Pathologic Protocols for Sentinel Lymph Nodes Ultrastaging in Cervical Cancer

Abstract

Context.— Ultrastaging of sentinel lymph nodes (SLNs) is a crucial aspect in the approach to SLN processing. No consensual protocol for pathologic ultrastaging has been approved by international societies to date. Objective.— To provide a review of the ultrastaging protocol and all its aspects related to the processing of SLNs in patients with cervical cancer. Data Sources.— In total, 127 publications reporting data from 9085 cases were identified in the literature. In 24% of studies, the information about SLN processing is entirely missing. No ultrastaging protocol was used in 7% of publications. When described, the differences in all aspects of SLN processing among the studies and institutions are substantial. This includes grossing of the SLN, which is not completely sliced and processed in almost 20% of studies. The reported protocols varied in all aspects of SLN processing, including the thickness of slices (range, 1–5 mm), the number of levels (range, 0–cut out until no tissue left), distance between the levels (range, 40–1000 μm), and number of sections per level (range, 1–5). Conclusions.— We found substantial differences in protocols used for SLN pathologic ultrastaging, which can impact sensitivity for detection of micrometastases and even small macrometastases. Since the involvement of pelvic lymph nodes is the most important negative prognostic factor, such profound discrepancies influence the referral of patients to adjuvant radiotherapy and could potentially cause treatment failure. It is urgent that international societies agree on a consensual protocol before SLN biopsy without pelvic lymphadenectomy is introduced into routine clinical practice.

Role of carbon nanoparticle suspension in sentinel lymph node biopsy for early‐stage cervical cancer: a prospective study

“…The common characteristics of these two patients included tumour diameters >20 mm with presence of DSI (≥50%) and LVSI (Table S3). These findings are consistent with those of previous studies that reported that FNR was higher for larger tumours (>20 mm), those with DSI (≥50%) and those with LVSI (blue dye, radio‐colloid and ICG) 19,32,33 . The prevalence can be attributed to the hypothesis that metastatic disease can alter the lymphatic drainage pattern 34 .…”

“…We also found that tumour size, stage and LVSI are independent risk factors for lymph node metastasis. The results of our study (CNS) are consistent with those of previous studies (blue dye, radio‐colloid and ICG) which showed that FNR was higher for larger tumours (>20 mm), those with DSI (≥50%) and those with LVSI 19,32‐34 . Therefore, the lower DR associated with larger tumours and those with LVSI can potentially increase false‐negative findings in patients who are at higher risk, which would be a limitation of this technology.…”

“…We found that among patients with metastases, 95.65% had SLN metastases, suggesting that SLN is a rather sensitive assessment indicator of metastatic lymph nodes. Among methods of assessing the PLN status, SLNB is more suitable than imaging techniques 19 . Moreover, compared with PLND, SLNB reduces complications of PLND, 20 and no difference was observed in the recurrence‐free survival rates of PLND and SLNB in a prospective trial 21 .…”

Micrometastases in Sentinel Lymph Nodes Represent a Significant Negative Prognostic Factor in Early-Stage Cervical Cancer: A Single-Institutional Retrospective Cohort Study

“…Even in our study, which is, to our knowledge, the largest single institutional retrospective cohort, we reported only 22 (10%) recurrences with the medium survival of more than five years. Secondly, and more importantly, in the absence of any universal protocol for SLN ultrastaging, pathological processing is so different that such discrepancies inevitably impact the accuracy of detection of not only MIC but also small MAC [27]. Other than this paper, only two out of nine previously published studies evaluating the impact of MIC on prognosis included pathological ultrastaging of SLN (Cibula 2012, Guani 2019) [1,20].…”

Lower-Limb Lymphedema after Sentinel Lymph Node Biopsy in Cervical Cancer Patients

“…Only two of all removed SLNs were localized in the presacral region. Using ultrastaging protocol [37], nine patients (6%) were diagnosed with SLN metastasis and treated with adjuvant treatment (eight chemoradiotherapy; one combined radiotherapy). In four patients, isolated tumor cells were detected, though no adjuvant treatment was administered.…”