| BackgroundSentinel lymph node (SLN) is the first node in the lymphatic system that drains the primary tumor site through specific lymphatic channels, may be the mostly possible metastases site, its pathologic status should then predict the pathologic status of the remaining lymphatic basin. The concet of SLN was introduced in 1977 by Cabanas for the management of patients with penile cancer using lymph-angiography of the dorsal lymphatics of the penis , the detection of SLN widly studied in patients with solid tumor, markedly successful in malignant melanoma and breast cancer , detection rate is very high and false- negative rate is very low,accuracy of SLN detection in breast cancer was 95%～ 98%, A number of departments use SLN biopsy as standard procedure.SLN are currently detected by the application of three techniques: blue dye, radioactive tracer, and the combination of the two techniques.Cervical cancer is the second most common female malignancy worldwide. Radical hysterectomy with pelvic lymphadenetomy remains the gold standard fortreatment of patients with early cervical cancer ( I A2-II A) , Lymph node status is a major prognostic factor and a decision criterion for adjuvant therapy in cervical cancer. Systematic lymphadenectomy, which remains the reference standard to assess the nodal status, has become one of the most controversialtopics, regarding the value and optimal extent of surgical dissection. The incidence of pelvic node metastasis is low, and 70-90% of pelvic node showed no metastasis. Pelvic lymphadenectomy increase morbidity as follows: damage vascular and nerve, lymphatic cyst, lymphedema, infection, may damage immue system when desect health lymph node. We should concern on how to improve survival rate and aviod lymphadenectomy for patient without lymph node metastases.To find simple and microstrauma method, which can be replace for pelvic lymphadenectomy lymphadenectomy, So SLN emerge as a replacement for pelvic lymphadenectomy.meet prelevance of individual in today's tumor therapy. After Echt in 1999 firstly studied SLN with 13 patients with early cervical cancer, many studies were reported, it is widly accepted the technique to identify SLN in cervical cancer is feasible, but remains some problems in how to improved detection rate and negative predict value, and how to dignose SLN during operation.So we study SLN with patients with early cervical cancer by combination of blue dye and radioactive tracer, to investigate the value of SLN detection in early cervical cancer; and SLN were dignosed rapidly during operation by frozen section and imprint cytology, to investigate method to dignose whether SLN was metastasis.MethodsFrome January 2005 to April 2006, a total of 50 patients with histologically proven early stage cervical cancer were treated in ZheJian cancer hospital, FIGO stage I B(n=28)and stage II A(n=22), for detection of pelvic sentinel lymph node via Dye-plus-isotope technique dy laparotomy. 33 cases were operated in the morning, the cervix was infiltrated in each quadrant around the tumor at 3,6,9,and 12 o'clock positions with a dose of 0.4ml of 99mTc—labelled sulfur colloid ( 0.4mci) in 18hrpreoperation (2pm the day before operation), 17 cases were operated on afternoon, isotope was infiltrated in 5hr preoperation ( 8am in the operation day) , Lymphoscintigraphy was performed 1hr after the injection. After opening the abdomen, 4ml of methylene blue was injected in a low lithotomy position in the same cervix position. Identification of SLN: visually blue node; node at the end of blue lymphatic vessel; Hot node (the counts were at least 3-10 fold above background levels. Firstly the SLN were resected, then perform radical hysterectomy and pelvic lymphadenectomy. The SLN of the last 30 cases were enrolled for pathologic examination during operation by frozen section and imprint cytology. All pelvic lymph node performed HE staining., negative SLN and radomly to chose one node from each negative non-SLN group were perform immunohistochemical-CK19 staining.Evaluation of SLN biopsy according the standard of American Louisville university, combine pathologic results by regular HE and immunohistochemical-CK19 staining as gold standard to evaluate accuracy of frozen section and imprint cytology.Results13 of 50 patients with early cervical cancers were pathologically diagnosed with pelvic lymph node metastasis after routine HE staining, metastatic rate was 26%. SLN were detected successfully in 48 cases, detection rate was 96%, 31 cases were detected bilaterally, bilater detection rate was 62%, one case with positive pelvic lymph node has no SLN detected, in all 48 patients, SLN of 11 cases were positive, SLN of 36 cases were negative , SLN of 1 case was false- negative .The sensitivity, accuracy, and false-negative rate for SLN detection were 84.6%, 100%,and 7.7%,respectively. Lymphoscintigraphy were successfully reviewed SLN in 68% cases, 60.4% meeted with detection by gamma-probe in operation. A total of 160 sentinel nodes were detected, mean 3.33(rangel —5), mean diameter 1.24cm (range 0.6—3cm) . site of SLN were scattered as follows: 126 nodes in internal iliac andobturator (79%), 22 nodes in external iliac (14%), 10 nodes in common iliac ( 6%) , 2 nodes in parametrial (1%) .30 patients were performed frozen section and imprint cytology during operation,the sensitivity, specificity,accuracy,and positive and negative predictive values were 92.3%,100%,98.9%,100%,98.8% for frozen section, and 92.3%, 97.6%, 96.8%, 85.7%, 98.8% for imprint cytology,respectively. No micrometastasis was found by immunohistochemical-CK19 staining.Conclusions1 .Detection SLN of early cervical cancer is feasible, with high dectection rate by Dye-plus-isotope technique; SLNs detection can predict the pelvic lymph node status in early stage cervical carcinoma.2.Frozen section and imprint cytology are the appropriate methods for assessing SLN metastasis intraoperatively in patients with early stage cervical carcinoma. |
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