To reduce extensive radical procedures and decrease morbidity in gynecologic malignancies, much effort is being focused on implementing less aggressive interventions. Two different approaches such as lymphatic mapping and lymphoscintigraphy are currently used to identify sentinel lymph nodes. In vulvar and cervical carcinomas, metastatic spread of disease commonly follows stepwise progressive drainage. Thus, sentinel lymph node identification may significantly reduce the number of patients undergoing unnecessary, extensive lymphadenectomy in the absence of metastatic disease. The addition of novel techniques, such as histopathologic ultrastaging, step sectioning, and immunohistochemistry staining, will help increase the accuracy and rate of detection of the disease. Any definitive statements can be made to the validity of sentinel lymphadenectomy until we got data with long-term follow-up.
Endometrial Neoplasms ; pathology ; Female ; Genital Neoplasms, Female ; pathology ; surgery ; Humans ; Lymph Node Excision ; methods ; Lymph Nodes ; diagnostic imaging ; pathology ; Lymphatic Metastasis ; Radionuclide Imaging ; Sentinel Lymph Node Biopsy ; Uterine Cervical Neoplasms ; pathology ; Vaginal Neoplasms ; pathology ; Vulvar Neoplasms ; pathology

The purpose of this study was to investigate the feasibility of sentinel node frozen biopsy to minimize the extensive pelvic lymph nodes dissection in early stage cervical cancer patients on the basis that the risk of skip metastasis to the paraaortic area is negligible. Twenty-six patients with early stage cervical cancer were enrolled in this study. Technetium-99m colloid albumin (Tc(99m)) was injected intradermally around the tumor for allowing preoperative lymphoscintigraphy and intraoperative hand-held gama probe detection of seninel nodes. For visual detection, isosulfan blue dye was injected into the peritumoral sites before peritoneal opening. Postoperative morbidity and negative predictive value were the endpoints of this study. The 26 patients, ranging in age from 32 to 71 yr, underwent intraoperative sentinel nodes mapping. All the patients underwent complete pelvic lymph nodes dissection including para-aortic nodes. There was one case with positive non-sentinel nodes despite the negative sentinel node by frozen biopsy (negative predictive value, 95.2%). This new technique of sentinel node mapping is safe and simple to perform. Further clinical trials using the combination of Tc(99m) and isosulfan blue dye are warranted and this technique will make a true advance for less aggressive management of patients with early stage cervical cancer.
Adult ; Aged ; Female ; Humans ; *Lymph Node Excision ; Lymph Nodes/pathology/radionuclide imaging/*surgery ; Middle Aged ; Pelvic Neoplasms/*pathology/radionuclide imaging/surgery ; Pelvis ; Predictive Value of Tests ; Rosaniline Dyes/metabolism ; Sensitivity and Specificity ; *Sentinel Lymph Node Biopsy ; Technetium Tc 99m Aggregated Albumin/diagnostic use ; Uterine Cervical Neoplasms/*pathology/radionuclide imaging/surgery

OBJECTIVETo investigate the distribution of metastatic pelvic lymph nodes in the women with early stage cervical carcinoma, and the feasibility of dividing these nodes into three stations in those patients.

METHODS(99m)Tc-DX of 2 ml was injected into the cervix to a depth of 5 to 10 mm at 3, 6, 9, 12 o'clock positions preoperatively in 196 patients with early stage cervical cancer. Pelvic lymphadenectomy and radical hysterectomy were performed in all patients. Pelvic lymph nodes were detected by gamma-probe. The sentinel lymph nodes (SLN) were determined if the radioactivity reached 5 times higher than that in the ipsilateral nodes. All resected pelvic lymph nodes were examined by histopathology with HE stained serial sections.

RESULTSOf the 196 patients, 41 were found to have metastasis in 83 lymph nodes. The metastatic rate was 78.3% (65/83) in the parametrial and obturator lymph nodes, 20.5% (17/83)in the internal and external iliac lymph nodes, 1.2% (1/83) in the commmon iliac lymph nodes. Of the 22 patients with metastatic parametrial lymph nodes, metastatic external iliac lymph nodes were detected in 5 patients, and metastatic internal iliac lymph nodes in 3 patients. Among the 19 patients with metastatic obturator lymph nodes, metastatic external iliac lymph nodes were found in 4 patients, and metastatic internal iliac lymph nodes in 3 cases. It was shown by Chi-sqare test that the metastases in parametrial and/or obturator lymph nodes were positively correlated with lymph node metastases in other pelvic sites. Eighty-one SLN were found to have metastasis. The metastatic rate of parametrial and obturator SLN was 79.0% (64/81) versus 21.0% (17/81) of internal and external iliac SLN. No statistically significant difference in 1- and 3-yr survival was observed between the groups with and without metastasis in parametrial and obturator lymph nodes, while the 5-yr survival rate in the patients without metastatic lymph node was 93.2%, significantly higher than that of patients with lymphatic metastasis (65.1%).

CONCLUSIONIt is feasible for cervical cancer to divide the pelvic lymph nodes into three levels. The level I lymph nodes consist of parametrial and obturator lymph nodes. Internal and external iliac lymph nodes can be considered as level II lymph nodes, and the common iliac and inguinal lymph nodes as level III nodes. A rational treatment plan can be made according to the distribution of metastatic pelvic lymph nodes.

Adenocarcinoma ; pathology ; surgery ; Adult ; Carcinoma, Squamous Cell ; pathology ; surgery ; Dextrans ; Female ; Follow-Up Studies ; Humans ; Hysterectomy ; methods ; Lymph Node Excision ; Lymph Nodes ; diagnostic imaging ; pathology ; surgery ; Lymphatic Metastasis ; pathology ; Middle Aged ; Neoplasm Staging ; Organotechnetium Compounds ; Pelvis ; Radionuclide Imaging ; Sentinel Lymph Node Biopsy ; Survival Rate ; Uterine Cervical Neoplasms ; pathology ; surgery ; Young Adult