Underwent Sentinel Lymph Node Mapping Research Articles

Feasibility of hand-assisted laparoscopic sentinel node biopsy in open endometrial cancer surgery

Background: The aim of this preliminary retrospective study was to assess the feasibility and accuracy of Indocyanine Green (ICG) sentinel node (SLN) sampling using a laparoscopic camera during open endometrial cancer surgery.Material and methods: Retrospective study. Fourteen women with endometrial cancer, not fit for a complete laparoscopic staging, underwent SLN mapping using the IMAGE1 camera during open surgery.Results: The median age of patients was 67 (range 33–86) years. Median BMI was 31 (range 23–58). Mean operative time 157.5 minutes and hospital stay three days. The overall detection rate of SLN mapping was 93%. Bilateral detection was 86%. No post-operative short or long-term complications were observed.Conclusions: Real-time NIR technology supported by the IMAGE1 S is a reliable system and represents a promising method for SLN mapping in selected cases with EC and severe surgical risks, during 48 traditional open approaches. The use of laparoscopy ICG in open surgery seems to be a feasible and useful tool for the detection of SLN in endometrial cancer patients with intraoperative and/or postoperative high morbidity risk. It represents a valid alternative to robotic surgery, particularly in countries and centers where the robotic platform or SPY system for open surgery are not available.

Risk factors for failure of sentinel lymph node mapping using indocyanine green/near-infrared fluorescent imaging in endometrial cancer.

Side-specific systematic lymphadenectomy is suggested if sentinel lymph node (SLN) mapping failed in early stages endometrial cancer. This study aimed to evaluate the risk factors associated with failed mapping which may lead to modify SLN mapping technique, increase the success of SLN mapping and reduce the necessity of systematic lymphadenectomy. Patients with early stage endometrial cancer were included in this study. All patients underwent SLN mapping with indocyanine green/near-infrared compatible surgical platforms. Indocyanine green was injected intracervical. "Bilateral mapping" and "failed bilateral SLN mapping (unilateral or bilateral failed mapping)" groups were compared for demographic, clinical, surgical, and pathological features. 101 cases were analyzed. The overall, unilateral, and bilateral SLN detection rates were 94.1%, 19.8%, and 74.3%, respectively. The failed (unilateral or no mapping) bilateral detection rate was 25.7%. Failed bilateral mapping rates were higher in patients with longer cervical and uterine longitudinal lengths, deep myometrial invasion and larger tumor size without statistical significance. Body mass index and operation type were not related with failed mapping. Increasing number of operations or injection of larger volume of indocyanine green (4mL vs. 2mL) did not improve mapping rate significantly. Cervical indocyanine green injection may overcome the negative effect of obesity on bilateral mapping. Although there was a negative correlation trend between the longitudinal cervical and uterine lengths and bilateral mapping, this possible relation needs to be confirmed in further studies.

Sentinel node mapping and ductal carcinoma in situ.

Pure ductal carcinoma in situ (DCIS) is typically unassociated with a risk of regional lymph node involvement. Retrospective series maintain that larger tumors or high-grade histopathology may harbor a risk of lymph node involvement. Our community hospital retrospectively reviewed a series wherein women with DCIS were subjected to sentinel lymph node biopsy based on large tumor size and/or high-grade histopathology. 232 consecutive women with a diagnosis of pure DCIS were evaluated independently by two breast surgeons, one who typically offers sentinel node mapping to patients with tumors larger than 10mm and the other who offers sentinel node mapping to women with grade3 tumors. 60 women (26%) underwent sentinel node mapping along with appropriate surgery directed to the breast. Women were offered risk-adjusted adjuvant radiotherapy and anti-endocrine therapy. At a median follow-up of 18months (range 6-132months), 9 women (15%) were identified with regional axillary nodal disease. A statistical analysis was conducted between women who did or did not undergo sentinel node mapping because there was overlap in large tumor size and high grade between the two groups. A univariate logistic regression statistic showed a trend toward a significant relationship between grade3 tumors and a risk of occult nodal involvement. This was not confirmed by multivariate analysis. In our moderate-sized surgical experience evaluating women with pure DCIS who underwent a sentinel node mapping due to large tumor size or high grade histology, we were unable to confirm that either is predictive of occult node involvement.

Green versus blue: Randomized controlled trial comparing indocyanine green with methylene blue for sentinel lymph node detection in endometrial cancer

ObjectiveTo ascertain the increase in detection rate of sentinel lymph node (SLN) associated with the use of indocyanine green (ICG) in comparison with methylene blue dye in women with endometrial cancer. MethodsFor this randomized controlled trial, all patients underwent SLN mapping after injection of blue dye on one side of the cervix and ICG on the other side. Randomization was for the side (right vs. left) on which ICG was used so that each patient's contralateral hemipelvis (HP) served as a control to her ipsilateral HP. We performed a two-tailed, normal-approximate McNemar test for paired-matched data. The primary endpoint was the difference in SLN detection rate for each HP according to the dye used. ResultsThis trial included 132 patients, and 46 patients underwent robotic-assisted surgery while 86 had standard laparoscopic surgery. Successful detection of SLN was 90.9% using ICG and 64.4% using blue dye (p < 0.0001). There were no differences in the duration of the SLN procedure (median 10 min per HP) and number of SLN per HP (mean 1.2) according to the dye used. The SLN detection rates for either dye were very similar whether the surgical approach was robotic (mean BMI 45) or laparoscopic (mean BMI 29). Crossover of dye to the contralateral HP was present in 3% of cases. ConclusionThe use of ICG instead of blue dye results in a 26.5% (95% CI 17.4%–35.6%) increase of SLN detection rates per HP in women with endometrial cancer.

Risk of empty lymph node packets in sentinel lymph node mapping for endometrial cancer using indocyanine green.

To determine whether the rate of sentinel lymph node (SLN) dissections that do not yield a lymph node on pathological analysis ('empty packet dissection') changes with increasing surgeon experience in the setting of patients undergoing minimally invasive hysterectomy and SLN mapping using indocyanine green dye for endometrial cancer. All patients undergoing SLN mapping using indocyanine green dye at the time of minimally invasive hysterectomy for endometrial cancer or complex atypical hyperplasia were identified between January 2013 and September 2017 at our institution. All surgeons had prior experience performing SLN mapping for endometrial cancer using other methods. The rate of empty packet dissections and SLN counts were evaluated using a logistic regression model analysis. In total, 236 patients undergoing SLN mapping for either endometrial cancer (85%) or complex atypical hyperplasia (15%) were identified from a prospectively maintained database. When examining all six surgeons together, the percentage of empty packet dissections decreased with increasing number of procedures performed. Each additional procedure was associated with a 3.6% reduction in the odds of an empty packet SLN dissection. After adjusting for individual surgeons, each additional procedure was associated with a 4.9% reduction in the odds of an empty packet. The expected odds of an empty packet after 10 additional procedures decreased by 40.1% (95% CI 12.4% to 58.6%). The addition of two covariates (age and body mass index) did not contribute significantly to the model (likelihood ratio test: X2=2.75, p=0.25). The rate of empty packets appeared to stabilize after approximately 30 procedures. The number of SLNs removed did not change with increasing surgeon experience. The rate of empty packet SLN dissections using indocyanine green dye decreases with increasing number of procedures. This stabilizes after 30 procedures, suggesting completion of a learning curve.

Adipose-only sentinel lymph nodes: a finding during the adaptation of a sentinel lymph node mapping algorithm with indocyanine green in women with endometrial cancer.

To identify factors that affect successful adaptation of sentinel lymph node mapping and those that lead to unintended adipose-only sentinel lymph node identification. Surgical and pathological data were prospectively collected on patients with endometrial cancer who underwent sentinel lymph node mapping with indocyanine green with or without pelvic and/or para-aortic lymph node dissection between November 2013 and April 2017. All mapping cases were performed with the robotic system. Adipose-only specimens were defined as a sentinel lymph node without a pathologically identified lymph node after ultrastaging. A total of 202 patients were included: 83% had endometrioid pathology, 12% serous, 3% carcinosarcoma, and 2% clear cell, with mixed pathology noted in 2%. The bilateral sentinel lymph node detection rate was 66%, and the rate of mapping at least a unilateral sentinel lymph node was 86%. Neither the bilateral nor the unilateral sentinel lymph node mapping rate changed with increased surgeon experience. The rate of adipose-only sentinel lymph node identification was more frequent when comparing the first 10 cases (37%), cases 11 - 30 (28%), and > 30 cases (9%) (P = 0.006). Body mass index > 30 kg/m2, uterine fibroids, The International Federation of Gynecology and Obstetrics (FIGO) grade, and histology were not found to have a statistically significant impact on either sentinel lymph node identification or adipose-only sentinel lymph node identification. Adipose-only sentinel lymph nodes were more likely with increased time from cervical injection to identification of the sentinel lymph node in the right hemipelvis. The median range was 28 min (14-73) for true sentinel lymph node identification vs 33 min (23-74) for adipose-only sentinel lymph node identification (P = 0.02). Patient and surgeon factors did not impact the identification of sentinel lymph nodes over time. Adipose-only sentinel lymph nodes were more frequently identified in the initial cases and represent a potential complication to adapting sentinel lymph node biopsy without lymphadenectomy. The increase in adipose-only sentinel lymph node identification that was associated with time from cervical injection may represent delayed or disrupted uptake of indocyanine green.

RA09.04: THE LYMPH NODE STATUS OF PT1 ESOPHAGOGASTRIC JUNCTIONAL ADENOCARCINOMA

Abstract Background There is no consensus regarding the optimal extent of lymphadenectomy for the esophagogastric junctional (EGJ) cancer. The Japanese esophagogastric cancer treatment guideline showed the tentative standard in the extent of lymphadenectomy based on the location, histology and T-categories. The purpose of this study is to identify the lymph node status in patients with pT1 EGJ adenocarcinoma. Methods From January 2000 to November 2016, we underwent radical resection with or without sentinel lymph node (SN) mapping for esophagogastric cancer at Keio University Hospital. We identified 38 patients with pT1 adenocarcinoma with its center located within 2cm of the junction. We then analyzed the lymph node status and SN distribution. Results The primary tumor that had their epicenter within the proximal of the cardia in 37%, that had their epicenter within the distal of the cardia in 63% of all patients (n = 12, 26). The surgical procedures were proximal gastrectomy (n = 30); subtotal esophagectomy (n = 4); and total gastrectomy(n = 4). Two patients (5%) had positive lymph node metastasis. Of the 2 patients with positive node, one patient had the metastatic lymph node along the short gastric vessels and the other patient had the metastatic lymph nodes along both the left gastric artery and the celiac artery. Those 2 patients with positive node had no recurrence. However, liver or local (anastomotic) recurrence occurred in 1 patients, respectively. SN was accomplished in all patients who underwent SN mapping and diagnostic accuracy based on the SN status was 100% (17/17). Conclusion Our results suggested that lower mediastinal lymphadenectomy was of limited significance in patients with pT1 EGJ adenocarcinoma. SN mapping may be contributory to the optimal extent of lymphadenectomy. Disclosure All authors have declared no conflicts of interest.

Challenging the conventional treatment of colon cancer by sentinel lymph node mapping and its role of detecting micrometastases for adjuvant chemotherapy.

All colon cancer patients with lymph node (LN) positive disease are treated with chemotherapy. Patients with node negative disease are usually cured by surgery alone. Yet about 20% of patients develop recurrence within 5years despite node negative status. This may often be the result of missed micrometastases by conventional examination. Sentinel lymph node (SLN) mapping was developed to find those nodes detected by blue dye which was ultrastaged to detect micrometastases. Consecutive patients, underwent SLN mapping with the blue dye with success rate of 99.2%. Average number of LN was 18.3, average number of SLN was 3/patient and overall nodal positivity was 45%. Ten patients had skip metastases. Overall survival of 235 patients was 84months with survival of node negative patients 97months versus 68months for node positive patients. For stage I-IV patients, overall survival was as follows: stage I-115 months, stage II-90 months, stage III-84months and stage IV-24months respectively. Patients with micrometastases after chemotherapy had average survival of 108months versus those without chemotherapy was 50months. Thus, SLN mapping techniques is highly successful, easily reproducible and finds micrmoetastases in over 15% of patients which could have been missed by conventional pathological examination. These patients when treated with adjuvant chemotherapy have similar survival as those of node negative disease. Similarly, patients without any nodal metastases after SLN mapping and ultrastaging, may be considered as true node negative disease and may avoid further adjuvant chemotherapy.

Risk factors for lymph node metastasis in non-sentinel node basins in early gastric cancer: sentinel node concept.

Sentinel node (SN) concept is being applied to early gastric cancer. However, when SNs are positive for metastasis, it is unclear how often LNs in other LN basins show metastasis. We aimed to investigate LN metastasis possibility in LN basins without SNs (non-SN basins). We determined risk factors for metastasis in non-SN basins and identified a prediction model for non-SN basin metastasis using classification and regression tree (CART) analysis. We enrolled 550 patients who were diagnosed with cT1N0M0 or cT2N0M0 gastric cancer with a single lesion and underwent SN mapping. We adopted a dual-tracer method using a radioactive colloid and blue dye to detect SNs. Of all, 45 (8.2%) patients had SN metastasis; we divided them into two groups: LN metastasis positive and LN metastasis negative in non-SN basins. Univariate analysis showed that the groups differed significantly regarding lymphatic invasion (p = 0.007), number of identified SNs (p = 0.032), and macrometastasis in SN basins (p = 0.005). The CART decision tree for predicting LN metastasis in non-SN basins had area under the curve value of 0.86. Moreover, there were significantly differences in cancer-specific survival (CSS) between the two groups (p = 0.028). Macrometastasis in SN basins, lymphatic invasion, and number of identified SNs ≥ 5 are risk factors for LN metastasis in non-SN basins among gastric cancer patients. We identified a prediction model with CART analysis; patients with macrometastasis in SN basins and lymphatic invasion were considered to be at the highest risk for LN metastasis.

The efficacy of sentinel lymph node mapping with indocyanine green in cervical cancer

BackgroundLymph node metastasis is a significant predictive factor for disease recurrence and survival in cervical cancer patients. Given the importance of lymph node metastasis, it is imperative that patients harboring metastasis are identified and can undergo appropriate treatment. Sentinel lymph node (SLN) mapping has drawn attention as a lymph node mapping technique. We evaluated the feasibility and efficacy of (SLN) mapping using indocyanine green (ICG) in cervical cancer.MethodsWe performed a single-center, retrospective study of 103 surgically treated cervical cancer patients who underwent SLN mapping. After using ICG to detect SLN during surgery, we removed the SLNs followed by laparoscopic or robotic-assisted radical surgery and bilateral pelvic lymphadenectomy.ResultsStage IB1 was the most common (61.17%). At least one SLN was detected in all cases. Eighty-eight patients (85.44%) had bilateral pelvic SLNs. The mean number of SLN per patient was 2.34. The side-specific sensitivity was 71.43%, the specificity was 100%, the negative predictive value (NPV) was 93.98%, and the false negative rate (FNR) was 28.57%. In cases of tumors smaller than 2 cm with negative lymph node metastasis on imaging, the study revealed a side-specific sensitivity of 100%, a specificity of 100%, a NPV of 100%, and a FNR of 0%. Large tumor size (≥ 4 cm), a previous history of a loop electrosurgical excision procedure (LEEP), depth of invasion (≥ 50%), the microscopic parametrial (PM) invasion, and vaginal extension were significantly associated with the false-negative detection of SLN. Moreover, the microscopic PM invasion was the only risk factor of the false-negative detection of SLN in multivariate analysis.ConclusionSLN mapping with ICG in cervical cancer is feasible and has high detection rate. The sensitivity of 100% was high enough to perform SLN biopsy alone in an early stage in which the tumor is less than 2 cm, with no lymphadenopathy on image examination. However, for large or invasive tumors, we would have to be cautious about performing SLN biopsy alone.Trial registrationRetrospectively registered 2017-0600.

Clinical significance of lymphatic flows around pylorus identified by sentinel node mapping in patients with gastric cancer.

12 Background: The sentinel node (SN) concept is safely applied and validated in early gastric cancer. Gastric lymph nodes are divided into five basins with the main gastric arteries. The suprapyloric lymph nodes (No. 5) and the anterosuperior lymph nodes with the common hepatic artery (No. 8a) are classified in the right gastric artery (r-GA) basin, and the subpyloric lymph nodes (No. 6) are classified in the right gastroepiploic artery (r-GEA) basin. The aim of this study is to analyze the lymphatic flows between these lymph nodes and basins. Methods: Five hundred and fourty-nine patients with cT1N0 or cT2N0 gastric cancer underwent SN mapping. We used technetium-99 tin colloid solution and blue dye as a tracer. Results: We detected SN No. 5 in 36 (6.6 %) patients. In these patients, we detected SN No. 5 with SNs that belonged to the left gastric artery (l-GA) basin (69 %), r-GA basin (14 %), and r-GEA basin (44 %). No. 6 was detected as SN significantly more frequently with SN No. 5. We detected SN No. 6 in 100 (18.2 %) patients. In these patients, we detected SN No. 6 with SNs that belonged to the l-GA basin (42 %), left gastroepiploic artery (l-GEA) basin (4 %), r-GA basin (28 %), and r-GEA basin (41 %). No. 4d, No. 5 and No. 8a were detected as SNs significantly more frequently with SN No. 6. We detected SN No. 8a in 43 (7.8 %) patients. In these patients, we detected SN No. 8a with SNs that belonged to the l-GA basin (65 %), l-GEA basin (7 %), r-GA basin (21 %), r-GEA basin (58 %), and posterior gastric artery (p-GA) basin (7 %). No. 6 and No. 9 were detected as SNs significantly more frequently with SN No. 8a. SN No. 5 and No. 8a were tend to be detected with not SNs that belonged to the r-GA basin but No. 6, and SN No. 6 was detected significantly more frequently with No. 4d, No. 5 and No. 8a. Conclusions: Our findings show that lymphatic flows exist not only between lymph nodes which are belonged to the same basin, but also between No. 5 and No.6, and No.6 and No. 8a. On the other hand, the lymphatic flows between No. 5 and No. 8a seem to be limited. Our results suggest that the lymph node dissection of No. 6 given lymphatic flows from lesser curvature side and retroperitoneal side is important for surgery of gastric cancer.

Sentinel lymph node mapping in endometrial cancer: a systematic review and meta-analysis.

Appropriate extent of lymphadenectomy in clinically, early stage endometrial cancer remains controversial but sentinel lymph node (SLN) mapping has emerged as an alternative staging strategy, until the advent of molecular prognostic markers. We sought to perform a systematic review of the literature to determine pooled estimates for SLN detection rate and diagnostic accuracy, while exploring impact of the SLN on adjuvant therapy and oncologic outcomes. We performed a systematic search utilizing Medline, EMBASE, and Web of Science electronic databases for all studies published in the English language until October 31, 2017. Studies were included for review and potential aggregate analyses if they contained at least 30 endometrial cancer patients with undergoing SLN mapping and reported on detection rates (overall, bilateral or para-aortic) or diagnostic accuracy (sensitivity and negative predictive value [NPV]). Pooled estimates were calculated via meta-analyses utilizing a random-effects model. Studies reporting on the impact of SLN on adjuvant therapy, as well as studies comparing SLN mapping to completion lymphadenectomy were qualitatively reviewed and analyzed as well. We identified 48 eligible studies, which included 5348 patients for review and inclusion in the meta-analysis for SLN detection or diagnostic accuracy. The pooled SLN detection rates were were 87% (95% CI: 84-89%, 44 studies) for overall detection, 61% (95% CI: 56-66%, 36 studies) for bilateral detection, and 6% (95% CI: 3-9%, 31 studies) for para-aortic detection. Indocyanine green use improved overall (94%, 95% CI: 92-96%, 19 studies) SLN detection rates compared to blue tracer (86%, 95% CI: 83-89%, 31 studies) or technetium-99 (86%, 95% CI: 83-89%, 25 studies). This trend was similarly seen in terms of bilateral detection rates (74% vs. 59% vs. 57%, respectively). There was no difference in para-aortic SLN detection rate between each tracer. The pooled estimates for diagnostic accuracy for 34 studies were 94% (95% CI: 91-96%) for sensitivity and 100% (95% CI: 99 - 100%) for NPV. Diagnostic accuracy of SLN mapping was not negatively affected in patients with high-grade endometrial histology. Patients with SLN mapping are more likely to receive adjuvant therapy and do not have inferior survival or recurrence outcomes compared to those undergoing completion lymphadenectomy. SLN mapping is a feasible and accurate alternative to stage patients with endometrial cancer. Utilizing indocyanine green results in the highest SLN detection rates. Future studies should prospectively examine the impact of SLN mapping on progression-free and overall survival.

Laparoendoscopic Single-Site Sentinel Lymph Node Detection in Endometrial Cancer

Study ObjectiveTo demonstrate the feasibility of sentinel lymph node (SLN) biopsy using a laparoendoscopic single-site (LESS) approach in endometrial cancer (EC). DesignA step-by-step video demonstration of the surgical procedure (Canadian Task Force Classification III). SettingThe satisfaction of patients who undergo LESS hysterectomy is greater than that reported by patients who undergo multiport laparoscopic hysterectomy, owing to better cosmesis and reduced postoperative analgesic requirements [1]. SLN biopsy is associated with significantly lower estimated blood loss, shorter operation time, and less morbidity compared with systematic lymphadenectomy [2]. LESS surgery can be more feasible and safer with the use of SLN biopsy compared with complete lymphadenectomy in patients with early-stage EC. InterventionsThis 69-year-old woman with grade 2 endometrioid EC underwent SLN mapping followed by LESS SLN biopsy, total hysterectomy, and bilateral salpingo-oophorectomy. Before the umbilical incision was made, 1.25 mg/mL of indocyanine green was injected into the cervical stroma at the 3 o'clock and 9 o'clock positions to both deep and superficial levels. A 10-mm 30° standard-length optical camera for near-infrared fluorescence imaging was used. The total operative time was 75 minutes, and the estimated blood loss was 20 mL. SLNs were detected bilaterally between proximal parts of the external iliac arteries and veins. After SLN resection, total hysterectomy and bilateral salpingo-oophorectomy were performed. No postoperative complications occurred. The patient was discharged at 30 hours after surgery. In the final pathology, stage 1A G2 EC was detected. ConclusionLESS SLN biopsy and TLH-BSO is a feasible procedure and sentinel lymph node concept may increase the use of LESS in EC.

Real-Time Fluorescent Sentinel Lymph Node Mapping with Indocyanine Green in Women with Previous Conization Undergoing Laparoscopic Surgery for Early Invasive Cervical Cancer: Comparison with Radiotracer ± Blue Dye

Study ObjectiveTo evaluate the added value of the fluorescence dye indocyanine green (ICG) for sentinel lymph node (SLN) mapping in women with cervical cancer who had undergone previous conization (stage 1A-1B1) by comparing ICG versus Tc99m radiotracer + blue dye (BD). DesignRetrospective study (Canadian Task Force classification II-2). SettingTwo European academic medical centers, San Gerardo Hospital, Italy and University of Berne, Switzerland. PatientsSixty-five women with early stage (IA-IB1) cervical cancer who had undergone previous conization and who underwent SLN mapping with Tc99m ± BD (n = 23) or ICG (n = 42) followed by pelvic lymphadenectomy and fertility-sparing surgery or hysterectomy were included in this analysis. InterventionOverall detection rate and bilateral SLN mapping rates of ICG were compared with those obtained using the standard Tc99m radiocolloid and BD. Measurement and Main ResultsOverall, 220 SLNs were detected. The median number of SLNs per patient in the Tc99m ± BD group was 2 (range, 1–5) and in the ICG group, 3 (range, 2–15). The detection rate of SLNs was 95.7% in Tc99m ± BD group and 100% in the ICG group (p = .354). The women injected with ICG had a higher rate of bilateral mapping of the SLNs as compared with the Tc99m ± BD group (95.2% vs 69.6%, p = .016%). Only 12% of the patients (8/65) presented metastatic nodes, 2 in the Tc99m ± BD group and 6 in the ICG group. ConclusionIn early-stage cervical cancer patients conization had no significant impact on the SLN detection rate using both techniques (ICG and radiotracer ± BD). In this scenario a higher bilateral mapping rate was confirmed using the fluorescent dye ICG rather than the standard techniques.

Performance of sentinel lymph node (SLN) mapping in high-risk endometrial cancer.

While the accuracy of the SLN procedure has been validated in patients with low risk EC, its relevance for high-risk EC remains debated. The aim of this study was to evaluate the accuracy of SLN mapping in patients with high-risk EC. We reviewed all patients with high risk EC (grade 3 endometrioid, serous, carcinosarcoma, clear cell and undifferentiated) who underwent primary surgery with SLN mapping followed by pelvic +/- paraaortic lymphadenectomy, between November 2010 and November 2016. Among 128 patients who underwent SLN mapping followed by a pelvic lymph node dissection, 41 (32%) had a positive pelvic lymph node. Overall, 48.8% of patients underwent paraaortic node sampling (62/128). Paraaortic lymph node metastasis was identified in 17.7% of patients in whom a para-aortic lymph node dissection was performed (11/62), and all had positive pelvic lymph nodes as well. Successful SLN mapping occurred in 115/128 (89,8%) patients, with a bilateral detection rate at 63.2% (81/128). Positive SLNs were identified in 30.4% of patients (39/128) including 7 isolated tumor cells (ITC), 4 micrometastasis and 28 macrometastasis. When the SLNs were detected bilaterally, only one false negative case occurred, providing a sensitivity and negative predictive value of 95.8% and 98.2% respectively. Accurate surgical staging is an important prognostic predictor of survival in patients with endometrial cancer. Given the high sensitivity and high negative predictive value found in our study, we believe that the use of SLN mapping appears to be an appropriate staging procedure in high-risk endometrial cancer.

Laparoscopic Typical and Atypical Locations of Sentinel Node Mapping with Indocyanine Green: Comparison of 2 Near-Infrared Fluorescence Systems

Study ObjectiveTo present our minimally invasive laparoscopic approach for sentinel lymph node (SLN) mapping with indocyanine green (ICG) using 2 fluorescence systems. DesignA step-by-step video description of the technique showing the most frequent typical and atypical location of SLNs (educational video). SettingLymph node staging in apparent confined endometrial cancer. PatientsWomen underwent SLN mapping in a minimally invasive setting. InterventionsLaparoscopic SLN mapping before comprehensive staging including simple hysterectomy, bilateral salpingo-oophorectomy, and pelvic and aortic bilateral lymphadenectomy in case of unilateral or no identification of SLNs. The PINPOINT 0 degree HD S1 SPY camera (PINPOINT Endoscopic Fluorescence Imaging System; NOVADAQ, Mississauga, ON, Canada) or the Full HD Image 1S with ICG camera (Karl Storz Endoscopy, Tuttlingen, Germany) were used for SLN detection [1,2]. The ICG powder was diluted to a final solution of 1.25 mg/mL of fluorescent dye. After the induction of general anesthesia, a total of 4 mL of the ICG solution was injected into the cervix at the 3 and 9 o'clock positions. Attention to the technical details is crucial to correctly identify SLNs that sometimes are located in atypical locations [3]. ConclusionBoth fluorescence systems are valid and applicable for SLN mapping in the case of apparent confined endometrial cancer. In our experience, the PINPOINT system seems to allow surgeons easier and faster nodal staging of the SLNs, particularly with the color-segmented fluorescence function activated, which can better discriminate between the lymphatic channels and the real SLNs [4,5].

Unexpected locations of sentinel lymph nodes in endometrial cancer.

To evaluate the anatomical location of sentinel lymph nodes (SLN) following intra-operative cervical injection in endometrial cancer. All consecutive patients with endometrial cancer undergoing sentinel lymph node mapping were included in this prospective study following intra-operative cervical injection of tracers. Areas of SLN detection distribution were mapped. Among 436 patients undergoing SLN mapping, there were 1095 SLNs removed, and 7.9% of these SLNs found in 13.1% of patients, were detected in areas not routinely harvested during a standard lymph node dissection. These included the internal iliac vein, parametrial, and pre-sacral areas. The SLN was the only positive node in 46.1% (15/36) of cases with successful mapping and completion lymphadenectomy, including 3 cases where the sentinel node in the atypical location was the only node with metastatic disease. SLN mapping using intra-operative cervical injection is capable to map out areas not typically included in a standard lymphadenectomy. The sentinel node is the most relevant lymph node to analyze and may enable to discover metastatic disease in unusual areas.

Indocyanine Green versus Radiotracer with or without Blue Dye for Sentinel Lymph Node Mapping in Stage >IB1 Cervical Cancer (>2 cm)

Study ObjectiveTo compare sentinel lymph node (SLN) mapping in women with cervical cancer stage >IB1 (tumor size >2 cm) using indocyanine green (ICG) versus the standard technique using radioisotope technetium 99m radiocolloid (Tc99m) radiotracer with or without blue dye. DesignEuropean multicenter, retrospective observational study (Canadian Task Force classification II-2). SettingFour academic medical centers. PatientsNinety-five women with stage IB1 cervical cancer (>2 cm) who underwent SLN mapping with Tc99m with or without blue dye or ICG and radical hysterectomy. InterventionThe detection rate and bilateral mapping rate were compared between ICG and standard Tc99m radiotracer with or without blue dye. Lymphadenectomy was performed, and the false-negative rate was assessed. Measurements and Main ResultsForty-seven patients underwent SLN mapping with Tc99m with or without blue dye, and 48 did so with ICG. All patients underwent radical hysterectomy with or without bilateral salpingo-oophorectomy between 2008 and 2016. The overall detection rate of SLN mapping was 91.5% for Tc99m with or without blue dye and 100% for ICG. A 91.7% rate of bilateral migration was achieved for ICG, significantly higher than the 66% obtained with Tc99m with or without blue dye (p = .025). Nine of the 23 SLN-positive patients (39.1%) were diagnosed exclusively as a result of the ultrastaging used to identify micrometastases or isolated tumor cells only. ConclusionsIn advanced cervical cancer (stage IB1 >2 cm), the detection rate and bilateral migration rate on real-time fluorescent SLN mapping were higher with ICG than with Tc99m radiotracer with or without blue dye. SLN mapping and ultrastaging can provide additional information for nodal staging in advanced cervical cancer. In this setting, ICG is a promising tool for mapping, appearing less affected by higher disease stage compared with traditional methods.

Comparative analysis of survival in colon cancer undergoing sentinel lymph node mapping vs conventional surgery based on number of positive lymph nodes.

e15154 Background: Unlike in breast cancer or melanoma, resection during sentinel lymph node mapping (SLNM) in colon cancer (CCa) includes regional lymphadenectomy including SLNs and non-SLNs. However, SLNM often identifies micrometastases that can be missed by conventional (Conv) surgery and pathologic examination. It is unknown whether this impacts survival or recurrence. Hence, a retrospective analysis was undertaken to study overall (OS) and disease -specific (DSS) survival between patients (pts) undergoing SLNM vs Conv surgery based on the number of +ve LNs. Methods: SLNM was done by subserosal injection with blue dye followed by segmental resection including regional lymphadenectomy. All SLNs were ultrastaged and other nodes were examined by conv. methods with H&amp;E. Results: There were 309 pts in SLNM (GpA) vs 499 pts in Conv surgery (GpB); with average no. of lymph nodes (LNs) and +ve LNs 17.3/1.6 vs 14.4/2.49 respectively. For GpA, success rate was 99.6% and the average no of SLN was 3. Of the pts in GpA vs GpB, 1+ve LN were found in 38% vs 27%, 2+ve LNs in 10% vs 16%, and &gt; 2 LNs in 53% vs 57%, respectively. Comparing 5 years OS between GpA vs GpB, for 1+ve LN was 62.8% vs 52.38%, for 2 +ve LNs 72.7% vs 48.65% and for &gt; 2 +ve LNs 35% vs 33.33%, respectively. Similarly, DSS for 1 +veLN was 54.4% vs 47.6%, 2+ve LNs 40% vs 40.54% and &gt; 2+ve LNs, 30.4% vs 25.76%, respectively (Table). Conclusions: Compared to Conv surgery, SLNM identified higher no. of LNs per pt with high success rate. Five-year OS and DSS also are better in SLNM vs Conv surgery for all +ve LN gps. Hence, SLNM in CCa may have prognostic value. A larger multicenter trial needs to be done to validate such data. [Table: see text]

Sentinel lymph node mapping reduces practice pattern variations in surgical staging for endometrial adenocarcinoma: A before and after study

ObjectiveTo examine the effects of universal sentinel lymph node mapping on the use of nodal staging in endometrial adenocarcinoma. MethodsTwo approaches to laparoscopic staging for endometrial adenocarcinoma were compared using a before and after study design. The before cohort underwent selective lymphadenectomy from January 1, 2014–October 1, 2015 while the after cohort underwent universal sentinel lymph node (SLN) mapping from October 2, 2015–September 29, 2016. ResultsThe before cohort comprised 215 patients and the after cohort 166 patients. In women undergoing SLN mapping, a sentinel node was identified at least unilaterally in 146/153 cases (95.4%), and bilaterally in 114/153 (74.5%) of cases. Pelvic nodes were removed in 35.8% of the before cohort versus 92.2% of the after cohort (p<0.0001) with more nodal evaluation among both low risk (9.6% vs. 91%, p<0.0001) and high risk cases (66% vs. 94%, p<0.0001). While the proportion of low risk cases diagnosed with nodal involvement did not significantly change (0.9% to 3.1%, p=0.32), there was a trend toward more diagnoses of nodal involvement in high risk cases (5% to 13.2%, p=0.06). Mean number of pelvic lymph nodes removed (15 vs. 4, p<0.0001), mean operative time (181min vs. 137min, p<0.0001), estimated blood loss (80ml vs. 56ml, p=0.004), and rate of post-operative complications (13% vs. 5.2%, p=0.04) all decreased after the adoption of SLN dissection. ConclusionsUniversal sentinel lymph node dissection for laparoscopic endometrial cancer staging reduces heterogeneity in surgeon staging practice, increases nodal detection, and lowers post-operative complications.