SENTINEL LYMPH NODES IN CERVICAL CANCER

Isabel RocaHU VALL HEBRON

The sentinel lymph node mappingand surgical biopsy

is anEMERGING TECHNIQUE

in early stages of cervical cancer

SENTINEL LYMPH NODE DETECTION IN EARLY STAGES OF CERVICAL CANCER

The purpose of thisstudy is

to describe theusefulness

andclinical impact

of this techniquein early stages

of cervical cancer

1- Detection rate of SLN in early stages

2- Predictive value of SLN for lymphatic spread3- Does the SLN detection improve the clinical management ?4- Describe the anatomic localization of the SLN

SENTINEL LYMPH NODE DETECTION IN EARLY STAGES OF CERVICAL CANCER

AIMS

CERVICAL CANCER CERVICAL CANCER REGIONAL LYMPH NODE REGIONAL LYMPH NODE

INVOLVEMENT INVOLVEMENT

HAICH KD , 1994

Stage I 0 - 16 % 0 - 22 %

Stage II 24,5- 31 % 11 - 19 %

pelviclymph node +

paraaorticlymph node +

LYMPHOEDEMALYMPHOCYST

NORMAL LYMPH NODE RESSECTION:NEGATIVE FOR IMMUNITY AND FOLLOW-UP

IN EARLY STAGES > 90% RESSECTED LYMPH NODES

WILL BE NEGATIVE Schneider A. et al (2001)

CERVICAL CANCERCERVICAL CANCERADVERSE EFFECTSADVERSE EFFECTS

PELVIC AND AORTIC LYMPHADENECTOMYPELVIC AND AORTIC LYMPHADENECTOMY

Emerging technique:

� 26 papers 1999-2005

� 13 2004-2005

SENTINEL NODE IN EARLY SENTINEL NODE IN EARLY STAGES OF CERVICAL CANCERSTAGES OF CERVICAL CANCER

REFERENCES

SENTINEL LYMPH NODE

TUMOUR

The SLN will be the

first involved lymph node in case of

lymphatic spread

LYMPHOSCINTIGRAPHYLYMPHOSCINTIGRAPHYIN CERVICAL CANCERIN CERVICAL CANCER

TECHNIQUE:• 99mTc nanocolloid• 4 injeccions• 0,2 ml• around the tumour

LYMPHOSCINTIGRAPHYLYMPHOSCINTIGRAPHYIN CERVICAL CANCERIN CERVICAL CANCER

post injection images

10-30 minutes

2-4 hours

LYMPHOSCINTIGRAPHYLYMPHOSCINTIGRAPHYIN CERVICAL CANCERIN CERVICAL CANCER

First visualized

lymph node

Lymph node with higher

activity

LYMPHOSCINTIGRAPHY :LYMPHOSCINTIGRAPHY :sentinelsentinel lymphlymph nodenodeIDENTIFICATIONIDENTIFICATION

isosulfan Blue-Dye 1% 4 injeccions

preanaestesic time same locations

GROUP OF STUDYN = 40

GROUP OF STUDYN = 40

FIGO stages N %IA2 2 5IB1 34 85IB2 1 2.5IIA 3 7.5

HISTOLOGY N %Squamous 25 62.5Adenocarcinoma 12 30Leiomyosarcoma 1 2.5Indifferenciated 1 2.5Neuroendocrine 1 2.5

PREVIOUS CONIZATION N %

YES 18 45NO 22 55

SURGICAL APPROACH N %

Laparotomy 28 70 Laparoscopy 12 30

Hot SLN or Blue DyeSurgery

Number of patients

37 37 35 40

No drainage 3 3 2 0

N SLN 79 83 70 99

Mean 2.14 2.24 2 2.48

Lympho scintigraphy

Hot SLN Surgery

Blue Dye Surgery

HOT and BLUE

HOT only BLUE only

Common Iliac 8 3 5 1 9Presacral 3 - - 3Interiliac 26 14 9 49External Iliac 12 6 1 19Obturator 8 1 4 13Parametrial 2 1 1 4TOTAL 79 54 29 16 99

LYMPHO SCINTIGRAPHY

SURGERY TOTAL

Aortic bifurcation2 2

N patients

69

- 2 -

SLN non-SLNSLN + 6 68aSLN - 93 666aTOTAL 99 734

ª all negative

TP 6

TN 93

FP 0

FN 0

SLN detection

SENTINEL LYMPH NODE DETECTION

HUVH Series N = 40

90 % 10 % 0 %

1- Detection rate of SLN in early stages100 %

2- Predictive value of SLN for lymphatic spread0% false negative in the first 40 cases

3- Does the SLN detection improve the clinical management ?N= 40 100% detection (combining isotope and blue dye)0% false negative

⇒ validation of the technique4- Describe the anatomic localization of the SLN+++ interiliac region

5% aortic bifurcation / paraaortic

CONCLUSIONSCONCLUSIONS

5. In early stages of cervical cancer, thelymphoscintigraphy with the surgical sentinellymph node detection is a useful techniquewhich can be incorporated to the clinicalpractice, both with laparotomy or by laparoscopic approach.

6.0% false negative in this series of 40 patients:• High NPV

7.SLN detection in non-usual locations

CONCLUSIONSCONCLUSIONS