S. P. Somashekhar

Role of sentinel lymph node biopsy in early cervical cancer.

Sentinel lymph node (SLN) is defined as the first echelon lymph node for an anatomical region reached by the lymphatic drainage [1]. In breast cancer and melanoma, the role of sentinel lymph node mapping and biopsy using peritumoral injection of radioactive colloid in combination with a blue dye is well established [2, 3]. A histologically negative SLN predicts the absence of tumor metastasis in the non sentinel nodes. [4, 5] In cervical cancer, involvement of regional lymph nodes is one of the most reliable prognostic factors [6, 7]. Presently radical hysterectomy with complete pelvic lymphadenectomy is the standard surgical procedure for patients with early cervical cancer. In patients with early cervical cancer (FIGO Stage IB1, IB2) pelvic lymph node metastasis is expected in 10–15 % of cases [8]. In node negative group of patients, pelvic lymphadenectomy has low benefit, but increases the risk of complications like lymphocyst formation and lymphedema. SLN mapping using peritumoral injection of radio-isotope and blue dye with or without lymphoscintigraphy, followed by intraoperative detection using a gamma probe has been proposed to be a useful technique for identification of SLNs in patients with early cervical cancers. Several blue dyes like cyalume, methylene blue and isosulfan blue were investigated for SLNB initially. Methylene Blue has been found to be one of the suitable and feasible dyes for sentinel node mapping [9]. The purpose of this study is to evaluate the feasibility, usefulness and clinical impact of this technique in twenty consecutive patients with early cervical cancer.

Role of Hormone Replacement Therapy (HRT) in Gynecological Cancers: Endocrinologist’s Perspective

The safety of HRT use in Gynecological cancer patients is a debatable issue and not entirely clear. The aim of this article was to review whether HRT is safe in Gynecological cancer patients or not. Squamous cell carcinoma, ovarian, vulva, vagina, endometrial serous carcinomas and uterine sarcomas are not considered estrogen dependent, and HRT can be given safely in these tumors. In early-stage endometrial cancer, HRT use has no harmful effect which may be due to no left behind residual cells. In advanced-stage tumors, HRT could have a harmful effect due to the hormone-responsive residual cells. Some studies have opposed the use of HRT in cancer patients, while some studies have supported the role of HRT in these patients; however, the evidences are based on case series without the proof of randomized trials. The variable responses in Gynecological cancer patients may be due to inclusion of heterogeneous patient with estrogen and progesterone receptor-positive or receptor-negative tumors. The responses may also vary depending on the tumor type, disease grade, stage and the type of drug used. Therefore, it is not possible to make definitive recommendations on the role of HRT. The objective of this article was to provide an overview about the current literature related to the role of HRT after Gynecological cancers treatment.

Robotic-Assisted Pelvic and High Para-aortic Lymphadenectomy (RPLND) for Endometrial Cancer and Learning Curve

Purpose and ObjectivesThe present prospective non-randomized observational study was designed to analyse the learning curve for robotic-assisted pelvic and high para-aortic lymphadenectomy for endometrial cancer patients.Materials and Methods Between 2011 and 2013, 131 consecutive endometrial cancer patients underwent type-1 extrafascial pan hysterectomy with pelvic and high para-aortic lymphadenectomy using the daVinci® robotic surgical procedures at single quaternary care Indian cancer institution. For lymph nodes retrieval data, the point at which as per AJCC-TNM staging, time taken to reach, recommended minimum number of lymph nodes at each segment of pelvic and para-aortic lymphadenectomy was plotted and analysed. Data were analysed for the number of lymph nodes retrieved in pelvic and high para-aortic lymphadenectomy specimen. The surgery was performed by the same surgeon in all cases.ResultsTarget number of pelvic lymph nodes 12 was achieved by ninth case, and consistently, more number of pelvic nodes were removed. Target number of para-aortic lymph nodes 10 was achieved at eighteenth case.ConclusionIn our study, adequate number of pelvic lymph nodes retrieval of 12 was achieved by ninth case, and consistently, more number of pelvic nodes were removed and para-aortic lymph nodes retrieval of 10 was after eighteenth case. Our study confirms the proficiency and efficiency of robotic surgical approach in treatment of endometrial cancer, with adequate lymph node retrieval, and offers a safe and useful alternative to conventional surgical techniques with shorter learning curve.

Pericardial Nodular Metastasis from Carcinoma Cervix Uteri

Carcinoma cervix is the second most common cancer in women worldwide and the most common cancer cause of death in the developing countries. In India, it is estimated that approximately 122,844 new cases are diagnosed and 67,477 deaths annually, accounting to nearly 1/3rd of the global cervical cancer deaths. Antemortem diagnosis of isolated metastasis to the pericardium is an uncommonly seen event. Till date few cases only are reported in the literature. We report pericardial nodular metastasis from known carcinoma cervix. Patients with dyspnea in the background of carcinoma cervix usually present with pleural effusion or pulmonary metastasis, but the remote possibility of pericardial metastasis is also to be considered in differential diagnosis.

Value of frozen section and primary tumor factors in determining sentinel lymph node spread in early breast carcinoma

IntroductionSentinel lymph node biopsy (SLNB) is the standard of care to assess the metastasis in breast carcinoma. Accuracy of intraoperative frozen section examination to evaluate SLN in detecting metastasis is important as it determines the further management of axilla. Primary tumor characteristics determining the metastasis to the lymph node will help in predicting the probability of spread and to determine the nature of disease. It also helps in refining selection of patients for SLNB. We evaluated all these criteria on Indian patients for the better management.Materials and methodsBetween January 2005 and April 2009, 114 consecutive patients of all age group of both sex, with cytology or biopsy proven carcinoma breast, clinical stage T1/T2 N0 M0 at Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore were subjected to SLNB and introperative frozen examination. First 75 cases had complete axillary clearance irrespective of SLNB result and subsequently, positive cases underwent axillary lymph node dissection (ALND). Age of the patient and primary tumor characteristics like size, grade, lymphovascular invasion (LVI), perineural invasion, ER/PR status, Her2-neu status and histological sub-types were evaluated for predicting the SLN metastasis. Feasibility of SLNB in previously treated patient is also evaluated.ResultsThe age of the patient ranged from 23 to 87 years and its association with SLN spread is not significant. Frozen section examination had accuracy of 97.37% in determining metastatic sentinel node with sensitivity of 96.15% and specificity of 100% with value P < 0.001. SLN remained significant indicator of the status of rest of axilla with value P < 0.001. Primary tumor characteristics like histological subtypes, grade (P = 0.353), ER/PR status (P = 0.839), Her2-neu status (P =0.296) were not significantly associated with SLN metastasis. Size of the primary tumor (P = 0.002), LVI (P < 0.001), perineural invasion (P = 0.084+) were significant factors determining the SLN metastasis. SLNB evaluation had no false negative values in previously treated breast.ConclusionSLNB is a valuable method of determining the axillary nodal metastasis. Intraoperative frozen section examination is highly ac-curate in detecting nodal metastasis. Primary tumor characteristics like size, LVI and perineural invasion are significant in predicting SLN metastasis. SLNB remains an important method of predicting axillary metastasis even in previously treated breast carcinomas.