nel carcinoma dell’endometrio -...

Biopsia del linfonodo sentinella

nel carcinoma dell’endometrio 99mTc vs Fluorescenza

Fabio Martinelli, MD

Gynecologic Oncology Department

fabio.martinelli@istitutotumori.mi.it

6°

4°

Surgical staging is a mandatory

Lymphadenectomy:-Yes/no-Pelvic/aortic?-Prognostic value?-Therapeutic value?

Surgical staging is a mandatory

Lymphadenectomy:-Yes/no-Pelvic/aortic?-Prognostic value?-Therapeutic value?

Endometrial cancer lymphadenectomy- contra

514 pts

1408 pts

Endometrial cancer lymphadenectomy- contra

514 pts

1408 pts

Endometrial cancer lymphadenectomy -pro

671 pts

509 pts

Sentinel node in endometrial cancer

First paper

Gynecol Oncol. Dec 2011

Gynecol Oncol. Dec 2011

19962011

1101 pts

..but not only..

2012

16 pts endometrial cancer

Lancet Oncol ,2011 May;12(5):469-76

Prospective multicenter studyEnd points: Detection rate and diagnostic accuracy of SLN125 pts St I-II

Cervical dual injection with Tc and patent blue (3-6-9-12 )

Systematic pelvic +/- aortic (15 pts) lymphadenectomy

Detection rate: 111/125 89%

NPV 97%; Sensitivity 84% (patient unit)N+ 19/111 17%; only IHC 9/111 (8%); 3 FN 15%5/111 5% an associated SLN in aortic region

Median pelvic nodes removed 12

Prospective databaseEnd point: FN rate498 pts

Cervical injection with blue dye (3-9)

Pelvic +/- aortic lymphadenectomy

Detection rate: 401/498 81%

NPV 98%; Sensitivity 85%N+ 47/401 11.7%; only IHC 9/401 (2%); 7 FN 15%17/401 4.5% a SLN in aortic region (15 associated, 2 only)

Median nodes removed 8

AlgorithmSens 98.1%NPV 99.8%FN 1.9%

RetrospectiveEnd point: detection rate 35 pts

Cervical injection with isosulfan blue dye and indocyanine green (3-6-9-12)Pelvic +/- aortic lymphadenectomy

Detection rate: 34/35 97%

NPV 96%; Sensitivity 90%N+ 10/35 28.6%; only IHC 4/35 (11.4%); 1 FN 10%

Median pelvic nodesremoved 23

Data on ICG

NO positive aortic SLN identified

Detection rate: 76/80 95%

NPV 98%Sensitivity 90%N+ 10/59 17%; only IHC 6/59 (10%); 1 FN 10%33/59 56% a SLN in aortic region (31 associated, 2 only)

Median nodes removed 48

Prospective studyEnd points: detection rate and diagnostic accuracy of SLN80 pts

Hysteroscopic injection of Tc peritumoralPelvic + aortic systematic lymphadenectomy

SENTIENDO MSKCC INT ICG

Study Prospective Prospective Prospective Retrospective

Years 7/2007-8/2009 9/2005-4/2011 1/2005-12/2010 5/2011-9/2011

Nr. pts 125 498 80 35

Type injection Cervical Cervical Hysteroscopic Cervical

Tracer Blue dye and Tc Blue Dye Tc99m Blue dye and

ICG

Detection rate 111/125 (89%) 401/498 (81%) 76/80 (95%) 34/35 (97%)

Aortic SLN 5% 4.5% 56% 0

Positive nodes 19/111 (17%) 47/401 (11.7%) 10/59 (17%) 10/35 (28.6%)

Median nodes

removed

14 (1-50) 8 (0-59) 48 (23-125) 23 (13-59) pelvic

Sensitivity 84% 85% 90% 90%

NPV 97% 98% 98% 96%

Open questions

• Surgical approach

– LPT

– LPS

– Robotic

• Which tracer:

– blue dyes

– Tc

– ICG

• Way of injection:

– cervical

– hysteroscopic

– miometrial/subserosal

• Pathological evaluation

– H/E

– IHC

Surgical approach

2012

Way of injection

PRO CONTRA

Subserosal/myometrial Easiest in laparotomy Not so easy in minimally

invasive approach

Less sensitivity

Intraoperative

Cervical Easy

Reproducible

Cervical and not uterine

dreinage

Hysteroscopic Respects uterine dreinage

(increased aortic SLN

identification)

Learning curve

Maybe more expensive

Risk of transtubal leakage

Way of injection

PRO CONTRA

Subserosal/myometrial Easiest in laparotomy Not so easy in minimally

invasive approach

Less sensitivity

Intraoperative

Cervical Easy

Reproducible

Cervical and not uterine

dreinage

Hysteroscopic Respects uterine dreinage

(increased aortic SLN

identification)

Learning curve

Maybe more expensive

Risk of transtubal leakage

TracerPRO CONTRA

Blue dyes Ready for use May cause allergic

reaction

May mask the operative

field

Tc Do not colour the

operative field

Problems with radio-

protection

Need dedicated probe

ICG Ready for use

Do not colour the

operative field

Need NIR camera

Need opening of

retroperitoeum

TracerPRO CONTRA

Blue dyes Ready for use May cause allergic

reaction

May mask the operative

field

Tc Do not colour the

operative field

Problems with radio-

protection

Need dedicated probe

ICG Ready for use

Do not colour the

operative field

Need NIR camera

Need opening of

retroperitoeum

TracerPRO CONTRA

Blue dyes Ready for use May cause allergic

reaction

May mask the operative

field

Tc Do not colour the

operative field

Problems with radio-

protection

Need dedicated probe

ICG Ready for use

Do not colour the

operative field

Need NIR camera

Need opening of

retroperitoeum

Pathological evaluation

+39% ofmets

844 pts23 ITC21 mm47 Mam

Pathological evaluation

+39% ofmets

844 pts23 ITC21 mm47 Mam

What we know

Site injection Tracer Detection rate

Cervical Blue-dye and/or Tc 62-89 %

Hysteroscopic Blue-dye and/or Tc 65-95%

Cervical ICG 95-97%

What are we evaluating?

What are we evaluating?

Results57 pts

DR 89% (new camera: 95%)

Bilateral DR 74.5%

47% mapped PA

1 pts isolated PA N+

1 pts pelvic and PA N+

1 pts pelvic only N+

2/3 N+ in the aortic area

SPIES with D-Light P

What we knowSite injection Tracer Detection rate

Cervical Blue-dye and/or Tc 62-89 %

Hysteroscopic Blue-dye and/or Tc 65-95%

Cervical ICG 95-97%

Hysteroscopic ICG 95%

•Comparable DR•NO radiation•NO colored surgical field•Possibility to dissect SLN under NIR

Conclusions • SLN is a reasonable middle ground between no lymphadenectomy and

full LA and pelvic nodes assestment

• In our experience, hysteroscopic injection of tracer identifies pelvic and

PA SLN according to the anatomy of uterine lymphatic system.

• Hysteroscopic injection of ICG seems to overcome the limits of Tc and

blue dyes

• The surgical procedure is not time consuming,the injection of tracer is

performed under direct laparoscopic observation and it is possible to

dissect SLN without a wide retroperitoneal space exposure

• The technical evolution of the light source and the camera sensitivity

allows the surgeon to dissect SLNs directly in NIR mode

2014

476 pts retrospective

Thanks

268 pts43 N+

24 Mam12 mm7 ITC

9.2 vs 36.8 LNX

No missed N+

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