Debora Verri

From Conventional Radiotracer Tc-99 m with Blue Dye to Indocyanine Green Fluorescence: A Comparison of Methods Towards Optimization of Sentinel Lymph Node Mapping in Early Stage Cervical Cancer for a Laparoscopic Approach

AbstractBackground The credibility of sentinel lymph node (SLN) mapping is becoming increasingly more established in cervical cancer. We aimed to assess the sensitivity of SLN biopsy in terms of detection rate and bilateral mapping in women with cervical cancer by comparing technetium-99 radiocolloid (Tc-99m) and blue dye (BD) versus fluorescence mapping with indocyanine green (ICG).MethodsData of patients with cervical cancer stage 1A2 to 1B1 from 5 European institutions were retrospectively reviewed. All centers used a laparoscopic approach with the same intracervical dye injection. Detection rate and bilateral mapping of ICG were compared, respectively, with results obtained by standard Tc-99m with BD.ResultsOverall, 76 (53 %) of 144 of women underwent preoperative SLN mapping with radiotracer and intraoperative BD, whereas 68 of (47 %) 144 patients underwent mapping using intraoperative ICG. The detection rate of SLN mapping was 96 % and 100 % for Tc-99m with BD and ICG, respectively. Bilateral mapping was achieved in 98.5 % for ICG and 76.3 % for Tc-99m with BD; this difference was statistically significant (p < 0.0001).ConclusionsThe fluorescence SLN mapping with ICG achieved a significantly higher detection rate and bilateral mapping compared to standard radiocolloid and BD technique in women with early stage cervical cancer. Nodal staging with an intracervical injection of ICG is accurate, safe, and reproducible in patients with cervical cancer. Before replacing lymphadenectomy completely, the additional value of fluorescence SLN mapping on both perioperative morbidity and survival should be explored and confirmed by ongoing controlled trials.

Near-Infrared Sentinel Lymph Node Mapping With Indocyanine Green Using the VITOM II ICG Exoscope for Open Surgery for Gynecologic Malignancies

Sentinel lymph node (SLN) mapping is emerging as an effective method for surgical staging of different gynecologic malignancies. Near-infrared (NIR) technology using a fluorescent dye such as indocyanine green (ICG) represents an interesting and feasible method for SLN mapping even in traditional open surgeries by applying video telescope operating microscope (VITOM) system technology. We report our preliminary experience in 12 women who underwent surgical nodal staging for early-stage vulvar and uterine or cervical cancer. Surgical and pathological outcomes are described, and the VITOM II ICG systems intraoperative image quality, handling and docking, and teaching value are assessed. The general impression of the surgical staff was that the VITOM II system is easy to use, and that the image quality of the anatomic structures is impressive. Traditional open SLN mapping with ICG appears to be easy to perform and reproducible, providing a new tool in the management of patients with gynecologic malignancies. Moreover, we believe that this technology has great potential as an operative teaching and learning modality for trainers for open surgical cases. Additional studies involving the VITOM system with a large sample size of patients are needed to confirm these promising results.

Is Occult Stress Urinary Incontinence a Reliable Predictive Marker

Objective Pelvic reconstructive surgery can be associated to correction, persistence, or onset of stress urinary incontinence. The aim of our study was to evaluate the incidence of stress incontinence (SI) after prolapse repair in 3 groups with different preoperative urodynamic findings and to find out the predictiveness of occult SI. Methods Patients undergoing vaginal hysterectomy, uterus-sacral ligament colposuspension, and traditional anterior repair for pelvic prolapse were retrospectively analyzed. No patient underwent any additional anti-incontinence procedure. Preoperative evaluation included clinical history, physical examination, and urodynamic assessment with a pessary reduction test. According to urodynamic findings, women were divided into SI (A), occult SI (B), and continence (C) groups. Primary outcome was to compare the incidence of postoperative SI among groups. Secondary outcome was to assess postoperative quality of life with International Consultation on Incontinence questionnaire-short form questionnaire. Results One hundred fifty patients were analyzed (A: n = 30; B: n = 43; C: n = 77). Mean follow-up was 18.4 ± 0.9 months without differences among groups. Patients in group B did not have higher postoperative SI rate compared to group C. There were no differences in International Consultation on Incontinence questionnaire-short form scores in symptomatic women among groups. Conclusions In our series, occult stress urinary incontinence is a poor urodynamic marker to predict the development of postoperative SI.

Cervical injection for sentinel lymph nodes detection in endometrial cancers is controversial: response to comments

We thank Abdelazim and Zhurabekova [1] for their interest in our recent paper in Clinical and Translational Imaging on sentinel lymph nodes (SLNs) in endometrial cancer [2]. As discussed in their comment, the injection site is controversial. In endometrial cancer patients one of the main criticisms regards cervical site injection and whether it maps the organ rather than the tumor [3]. The study of Khoury-Collado et al. [4] challenged the reservations about the effectiveness of cervical site injection, since after a cervical site injection, SLNs were three times more likely to harbour disease than non-SLNs. Abu-Rustum et al. demonstrated that the addition of a fundal injection to the cervical injection did not appear to produce a higher detection rate [5]. In the study by Rossi et al., women were injected with indocyanine green (ICG) either into the cervix or into the endometrium during hysteroscopy, and the authors concluded that cervical injection achieved a higher SLN detection rate and a similar anatomic nodal distribution [6]. Our data are consistent with those of Bodurtha Smith et al. [7], showing that cervical injection is associated with higher rates of bilateral SLN detection. In addition, they found that it was associated with a significantly lower detection rate in the aortic area [7]. In our analysis, we focused on bilateral migration rate (a selective lymphadenectomy is required in presence of unilateral mapping) rather than on the aortic detection rate considering that studies in which the protocol includes a systematic para-aortic lymphadenectomy demonstrated a higher rate of detection of para-aortic SLNs, as well as isolated aortic node involvement [8]. In published series including more than 100 cases of endometrial cancer patients (6858 evaluated patients), the overall rate of isolated aortic metastasis recorded was 1.7% [3]. Cormier et al. showed that deeper (≥ 3 cm), as opposed to superficial (≤ 2 cm) cervical injection may increase the detection of para-aortic SLN, and that the use of ICG increases the detection rate of para-aortic SLN [8]. Our meta-analysis described advantages and disadvantages of different techniques. Although the site of injection is still a question to be definitively addressed, NCCN guidelines based on available data, suggest that combination of a superficial (1–3 mm) and deep (1–2 cm) cervical injection leads to dye delivery to the main layers of lymphatic channel origins in the cervix and corpus [9].