Lymphatic mapping in endometrial cancer: comparison of hysteroscopic and subserosal injection and the distribution of sentinel lymph nodes.

INTRODUCTION: Endometrial cancer incidence increases over the age of 65 and lymphadenectomy in these women is a morbid procedure. Sentinel lymph node (SLN) should avoid extensive lymphadenectomy in node negative patients. The aim of this prospective study is to determine the feasibility and usefulness of lymphatic mapping and SLN identification in the management of endometrial cancer. METHODS: From January 2004 to December 2007 101 women with endometrial cancer participated in the study. We injected Tc hysteroscopically, peritumorally 2 hours before laparotomy in 24 women. We applied Tc and blue dye subserously after laparotomy and before adhesiolysis in 67 women. Ten patients with metastatic disease in ovary, omentum, peritoneum, and bulky nodes were excluded from analysis. RESULTS: We detected SLN in 12 women (50%) in hysteroscopic group and in 49 women (73.1%) in subserous group. We identified 133 SLNs in 61 women. We found 20 SLNs (15.0%) in supraobturator region, 78 (58.6%) in external iliac area, 11 (8.3%) in paraaortal area, 13 (9.8%) on common iliac artery, 8 (6.0%) in medial part of lateral parametrium, and 3 (2.3%) in presacral area. CONCLUSIONS: Sentinel lymph node identification is a new strategy that can be used to examine nodal status with a high successful rate in breast, cervical, and vulvar cancer. Results in endometrial cancer are not as successful, however. In the future, it will be necessary to find optimal timing, the best route of application, and the "right" size of the Tc particles. Subserous application seems to be superior to hysteroscopic application.

A less radical treatment option to the fertility-sparing radical trachelectomy in patients with stage I cervical cancer.

The purpose of the two pilot studies was to determine the feasibility and safety of using less-radical fertility-preserving surgery: laparoscopic lymphadenectomy with sentinel lymph node identification (SLNI) followed by a large cone or simple trachelectomy (LAP-I protocol) and the LAP-III protocol, which includes neoadjuvant chemotherapy (NAC). LAP-I: Forty women underwent laparoscopic SLNI, frozen-section analysis, and a complete pelvic lymphadenectomy as the first step of treatment. Seven days after final histopathological processing of dissected nodes, a large cone or simple vaginal trachelectomy was performed in patients with negative nodes. Nine women had a tumor larger than 20 mm, prompting the administration of three cycles of NAC before surgery. LAP-I: Six frozen sections were positive (15%). In these cases, a type III Wertheim was immediately performed. There were no false-negative SLNs. There was one central recurrence, but after chemoradiation therapy, there was no evidence of the disease 62 months post-treatment. Twenty-four of 32 women whose reproductive ability had been maintained tried to conceive. Of these 24 women, 17 became pregnant (71% pregnancy rate). Eleven mothers gave birth to 12 children (1 at 24 weeks, 1 at 34 weeks, 1 at 36 weeks, and 9 between 37 and 39 weeks). LAP-III: Nine patients were included. In 7 of these 9 women, reproductive ability was maintained, with 3 women becoming pregnant (1 full term and 2 ongoing). SLNI improves safety in fertility-sparing surgery. Large cone or simple trachelectomy combined with laparoscopic pelvic lymphadenectomy can be a feasible method that yields a high, successful pregnancy rate. NAC followed by fertility-sparing surgery is an experimental alternative treatment for larger tumors.

A prospective study of sentinel lymph node status and parametrial involvement in patients with small tumour volume cervical cancer.

OBJECTIVE: The purpose of prospective study is to determine incidence and distribution of pelvic lymph node (LN) involvement, sentinel lymph node (SLN) involvement and pathologic parametrial involvement (PI) in stage Ia2 and small Ib1 cervical cancer. PI is defined as positive parametrial LN or discontinuous malignant cells in parametrium. METHODS: After radical abdominal hysterectomy, 158 women patients were stratified into two groups based on tumour size: In Group 1 (91 women) tumours were less than 20 mm and less than half of stromal invasion. In Group 2 (67 women) tumours were between 20 and 30 mm and infiltration was not more than 2/3 of cervical stroma. RESULTS: In Group 1 positive SLN was detected in 11(12.1%) patients; of these, 3 (27.3%) had positive PI. In 80 women with negative SLN PI was not detected. In Group 2 positive SLN was detected in 14 (20.9%) patients: PI was found in four (28.6%) of these 14 patients. No PI was detected in 53 women with negative SLN. CONCLUSION: No PI was observed in early cervical cancer if SLNs were negative. However, we found PI in 28.0% of women with positive SLN. Statistical analysis revealed that the results were highly significant. Based on our results, radical removal of parametrium in SLN negative patients is questionable.

Predicting term birth weight using ultrasound and maternal characteristics.

OBJECTIVES: The aim of the study was to compare an ultrasound-based prediction formula of Shepard, Hadlock, our new equation and equation of Nahum based on maternal characteristics. STUDY DESIGN: Two groups of 125 (group A) and 130 (group B) healthy term pregnant women were sampled. Standard ultrasonographic measurements were performed and maternal characteristics recorded. A new birth weight equation was developed by multiple stepwise regression analysis from the group A data and then compared to the different birth weight prediction equations of Hadlock, Shepard and Nahum on group B. RESULTS: New prediction equation: log(10) EFW=0.64041xBPD-0.03257xBPD(2)+0.00154xACxFL. Our new (Halaska) and Hadlock's ultrasound estimations are comparable. Both equations are superior to Shepard and Nahum's equations. The Nahum equation is comparable to the Shepard estimation. Halaska equation tends to have the highest overall accuracy, Hadlock's estimation predicts better fetuses over 4000g, but this needs to be further validated. CONCLUSIONS: The Halaska and Hadlock's estimations are comparable to one another; the Nahum equation is comparable to Shepard's and can be used as simple, inexpensive and approximative estimate.

Study of lymphatic mapping and sentinel node identification in early stage cervical cancer.

OBJECTIVE: The aim of our study was to compare the identification of sentinel lymph nodes (SLN) by blue dye and (99m) Tc; to evaluate detection rate per patient and specific side detection rate (SSDR) of SLN, distribution of SLN and distribution of positive SLN and false negative rate of the methods. PATIENTS AND METHODS: From February 2000 until September 2004, we included 183 women with early stage cervical carcinoma. We evaluated two methods of detection of SLN (100 cases by Patent blue, 83 cases by Patent blue with (99m)Tc). We stratified the group upon the size of the tumor and upon the type of surgical method (laparoscopy, laparotomy). RESULTS: SLN identification increased in cases when we used combination of both methods (Tc + blue dye) SSDR = 93% versus the use of blue dye only SSDR = 71% (OR:5,76, CI 95% -2.9 -11.4, <0.0001). Distribution of 462 SLN-45.0% external iliac artery and vein, 42.6% supraobturator, 4.8 bifurcation and common illiac artery and vein, 4.6% praesacral, 3% medial part of lateral parametrium. Distribution of 44 positive SLN-approximately 38.6% external illiac artery and vein, 45.5% supraobturator, 6.8% bifurcation and common illiac artery and vein, 4.5% praesacral, 4.5% medial part of lateral parametrium. One false negative SN was in presacral area. CONCLUSION: Detection of SLN by combination of (99m)Tc and blue dye was statistically significantly better than blue dye alone. Our study documents high sensitivity, specificity and low false negativity of the method.