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The sentinel node approach in gynaecological malignancies

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ABSTRACT

This review discusses the state-of-the-art of sentinel lymph node mapping in gynaecological malignancies, including cervical cancer, endometrial cancer, and vulvar cancer, with an emphasis on new technological advances. For this objective, PubMed/MEDLINE was searched for relevant studies about the sentinel lymph node procedure in gynaecology. In particular, the use of preoperative lymphatic mapping with lymphoscintigraphy and single photon emission tomography/computed tomography (SPECT/CT) was identified in 18 studies. Other recent advances as hybrid tracers (e.g. ICG-99mTc-nanocolloid) and intraoperative tools (portable γ-camera and 3D navigation devices) appear to also represent a useful guide for the surgeon during the operation. Concerning vulvar and cervical cancers, the sentinel lymph node procedure has been incorporated to the current guidelines in Europe and North America, whereas for endometrial cancer it is considered investigative.

No MeSH data available.


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Cervical cancer. Planar images show a bilateral drainage in pelvic area (a–c). Volume-rendering image displays the level of sentinel nodes (d). SPECT/CT axial-fused images showing two separate nodes with high tracer uptake in right obturator fossa as well as three tiny nodes in left side (e). Corresponding axial CT slice (f)
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Fig2: Cervical cancer. Planar images show a bilateral drainage in pelvic area (a–c). Volume-rendering image displays the level of sentinel nodes (d). SPECT/CT axial-fused images showing two separate nodes with high tracer uptake in right obturator fossa as well as three tiny nodes in left side (e). Corresponding axial CT slice (f)

Mentions: Cervical cancer (CC) is the third most common gynaecological cancer with an estimated of 12,990 new cases and 4120 deaths in the US, in 2016 [1]. The pattern of dissemination of CC principally concerns the adjacent pelvic organs, but can also spread to locoregional lymph nodes (LN), while hematogenous spread to lung, liver, bone, and brain is rare. The most important prognostic factor is the presence of metastatic locoregional LN(s), including the pelvic- and para-aortic lymph nodes [2, 3]. According to the current guidelines, the preferred treatment for early-stage disease (FIGO stages IA-2, IB-1, IIA-1) is radical hysterectomy and SLN mapping with or without bilateral pelvic lymphadenectomy [4, 5]. The SLN(s) are the lymph node(s) that receive direct drainage from the tumour [6]; thus, the tumour status of SLN(s) reflects the status of the entire lymph node field. The SLN status plays an important role, because when an SLN contains metastases at histopathology, the best treatment approach would be based on chemo-radiotherapy. In addition, when SLNs are negative for metastases, the pelvic lymph node dissection can be safely avoided [4], reducing concomitant surgical morbidity. The uterine cervix is a midline organ; thus, lymphatic drainage is almost always bilateral and principally to the pelvic region. The most frequent localization of pelvic lymph node metastasis is the obturator followed by the external iliac basins [7]. In addition, the lymphatic drainage may spread to other areas, such as the common iliac and para-aortic basins [8]. Nevertheless, it is rare to find “skip metastasis” in the para-aortic basin without pelvic lymph node metastases [9, 10]. Therefore, the SLN mapping is useful for detection of lymphatic drainage patterns in particular to regions not routinely explored in conventional surgery, such as para-aortic chains. The SLN mapping is performed by peri-tumoural/peri-orificial injection of radiocolloid (e.g. 99mTc-nanocolloid) in the four quadrants of the cervix using a 20 or 22-gauge spinal needle. In the case of previous conisation, the peri-cicatricial injection at the four quadrants is recommended [5]. The most frequently used tracer dose is approximately 110 MBq in a total volume of 2 mL [11]. The injection may be carried out the day before surgery or on the same day of surgery. The Conventional planar images are acquired for 3–5 min in anterior and lateral views at 30 (early) and 60–120 (delayed) min after injection [5]. The early images are used to visualize lymphatic duct(s) and the first-draining lymph node(s). The delayed images are used to differentiate the SLN(s) from higher echelon nodes [12]. A higher echelon node is defined as an LN draining from the SLN(s). The preoperative planar lymphoscintigraphy does not give a precise anatomical localization of the SLN(s) [13]. Therefore, SPECT in conjunction with low-dose CT (SPECT/CT) is recommended immediately after delayed imaging as a complementary modality [5], providing not just better contrast and spatial resolution in comparison to planar imaging, but also accurate anatomical information (Fig. 2).Fig. 2


The sentinel node approach in gynaecological malignancies
Cervical cancer. Planar images show a bilateral drainage in pelvic area (a–c). Volume-rendering image displays the level of sentinel nodes (d). SPECT/CT axial-fused images showing two separate nodes with high tracer uptake in right obturator fossa as well as three tiny nodes in left side (e). Corresponding axial CT slice (f)
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Fig2: Cervical cancer. Planar images show a bilateral drainage in pelvic area (a–c). Volume-rendering image displays the level of sentinel nodes (d). SPECT/CT axial-fused images showing two separate nodes with high tracer uptake in right obturator fossa as well as three tiny nodes in left side (e). Corresponding axial CT slice (f)
Mentions: Cervical cancer (CC) is the third most common gynaecological cancer with an estimated of 12,990 new cases and 4120 deaths in the US, in 2016 [1]. The pattern of dissemination of CC principally concerns the adjacent pelvic organs, but can also spread to locoregional lymph nodes (LN), while hematogenous spread to lung, liver, bone, and brain is rare. The most important prognostic factor is the presence of metastatic locoregional LN(s), including the pelvic- and para-aortic lymph nodes [2, 3]. According to the current guidelines, the preferred treatment for early-stage disease (FIGO stages IA-2, IB-1, IIA-1) is radical hysterectomy and SLN mapping with or without bilateral pelvic lymphadenectomy [4, 5]. The SLN(s) are the lymph node(s) that receive direct drainage from the tumour [6]; thus, the tumour status of SLN(s) reflects the status of the entire lymph node field. The SLN status plays an important role, because when an SLN contains metastases at histopathology, the best treatment approach would be based on chemo-radiotherapy. In addition, when SLNs are negative for metastases, the pelvic lymph node dissection can be safely avoided [4], reducing concomitant surgical morbidity. The uterine cervix is a midline organ; thus, lymphatic drainage is almost always bilateral and principally to the pelvic region. The most frequent localization of pelvic lymph node metastasis is the obturator followed by the external iliac basins [7]. In addition, the lymphatic drainage may spread to other areas, such as the common iliac and para-aortic basins [8]. Nevertheless, it is rare to find “skip metastasis” in the para-aortic basin without pelvic lymph node metastases [9, 10]. Therefore, the SLN mapping is useful for detection of lymphatic drainage patterns in particular to regions not routinely explored in conventional surgery, such as para-aortic chains. The SLN mapping is performed by peri-tumoural/peri-orificial injection of radiocolloid (e.g. 99mTc-nanocolloid) in the four quadrants of the cervix using a 20 or 22-gauge spinal needle. In the case of previous conisation, the peri-cicatricial injection at the four quadrants is recommended [5]. The most frequently used tracer dose is approximately 110 MBq in a total volume of 2 mL [11]. The injection may be carried out the day before surgery or on the same day of surgery. The Conventional planar images are acquired for 3–5 min in anterior and lateral views at 30 (early) and 60–120 (delayed) min after injection [5]. The early images are used to visualize lymphatic duct(s) and the first-draining lymph node(s). The delayed images are used to differentiate the SLN(s) from higher echelon nodes [12]. A higher echelon node is defined as an LN draining from the SLN(s). The preoperative planar lymphoscintigraphy does not give a precise anatomical localization of the SLN(s) [13]. Therefore, SPECT in conjunction with low-dose CT (SPECT/CT) is recommended immediately after delayed imaging as a complementary modality [5], providing not just better contrast and spatial resolution in comparison to planar imaging, but also accurate anatomical information (Fig. 2).Fig. 2

View Article: PubMed Central - PubMed

ABSTRACT

This review discusses the state-of-the-art of sentinel lymph node mapping in gynaecological malignancies, including cervical cancer, endometrial cancer, and vulvar cancer, with an emphasis on new technological advances. For this objective, PubMed/MEDLINE was searched for relevant studies about the sentinel lymph node procedure in gynaecology. In particular, the use of preoperative lymphatic mapping with lymphoscintigraphy and single photon emission tomography/computed tomography (SPECT/CT) was identified in 18 studies. Other recent advances as hybrid tracers (e.g. ICG-99mTc-nanocolloid) and intraoperative tools (portable γ-camera and 3D navigation devices) appear to also represent a useful guide for the surgeon during the operation. Concerning vulvar and cervical cancers, the sentinel lymph node procedure has been incorporated to the current guidelines in Europe and North America, whereas for endometrial cancer it is considered investigative.

No MeSH data available.


Related in: MedlinePlus