Sentinel lymph node mapping with indocyanine green in cervical cancer patients undergoing open radical hysterectomy: a single-institution series

Abstract

Purpose To assess the rate of bilateral sentinel lymph node (SLN) detection with indocyanine green (ICG), to evaluate the sensitivity and the negative predictive value of cervical cancer patients undergoing open radical hysterectomy; to compare open versus minimally invasive SLN biopsy performance and to assess factors related to no/unilateral SLN mapping. Methods We retrospectively reviewed consecutive patients with FIGO 2018 stage IA1 with lymph-vascular space involvement to IIB and IIIC1p cervical carcinoma who underwent SLN mapping with ICG followed by systematic pelvic lymphadenectomy between 05/2017 and 06/2020. Patients were divided according to surgical approach for statistical analysis. Results Eighty-five patients met inclusion criteria. Twenty-seven (31.8%) underwent open and 58 (68.2%) underwent minimally invasive SLN mapping. No difference in any SLN mapping (laparotomy 92.6% and minimally invasive 91.4%) or in SLN bilateral detection (laparotomy 72.0% and minimally invasive 84.9%) (p = 0.850 and p = 0.222, respectively), in median number of SLNs mapped and retrieved (2 in both groups, p = 0.165) and in site of SLN mapping per hemi-pelvis (right side, p = 0273 and left side, p = 0.618) was evident between open and minimally invasive approach. Per-patient sensitivity of SLN biopsy in laparotomy was 83.3% (95% CI 35.9–99.6%) and the negative predictive value was 95.0% (95% CI 76.0–99.1%). No difference in per-patient sensitivity was noted between two approaches (p = 0.300). None of the analyzed variables was associated with no/unilateral SLN mapping. Conclusion The use of ICG to detect SLN in cervical cancer treated with open surgery allows a bilateral detection, sensitivity and negative predictive value comparable to minimally invasive surgery with potential advantages of ICG compared to other tracers.

Sentinel Lymph Node Staging with Indocyanine Green for Patients with Cervical Cancer: The Safety and Feasibility of Open Approach Using SPY-PHI Technique

“…There is accumulating evidence in the literature to support the safety and feasibility of lymphatic mapping and sentinel lymph nodes staging in cervical cancer [ 12 , 13 , 16 , 32 ]. Notwithstanding the large tumor size up to 4 cm, there is still a good detection rate of SLN reported in a few studies; The SENTICOL I (Ganglion Sentinelle dans le Cancer du Col) study showed a 92% sensitivity and 98.2% negative predictive value for node metastasis detection in patients with cervical cancer who underwent technetium-99 lymphoscintigraphy and Patent Blue injection followed by the laparoscopic lymph node mapping [ 33 ].…”

“…Retrospectively reviewed data from five European centres have already shown ICG to be superior to 99 m technetium and blue dye with a detection rate reaching 100% and with better visualization of the bilateral lymph drainage pathways (99%) [ 34 , 35 ]. A new Italian study demonstrated that there is no significant difference in ICG SLN diagnostic performance in cervical cancer between open and minimal access surgery, with a sensitivity and negative predictive values of 83.3% and 95.0%, respectively in open access surgery, and 92.9% and 97.5%, respectively in minimal access surgery [ 13 ]. These critical results emphasize the high unmet medical need and growing demand for more data on SLN detection using ICG in open surgery for cervical cancer, in particular following the LACC-trial findings [ 20 ], which have shifted our practice towards open access with a few exemptions.…”

“…In our opinion, the very good detection rates, sensitivity, and negative predictive values in this study may be attributed to the first and second echelons resection of sentinel lymph nodes, which led to the high median number of retrieved sentinel lymph nodes per pelvic sidewall. On the other hand, the most frequent site of SLN mapping was external iliac, followed by obturator region in the most studies considering the first labelled SLN only [ 13 , 36 , 37 ]. In our study was the common iliac region the most common site for SLN lymph nodes even because we retrieved not only the first but too the second echelon of labelled lymph nodes.…”

“…Indocyanine green (ICG) has been shown to be superior to blue dye or radioactive tracer in SLN bilateral detection rate in minimal access surgery [ 11 , 12 ]. However, its use in open surgery is limited to few case reports or case series [ 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. Following the Laparoscopic Approach to Cervical Cancer (LACC) Trial published data [ 20 ], international societies, albeit with some bias, have adopted open surgery as the recommended approach [ 21 , 22 ].…”

“…Therefore, there is now a higher demand to offer more reliable data on the feasibility and safety of SLN in open surgery for cervical cancer, especially as using ICG has proven to be the best tracer in this disease. Different studies assessed the role of SLN in open radical surgery with blue dye or radioactive tracer [ 23 , 24 , 25 , 26 , 27 ], but only a few with ICG [ 13 ].…”