Faculty Bibliography

OBJECTIVES/OBJECTIVE:Planar lymphoscintigraphy (LSG) is frequently performed for the assessment of the sentinel lymph nodes (SLN) in gynecologic malignancies. Planar imaging helps to localize hot nodes but lacks accuracy of the anatomic location of those nodes. In this study, we compared SPECT-CT to planar LSG in endometrial and cervical cancer to assess its ability to localize SLN. METHODS:We conducted a prospective nonrandomized study of SLN mapping in women with endometrial and cervical cancer. Forty patients with endometrial cancer and 10 with cervical cancer underwent pre-operative LSG with 1 or 4 mCi of (99m)Tc sulfur colloid administered as injections into the cervix. All patients were scanned immediately with planar LSG obtained in the anterior and lateral views. SPECT-CT imaging was obtained following the planar imaging. RESULTS:Planar LSG alone localized SLN in 30/40 (75%) endometrial cancer patients while SPECT-CT localized SLN in all 40 patients (100%). In the 10 cases where SLN was not identified with planar imaging, SPECT-CT localized nodes in the external iliac, internal iliac, common iliac and obturator groups. In cervical cancer, planar LSG alone localized sentinel lymph nodes in 8/10 patients (80%) as compared to SPECT-CT, which localized nodes in all 10 patients (100%). SPECT-CT imaging was especially useful in delineating external iliac versus internal iliac or obturator nodes, and the parametrial nodal uptake. CONCLUSIONS:SPECT-CT appears to improve sentinel lymph node detection and anatomic localization as compared to planar imaging in cervical and uterine cancer.

BACKGROUND:Axillary lymph node dissection (ALND) in patients with immunohistochemistry (IHC)-determined metastases to the sentinel lymph node (SLN) is controversial. The goal of this study was to examine factors associated with ALND in IHC-only patients. METHODS:Retrospective review of an institutional SLN database from July 1997 to July 2003 was performed. We compared sociodemographic, pathologic, and therapeutic variables between IHC-only patients who had SLN biopsy alone and those that had ALND. RESULTS:Our study group consisted of 171 patients with IHC-only metastases to the SLN. Young age, estrogen receptor negative status, high Memorial Sloan-Kettering Cancer Center nomogram score, and chemotherapy were associated with ALND. Among patients who had ALND (n = 95), 18% had a positive non-SLN. Rates of systemic therapy were similar between those with and without positive non-SLNs at ALND. No axillary recurrences were observed in this series with a median follow-up of 6.4 years. The percentage of patients who were recurrence-free after 5 years was 97% (95% confidence interval, 92.1-98.6). CONCLUSIONS:On the basis of our findings and the lack of prospective randomized data, the practice of selectively limiting ALND to IHC-only patients thought to be at high risk and to patients for whom the identification of additional positive nodes may change systemic therapy recommendations seems to be a safe and reasonable approach.

The treatment of gynecologic malignancies can include surgery, systemic therapy, and radiation. Depending on the primary site of disease and the extent of the disease, these treatment strategies are applied alone or in combination. Trends over the past few decades have concentrated on performing more comprehensive staging procedures for a large percentage of patients with gynecologic malignancies. The surgical techniques available for comprehensive staging have facilitated a greater understanding of stage and prognosis overall, and better tailoring of postsurgical treatment. One such technique is regional lymphadenectomy. Although the role of regional lymphadenectomy as a therapeutic procedure in some gynecologic cancers is debated and challenged (regional lymphadenectomy and multimodality therapy increases adverse side effects and long-term sequelae without proven survival benefit), there is no controversy regarding the staging and prognostic benefit of the evaluation of regional lymph nodes. The sentinel lymph node (SLN) concept was successfully introduced in melanoma. It has since become the standard of care in breast cancer and has had a significant impact on postoperative morbidity for a large percentage of breast cancer patients. Interest in using SLN techniques in gynecologic cancers was thus a natural progression. In light of the growing body of evidence in the literature opposing the therapeutic benefit of systematic lymphadenectomy, the SLN concept will continue to play an important role in the treatment of gynecologic malignancies. This technique can provide accurate staging information in some gynecologic cancers. Increased use of this technique could potentially impact the quality of life of gynecologic cancer survivors while still providing important staging information without compromising oncologic safety. In this review, we examine the body of literature related to gynecologic cancer malignancies and SLN biopsy.

BACKGROUND:The therapeutic significance of intramammary lymph nodes is uncertain. The purpose of this study was to identify the appropriate surgical management of the axilla in intramammary node-positive patients undergoing sentinel lymph node (SLN) biopsy. METHODS:A retrospective review of consecutive patients staged between September 1996 and December 2004 was performed. Intramammary node identification and pathologic findings were compared with the status of axilla. RESULTS:Among 7,140 patients, intramammary nodes were identified in 151 (2%). Positive intramammary nodes were identified in 36 patients (24%). Axillary disease was identified in 61% of intramammary node-positive patients. No additional axillary disease was identified when axillary lymph node dissection was performed in intramammary node-positive patients with negative axillary SLN biopsy results. CONCLUSIONS:The results suggest that completion axillary lymph node dissection may be based on the status of axillary SLN biopsies in clinically node negative patients when intramammary lymph node metastases are identified in the breast specimens.

BACKGROUND:Completion axillary lymph node dissection (CALND) is routinely performed in breast cancer patients with positive sentinel lymph nodes (SLN). We sought to determine the sociodemographic, pathologic, and therapeutic variables that were associated with CALND. METHODS:From 7/1997 to 7/2003, 1,470 patients with invasive breast cancer were SLN positive by intraoperative frozen section or final pathologic exam by hematoxylin-eosin and/or immunohistochemistry (IHC). A comorbidity score was assigned using Adult Comorbidity Evaluation-27 system. Fisher's exact, Wilcoxon tests, and multivariate logistic regression analysis were used. RESULTS:CALND was performed less often in patients with age >or= 70 years compared with age < 70 years, moderate or severe comorbidities compared with no or mild, IHC-only positive SLN and breast conservation therapy (BCT compared with mastectomy. Patients who did not undergo CALND were less likely than CALND patients to have grade III disease, lymphovascular invasion multifocal disease, tumor size > 2 cm or to receive adjuvant chemotherapy. However, they were more likely to undergo axillary radiotherapy (RT). On multivariate analysis, age >or= 70 years [odds ratio (OR) 0.4, 95% confidence interval (CI) 0.26-0.63], IHC-only positive SLN (OR 0.13, 95%CI 0.09-0.19), presence of moderate to severe comorbidities (OR 0.64, 95%CI 0.41-0.99), tumor size <or= 2 cm (OR 0.44, 95%CI 0.29-0.66), axillary RT (OR 0.39, 95%CI 0.20-0.78), and BCT (OR 0.54, 95%CI 0.37-0.79) were all independently associated with lower odds of CALND. CONCLUSIONS:The decision to perform CALND following positive SLN biopsy was multifactorial. Patient factors were a primary determinant for the use of CALND in our study. The decreased use of CALND in the BCT patients probably reflects reliance on the radiotherapy tangents to maintain local control in the axilla.

OBJECTIVE:A breast and/or axillary mass in a patient with epithelial ovarian cancer (EOC) may be due to an EOC breast metastasis or a second primary breast cancer. We sought to review our experience with patients with a history of EOC presenting with a breast and/or axillary mass to determine if clinical features differed between these entities. METHODS:Between 1/90 and 10/07, 29 women with epithelial EOC presented with a breast or axillary mass, including 10 patients with EOC metastatic to the breast and/or axilla and 19 patients with a second primary breast cancer following their original EOC diagnosis. Clinicopathologic factors/survival were retrospectively abstracted from medical records. RESULTS:The mean EOC disease-free survival (DFS) was 14.9 mo versus 77.4 mo (P<0.001) for patients with recurrent epithelial ovarian cancer metastatic to the breast and/or axilla and patients with a second primary breast cancer, respectively. Similarly, the mean interval between diagnosis of EOC and the breast and/or axillary event was 31.2 mo versus 70.7 mo for those patients who had metastatic recurrent EOC and those patients with breast cancer (P=0.02). Patients with a second primary breast cancer were more likely to be diagnosed on mammogram and have a family history of breast and ovarian carcinoma than patients with metastatic EOC to the breast and/or axilla (14/19 [73.7%] versus 2/9 [22.8%], P=0.02; and 12/18 [66.7%] versus 2/10 [20%], P=0.05, respectively). Median overall survival for patients with EOC metastasis was 26 mo but was not yet reached for those patients with a second primary breast cancer. On univariate analysis, an ovarian cancer DFS of 12 mo or more and the performance of breast/axillary surgery were associated with a significantly longer overall survival (P=0.01 and 0.02, respectively), whereas an elevated CA125 level at the time of the breast/axilla event and the presence of EOC metastases to the breast and axilla were significant negative predictors of survival (P=0.01 and 0.05, respectively). CONCLUSION/CONCLUSIONS:The interval between EOC diagnosis and the breast and/or axilla event, an elevated CA125 level, and a family history of breast and/or ovarian cancer may help differentiate patients with metastatic EOC to the breast and/or axilla from those patients with a second primary breast cancer. The presence of a metastatic EOC portends a poor prognosis.

OBJECTIVE: To describe sentinel lymph node (SLN) detection rates in endometrial cancer and estimate how many cases are needed to achieve >90% SLN detection. METHODS: We conducted a prospective study of patients undergoing primary surgery for endometrial cancer between September 2005 and March 2009. Lymph node mapping was performed using blue dye injection into the cervix in all cases. Additional injection methods included blue dye injection in the uterine fundus, and cervical injection of Tc99m. SLNs were identified and removed, followed by regional lymph node dissection. The results were analyzed according to two study periods: an "early" phase (September 2005-December 2007) and a "late" phase (January 2008-March 2009). RESULTS: One hundred and fifteen patients with endometrial cancer were included. The cervix was the only site of injection in 82 cases (71%), while a combined cervical and fundal injection was performed in 33 cases (29%). Overall, SLN detection was achieved in 98 (85%) cases. In the initial 27 months of the study, a SLN was identified in 50 of 64 cases (78%), with 2 false negative cases. In the subsequent 15 months, successful mapping was achieved in 48 of 51 cases (94%) with no false negative cases. When examining an individual provider's performance, after the first 30 cases, the rate of successful mapping significantly increased from 77% to 94% (P=0.033). CONCLUSION: Sentinel node mapping in uterine cancer requires a dedicated effort to achieve high detection rates. Surgeons should determine their individual detection rates and false negative rates. Our data demonstrate that high SLN detection rates can be achieved in women with uterine cancer and increasing surgical volume (30 cases) is associated with significantly increased detection rates.

OBJECTIVE: To describe the accuracy of SLN mapping in patients with a preoperative diagnosis of grade 1 endometrial cancer. METHODS: A prospective, non-randomized study of women with a preoperative diagnosis of endometrial cancer and clinical stage I disease was conducted. A subset analysis of patients with a preoperative diagnosis of grade 1 endometrial endometrioid cancer was performed. All patients had preoperative lymphoscintigraphy with Tc99m on the day of or day before surgery followed by an intraoperative injection of 2 cm(3) of isosulfan or methylene blue dye deep into the cervix or both cervix and fundus. All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and regional nodal dissection. Hot and/or blue nodes were labeled as SLNs and sent for histopathological analysis. RESULTS: Forty-two patients with a preoperative diagnosis of grade 1 endometrial carcinoma treated from 3/06 to 8/08 were identified. Twenty-five (60%) had laparoscopic surgery; 17 (40%) were treated by laparotomy. Preoperative lymphoscintigraphy visualized SLNs in 30 patients (71%); intraoperative localization of the SLN was possible in 36 patients (86%). A median of 3 SLNs (range, 1-14) and 14.5 non-SLNs (range, 4-55) were examined. In all, 4/36 (11%) had positive SLNs-3 seen on H&E and 1 as cytokeratin-positive cells on IHC. All node-positive cases were picked up by the SLN; there were no false-negative cases. The sensitivity of the SLN procedure in the 36 patients who had an SLN identified was 100%. CONCLUSION: Sentinel lymph node mapping using a cervical injection with combined Tc and blue dye is feasible and accurate in patients with grade 1 endometrial cancer and may be a reasonable option for this select group of patients. Regional lymphadenectomy remains the gold standard in many practices, particularly for the approximately 15% of cases with failed SLN mapping.

Techniques for sentinel lymph node injections have varied over the years in both cervical and uterine malignancy lymph node mapping. There remains considerable variation in techniques, particularly for uterine malignancies. This review summarizes some of the techniques that have been published and are currently utilized in sentinel lymph node mapping for cervical and uterine malignancies.

OBJECTIVES/OBJECTIVE:To describe the surgical and pathologic findings of fertility-sparing radical abdominal trachelectomy using a standardized surgical technique, and report the rate of post-trachelectomy adjuvant therapy that results in permanent sterility. METHODS:A prospectively maintained database of all patients with FIGO stage IB1 cervical cancer admitted to the operating room for planned fertility-sparing radical abdominal trachelectomy was analyzed. Sentinel node mapping was performed via cervical injection of Technetium and blue dye. RESULTS:Between 6/2005 and 5/2008, 22 consecutive patients with FIGO stage IB1 cervical cancer underwent laparotomy for planned fertility-sparing radical abdominal trachelectomy. Median age was 33 years (range, 23-43). Histology included 13 (59%) with adenocarcinoma and 9 (41%) with squamous carcinoma. Lymph-vascular invasion was seen in 9 (41%) cases. Only 3 (14%) needed immediate completion radical hysterectomy due to intraoperative findings (2 for positive nodes, 1 for positive endocervical margin). Median number of nodes evaluated was 23 (range, 11-44); and 6 (27%) patients had positive pelvic nodes on final pathology - all received postoperative chemoradiation. Sixteen (73%) patients agreed to participate in sentinel node mapping which yielded a detection rate of 100%, sensitivity of 83%, specificity of 100% and false-negative rate of 17%. Eighteen of 19 (95%) patients who completed trachelectomy had a cerclage placed, and 9/22 (41%) patients had no residual cervical carcinoma on final pathology. Median time in the operating room was 298 min (range, 180-425). Median estimated blood loss was 250 ml (range, 50-700), and median hospital stay was 4 days (range, 3-6). No recurrences were noted at the time of this report. CONCLUSIONS:Cervical adenocarcinoma and lymph-vascular invasion are common features of patients selected for radical abdominal trachelectomy. The majority of patients can undergo the operation successfully; however, nearly 32% of all selected cases will require hysterectomy or postoperative chemoradiation for oncologic reasons. Sentinel node mapping is useful but until lower false-negative rates are achieved total lymphadenectomy remains the gold standard. Investigating alternative fertility-sparing adjuvant therapy in node positive patients is needed.