Results: In 39 patients, at least one sentinel node (SN) was evident either in .... external iliac 26.2%, common iliac 9.5%, lower para-aortic. 2.4% (Table II).
ANTICANCER RESEARCH 30: 183-188 (2010)
Clinical Value of Preoperative Lymphoscintigraphy in Patients with Early Cervical Cancer Considered for Intraoperative Lymphatic Mapping STELIOS FOTIOU1, PETROS ZARGANIS2, GEORGE VORGIAS2, ERASMIA TRIVIZAKI3, KONSTANTINOS VELENTZAS2, THRASSYVOULOS AKRIVOS2 and GEORGE CREATSAS1 1Second
Department of Obstetrics and Gynecology, University of Athens, School of Medicine, Aretaieion Hospital, Athens, Greece; Departments of 2Gynecology and 3Nuclear Medicine, Metaxa Memorial Cancer Hospital, Athens, Greece
Abstract. The purpose of this study was to examine the clinical usefulness of preoperative lymphoscintigraphy (PLS) for sentinel node identification in patients undergoing lymphatic mapping during surgery for early cervical cancer. Patients and Methods: Day-before PLS was performed in 42 patients who were candidates for open radical hysterectomy and intraoperative lymphatic mapping, using a combination of radiocolloid and blue dye technique. Results: In 39 patients, at least one sentinel node (SN) was evident either in the lymphoscintigram or during the operation (detection rate 92.8%). Lymphoscintigraphy revealed unilateral SNs in 24 (61.5%) cases and bilateral SNs in 15 (38.5%). A total of 56 SNs were identified. Intraoperatively, 5 out of 24 patients with unilateral SNs on PLS had bilateral identification. The total number of SNs retrieved was 103 (2.6/patient). While one SN was identified in 25 cases on PLS, 32 patients had two or more SNs intraoperatively. The agreement between preoperative and intraoperative detection regarding laterality, number and location of SNs was poor (Kappa2 LVSI Present Absent Patients with nodal metastases Sentinel not detected False negatives Detection rate
Patient numbers
%
3 37 2
7.1 88.1 4.8
39 3
92.9 7.1
17 25
40.5 59.5
7 35 8 3 1 39/42
16.7 83.3 19 7.1 2.4 92.9
Intraoperative lymphatic mapping. A total of 103 SNs were retrieved from 39 successful intraoperative detections (2.6/patient). The anatomic distribution of SNs is shown in Table II. Bilateral SNs were harvested in 19 (48.7%) patients and unilateral in 20 (51.3%). Correlation of preoperative lymphoscintigraphy with intraoperative lymphatic mapping. The number of patients in whom at least one SN was identified on PLS and ILM (using the dual method) was equal (39 out of 42 cases). However, the total number of SNs harvested intraoperatively was much higher (n=103) than the number of hot spots identified during lymphoscintigraphy (n=56). On PLS, 25 patients showed only one SN location, while during the operation, 32 proved to have 2 or more SN locations (K=0.218 Table IV). Of 19 cases with bilateral detection of SNs during ILM, PLS showed unilateral hot spots in 5 (K=0.69 Table V). The correlative anatomic distribution of SNs on PLS and ILM is shown in Table VI. The degree of concordance between them as measured by Cohen’s kappa value was poor (K=0.284). General diagnostic indices. The diagnostic indices concerning the verification of the SN concept were calculated from Table VII. There was one false-negative case (2.38%). Sensitivity was 80%, specificity 97%, accuracy 94.8%, NPV 97%, and PPV 80%.
Discussion The literature data show that SN detection is feasible in 80% to 100% of patients with early cervical cancer undergoing open or laparoscopic surgery (3-9, 14-19). The results of this
Fotiou et al: The Value of Preoperative Lymphoscintigraphy in Early Cervical Cancer
Table II. Preoperative and intraoperative SN locations. The relative proportions may seem similar but the location was different when examined case by case.
Table III. Preoperative detection laterality and final tumor size (p=0.03). Tumor size Gamma camera laterality Unilateral Bilateral Total
≤2 cm 6 11
Total
>2 cm 18 4
17
24 15
22
39
Table IV. Concordance of the number of SN locations between lymphoscintigraphy and intraoperative detection K=0.218. Intraoperative SNs (cases)
study are in agreement with the previous data, showing successful identification of the SN in 93% (39/42) of patients using the dual technique. Overall diagnostic test indices concerning the validity of the SN concept (whether it reflects the status of the other nodes) such as sensitivity, specificity, accuracy, NPV and PPV were 80%, 97%, 94.8%, 97% and 80% respectively, in accordance with the value ranges reported in the literature (3-22). Currently, PLS is used with ILM for SN detection. In this study, although PLS successfully depicted hot spots in all patients in whom intraoperative SNs were identified, it was however inferior to ILM regarding laterality of SN detection, number of SNs retrieved and anatomical location. According to the presented data, PLS failed to detect bilateral SNs in 5 out of 19 (26.3%) cases, making the concordance of preoperative and intraoperative lymphatic mapping poor (K=0.69). Furthermore, after a case by case examination, preoperative and operative SN anatomical correlation was even lower (K=0.284). As far as the actual number of SNs is concerned, 25 patients where found to have only one SN on PLS, but 32 had 2 or more SNs intraoperatively (poor concordance, K=0.218). There are only three studies in the literature focusing on the concordance between the findings of preoperative lymphoscintigraphy and surgical SN mapping (10, 12, 13). Their results, shown in Table VIII, are similar to the present data, indicating a poor correlation between preoperative and ILM. Frumovitz et al. found that surgical lymphatic mapping revealed more than one sentinel lymph basin in 15 out of 21 patients with solitary SNs and bilateral SN basins in 11 out
Total
Preoperative SNs ≥2
