Senteneal node 2
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This document summarizes the use of sentinel lymph node biopsy (SLNB) in gynecological malignancies, specifically vulvar cancer. It discusses how SLNB can help stage and predict prognosis in vulvar cancer patients, with a lower morbidity than traditional inguinal lymphadenectomy. Several studies demonstrated high detection rates of over 95% and low false negative rates of less than 10% when using radiotracer and blue dye to map sentinel lymph nodes in vulvar cancer patients. Larger multicenter trials provide further support for the accuracy and reduced complications of SLNB compared to lymphadenectomy in early stage vulvar cancer.
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Senteneal node 2
- 1. Sen$nel Lymph node in Gynecological malignancies Khalid Sait FRCSC Professor, Faculty of medicine, King Abdulaziz University Jeddah, Saudi Arabia
- 2. Sen$nel lymph node (SLN) • SLN: The first lymph node in a chain of lymph nodes within a lympha$c basin that receives drainage from the primary tumor.
- 3. If SLN is nega$ve, the remainder of the lymph nodes in the nodal basin should be free of disease as well
- 6. Advantage of SLNS • Decrease short-‐term and long-‐term morbidity associated with complete nodal dissec$ons • Reduced opera$ve $me. • Reduced blood loss. • Reduc$on in nerve, blood vessel, and ureteral injuries. • Increased iden$fica$on of metasta$c lymph nodes through ultra-‐staging . • It may iden$fy lymph nodes in areas that may not be dissected in a standard lymphadenectomy
- 8. SLN • Standard of care in breast cancer and melanomas
- 9. Vulva Cancer • Vulva :-‐ – Superficial inguinal lymph nodes, . – Deep inguinal Lymph nodes. – Femoral lymph nodes.. – Deep pelvic nodes including; the external iliac, common iliac, then para-‐aor$c lymph nodes.
- 10. Current standard radical wide local excision and either deep or superfacial inguinal node dissec$on radical vulvectomy with en bloc inguinal femoral lymphadnectomy wound breakdown chronic lymphedema 85% 30-‐70 % 70% 20-‐40 % Morbidity Historical Standard Treatment of Early stage Vulvar Cancer
- 11. Important of lymphadnectomy ( not clinically suspicious) • Staging • Prognosis
- 12. Staging • Only 27 % of pa$ents who undergo inguinal lymphadnectomy will have posi$ve node • i.e more than 70 % of women will have an inguinal node dissec$on with out any clinical benefit.
- 13. Prognosis • 5 years survival rate in pa$ents with: v nega$ve inguinal lymph. node is 96% v Less or two posi$ve is 80 % v More than two is 12 %
- 14. Alterna$ve?
- 15. Alterna$ve?
- 16. Technique for sen$nel node • Blue Dye :-‐ – Injected into the $ssue surrounding the tumour . • Radiolymphoscin5graphy :-‐ – Radio ac$ve tracers usually Techne$um-‐99m: • Techne$um with sulfur colloid injected 2-‐4 pre OP. • Techne$um with albumin injected pre-‐op day 1.
- 17. Technique for sen$nel node
- 18. Authors No. of Patients Detection method Detection percentage Faise-negative percentage Levenback (1995) 21 blue day 66 0 DeCesare (1997) 10 blue day + radiocolloid 100 0 Ansink (1999) 51 blue day 56 2 De Hullu (2000) 59 blue day + radiocolloid 100 0 Sideri (2000) 44 radiocolloid 100 0 De Cicco (2000) 37 radiocolloid 100 0 Levenback (2001) 52 blue day 88 3 Sliutz (2002) 26 blue day + radiocolloid 100 0 Puig-Tintore (2003) 26 blue day + radiocolloid 96 0 Moore (2003) 21 blue day + radiocolloid 100 0 Merisio (2005) 10 radiocolloid 100 3 Terada (2006) 21 blue day + radiocolloid 100 0 Haupsy (2007) 41 blue day + radiocolloid 95 0 Sentinel lymph node detection rates in vulvar cancer
- 19. mul$center study Hampl et al. in 2008. 127 pa5ents with stage T1 – T3 squamous cell cancer lesions. 128 With early stage vulva cancer with use of SLNS detec$on rate false-‐nega$ve rate sensi$vity 125 of the 127 pa$ents 98% 7.7% 92.3%
- 20. • GOG 173 RESULT PENDING
- 21. Criteria for SLNS IN VULVA CANCER EXPERT PANEL! • Tumors 4 cm or less, • Clinically nega$ve groins, and tumor invasion greater than 1mm • midline tumors should have bilateral SLN biopsies performed. • Competency : An expert panel recommended an arbitrary number of 10 consecu$ve cases with successful SLN iden$fica$on and no false-‐ nega$ve results be performed prior to performing SLN biopsy without lymphadenectomy
- 22. Vulvar SLNS protocol -‐ve +ve Complete lymphadenectomy Groin radia$on No further disec$on sixth biennial meet-‐ ing of the Interna$onal Sen$nel Lymph Node Society an expert panel issued a statement 2008
- 23. GROINSS-‐V-‐I(mul$center observa$onal study) radioac$ve tracer and blue dye, in pa$ents with unifocal vulvar squamous cell carcinoma less than 4cm in diameter. -‐ve 276 +ve No pts 403 Follow up lymphadenectomy Recurrent 8 (2.9%) lymphodema 1.9% 25.2% (p<0.001)
- 24. P value SLNS lymphadenectomy p<0.001 0.4% 16.2% Recurence erysipelas p<0.001 4.5% 21.3%, Celluli$ts p<0.001 11.7% 34% Wound breakdown p<0.001 8.4 days 13.7 days Hospital stay 97% Disease-‐specific survival rate for pa$ents with unifocal vulvar cancer and nega$ve SLN
- 25. GROINSS-‐V-‐II study mul$center observa$onal study +ve SLN Radia$on and chenotheray radia$on ?
- 26. Is their any survival benefit?
- 27. • in summary, SLN biopsy in early-‐stage vulvar cancer pa$ents appears to be a reasonable alterna$ve to complete inguinal lymphadenectomy.
- 28. Cervical cancer • Standard treatment for early stage radical hystrectomy /trachlectomy and pelvic lymphadnectomy • Complica$on include short term morbidity and long term • Lymphcyst and lymphoedema and nerve and vascular injury
- 29. • Cervix :-‐ – Two groups : • Primary groups: Paracervical, parametrial, obturator, internal and external iliac nodes. • Secondary groups: Common iliac, para-‐ aor$c, and lateral sacral lymph nodes.
- 30. FIGO stage IIB FIGO stage IB 39–43% 11–21% pelvic lymph node metastasis 7–17% 2–4% para-‐aor$c lymph node metastasis
- 31. Problem with standard lymphadnectomy • Short and long term morbidity • Chance of missing posi$ve Lymph node
- 32. Alterna$ve?
- 33. Alterna$ve?
- 34. Cervical Sen$nel LN mapping • the cervical stroma is injected circumferen$ally. Peri-‐ tumoral injec$on is preferred, as it should allow the tracer to follow the same path as the lympha$c drainage of the lesion itself. Near-‐infrared fluorescence imaging using indocyanine green
- 35. Authors No. of Patients Detection method Unilateral Detection percentage Bilateral detection percentage Faise-negative percentage O’Boyle (2000) 20 blue day 70 42 0 Malur (2001) 50 blue day 55 NS 17 radiocolloid 76 NS blue day + radiocolloid 90 NS Levenback (2002) 39 blue day + radiocolloid 100 NS 13 Dargent (2003) 70 blue day + radiocolloid 90 NS 0 Plante (2003) 70 blue day + radiocolloid 93 72 0 blue day 83 51 Hubalewska (2003) 37 blue day + radiocolloid 100 65 Pijpers (2004) 37 blue day + radiocolloid 97 94 8 Rob (2005) 183 blue day + radiocolloid 96 90 3 blue day 80 62 Di Stefano (2005) 50 blue day 90 60 10 Silva (2005) 56 radiocolloid 93 38 18 Angioli (2005) 37 radiocolloid 70 31 0 Wydra (2006) 100 blue day + radiocolloid 100 66 3 Frumovitz (2006) 50 blue day + radiocolloid 96 60 0 Kraft (2006) 54 blue day + radiocolloid 93 43 0 Haupsey (2007) 42 blue day + radiocolloid 98 72 0 Yuan (2007) 81 blue day 83 78 23 Seong (2007) 89 blue day 57 NS 9 Fader (2008) 38 blue day + radiocolloid 92 47 3 Altgassen (2008) 590 blue day + radiocolloid 89 NS 4 Sentinel lymph node detection rates in cervical cancer
- 36. • GOG 206, an ongoing, mul$center trial examining the u$lity of SLN biopsy in early cervical cancer pa$ents. • Pending result…….. • These results will likely direct future research on this topic.
- 37. Is their any survival benefit?
- 38. Endometrial cancer • Standard management hysterectomy and bso and pelvic and para aor$c lymphadnectomy • Lymphadnectomy associated with increase morbidity and mortality • Most onen all node be nega$ve especially in early stage and grade 1
- 39. • Uterus :-‐ – Pelvic Lymph node – para-‐aor$c LNs via the ovarian vessels
- 40. • 90% of pa$ents with stage I endometrium cancer will not have lymph node metastasis at the $me of diagnosis
- 41. Problem with standard lymphadnectomy • Short and long term morbidity • Chance of missing posi$ve Lymph node
- 42. Alterna$ve?
- 43. Alterna$ve?
- 44. Technique Near-‐infrared fluorescence imaging using indocyanine green
- 45. Authors No. of Patients Injection site Detection method Unilateral Detection percentage Bilateral detection percentage Faise-negative percentage Burke (1996) 15 SSM blue day 67 NS 50 Echt (1999) 8 SSM blue day 0 0 0 Holub (2002) 13 SSM blue day 62 NS 0 12 SSM + PC blue day 83 NS 0 Pelosi (2002) 16 PC blue day + radiocolloid 94 56 0 Gargiulo (2003) 11 PC blue day + radiocolloid 100 35 0 Raspagliesi (2004) 18 HS blue day + radiocolloid 100 NS 0 Holub (2004) 25 SSM + PC blue day 84 81 0 Fersis (2004) 10 HS radiocolloid 70 20 0 Niikura (2004) 28 HS radiocolloid 82 NS 0 Maccuro (2005) 26 HS blue day + radiocolloid 100 NS 0 Bats (2005) 26 PC blue day + radiocolloid 81 NS 0 Li (2007) 20 SSM blue day 75 NS Ns Frumovitz (2007) 18 SSM blue day + radiocolloid 45 39 0 Altgassen (2007) 23 SSM blue day 92 NS NS Delpech (2007) 23 PC blue day + radiocolloid 83 48 NS Barranger (2009) 33 PC blue day + radiocolloid 82 54 0 Sentinel lymph node detection rates in endometrial cancer
- 46. • A meta-‐analysis of 26 studies including 1101 sen$nel node procedures found a sensi$vity of 93 percent for the detec$on of lymph node metastases in women with endometrial carcinoma . • Studies have evaluated two sites of injec$on for SLN mapping:-‐ • percervical . (Higher detec$on rate) • hysteroscopically-‐guided (Lower detec$on rate).
- 48. Is their any survival benefit?
- 49. Conclusion • Sen$nel node mapping will allow for selec$ve removal of nodes at risk, while sparing other nodes and reducing opera$ve morbidity substan$ally. • For gynecologic cancers, the results are promising, par$cularly for vulvar cancer which can be an alterna$ve of the standard of care • This technological advancement will be considered promising, but not yet a standard of care for treatment of women with endometrium and cervical cancer
- 50. Conclusion • The safety of the SLN procedure is strongly associated with the number of women treated within a specific center and the presence of a well trained oncology team • Given the collec$ve interest in the less morbid treatment for pa$ents with gynecological cancer, sen$nel node mapping deserves con$nued development.