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Biopsia del linfonodo sentinella
nel carcinoma dell’endometrio 99mTc vs Fluorescenza
Fabio Martinelli, MD
Gynecologic Oncology Department
6°
4°
Surgical staging is a mandatory
Lymphadenectomy:-Yes/no-Pelvic/aortic?-Prognostic value?-Therapeutic value?
Surgical staging is a mandatory
Lymphadenectomy:-Yes/no-Pelvic/aortic?-Prognostic value?-Therapeutic value?
Endometrial cancer lymphadenectomy- contra
514 pts
1408 pts
Endometrial cancer lymphadenectomy- contra
514 pts
1408 pts
Endometrial cancer lymphadenectomy -pro
671 pts
509 pts
Sentinel node in endometrial cancer
First paper
Gynecol Oncol. Dec 2011
Gynecol Oncol. Dec 2011
19962011
1101 pts
..but not only..
2012
16 pts endometrial cancer
Lancet Oncol ,2011 May;12(5):469-76
Prospective multicenter studyEnd points: Detection rate and diagnostic accuracy of SLN125 pts St I-II
Cervical dual injection with Tc and patent blue (3-6-9-12 )
Systematic pelvic +/- aortic (15 pts) lymphadenectomy
Detection rate: 111/125 89%
NPV 97%; Sensitivity 84% (patient unit)N+ 19/111 17%; only IHC 9/111 (8%); 3 FN 15%5/111 5% an associated SLN in aortic region
Median pelvic nodes removed 12
Prospective databaseEnd point: FN rate498 pts
Cervical injection with blue dye (3-9)
Pelvic +/- aortic lymphadenectomy
Detection rate: 401/498 81%
NPV 98%; Sensitivity 85%N+ 47/401 11.7%; only IHC 9/401 (2%); 7 FN 15%17/401 4.5% a SLN in aortic region (15 associated, 2 only)
Median nodes removed 8
AlgorithmSens 98.1%NPV 99.8%FN 1.9%
RetrospectiveEnd point: detection rate 35 pts
Cervical injection with isosulfan blue dye and indocyanine green (3-6-9-12)Pelvic +/- aortic lymphadenectomy
Detection rate: 34/35 97%
NPV 96%; Sensitivity 90%N+ 10/35 28.6%; only IHC 4/35 (11.4%); 1 FN 10%
Median pelvic nodesremoved 23
Data on ICG
NO positive aortic SLN identified
Detection rate: 76/80 95%
NPV 98%Sensitivity 90%N+ 10/59 17%; only IHC 6/59 (10%); 1 FN 10%33/59 56% a SLN in aortic region (31 associated, 2 only)
Median nodes removed 48
Prospective studyEnd points: detection rate and diagnostic accuracy of SLN80 pts
Hysteroscopic injection of Tc peritumoralPelvic + aortic systematic lymphadenectomy
SENTIENDO MSKCC INT ICG
Study Prospective Prospective Prospective Retrospective
Years 7/2007-8/2009 9/2005-4/2011 1/2005-12/2010 5/2011-9/2011
Nr. pts 125 498 80 35
Type injection Cervical Cervical Hysteroscopic Cervical
Tracer Blue dye and Tc Blue Dye Tc99m Blue dye and
ICG
Detection rate 111/125 (89%) 401/498 (81%) 76/80 (95%) 34/35 (97%)
Aortic SLN 5% 4.5% 56% 0
Positive nodes 19/111 (17%) 47/401 (11.7%) 10/59 (17%) 10/35 (28.6%)
Median nodes
removed
14 (1-50) 8 (0-59) 48 (23-125) 23 (13-59) pelvic
Sensitivity 84% 85% 90% 90%
NPV 97% 98% 98% 96%
Open questions
• Surgical approach
– LPT
– LPS
– Robotic
• Which tracer:
– blue dyes
– Tc
– ICG
• Way of injection:
– cervical
– hysteroscopic
– miometrial/subserosal
• Pathological evaluation
– H/E
– IHC
Surgical approach
2012
Way of injection
PRO CONTRA
Subserosal/myometrial Easiest in laparotomy Not so easy in minimally
invasive approach
Less sensitivity
Intraoperative
Cervical Easy
Reproducible
Cervical and not uterine
dreinage
Hysteroscopic Respects uterine dreinage
(increased aortic SLN
identification)
Learning curve
Maybe more expensive
Risk of transtubal leakage
Way of injection
PRO CONTRA
Subserosal/myometrial Easiest in laparotomy Not so easy in minimally
invasive approach
Less sensitivity
Intraoperative
Cervical Easy
Reproducible
Cervical and not uterine
dreinage
Hysteroscopic Respects uterine dreinage
(increased aortic SLN
identification)
Learning curve
Maybe more expensive
Risk of transtubal leakage
TracerPRO CONTRA
Blue dyes Ready for use May cause allergic
reaction
May mask the operative
field
Tc Do not colour the
operative field
Problems with radio-
protection
Need dedicated probe
ICG Ready for use
Do not colour the
operative field
Need NIR camera
Need opening of
retroperitoeum
TracerPRO CONTRA
Blue dyes Ready for use May cause allergic
reaction
May mask the operative
field
Tc Do not colour the
operative field
Problems with radio-
protection
Need dedicated probe
ICG Ready for use
Do not colour the
operative field
Need NIR camera
Need opening of
retroperitoeum
TracerPRO CONTRA
Blue dyes Ready for use May cause allergic
reaction
May mask the operative
field
Tc Do not colour the
operative field
Problems with radio-
protection
Need dedicated probe
ICG Ready for use
Do not colour the
operative field
Need NIR camera
Need opening of
retroperitoeum
Pathological evaluation
+39% ofmets
844 pts23 ITC21 mm47 Mam
Pathological evaluation
+39% ofmets
844 pts23 ITC21 mm47 Mam
What we know
Site injection Tracer Detection rate
Cervical Blue-dye and/or Tc 62-89 %
Hysteroscopic Blue-dye and/or Tc 65-95%
Cervical ICG 95-97%
What are we evaluating?
What are we evaluating?
Results57 pts
DR 89% (new camera: 95%)
Bilateral DR 74.5%
47% mapped PA
1 pts isolated PA N+
1 pts pelvic and PA N+
1 pts pelvic only N+
2/3 N+ in the aortic area
SPIES with D-Light P
What we knowSite injection Tracer Detection rate
Cervical Blue-dye and/or Tc 62-89 %
Hysteroscopic Blue-dye and/or Tc 65-95%
Cervical ICG 95-97%
Hysteroscopic ICG 95%
•Comparable DR•NO radiation•NO colored surgical field•Possibility to dissect SLN under NIR
Conclusions • SLN is a reasonable middle ground between no lymphadenectomy and
full LA and pelvic nodes assestment
• In our experience, hysteroscopic injection of tracer identifies pelvic and
PA SLN according to the anatomy of uterine lymphatic system.
• Hysteroscopic injection of ICG seems to overcome the limits of Tc and
blue dyes
• The surgical procedure is not time consuming,the injection of tracer is
performed under direct laparoscopic observation and it is possible to
dissect SLN without a wide retroperitoneal space exposure
• The technical evolution of the light source and the camera sensitivity
allows the surgeon to dissect SLNs directly in NIR mode
2014
476 pts retrospective
Thanks
268 pts43 N+
24 Mam12 mm7 ITC
9.2 vs 36.8 LNX
No missed N+
33
33
