic sentinel lymph node biopsy for epidermoid carcinoma of the cervix. Pathology showed a 5-mm residual tumor at the cervix and the patient was referred for laparoscopic radical nerve-sparing parametrectomy and bilateral pelvic lymphadenectomy. Methods: This video shows the complete technique of the surgery, including patient and team positioning, trocar placement, and step-bystep dissection of planes, vessels, nerves, and other pelvic structures. Snapshots of the surgery with all relevant anatomic structures identified are shown during the video. Conclusions: This didactic surgical film demonstrates that parametrectomy, when systematically performed, is a reliable procedure with minimal complications.

Factors associated with successful bilateral sentinel lymph node mapping in endometrial cancer

Objectives: As our understanding of sentinel lymph node (SLN) mapping for endometrial cancer (EC) evolves, tailoring the technique to patients at high risk for failed mapping may result in a higher successful bilateral mapping (SBM) rate. Patient and tumoral factors may influence the rate of SBM. The study objective was to identify factors associated with SBM in patients with endometrial neoplasia.