Pelvic lymphadenectomy improves survival in patients with cervical cancer with low-volume disease in the sentinel node: a retrospective multicenter cohort study.

OBJECTIVE: In this study, we aimed to describe the value of pelvic lymph node dissection (LND) after sentinel lymph node (SN) biopsy in early-stage cervical cancer. METHODS: We performed a retrospective multicenter cohort study in 8 gynecological oncology departments. In total, 645 women with International Federation of Gynecology and Obstetrics stage IA to IIB cervical cancer of squamous, adeno, or adenosquamous histologic type who underwent SN biopsy followed by pelvic LND were enrolled in this study. Radioisotope tracers and blue dye were used to localize the sentinel node, and pathologic ultrastaging was performed. RESULTS: Among the patients with low-volume disease (micrometastases and isolated tumor cells) in the sentinel node, the overall survival was significantly better (P = 0.046) if more than 16 non-SNs were removed. No such significant difference in survival was detected in patients with negative or macrometastatic sentinel nodes. CONCLUSIONS: Our findings indicate that in patients with negative or macrometastatic disease in the sentinel nodes, an additional LND did not alter survival. Conversely, our data suggest that the survival of patients with low-volume disease is improved when more than 16 additional lymph nodes are removed. If in a prospective trial our data are confirmed, we would suggest a 2-stage operation.

What is the risk for parametrial involvement in women with early-stage cervical cancer with tumour <20 mm and with negative sentinel lymph nodes?

AIMS: To evaluate the incidence of parametrial involvement in women with early-stage cervical cancer with tumour <20 mm and with negative sentinel lymph nodes (SLN). METHODS: We reviewed the cases of all women who underwent radical hysterectomy and pelvic lymphadenectomy with SLN biopsy for invasive cervical cancer between April 2004 and December 2009. Parametrial involvement was defined as direct extension, nodal disease or spread through vascular channels. RESULTS: From the 204 women who underwent radical surgery with SLN biopsy, 63 (FIGO stage IA2-10, IB1-53) met the inclusion criteria: tumour <20 mm in the largest diameter regardless of the depth of stromal invasion (less or more than half stromal invasion) and negative sentinel lymph nodes. Median age was 44.3 years (range 24-72). Lymph-vascular space invasion was present in 25 women. The histology identified squamous carcinoma in 50 women, adenocarcinoma in 11 women and adenosquamous carcinoma in two women. Tumour grade 1 occurred in 41, grade 2 in 16 and grade 3 in 6 of the cases. No parametrial involvement was observed. The false negative rate of SLN biopsy was 0%. CONCLUSION: No parametrial involvement was observed in women with early-stage cervical cancer with tumour <20 mm in diameter and negative sentinel lymph nodes regardless of the presence of lymph-vascular space invasion, histology subtype and grade of the tumour. Radical removal of the parametrium in this low-risk group is questionable.

Bilateral ultrastaging of sentinel lymph node in cervical cancer: Lowering the false-negative rate and improving the detection of micrometastasis.

OBJECTIVE: To evaluate the sensitivity of sentinel node (SN) ultrastaging and to define parameters that may reduce the overall false-negative rate in women with early-stage cervical cancer. METHODS: We analyzed data from a large retrospective multicenter cohort group with FIGO stages IA-IIB cervical cancer in whom at least one SN was identified and systematic pelvic lymphadenectomy was uniformly performed. All who were SN negative by initial evaluation were subjected to ultrastaging. RESULTS: In all, 645 patients were evaluable. SN were detected bilaterally in 72% of cases and unilaterally in 28%. Patients with optimal bilateral SN detection were significantly more likely to have any metastasis detected (33.3% vs. 19.2%; P<0.001) as well as micrometastasis detected in their SN (39.6% vs. 11.4%). SN ultrastaging resulted in a low overall false-negative rate of 2.8% (whole group) and an even lower false-negative rate of 1.3% for patients with optimal bilateral mapping. Patients with false-negative SN after ultrastaging had a higher prevalence of LVSI and more frequent unilateral SN detection. Sensitivity of SN ultrastaging was 91% (95% CI: 86%-95%) for the whole group and 97% (95% CI: 91%-99%) in the subgroup with bilateral SN detection. CONCLUSION: These data confirm previous observations that optimal bilateral SN detection substantially decreases the false negative rate of SN ultrastaging and increases detection of micrometastasis. In patients with bilateral SN detection, the sensitivity of SN ultrastaging is not reduced in more advanced stages of the disease. SN mapping and ultrastaging should become standard practice in the surgical management of early-stage cervical cancer.

Characteristics of sentinel lymph nodes' metastatic involvement in early stage of vulvar cancer.

BACKGROUND: Nodal involvement is one of the most significant prognostic factors in early-stage vulvar cancer. AIMS: To determine the diagnostic accuracy of sentinel lymph node (SLN) detection in early-stage vulvar cancer and to describe the characteristics of metastatic lymph node involvement. METHODS: Of 23 women with early-stage squamous cell vulvar cancer included in the study, five had lateral lesions and 18 had midline lesions. SLN detection was performed by using a radioactive tracer and blue dye, followed by radical vulvectomy or radical wide excision with uni/bilateral inguinofemoral lymphadenectomy, depending on tumour size and localization. SLNs were subsequently examined with haematoxylin-eosin and immunohistochemistry. RESULTS: The SLN detection was successful in all 23 women (100%) and in 38 of 41 groins (92.3%) tested. The total number of SLNs was 67, with an average of 1.76 per groin. In total, 20 positive SLNs were detected in 14 of 23 patients. From a total of 20 positive SLNs, micrometastases were found in five SLNs and isolated tumour cells in one SLN. We experienced one case with a false negativity of SLN. Sensitivity, negative predictive value, accuracy and false negativity of SLN detection were 93.3%, 88.8%, 95.6% and 7.1% respectively. CONCLUSION: The SLN biopsy performed by an experienced team is a feasible method, with high accuracy in patients with early-stage vulvar cancer. Prognostic value of micrometastases should be confirmed in further studies.

Detection of sentinel lymph nodes in cervical cancer. A comparison of two protocols.

BACKGROUND: The aim of this study was lymphatic mapping to identify SLN in cervical cancer (CaCerv) with radioactive colloids, intraoperative detection with patent blue dye (PBD) and gamma probe (GP) and biopsy and comparison of two protocols. MATERIAL AND METHODS: In 54 patients with CaCerv before hysterectomy and lymph nodes dissection (LND) we performed preoperative lymphoscintigraphy utilizing 99mTc-colloid (Nanocoll, SentiScint or Nanocis), activity 40 MBq, on the operation day (30 women) or the day before operation (24 women). Gynaecologists injected 4 peritumoural injections of colloid into the cervix around the tumour. Scintigraphy followed 25-50 minutes (one-day protocol) or 12-19 hours (two-day protocol) after injection. Gynaecologists also injected 4 peritumoural injections of PBD into the cervix around the tumour. All women underwent SLN biopsy and LND (in average 35 lymph nodes were taken) and hysterectomy. SLNs (active and/or blue lymph nodes) were examined by a pathologist [histopathology and immunohistochemistry (IH) with detection of cytokeratine]. No SLN was examined without IH. RESULTS: The gynaecologists withdrew 123 SLNs (on average 2.27/1 patient) and in total 1898 lymph nodes (on average 35/1 patient). In 1 woman the tumour was inoperable. Two-day protocol, which involved scintigraphy, PBD and GP detected SLNs on both sides (45 SLNs) in 17 women (70.8%), SLNs on the one side (6 SLNs) in 3 patients (12.5%) and no SLNs were found in 4 women (16.7%). One-day protocol detected SLNs on both sides in 23 patients (74.1%)--63 SLNs, in 7 women on one side (25.9%)--9 SLNs. Metastases in SLNs (with or without metastases in other LN) were found in 21 patients (38.9%)--in 1 woman of stage FIGO IB1, in 1 woman of stage FIGO IB2, in 1 patient of stage FIGO IIIA and in all 18 patients of stage FIGO IIIB. False negative SLN detection was 0%. CONCLUSIONS: In SLN detection in patients with CaCerv, all 3 methods--scintigraphy, PBD and GP--should be used, and the success rate of SLN detection increases, although scintigraphy has lower significance than in SLN detection in malignant melanoma and breast cancer. One-day protocol had a better detection rate of SLN than two-day protocol. The method is promising but its results are not as unequivocal and optimistic as in breast cancer and malignant melanoma, and it is still experimental. Additional experience is necessary.