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Laparoscopic Sentinel Node Procedure in Patients With Cervical Cancer

Hôpital Tenon, Paris, France

To the Editor:The article by Levenback et al¹ in the February 1, 2002, issue of the Journal of Clinical Oncology examines the utility of intraoperative lymphatic mapping with blue dye and radiocolloid in patients with cervical cancer. In a large series of patients with early-stage disease, combined detection by laparotomy identified sentinel nodes (SNs) in 100% of cases. Except for Verheijen et al,² who used combined detection, previous studies using blue dye or lymphoscintigraphy alone have shown an SN detection rate of between 15.4% and 100%.^3-7 The article by Levenback et al raises several issues. Indeed, the study involved two institutions, but no information was given on the number or experience of the surgeons who performed the SN procedure. As in breast cancer, successful adoption of the SN procedure for patients with cervical cancer—as a substitute for total pelvic lymphadenectomy—depends on the surgeons’ experience.⁸ The number of cases necessary to obtain a consistently low rate of false-negative results is not dealt with in this article, which involves the largest series published to date.

Two main end points are used to assess the success rate of SN procedures, namely, the SN identification rate and the false-negative rate. The latter is particularly important, as it may influence the recurrence rate and potentially serve as a secondary source of malignant seeding affecting patient survival. The false-negative rate was high in this study (12%), suggesting that routine pelvic lymphadenectomy may still be warranted. In an early study of combined SN procedures in breast cancer, the identification and false-negative rates were 92% and 0%, respectively.⁹ In contrast to breast cancer, the authors failed to show that the use of blue dye in combination with radioactive colloid reduced the rate of false-negative results.

We used an SN procedure with both patent blue and radioactive isotope detection by endoscopic gamma probe in 10 patients with early cervical cancer who were treated with laparoscopic pelvic lymphadenectomy and laparoscopic radical hysterectomy (five patients) or the Schauta-Amreich operation (five patients) (Fig 1). All of the procedures were carried out by two surgeons who had previously performed at least 30 laparoscopic pelvic lymphadenectomies. SNs were detected in nine of the 10 patients (median number of SNs detected, two; range one to three). No lymph space involvement was detected in the SN or pelvic or para-aortic nodes. To our knowledge, this is the first report of the feasibility of a laparoscopic SN procedure based on combined detection. The SN procedure is a minimally invasive staging method for early-stage cervical cancer. In contrast to breast cancer and melanoma, the exploration of SNs is still in a relatively early stage of evaluation. Laparoscopic SN procedures have many advantages for detecting node metastases in patients with a low risk of node involvement. As in our experience, Levenback et al¹ reported that combined detection was able to identify para-aortic SNs. Minimally invasive management of early cervical cancer could be improved by combined use of the laparoscopic SN technique followed by laparoscopic radical hysterectomy or the Schauta-Amreich operation.

View larger version (131K): [in this window] [in a new window]   Fig 1. Intraoperative laparoscopic view of the pelvis. Identification and removal of the blue-dyed and hot SN on the right of the pelvis using an endoscopic gamma probe. The external iliac artery (EIA) and the external iliac vein (EIV) are noted.

1. Levenback C, Coleman RL, Burke TW, et al: Lymphatic mapping and sentinel node identification in patients with cervix cancer undergoing radical hysterectomy and pelvic lymphadenectomy. J Clin Oncol 20: 688-693, 2002[Abstract/Free Full Text]

2. Verheijen RH, Pijpers R, van Diest PJ, et al: Sentinel node detection in cervical cancer. Obstet Gynecol 96: 135-138, 2000[CrossRef][Medline]

3. Lantzsch T, Wolters M, Grimm J, et al: Sentinel node procedure in Ib cervical cancer: A preliminary series. Br J Cancer 85: 791-794, 2001[CrossRef][Medline]

4. Echt ML, Finan MA, Hoffman MS, et al: Detection of sentinel lymph nodes with Lymphazurin in cervical, uterine, and vulvar malignancies. South Med J 92: 204-208, 1999[CrossRef][Medline]

5. O’Boyle JD, Coleman RL, Bernstein SG, et al: Intraoperative lymphatic mapping in cervix cancer patients undergoing radical hysterectomy: A pilot study. Gynecol Oncol 79: 238-243, 2000[CrossRef][Medline]

6. Dargent D, Martin X, Mathevet P: Laparoscopic assessment of the sentinel lymph node in early stage cervical cancer. Gynecol Oncol 79: 411-415, 2000[CrossRef][Medline]

7. Kamprath S, Possover M, Schneider A: Laparoscopic sentinel lymph node detection in patients with cervical cancer. Am J Obstet Gynecol 182: 1648, 2000 (letter)

8. McMasters KM, Wong SL, Chao C, et al: Defining the optimal surgeon experience for breast cancer sentinel lymph node biopsy: A model for implementation of new surgical techniques. Ann Surg 234: 292-299, 2001[CrossRef][Medline]

9. Albertini JJ, Lyman GH, Cox C, et al: Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA 276: 1818-1822, 1996[Abstract/Free Full Text]

Response

University of Texas M.D. Anderson Cancer Center, Houston, TX
University of Texas Southwestern Medical Center, Dallas, TX

In Reply:Barranger et al have made some interesting observations regarding our recent report describing combined lymphatic mapping during radical hysterectomy.¹ The issue of surgeon experience is important and has been widely discussed in the breast and melanoma literature. The ongoing phase III trials at these disease sites (American College of Surgeons Oncology Group Z-10, National Surgical Adjuvant Breast and Bowel Project B-32, Melanoma Sunbelt Trial, and the Multi-Center Lymphadenectomy Trial) all require surgeon skill verification of up to 30 cases before individual clinicians may participate. This standard is clearly impractical for gynecologic oncologists. Gynecologic Oncology Group Trial 173, a validation trial in vulvar cancer patients, and Gynecologic Oncology Group Trial CVM 0111, a validation trial in radical hysterectomy patients under development, do not have surgeon skill verification requirements. In our study, the two lead authors personally performed 19 (49%) of 39 procedures and assisted with others.

It is premature to draw any conclusion about the false-negative rate with mapping in this setting. Our false-negative patient had small positive medial parametrial nodes resected with the primary tumor that are essentially impossible to locate with blue dye or the gamma probe. In addition, the importance to survival of medial parametrial node involvement, in and of itself, has been questioned.² Our study did not directly compare sentinel node identification rates with blue dye alone to the combined approach. However, the results reported in this study are clearly superior to our previously published results from the University of Texas Southwestern.³

The combination of laparoscopy and sentinel node biopsy is very attractive in patients with cervix cancer. Three studies have described laparoscopic identification of sentinel nodes in patients with cervix cancer.^4-6 Dargent et al⁴ reported excellent results with blue dye alone, as did Kamprath et al⁶ with radiocolloid alone. Malur et al⁵ described the use of a laparoscopic gamma probe in a small subset of cases.

We would like to restate our conviction that there is not sufficient data available to recommend replacement of pelvic lymphadenectomy with sentinel node biopsy alone. Nevertheless, we believe that cervix cancer is an excellent target for the mapping strategy and are very interested by the work of Barranger and his colleagues. We look forward to a more complete description of their series.

REFERENCES

1. Levenback C, Coleman RL, Burke TW, et al: Lymphatic mapping and sentinel node identification in patients with cervix cancer undergoing radical hysterectomy and pelvic lymphadenectomy. J Clin Oncol 20: 688-693, 2002

2. Winter R, Haas J, Reich O, et al: Parametrial spread of cervical cancer in patients with negative pelvic lymph nodes. Gynecol Oncol 84: 252-257, 2002[CrossRef][Medline]

3. O’Boyle JD, Coleman RL, Bernstein SG, et al: Intraoperative lymphatic mapping in cervix cancer patients undergoing radical hysterectomy: A pilot study. Gynecol Oncol 79: 238-243, 2000

4. Dargent D, Martin X, Mathevet P: Laparoscopic assessment of the sentinel lymph node in early stage cervical cancer. Gynecol Oncol 79: 411-415, 2000

5. Malur S, Krause N, Kohler C, et al: Sentinel lymph node detection in patients with cervical cancer. Gynecol Oncol 80: 254-257, 2001[CrossRef][Medline]

6. Kamprath S, Possover M, Schneider A: Laparoscopic sentinel lymph node detection in patients with cervical cancer. Am J Obstet Gynecol 182: 1648, 2000 (letter)

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