Sentinel Lymph Node in Cervical Cancer: Time to Move Forward

Vincent Balaya; Benedetta Guani; Basile Pache; Yves-Gérard Durand; Hélène Bonsang-Kitzis; Charlotte Ngô; Patrice Mathevet; Fabrice Lécuru

Disclosures

Chin Clin Oncol. 2021;10(2):18 

In This Article

Rational

Lymph node staging consisting in preoperative imaging and intraoperative sampling is mandatory for choosing the best therapeutic strategy.[9] Pelvic lymphadenectomy sought to provide prognostic information that would indicate adjuvant radiotherapy to reach a loco-regional control of the disease. However, some substantive changes have to be considered about positive nodes in the modern era compared to old previous report.[21–23] Size of metastatic node is usually small and is smaller than 2 mm in 22% to 60% of positive node patients.[24–26] Given that most of metastatic nodes measured less than 10 mm,[27] pelvic MRI and PET-CT lack of sensibility and fail to identify positive-node patients.[28] Nonetheless, the recent results of UTERUS-11 study did not show a difference in disease-free survival between surgical and clinical staging in patients with locally advanced cervical cancer.[29]

In addition, the mean rate of positive nodes in patients with early-stage cervical cancer is lower than 20%[15,18,26] and the number of metastatic nodes per patient ranges from 1 to 3, with only one node being involved in near half of pN1-patients.[30,31] The full pelvic lymphadenectomy, consisting in removing at least 15 nodes which are analysed by one cut level and standard pathology, raised two main pitfalls: the induced postoperative morbidity and its efficiency. As previously stated, near 80% of patients who are free of nodal metastases would undergo useless pelvic lymphadenectomy and therefore would ensure associated complications such as longer operative time, blood loss, postoperative infection, lymphocyst and lower limbs lymphedema.[12,32] Although pelvic lymphadenectomy is completed, 10% to 15% of patients initially considered as N0 will experience cancer recurrences in the lymphatic area, due to the presence of atypical lymphatic drainage pathway.[33] A targeted lymph node sampling appears more appropriate and SLN biopsy addresses particularly to this issue.

The SLN is defined as the first draining node of a solid tumor and represent the status of regional and downstream nodes. This concept applies to tumor with a sequential lymphatic drainage and a low rate of nodal involvement. The selective removal of these SLNs aims to ensure the absence of lymphatic tumor spread in the first draining node and thus to predict the absence of distant lymphatic metastases in the secondary nodes. The SLN biopsy is a targeted sampling which should provide the same diagnostic information as the pelvic lymphadenectomy (pN0 or pN1) with less morbidity and without compromising oncologic outcomes.

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