Search

Background: Sentinel node and occult lesion localization (SNOLL) calls for a combination of two specific procedures: intraoperative detection of sentinel lymph node (SLN) and radio-guided occult lesion localization (ROLL). The safety and benefits of radio-guided localization in the surgical treatment of non-palpable breast cancer have been confirmed. The aim of this study was to evaluate the potential role for an intra-operative handheld tumor resection gamma camera (TReCam) in SNOLL procedures., Methods: Fifteen patients were enrolled. The SNOLL procedure was performed in all patients with conventional lymphoscintigraphy (LS). TReCam was used to obtain nuclear imaging in the operating theater. Concordance between LS and TReCam images, duration of use and assessment of difficulties in data acquisition with TReCam were reported., Results: Concordance for tumor localization between single-detector gamma probe and TReCam was excellent (15/15). The number of radioactive SLNs visualized between LS and TReCam was equivalent in 53.3% of cases (8/15). TReCam was considered to be very easy-to-use (12/15) or easy-to-use (3/15). Average duration of acquisition with TReCam was 4 minutes and 45 seconds for the SLN procedure, and 2 minutes and 10 seconds for lumpectomy., Conclusions: This study suggests that TReCam is easy-to-use and does not increase operative time. Its exact role in radio-guided surgery needs to be clearly defined in a larger study. However, its usefulness and benefits in radio-guided breast surgery seem to be promising.

Purpose: GANEA2 study was designed to assess accuracy and safety of sentinel lymph node (SLN) after neo-adjuvant chemotherapy (NAC) in breast cancer patients., Methods: Early breast cancer patients treated with NAC were included. Before NAC, patients with cytologically proven node involvement were allocated into the pN1 group, other patient were allocated into the cN0 group. After NAC, pN1 group patients underwent SLN and axillary lymph node dissection (ALND); cN0 group patients underwent SLN and ALND only in case of mapping failure or SLN involvement. The main endpoint was SLN false negative rate (FNR). Secondary endpoints were predictive factors for remaining positive ALND and survival of patients treated with SLN alone., Results: From 2010 to 2014, 957 patients were included. Among the 419 patients from the cN0 group treated with SLN alone, one axillary relapse occurred during the follow-up. Among pN1 group patients, with successful mapping, 103 had a negative SLN. The FNR was 11.9% (95% CI 7.3-17.9%). Multivariate analysis showed that residual breast tumor size after NAC ≥ 5 mm and lympho-vascular invasion remained independent predictors for involved ALND. For patients with initially involved node, with negative SLN after NAC, no lympho-vascular invasion and a remaining breast tumor size 5 mm, the risk of a positive ALND is 3.7% regardless the number of SLN removed., Conclusion: In patients with no initial node involvement, negative SLN after NAC allows to safely avoid an ALND. Residual breast tumor and lympho-vascular invasion after NAC allow identifying patients with initially involved node with a low risk of ALND involvement.

Objective: Sentinel lymph node biopsy (SLNB) is a standard for patients with early breast cancer. Using a gamma-detecting probe connected to an infrared camera, the Declipse freehand SPECT (FhSPECT) system (Surgiceye(®)) is able to detect and locate any radioactive source in 3D. The objective of this study was to evaluate the potential interest of FhSPECT imaging for real-time guidance SLNB in breast cancer., Methods: A prospective single-center clinical study assessed sensitivity and usability of FhSPECT for SLN detection and surgical guidance in breast cancer patients. SLN detection rate with FhSPECT was compared with lymphoscintigraphy (LS) and colorimetric method. Durations of FhSPECT acquisitions and of the SLNB procedure were measured in order to evaluate the practicability of the device., Results: Between May and September 2014, 20 patients with early stage invasive breast cancer (cT0-2N0) underwent SLNB using FhSPECT and blue dye detection. Preoperative LS revealed 41 radioactive axillary SLNs (median=2 SLN per patient; range 0-4) in 20 patients. Preoperative FhSPECT detected 40 axillary SLNs (median=2; range: 1-4) in 20 patients. The corresponding sensitivity of FhSPECT was 97.5%. For 4 patients (20%), FhSPECT detected more axillary SLNs than LS. The colorimetric method identified only 24 axillary SLNs (2 patients had no blue dye injection on account of a history of allergy), leading to a sensitivity of 67% (24 blue SLNs/36 resected SLNs after blue dye injection). Median duration of FhSPECT acquisitions was 5minutes (range: 1-26min). Median duration of SLNB procedure was 11.5minutes (range: 3-55min). Duration of acquisitions analysis based on the number of use of the device showed decreasing values suggesting the existence of a short learning curve., Conclusion: This study demonstrated that FhSPECT is feasible and facilitates SLN identification., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

The main goal of preoperative chemotherapy is to reduce the size of the tumor and allow conservative treatment. Neoadjuvant treatment can affect axillary status with a downstaging in one third of the cases. For these patients, the benefit of axillary node dissection is questioned and the sentinel node biopsy (SLNB) seems to be a relevant option. However, the timing of performing SLNB is still debated especially for clinical negative patients with negative axillary ultrasound before preoperative chemotherapy. For axillary positive nodes proved by biopsy/cytology before preoperative chemotherapy, SLNB can be an option if there is a good clinical and radiological response., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Objective: Assess the biopsy's feasibility of the sentinel lymph node biopsy (SLNB) using optonuclear probe after of indocyanine green (ICG) and radio-isotope (RI) injections., Methods: Twenty-one patients with a localized breast cancer and unsuspicious axillary nodes underwent a SLNB after both injections of ICG and radio-isotope., Results: One or more SLN were identified on the 21 patients (identification rate of 100%). The median number SLN was 2 (1-3). Twenty SLN were both radio-actives and fluorescents (54.1%), 11 fluorescent only (29.7%) and 6 were only radio-actives (16.2%). Seven patients had a metastatic SLN (8 SLN overall). Among them, only one had a micrometastasic SLN, 5 others had a macrometastatic SLN and one patient had two macrometastatic SLNs. Among the 8 metastatic SLN, 5 were both fluorescent and radioactive, 2 were only fluorescent and 1 was only radioactive., Conclusion: Detection SLN using optonuclear probe after indocyanine green and radio-isotope injections is effective and could be, after validation by randomized trial, a reliable alternative to the blue dye injection for teams who consider that combined detection as the reference., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

The sentinel node procedure (GS) is the recommended technique for axillary surgical exploration in localized breast cancer with no clinical or radiological lymph node involvement. This surgical technique is based on a dual isotope and colorimetric detection. Although it allows a significant reduction in morbidity compared to axillary dissection (CA), this procedure induces a number of organizational constraints, in particular for the radioisotope injection. Specially for this reason, other GS methods have emerged in recent years, some of which appear promising (detection by fluorescence and magnetic iron). The objective of this paper was to carry out a synthesis of the reference method of detection (radioisotope) GS and analyze the recent literature on new detection methods., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

The sentinel lymph node (SLN) is a standard for the surgical treatment of axillary localized breast cancer N0. It is based on a double isotopic and color detection. With a gamma detecting probe connected to an infrared camera, Déclipse SPECT system (Surgiceye(®)) is able to detect and locate any radioactive source in 3D. Mobile character for use in the operating room is particularly interesting for the intraoperative detection of SLN. We illustrate its usefulness in a clinical case where the preoperative identification of SLN by lymphoscintigraphy was not informative., (Copyright © 2014. Published by Elsevier SAS.)

Objective: To evaluate the feasibility of the magnetic technique for sentinel node biopsy (SNB) in breast cancer., Patients and Methods: A total of 10 consecutives patients with breast cancer scheduled for SNB, who were clinically node negative, were recruited. SNB was undertaken after injection of both magnetic and radio-isotopic tracers., Results: One or more SN were identified among 10 patients (identification rate of 100%). The median number of GS taken was 1.7 (range 1-3). In total, 17 GS were taken. SN were radioactive and ferromagnetic (82.3%), 3 were only radioactive and none was only ferromagnetic., Discussion and Conclusion: The magnetic technique is feasible, but cannot be used alone due to technical constraints., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objectives: The results of the ACOSOG Z0011 questioned the usefulness of axillary lymph node dissection (ALND) in case of metastatic sentinel lymph node (SLN). The aim of our study was to assess the impact of the omission of ALND according to the inclusion criteria of the ACOSOG Z0011 study if SLN are metastatic but also the consequences on prescription of the application of a new standard of care for adjuvant treatment., Patients and Methods: This retrospective study included, between November 2007 and January 2012, patients with T1-T2N0 breast cancer and metastatic SLN meeting the criteria for omission of completion ALND according to the study of the ACOSOG Z0011. Patients were submitted anonymously and randomly in multidisciplinary meeting (MM) 3 times: with complete information including ALND (MM1), with information from SLN alone (MM2) and with complete information of ALND according to the current protocols in 2013 (MM3). During each presentation, we collected the decision of the different adjuvant treatments proposed: chemotherapy, hormonal therapy, radiotherapy (with radiation fields). Then, we compared therapeutic proposals of the 3 presentations., Results: Fifty-eight patients were eligible for inclusion criteria of the ACOSOG Z0011. Treatments actually proposed during MM1 consisted of 94.8 % of chemotherapy, 77.6 % of breast and lymph nodes radiotherapy and 91.4 % of hormone therapy. During the MM2, there was no significant difference compared to the decision taken during MM1. In fact, during MM2, we decided chemotherapy, radiotherapy and hormonotherapy respectively in 89.7, 79.3 and 91.4 % of the cases. During the MM3, it was shown a significant decrease in the indications of chemotherapy (82.8 %, P=0.03) and lymph nodes irradiation (56.9 %, P=0.02) compared to the therapeutic proposals of the MM1., Discussion and Conclusion: The lack of information of ALND does not seem to significantly alter indications for adjuvant treatment. Otherwise, the evolution of our references causes a decrease in adjuvant therapy., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Purpose: To determine the exportability of the criteria defined by the American College of Surgeons Oncology Group Z0011 trial for selecting patients who are eligible for omitting completion axillary lymph node dissection (cALND) after a positive sentinel lymph node (SLN) biopsy result and to investigate whether not following the Z0011 criteria might affect patient outcomes., Methods: From a multicenter database, we selected 188 patients with positive SLNs and then excluded patients with positive SLNs on immunohistochemistry only. We retrospectively applied the Z0011 criteria and grouped the patients as eligible or ineligible for omitting cALND. The eligible group was compared with the cohort included in the Z0011 trial and with the ineligible group. Kaplan-Meier survival curves were calculated for each group, and univariate analyses assessed associations between the groups and clinicopathological variables., Results: The final analysis involved 125 patients with positive SLNs. Eighty-seven patients (69.6 %) were potentially eligible for omitting cALND. The estrogen receptor status, T stage, grade, and number of positive non-SLNs were not statistically different between the eligible group and the Z0011 cohort. The ineligible group had significantly more positive non-SLNs (P = 0.01) and a lower 5-year overall survival rate than the eligible group (P < 0.001)., Conclusions: The similarity of clinical characteristics between the Z0011 trial cohort and our eligible group confirms the exportability of these criteria to another population. The worse prognosis of patients who did not meet the Z0011 criteria suggests prudence before disregarding or enlarging broadening the indications for omitting cALND.

Objective: To establish an inventory concerning the consistency of current medical practices in the management of axillary support for non-metastatic breast cancer since the publication of the ACOSOG-Z0011 randomized trial., Patients and Methods: A descriptive survey practice using a questionnaire sent by email was conducted in medical care teams for breast cancer., Results: Forty-eight medical teams across the French territory answered to the questionnaire. It has been noted that 72.9% of medical teams have said to consistently achieve an additional axillary lymph node dissection (ALND) in case of macrometastatic sentinel node (SN), 12.5% in case of micrometastatic SN and only 2.1% in isolated tumor cells SN. The majority of medical teams (61.9%) claimed they did not perform the procedure GS before or after neoadjuvant chemotherapy (NAC). The SN biopsy was performed in only 29.1% of teams before and 9% after NAC, outside study. Axillary irradiation was performed in case of macrometastatic SN without complementary by 27.1% of interviewed medical teams and by 4.1% in the case of micrometastic SN., Discussion and Conclusion: This survey of practice in patients with breast cancer highlights the evolution of medical practice for the axillary management in France. It also illustrates the diversity of practices in medical teams and the significant compensatory increase in the expansion of radiation fields in patients with metastatic SN without additional ALND., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background: Axillary treatment of breast cancer patients is undergoing a paradigm shift, as completion axillary lymph node dissections (ALNDs) are being questioned in the treatment of patients with tumor-positive sentinel nodes. This study aims to develop a novel multi-institutional predictive tool to calculate patient-specific risk of residual axillary disease after tumor-positive sentinel node biopsy., Methods: Breast cancer patients with a tumor-positive sentinel node and a completion ALND from five European centers formed the original patient series (N = 1000). Statistically significant variables predicting nonsentinel node involvement were identified in logistic regression analysis. A multivariable predictive model was developed and validated by area under the receiver operating characteristics curve (AUC), first internally in 500 additional patients and then externally in 1068 patients from other centers. All statistical tests were two-sided., Results: Nine tumor- and sentinel node-specific variables were identified as statistically significant factors predicting nonsentinel node involvement in logistic regression analysis. A resulting predictive model applied to the internal validation series resulted in an AUC of 0.714 (95% confidence interval [CI] = 0.665 to 0.763). For the external validation series, the AUC was 0.719 (95% CI = 0.689 to 0.750). The model was well calibrated in the external validation series., Conclusions: We present a novel, international, multicenter, predictive tool to assess the risk of additional axillary metastases after tumor-positive sentinel node biopsy in breast cancer. The predictive model performed well in internal and external validation but needs to be further studied in each center before application to clinical use.

Sentinel lymph node (SLN) mapping and biopsy have emerged as the technique of choice for axillary staging of breast cancer. Several methods have been developed to identify SLNs, including peritumoral or periareolar injection of blue dye or technetium colloid. The optimal site for injection of mapping tracers is controversial in SLN. The peritumoral injection provides information on the deep lymphatic drainage and the internal mammary chain. The advantages of periareolar injection are simplicity, the ability to perform it in non-palpable tumors, and the potential enhancement of uptake via the subareolar lymphatic plexus. The results of multiinstitutional study have indicated that superficial injection (periareolar or peritumoral) is associated with a better identification rate and an equal false-negative rate compared to deep peritumoral (PT) injection. However, the false-negative rate of periareolar injection has not been formally demonstrated., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Unlabelled: The aim of this study was to compare the effectiveness of a hand-held preoperative compact imager (POCI) camera with conventional lymphoscintigraphy using a γ-camera for sentinel lymph node (SLN) detection in breast cancer., Methods: The main objective was to demonstrate the noninferiority of the POCI relative to conventional lymphoscintigraphy and to compare the number of SLNs detected by the 2 imaging devices. Our study, a clinical prospective, double-blind, noninferiority study, planned to include 200 patients with early breast cancer and started in January 2006. A standard SLN protocol (4 periareolar injections of 37 MBq of (99m)Tc-nanocolloids, 2 h before lymphoscintigraphy) was performed preoperatively using a conventional γ-camera and then the POCI camera. Scans were obtained by 2 different nuclear medicine physicians unaware of each other's results. The day after, in the operating room, the surgeon, after receiving the previous results, used the counting probe for surgical SLN biopsy. The number and localization of axillary SLNs obtained by lymphoscintigraphy and the POCI and the duration of the whole procedure were determined., Results: Among the 162 patients included, 138 were evaluable. The POCI detected more SLNs than did lymphoscintigraphy in 50 patients (36%), the same number of in 54 patients (39%), and fewer SLNs in 34 patients (25%), representing 84 (61%) discordant pairs. The noninferiority of preoperative compact imaging of axillary SLNs numbers was found to be statistically significant (95% confidence interval, 30%-52%, P = 0.025) using the McNemar test. The duration of acquisition was shorter using the POCI (<10 min in 84% [n = 117] of patients; mean, 7.5 ± 3.3 min) than lymphoscintigraphy (13% [n = 18] of patients; mean, 15.7 ± 3.4 min), with P < 0.001 using the McNemar test for paired proportions., Conclusion: Preoperative compact imaging using a hand-held camera was able to predict the number and localization of breast cancer SLNs and was not inferior to conventional lymphoscintigraphy in this study. Further studies will determine whether preoperative compact imaging could replace lymphoscintigraphy, especially in surgical centers without an on-site nuclear medicine department.

Lymph node status is a major prognostic element in endometrial cancer and affects the choice of adjuvant therapy. The sentinel lymph node (SLN) procedure is proposed as an alternative to lymphadenectomy. This review aims to assess its feasibility. To this end, 19 studies have been analysed. It appears that double detection (colorimetric and isotopic) is better than single detection, independent of injection site. Hysteroscopic injection is technically more difficult, yet can be done near the tumoral lesion. The cervical site does not accurately reflect the lymphatic drainage of the uterine body but is easier to access. SLN detection rate is notably identical between these two injections sites. Lomboaortic detection rate is lower for cervical injections than for endometrial ones. The myometrial site is also difficult to access (intraoperatively), due to same limitations as the hysteroscopic route, and can be deceiving (insufficient detection rate and high false-negative rate). The SLN allows for ultrastadification (micrometastases and isolated tumoral cells) with the development of new pathological techniques (serial sections and immunohistochemistry). Data on SLN in endometrial cancer is very heterogeneous in terms of methodology and populations studied. Despite being well-known, the SLN procedure in endometrial cancer remains in its feasibility stage. Its place in therapeutic strategies needs to be further explored and its potential benefit remains to be confirmed.

Sentinel node (SN) biopsy is considered as a standard of care in the staging of breast cancer. We report SN biopsy in a rare case of second ipsilateral subcutaneous recurrence in patient with previous left breast cancer initially treated by breast radiotherapy followed by mammectomy with axillary dissection and multiple mammoplasty. Lymphoscintigraphy was performed. Two axillary radioactive SNs were identified and removed without lymph node involvement at final histology. To conclude, re-operative axillary dissection by SN biopsy after previous axillary and breast surgeries is technically feasible., (2010 Elsevier Masson SAS. All rights reserved.)

Purpose: Three models have been developed to predict four or more involved axillary lymph nodes (ALNs) in patients with breast cancer with one to three involved sentinel lymph nodes (SLNs). Two scores were developed by Chagpar et al (Louisville scores excluding or including method of detection), and a nomogram was developed by Katz et al. The purpose of our investigation was to compare these models in a prospective, multicenter study., Patients and Methods: Our study involved a cohort of 536 patients having one to three involved SLNs who underwent ALN dissection. We evaluated the area under the receiver operating characteristic curve (AUC), calibration (for the Katz nomogram only), false-negative (FN) rate, and clinical utility of the three models. Results were compared with the optimal logistic regression (OLR) model that was developed from the validation cohort., Results: Among the 536 patients, 57 patients (10.6%) had > or = four involved ALNs. The AUC for the Katz nomogram was 0.84 (95% CI, 0.81 to 0.86). The Louisville score excluding method of detection was 0.75 (95% CI, 0.72 to 0.78). The Louisville score including method of detection was 0.77 (95% CI, 0.74 to 0.79). The FN rates were 2.5% (eight of 321 patients), 1.8% (two of 109 patients), and 0% (zero of 27 patients) for the Katz nomogram and the Louisville scores excluding and including method of detection, respectively. The Katz nomogram was well calibrated. Optimism-corrected bootstrap estimate AUC of the OLR model was 0.86. Using this result as a reasonable target for an external model, the performance of the Katz nomogram was remarkable., Conclusion: We validated the three models for their use in clinical practice. The Katz nomogram outperformed the two other models.

Early-stage cervical cancer (IA2 and IB1) treatment consists in surgery with a radical colpohysterectomy associated to a systematic pelvic lymphadenectomy more or less a paraaortic lymphadenectomy (Wertheim-Meigs surgery). Pelvic lymph node involvement is the main independent prognostic factor and justifies an adjuvant therapy. Sentinel lymph node (SLN) procedure allows a reliable evaluation of the lymph node status thanks to an accurate histologic analysis. This procedure is still not validated in practice, which means the bilateral pelvic lymphadenectomy is systematically done whatever the lymph node status is. Nevertheless the purpose of the SLN biopsy in cervical cancer does not consist in avoiding an unnecessary lymphadenectomy, which is not really associated with a major morbidity. Actually, a better initial stadification would allow to fit to the risk of recurrence not only the radicality of the surgery, but also the adjuvant therapy. The morbidity of a radical surgery could be limited for good prognosis patients and avoided for the benefit of a concomitant chemoradiotherapy.

Background: Patent blue is a commonly used agent in the detection of sentinel nodes (SN) in solid cancer. Similar to any drug, it is possible to have an allergic reaction during surgery. Anaphylactic reactions to patent blue have been rarely reported especially in cervical cancer., Case: We reported here a rare case of anaphylactic shock due to patent blue in response to injection of patent blue for SN mapping in a woman with cervical cancer. We presented our management of the shock, our diagnostic process of the allergen and the treatment of the cervix cancer after the anaphylactic reaction., Conclusion: Surgeons and anesthetists must be aware of the potential allergic of patent blue during the SN procedure.

Background: Axillary lymph node dissection (ALND) is the standard treatment for patients with sentinel node (SN) metastasis, but most of these patients have negative non-sentinel nodes (non-SN). We have developed a scoring system (the Tenon score) to help identify a subgroup of patients who have a low risk of having non-SN metastases and who may thus forgo ALND. Here we validated the Tenon score in an independent cohort of SN-positive patients., Patients and Methods: We tested the accuracy of the Tenon score for predicting non-SN status in a prospective multicenter study of 226 SN-positive breast cancer patients. We calculated the false-negative rate, sensitivity, specificity, and positive (PPV) and negative predictive values (NPV). Receiver operating characteristics (ROC) curves were constructed and the areas under the curve (AUC) were calculated as a measure of discriminatory capacity., Results: At least one non-SN was positive in 63 patients (27.9%). One hundred and twenty (53.1%) of the 226 patients had a Tenon score of 3.5 or less. Among these 120 patients, five had at least one positive non-SN. With a score cut-off of 3.5, the negative predictive value was 95.8% and the false-negative rate was 4.2%. Overall, the Tenon score accurately predicted non-SN status, with an AUC of 0.82 (95% confidence interval, 0.77-0.88)., Conclusion: In this multicenter study of an independent patient population, the Tenon score was accurate and reproducible for predicting non-SN status in breast cancer patients. The simplicity and reliability of the variables on which the Tenon score is based may be an advantage over other scoring systems.

Background: To evaluate the feasibility of a laparoscopic sentinel node (SN) procedure based on combined method in patients with endometrial cancer., Methods: Thirty-three patients (median age 66.1 years) with endometrial cancer of apparent stage I or stage II underwent a laparoscopic SN procedure based on combined radiocolloid and patent blue injected pericervically. After the SN procedure, all the patients underwent laparoscopic bilateral pelvic lymphadenectomy., Results: SNs were identified in only 27 patients (81.8%). The mean number of SNs was 2.5 per patient (range 1-5). Only 18 patients (54.5%) had an identified bilateral SN. The most common site of the SNs was the medial external iliac region (67.6%). Fourteen SNs (19.7%) from 8 patients (24.2%) were found to be metastatic at the final histological assessment. No false-negative SN results were observed., Conclusions: A SN procedure based on a combined detection and laparoscopic approach is feasible in patients with early endometrial cancer. However, because of a low rate of bilateral and global SN detections and problems of injection site using pericervical injection of radiocolloid and blue dye, alternative methods should be explored. Pericervical injections should be avoided.

The presence of lymph node (LN) metastases has a major impact on the prognosis of women with endometrial cancer and compromises recurrence-free time. LN assessment has become the standard of care in the surgical staging of patients and plays a crucial role in decision making. Sentinel lymph node (SLN) detection improves the accuracy of lymphatic drainage mapping compared to pelvic node dissection used alone. Serial sectioning of SLNs followed by immunohistochemical examination with conventional histology improves accuracy of micrometastatic identification. In this review, we found a high incidence of micrometastases in endometrial cancer, reaching 25% depending on the stage and the techniques used for the node examination. Current data are insufficient to evaluate the prognostic impact of the presence of micrometastases, but it seems that more accurate detection of lymphatic spread will allow better stratification of intermediate risk patients. Ultimately, this will assist in tailoring adjuvant treatment.

Lymph node metastases is a recognized prognostic factor in women with cervical cancer. However, there is a need for consensual histological definition of micrometastases in this indication which could give rise to a classification system similar to that used in breast cancer. We thus conducted a MEDLINE and EMBASE database analysis to evaluate the concept of micrometastases in cervical cancer. Retrospective studies place the incidence of micrometastasis between 1.5 and 15% depending on the technique used to evaluate lymph node status. Sentinel lymph node biopsy with serial sectioning and immunohistochemical analysis appears to be the most accurate micrometastases detection technique. The value of RT-PCR in micrometastases detection remains to be clarified by further studies. From a clinical view point, few data are available to support the prognostic relevance of micrometastases. However, case control and longitudinal studies have underlined the risk of recurrence in women with micrometastases, raising the issue of a revision of adjuvant therapy indications in this specific population.

In vulvar cancer, lymph node status is a major prognostic factor. Currently, the reference regarding nodal exploration is the groin lymphadenectomy responsible for a significant morbidity. The sentinel node technique in breast cancer has become a standard of care. This technique has been studied for fifteen years in vulvar cancer, on small numbers because of its low incidence. There is not yet consensus about its use in practice. This article is a focus on this technology, its feasibility and the benefits of sentinel node detection applied to vulvar cancer.

Background: Lymph node status is a major prognostic factor and a criterion for adjuvant therapy in endometrial cancer. The sentinel lymph node (SN) procedure has emerged as a possible alternative to systematic lymphadenectomy. The aims of this study were to determine the detection rate and the false-negative rate of the SN procedure, and its contribution to the staging of women with endometrial cancer., Methods: Forty-six patients with endometrial cancer underwent the sentinel node procedure followed by pelvic lymphadenectomy. SNs were detected with a dual or single labelling method in 39 and 7 cases, respectively. All SNs were analysed by both hematoxylin and eosin (H&E) staining and immunochemistry., Results: SNs were identified in 40 patients (87%), whose mean number of SN was 2.6 (range 1-5). The SN detection rate was significantly lower with the single label than with the dual label (p = 0.01). Ten women (25%) had a positive SN on final histology (i.e. there were no false negatives). A correlation was observed between lymph node involvement and both histological grade (p = 0.01) and lymphovascular space involvement (p = 0.001). The stage predicted by magnetic resonance (MR) imaging correlated poorly with the Federation International of Gynaecology and Obstetrics (FIGO) stage. Among the ten women with a positive SN, three of the four women with a grade 1 tumour at biopsy had grade 2-3 disease on final histology. Seven of the ten women with a positive SN underwent external pelvic radiotherapy, based solely on their SN involvement., Conclusion: The SN procedure can reliably determine lymph node status in women with endometrial cancer. Given the limited capacity of MR imaging to detect myometrial invasion, and of biopsy to determine histological grade, our results support the systematic use of the SN procedure in women with endometrial cancer, including those with presumed early-stage disease and/or well-differentiated tumours.

The sentinel lymph node procedure has become the standard in the surgical management of localised breast cancer. However, it is submitted to the uncertainties of intraoperative examination. Indeed, intraoperative examination has three major disadvantages: the type of histological method (frozen section versus imprint cytology), the size of sentinel node metastasis (macro- versus micrometastases) and the time requested for this technique. All of these limits are responsible for secondary re-interventions to complete axillary lymph node dissection. Few medical teams have described a new surgical strategy to avoid these limits. They proposed the detection of the sentinel lymph node under local anaesthesia and to wait for the definitive histological analysis before carrying out lumpectomy and axillary lymphadenectomy if necessary under general anaesthesia. We realized a review of the literature on this new procedure to evaluate its feasibility and to assess the technical aspects.

The role of sentinel lymph node (SLN) biopsy in patients with initial diagnosis of ductal carcinoma in situ (DCIS) is still a dilemma. Different studies are trying to define predicting factors of invasive cancer in DCIS. The aim of this study was to confirm the value of SLN biopsy in DCIS because of the invasive upstaging risk on final histology. Patients with initial diagnosis of DCIS and with axillary SLN biopsy were selected. All diagnoses were confirmed by biopsy of mammographic lesions. Surgical treatment was lumpectomy or mastectomy associated with SLN biopsy. Imprint stains were performed, and then serial sections were stained with hematoxylin and eosin (H&E) and with immunohistochemistry (IHC). A complete axillary lymph node dissection (ALND) was performed during the same surgery when a node metastasis was found. Eighty patients were enrolled in the study. Of the 61 patients who were initially diagnosed with DCIS, 12 (20%) were upstaged to microinvasive or invasive carcinoma and 9 (15%) had a metastatic SLN. Patients upstaged to invasive carcinoma had macrometastatic SLN immediately fed by a complete ALND. SLN micrometastases and isolated cells were detected by IHC and secondary complete ALND found an additional metastatic lymph node in one patient. Tumor size larger than 30 mm and mastectomy were the only significative predicting factors of upstaged disease (p < 0.0001) in our study. In patients with initial diagnosis of large DCIS programmed for mastectomy, SLN biopsy should be discussed in order to detect underlying invasive disease and to spare patients a second operating time.

Background: The sentinel node (SN) is defined as the first node in the lymphatic system that drains a tumor site. If the SN is not metastatic, then all other nodes should also be disease-free. We used serial sections and immunohistochemical (IHC) staining to examine both SN and non-sentinel nodes (non-SNs)., Patients and Methods: Twenty-three patients (median age 69 years) with early endometrial cancer underwent a laparoscopic SN procedure based on a combined detection method, followed by complete laparoscopic pelvic lymphadenectomy. If the SN was free of metastasis by both hematoxylin and eosin (H&E) and IHC staining, all non-SNs were also examined by the combined staining method., Results: SNs were identified in 19 patients (82.6%). A total of 47 SNs were removed (mean 2.5). Ten SNs (21.3%) from five patients (26.3%) were found to be metastatic at the final histologic assessment. In 14 patients, no metastatic SN involvement was detected by H&E and IHC staining. In these 14 patients, 120 non-SNs were examined by serial sectioning and IHC, and none were found to be metastatic., Conclusion: The SN procedure appears to reliably predict the metastatic status of the regional lymphatic basin in patients with early endometrial cancer.

Background: It has been suggested that histologically undetectable or 'occult' metastases in the lymphatic system could explain some recurrences. HPV DNA screening by means of the polymerase chain reaction (PCR) has been proposed as a method to detect occult metastases. This study was designed to determine the frequency of HPV DNA detection by PCR in sentinel lymph node (SN), and its relation to the clinical characteristics and outcome of women with cervical cancer., Patients and Methods: The primary cervical tumor and SN were tested for HPV DNA by means of PCR in 59 patients., Results: Fifteen (25.4%) of the 59 women undergoing the SN procedure had an involved SN. HPV DNA was more frequent in positive SN than in negative SN (P < 0.0001). Seven patients had a recurrence, after a mean delay of 17 months (range: 10-26). One of seven patients with a recurrence had an involved SN. HPV DNA was detected in an SN of one of seven patients with recurrence and nine (19.5%) of 46 patients without recurrence (not significant)., Conclusion: In women with cervical cancer, HPV DNA screening of sentinel nodes might help to identify patients at risk of lymph node metastases and recurrence.

Objective: To evaluate the contribution of the sentinel node (SN) procedure followed by pelvic and paraaortic lymphadenectomy to determine lymph node status in women with locally advanced cervical cancer., Patients and Methods: A total of 21 women with locally advanced cervical cancer underwent a first laparoscopic SN procedure and pelvic and paraaortic lymphadenectomy followed by concurrent chemoradiotherapy (CCR). Laparoscopic radical hysterectomy was performed after CCR when the pelvic and paraaortic nodes were not involved., Results: SNs were detected by means of lymphoscintigraphy in 10 women (47.6%) and intra-operatively in 14 women (66.6%). Of the latter 14 patients, 9 (64%) had an involved SN and 1 of the remaining 5 had pelvic non-SN metastases. The SN false-negative rate was 10%. At final histology, 13 of the 21 women (62%) had lymph node metastases. The total number of recovered pelvic non-SNs was 262, and 10 nodes in 8 women were involved. The total number of paraaortic non-SNs was 255, and 2 nodes in 2 women were involved., Conclusion: This study shows the poor correlation between pre-operative lymphoscintigraphy and surgical SN mapping in women with locally advanced cervical cancer. A high proportion of women had SN metastases, underlining the importance of multiple sectioning and immunohistochemical staining of SNs.

Sentinel lymph node (SN) biopsy for breast cancer has been introduced in the mid-1990s and it has now been performed on thousands of patients. This procedure has been rapidly adopted around the world by surgical specialists in clinical practice as a diagnostic procedure instead of the axillary lymph node dissection. The diffusion of the SN mapping in routine must be careful by respecting some principles of methodology and especially of training, in order to maintain its irreversible development. However, the advent of this mini-invasive technique revealed new questions, which the concept of the SN procedure raises: can we increase the current indications? Could axillary lymph node dissection be avoided in patients with metastatic SN? What is the morbidity of the biopsy of the SN? Which is the prognostic value of micrometastatis discovered by the diffusion of the ultra-stadification of the SNs? The GS procedure is a diagnostic method the reliability of which is now on accepted in its usual indications (tumours in place, small size breast tumour without palpable adenopathy). The value of the axillary dissection after metastatic SN is the subject of debates and controversies although axillary dissection remains recommended. So the use of scores or predictive nomograms is currently developed to select the patients being able not to justify of complementary axillary dissection, and seems promising.

Background: To evaluate the feasibility after 5 years experience of a laparoscopic sentinel node (SN) procedure with combined radioisotopic and patent blue labeling in patients with cervical cancer., Methods: Sixty-seven patients (median age 48.9 years) with cervical cancer underwent a laparoscopic SN procedure using an endoscopic gamma probe, after both radioactive and patent blue injections. After the procedure, all the patients underwent complete laparoscopic pelvic/para-aortic lymphadenectomy., Results: At least one SN was identified in 57 patients (85.1%). According to the Stage, the SN identification rate was 91.2% in early-stage cervical cancer and 78.5% in locally advanced cervical cancer. The mean number of SN was 2.3 per patient (range 1-5). A total of 129 SNs were removed. Lymph node metastasis involvement was identified in the 20 SNs (15.5%) from 14 patients (24.6%). Nine of the 14 patients had at least one macrometastases, three patients presented micrometastases in H&S, and two patients presented isolated single cells. Six patients presented a pelvic non-SN involvement including two patients whose SNs were uninvolved. The false-negative SNs rate was 12.5% (two patients out of 16). Both patients have locally advanced cervical cancer., Conclusion: This study confirms that laparoscopic SN detection with a combination of radiocolloid and patent blue is accurate in patients with early cervical cancer to assess pelvic lymph node status.

In cancer research, regional lymph node status is a major prognostic factor and a decision criterion for adjuvant therapy. The sentinel node procedure, which has emerged to reduce morbidity of extensive lymphadenectomy, remains a major step in the surgical management of various cancers. Sentinel node procedure has become a standard technique for the determination of the nodal stage of the disease in patients with melanoma, vulvar cancer and in breast cancer. In endometrial cancer, the sentinel node biopsy is still at the stage of feasibility. In this article, we review the technical aspects, results, clinical implications and limitations of sentinel node procedure in endometrial cancers.

Sentinel node (SN) biopsy is become a standard of care in breast cancer surgical practice. However, the advent of this technique, recently discussed during the 29th San Antonio Breast Cancer Symposium 2006, revealed new questions, which the concept of the SN procedure raises: can we increase the current indications? Could be axillary lymph node dissection avoided in patients with metastatic SN? the morbidity of the biopsy of the SN, which is the prognostic value of micrometastatis discovered by the diffusion of the ultra-stadification of the SNs?