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Is preoperative lymphoscintigraphy for sentinel node in cervical cancer required?

2007; Elsevier BV; Volume: 197; Issue: 1 Linguagem: Inglês

10.1016/j.ajog.2007.03.046

1097-6868

Anne‐Sophie Bats, Vincent Lavoué, Emmanuel Barranger, Émile Daraï,

Cancer Risks and Factors

We read with interest the article by Frumovitz et al1Frumovitz M. Coleman R.L. Gayed I.W. et al.Usefulness of preoperative lymphoscintigraphy in patients who undergo radical hysterectomy and pelvic lymphadenectomy for cervical cancer.Am J Obstet Gynecol. 2006; 194 (discussion 193-5): 1186-1193Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar on the use of preoperative lymphoscintigraphy in women undergoing radical hysterectomy and the sentinel node procedure for cervical cancer. A sentinel node was detected in 96% of women, a rate far higher than in our previous study.2Barranger E. Cortez A. Grahek D. Callard P. Uzan S. Daraï E. Value of intraoperative imprint cytology of sentinel nodes in patients with cervical cancer.Gynecol Oncol. 2004; 94: 175-180Crossref PubMed Scopus (46) Google Scholar This difference could be explained by technical parameters such as the use of filtered technetium-99 radiocolloid, which has a higher content of small particles and may thus be taken up by second- or third-tier lymph nodes in addition to the sentinel node.3Mariani G. Moresco L. Viale G. et al.Radio-guided sentinel lymph node biopsy in breast cancer surgery.J Nucl Med. 2001; 42: 1198-1215PubMed Google Scholar Moreover, Frumovitz et al used a larger volume of radiocolloid than we did, possibly reducing its distribution. Frumovitz et al reported poor concordance between preoperative lymphoscintigraphy and intraoperative lymphatic mapping but stated that some women required a second injection of radiocolloid without second lymphoscintigraphy preoperatively. Moreover, the sentinel node was defined by the ex vivo count, explaining why parametrial sentinel nodes were reported, whereas they cannot be detected by lymphoscintigraphy or peroperative lymphatic mapping, owing to the large amount of localized radioactivity.Despite these concerns, we totally agree with the comment regarding the relatively poor contribution of preoperative lymphoscintigraphy to the sentinel node procedure. Indeed, in our experience (data under submission), in which 71 women with cervical cancer underwent the sentinel node (SN) procedure by laparoscopy after 4 injections of 0.2 mL of unfiltered technetium sulfur colloid (20 MBq per injection), the detection rate was 84.5% (60 women). Fifty-eight women had the SN located in the external iliac chain, 1 had 1 SN located in the external iliac chain and another in the common iliac chain, and 1 woman had 1 SN in the common chain. Three of the 11 women in whom no sentinel node was identified by peroperative lymphoscintigraphy were found to have hot sentinel nodes preoperatively. Moreover, among the 28 women in whom 2 SNs were detected by lymphoscintigraphy, 17 (60%) had more than 3 hot SNs found during surgery.These results raise issues as to the true definition of sentinel nodes and the cost-effectiveness of preoperative lymphoscintigraphy. We read with interest the article by Frumovitz et al1Frumovitz M. Coleman R.L. Gayed I.W. et al.Usefulness of preoperative lymphoscintigraphy in patients who undergo radical hysterectomy and pelvic lymphadenectomy for cervical cancer.Am J Obstet Gynecol. 2006; 194 (discussion 193-5): 1186-1193Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar on the use of preoperative lymphoscintigraphy in women undergoing radical hysterectomy and the sentinel node procedure for cervical cancer. A sentinel node was detected in 96% of women, a rate far higher than in our previous study.2Barranger E. Cortez A. Grahek D. Callard P. Uzan S. Daraï E. Value of intraoperative imprint cytology of sentinel nodes in patients with cervical cancer.Gynecol Oncol. 2004; 94: 175-180Crossref PubMed Scopus (46) Google Scholar This difference could be explained by technical parameters such as the use of filtered technetium-99 radiocolloid, which has a higher content of small particles and may thus be taken up by second- or third-tier lymph nodes in addition to the sentinel node.3Mariani G. Moresco L. Viale G. et al.Radio-guided sentinel lymph node biopsy in breast cancer surgery.J Nucl Med. 2001; 42: 1198-1215PubMed Google Scholar Moreover, Frumovitz et al used a larger volume of radiocolloid than we did, possibly reducing its distribution. Frumovitz et al reported poor concordance between preoperative lymphoscintigraphy and intraoperative lymphatic mapping but stated that some women required a second injection of radiocolloid without second lymphoscintigraphy preoperatively. Moreover, the sentinel node was defined by the ex vivo count, explaining why parametrial sentinel nodes were reported, whereas they cannot be detected by lymphoscintigraphy or peroperative lymphatic mapping, owing to the large amount of localized radioactivity. Despite these concerns, we totally agree with the comment regarding the relatively poor contribution of preoperative lymphoscintigraphy to the sentinel node procedure. Indeed, in our experience (data under submission), in which 71 women with cervical cancer underwent the sentinel node (SN) procedure by laparoscopy after 4 injections of 0.2 mL of unfiltered technetium sulfur colloid (20 MBq per injection), the detection rate was 84.5% (60 women). Fifty-eight women had the SN located in the external iliac chain, 1 had 1 SN located in the external iliac chain and another in the common iliac chain, and 1 woman had 1 SN in the common chain. Three of the 11 women in whom no sentinel node was identified by peroperative lymphoscintigraphy were found to have hot sentinel nodes preoperatively. Moreover, among the 28 women in whom 2 SNs were detected by lymphoscintigraphy, 17 (60%) had more than 3 hot SNs found during surgery. These results raise issues as to the true definition of sentinel nodes and the cost-effectiveness of preoperative lymphoscintigraphy.