Clinical Lymphatic Mapping

in Gynecologic Cancers
 Clinical Lymphatic Mapping
in Gynecologic Cancers
Second Edition

Edited by
Charles F. Levenback, MD
Professor (Retired), Department of Gynecologic Oncology
University of Texas MD Anderson Cancer Center, Houston, Texas

Ate G.J. van der Zee, MD, PhD

Professor of Gynecological Oncology and CEO
University Medical Center Groningen, The Netherlands

Robert L. Coleman, MD, FACOG, FACS

Chief Scientifc Offcer, US Oncology Research, The US Oncology
Network, McKesson Specialty Health, The Woodlands, Texas

Boca Raton London New York

CRC Press is an imprint of the

Taylor & Francis Group, an informa business
Second edition published 2022
by CRC Press
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
and by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487–2742
© 2022 Taylor & Francis Group, LLC
First edition published 2004
CRC Press is an imprint of Informa UK Limited
This book contains information obtained from authentic and highly regarded sources. While all
reasonable efforts have been made to publish reliable data and information, neither the author[s]
nor the publisher can accept any legal responsibility or liability for any errors or omissions that may
be made. The publishers wish to make clear that any views or opinions expressed in this book by
individual editors, authors or contributors are personal to them and do not necessarily refect the
views/opinions of the publishers. The information or guidance contained in this book is intended
for use by medical, scientifc or health-care professionals and is provided strictly as a supplement to
the medical or other professional’s own judgement, their knowledge of the patient’s medical history,
relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the
rapid advances in medical science, any information or advice on dosages, procedures or diagnoses
should be independently verifed. The reader is strongly urged to consult the relevant national drug
formulary and the drug companies’ and device or material manufacturers’ printed instructions, and
their websites, before administering or utilizing any of the drugs, devices or materials mentioned in
this book. This book does not indicate whether a particular treatment is appropriate or suitable for
a particular individual. Ultimately it is the sole responsibility of the medical professional to make
his or her own professional judgements, so as to advise and treat patients appropriately. The authors
and publishers have also attempted to trace the copyright holders of all material reproduced in this
publication and apologize to copyright holders if permission to publish in this form has not been
obtained. If any copyright material has not been acknowledged please write and let us know so we
may rectify in any future reprint.
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form
or by any electronic, mechanical, or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or retrieval system, without permission
in writing from the publishers.
For permission to photocopy or use material electronically from this work, access www.
copyright.com or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive,
Danvers, MA 01923, 978–750–8400. For works that are not available on CCC please contact
mpkbookspermissions@tandf.co.uk
Trademark notice: Product or corporate names may be trademarks or registered trademarks and are
used only for identifcation and explanation without intent to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
Names: Levenback, Charles, editor. | Zee, Ate Gerard Jan van der, editor. | Coleman, Robert L., editor.
Title: Clinical lymphatic mapping in gynecologic cancers / edited by Charles Levenback,
Ate G.J. van der Zee, Robert L. Coleman.
Description: Second edition. | Boca Raton : CRC Press, [2022] | Includes bibliographical references
and index.
Identifers: LCCN 2021037615 (print) | LCCN 2021037616 (ebook) | ISBN 9781032186436 (hardback) |
ISBN 9781032186443 (paperback) | ISBN 9781003255536 (ebook)
Subjects: MESH: Genital Neoplasms, Female—surgery | Breast Neoplasms—surgery | Lymph Node
Excision—methods | Sentinel Lymph Node Biopsy
Classifcation: LCC RC280.G5 (print) | LCC RC280.G5 (ebook) | NLM WP 145 | DDC 616.99/465—dc23
LC record available at https://lccn.loc.gov/2021037615
LC ebook record available at https://lccn.loc.gov/2021037616
ISBN: 978-1-032-18643-6 (hbk)
ISBN: 978-1-032-18644-3 (pbk)
ISBN: 978-1-003-25553-6 (ebk)
DOI: 10.1201/9781003255536
Typeset in Times
by Apex CoVantage, LLC
 For Ginny
Charles F. Levenback

To my parents, Biny Van der Zee-Muntingh and Martin van der Zee, for their love
and long-lasting support. To my wife, Joukje van der Naalt, and my children,
Wierd, Heleen, and Hannah, for bringing so much joyful distraction into my life.
Ate G.J. van der Zee

To my parents, Marlene and Gary Beatty and Robert and Sharon Coleman, for their
unending encouragement, support, love, and guidance. To my wife, Fay, whose
love, insight, and daily selfess sacrifce strengthen and inspire me. To my children,
Jay, Christina, Kay, Joe, Mary, and Teresa, and grandchildren (so far . . . ), Noelle,
Jason, Nate, Marten, Lily, and Eli, who bring true color, joy, and happiness to
my life. To my patients, whose charity of self makes this endeavor possible.
Robert L. Coleman
Contents

List of contributors.......................................................................................................................................................................... ix
Preface ............................................................................................................................................................................................ xi

1 The history of lymphatic mapping: a gynecologic perspective.......................................................................................... 1

Charles F. Levenback

2 Lymphatic anatomy: microanatomy and physiology.......................................................................................................... 9

Erin K. Crane and Charles F. Levenback

3 Lymphatic anatomy: lymphatics of the vulva ................................................................................................................... 15

Anca Chelariu-Raicu and Robert L. Coleman

4 Lymphatic anatomy: lymphatics of the cervix .................................................................................................................. 23

Anca Chelariu-Raicu and Katherine C. Kurnit

5 Lymphatic anatomy: lymphatics of the uterus.................................................................................................................. 29

Jennifer J. Mueller and Nadeem R. Abu-Rustum

6 Lymphatic anatomy: lymphatics of the ovary ................................................................................................................... 35

Ate G.J. van der Zee

7 Lymphatic anatomy: lymphatics of the breast and axilla ................................................................................................ 39

James V. Fiorica

8 Modalities of detection of sentinel nodes in lymphatic mapping..................................................................................... 43

Blanca Segarra, Nuria Agusti, and Pedro T. Ramirez

9 Ultrastaging of the sentinel node ........................................................................................................................................ 55

Celien P.H. Vreuls, Ate G.J. van der Zee, and Paul J. van Diest

10 Sentinel lymph node biopsy of the vulva............................................................................................................................ 65

Maaike Oonk and Ate G.J. van der Zee

11 Sentinel lymph node mapping in cervical cancer ............................................................................................................. 71

David Cibula and Martina Borcinova

12 Sentinel lymph node mapping in breast cancer ................................................................................................................ 83

Angelena Crown and Mary L. Gemignani

13 Sentinel lymph node biopsy of the endometrium .............................................................................................................. 99

Jennifer J. Mueller and Nadeem R. Abu-Rustum

14 Impact of sentinel lymph node mapping on quality of life..............................................................................................111

Mariana Antonella Nigra, Pedro T. Ramirez, and Larissa Meyer

15 Radiation oncology considerations ....................................................................................................................................117

Gwendolyn Joyce McGinnis and Anuja Jhingran

vii
viii Contents

16 Special considerations ........................................................................................................................................................ 129

Michael Frumovitz

17 Clinical trial design ............................................................................................................................................................ 135

Scott Jordan and Brian M. Slomovitz

Index .............................................................................................................................................................................................143
Contributors

Nadeem R. Abu-Rustum, MD Anuja Jhingran, MD

Gynecology Service Radiation Oncology
Department of Surgery University of Texas MD Anderson Cancer Center
Memorial Sloan Kettering Cancer Center Houston, Texas
New York, New York
Scott Jordan, MD, FACOG
Nuria Agusti, MD Florida International University and Broward Health
IRTA Cabrils Fort Lauderdale, Florida
Barcelona, Spain
Katherine C. Kurnit, MD, MPH
Martina Borcinova, MD Gynecologic Oncology
Gynecologic Oncology Center NCH Medical Group
Department of Obstetrics and Gynecology Arlington Heights and University of Chicago Hospitals
First Faculty of Medicine Chicago, Illinois
Charles University and General University Hospital
Prague, Czech Republic Gwendolyn Joyce McGinnis, MD
Radiation Oncology
Anca Chelariu-Raicu, MD University of Texas MD Anderson Cancer Center
Department of Gynecologic Oncology & Reproductive Medicine Houston, Texas
University of Texas MD Anderson Cancer Center
Houston, Texas Larissa Meyer, MD
Department of Gynecologic Oncology & Reproductive Medicine
David Cibula, MD, PhD, FCMA University of Texas MD Anderson Cancer Center
Gynecologic Oncology Center Houston, Texas
Department of Obstetrics and Gynecology
First Faculty of Medicine Jennifer J. Mueller, MD
Charles University and General University Hospital Gynecology Service
Prague, Czech Republic Department of Surgery
Memorial Sloan Kettering Cancer Center
Erin K. Crane, MD, MPH
New York, New York
Department of Gynecologic Oncology
Levine Cancer Institute Mariana Antonella Nigra, MD
Charlotte, North Carolina Department of Gynecologic Oncology
Sanatorio Allende
Angelena Crown, MD
Cordoba, Argentina
Breast Service
Department of Surgery Maaike Oonk, MD, PhD
Memorial Sloan Kettering Cancer Center Department of Gynecologic Oncology,
New York, New York University Medical Center Groningen
James V. Fiorica, MD Groningen, The Netherlands
Sarasota Memorial Hospital
Pedro T. Ramirez, MD
Florida State University College of Medicine
Department of Gynecologic Oncology & Reproductive Medicine
Sarasota, Florida
University of Texas MD Anderson Cancer Center
Michael Frumovitz, MD, MPH Houston, Texas
Department of Gynecologic Oncology & Reproductive Medicine
University of Texas MD Anderson Cancer Center Blanca Segarra, MD
Houston, Texas Department of Gynecologic Oncology & Reproductive Medicine
University of Texas MD Anderson Cancer Center
Mary L. Gemignani, MD, MPH Houston, Texas
Breast Service
Department of Surgery Brian M. Slomovitz, MD, MS, FACOG
Memorial Sloan Kettering Cancer Center Florida International University and Broward Health
New York, New York Fort Lauderdale, Florida

ix
Preface
The editors spent a large part of their surgical training per-
forming regional lymphadenectomy for women with vulvar,
endometrial, and cervical cancer. This huge diagnostic sur-
gical effort appeared to be of no beneft to the survival of
approximately 80% of women who had negative nodes, while
simultaneously being associated with signifcant negative long-
term side effects. When we learned of the pioneering work
of Dr. Donald Morton regarding sentinel lymph node biopsy
in patients with cutaneous melanoma, we independently real-
ized the technique could be easily adapted to vulvar and other
gynecologic cancer patients. That started for us a two-decade
journey to apply sentinel node biopsy to our patient popula-
tion. On that journey we have made many friends around the
world, trained numerous other physicians, and, most impor-
tantly, improved outcomes for women suffering from gyne-
cologic cancer. We published the frst edition of this book to
create an easy-to-use resource for gynecologic oncologists
incorporating sentinel lymph node biopsy into their practice.
Incredibly, due to the hard work and collaboration of gyne-
cologic oncologists worldwide, regional lymphadenectomy has
been largely eliminated from the routine care of women with
vulvar, endometrial, and cervical cancer. As we near the end
of our careers, we decided to publish a second edition as an up-
to-date reference for those practicing gynecologic oncology.
Our ultimate goals remain unchanged from 20 years ago, to
improve the outcomes for women who have trusted us with
their care during one of the greatest challenges of their lives.
A large part of the story of the development of sentinel node
biopsy is the importance of time-honored clinical skills like
knowledge of surgical anatomy, careful surgical technique,
and patient safety to improve surgical outcomes. In addition
the editors have spent signifcant efforts during their careers
to build global collaborative clinical study groups to enable
the performance of carefully designed clinical trials on the
implementation of innovative surgical techniques, which is a
challenge, especially in relatively rare cancers such as most
gynecologic cancers.
Even as new targeted and immunotherapies become avail-
able, the aforementioned skills remain of critical importance
to patient outcomes. We hope that our work inspires new
investigators to continue the never-ending journey of continu-
ous study and improvement of our core clinical knowledge
base and skills for the beneft of our patients and their families.
Charles F. Levenback
Ate G.J. van der Zee
Robert L. Coleman
xi
1
The history of lymphatic mapping: a gynecologic perspective

Charles F. Levenback

CONTENTS
Introduction ...................................................................................................................................................................................... 1
Cadaver studies of lymphatic anatomy ............................................................................................................................................ 1
Halsted model for surgical management of solid tumors ................................................................................................................ 3
In vivo injection of dyes................................................................................................................................................................... 3
Early efforts at sentinel node identifcation ..................................................................................................................................... 4
Progress toward the modern lymphatic mapping concept ............................................................................................................... 6
Safety and surgical innovation ............................................................................................................................................... 7
References........................................................................................................................................................................................ 7

Introduction
In the new millennium, it is commonly believed that the
answers to cancer questions will result from innovations in
molecular biology that are brought from the bench to the bed-
side through the work of translational researchers. However,
the story of the development of lymphatic mapping serves as
a reminder to us that, even now, some advances in cancer care
still come from the more traditional routes of careful study of
anatomy, clinical observation, and literature research.
The history of the development of lymphatic mapping is also
a humbling lesson in how important innovations in medicine can
diffuse slowly. The term ‘sentinel node’ was frst used in 1960,1
yet even today the full potential of this concept has not been real-
ized. Initial reports of success with the sentinel node concept
were largely ignored or misinterpreted. Old ideas can be diffcult
to abandon, and new ideas are not always what they appear.
The relative infrequency of gynecologic tumors is an addi-
tional impediment to the development of lymphatic mapping
in our specialty. Fortunately, we can learn a lot from the expe-
rience of others in treating more common diseases. I saw the
lymphatic mapping procedure for the frst time when a patient
presented to MD Anderson Cancer Center in 1992 with syn-
chronous primary tumors: a 2-cm squamous cell cancer of the
cervix and a thin cutaneous melanoma of the anterior thigh.
Standard treatment at the time would have required inguinal,
femoral, and pelvic lymphadenectomy that would have surely
left the patient with signifcant lymphedema. After extensive
consultation, the surgical oncologist performed lymphatic
mapping and sentinel node biopsy. I was amazed to see lym-
phatic channels and the blue sentinel lymph node. Up to this
time any type of preoperative or intraoperative direct imag-
ing of lymphatic channels and lymph nodes was not possible.
When I saw the blue node in the groin, it was clear that the
same technique could be applied to carcinoma of the vulva.
Since the frst edition of this book there has been an explo-
sion in knowledge about patient safety and the risks associated
with the introduction of new procedures and medical devices
into surgical practice. In this chapter, we will explore lessons
learned from the introduction of sentinel lymph node biopsy
into gynecologic oncology surgical practice. Subsequent chap-
ters will review the lymphatic anatomy of the female lower
genital tract and breast and the current state of knowledge
regarding lymphatic mapping for tumors at these sites.
Cadaver studies of lymphatic anatomy
Early anatomists learned about lymphatic anatomy from
cadavers. This work was complicated by the fact that lym-
phatic channels are diffcult to see and very fragile and by
the fact that tissue had to be extensively putrefed or fxed to
be studied. Painstaking dissections led to the production of
remarkable drawings of lymphatic anatomy. These illustra-
tions were frequently reproduced by subsequent investigators
with small improvements (Figures 1.1 and 1.2). Anatomists
developed a variety of aids to help visualize the lymphatic
channels, including a number of mercurial compounds that,
when injected into various soft tissues, canalized the lym-
phatics. This technique most likely contributed to the depic-
tions of lymphatic anatomy that erroneously show vulvar
lymphatics crossing the labial-crural fold, best represented
by Sappey’s illustration (Figure 1.3). In the early twentieth
century, the French gynecologists Leveuf and Godard2 stud-
ied the lymphatic anatomy of the cervix using injection of
Gerotti blue into the cervices of neonatal cadavers. They
found that the dye drained in a highly reproducible way to a
lymph node usually found in the obturator space or close to
the iliac vessels. They named this the ‘principal’ lymph node
(Figure 1.4).

DOI: 10.1201/9781003255536-1 1
2 Clinical Lymphatic Mapping

FIGURE 1.3 Vulvar lymphatics depicted by P.C. Sappey (1879). Note

that lymphatics cross the labial-crural fold and buttocks. (Reproduced
from Parry-Jones19 with permission.)

FIGURE 1.1 Lymphatics of the abdomen and pelvis (1787) by P.

Mascagni. (Reproduced from Plentl and Friedman4 with permission from
Elsevier.)

FIGURE 1.2 Lymphatics of the abdomen and pelvis. (From a nine- FIGURE 1.4 Leveuf and Godard’s2 description (1923) of lymphatic
teenth-century French textbook.) drainage of the cervix. (Courtesy of Dr. Daniel Dargent.)
The history of lymphatic mapping 3

Halsted model for surgical

management of solid tumors
The great anatomist of the second century, Galen, believed that
cancer was a local process resulting from a systemic disease
of bodily fuids and humors. In the West, this concept was not
challenged until the seventeenth century, when Valsalva pro-
posed that cancer spread from primary tumors to lymph nodes.3
This understanding of cancer and the metastatic process ulti-
mately led to the Halstedian model for surgical management
of solid tumors. In this model, the primary tumor, the primary
regional lymph nodes, and the second-echelon regional nodes,
as well as all of the intervening lymphatic channels – including
the fne cutaneous lymphatics – were resected en bloc. This
approach was integrated into the treatment of gynecologic can-
cers by several gynecologic surgeons working in multiple sites
on the European continent. Rupprecht, Basset, Stoeckel, and
Bucura are credited with simultaneous descriptions in 1912
of what we now refer to as radical vulvectomy and bilateral
inguinal femoral lymphadenectomy.4 The next generation of
gynecologic cancer surgeons, including Twombly,5 Taussig,6
and Way,7 championed radical vulvectomy and bilateral ingui-
nal femoral lymphadenectomy, with only minor revisions for
patients with vulvar cancer, because of the dramatic improve-
ment in survival compared with less radical or nonsurgical
treatments. Stanley Way summarized the surgical philosophy
of the day in 1951 when he stated, “The most important steps
in the operation are undoubtedly the very wide removal of the
vulva and the resection of the lymph nodes, certainly as far as
the node of Cloquet”8 (Figure 1.5). Way added that the morbid-
ity and mortality of the procedure were justifed and that the
operation “represents the fnal achievement of surgery in this
disease.” Within a generation, however, the radicality of surgi-
cal treatment of the vulva would be diminishing, and today,
no indications remain for radical vulvectomy and bilateral
inguinal femoral lymphadenectomy for the primary treatment
of vulvar cancer.
Although Way was incorrect in his assessment, he did make
a prophetic plea for the establishment of special treatment cen-
ters for patients with vulvar cancer because of its rarity, the
diffculty of radical surgery for vulvar cancer, and the need
for experienced medical and nursing care. Way foreshadowed
both the formation of the subspecialty of gynecologic oncol-
ogy and the establishment of comprehensive cancer centers.

In vivo injection of dyes

The next advances in the study of lymphatic anatomy and the
development of lymphatic mapping came from in vivo studies.
Intraoperative observation of the lymphatics has always been
hampered by two facts: The lymphatics are essentially invis-
ible, and the lymph is colorless. Two of the frst investigators to
use living subjects for study were Stephen Hudack and Phillip
McMaster.9 They experimented with injecting a variety of vital FIGURE 1.5 Depiction of inguinal nodes (a) and pelvic nodes (b) by
dyes into the skin of a variety of mice, rats, and rabbits. They Stanley Way8 in 1951. The relationship of the nodal groups, including
then used themselves and six other volunteers as experimen- direct clitoral drainage to ‘deep femoral’ nodes and contralateral labial
tal subjects to study the cutaneous lymphatics of the skin and drainage, envisaged by Way in schematic form (c – redrawn for clarity).
4 Clinical Lymphatic Mapping

lymphatic drainage patterns. Using very fne needles, small

quantities of vital blue dyes, and photographic magnifcation,
they were able to demonstrate the fne lymphatic capillaries of
the skin. They varied the type of dye and the volume injected
and measured the rate of lymph transport (up to 15 cm in 5
min) and the impact of infamed skin, heat, and wheal forma-
tion on lymph transport. In their examination of the effect of
wheal formation, they studied one individual who responded
to “a frm stroke with a blunt instrument,” with formation of
a wheal within 2–3 min. The lymphatics in the region of the
wheal became less effective at draining the dye.
Clinicians began to experiment with injection of a variety of
dyes to help visualize lymph nodes. Gray10 injected sky-blue
dye into freshly resected skin to study cutaneous lymphatics.
Zeit and Wilcoxon11 injected India ink into the cervices of
patients before surgery to assist in the visualization of pelvic
lymph nodes. The authors observed that this technique aided
in teaching a relatively new procedure, radical hysterectomy
and pelvic lymphadenectomy. Injections of 0.5 mL of India ink
into the cervix at 3 and 9 o’clock at least 8 h prior to surgery
stained all of the pelvic nodes black. Braithwaite12 injected
indigo carmine into the cecum in an attempt to link appen-
dicitis and duodenal ulcers. Weinberg and Greaney13 injected
sky-blue dye into the peritoneum during radical gastrectomy
to assist the pathologists in identifcation of draining lymph
nodes in the specimen.
Eduard Eichner systematically studied the anatomy of the
female lower genital tract using intraoperative injections of blue
dyes. In a remarkable 2-year period, he published three papers
that described anatomic fndings after injections in the cervix,
ovary, uterine fundus, vulva, and vagina14–16 (Figure 1.6). He
supplemented his work with a fourth study published in 1958,
of patients with cervical stumps.17 Eichner experimented with
obstructing lymphatic fow at various points – for example, he
tied off the infundibulopelvic ligament to see how this would
alter lymphatic fow. Eichner made several important observa-
tions; however, he also made errors that contributed to mis-
conceptions about lymphatic drainage of the genital tract, in
particular the vulva. Eichner engaged in a series of injections
of various vulvar sites. Unlike Hudack and McMaster, who
used intradermal injections, Eichner used deep subcutaneous FIGURE 1.6 (a) Lymphatic drainage of the cervix as depicted by
injections. Eichner was unable to demonstrate dye in the ingui- Eduard Eichner17 in 1958 (reproduced with permission); (b) key aspects
nal nodes of his subjects; rather, he found dye in the pelvic of depiction.
nodes. Presumably, the dye was following the prevascular lym-
phatics of the deep vessels of the vulva directly to the pelvis
rather than following the superfcial cutaneous lymphatics that negative, the remaining lymph nodes of the neck would also be
drain the groin. This work suggested direct lymphatic drain- negative and full neck dissection could be avoided.
age from the vulva to the pelvis. It took several decades to The individual who combined the two elements of the mod-
demonstrate that this very rarely, if ever, occurs. ern approach, lymphatic mapping and sentinel node iden-
tifcation, is Ramon Cabanas. Cabanas, along with Manuel
Riveros and Ramiro Garcia, frst described lymphography
of the penis in a 1967 report of an anatomic study performed
Early efforts at sentinel node identification
while Cabanas was at the National University in Asuncion,
The individual most frequently credited with coining the Paraguay.18 Paraguay has one of the highest incidences of
phrase ‘sentinel node’ is Ernest Gould.1 He proposed using the penile carcinoma in the world. Cabanas later did a fellowship
lymph node found at the junction of the anterior and posterior in urologic oncology at Memorial Sloan-Kettering Cancer
facial veins for frozen-section analysis to determine the need Center. Over an 8-year period, Cabanas amassed a series of
for a full neck dissection. His hypothesis, based on fndings 80 patients with penile cancer in whom he used lymphography
in 28 patients with parotid cancer, was that if this node was to identify the sentinel lymph node in the groin (Figure 1.7).
The history of lymphatic mapping
FIGURE 1.7 (a and b) Cabanas’s technique for penile lymphography.
Blue dye injected into the phallus of the penis is taken up by cutaneous
lymphatics. A cut-down is performed, and the dorsal lymphatic is cana-
lized and injected with ethiodized oil. (c) Plain radiographs identify both
the lymphatic channel and ethiodized oil deposited in the sentinel node.
(Reproduced from Cancer with permission18.)
5
FIGURE 1.7 (Continued)
He found that the sentinel lymph node was always located
among the superfcial inguinal nodes, that the sentinel node
was involved with disease in all patients who had metastases,
and that the sentinel node was the only positive node in 12
cases. Cabanas suggested that only patients with a positive
sentinel lymph node required the more extensive (and morbid)
procedure of complete lymphadenectomy.
In the 1970s, Cabanas was conducting his studies of sentinel
nodes in patients with penile cancer, while gynecologic oncol-
ogists were attempting to fnd ways to reduce the morbidity of
radical vulvectomy and bilateral inguinal femoral lymphad-
enectomy. Parry-Jones19 performed in vivo injections of blue
dye to show that vulvar lymphatics do not cross the buttock
and labial-crural fold, as had been depicted by Sappey. This
observation permitted surgeons to reduce the radicality of the
operation while still adhering to Halstedian principles. In con-
trast to Eichner, Parry-Jones used intradermal injections and
found in all cases that the dye was arrested in the groin and did
not reach the pelvic nodes. This conficted with his hypothesis
that there is direct lymphatic drainage from the vulva to the
pelvis. Rather than reject his hypothesis, Parry-Jones rejected
his methods. After experimenting with several compounds, he
settled on Imferon injected into the subcutaneous tissue of the
vulva 24 h prior to surgery. Iron particles found in the iliac
lymph nodes confrmed for Parry-Jones his hypothesis that the
vulva has lymphatic drainage directly to the pelvic nodes.19
6 Clinical Lymphatic Mapping

Other investigators took other avenues to reduce the mor- Donald Morton developed the frst important clinical applica-
bidity of radical vulvectomy and bilateral inguinal femoral tion of lymphoscintigraphy by using colloidal gold to identify
lymphadenectomy. Wharton et al.20 suggested that the risk of the primary nodal drainage basin in patients with cutaneous
lymph node metastases in patients with less than 5-mm inva- melanoma at sites on the body with ambiguous lymphatic
sion was so low that lymphadenectomy could be omitted in drainage patterns, primarily the trunk (Figure 1.8).
these patients. This approach was rapidly abandoned, how- At the time of Morton’s studies, there was a major debate
ever, following the subsequent publication of several reports of regarding the management of patients with early-stage mela-
lymph node metastases in patients with less than 5-mm inva- noma. The vast majority of these patients, 90%, have nega-
sion.21 Morris22 suggested that patients with well-lateralized tive nodes, and the effcacy of regional lymphadenectomy in
lesions could be treated with hemivulvectomy. This work the 10% with positive nodes was the subject of intense debate.
represented one of the earliest departures from the practice of Some clinicians recommended a complete lymphadenectomy
performing radical vulvectomy for the treatment of invasive in all patients with stage I disease, while others recommended
vulvar cancer and was a clear departure from the Halstedian observation. Morton set out to determine whether the senti-
concept of en bloc resection. nel node as described by Cabanas and others could be iden-
Philip DiSaia focused the attention of the gynecologic oncol- tifed intraoperatively. His group studied various dyes in a
ogy community on the devastating effect of radical vulvectomy feline model29 and selected isosulfan blue as the best choice
on body image and sexual function. In 1979, he described com- for intraoperative lymphatic mapping. In 1992, Morton et al.30
bining less radical resection of the primary tumor with a less described their results in 223 patients with cutaneous mela-
radical approach to groin dissection, as suggested by Cabanas. noma. A total of 237 lymphatic basins were mapped, and the
DiSaia proposed radical local excision and superfcial inguinal sentinel node was identifed in 82% of them. More than 3000
lymphadenectomy for selected patients with vulvar cancer.23 lymph nodes were removed, of which 8% were sentinel, and in
DiSaia introduced the term ‘sentinel nodes’ to the gynecologic only two cases did nonsentinel nodes contain metastatic dis-
oncology community in North America. He suggested that the ease when the sentinel nodes were disease free. This paper is
superfcial inguinal lymph nodes were the sentinel nodes of one of the most cited references in modern surgical oncology
the vulva. This is the location where Cabanas always found the and prompted an explosion of interest in this technique.
sentinel nodes in patients with penile cancer, and DiSaia added
his own observation that the femoral nodes were never positive
if the superfcial inguinal nodes were negative. DiSaia relied
on location relative to anatomic landmarks to identify ‘senti-
nel nodes’ – a technique similar to that described by Gould in
1960 – rather than relying on landmarks in combination with
lymphatic mapping, as described by Cabanas. DiSaia funda-
mentally misrepresented the sentinel node concept; however, it
was embraced by gynecologic oncologists interested in reduc-
ing the morbidity of groin dissection. Berman et al.24 reported
no groin relapses in a group of 50 cervical cancer patients; how-
ever, these outstanding results could not be reproduced. In the
Gynecologic Oncology Group (GOG) protocol 75, reported by
Stehman et al,25 almost 8% of the 121 patients with vulvar can-
cer suffered a groin recurrence following superfcial inguinal
lymphadenectomy with negative nodes. This compares with
a recurrence rate of less than 1% following inguinal femoral
lymphadenectomy with negative nodes in a group of more than
300 patients participating in GOG protocol 37.26 On the basis
of the GOG results, gynecologic oncologists have abandoned
superfcial inguinal lymphadenectomy as it was described by
DiSaia in 1978.

Progress toward the modern

lymphatic mapping concept
Injection of radionuclides into human subjects to localize
regional lymph nodes was frst reported in 1953 by Sherman
and Ter-Pogossian.27 Numerous radiolabeled compounds
have since been used for this purpose. The frst gynecologic
application of lymphoscintigraphy was in 1982, when Iversen
and Aas28 studied vulvar lymphatic drainage in a group of 52
patients, most of whom had cervix cancer. A group led by
FIGURE 1.8 Lymphoscintogram of a patient with a cutaneous mela-
noma of the midback. Note lymphatic drainage to three of four potential
lymphatic basins. (From Nieweg O, Jansen L, Uren RF, et al, Instructive.)
Cases: Case 4: Drainage to Multiple Basins. In Nieweg O, Essner R,
Reintgen D, eds, Lymphatic Mapping and Probe Applications in Oncology.
(Marcel Dekker, Inc.: New York, 2000) 292–4, with permission.)
The history of lymphatic mapping
In rapid succession, several large series of lymphatic map-
ping and sentinel node biopsy in patients with breast cancer
and melanoma were published from centers around the world,
essentially all confrming Morton et al.’s observations. A
decade later, reports have been published describing lymphatic
mapping and sentinel node identifcation in patients with head
and neck, endocrine, gastrointestinal, genitourinary, and
reproductive cancers.
The impact of Morton’s work cannot be overstated. Between
Cabanas’s landmark 1978 study and Morton’s in 1992 there
were 16 citations in PubMed with ‘sentinel node’ in the title
or abstract. Vulvar cancer was the frst disease site other than
penile, melanoma, and breast to be cited associated with ‘sen-
tinel node.’31 The frst reference to sentinel node biopsy in
endometrial cancer was in 1996.32 From 1995 to 2020 there
have been 365 citations with sentinel and vulvar in the title, as
well as 554 with sentinel and endometrial in the title. The cor-
responding numbers for breast cancer and melanoma are 7515
and 3957. For all these disease sites the number of citations is
still increasing.33
Dr. Morton was one of the founders of the International
Sentinel Node Society in 1998. Numerous validation trials in
melanoma were conducted under his leadership. The sixth edi-
tion of the AJCC Cancer Staging Manual for breast cancer
included substages for micro-metastases in regional lymph
nodes, a change forced by the adoption of sentinel lymph node
biopsy.34 By 2001 there were over 17,000 analytic melanoma
cases that resulted in the incorporation of sentinel lymph node
biopsy into the American Joint Committee on Cancer (AJCC)
staging of melanoma.35 The current staging manuals and treat-
ment guidelines for breast cancer and melanoma depend com-
pletely on the status of sentinel lymph nodes.
Staging and consensus guidelines for the management of
gynecologic cancers increasingly incorporate sentinel lymph
node biopsy. The NCCN Vulvar Squamous Cell Carcinoma
Guidelines Version 2.202136 indicate that inguinal femoral
lymphadenectomy should only be performed when a senti-
nel lymph node cannot be identifed. The NCCN Guidelines
Version 1.2021 Endometrial Carcinoma Principles for
Evaluation and Surgical Staging state that “sentinel lymph
node mapping may be considered” as a staging procedure.37
Similarly, Cerc-C38 (NCCN guidelines version 1.2021
Cervical Cancer) recommends “bilateral pelvic lymphadenec-
tomy (with or without sentinel lymph node mapping)” as the
surgical management of appropriate patients.
The outcome of all of this work is an enormous shift in surgi-
cal management of solid tumors. Regional lymphadenectomy
has been eliminated from most aspects of surgical oncology,
including gynecologic oncology. The morbidity associated
with regional lymphadenectomy, including wound infection,
bleeding, and lymphedema, have decreased. Long-term out-
comes, including survival, are increasing with more accurate
staging and improved treatment options.
Safety and surgical innovation
During the same period of the development of sentinel
lymph node biopsy, health care leaders have observed indus-
tries such as commercial aviation and nuclear energy that
7
are ultrasafe and still provide high satisfaction to consum-
ers. High-reliability organizations (HROs) operate in high-
risk environments by being highly sensitive to operations,
deferring to expertise, and not trying to simplify complex
operations, in addition to a preoccupation with failure and
a commitment to resilience. The lessons of HROs are being
applied in health care, especially in surgery and anesthesiol-
ogy. For example, the World Health Organization Surgical
Safety Checklist has transformed how surgical procedures are
conducted. Risk-adjusted data, such as the National Surgical
Quality Improvement Database (NSQIP), allow accurate mea-
surement of new protocols to reduce surgical site infections.
Minimally invasive surgery and enhanced recovery protocols
have reduced the surgical length of stay dramatically. Low-
risk anesthesia for outpatient procedures is ultrasafe.
Organizations are also looking more carefully at how
surgical innovations are introduced to the operating room.
Marcus et al.39 noted that new devices and procedures are
usually associated with a spike in complications that are hid-
den from patients and the public. The introduction of sentinel
node biopsy in vulvar cancer is notable because most patients
with a negative sentinel node do not get adjuvant therapy, and
groin relapses have a very high mortality rate. This differed
from breast cancer, where many node-negative patients still
received some type of adjuvant therapy. For example, in GOG
173 there were 13 false-negative cases. These occurred in ten
member institutions, and seven of the cases were accession
cases 1, 2, or 3. Fortunately these patients also had an ingui-
nal femoral lymphadenectomy. However, in situations where
there is a false-negative sentinel node and no regional lymph-
adenectomy or adjuvant therapy, morbidity and mortality go
up sharply.
Finally, Chassin and Loeb, writing on behalf of The Joint
Commission, noted, “high reliability organizations do not tolerate
the existence of behaviours that suppress the reporting of safety
concerns and perpetuate the existence of unsafe conditions.”40
The aviation industry has been especially adept at the use of sim-
ulators, checklists, and anonymous error reporting to reduce pre-
ventable commercial airline deaths. The safety standards cannot
be circumvented based on seniority or other privilege.
The future of sentinel lymph node biopsy is bright. All the
tools of quality and safety should be used to avoid some of the
pitfalls of the past, as well as those yet to be discovered.41
REFERENCES
1. Gould EA, Winship T, Philbin PH, et al. Observations
on a ‘sentinel node’ in cancer of the parotid. Cancer.
1960;13:77–8.
2. Leveuf J, Godard H. Les lymphatiques de l’utérus. Rev
Chir. 1923;219–48.
3. Borgstein P, Meijer S. Historical perspective of lymphatic
tumour spread and the emergence of the sentinel node con-
cept. Eur J Surg Oncol. 1998;24:85–9.
4. Plentl AA, Friedman EA. Lymphatics of the cervix uteri.
In: Lymphatic System of the Female Genitalia. Philadelphia
WB Saunders; 1971. pp. 75–115.
5. Twombly G. The technique of radical vulvectomy for carci-
noma of the vulva. Cancer. 1953;3:516–30.
8 Clinical Lymphatic Mapping
6. Taussig FJ. Cancer of the vulva: an analysis of 155 cases.
Am J Obstet Gynecol. 1940;40:764–73.
7. Way S. Carcinoma of the vulva. Am J Obstet Gynecol.
1960;79:692.
8. Way S. Carcinoma of the vulva. In: Malignant Disease of the
Female Genital Tract. Philadelphia: Blakiston; 1951. pp. 27–8.
9. Hudack S, McMaster P. The lymphatic participation in
human cutaneous phenomena. J Exp Med. 1933;57:751–74.
10. Gray J. The relation of lymphatic vessels to the spread of
cancer. Br J Surg. 1938;6:462–95.
11. Zeit PR, Wilcoxon G. In vivo coloring of pelvic lymph nodes
with India ink. Am J Obstet Gynecol. 1950;59:1164–6.
12. Braithwaite L. Flow of lymph from iliocecal angle. Br J
Surg. 1923;11:7.
13. Weinberg JA, Greaney EM. Identifcation of regional lymph
nodes by means of a vital staining during surgery of gastric
cancer. Surg Gyn Obst. 1950;90:561–5.
14. Eichner E, Bove ER. In vivo studies on the lymphatic drain-
age of the human ovary. Obstet Gynecol. 1954;3:287–97.
15. Eichner E, Goldberg I, Bove ER. In vivo studies with direct
sky blue of the lymphatic drainage of the internal genitals
of women. Am J Obstet Gynecol. 1954;67:1277–86.
16. Eichner E, Mallin LP, Angell ML. Further experience with
direct sky blue in the in vivo studies of gynecologic lym-
phatics. Am J Obstet Gynecol. 1955;69:1019–26.
17. Eichner E, Rubinstein L. Cervical stump lymphatics. Obstet
Gynecol. 1958;12:521–7.
18. Riveros M, Garcia R, Cabanas R. Lymphadenectomy of the
dorsal lymphatics of the penis. Cancer. 1967;20:2026–31.
19. Parry-Jones E. Lymphatics of the vulva. J Obstet Gynaecol
Br Commonwealth. 1963;70:751–65.
20. Wharton J, Fletcher G, Delclos L. Invasive tumors of the
vagina: clinical features and management. In: Coppleson
M, editor, Gynecologic Oncology: Fundamental Principles
and Clinical Practice. New York: Churchill-Livingstone;
1981. pp. 345–59.
21. Parker RT, Duncan I, Rampone J, et al. Operative manage-
ment of early invasive epidermoid carcinoma of the vulva.
Am J Obstet Gynecol. 1975;123:349–55.
22. Morris JM. A formula for selective lymphadenectomy: its appli-
cation to cancer of the vulva. Obstet Gynecol. 1977;50:152–8.
23. DiSaia PJ, Creasman WT, Rich WM. An alternate approach
to early cancer of the vulva. Am J Obstet & Gynecol.
1979;133:825–32.
24. Berman ML, Keys H, Creasman W, et al. Survival and pat-
terns of recurrence in cervical cancer metastatic to periaor-
tic lymph nodes (a Gynecologic Oncology Group study).
Gynecol Oncol. 1984;19:8–16.
25. Stehman FB, Bundy BN, Dvoretsky PM, et al. Early stage
I carcinoma of the vulva treated with ipsilateral superfcial
inguinal lymphadenectomy and modifed radical hemivul-
vectomy: a prospective study of the Gynecologic Oncology
Group. Obstet Gynecol. 1992;79:490–7.
26. Homesley HD, Bundy BN, Sedlis A, et al. Radiation therapy
versus pelvic node resection for carcinoma of the vulva with
positive groin nodes. Obstet Gynecol. 1986;68:733–40.
27. Sherman A, Ter-Pogossian M. Lymph-node concentration
of radioactive colloidal gold following interstitial injection.
Cancer. 1953;6:1238–40.
28. Iversen T, Aas M. Lymph drainage from the vulva. Gynecol
Oncol. 1983;16:179–89.
29. Wong JH, Cagle LA, Morton DL. Lymphatic drainage of
skin in a sentinel lymph node in a feline model. Ann Surg.
1991;214:637–41.
30. Morton DL, Wen DR, Wong JH, et al. Technical details
of intraoperative lymphatic mapping for early stage mela-
noma. Arch Surg. 1992;127:392–9.
31. Levenback C, Burke TW, Gershenson DM, et al.
Intraoperative lymphatic mapping for vulvar cancer. Obstet
Gynecol. 1994;84(2):163–7.
32. Burke TW, Levenback C, Tornos C, et al. Intraabdominal
lymphatic mapping to direct selective pelvic and para-
aortic lymphadenectomy in women with high-risk endo-
metrial cancer: results of a pilot study. Gynecol Oncol.
1996;62(2):169–73.
33. Balch CM. Detection of melanoma metastases with the
sentinel node biopsy: the legacy of Donald L. Morton, MD
(1934–2014). Clin Exp Metastasis. 2018;35(5–6):425–9.
34. Singletary SE, Allred C, Ashley P, et al. Staging sys-
tem for breast cancer: revisions for the 6th edition of the
AJCC Cancer Staging Manual. Surg Clin North Am.
2003;83(4):803–19.
35. Balch CM, Soong SJ, Gershenwald JE, et al. Prognostic fac-
tors analysis of 17,600 melanoma patients: validation of the
American Joint Committee on Cancer melanoma staging
system. J Clin Oncol. 2001;19(16):3622–34.
36. NCCN Vulvar Squamous Cell Carcinoma Guidelines
Version 2.2021. Available from: www.nccn.org.
37. NCCN Guidelines Version 1.2021, endo-C, p. 1. Available
from: www.nccn.org.
38. NCCN guidelines version 1.2021 Cervical Cancer.
Available from: www.nccn.org.
39. Marcus RK, Lillemoe HA, Caudle AS. Facilitation of sur-
gical innovation: is it possible to speed the introduction of
new technology while simultaneously improving patient
safety? Ann Surg. 2019;270(6):937–41.
40. Chassin MR, Loeb JM. High-reliability health care: getting
there from here. Milbank Q. 2013;91(3):459–90.
41. Levenback CF. Editorial, International Journal of
Gynecologic Oncology, in Press.
2
Lymphatic anatomy: microanatomy and physiology

Erin K. Crane and Charles F. Levenback

CONTENTS
Introduction ...................................................................................................................................................................................... 9
Early studies of the lymphatic system ............................................................................................................................................. 9
Lymph and lymphatic vessels ........................................................................................................................................................ 10
Physiology...................................................................................................................................................................................... 10
Lymph nodes .................................................................................................................................................................................. 10
Immunology of regional lymph nodes........................................................................................................................................... 11
Surgical anatomy of the lymphatic system .................................................................................................................................... 12
Summary ........................................................................................................................................................................................ 13
References...................................................................................................................................................................................... 13

demonstrated hydrostatic and oncotic pressures within the

Introduction
Formed by an intricate network of lymphatic channels and
lymph nodes, the human lymphatic system performs many cru-
cial functions, including maintenance of interstitial and intra-
vascular equilibrium, fltration of immunogens and particulate
matter, and transport of lipids and immune cells. Lymphatics
are paramount in facilitating the immune response to patho-
gens and malignancy and directing interactions between
immune cells and antigens, ultimately determining whether to
engage in an immune response or tolerance. The purpose of
this chapter is to provide an overview of the lymphatic system
with an emphasis on how it relates to lymphatic mapping.
Early studies of the lymphatic system
Lymphatic vessels were frst detailed in ancient Greek writ-
ings of Hippocrates and Aristotle in the fourth century BC as
“fbers which take a position between blood vessels and nerves
and which contain a colorless liquid.”1 As cadaveric dissec-
tions became more accepted, knowledge of the human lym-
phatic system expanded. In the mid-1600s, Bartholin coined
the term ‘lymphatics,’ also recognizing lymphatic dysfunction
in ascites and edema.2 In the early 1700s, the French surgeon
Petit described lymphatic spread of breast cancer to axil-
lary lymph nodes.3 Virchow similarly described the involve-
ment of lymphatics in cancer, suggesting a role in fltration.4
Despite advances made by cadaveric dissection, lymphatic
study in vivo contributed the most knowledge to understand-
ing the details of the lymphatic system. In the 1890s, Starling
lymphatic system.5
At the start of the twentieth century, the clinical use of sur-
gery became more popular, and intraoperative observations
stimulated interest in lymphatic function. Braithwaite observed
that pigmented lymph nodes from an infected appendix could
be followed along the superior mesenteric artery to the duo-
denum and coined the term ‘glands sentinel’ after studying
omental lymph node drainage from an intestine.6 In 1938,
Gray studied freshly resected skin using thorium oxide injec-
tions (Thorotrast), which permitted a detailed study of skin
lymphatics.7 He further defned histologic criteria for identi-
fying lymphatics, including 1) endothelial lining, 2) frequent
semilunar valves, 3) connection of lymph vessels to lymph
glands, and 4) the presence of coagulated lymph or nothing in
the lymph channels.7 In the 1950s, Kinmoth injected contrast
into lymphatics, giving rise to the lymphoscintigram.8
Through injection of thorium oxide into freshly resected
breast tumors, Gray concluded that “the mode of spread of
cancer to lymph glands is generally by means of lymphatic
emboli of cancer cells carried along the lymph stream.”7 The
infuential William Halsted supported this concept in his
work on axillary lymph node dissections for breast cancer,
suggesting that malignancy spreads in an organized fashion
from lymph nodes to viscera.7,9 This view was debated by
many, particularly Tyzzer, who published the discovery of
metastatic disease in patients in the absence of regional lymph
node metastases.10 While our modern understanding of malig-
nancies incorporates concepts of both lymphatic and hema-
togenous dissemination, the basis of these historic works has
established lymph node assessment as an essential procedure
in surgical oncology.

DOI: 10.1201/9781003255536-2 9
10
Lymph and lymphatic vessels
Lymphatics permeate the human body, located in nearly every
organ except bone marrow, cartilage, and the cornea. It was
thought that the central nervous system lacked lymphatics,
until recently in 2015, when Louveau et al. demonstrated lym-
phatic vessels lining the dura within the brain.11
The lymphatic system begins with small lymphatic capil-
laries (terminal lymphatics), which function as sites of fuid
exchange. Terminal lymphatics have blind ends and are lined
by a single layer of overlapping endothelial cells, with fenes-
trations ranging in size from 10 to 25 μm12 (Figure 2.1). These
cells are anchored by collagen flaments to the surrounding
connective tissue. A combination of diapedesis, hydrostatic
forces, and colloidal gradients guides particles and fuid into
the gaps between overlapping endothelial cells. It has been
hypothesized that the contraction and relaxation of the fla-
ments facilitate permeation through the endothelial cells, form-
ing microvalves between the lymphatics and interstitium.13
Afferent (collecting) lymph channels are connected to the
terminal lymphatics. Unlike terminal lymphatics, collecting
lymphatic vessels lack flamentous attachments and possess
smooth muscle fbers and valves. The thicker afferent chan-
nels coalesce to form larger lymphatics that ultimately drain
to regional lymph nodes. Larger afferent channels contain an
inner layer of circular smooth muscle and may be located in
close proximity to blood vessels or contain vasa vasorum for
nutritional support13 (Figure 2.1). Secondary valves prevent
lymphatic backfow and delineate ‘lymphangions,’ or individ-
ual units with contractile properties.14
More recently, various lymphatic endothelial markers,
including PROX1 (prospero homeobox protein), LYVE1 (lym-
phatic vessel endothelial hyaluronan receptor 1), and VEGFR3
(vascular endothelial growth factor receptor-3), have aided in
the histologic detection of lymphatic channels and advanced
our understanding of lymphangiogenesis and lymphatic
anatomy.15–17
FIGURE 2.1 Blind terminal sacs of lymphatic capillaries with a single
overlapping layer of endothelial cells. These are 10–25 μm in diameter
and allow interstitial fuid to pass in and out of the lymphatic capillary.
(Modifed from Kam C, Uren RF. Microanatomy and physiology of the
lymphatic system. In: Nieweg O, et al, eds, Lymphatic Mapping and Probe
Applications in Oncology [Marcel Dekker: New York, 2000] 1–22.)
Clinical Lymphatic Mapping
Physiology
The body circulates 8–12 L of lymphatic fuid daily,13 much
of which occurs passively and depends on several factors,
including hydrostatic pressure, osmotic pressure, diffusion and
convection, and chemotaxis. Terminal lymphatics remain col-
lapsed under normal conditions until an increase in interstitial
pressure causes the anchoring flaments to pull the endothe-
lial cells apart, allowing an infux of lymph into the terminal
capillary. The larger channels containing smooth muscle then
contract and propel lymph fuid and particulate matter forward
through the lymph system, until it returns into the circula-
tion. The lymphatic system lacks a central pump and relies on
valves to prevent backfow of lymph. Lymphatic vessels have
very low pressure and are sensitive to small changes, requiring
only 2–4 cm of H2O to initiate rhythmic contractions.18 Gray
massaged tissue after injection to accelerate lymphatic fow.
Many clinicians still perform external massage during lym-
phatic mapping to enhance dispersal of dye.
In general, lymph fuid is clear and colorless, resembling
diluted plasma. The volume, rate of fow, and composition of
lymph vary with site and activity. The rate of lymphatic fow is
of particular clinical interest in sentinel node mapping and has
been characterized in various studies by employing lymphos-
cintigraphy. In lymphoscintigraphy, a tagged colloid is imaged
as it transits through lymphatics. Lymphatic fow varies based
on tissue type; for example, lymph travels slower in skin as
compared to skeletal muscle and is cleared much faster when
injected intradermally versus subcutaneously.19 In conditions
such as edema or lymphedema, lymphatic fow slows, whereas
during exercise or infammation fow rate increases. Anatomic
location affects fow rate, with the lowest rate observed in the
head and neck and the highest rate in the lower extremity.20
From a gynecologic perspective, the primary tumor in
patients with vulvar, cervical, or uterine cancers is relatively
close to the regional lymph node bed, and therefore both dye
and radionuclide are transferred quickly to the sentinel node
or nodes. In endometrial cancer, for example, time from injec-
tion of indocyanine green in the cervix to pelvic lymph node
visualization approximates 5 minutes and lasts up to 1 hour.21
Lymph nodes
Spread throughout the body are small, bean-shaped lymph
nodes (Figure 2.2). Lymph nodes are highly complex organs
which function as the primary antigen recognition site in the
body and act as flters for particulate matter, antigens, and can-
cer cells.
Afferent lymphatics transport lymphatic fuid into lymph
nodes, which enters the medullary sinus – a common site for
small metastases. The lymph fuid fows through the medulla
and germinal centers of the lymph node and then exits the
efferent channel. The lymphatics of the lower extremities
and pelvis coalesce into large collecting ducts and ultimately
form the thoracic duct. The thoracic duct and right lym-
phatic duct join the venous system at the junction of the left
subclavian and jugular veins (Figure 2.3). Consequently, the
Anatomy: microanatomy and physiology
FIGURE 2.2 Anatomy of a lymph node. Lymph nodes flter debris from
lymph and are a critical site of antigen presentation and immune activa-
tion. (Modifed from Kam C, Uren RF. Microanatomy and physiology of
the lymphatic system. In: Nieweg O, et al, eds, Lymphatic Mapping and
Probe Applications in Oncology [Marcel Dekker: New York, 2000] 1–22.)
FIGURE 2.3 Main lymphatic collecting trunks have valves that ensure
unidirectional fow. (Modifed from Kam C, Uren RF. Microanatomy and
physiology of the lymphatic system. In: Nieweg O, et al, eds, Lymphatic
Mapping and Probe Applications in Oncology (Marcel Dekker: New
York, 2000) 1–22.)
11
left supraclavicular lymph nodes represent a common site for
metastases from gynecologic cancers.
The afferent lymphatics transport lymphocytes and antigen-
presenting cells (APCs) into the lymph nodes, which are then
directed by stromal chemokines toward their designated loca-
tions and roles.22 Dendritic cells present antigens to T-cells
within the lymph node cords, whereas follicular dendritic cells
present antigens to B-cells within the lymph node follicles.23
Lymphocytes that do not encounter antigens exit the lymph
node and continue on to other lymph nodes.
Lymph node metastases occur when detached malignant
cells enter the lymphatic circulation and drain through regional
lymph nodes. Some tumors such as sarcomas spread primar-
ily hematogenously with a low rate of lymph node metastases,
while others, such as carcinoids, may produce larger lymph
node metastases than the primary tumor size itself. In gyne-
cologic malignancies such as endometrial adenocarcinomas
and squamous cell carcinomas of the vulva and cervix, lymph
node status is the single most important prognostic factor.
Immunology of regional lymph nodes
Within the last 10 years, our knowledge of the immune
response to cancer has grown exponentially. Paradoxically,
lymph nodes and the immune system can both inhibit and
permit the propagation of metastatic disease. Dendritic cells
bearing tumor antigens may migrate from the periphery into
the lymph node, or antigens may drain directly into the node
itself, where APCs within the node such as macrophages, fol-
licular dendritic cells, or B-cells may detect them and induce
an immunologic response – or conversely – immunogenic
tolerance.24
In one study where melanoma cells were injected directly
into lymph nodes, a CD8+ cytotoxic response resulted in cell
death.25 Another group found that lymphocytes harvested
from lymph nodes were less likely to inhibit melanoma cell
line growth when taken closer to the primary tumor, whereas
more distant lymph nodes were more effective at inducing
apoptosis.26 These observations support the belief that after
an initial robust immune response, eventually the continued
exposure to tumor antigens results in exhaustion, with antigen
tolerance and immunosuppression.24 Additionally, the sentinel
nodes play an important role in the ‘premetastatic niche’ and
are primed by tumor-secreted factors such as vascular endo-
thelial growth factor (VEGF), which induce lymphangiogen-
esis and augment lymphatic fow, thus preparing the “soil for
the seed.”27
In the feld of gynecologic oncology, a similar microenvi-
ronment of relative immune suppression has been observed
in sentinel lymph nodes. In cervical cancer, Heeren and col-
leagues found that in comparison to nonmetastatic tumor-
draining lymph nodes, those with metastases had molecular
profles more associated with immune suppression.28 An anal-
ysis of dendritic cells in sentinel and nonsentinel lymph nodes
in endometrial and cervical cancer indicated that while the
dendritic cells in the sentinel nodes had a higher concentration
of markers of immune stimulation, those with metastases had
a lower number of mature dendritic cells, suggesting relative
12 Clinical Lymphatic Mapping

immune suppression.29 Concordantly, Baiocchi and colleagues nodes.33 Fortunately, the wide acceptance of sentinel lymph
demonstrated that the size of the sentinel lymph node metas- node mapping in uterine, cervical, and vulvar cancer has nul-
tasis was associated with the risk of nonsentinel lymph node lifed the importance of lymph node count.
metastases.30 This suggests that perhaps a smaller antigenic While a full lymphadenectomy with a higher lymph node
load may allow the sentinel node to retain its immunogenic- count may portend an improved diagnostic sensitivity, it also
ity. This may also account for the observation that the pres- causes an increased risk of surgical complications. Such com-
ence of isolated tumor cells within sentinel nodes is generally plications may range from incisional infections to lymphocyst
clinically insignifcant in a range of malignancies. Fattorossi et formation. While most lymphocysts may undergo expectant
al. described differences in lymphocyte composition between management, some require drainage, surgical intervention,
lymph nodes more proximal to the tumor site than the more or even sclerotherapy. Extensive lymphadenectomy may also
distal ones in patients with endometrial and cervical cancer.31 result in lymphedema, most commonly experienced in the
The notion that sentinel nodes eventually become over- lower extremities in patients with gynecologic malignancies.
whelmed by antigens while more distant lymph nodes remain Surgically induced lymphedema occurs as a result of lymphatic
immunocompetent supports the practice of sentinel lymph disruption, with subsequent pooling of lymph and increased
node mapping in gynecologic malignancies, in addition to the lymphatic pressure required to bypass the obstructed site
concept that full lymphadenectomy is not superior to sentinel (Figure 2.5). Interventions such as compression hose, sequen-
lymph node mapping. tial compression devices, massage, and simple elevation all
Much more work is required in these areas to understand can help control lymphedema but cannot fully reverse it. In
fully the metastatic process in sentinel lymph nodes and how a large review of 1000 lymphadenectomies for gynecologic
to use this knowledge in treatment strategies. malignancies, Querleu et al. reported 71 lymphocysts, 15% of
which required intervention.34 In vulvar cancer, full inguino-
femoral lymphadenectomy harbors a 30% lymphedema rate,
Surgical anatomy of the lymphatic system
Lymphatic channels are usually not visible during surgery, but
with the advent of lymphatic mapping, often a blue or green
channel becomes visible (Figure 2.4). Similarly, lymph nodes
vary in size and consistency so that some, but not all, nodes
are visible or palpable during surgery. Lymphatics may be
disrupted during surgery without any adverse consequences,
owing to a large network of low-pressure lymphatic vessels
with extensive collateral fow.
Surgeons often note a wide variation in the number of
regional lymph nodes described in surgical pathology reports.
Historically, a higher lymph node yield corresponded to a
higher sensitivity in detecting lymph node metastases and, as
some suggested, even a better prognosis.32 Perhaps as impor-
tant, lymph node yield is often interpreted as an indication of
surgical skill. However, lymph node count not only varies by
surgeon but also by pathologist and method of isolating lymph

FIGURE 2.5 Various degrees of lymphedema. Mild lymphedema

(a) causes little effect on lifestyle. Moderate lymphedema (b) requires
FIGURE 2.4 Larger lymphatic trunks may be seen during lymphatic compression devices and massage; however, most patients continue to
mapping. function well. Severe lymphedema (c) is debilitating.
Anatomy: microanatomy and physiology 13

Summary
Our understanding of lymph node physiology and immunol-
ogy is ever-expanding. Lymph nodes, especially sentinel
nodes, are the site of the initial immune response, but also
play an important role in immune tolerance and immuno-
genic escape. Lymphatic mapping and sentinel node biopsy
provide an opportunity to narrow the focus of basic science
and translational, as well as clinical, investigation. As such,
future research should focus on exploiting the differences in
sentinel and nonsentinel nodes and harnessing the potential of
immunology.

REFERENCES
FIGURE 2.5 (Continued)
with an even higher incidence in patients requiring adjuvant
radiation.35 Indeed, sentinel lymph node mapping offers a
signifcant decrease in such complications, which will be dis-
cussed in more detail in subsequent chapters.
1. Crivellato E, Travan L, Ribatti D. The Hippocratic trea-
tise ‘on glands’: the frst document on lymphoid tissue and
lymph nodes. Leukemia. 2007;21:591–2.
2. Rusznyak I. [Signifcance of lymphatic circulation]. Orv
Hetil. 1959;100:1857–63.
3. Olson JS. Bathsheba’s Breast: Women, Cancer, and History.
1st ed. Baltimore, MD: The Johns Hopkins University
Press; 2005. pp. 27–45.
4. Loukas M, et al. The lymphatic system: a historical per-
spective. Clin Anat. 2011;24:807–16.
5. Taylor AE. Capillary fuid fltration. Starling forces and
lymph fow. Circ Res. 1981;49:557–75.
6. Braithwaite L. Flow of lymph from iliocecal angle. Br J
Surg. 1923;11:7.
7. Gray J. The relation of lymphatic vessels to the spread of
cancer. Br J Surg. 1938;26:462–95.
8. Liapis C, Balzer K, Benedetti-Valentinni F. Vascular
Surgery. Berlin: Springer; 2007.
9. Halsted WS, Dahlen G, Ohman AE. The results of opera-
tions for the cure of cancer of the breast performed at
the Johns Hopkins Hospital from June, 1889, to January,
1894. The Johns Hopkins Hospital Reports. Ann Surg.
1894;20(5):497–555.
10. Tyzzer EE. Factors in the production and growth of tumor
metastases. J Med Res. 1913;28:309–32;301.
11. Louveau A, et al. Structural and functional features
of central nervous system lymphatic vessels. Nature.
2015;523:337–41.
12. Tanis PJ, Nieweg OE, Valdes Olmos RA, et al. Anatomy
and physiology of lymphatic drainage of the breast from
the perspective of sentinel node biopsy. J Am Coll Surg.
2001;192:399–409.
13. Breslin JW, et al. Lymphatic vessel network structure and
physiology. Compr Physiol. 2018;9:207–99.
14. Mislin H. Active contractility of the lymphangion
and coordination of lymphangion chains. Experientia.
1976;32:820–2.
15. Wigle JT, et al. An essential role for Prox1 in the induc-
tion of the lymphatic endothelial cell phenotype. EMBO J.
2002;21:1505–13.
16. Thiele W, Rothley M, Schmaus A, et al. Flow cytometry-
based isolation of dermal lymphatic endothelial cells from
newborn rats. Lymphology. 2014;47:177–86.
17. Jussila L, et al. Lymphatic endothelium and Kaposi’s sar-
coma spindle cells detected by antibodies against the
14
vascular endothelial growth factor receptor-3. Cancer Res.
1998;58:1599–604.
18. Aukland K, Reed RK. Interstitial-lymphatic mechanisms
in the control of extracellular fuid volume. Physiol Rev.
1993;73:1–78.
19. Modi S, Stanton AW, Mortimer PS, et al. Clinical assess-
ment of human lymph fow using removal rate constants of
interstitial macromolecules: a critical review of lympho-
scintigraphy. Lymphat Res Biol. 2007;5:183–202.
20. Uren RF, Howman-Giles RB, Thompson JF. Demonstration
of second-tier lymph nodes during preoperative lymphos-
cintigraphy for melanoma: incidence varies with primary
tumor site. Ann Surg Oncol. 1998;5:517–21.
21. Choi HJ, et al. Time-lapse imaging of sentinel lymph node
using indocyanine green with near-infrared fuorescence
imaging in early endometrial cancer. J Gynecol Oncol.
2016;27:e27.
22. Gasteiger G, Ataide M, Kastenmuller W. Lymph node – an
organ for T-cell activation and pathogen defense. Immunol
Rev. 2016;271:200–20.
23. Willard-Mack CL. Normal structure, function, and histol-
ogy of lymph nodes. Toxicol Pathol. 2006;34:409–24.
24. Sleeman JP. The lymph node pre-metastatic niche. J Mol
Med (Berl). 2015;93:1173–84.
25. Preynat-Seauve O, et al. Extralymphatic tumors pre-
pare draining lymph nodes to invasion via a T-cell cross-
tolerance process. Cancer Res. 2007;67:5009–16.
26. Farzad Z, et al. Lymphocytes from lymph nodes at different
distances from human melanoma vary in their capacity to
inhibit/enhance tumor cell growth in vitro. Melanoma Res.
1997;7(Suppl 2):S59–65.
Clinical Lymphatic Mapping
27. Qian CN, et al. Preparing the ‘soil’: the primary tumor
induces vasculature reorganization in the sentinel lymph
node before the arrival of metastatic cancer cells. Cancer
Res. 2006;66:10365–76.
28. Heeren AM, et al. Nodal metastasis in cervical cancer occurs
in clearly delineated felds of immune suppression in the pel-
vic lymph catchment area. Oncotarget. 2015;6:32484–93.
29. Kara PP, et al. Analysis of dendritic cells in sentinel lymph
nodes of patients with endometrial and patients with cervi-
cal cancers. Int J Gynecol Cancer. 2009;19:1239–43.
30. Baiocchi G, Salani R. Meeting report from the 19th meet-
ing of the International Gynecologic Cancer Society
(IGCS) 2019: summary of selected abstracts and meeting
highlights. Gynecol Oncol. 2019;155:389–92.
31. Fattorossi A, et al. Lymphocyte composition of tumor
draining lymph nodes from cervical and endometrial can-
cer patients. Gynecol Oncol. 2004;92:106–15.
32. Abu-Rustum NR, et al. Is there a therapeutic impact
to regional lymphadenectomy in the surgical treat-
ment of endometrial carcinoma? Am J Obstet Gynecol.
2008;198:457:e451–5; discussion 457:e455–6.
33. Cormier B, Sauthier P, Lussier C, et al. Determinants of
lymph node count in endometrial cancer surgical staging.
Int J Gynecol Cancer. 2012;22:1361–6.
34. Querleu D, et al. Audit of preoperative and early compli-
cations of laparoscopic lymph node dissection in 1000
gynecologic cancer patients. Am J Obstet Gynecol.
2006;195:1287–92.
35. Huang J, Yu N, Wang X, et al. Incidence of lower limb
lymphedema after vulvar cancer: a systematic review and
meta-analysis. Medicine (Baltimore). 2017;96:e8722.
3
Lymphatic anatomy: lymphatics of the vulva

Anca Chelariu-Raicu and Robert L. Coleman

CONTENTS
The vulva........................................................................................................................................................................................ 15
Embryology of the vulva and the groin................................................................................................................................ 15
Topography of the vulva....................................................................................................................................................... 15
Topography of the inguinal lymphatics................................................................................................................................ 15
Superfcial inguinal lymphatics ............................................................................................................................................ 17
Femoral (deep) inguinal lymphatics..................................................................................................................................... 17
Lymphatic drainage .............................................................................................................................................................. 18
Natural history and patterns of spread ........................................................................................................................................... 18
Illustration of the anatomy of the groin ......................................................................................................................................... 19
Summary ........................................................................................................................................................................................ 22
References...................................................................................................................................................................................... 22

The vulva
In certain respects, understanding the anatomy of the vulva, its
targeted nodal basin, and its directed, physiologic lymphatic
drainage should provide the clearest insight into why lymphatic
mapping as a surgical procedure garners clinical relevance.
Detailed study of this anatomy coupled with clinical correlates
of patients with vulvar carcinoma has dictated surgical care, of
which lymphatic mapping and sentinel lymph node biopsy have
become standard procedures over en bloc nodal resection. This
section will highlight the anatomy of the vulva and the groin,
drawing on embryologic and postmortem studies, which have
challenged the traditional concepts of nodal location and thus
are important to surgical concepts guiding management.
(Figure 3.1). Superfcially, these structures consist of, or are
covered by, a keratinized, stratifed, squamous epithelium to
the level of the vestibule, where the epidermis becomes a non-
keratinized squamous mucous membrane. The vulvar struc-
tures are situated atop the superfcial perineal fascia, a caudal
continuation of the abdominal Scarpa’s layer. Support is given
to the vulva through loose attachment to this fascia. Deep to
this layer are the erectile and muscular contents of the genital
foor (Figure 3.2). The deep or inferior fascia of the urogenital
diaphragm, on which the clitoris and ischiocavernosus, bul-
bocavernosus, and deep transverse perineal muscles lie, is an
important surgical landmark indicating the deep margin of
locoregional resection. This fascial layer becomes continuous
with the fascia lata laterally.

Embryology of the vulva and the groin
Embryologically, the external female genitalia arise from undif-
ferentiated tissues that comprise the genital tubercle, labio-
scrotal swellings, and urogenital folds.1 In the absence of fetal
androgens, further differentiation of these tissues forms the
external female phenotype, which is distinguishable 12 weeks
after fertilization. Ambiguity of this differentiation can result
from the presence of exogenous or endogenous sex steroids dur-
ing development; however, the null phenotype is female.
Topography of the vulva
The vulva comprises the mons pubis, the clitoris, the labia
majora and minora, the vestibule (urethral meatus and
hymenal remnant), the perineal body, the associated erectile
tissues and muscles, and the supporting subcutaneous tissues
Topography of the inguinal lymphatics
The landmarks and topographic anatomy of the groin are illus-
trated in Figure 3.3. The same keratinizing squamous epithe-
lium that covers the vulva covers the groin. Deep to the skin is
the subcutaneous tissue, which is divided by the superfcial, or
Camper’s, fascia. Dorsal to this layer is fatty tissue containing
the superfcial inguinal nodes and the superfcial vasculature,
such as the superfcial external circumfex vessels, the super-
fcial inferior epigastric vessels, and the superfcial external
pudendal vessels. Removal of this layer reveals the deep femo-
ral fascia, which is continuous laterally with the fascia lata of
the thigh and medially with the fascia of the adductor longus
muscle, and which is coplanar with the inferior fascia of the
urogenital diaphragm. The fossa ovalis is demarcated by the
falciform, or Hey’s, ligament and is perforated by the great
saphenous vein and other small vessels. As described later, the

DOI: 10.1201/9781003255536-3 15
16 Clinical Lymphatic Mapping

FIGURE 3.1 The external female genitalia are highlighted with the major anatomic landmarks.

FIGURE 3.2 The deep vulvar tissues are positioned in relation to the deep perineal fascia (urogenital diaphragm).

FIGURE 3.3 The topographic anatomy of the groin is presented (right side).
Anatomy: lymphatics of the vulva
perforate covering over the fossa is most aptly termed the crib-
riform lamina. Below the femoral fascia lies the femoral ves-
sels and nerve, along with the deep musculature of the groin.
The femoral or deep inguinal nodes are located along the fem-
oral vein and usually within the fossa ovalis. The most supe-
rior node is commonly referred to as the node of Rosenmüller
or Cloquet.
Lymphatic drainage of the vulva (and the lower third of the
vagina) goes principally to the groin by traversing the subcuta-
neous tissue medial to the labial-crural fold. The node groups
are situated in the subcutaneous tissue overlying the femoral
triangle (Scarpa’s triangle) bounded by the inguinal ligament
cephalad, the sartorius muscle inferior-laterally, and the adduc-
tor longus medially Anatomically, these nodes are categorized
as ‘superfcial’ and ‘deep’ according to their location in refer-
ence to the fascia lata and position in the fossa ovalis (Figure
3.4). Traditional illustrations of the fossa ovalis depict it as cov-
ered by a perforated membrane contiguous with the fascia lata
called the cribriform fascia. However, embryologic studies have
documented that this ‘fascia’ is actually distinct from the fascia
lata (femoral portion) and develops in midgestation (23–24 fetal
weeks) from the connective tissue of the fossa ovalis.2–4 Through
condensation, the connective tissue’s superfcial layer becomes
a thickened membrane; therefore, it is more correctly termed
cribriform ‘lamina.’ This distinction is important and relevant
to the anticipated location of the inguinal nodes, as embryologic
nodal buds, which make up the deep femoral chain, arise from
superfcial nodes in this same connective tissue.
Superficial inguinal lymphatics
The superfcial inguinal nodal group primarily receives afferent
channels from the vulvar tissues traversing the labia and mons
veneris. This group contains approximately ten nodes, which
lie in the subcutaneous tissue in or around the fossa ovalis and
the saphenous vein and its tributaries. Detailed topographic
studies of this nodal group have demonstrated that these nodes
lie uniformly within Scarpa’s triangle. Medially and inferi-
orly, the superfcial bundle is limited by the femoral triangle.
FIGURE 3.4 The superfcial inguinal nodes are illustrated in relationship to the femoral fascia and fossa ovalis.
17
Nicklin et al. detailed this nodal group location in reference
to anatomic-surgical landmarks, such as the anterior superior
iliac spine and the pubic tubercle, using lymphangiography.5
They noted that the most lateral node in this group was never
positioned in the outer 15% of the right inguinal ligament or the
outer 20% of the left inguinal ligament. A subsequent study by
Micheletti et al. correlated this observation anatomically and
embryologically as being associated with the superfcial exter-
nal circumfex vasculature.3,6 In their study of preterm fetuses,
nodal tissue was identifed around these vessels and never lat-
eral to the crossing of the medial border of the sartorius muscle
and the inguinal ligament. Rob et al. proposed another distribu-
tion of superfcial nodes into three groups: superfcial medial
group (Sf-M), located above and medially from the femoral
vein and medially to the great saphenous vein; superfcial inter-
mediate group (Sf-IM), including nodes in the vicinity of the
saphenous and femoral veins and superior-laterally from them;
and superfcial lateral group (Sf-L) as the group of nodes in
the outer third of the groin.7 The authors reported the highest
percentage of nodes in the medial group (50%), followed by the
intermediate group (34.7%). The surgical implications of these
fndings support limiting the lateral extent of skin and groin
nodal dissection, which in turn may reduce operative morbidity
by not disrupting important potential collateral lymphatic fow.
Femoral (deep) inguinal lymphatics
The femoral or deep nodes, as mentioned, develop embryo-
logically from a nodal mass, which is situated by 11 weeks’
gestation on top of the femoral fascia. During gestation, the
connective tissue of the fossa proliferates and differentiates,
dividing the nodal bundle into individual nodes. A few, usually
one to fve in total, migrate in the fossa to lie along the femoral
vein and become the femoral nodes.6 Cadaveric studies of the
groin have found that these nodes are most often found at or
below the junction of the saphenous vein with the femoral vein
(Figure 3.5). In one-third of cases, the nodal tissue is located
cephalad to this point.2 All nodal tissue appears to be bound
by the margins of the fossa ovalis. No nodal tissue is found
18
FIGURE 3.5 The relationship between the deep inguinal nodes and the femoral triangle is depicted.
beneath the fascia lata in any direction, and it is never located
lateral to the femoral artery. Interestingly, Cloquet’s node in
their series was identifed in just 46% of the dissections and
was unilateral in 30%, rendering it an imperfect marker of
cephalad nodal extent. It is hypothesized that this node’s loca-
tion is also variably identifed as the most distal node in the
external iliac chain. Rob et al. reported 16.1% of deep inguinal
nodes from all the nodes dissected in the groin.7
Lymphatic drainage
The clinically important features of in vivo vulvar lymphatic
drainage, frst described by Eichner and later by Parry-Jones,
are that ipsilateral fow from the vulva does not cross the labial-
crural fold laterally and that, in general, only midline struc-
tures (clitoris and perineum) have bilateral efferent drainage.8,9
Previously observations regarding the direct communication of
the clitoral lymphatics to the pelvis, although this is clinically
very rare, have been confrmed by a more recent study. The pre-
viously mentioned results showed that the risk of contralateral
nonsentinel metastasis in the case of bilateral sentinel mapping
with unilateral positivity is very low.10 Ordered lymphatic fow
from the vulva generally goes to the superfcial group frst, fol-
lowed by drainage to the femoral nodes. From there, the efferent
channels pass under the inguinal ligament in the femoral canal
to communicate with the external iliac and pelvic nodal chains.
Lymphatic mapping studies in women undergoing groin dissec-
tion for cancer of the vulva have confrmed the variable location
of the sentinel node, although it is most commonly a medi-
ally located superfcial node near the fossa ovalis.11 Confusion
regarding the existence of direct vulvar lymphatic drainage to the
pelvis has been confounded by different in vivo mapping tech-
niques. However, studies that have used intradermal injection
demonstrate exclusive primary lymphatic drainage to the groin.
However, studies using deep subcutaneous injections have shown
direct drainage to the pelvis. Clinical experience has indicated
that the best candidates for lymphatic mapping of cutaneous
tumors are those with small, superfcial tumors that essentially
have exclusive lymphatic drainage via cutaneous lymphatics.
Clinical Lymphatic Mapping
Natural history and patterns of spread
Although many tumor cell types can arise within the vulva or
its associated adnexal structures, most primary carcinomas of
the vulva are squamous cell and arise from the epithelium.12
The most frequent sites of involvement are the labia minora,
clitoris, fourchette, perineal body, and medial labia majora.
The classic pattern of growth and spread is local extension and
lymphovascular embolization to either regional or distant sites.
With the exception of vulvar melanoma, the pattern of spread
is relatively predictable. Local growth of the primary carci-
noma generally occurs in a radial pattern, as well as invad-
ing deep into the underlying subcutaneous tissues. Objective
measures of this growth have been standardized with creation
of the TNM staging system.13 In this manner, the tumor is
described in reference to size (T1 ≤2 cm, T2 >2 cm), involve-
ment of the distal midline structures (T3: urethra, vagina, and
anus), and invasion of the midline organs (T4: bladder mucosa,
upper urethra, and rectal mucosa) or bony fxation.
Once invasion occurs, the tumor can spread via the dermal
lymphatics to the regional nodes following the previously
described pattern of fow. There appears to be a threshold with
regard to the likelihood of groin metastatic disease based on
the depth of invasion. Kelley and colleagues reported that the
frequency of metastatic disease among 24 patients with 1 mm
or less of invasion (measured as depth of deepest invasion from
the most proximal adjacent rete peg) was 0%.14 In contrast,
tumors with >1 mm invasion have a risk of nodal metastases
of up to 34%.15 This observation has led to a subclassifcation
of stage I disease (IA: T1 lesion with 1-mm invasion or less,
IB: T1 lesion with greater than 1-mm invasion), with the clini-
cal implication being that nodal dissection may safely be dis-
missed in these patients. Another group investigated in their
study an alternative method of measuring the depth of invasion
(from the basement membrane of the deepest adjacent tumor-
free rete ridge to the deepest point of invasion) and evaluated
its accuracy by comparing it with the conventional method of
measuring and clinical outcome. Interestingly, the fndings
Anatomy: lymphatics of the vulva
of this study showed that by using the alternative measur-
ing method 19% of patients with FIGO stage IB tumor were
downstaged to FIGO stage IA, and in consequence would have
spared these patients from groin surgery.16 However, the alter-
native method of measuring needs further clinical validation;
therefore, the conventional one remains the standard.
The current management of early vulvar cancer is separate
resection of the primary tumor and the at-risk groin(s).17–19
Careful inspection of en bloc tumor resections and biopsies by
Cherry and Glücksmann demonstrated that tumor lymphatic
emboli were present in only 19% of cases.20 Clinically, recur-
rences in the retained skin bridges among patients undergo-
ing separate incision removal of the primary lesion and the
regional lymphatics are uncommon. This observation would
support the hypothesis that lymphatic metastases occur as a
result of embolization rapidly and most often without interval
deposition of viable tumor.
FIGURE 3.6 (a, b, and c) Lymphatic anatomy of the right groin as demonstrated in 1971 by Plentl and Friedman27 (redrawn for added clarity).
19
Illustration of the anatomy of the groin
There is no other anatomic area of concern to gynecologic
oncologists where so much confusion reigns regarding anat-
omy and nomenclature as the groin. The nomenclature issues
have been explored in detail by several authors.2,3,21 Confusion
regarding nomenclature has been compounded by errors in
illustration of groin anatomy that are propagated by new com-
ment on the subject. This section will review the efforts of pre-
vious illustrators to depict groin anatomy, as well as identify
the most accurate images.
In 1971, Plentl and Friedman offered a new set of illustra-
tions of the groin that were widely imitated22 (Figure 3.6a–c).
In Figure 3.6a, the general location of the superfcial ingui-
nal nodes are accurate; however, the number (fve) is fewer
than the eight to ten commonly found. In all the fgures, the
20 Clinical Lymphatic Mapping

superfcial and femoral nodes are shown as the same size. It is
common for the nodes to vary in size; sentinel nodes are usu-
ally at least 1 cm in size.
In the cross-section in Figure 3.6c, the patient is very thin,
as there is almost no fat between the skin and Camper’s fas-
cia. This fgure shows the superfcial nodes very close to the
skin. In other patients, the ‘superfcial’ inguinal nodes can
be very ‘deep’ to the skin due to a thick layer of subcutane-
ous fat. This overlooked observation contributed to the poor
results observed with external beam radiation therapy by
the Gynecologic Oncology Group.23 The cribriform fascia is
depicted as a bold black line separating the superfcial and
femoral nodes. As described earlier, this structure is more
appropriately described as a lamina.
Figures drawn by Cabanas24 to illustrate the location of sen-
tinel nodes in the male groin were modifed by DiSaia et al. in
1979 to depict the location of the superfcial inguinal nodes25
(Figure 3.7a). This fgure shows the nodes as being rather large
and shows ‘sentinel’ nodes in multiple sites. Current map-
ping experience suggests that sentinel nodes are usually at
the medial edge of the femoral triangle and rarely lateral to
the saphenous vein. DiSaia et al. also introduced a new cross-
section illustration of the groin (Figure 3.7b). This illustration
shows seven nodes in a single cross-section, with the femo-
ral nodes larger than the superfcial nodes, the femoral nodes
lateral to the femoral artery, and the cribriform fascia as a
continuous thick structure. This illustration has been updated
to portray more accurately cribriform fascia as fenestrated
(Figure 3.8). In addition, the traditionally described ‘femo-
ral’ nodes are now within the fossa ovalis, and the distinc-
tion of these nodes as ‘below’ the cribriform fascia has been
de-emphasized.

FIGURE 3.7 (a and b) Sentinel lymph nodes and inguinal femoral anatomy as illustrated by DiSaia et al.25 (redrawn for added clarity).

FIGURE 3.8 Further update of cross-sectional anatomy of the groin (redrawn from Ref. 28 for added clarity).
Anatomy: lymphatics of the vulva 21

Other texts have taken a different approach (Figure 3.9a–b). fascia follows an undulating path with the appearance of all the
In Figure 3.9a, the lymphatics of the vulva appear to cross lymph nodes ‘above’ this structure. Rouzier et al.26 attempted
the labial-crural fold, contrary to the work of Parry-Jones.7 In to illustrate the levels of the groin with schematic diagrams that
Figure 3.9b, Camper’s fascia is not shown, and the cribriform show the extent of various surgical approaches (Figure 3.10).

FIGURE 3.9 (a and b) Vulvar and inguinal lymphatic anatomy (redrawn from Ref. 29 for added clarity).

FIGURE 3.10 Operative (A) and cross-sectional (B) anatomy of the groin. a, fascia lata; b, fossa ovalis; c, great saphenous vein; d, superfcial epigas-
tric vein; e, inguinal ligament. The compartments of the groin are (1) superfcial medial inguinal nodes, (2) medial femoral nodes, and (3) superfcial
lateral inguinal nodes. Sentinel nodes are most commonly found in compartment 1 and sometimes in compartment 3. Femoral sentinel nodes are rarely,
if ever, seen. (Redrawn from Ref. 26 for added clarity.)
22
Summary
The anatomic considerations of the vulva and groin continue
to play a vital role in the evolution of contemporary manage-
ment strategies. Lymphatic mapping and sentinel node pro-
cedures have led to a better understanding of in vivo groin
anatomy, particularly since the blue dye procedure allows
clear visualization of lymphatic channels and lymph nodes. It
is anticipated that future study will further elucidate important
selection criteria whereby patients will undergo individualized
curative extirpative surgery with minimal morbidity.
REFERENCES
1. Langman J. Urogenital system. In: Langman J, editor,
Medical Embryology. Baltimore, MD: William & Wilkins;
1981. pp. 255–9.
2. Borgno G, Micheletti L, Barbero M, et al. Topographic
distribution of groin lymph nodes. J Reprod Med.
1990;35:1127–9.
3. Micheletti L, Preti M, Zola P, et al. A proposed glossary
of terminology related to the surgical treatment of vulvar
carcinoma. Cancer. 1998;83:1369–75.
4. Micheletti L, Levi AC, Bogliatto F, et al. Rationale and
defnition of the lateral extension of the inguinal lymphad-
enectomy for vulvar cancer derived from an embryological
and anatomical study. J Surg Oncol. 2002;81:19–24.
5. Nicklin JL, Hacker NF, Heintze SW, et al. An anatomi-
cal study of inguinal lymph nodes topography and clinical
implications for the surgical management of vulval cancer.
Int J Gynecol Cancer. 1995;5:128–33.
6. Micheletti L, Levi AC, Bogliatto F. Anatomosurgical impli-
cations derived from an embryological study of Scarpa’s tri-
angle with particular reference to groin lymphadenectomy.
Gynecol Oncol. 1998;70:358–64.
7. Rob L, Robova H, Pluta M, et al. Further data on senti-
nel lymph node mapping in vulvar cancer by blue dye and
radiocolloid Tc99. Int J Gynecol Cancer. 2007;17(1):147–53.
8. Parry-Jones E. Lymphatics of the vulva. J Obstet Gynecol
Br Commonwealth. 1963;70:751–65.
9. Eichner E, Mallin LP, Angell ML. Further experience with
direct sky blue in the in vivo studies of gynecologic lym-
phatics. Am J Obstet Gynecol. 1955;69:1019–26.
10. Woelber L, Eulenburg C, Grimm D, et al. The risk of con-
tralateral non-sentinel metastasis in patients with primary
vulvar cancer and unilaterally positive sentinel node. Ann
Surg Oncol. 2016;23(8):2508–14.
11. Levenback C, Coleman RL, Burke TW, et al. Intraoperative
lymphatic mapping and sentinel node identifcation with
blue dye in patients with vulvar cancer. Gynecol Oncol.
2001;83:276–81.
12. Wilkinson E. Premalignant and malignant tumors of the
vulva. In: Kurman R, editor, Blaustein’s Pathology of the
Female Genital Tract. New York: Springer-Verlag; 1994.
pp. 87–129.
Clinical Lymphatic Mapping
13. AJCC. Cancer Staging Manual. Atlanta, GA: Lippincott-
Raven; 1997.
14. Kelley JL, Burke TW, Tornos C, et al. Minimally invasive
vulvar carcinoma: an indication for conservative surgical
therapy. Gynecol Oncol. 1992;44:240–4.
15. Burke TW, Levenback C, Coleman RL, et al. Surgical ther-
apy of T1 and T2 vulvar carcinoma: further experience with
radical wide excision and selective inguinal lymphadenec-
tomy. Gynecol Oncol. 1995;57:215–20.
16. Yoder BJ, Rufforny I, Massoll NA, et al. Stage IA vulvar
squamous cell carcinoma: an analysis of tumor invasive
characteristics and risk. Am J Surg Pathol. 2008;32(5):765–
72. https://doi.org/10.1097/PAS.0b013e318159a2cb. PMID:
18379417.
17. van den Einden LC, Massuger LF, Jonkman JK, et al. An
alternative way to measure the depth of invasion of vulvar
squamous cell carcinoma in relation to prognosis. Mod
Pathol. 2015;28(2):295–302.
18. Berman ML, Soper JT, Creasman WT, et al. Conservative
surgical management of superfcially invasive stage I vulvar
carcinoma. Gynecol Oncol. 1989;35:352–7.
19. Hacker NF, Berek JS, Lagasse LD, et al. Individualization
of treatment for stage I squamous cell vulvar carcinoma.
Obstet Gynecol. 1984;63:155–62.
20. Cherry C, Glucksmann A. Lymphatic embolism and lymph
node metastasis in cancers of vulva and of uterine cervix.
Cancer. 1955;8:564.
21. Levenback C, Morris M, Burke TW, et al. Groin dissection
practices among gynecologic oncologists treating early vul-
var cancer. Gynecol Oncol. 1996;62:73–7.
22. Plentl AA, Friedman EA. Clinical signifcance of the vul-
var lymphatics. In: Lymphatic System of Female Genitalia.
Philadelphia, PA: W.B.Saunders; 1971. pp. 27–50.
23. Stehman FB, Bundy BN, Thomas G, et al. Groin dissec-
tion versus groin radiation in carcinoma of the vulva: a
Gynecologic Oncology Group study. Int J Radiat Oncol
Biol Phys. 1992;24:389–96.
24. Cabanas RM. An approach for the treatment of penile car-
cinoma. Cancer. 1977;39:456–66.
25. DiSaia PJ, Creasman WT, Rich WM. An alternate approach
to early cancer of the vulva. Am J Obstet Gynecol.
1979;133:825–32.
26. Rouzier R, Haddad B, Dubernard G, et al. Inguinofemoral
dissection for carcinoma of the vulva: effect of modifca-
tions of extent and technique on morbidity and survival. J
Am Coll Surg. 2003;196:442–50.
27. Plentl AA, Friedman EA. Lymphatics of the cervix uteri.
In: Plentl AA, Friedman EA, editors, Lymphatic System of
Female Genitalia. Philadelphia: WB Saunders; 1971. pp.
75–115.
28. DiSaia P. Invasive cancer of the vulva. In: DiSaia P,
Creasman WT, editors, Clinical Gynecologic Oncology. St
Louis, MO: Mosby; 2002.
29. Doherty M. Clinical anatomy of the pelvis. In: Copeland
L, editor, Textbook of Gynecology. Philadelphia, PA: WB
Saunders; 1993. pp. 48–84.
4
Lymphatic anatomy: lymphatics of the cervix

Anca Chelariu-Raicu and Katherine C. Kurnit

CONTENTS
Topographic anatomy of the cervix ............................................................................................................................................... 23
Topographic anatomy of the cervical lymphatics .......................................................................................................................... 24
Lateral trunk ......................................................................................................................................................................... 24
Posterior trunk ...................................................................................................................................................................... 25
Anterior trunk ....................................................................................................................................................................... 25
The natural history of cervix cancer relevant to its lymphatic anatomy ........................................................................................ 26
Summary ........................................................................................................................................................................................ 26
References...................................................................................................................................................................................... 27

Although the uterine cervix and the uterine corpus differ ana- The cervix is composed of fbrous, elastic, and smooth mus-
tomically and functionally, their respective lymphatic systems cular tissue. It is more fbrous than the corpus, with smooth
are similar. The mucosa, muscularis, and serosa have distinct muscle comprising just 15% of the body of the cervix, primar-
lymphatic fow, but within each layer, fow between the cervix ily at the endocervix. It is lined by columnar and squamous
and the corpus is continuous. We have chosen to discuss the epithelium. The endocervix is lined by a single layer of mucin-
uterine cervix and uterine corpus separately given that tumors producing columnar epithelium, which also lines the many
arising in the cervix are treated differently from tumors arising endocervical glands. In this respect, the mucin-producing
in the corpus. Understanding and exploitation of the normal apparatus is not truly glandular but is a complex infolding of
lymphatic anatomy of the uterine cervix have led to refne- the mucosal surface. The distal extent of this mucosa joins
ment and individualization of treatment for the diseased cer- stratifed, nonkeratinizing squamous epithelium on or near the
vix. Further elucidation of how disease affects the lymphatic exocervix. The location of this abrupt transformation is vari-
framework of the cervix and lymphangiogenic processes will able and changes continuously during the reproductive years,
be important in clarifying the natural history of cervical can- responding to the lower vaginal pH after puberty.3 In this
cer and increasing our therapeutic acumen. process, columnar epithelium undergoes metaplastic change
to become more resilient squamous epithelium.4 It is in this
transformation zone that most preinvasive and invasive cervi-
cal lesions arise. Distally, the exocervical tissue is continuous
Topographic anatomy of the cervix with the vaginal epithelium.
Anatomically, the cervix is defned as the region of the uterus
from the isthmus to its vaginal termination. Depending on
a woman’s age and on uterine and cervical factors, the size
of the cervix varies with respect to the size of the corpus.1
In general, the cervix ranges from 2 to 4 cm in length in the
nulligravid woman. It is connected to the vagina through an
oblique fbrous attachment where approximately one-third
of the anterior wall and approximately one-half of the pos-
terior wall are exposed to the vagina (infravaginal cervix)2
(Figure  4.1). The vaginal portion, or exocervix, is convex.
Centrally located within the exocervix is the external cervical
os. The size of this opening to the uterus varies depending on a
woman’s age and history of parturition. Proximal to the exter-
nal os is the elliptical endocervical canal, which terminates
at the internal cervical os. Here the cervix joins the uterine
isthmus. Anteriorly and posteriorly, the supravaginal cervix is
covered by the parietal peritoneum. FIGURE 4.1 Topographic anatomy of the cervix.

DOI: 10.1201/9781003255536-4 23
24
FIGURE 4.2 The cervix is supported by the cardinal and uterosacral ligaments, which blend with the fascia of the pelvic diaphragm.
The paired uterosacral and cardinal ligaments primarily
support the cervix and uterus. The uterosacral ligaments attach
at the base of the uterus and run in the rectouterine perito-
neal folds to the sacrum. The cardinal ligaments are thickened
bands of fbrous tissue in continuation with the endopelvic
fascia that extend to the lateral pelvic sidewall (Figure 4.2).
Within these bands also run the nerves and vessels to the cer-
vix and pelvic viscera.
Topographic anatomy of the cervical lymphatics
The lymphatic vessels of the endocervical mucosa are found
immediately below the cuboidal/columnar glandular epithe-
lium and are irregular in their arrangement. The fragile indi-
vidual vessels coalesce to form channels, which fow out from
the mucosa within the plicae palmatae, generally perpendicu-
lar to the axis of the cervical canal. Interfacing with the stroma,
the channels fatten and angle to run parallel with the endocer-
vical canal, where they combine further to make larger chan-
nels. Ultimately, these vessels converge upon intermediate
trunks located within the stromal vasculature. Within the cer-
vical stroma, a dense and regular lattice of lymphatic vessels is
found. Near the mucosal surface, lymphatics grossly outnum-
ber vascular channels and seemingly bear no consistent rela-
tionship with blood vessels or each other. Circumferentially, as
these channels coalesce into larger trunks, they course more
regularly with the cervical veins, often surrounding them to
the serosa. A small number of reports have documented the
existence of a valvular system within stromal lymphatics that
prevents retrograde fow in all but disease states.
Clinical Lymphatic Mapping
When the stromal lymphatics reach the serosa, they inter-
face through a series of lacunae, which go on to invest the
entire corpus.5 These major efferent systems coalesce in the
cervix to form three dominant extravisceral trunks (anterior,
lateral, and posterior). It should be noted that these cervical
lymphatic vessels often share terminal nodes with other sites,
such as the uterine corpus and the vagina. However, it is rele-
vant that there is little intermixing of lymph; rather, separate
lymphatic trunks from these sites run in parallel to common
basins and particular terminal nodes. Valves within these
trunks also prevent retrograde fow under normal conditions.
Lateral trunk
The largest and most signifcant pathway of the extravisceral
cervical drainage comes from the lateral trunk. There are
three branches within this trunk, each of which drains into
specifc nodal basins within the pelvis (Figure 4.3). The upper
branches of the lateral trunk are two to three large vessels that
course from the cervical serosa cephalad and anterior along
the path of the uterine vessels, crossing over the ureter and
obliterated umbilical artery, and coming to rest in the inter-
iliac nodal basin at the bifurcation of the external and inter-
nal iliac vessels. The lateral-trunk drainage is considered the
dominant drainage of the cervix and was referred to by Leveuf
and Godard as “la voie principale.”6 The large node in this
location is consistent clinically; however, in its absence, a sec-
ondary node is often found in the common iliac chain. On the
right, this secondary node is often located on the common iliac
vein; on the left, it can be found between the iliopsoas muscle
and common iliac artery.
Anatomy: lymphatics of the cervix
FIGURE 4.3 The dominant lateral lymphatic trunk drains into several lower pelvic nodal basins. (Modifed from Plentl and Friedman.)5
The path of the upper branches of the lateral trunk to the
iliac nodes can be interrupted by small parametrial lymph
nodes. These lymph nodes are diffcult to study. They can eas-
ily be overlooked in cadaver studies. In vivo, they are not seen
during radical hysterectomy. They are very close to the cer-
vix and therefore are not imaged well on lymphoscintigraphy
because of the large amount of residual radioactivity in the
cervix. They are not seen well on blue dye studies either, again
because of their small size, their proximity to the cervix, and
the fact that they are not seen on dissection.
The equally important middle branches of the lateral trunk
serve as a dominant pathway to the obturator lymph nodes,
also referred to by some as the posterior interiliac nodes. The
course of the lymph in this case is along the middle cardinal
ligament to the posterior aspect of the internal iliac vessel.
Arising from the lateral dorsal cervix are the lower branches
of the lateral trunk. Some of these pass posteriorly around the
ureter and course either dorsally to the uterosacral ligament,
terminating in the inferior gluteal nodes, or cephalad and ven-
trally, terminating in the superior gluteal nodes. Still others
course posteriorly along the sacral hollow, terminating in the
sacral and subaortic nodes directly.
The lower branches of the lateral trunk serve as a pathway
to the superior and inferior gluteal lymph nodes. This pathway
25
is described in the classic, cadaver-based anatomic studies.
Clinical reports rarely comment on these lymph nodes, and
gluteal nodes appear to be a rare site for metastatic disease.
The lower branches of the lateral trunk continue on towards
the presacral (subaortic) lymph nodes, as described later.
Posterior trunk
The posterior collecting trunk primarily drains towards the
subaortic nodal basin. This trunk arises from the posterior cer-
vix and courses along the uterosacral ligament to the lateral
rectal fascia, continuing anteriorly over the sacral promontory
or posteriorly to the superior rectal nodes (Figure 4.4). Direct
drainage to the aortic nodes can be demonstrated in vessels
from this trunk, which travel with the ureter to the pelvic brim,
where they diverge into the common iliac, subaortic, and aor-
tic nodal basins.
Anterior trunk
The anterior trunk leaves the anterior cervix and courses along
the posterior surface of the bladder to the superior vesical
artery. From there it travels to the obliterated umbilical vessel
and terminates in the distal interiliac nodal basins anteriorly.
26
FIGURE 4.4 The posterior lymphatic trunk courses along the uterosac-
ral ligament to drain into the common iliac, subaortic, aortic, and superior
gluteal nodes. A blue lymph node is shown at a common location to fnd
sentinel lymph nodes in patients with cervical cancer. Sentinel nodes may
also be found in obturator, common iliac, presacral, and paraaortic sites.
(Modifed from Plenty and Friedman.)5
Separate but parallel vessels run along the cardinal ligament,
where they meet without intermixing with the lateral trunk
and drain into that trunk’s distribution.
The natural history of cervix cancer
relevant to its lymphatic anatomy
Most cancers arising in the uterine cervix are carcinomas of
its epithelium. The predominant histologic subtype is squa-
mous; however, an increasing proportion of adenocarcinoma,
comprising approximately 25% of cases, has been observed.7,8
Cervical carcinomas are largely believed to develop from a
preinvasive lesion, carcinoma in situ, over a number of years.
However, another model has been proposed which hypothe-
sizes that carcinoma in situ may develop rapidly following a
human papillomavirus (HPV) infection and not develop from
low-grade dysplasia.9 Even though many of the molecular
events driving the transformation from carcinoma in situ to
invasive cancer are not well known, the link between geni-
tal HPV infections and cervical cancer was demonstrated as
early as the 1980s by Harold zur Hausen.10 Some data suggest
that the presence of HPV and a high viral load place patients
Clinical Lymphatic Mapping
TABLE 4.1
Likelihood of Lymph Node Metastases in Patients with Early-Stage
Cervical Cancer
Stage % of patients with metastases
IA1 0.3
IA2 1–7
IB1 16
IB2 32
IIA 25
IIB 27–43
at increased risk of developing cervical cancer.11,12 Most cer-
tainly, the shift from carcinoma in situ to invasive cancer is the
result of an accumulation of genetic errors and the interaction
of HPV DNA with the host genome.9,13–16 Cervical cancer is
believed to progress through a state of microscopic invasion
into the stroma and radial growth on the surface. Ultimately,
a locus is formed that, in general, grows locally to invade the
deeper stroma and, later, the paracervical and parametrial tis-
sues. If left untreated, the disease will expand through these
tissues to involve the lateral pelvic side wall. In addition, it
may grow to involve the bladder, rectum, or both.
Cancer arising from the cervix has been reported to extend
into the uterine corpus in 10%–30% of cases and into the uter-
ine adnexa in 0.5%–1.6% of cases.17–19 Considering that as
many as 17% of patients with early-stage cervix cancer have
lymph node metastases,20–22 lateral spread from the pelvic
lymph nodes (obturator, internal iliac, and external iliac lymph
nodes) to the pelvic sidewall, to the common iliac lymph nodes,
and then the paraaortic lymph nodes was thought to be the
rule.20 However, studies using sentinel lymph node mapping
have demonstrated that any of the pelvic lymph node groups,
and even the paraaortic lymph nodes, may contain the frst
draining lymph node.23 Still, it is uncommon to fnd isolated
paraaortic lymphatic spread in the absence of metastatic pel-
vic disease.20,24 Thus, as a group, the pelvic lymph nodes are
still the most commonly involved sites of lymphatic spread.20
The likelihood of nodal involvement by disease stage among
patients with early-stage disease is shown in Table 4.1.
Hematogenous spread of disease is relatively unusual and
most frequently involves the lungs, bones, intraabdominal vis-
cera, or distant lymphatics.25 One study indicated that patients
with hematogenous metastasis had a 5.3-fold higher risk of
death compared to those with lymphatic metastasis.26 Variant
cell types, such as neuroendocrine or glassy cell carcinoma,
may be associated with distant disease in the absence of local
spread. Current therapy for these variants typically involves
multimodality strategies designed to address the tumor’s
potential for local and distant metastasis.27,28
Summary
Lymphatic anatomy of the cervix is surprisingly complex.
Pelvic lymph nodes actually refer to several nodal basins
immediately adjacent to one another. Lymphatic mapping
Anatomy: lymphatics of the cervix
studies have the potential to help understand the clinical sig-
nifcance, if any, of the various anatomic variations.
REFERENCES
1. Bartoli JM, Moulin G, Delannoy L, et al. The normal
uterus on magnetic resonance imaging and variations
associated with the hormonal state. Surg Radiol Anat.
1991;13(3):213–20.
2. Ferenczy A, Wright T. Anatomy and histology of the cervix.
In: Kurman RK, editor, Blaustein’s Pathology of the Female
Genital Tract. New York: Springer-Verlag; 1994. pp. 185–201.
3. Singer A. The uterine cervix from adolescence to the meno-
pause. Br J Obstet Gynaecol. 1975:82:1–99.
4. Reich O, Regauer S, McCluggage WG, et al. Defning the
cervical transformation zone and squamocolumnar junc-
tion: can we reach a common colposcopic and histologic
defnition? Int J Gynecol Pathol. 2017;36(6):517–22.
5. Plentl A, Friedman E. Lymphatics of the cervix uteri. In:
Lymphatic System of Female Genitalia. Philadelphia, PA:
WB Saunders; 1971. pp. 75–115.
6. Leveuf J, Godard H. Les lymphatiques de l’utérus. Rev
Chir. 1923:3:219–48.
7. Smith HO, Tiffany MF, Qualls CR, et al. The rising inci-
dence of adenocarcinoma relative to squamous cell carci-
noma of the uterine cervix in the United States – a 24-year
population-based study. Gynecol Oncol. 2000;78(2):97–105.
8. van der Horst J, Siebers AG, Bulten J, et al. Increasing
incidence of invasive and in situ cervical adenocarci-
noma in the Netherlands during 2004–2013. Cancer Med.
2017;6(2):416–23.
9. Nedjai B, Reuter C, Ahmad A, et al. Molecular progres-
sion to cervical precancer, epigenetic switch or sequential
model? Int J Cancer. 2018;143(7):1720–30.
10. zur Hausen H. Papillomaviruses causing cancer: evasion
from host-cell control in early events in carcinogenesis. J
Natl Cancer Inst. 2000;92(9):690–8.
11. Josefsson AM, Magnusson PK, Ylitalo N, et al. Viral load
of human papilloma virus 16 as a determinant for develop-
ment of cervical carcinoma in situ: a nested case-control
study. Lancet (London, England). 2000;355(9222):2189–93.
12. Moberg M, Gustavsson I, Wilander E, et al. High viral
loads of human papillomavirus predict risk of invasive cer-
vical carcinoma. Br J Cancer. 2005;92(5):891–4.
13. Park TW, Fujiwara H, Wright TC. Molecular biology of
cervical cancer and its precursors. Cancer. 1995;76(10
Suppl):1902–13.
14. Muller CY, O’Boyle JD, Fong KM, et al. Abnormalities of
fragile histidine triad genomic and complementary DNAs
in cervical cancer: association with human papillomavirus
type. J Nat Cancer Inst. 1998;90(6):433–9.
27
15. Wistuba, II, Montellano FD, Milchgrub S, et al. Deletions
of chromosome 3p are frequent and early events in the
pathogenesis of uterine cervical carcinoma. Cancer Res.
1997;57(15):3154–8.
16. Wentzensen N, Sherman ME, Schiffman M, et al. Utility
of methylation markers in cervical cancer early detec-
tion: appraisal of the state-of-the-science. Gynecol Oncol.
2009;112(2):293–9.
17. Reyes C, Murali R, Park KJ. Secondary involvement of the
adnexa and uterine corpus by carcinomas of the uterine
cervix: a detailed morphologic description. Int J Gynecol
Pathol. 2015;34(6):551–63.
18. Sutton GP, Bundy BN, Delgado G, et al. Ovarian metas-
tases in stage IB carcinoma of the cervix: a Gynecologic
Oncology Group study. Am J Obstet Gynecol. 1992;166(1
Pt 1):50–3.
19. Kim MJ, Chung HH, Kim JW, et al. Uterine corpus involve-
ment as well as histologic type is an independent predictor
of ovarian metastasis in uterine cervical cancer. J Gynecol
Oncol. 2008;19(3):181–4.
20. Hopkins MP, Morley GW. Stage IB squamous cell cancer
of the cervix: clinicopathologic features related to survival.
Am J Obstet Gynecol. 1991;164(6 Pt 1):1520–7; discussion
7–9.
21. Sevin BU, Nadji M, Averette HE, et al. Microinvasive car-
cinoma of the cervix. Cancer. 1992;70(8):2121–8.
22. Chen B, Wang L, Ren C, et al. The effect of neoadjuvant
chemotherapy on lymph node metastasis of FIGO stage
IB1-IIB cervical cancer: a systematic review and meta-
analysis. Front Oncol. 2020;10:570258.
23. Levenback C, Coleman RL, Burke TW, et al. Lymphatic
mapping and sentinel node identifcation in patients with
cervix cancer undergoing radical hysterectomy and pelvic
lymphadenectomy. J Clin Oncol. 2002;20(3):688–93.
24. Balaya V, Mathevet P, Magaud L, et al. Predictive factors
of unexpected lymphatic drainage pathways in early-stage
cervical cancer. Gynecol Oncol. 2019;154(1):102–9.
25. Delgado G, Bundy BN, Fowler WC, et al. A prospective sur-
gical pathological study of stage I squamous carcinoma of
the cervix: a Gynecologic Oncology Group Study. Gynecol
Oncol. 1989;35(3):314–20.
26. Kim K, Cho SY, Kim BJ, et al. The type of metastasis
is a prognostic factor in disseminated cervical cancer. J
Gynecol Oncol. 2010;21(3):186–90.
27. Lagasse LD, Creasman WT, Shingleton HM, et al. Results
and complications of operative staging in cervical cancer:
experience of the Gynecologic Oncology Group. Gynecol
Oncol. 1980;9(1):90–8.
28. Cohen JG, Kapp DS, Shin JY, et al. Small cell carcinoma of
the cervix: treatment and survival outcomes of 188 patients.
Am J Obstet Gynecol. 2010;203(4):347 e1–6.
5
Lymphatic anatomy: lymphatics of the uterus
Jennifer J. Mueller and Nadeem R. Abu-Rustum
CONTENTS
Introduction .................................................................................................................................................................................... 29
References...................................................................................................................................................................................... 33
Introduction
The lymphatic anatomy of the uterine corpus compared to
that of other solid organs is complex, and we are indebted to
the pioneering clinicians and anatomists for their ingenuity
and devotion in studying and revealing its intricacies across
a historic body of literature. A portion of early works focused
on lymphatic mapping in the normal-appearing uterus, while
another portion focused on lymphatic mapping of uterine can-
cers to establish the path of tumor emboli. In the former, repro-
ducible patterns of lymphatic drainage were established, and
in the latter, an enhanced understanding of metastatic lym-
phatic spread in endometrial cancer emerged.
In this section, we will review key early work that describes
the lymphatic drainage pathways of the uterine corpus. We
will review common patterns of metastatic lymph node spread
in endometrial cancer based on necropsy studies and the cur-
rent literature describing lymphatic spread patterns in endo-
metrial cancer.
The lymphatics of the uterus are complex, given the asso-
ciated distinct anatomic regions (e.g., cervix, uterine body,
fundus, and fallopian tubes) and tissue layers (e.g., endome-
trium, myometrium, and serosa). The most challenging is
the endometrial lymphatic anatomy due to valves within the
lymphatics that preclude dye study and the changes that occur
in cycling endometrium. In the 1980s, Blackwell and Fraser
described the superfcial lymphatics of the endometrium
using curettage specimens from 42 normally cycling women.1
They used electron and light microscopy ultrastructure data
to three-dimensionally reconstruct endometrial lymphatic
architecture. Lymphatics originate as blind vessels in the
endometrium. These capillaries extend to the endomyometrial
interface and enlarge and coalesce with frequent anastomo-
ses. Ultrastructural reconstruction suggests the blind termi-
nal ends serve an absorptive function by drawing fuid into
the lymphatic system, which could provide a ready conduit
for lymphatic dissemination of endometrial cancer, even in
early stages. As lymphatic capillaries traverse the endome-
trium, they enlarge in diameter and coalesce to form lacunae,
which lie parallel to the muscularis layer of the myometrium.
Lymphatic channels emerge from the lacunae and perforate
DOI: 10.1201/9781003255536-5
the myometrium in a regular and perpendicular pattern. The
lymphatics travel to the uterine serosa. Along this journey to
the serosa, they anastomose with other lymphatics and enlarge
in diameter. Anastomotic connections between the corpus and
cervix within the mucosal and muscular layers develop in this
manner. The lymphatic trunks arising from this vast network
condense to form the major collecting channels that drain the
uterus extraviscerally. They are joined by the serosal lymphat-
ics. This creates a dominant confuence of lymph towards the
lateral margins of the uterus.
Gynecologist and anatomist Dr. Erle Henriksen described
the major lymphatic drainage patterns of the uterine corpus.2,3
In his study of 420 uterine cancer necropsies, Henriksen
described a high degree of variability in lymphatic channels,
with frequent anomalous and anastomotic relationships to
other channels and nodes.3 Anatomists predating Henriksen
also described a highly irregular, anastomosing endometrial
lymphatic network that maintains lymphatic continuity across
all regions of the uterus.4
Henriksen described three major lymphatic channels drain-
ing the cervix. The frst major channel exits the cervix and
connects to paracervical, external iliac, and obturator lymph
nodes. The second courses along in a similar manner to con-
nect to internal iliac lymph nodes. The third major channel
travels back and forth within the uterosacral folds, connect-
ing to presacral lymph nodes. These channels were observed
intercommunicating between interiliac and presacral nodal
basins. Henriksen also described three main channels drain-
ing the corpus. The upper corpus lymphatics join ovarian ves-
sels and drain paraaortic nodal basins below the renal vessels.
The middle and lower corpus (in close association with cervi-
cal lymphatic channels) coalesce and course along the uterine
vessels, draining paracervical, interiliac, and obturator nodes.
The fundus lymphatic channels follow the round ligament to
the inguinal nodal basins.
Plentl and Friedman4 described four key lymphatic drain-
age routes for the uterus in an excellent textbook review of
this topic: 1) A fundal/ovarian route in which lymphatics travel
cephalad to infrarenal paraaortic lymph nodes. 2) A fallopian
tube/uterine cornu route in which lymphatics anastomose
with ovarian lymphatic channels to drain aortic and superior
29
30 Clinical Lymphatic Mapping

gluteal lymph nodes. 3) A mid and lower uterine body route
in which lymphatics condense in the broad ligament. A longi-
tudinal channel named ‘the anastomosis of Poirier’ connects
subserosal corpus lymphatics with the cervix in this region.
The lymphatic channels within the broad ligament pass over
the obliterated hypogastric artery and terminate to interiliac
nodes. 4) A round ligament route in which lymphatics drain to
femoral lymph nodes, which was deemed less important.
Lecuru et al. injected a colored dye into the uterus of 11
female cadavers, 5 within the corpus and 6 within the cervix,
and mapped lymphatic drainage to determine any difference
in these patterns for cervical versus uterine malignancies.5 The
cervical injections drained primarily to internal iliac nodes,
with no paraaortic connections. The corpus injections drained
to nodes posterior to the external iliac vessels in the obturator
region primarily and, less commonly, to the paraaortic region.
In summary, uterine lymphatic drainage pathways consis-
tently follow an ovarian drainage pathway to the aortic and
gluteal nodal region, a round ligament drainage pathway to
the inguinofemoral nodal region, and a cervical/midbody uter-
ine drainage pathway to the external iliac and obturator nodal
region, as well as the common, internal iliac, and presacral
nodal region (Figure 5.1).
This early work prompted additional questions for research-
ers. Which nodal basins are the most critical to surgically eval-
uate? Are there dominant drainage pathways early in cancer
progression? Does endometrial tumor location infuence nodal
spread of disease?
Henriksen was among the frst to describe lymph node spread
patterns in cervical and uterine carcinomas in a series of 64
patients with varying stages of disease, some treated with radi-
ation.3 Tumor metastases were noted via gross anatomic study

FIGURE 5.1 Main lymphatic drainage pathways of the uterus. The left side illustrates the three main lymphatic drainage pathways of the uterine
corpus. The frst pathway drains the cervical and mid/lower uterine lymphatics to pelvic nodal basins along the iliac and obturator vessels. The most
common pattern in this pathway is the upper or ventral paracervical pathway. Lymphatic trunks condense in the paracervix and cross medial to lateral
over the cranial part of the obliterated umbilical ligament. The less common pattern is the lower or dorsal paracervical pathway. These trunks condense
in the paracervix and traverse dorsally in the meso-ureter to drain the presacral common iliac nodes. The second pathway drains the fundal portion
of the uterus, including the serosa, which joins with the ovarian vessels and drains to paraaortic nodal basins. The third pathway (and least dominant)
drains the mid-uterine lymphatics, which travel within the round ligament to the inguinal nodal basins. The right side illustrates the uterine serosal
lymphatics. Lymphatic capillaries traverse the endometrium and enlarge and coalesce as lacunae on their journey through the myometrium to the
serosa. Frequent anastomotic connections between the corpus and cervix in the muscularis and mucosal layers develop and help form a vast network
of interconnected channels that drain the uterus extraviscerally.
Anatomy: lymphatics of the uterus
alone. Nodal metastases were located in external, internal, and
common iliac regions, as well as obturator, presacral, aortic,
and inguinal regions. Henriksen later studied 188 endometrial
cancer necropsies and made several key observations. First,
in 15% of patients, only aortic nodes were involved, with no
other distant metastases. Second, tumor emboli in a lymphatic
channel or node were seen to interfere with lymphatic fow
and created shunts to alternative channels. This collateraliza-
tion led to unpredictable sites of metastases and bypassed the
primary nodal basins typically involved. Third, widespread
pelvic nodal metastases without aortic nodal involvement were
observed, and contrarily, widespread aortic nodal metastases
without pelvic nodal involvement were also observed.3
Taken as a whole, this body of research rationalized the
importance of lymph node evaluation in endometrial cancer.
Since then, researchers have sought to understand the risk of
nodal metastases development and the relative incidence based
on nodal basin involvement, an outgrowth of this early work.
In 1989, Ayhan et al.6 published a key paper on nodal metas-
tasis in clinical stage I endometrial cancer, noting a 15% rate
of pelvic and 9% rate of paraaortic nodal metastasis in a series
of 106 patients. They also observed that specifc uterine risk
factors, including increasing tumor grade, presence of lymph-
vascular space invasion, increasing depth of myometrial inva-
sion, and lower uterine segment involvement, correlated with
an increasing incidence of pelvic and paraaortic nodal metas-
tases. This work has been recapitulated multiple times in other
studies showing the same relationship between nodal metasta-
ses and these uterine risk factors.7–10
Mariani et al. examined routes of lymphatic spread in 112
surgically staged patients with clinical stage I endometrial
cancer and reported that external iliac lymph nodes, fol-
lowed by obturator lymph nodes, were the most commonly
involved nodes across all patients assessed.11 In patients with
tumors involving the cervix, there was a signifcant increase in
common iliac nodal metastases. The authors found paraaor-
tic nodal metastases in 35 patients (31%), and all but 3 (9%)
had concurrent pelvic nodal metastases. Based on their data,
Mariani and colleagues concluded that paraaortic nodal dis-
semination occurs via the common iliac nodes when the cer-
vix is involved. When the cervix is not involved, paraaortic
nodal dissemination occurs via routes shared by the external
iliac and obturator lymph nodes, an uncommon event.
Matsumoto et al.12 compared the lymphatic spread of 27
endometrial, 25 cervical, and 58 ovarian node-positive cancers
and described their major drainage pathways. Endometrial
cancers metastasized to both pelvic (primarily iliac and obtu-
rator) and aortic (primarily above the inferior mesenteric artery
[IMA]) nodal basins, although pelvic nodal metastasis was the
dominant pattern, with few direct aortic metastases (7%). This
was in contrast to ovarian cancer, which metastasized to pelvic
and aortic nodal basins equally. Cervical cancers metastasized
primarily to pelvic nodal basins.
Research has demonstrated the prognostic signifcance of
nodal spread in endometrial cancer;13–15 however, locating a
positive lymph node can be challenging. Metastatic lymph
nodes are often only detected microscopically, the lymphatic
drainage of the corpus is complex, and the presence and loca-
tion of nodal metastases can be infuenced by tumor location,
31
histologic grade, and depth of myometrial invasion. This
helped to rationalize comprehensive pelvic and paraaortic
lymphadenectomy as a surgical staging procedure in early-
stage endometrial cancer.16–18
Sentinel lymph node (SLN) mapping emerged by combin-
ing our understanding of lymphatic drainage pathways with
locations of occult nodal spread in endometrial cancer. SLN
mapping allows the surgeon to see lymphatic channels drain
an individual uterus in real time. Live demonstrations of SLN
mapping and SLN data generated over the years have expanded
our knowledge of endometrial cancer nodal spread and have
helped surgeons observe pelvic drainage using a modern
approach. The method identifes nodal areas at risk, avoids
removal of less likely affected nodal basins, and ultimately,
increases surgical precision for this disease. The frst such
study of selective lymph node biopsy in endometrial cancer
was conducted by Burke et al. in 1996. The authors described
the feasibility of using a fundal injection of blue dye to target
select nodes for biopsy in 15 patients with high-grade endome-
trial cancer.19 Only many years later was the concept of SLN
mapping for endometrial cancer revived. Some SLN mapping
studies have annotated the specifc locations of SLNs. Jewell
et al. reported on 217 surgically staged patients with endome-
trial cancer of various histologies. The majority of SLNs were
located in the external and internal iliac nodal basins (63%),
and the remaining nodes were in the obturator, common iliac,
and aortic nodal basins.20 The prospective FIRES trial ana-
lyzed surgically staged patients with endometrial cancer and
found that the external iliac (38%) and obturator (25%) nodal
basins were the most common locations for SLNs, followed by
the paraaortic (below the IMA), internal iliac, and presacral
nodal basins.21
Cervical tracer injection for SLN mapping in endometrial
cancer has become the most popular injection site, as it is
effective in mapping pelvic lymphatics and is easy to adopt
and perform in a consistent manner. Injecting this portion
of the uterus is an approach supported by data from the nec-
ropsy studies mentioned earlier. A cervical injection allows for
tracer uptake within the predominant drainage channels of the
corpus, although this practice has been criticized due to less
frequent tracer uptake in the aortic nodal basins.22,23
A cervical injection of dye leads to two primary drainage
routes, as described in historical anatomic textbooks and
confrmed by live intraoperative demonstrations reported by
Abu-Rustum and the Memorial Sloan Kettering Cancer Center
group. The most common route emerges from the lateral uter-
ine body and crosses over the obliterated umbilical ligament
to drain into external iliac and obturator lymph nodes (upper
or ventral paracervical pathway). The less common pathway
travels within the mesoureter cephalad to drain common
iliac and presacral lymph nodes (lower or dorsal paracervical
pathway).24 Figures 5.2 and 5.3 illustrate the two major pelvic
SLN mapping patterns following a cervical injection of dye in
endometrial cancer. In 2017, Geppert and colleagues published
their work with mapping uterine lymphatics after either a fun-
dal or cervical tracer injection and confrmed these observa-
tions, noting the lower paracervical drainage pathway was
more common.25 Interesting work by Bollino et al.26 demon-
strated high-risk endometrial cancers, as opposed to low-risk
32 Clinical Lymphatic Mapping

FIGURE 5.2 Most common pelvic sentinel lymph node mapping pattern following a cervical injection of dye in endometrial cancer. Lymphatic chan-
nels condense in the paracervix and emerge from the lateral uterine body and cross over the obliterated umbilical ligament to drain into the external
iliac and obturator lymph nodes. This is also termed the upper or ventral paracervical pathway.

FIGURE 5.3 Less common pelvic sentinel lymph node mapping pattern following a cervical injection of dye in endometrial cancer. Lymphatic chan-
nels condense in the paracervix but do not cross over the obliterated umbilical ligament. Rather, these channels travel cephalad within the meso-ureter
to drain common iliac and presacral lymph nodes. This is also termed the lower or dorsal paracervical pathway.
Anatomy: lymphatics of the uterus
subtypes, more frequently drained via the upper paracervical
pathway. For a comprehensive discussion on SLN mapping in
endometrial cancer, see Chapter 13.
REFERENCES
1. Blackwell PM, Fraser IS. Superfcial lymphatics in the
functional zone of normal human endometrium. Microvasc
Res. 1981;21(2):142–52.
2. Henriksen E. The lymphatic spread of carcinoma of the cer-
vix and of the body of the uterus. A study of 420 necropsies.
Am J Obstet Gynecol. 1949;58(5):924–42.
3. Henriksen E. The lymphatic dissemination in endome-
trial carcinoma. A study of 188 necropsies. Am J Obstet
Gynecol. 1975;123(6):570–6.
4. Plentl AA, Friedman EA. Lymphatics of the cervix uteri.
In: Lymphatic System of the Female Genitalia: The
Morphologic Basis of Oncologic Diagnosis and Therapy.
Philadelphia: WB Saunders; 1971. pp. 75–115.
5. Lecuru F, Neji K, Robin F, et al. Drainage lymphatique de
l’uterus. Resultats preliminaires d’une etude experimentale.
J Gynecol Obstet Biol Reprod (Paris). 1997;26(4):418–23.
6. Ayhan A, Yarali H, Urman B, et al. Lymph node metastasis
in early endometrium cancer. Aust N Z J Obstet Gynaecol.
1989;29(3 Pt 2):332–5.
7. Creasman WT, Morrow CP, Bundy BN, et al. Surgical patho-
logic spread patterns of endometrial cancer. A Gynecologic
Oncology Group Study. Cancer. 1987;60(8 Suppl):2035–41.
8. Chi DS, Barakat RR, Palayekar MJ, et al. The incidence of
pelvic lymph node metastasis by FIGO staging for patients
with adequately surgically staged endometrial adenocar-
cinoma of endometrioid histology. Int J Gynecol Cancer.
2008;18(2):269–73.
9. Creasman WT, Ali S, Mutch DG, et al. Surgical-
pathological fndings in type 1 and 2 endometrial cancer:
an NRG Oncology/Gynecologic Oncology Group study on
GOG-210 protocol. Gynecol Oncol. 2017;145(3):519–25.
10. Mueller JJ, Nobre SP, Braxton K, et al. Incidence of pel-
vic lymph node metastasis using modern FIGO staging and
sentinel lymph node mapping with ultrastaging in surgi-
cally staged patients with endometrioid and serous endo-
metrial carcinoma. Gynecol Oncol. 2020;157(3):619–23.
https://doi.org/10.1016/j.ygyno.2020.03.025.
11. Mariani A, Webb MJ, Keeney GL, et al. Routes of lym-
phatic spread: a study of 112 consecutive patients with
endometrial cancer. Gynecol Oncol. 2001;81(1):100–4.
12. Matsumoto K, Yoshikawa H, Yasugi T, et al. Distinct
lymphatic spread of endometrial carcinoma in compari-
son with cervical and ovarian carcinomas. Cancer Lett.
2002;180:83–9.
13. Benedetti Panici P, Basile S, Maneschi F, et al. Systematic
pelvic lymphadenectomy vs. no lymphadenectomy in
33
early-stage endometrial carcinoma: randomized clinical
trial. J Natl Cancer Inst. 2008;100(23):1707–16.
14. Barton DP, Naik R, Herod J. Effcacy of systematic pel-
vic lymphadenectomy in endometrial cancer (MRC
ASTEC Trial): a randomized study. Int J Gynecol Cancer.
2009;19(8):1465.
15. Yokoyama Y, Maruyama H, Sato S, et al. Indispensability
of pelvic and paraaortic lymphadenectomy in endometrial
cancers. Gynecol Oncol. 1997;64(3):411–17.
16. Hirahatake K, Hareyama H, Sakuragi N, et al. A clinical
and pathologic study of para-aortic lymph node metastasis
in endometrial carcinoma. J Surg Oncol. 1997;65(2):82–7.
17. Chuang L, Burke TW, Tornos C, et al. Staging laparotomy
for endometrial carcinoma: assessment of retroperitoneal
lymph nodes. Gynecol Oncol. 1995;58(2):189–93.
18. Larson DM, Johnson KK. Pelvic and para-aortic lymph-
adenectomy for surgical staging of high-risk endometri-
oid adenocarcinoma of the endometrium. Gynecol Oncol.
1993;51(3):345–8.
19. Burke TW, Levenback C, Tornos C, et al. Intraabdominal
lymphatic mapping to direct selective pelvic and para-
aortic lymphadenectomy in women with high-risk endo-
metrial cancers: results of a pilot study. Gynecol Oncol.
1996;62(2):169–73.
20. Jewell EL, Huang JJ, Abu-Rustum NR, et al. Detection of
sentinel lymph nodes in minimally invasive surgery using
indocyanine green and near-infrared fuorescence imag-
ing for uterine and cervical malignancies. Gynecol Oncol.
2014;133(2):274–7.
21. Rossi EC, Kowalski LD, Scalici J, et al. A comparison
of sentinel lymph node biopsy to lymphadenectomy for
endometrial cancer staging (FIRES trial): a multicen-
tre, prospective, cohort study. Lancet Oncol. 2017;18(3):
384–92.
22. Rossi EC, Jackson A, Ivanova A, et al. Detection of sentinel
nodes for endometrial cancer with robotic assisted fuores-
cence imaging: cervical versus hysteroscopic injection. Int
J Gynecol Cancer. 2013;23(9):1704–11.
23. Rossi EC. Current state of sentinel lymph nodes for
women with endometrial cancer. Int J Gynecol Cancer.
2019;29(3):613–21.
24. Abu-Rustum NR. Sentinel lymph node mapping for endo-
metrial cancer: a modern approach to surgical staging. J
Natl Compr Canc Netw. 2014;12(2):288–97.
25. Geppert B, Lonnerfors C, Bollino M, et al. A study on uter-
ine lymphatic anatomy for standardization of pelvic senti-
nel lymph node detection in endometrial cancer. Gynecol
Oncol. 2017;125(2):256–61.
26. Bollino M, Geppert B, Lonnerfors C, et al. Pelvic senti-
nel lymph node biopsy in endometrial cancer: a simplifed
algorithm based on histology and lymphatic anatomy. Int J
Gynecol Cancer. 2020;30(3):339–45.
6
Lymphatic anatomy: lymphatics of the ovary

Ate G.J. van der Zee

CONTENTS
Introduction .................................................................................................................................................................................... 35
Lymphatic anatomy........................................................................................................................................................................ 35
Distribution of pelvic and aortic lymph node metastasis in patients with ovarian cancer ............................................................. 35
Sentinel node detection in ovarian cancer...................................................................................................................................... 36
References...................................................................................................................................................................................... 37

Introduction
Comparable to the other major gynecologic malignancies,
information on the lymphatics of the ovary can be obtained
from three different types of studies: 1) descriptive anatomy
reports in which the lymphatic anatomy is studied with or
without previous injection of different types of dyes; 2) studies
on the distribution of pelvic and aortic lymph node metastases
in patients with early-stage ovarian cancer who underwent pel-
vic and aortic lymph node evaluation; and 3) studies in which
lymphatic mapping by injection of a tracer has been performed
in patients with early-stage ovarian cancer. However, in com-
parison to cervical, endometrial, and vulvar cancer, the num-
ber of this third category of studies in ovarian cancer is very
limited. This lack of studies on lymphatic mapping may well
be due to the fact that lymphogenous pathways are not always
of primary relevance in the dissemination of ovarian cancers.
The most common and earliest mode of dissemination is by
exfoliation of cells that implant along the surfaces of the peri-
toneal cavity. However, in 1985, the International Federation
of Gynecologists and Obstetricians (FIGO) modifed the stag-
ing for ovarian cancer, in part to refect the prognostic signif-
cance of metastatic spread to the pelvic or paraaortic lymph
nodes.1 Especially in patients with disease macroscopically
confned to one of the ovaries, survival decreases signifcantly
when retroperitoneal extension is found, thereby emphasizing
the need for proper evaluation of the lymph nodes, and con-
sequently justifying more aggressive adjunctive therapy when
positive nodes are found.2
Lymphatic anatomy
The tunica albuginea of the ovary is essentially devoid of lym-
phatics, while the parenchymal lymphatics comprise a rich
network, whose presence is related to developing follicles.
Lymph from the ovary is drained peripherally by six to eight
large collecting trunks that leave the ovarian hilus within the
mesovarium to form the subovarian plexus, which is composed
of efferent trunks from the uterine corpus, fallopian tube, and
ovary. Mixing of lymph that has originated from each organ
does occur. Efferent vessels from this plexus drain in a cepha-
lad direction along with the ovarian blood vessels to terminate
in the aortic nodes. In about 25% of women, a collateral trunk
exists which bypasses the subovarian plexus. It reaches the
pelvic wall within the folds of the broad ligament, terminating
in the uppermost interiliac nodes.3
Distribution of pelvic and aortic lymph node
metastasis in patients with ovarian cancer
When one looks at ovarian cancer, pelvic and aortic nodes
could also be primary and sentinel ones, in view of the fre-
quent observations of pelvic and aortic lymph node metastasis
alone in patients with ovarian cancer. In a study by Matsumoto
et al., in which systematic pelvic and aortic lymph node dissec-
tion was performed, the incidence of aortic lymph node metas-
tasis alone in node-positive ovarian cancer patients (all FIGO
stages) was 21%,4 a fgure which is consistent with fgures pre-
viously reported (15%–55%).5–8 Overall, these data show that
direct metastasis to the aortic lymph nodes frequently occurs
in ovarian cancer. Matsumoto and colleagues also showed that
metastasis at both pelvic and aortic lymph nodes is common
in ovarian cancer, again in keeping with previous studies in
ovarian cancer. However, the incidence of aortic lymph node
metastasis was not related to the incidence of positive common
iliac and sacral nodes, a subgroup which could be assumed
to be affected when aortic lymph node metastasis spreading
from pelvic nodes occurs. In combination with an incidence
of pelvic lymph node metastasis alone in patients with ovarian
cancer of 17%, these data clearly indicate two separate ways of
lymphatic spread in ovarian cancer. Therefore, it appears that

DOI: 10.1201/9781003255536-6 35
36
FIGURE 6.1 Lymphatic drainage of the ovary and fallopian tube.
(Modifed from Plentl and Friedman.3)
metastasis in ovarian cancer may take two separate routes: one
via the broad ligament to the internal and external iliac and
obturator lymph nodes and one via the infundibulopelvic liga-
ment to the aortic lymph nodes (Figure 6.1).
The pattern of lymphatic spread in ovarian cancer macro-
scopically confned to one ovary is controversial with respect
to whether contralateral lymph node metastases do occur. In
a retrospective study in this category of patients, Cass et al.
found positive pelvic nodes alone in 50%, positive aortic
nodes alone in 36%, and both in 14% of cases, while iso-
lated contralateral lymph node metastases were seen in 4%.9
Comparable low fgures have also been reported by others,10–13
while several studies did not fnd contralateral metastases.14,15
Based on the lymphatic anatomy, it is hard to imagine a way
of contralateral spread. All the studies that have reported con-
tralateral metastasis were retrospective, and it may well be
that a lesion such as occult disease in the ipsilateral ovary has
been missed.
Sentinel node detection in ovarian cancer
More than 20% of patients with epithelial ovarian cancer will
be diagnosed at an apparent early stage (I–II), with the dis-
ease macroscopically confned to the pelvis.16 Attributed to
the extrapelvic vascular supply of the adnexa, approximately
Clinical Lymphatic Mapping
30% of patients with presumed early-stage cancer will expe-
rience an upstaging of the disease after comprehensive lym-
phatic and peritoneal staging.17 Pelvic and paraaortic lymph
node dissection is therefore part of a comprehensive surgical
staging in early disease to defne the accurate stage that will
have signifcant implications on the choice and indication of
the adequate adjuvant systemic treatments. The incidence
of lymph node metastasis in apparent early-stage epithelial
ovarian cancer (EOC) (all histologic grades) is estimated to
be around 14%–15%;18–19 approximately 35% of patients have
only pelvic-positive nodes, 37% have only paraaortic-positive
nodes, and the remaining 28% have both pelvic and paraaor-
tic involvement.20 In particular, patients with apparent early-
stage cancer might be candidates for sentinel node detection
in order to obviate the side effects associated with full pelvic
and paraaortic lymphadenectomy in patients with, in principle,
a low likelihood of metastatic lymph nodes. A recent review
indicates a frequency of approximately 3% metastatic nodes in
these patients, which stresses the need for alternative staging
techniques, i.e., sentinel node detection rather than full lymph-
adenectomy in these patients.21
As already mentioned in the introduction of this chapter,
limited data are available on lymphatic mapping in ovarian
cancer. Until recently, only retrospective studies on small
series of patients with a variety of tracers and injection sites
were published. From the available retrospective literature,
the most promising technique seems to be injection into the
infundibulopelvic, as well as the proper ovarian ligament.
Indocyanine green seems to be an excellent tracer for suc-
cessful sentinel node detection of ovarian tumors, which can
be used during laparoscopic or robotic surgery. The detec-
tion rates and true positive rates of studies support further
investigation of the technique (for reviews, see Refs. 22 and
23). In a prospective phase II study, Lago et al. recently
showed the feasibility and safety of sentinel node detec-
tion for ovarian cancer staging. In their protocol 99mTc and
indocyanine green were injected intraoperatively (either at
laparotomy or laparoscopy) into both the utero-ovarian and
infundibulopelvic ligament stump.24 The Sentinel Lymph
Nodes in Early-Stage Ovarian Cancer trial (SELLY) is an
ongoing prospective, phase II, single-arm study that includes
patients with presumed stages I–II epithelial ovarian cancer
planned for immediate or delayed minimally invasive com-
prehensive staging. An interim analysis on the frst 31 patients
was recently published and showed that the detection rate of
the sentinel node in early-stage ovarian cancer is low when
patients are submitted to delayed-staging surgery. However,
the interim analysis also shows that the sentinel node proce-
dure with injection of indocyanine green in the ovarian ped-
icle is feasible, but technically challenging. Preliminary data
on its diagnostic accuracy indicate that the sentinel node tech-
nique with intraoperative indocyanine green has the potential
to provide reliable and useful information on nodal status and
may allow the avoidance of systematic lymphadenectomy in
the majority of apparent early-stage patients.25 However, more
mature data from this trial and others need to be awaited and
until then the application of the sentinel node technique in
ovarian cancer patients should only be used within the protec-
tion of clinical trials.
Anatomy: lymphatics of the ovary 37

REFERENCES 14. Burghardt E, Girardi F, Lahousen M, et al. Patterns of pel-

vic and paraaortic lymph node involvement in ovarian can-
1. FIGO. Changes in gynecologic staging by the International
cer. Gynecol Oncol. 1991;40:103–6.
Federation of Gynecologists and Obstetricians. Am J Obstet
15. Benedetti Panici P, Greggi S, Maneschi F, et al. Anatomical
Gynecol. 1990;162:610–11.
and pathological study of retroperitoneal nodes in epithelial
2. Carnino F, Fuda G, Ciccone G, et al. Signifcance of
ovarian cancer. Gynecol Oncol. 1993;51:150–4.
lymph node sampling in epithelial carcinoma of the ovary.
16. Young RC, Walton LA, Ellenberg SS, et al. Adjuvant ther-
Gynecol Oncol. 1997;65:467–72.
apy in stage I and stage II epithelial ovarian cancer. Results
3. Plentl A, Friedman E. Lymphatic System of the Female
of two prospective randomized trials. N Engl J Med.
Genitalia. Vol. 2. Philadelphia, PA: WB Saunders; 1971.
1990;322:1021–7.
4. Matsumoto K, Yoshikawa H, Yasugi T, et al. Distinct lym-
17. Timmers PJ, Zwinderman K, Coens C, et al. Lymph node
phatic spread of endometrial carcinoma in comparison with
sampling and taking of blind biopsies are important ele-
cervical and ovarian carcinomas. Cancer Lett. 2002;180:83–9.
ments of the surgical staging of early ovarian cancer. Int J
5. Chen SS, Lee L. Incidence of para-aortic and pelvic lymph
Gynecol Cancer. 2010;20:1142–7.
node metastases in epithelialcarcinoma of the ovary.
18. Berek JS, Crum C, Friedlander M. Cancer of the ovary,
Gynecol Oncol. 1983;16:95–100.
fallopian tube, and peritoneum. Int J Gynaecol Obstet.
6. Onda T, Yoshikawa H, Yokota H, et al. Assessment of
2012;119(Suppl 2):S118–29.
metastases to aortic and pelvic lymph nodes in epithelial
19. Ledermann JA, Raja FA, Fotopoulou C, et al. Newly diag-
ovarian carcinoma. A proposal for essential sites for lymph
nosed and relapsed epithelial ovarian carcinoma: ESMO
node biopsy. Cancer. 1996;78:803–8.
Clinical Practice Guidelines for diagnosis, treatment and
7. Sakai K, Kamura T, Hirakawa T, et al. Relationship
follow-up. Ann Oncol. 2013;24(Suppl 6):vi24–32.
between pelvic lymph node involvement and other dis-
20. Ledermann JA, Luvero D, Shafer A, et al. Gynecologic
ease sites in patients with ovarian cancer. Gynecol Oncol.
Cancer InterGroup (GCIG) consensus review for mucinous
1997;65:164–8.
ovarian carcinoma. Int J Gynecol Cancer. 2014;24(9 Suppl
8. Tsumura N, Sakuragi N, Hareyama H, et al. Distribution
3):S14–19.
pattern and risk factors of pelvic and para-aortic lymph
21. Lago V, Minig L, Fotopoulou C. Incidence of lymph node
node metastasis in epithelial ovarian carcinoma. Int J
metastases in apparent early-stage low-grade epithelial
Cancer. 1998;79:526–30.
ovarian cancer: a comprehensive review. Int J Gynecol
9. Cass I, Li AJ, Runowicz CD, et al. Pattern of lymph node
Cancer. 2016;26:1407–14.
metastases in clinically unilateral stage I invasive epithelial
22. Uccella S, Gisone B, Ghezzi F. Laparoscopic senti-
ovarian carcinomas. Gynecol Oncol. 2001;80:56–61.
nel node detection with ICG for early ovarian cancer:
10. Wu P, Qu J, Lang J, et al. Lymph node metastasis of ovarian
description of a technique and literature review. EJOGR.
cancer: a preliminary survey of 74 cases of lymphadenec-
2018;221:193–4.
tomy. Am J Obstet Gynecol. 1986;155:1103–8.
23. Mach P, Kimmig R, Buderath P. The role of sentinel-
11. Petru E, Lahousen M, Tamussino K, et al. Lymphadenec-
node biopsy in ovarian cancer. Minerva Ginecol.
tomy in stage I ovarian cancer. Am J Obstet Gynecol.
2020;72(6):399–403.
1994;170:656–62.
24. Lago V, Bello P, Montero B, et al. Sentinel lymph node
12. Onda T, Yoshikawa H, Yasugi T, et al. Patients with ovar-
technique in early-stage ovarian cancer (SENTOV):
ian carcinoma upstaged to stage III after systematic lymph-
a phase II clinical trial. Int J Gynecol Cancer.
adenectomy have similar survival to stage I/II patients
2020;30(9):1390–6.
and superior survival to other stage III patients. Cancer.
25. Uccella S, Nero C, Vizza E, et al. Sentinel-node biopsy in
1998;83:1555–60.
early-stage ovarian cancer: preliminary results of a pro-
13. Walter AJ, Magrina JF. Contralateral pelvic and aortic
spective multicentre study (SELLY). Am J Obstet Gynecol.
lymph node metastasis in clinical stage I epithelial ovarian
2019;221(4):324.e1–324.e10.
cancer. Gynecol Oncol. 1999;74:128–9.
7
Lymphatic anatomy: lymphatics of the breast and axilla
James V. Fiorica
CONTENTS
References...................................................................................................................................................................................... 42
Lymphatic mapping of the breast is altering the long-standing
approach to the breast cancer treatment model: radical mas-
tectomy with complete axillary lymphadenectomy. It is a dra-
matic departure from Halsted’s modality of 100 years ago.1
The status of the axillary lymph node has consistently been
shown to be the most signifcant prognostic factor in patients
with breast cancer.2 The breast lies within the superfcial fascia
of the anterior thoracic wall. It is situated between the second
and sixth ribs and the sternal edge and midaxillary line. The
posterior surface of the breast ends abruptly at the chest wall,
where it reaches the pectoralis major fascia. It is composed of
skin, parenchyma, and stroma. The stroma and connective tis-
sue are intertwined with blood vessels, nerves, and lymphatics.
Beneath the nipples are fve to ten milk ducts which connect to
fve to ten additional ducts, each draining an individual breast
lobe. Each lobe is composed of 20–40 lobules, which in turn
connect to 10–100 tubulosaccular units called alveoli. The
subcutaneous connective tissue surrounds glands and extends
as septa between the lobes and lobules, providing support for
the glandular elements. Cooper’s ligaments are suspensory
structures that insert perpendicular to the dermis.
The pectoralis major muscle is a fan-shaped muscle with two
divisions. The clavicular division originates from the clavicle
and can be easily distinguished from the larger costosternal
division that originates from the sternum and costal cartilage
of ribs 2–6. These fbers converge on the greater tubercle of
the humerus. The pectoralis minor muscle is located beneath
the pectoralis major muscle and arises from the external sur-
face of ribs 2–5. The posterior suspensory ligaments extend
from the deep surface of the breast to the deep pectoral fascia.
The subscapular muscle arises from the frst rib near the costo-
chondral junction and extends laterally to insert on the inferior
surface of the clavicle.
The axillary sheath extends from the neck to the axilla and
is surrounded by a layer of fascia. This sheath contains the
great vessels and nerves of the upper extremities. The axillary
artery is divided into three parts. The frst segment, located
medial to the pectoralis minor muscle, has the supreme tho-
racic branch. This segment supplies the frst and second inter-
costal spaces. The second segment, located posterior to the
pectoralis minor muscle, contains the thoracoacromial trunk
and the lateral thoracic artery branches. Located lateral to the
pectoralis minor muscle is the third segment of the axillary
DOI: 10.1201/9781003255536-7
artery. It has three branches, which are the anterior and pos-
terior humoral circumfex arteries and the subscapular artery.
The largest of the axillary branches is this subscapular artery.
This artery branches into the subscapular circumfex and the
thoracodorsal arteries, which are associated with the central
and subscapular lymph nodes, which are described in more
detail later in this chapter.
The internal mammary artery medially (65%) and the lat-
eral thoracic artery (35%) supply blood to the breast (Figure
7.1). The cephalic vein serves as a landmark separating the
pectoralis major muscle from the deltoid muscle. The vein
travels through the deltopectoral triangle and pierces the cla-
vipectoral fascia, joining the axillary vein. Branches of the
brachial plexus are located throughout the course of the axilla.
The long thoracic nerve is located on the medial wall of the
axilla, arising in the neck from the ffth, sixth, and seventh
roots of the brachial plexus. It innervates the serratus anterior
muscle, which permits raising the arm above the shoulder. The
intercostobrachial nerve is the lateral cutaneous branch of the
second intercostal nerve and the joining of the medial cutane-
ous nerve of the arm, supplying the skin of the foor of the
axilla and the upper medial aspect of the arm.
The lymphatic system of the breast is just as intricate and
complicated. The subaerolar lymphatic plexus of Sappey com-
municates to the vertical lymphatics in a subepithelial and
subdermal manner. The unidirectional lymphatics fow from
this superfcial subaerolar plexus through the lactiferous duct
lymphatics to the perilobar and deep subcutaneous lymphatic
plexus. This deep lymphatic plexus drains in a centrifugal
direction to the axillary nodes (97%) and the internal mam-
mary nodes (3%). The axillary nodes are divided into six
groups: the lateral (axillary) group lies medial and posterior
to the axillary vein (four to six nodes), the external mammary
group (anterior or pectoral) lies along the lower border of the
pectoralis minor muscle adjacent to the lateral thoracic ves-
sels (four to fve nodes), the subscapular (posterior) group lies
along the posterior wall of the axilla at the lateral border of the
scapula (six to seven nodes), and the central group is embed-
ded in the fat of the axilla behind the pectoralis minor muscle
and is the common shallow palpable group of nodes (three to
four nodes). The apical (subclavicular) nodes are located at
the upper border of the pectoralis minor muscle and receive
lymph from all areas (6–12 nodes). Two additional pathways
39
40
FIGURE 7.1 Primary blood supply to the breast.
FIGURE 7.2 Primary lymph nodes of the breast and axilla.
are the transpectoral and the retropectoral (Rotter’s nodes).
The Rotter’s interpectoral group is located between the pecto-
ralis major and minor muscles (one to four nodes) and passes
to the central and apical nodes directly. Prepectoral nodes
refer to single lymph nodes, which are found in the subcutane-
ous tissue within the breast (Figure 7.2).
Clinical Lymphatic Mapping
The internal mammary nodes are located in the retrosternal
interspaces within 2 cm of the sternal margin and transverse
the internal mammary vessels. The right internal mammary
nodes enter the internal mammary lymphatic trunk, which
terminates in the subclavicular nodal group. The left internal
mammary chain enters the main thoracic duct.3 The surgeon
Lymphatics of the breast and axilla 41

TABLE 7.1 and tumor biology in the current era of more conservative sur-
Classifcation of Lymph Nodes Draining the Breast gery and newer systemic neoadjuvant therapies. The risk of
metastases and death increases with both breast cancer size at
Nodal group Anatomic name Level Number of nodes
detection and number of axillary lymph nodes involved.9 The
Axillary External mammary I 4–5 breast lymphatic level approach is a more focused and less rad-
Subscapular I 6–7 ical dissection to remove the disease.10 Additionally, sentinel
Lateral I 4–6 node biopsy will reduce complications from more extensive
Central II 3–4 surgical procedures or adjuvant therapies. If women do have
Rotter’s II 1–4 micrometastasis in the supraclavicular nodes, they are classi-
Apical III 6–12 fed as having stage IV disease.
Internal mammary – 6–8
With proper injection techniques and timing, certain
anatomic landmarks are helpful for identifying the sentinel
Prepectoral nodes – 1
node. If one draws a line from the lateral border of the pec-
Deltopectoral – 1–2
toralis major muscle and another at the lateral border for the
Supraclavicular (Stage IV) – 2–3
latissimus dorsi muscle in the axilla, these lines will outline
the outer borders of the axillary limits for dissection. A tan-
gential line is drawn at the axillary hairline in a perpendicu-
should be familiar with the anatomy of the breast’s lym- lar, anterior-to-posterior direction. Another line can then be
phatic system to avoid false-negative results of sentinel nodes. drawn through the axis of the axilla, through the center point
Patients can be undertreated with poor oncologic outcomes if of the hairline. The intersecting lines mark the center of a
high false-negative rates occur.4 5-cm circle on the axilla. Ninety-four percent of the SLNs
The level of nodes is often described as level I, II, or III are within this circle. The remaining 6% are in the level II
in relationship to the pectoralis minor muscle. Nodal tissue location (Figure 7.3). Once the SLN is identifed on the skin,
lateral to the minor muscle is known as level I (external mam- an accurate incision may be made, overlying the area of high-
mary, lateral, and subscapular). Those lymphatics beneath est activity with the gamma probe. Internally, the anatomic
the muscle are level II (central ± subscapular), and the lymph landmarks are the central axillary vein and the third branch
nodes on the medial edge of the pectoralis minor muscle are
known as level III (apical) lymph nodes. During the standard
dissection, level I and a portion of level II nodes are removed5
(Table 7.1).
Advocates of axillary dissection contend that this method
renders regional control of axillary disease. Since the time of
Halsted, the status of the regional nodal basin has remained
the single most important variable in predicting prognosis.6
Recent thinking supports the idea that microscopic disease
may be cured with adjuvant chemotherapy with or without
node dissection. Some physicians advocate abandoning the
axillary lymph node dissection. The development of intra-
operative lymphatic mapping and selective lymphadenectomy
has permitted the mapping of lymphatic fow from the primary
tumor and the identifcation of the sentinel lymph node (SLN)
in the regional basin.
SLN biopsy for breast cancer may obviate the need for rou-
tine axillary node dissections in most node-negative patients
and still provide prognostic information to the patient and cli-
nician. The assignment of levels I, II, and III was relatively
arbitrary and has led to a high (15%) prevalence of skip metas-
tasis.7 Data from the American College of Surgeons Oncology
Group 20011 Trial suggested that patients with even a stage
T1 or T2 tumor along with one or two positive lymph nodes
can be spared axillary lymph node dissection.8 With lym-
phatic mapping, variations of breast lymph drainage have been
apparent. Direct lymphatic drainage from primary sites has
been noted to level II and III axillary nodes, subclavian nodes,
and supraclavicular nodes. More accurate staging can improve
survival by identifying patients who will gain with either the
surgical procedure itself (complete dissection) or the accompa-
nying adjuvant therapy. Tumor size and nodal status still have
a signifcant infuence on overall mortality independent of age FIGURE 7.3 Location of sentinel lymph nodes of the axilla.
42
of the intercostal nerve beneath the clavipectoral fascia.
The vein may be found easily, and when the nerve crosses
over the vein, four quadrants are defned within the circle
described earlier. The node is considered an SLN if it is blue
or has a blue-stained afferent lymphatic vessel leading to it.
In addition, the node is sentinel if it has an in vivo radioactiv-
ity (radioactivity in the SLN/neighboring non-SLN) of 3:1 or
an ex vivo activity of 10:1.11
The mapping techniques vary slightly from center to center.
However, the results have attained similar high success rates
in skilled hands. Sensitivity and diagnostic accuracy rates
have been greater than 95%, with false-negative (skip) rates
of 0%–10%. These results suggest that lymphatic mapping has
the potential to change the standards for surgical management
of breast cancer.12
Newer studies under investigation include a radioactive
infrared activated fducial refection. Preliminary fnd-
ings show that this refective guided excision may more
accurately refect the status of the axilla after neoadjuvant
chemotherapy.13
REFERENCES
1. Chua B, Ung O, Boyages J. Competing considerations in
regional nodal treatment for early breast cancer. Breast J.
2002;8:15–22.
2. Manca G, Rubello D, Tardelli E, et al. Sentinel lymph node
biopsy in breast cancer: indications, contraindications, and
controversies. Clin Nucl Med. 2016;41:126–33.
3. Bland K, Klimberg V, Copeland EM, et al.  Anatomy of
the breast, axilla, chest wall, and related metastatic sites.
In: The Breast Comprehensive Management of Benign
and Malignant Diseases. Philadelphia, PA: Elsevier; 2018.
pp. 20–36.
Clinical Lymphatic Mapping
4. Goel V, Raju K, Dasu S, et al. Awareness of lymphatic sys-
tem to decrease false negative sentinel node rate in breast
cancer. Indian J Surg Oncol. 2019;10:673–5.
5. Nathanson SD, Wachna DL, Gilman D, et al. Pathways
of lymphatic drainage from the breast. Ann Surg Oncol.
2001;8:837–43.
6. Heerdt AS. Lymphatic mapping and sentinel lymph node
biopsy for breast cancer.  JAMA Oncol.  2018;4(3):431.
https://doi.org/10.1001/jamaoncol.2017.4000.
7. Veronesi U, Rilke F, Luini A, et al. Distribution of axillary
node metastases by level of invasion. An analysis of 539
cases. Cancer. 1987;59:682–7.
8. Marino MA, Avendeno D, Zapata R, et al. Lymph node
imaging in patients with primary breast cancer: concurrent
diagnostic tools. Oncologist. 2020;25:e231–42.
9. Saadatmand S, Bretveld R, Siesling S, et al. Infuence of
tumour stage at breast cancer detection on survival in mod-
ern times: population based study in 173797 patients. BMJ.
2015;351:h4901–10.
10. Yuan Q, Hou J, He Y, et al. Minimize the extent and
morbidity of axillary dissection for node-positive breast
cancer patients: implementation of axillary lymph node
dissection based on breast lymphatic level. BMC Cancer.
2021;21:293–302.
11. Cox C. Techniques for lymphatic mapping in breast carci-
noma. In: Whitman D, Reintgen D, editors, Radioguided
Surgery. Austin, TX: Landes Biosciences; 1999. pp. 72–82.
12. Reintgen M, Kerivan L, Reintgen E, et al. Breast lymphatic
mapping and sentinel lymph node biopsy: state of the art
2015. Clin Breast Cancer. 2016;16:155–65.
13. Taback B, Jadeja P, Ha R. Enhanced axillary evaluation
using refective-guided sentinel lymph node biopsy: a pro-
spective feasibility study and comparison with controver-
sial lymphatic mapping techniques. Clin Breast Cancer.
2018;18:e869–74.
8
Modalities of detection of sentinel nodes in lymphatic mapping

Blanca Segarra, Nuria Agusti, and Pedro T. Ramirez

CONTENTS
Introduction.................................................................................................................................................................................... 43
Mapping tracers ............................................................................................................................................................................. 43
Blue dye agents .................................................................................................................................................................... 44
Colloids and lymphoscintigraphy......................................................................................................................................... 44
Indocyanine green ................................................................................................................................................................ 45
Empty lymph node packet syndrome ...................................................................................................................... 45
Technique by disease site............................................................................................................................................................... 46
Vulvar cancer........................................................................................................................................................................ 46
Sentinel lymph node technique................................................................................................................................ 46
Endometrial cancer............................................................................................................................................................... 47
Dose of ICG on the SLN mapping................................................................................................................................................. 48
Cervical cancer..................................................................................................................................................................... 48
Ovarian cancer...................................................................................................................................................................... 49
Safety.................................................................................................................................................................................... 49
Blue dye................................................................................................................................................................... 49
Technetium .............................................................................................................................................................. 49
Indocyanine green.................................................................................................................................................... 49
Mapping in special settings .................................................................................................................................................. 50
Pregnancy ................................................................................................................................................................ 50
Obesity..................................................................................................................................................................... 50
Novel modalities ............................................................................................................................................................................ 50
Intraoperative identifcation techniques ............................................................................................................................... 50
[99mTechnetiumTc] tilmanocept ............................................................................................................................... 50
Carbon nanoparticles............................................................................................................................................................ 50
India ink................................................................................................................................................................... 51
Superparamagnetic iron........................................................................................................................................... 51
Imaging-enhanced modalities .............................................................................................................................................. 51
Contrast-enhanced ultrasound ................................................................................................................................. 51
Conclusion ..................................................................................................................................................................................... 51
References...................................................................................................................................................................................... 51

Introduction Mapping tracers

The landscape of lymphatic mapping tracers has evolved
over the years, with broader expansion in the feld of gyneco-
logic oncology. Newer substances are associated with higher
detection rates, improved side effect profles, and lower cost.
Mapping substances range in their abilities and use, given their
different compositions. The ideal mapping substance should
have a high detection rate with the least possible cost and num-
ber of side effects. In the setting of sentinel lymph node (SLN)
mapping, this would entail a low false-negative rate (negative
SLNs on pathology in the setting of a positive lymph node
in the remainder of the lymph node dissection) to minimize
undertreatment of patients.
The three conventional tracers currently used in gyneco-
logic surgery are technetium-99m radiocolloid (99mTc), vari-
ous blue dyes, and indocyanine green (ICG). Historically,
the SLN detection was usually performed by peritumoral
or intratumoral injection of a tracer. In most tumors, blue
dye associated with 99mTc-nanocoloid albumin has been the
most commonly used agent in gynecologic cancer because
this combination increases detection rates.1 Recently, ICG, a
nonradioactive tracer based on fuorescence, detectable by its
light emission after excitation with a specifc wavelength, has
been used more commonly, becoming the standard tracer in
many institutions.

DOI: 10.1201/9781003255536-8 43
44
Blue dye agents
The two substances most commonly used as blue dyes are
methylene blue and isosulfan blue (sometimes referred to as
patent blue). The substances are functionally interchangeable
when used as biotracers and with equal effcacy; however,
their different chemical structures explain critical differences
between the elements. Methylene blue is an organic chloride
salt with a molecular mass of 319.8 g/mol. It may not be an
ideal tracer because it is very poorly absorbed when injected
intradermally and easily diffuses into the surrounding tissue,
causing substantial tissue stain without specifc targeting of
the sentinel node. However, some claim that among its benefts
is the fact that it is cheaper, more readily available, and has a
better side effect profle than isosulfan blue. It should be noted
that methylene blue has been associated with higher rates of
anaphylaxis. Another mapping agent in this category is iso-
sulfan blue. It has a molecular mass of 566.7 g/mol and is a
2,5-disulfonic acid isomer of patent blue. Approximately 50%
of isosulfan blue is weakly bound to serum proteins, and it is
rapidly transported through the lymphatics after intradermal
injection, making it less likely to diffuse into the surrounding
tissue. The structure of both blue dyes contains both hydro-
phobic and hydrophilic regions. The hydrophilic areas allow
for intravenous administration, as the substances dissolve in
water and blood. The hydrophobic regions serve as high-affnity
binding sites for oncotic proteins that circulate throughout the
lymphovascular system. Blue dyes can only be seen in the vis-
ible light spectrum. This difference contributes to the overall
accessibility and low cost of blue dye technology.
Colloids and lymphoscintigraphy
Scintigraphy tracks a radioactive tracer in a living body and
provides a view of the position and concentration of a radioiso-
tope within the body. 99mTc is responsible for more than 80% of
applications in nuclear medicine. Technetium derives its name
from the Latin word for “artifcial,” as it was the frst artif-
cially formed element. While 99mTc, where “m” stands for a
metastable isotope, can be found in nature, the majority of the
world’s supply is manufactured. 99mTc products have different
biological absorptive properties depending on their oxidative
states. 99mTc-labeled radiopharmaceuticals are used in 85%
of all nuclear medicine procedures because of the following
benefts:
• Half-life time of approximately 6 hours. This shorter
half-life allows for the capture of an increased
number of emissions over a short period, creating
an emission density that can form high-resolution
images.
• Small particles that fow into secondary lymph nodes
more rapidly, therefore enabling the identifcation of
an increased number of nodes.
• Gamma photon emission energy of 140 keV is ideal
both for detection by diagnostic gamma camera
imaging and for gamma probe detection. This energy
level provides adequate tissue penetration and man-
ageable imaging technologies.
Clinical Lymphatic Mapping
• Low patient-absorbed radiation dose, minimiz-
ing patient exposure to doses of harmful radiation.
Although the half-life is relatively short, the dose is
enough to detect positive nodes more than 24 hours
post-injection.
• Low cost per patient doses. The availability of
radioisotope-based medicines, as well as the costs
of production and research, transportation, and stor-
age, signifcantly infuence use. Generator-produced
radioisotopes are still the most commonly used.
Their costs, higher than those of radioisotopes
obtained in a reactor, are compensated for by their
wide application.
• Widespread commercial availability.
Planar imaging is the most commonly applied preoperative
imaging for sentinel node identifcation. Lymphoscintigraphy
is a safe, reproducible, and noninvasive technique utiliz-
ing radionuclides to image regional lymph node drainage.1
The lymphatic channels are best appreciated in a composite
dynamic image from the individual progressive frames. This
process usually takes 20 minutes in total. Delayed scans are
then performed at 2.5–3 hours after injection of the radiocol-
loid tracer. These scans should include all node felds that can
receive drainage from the injection site. Each static acquisition
may last 5–10 minutes to guarantee that even very weak senti-
nel nodes are detected.2 Another often used imaging modality
is the single photon emission computed tomography (SPECT)
overlaid with traditional computed tomography (CT) scan –
SPECT/CT. This tool allows surgeons to determine the ana-
tomic location of sentinel nodes, and the images correlate with
the anatomic location of the sentinel node location. SPECT/
CT appears to offer a signifcant improvement in sentinel node
detection and anatomic localization when compared with lym-
phoscintigraphy because it provides more accurate imaging of
pathological lesions and enables correction for absorption of
radiation in the patient’s body.3
The intraoperative detection of the sentinel node relies not
only on the visual inspection of the lymphatic basin to iden-
tify the ‘blue node’ but also on the assessment of the radioac-
tive colloid in the sentinel node, or ‘hot node,’ through the aid
of a gamma detection device. Detection devices used intra-
operatively are surgical gamma probes and portable imaging
gamma cameras. These portable systems might reduce the rate
of unidentifed positive SLNs. In summary, the performance
of a gamma detection probe can best be described by the fol-
lowing quality criteria:4
• Spatial selectivity at 30 cm (radial sensitivity distri-
bution): This describes the width of the measurement
cone, and it has a strong infuence on the detection of
lymph nodes in the presence of nontarget radiation
with a broad measurement cone. The importance is
because the background signal can exceed the target
signal of the lymph node.
• Spatial resolution: This determines the minimal
distance needed between two lymph nodes to be
detected separately. In the axillary, inguinal, and
Modalities of detection
iliac regions, spatial resolution higher than 25 mm
is recommended. For the SLN procedure, high spa-
tial resolution probes are required to ensure a more
accurate localization. Where more precise spatial
localization of activity is needed, collimation of the
detector may be required.
• Shielding (sensitivity at the probe housing): The leak
sensitivity should not exceed 0.1% of the system’s
sensitivity. Intraoperative probes are intended for
directional counting and must have adequate shield-
ing on the back and sides.
• Sensitivity: It is defned by the count rate per unit of
activity and is determined at the tip of the probe. It
may be increased by widening the energy window
and/or by reducing collimation and shielding.
• Energy discrimination: High-energy resolution
enables using two different radioisotopes at a time
and distinguishing the signal of the patient’s radia-
tion from those of background radiation.
• Display and acoustics: A clear correlation between
the tone and the measurement signal. A digital or
analog display is recommended.
• The shape of the probe: A slender and kinked probe
is desirable.
Until the introduction of ICG as a mapping tracer, blue dye
was considered the standard mapping tracer. However, tech-
niques such as radioactive colloid injections and lymphoscin-
tigraphy have provided a viable alternative as an added tool
when using blue dye in the setting where ICG is not available.
The primary advantage of using radiocolloid and lympho-
scintigraphy is the improvement in detecting lymph nodes that
are outside the routine anatomic landmarks of dissection, and
consequently, the reduction of the failure rate of SLN identif-
cation. In addition, using the gamma probe, the surgeon may
explicitly target those areas suggesting the presence of a sen-
tinel node that may have been missed due to poor blue dye
uptake and have not been identifed by lymphoscintigraphy.
Close cooperation between nuclear medicine specialists, sur-
geons, pathologists, and in many cases radiologists and medi-
cal physicists is required to assure the highest success rate of
detection.5
The frst stage of SLN identifcation is preoperative lym-
phoscintigraphy. It is performed in a 1- or 2-day protocol
with the injection of 99mTc-labeled radiocolloid on the day of
the surgery, 4–6 hours before the planned surgery, or a day
before, 16–20 hours before the scheduled surgery, respectively.
The preparations are based on the protocol used, 15–20 MBq
(1-day protocol) or 37–74 MBq (2-day protocol). The protocol
choice depends on the logistics and experience of the team.6
Intraoperative lymphoscintigraphy is usually performed 120
minutes after administration of the radiocolloid (the static
phase of examination). In some instances, to establish the
direction of lymphatic drainage and to facilitate identifying
the SLN, a dynamic exam is performed immediately after the
administration of the radioactive tracer.7 It is recommended to
perform a quantitative measure of the radioactivity in the sen-
tinel node with the gamma probe in order to detect an increase
45
in the radiation count compared with the basal count (at least
fve to ten times greater than background radioactivity).
Indocyanine green
ICG is a sterile, anionic, water-soluble tricarbocyanine dye
that shows diffuse fuorescence in the near-infrared spectrum
when illuminated by 806-nm light.8 Its biological half-life is
150–180 seconds. It is odorless, unstable in solution, soluble
in water and methanol, and insoluble in all other organic sol-
vents.1 ICG emits light with a wavelength of approximately 820
nm that is captured using a specifc video camera device that
enables it to be displayed in the visible-light spectrum. The
organic structure of ICG allows for it to be safely delivered
intravenously. Following intravenous injection, ICG is rapidly
bound to plasma proteins, especially lipoproteins, and distrib-
uted throughout the lymphovascular systems.9 ICG metabolism
has no extrahepatic or enterohepatic circulation. Therefore,
ICG is absorbed from the plasma exclusively by hepatic paren-
chymal cells and secreted entirely into the unconjugated bile.
Intracervical ICG distributes in the lymphatic system, where
it binds to lipoproteins and drains via lymphatic channels and
nodes. From the lymph nodes, fltered lymph is propelled back
to the blood circulation via the subclavian vein to maintain tis-
sue fuid homeostasis.8
Intravenous and submucosal administration are the two
main routes available.9 There is currently no consensus regard-
ing the concentration and volume of ICG to be infused. These
range from 1.25 to 5 mg (single image sequence) for intrave-
nous and from 1.25 to 5 mg/mL (4–10 mL) for intracervical
submucosal injection. Nevertheless, the maximum dosage
must never exceed 2 mg/kg (intravenous) or 5 mg (intersti-
tially).8 The standard dose commonly administered in clinical
practice (0.1–0.5 mg/mL/kg) is well below the toxicity level.
ICG should be injected at a concentration of 1.25 mg/mL.
A 25-mg vial with ICG powder is diluted in 20 mL of sterile
aqueous water. If the ICG solution is stored at 4°C, ICG should
be used within 1–2 days after the preparation.10 The timing
of ICG injection in gynecologic surgery during laparotomy is
not well established; however, we recommend the infusion be
performed before the incision. In laparoscopic and robotic-
assisted surgery, injection is performed before insertion of a
uterine manipulator and/or docking. When the endometrium
is the site of injection, the tubes are sealed before injection.
Although there are not enough data to defne the optimal time
to begin dissection, Rossi et al. suggest waiting 10 minutes
between injection and lymph node dissection.11 When con-
sidering the learning curve, it has been demonstrated that
surgeons require 30 procedures to achieve the detection and
false-negative rates necessary to perform this technique by
minimally invasive methods.12
Empty lymph node packet syndrome
Removal of presumed mapped lymph nodes that on fnal
pathology are determined to be only lymphatic trunks or adi-
pose tissue without nodal tissue is a phenomenon that seems to
be more associated with increased ICG utilization. The FILM
study13 was designed to determine whether ICG is superior to
46
isosulfan blue dye in detecting SLNs in women with clinical
stage I endometrial or cervical cancer who underwent cura-
tive surgery. This study described a 5%–6% rate of presumed
“nodes” with bright signal that were not confrmed to be
lymph nodes on pathology. More recently, Thomaier and col-
leagues14 evaluated whether the rate of empty packet dissec-
tion changed with increasing surgeon experience. In total, 236
patients undergoing SLN mapping during minimally invasive
hysterectomy for either endometrial cancer (85%) or complex
atypical hyperplasia (15%) were evaluated. The study showed
that the proportion of empty packet dissections declined with
an increasing amount of procedures. The amount of SLNs
removed did not change as surgeon expertise improved. The
authors concluded that the rate of empty packet SLN dissec-
tions using indocyanine green dye decreases with an increas-
ing number of procedures and that this stabilizes after 30
procedures. When the surgeon is concerned about this phe-
nomenon, it is recommended for the tissue to be sent to the
pathologist to confrm that the sample contains lymph node
tissue rather than adipose tissue.
Technique by disease site
Vulvar cancer
SLN mapping has been proposed as an alternative to inguino-
femoral lymph node dissection in early-stage vulvar cancer.
Mapping for vulvar cancer has been traditionally performed
using a dual-modality approach: 1) preoperative 99mTc injec-
tion with lymphoscintigraphy intraoperative gamma probe
detection or 2) intraoperative peritumoral vulvar injection
with blue dye. Radiocolloid tracers should be used alone or
with blue dye. In patients where lymphoscintigraphy did not
identify a sentinel node in the groin(s) of interest, the addi-
tion of blue dye should be used. A meta-analysis performed by
the Cancer Care Ontario group reported a 63% overall detec-
tion rate with the use of blue dye alone compared to 85% with
the use of radiocolloid alone.15 The overall detection rate with
the combination of blue dye and radiocolloid was 86.9%. The
false-negative rates with blue dye alone and radiocolloid alone
were 9.3% and 10.4%, respectively, but when both techniques
were combined, it lowered this rate to 6.6%. Given these fnd-
ings, the group recommended the use of radiocolloid tracers
alone or in combination with blue dye for SLN mapping of
early-stage vulvar cancer.
The introduction of radiotracers allowed improved localiza-
tion of the SLN as well as better reliability. Puig-Tintore et al.16
published the feasibility of lymphoscintigraphy combined with
a handheld gamma probe and isosulfan blue in detecting the
SLN in vulvar cancer. In their study the introduction of radio-
tracers allowed an improved localization rate of the SLN to
98%, and the authors concluded that the combination of the
two methods is the best approach. Therefore, the use of radio-
tracers enhances the localization of the SLN and gives better
results than when the blue dye technique alone is used. There
is insuffcient evidence to make recommendations regarding
preoperative lymphoscintigraphy. However, it seems to facili-
tate the presence, location (unilateral vs. bilateral), and number
Clinical Lymphatic Mapping
of sentinel nodes mainly when the use of lymphatic mapping
and SLN biopsy alone is planned. The injection of radiocol-
loid should be followed by imaging (lymphoscintigraphy and/
or SPECT-CT) and surgery within 1–6 hours.
The use of radiotracers requires complex logistics, and
despite the need for radiocolloids during preoperative plan-
ning, this technology is based on intraoperative acoustic
feedback and is unable to provide real-time visual guidance.
More recently, ICG has been used for lymphatic mapping
at multiple solid tumor sites. The greatest advantage of this
technique using the fuorescent agent is that it can be per-
formed in a one-step, all intraoperative procedure, thus reduc-
ing patient discomfort associated with the current two-step
procedure, including preoperative injections of radiocolloid.
Furthermore, theoretically, the lymphatic channels and SLNs
in vulvar cancer are often located in a relatively superfcial
location in the groin when compared to other tumors; there-
fore, near-infrared fuorescence imaging could be particularly
useful for this indication. Nevertheless, this technique requires
special equipment (near-infrared imaging cameras) that is not
currently available at most centers.
Crane et al.17 published the frst clinical study evaluating the
technical feasibility of intraoperative near-infrared fuores-
cence imaging for SLN detection in vulvar cancer. The authors
reported the successful use of ICG alone at a concentration
of 0.5 mg/mL in conjunction with an intraoperative imaging
system for the SLN procedure in vulvar cancer. In that study,
involving ten patients, 26 of 29 SLNs (90%) were detected in
vivo by near-infrared fuorescence. Furthermore, lymphatic
channels could be visualized in 5 of 16 groins (31%) contain-
ing SLNs. In conclusion, radiocolloid tracers alone or in com-
bination with blue dye remain the standard for the detection of
SLNs in vulvar cancer in most institutions.
Sentinel lymph node technique
To perform SLN mapping with blue dye and 99mTc nanocolloid,
it is recommended that the combination of preoperative imag-
ing and the use of a gamma probe is most effective in detecting
the sentinel node within the inguinofemoral region.
The day before surgery, a total of 1–2.5 mCi of 99mTc in
2–4 mL of volume may be injected. Mapping substances are
injected intradermally using a four-point injection technique
usually at the 2, 5, 7, and 10 o’clock positions.18 It is important
to note that tracers should not be injected intratumorally, but
rather into normal epithelium, just lateral to the gross edge
of the tumor. To access the superfcial dermal lymphatics that
drain to the groin, it is important to perform an intradermal
injection. A deeper injection might lead the tracers to the lym-
phatic channels into the pelvis and therefore not represent the
true lymphatic mapping of the primary vulvar tumor.
The following day, after induction of anesthesia, a total of 4 mL
of blue dye is injected at the same locations. During the surgery,
handheld gamma-ray detection is used to confrm that lympho-
scintigraphy marked the area of greatest activity in the groin.
This is important to consider prior to making the groin incision in
order to tailor the location and size of the incision. The scarpa fas-
cia is incised, followed by dissection through the underlying tis-
sue in an attempt to identify lymphatic channels. Once the groin
Modalities of detection
lymphatic basin has been exposed, the surgeon should follow the
tinted blue dye channels. With the intermittent use of the gamma
probe, the sentinel node is identifed and removed. The sentinel
node is excised separately, and measurements are again repeated
ex vivo. After removal of the frst sentinel lymph node, the groin
is reexamined for radioactivity. If radioactivity is detected at a
level greater than 10% of the frst excised SLN, the dissection is
continued in search of additional SLNs.
The feasibility of near-infrared fuorescence-guided SLN
biopsy in vulvar cancer has been previously demonstrated using
several ICG-based tracer formulas. For the detection of SLN,
the near-infrared fuorescence signal is measured percutane-
ously prior to skin incision19 and continuously during the sur-
gical procedure. To verify nodal removal, the surgical wound
should be reexamined using fuorescence imaging as well as
the other techniques such as radiotracing/imaging and visual
inspection for blue dye and palpation if applicable. With this
technique the sentinel node should also be examined ex vivo.
Endometrial cancer
There are three different techniques for SLN uterine cancer
mapping based on the site of injection: subserosal uterine
fundus, cervical, or endometrial through hysteroscopy. Given
the obstacles of the subserosal and hysteroscopic techniques,
such as the fact that they are more technically challenging,
less reproducible, and more expensive than the cervical injec-
tion, these approaches have not gained popularity. There is
evidence that cervical injection achieves a higher detection
rate and a similar anatomic nodal distribution as the hystero-
scopic injection for SLN mapping.11 It provides excellent dye
penetration to the region of the main uterine lymphatic trunks
that condense in the parametria and appear in the broad liga-
ment leading to the pelvic and, occasionally, paraaortic senti-
nel nodes. The cervix is easily accessible and rarely distorted
or scarred from prior procedures.
Regarding tracer options, several studies have evaluated the
use of ICG alone or in combination with blue dye and 99mTc.
A prospective randomized study aimed to evaluate whether
three tracers (blue dye, ICG, and 99mTc) performed better than
two (ICG and 99mTc) tracers. One hundred and ffty-seven
patients were included. Eighty patients received ICG and 99mTc
FIGURE 8.1 Common cervical injection sites for mapping uterine cancer. (From Abu-Rustum NR, Rob L, Sentinel lymph node identifcation for
early-stage cervical and uterine cancer, in Abu Rustum NR, Barakat RR, Levine DA, eds, Atlas of Procedures in Gynecologic Oncology 3E, CRC
Press, 2013, with permission.)
47
with 97.5% and 81.3% unilateral and bilateral SLN detection
rates, respectively. Seventy patients received all three tracers
with 93.5% and 80.5% unilateral and bilateral detection rates,
respectively. No signifcant differences were observed between
the two groups in unilateral or bilateral detection rates or in
the identifcation of lymph node metastasis.20
The major advantage with the use of blue tracers is that they
do not require dedicated and often costly equipment. Blue dye
is injected in the operating room while the patient is under
anesthesia. A spinal needle is used to inject 4 mL of dye at
a rate of 5–10 seconds per quadrant to optimize lymphatic
penetration and minimize deep pelvic tissue staining.21 The
injection consists of 1 mL of a 10-mg/m: blue dye solution for
a total dose of 40 mg. This dose is injected in the cervix super-
fcially (2–3 mm cervical submucosa) and deep (3–4 mm) at
3 and 9 o’clock positions for four injections in total. For cen-
ters wishing to use radiolabeled colloid as the tracer of choice
for SLN mapping, the most commonly used is 99mTc. It should
be injected before surgery (generally the day before) into a
radio-protected setting. Four cervical injections of 0.2 mL (20
MBq each) of unfltered technetium sulfur colloid (Nanocis;
CIS Bio International, Saclay, France) are recommended with
a 25-gauge spinal needle at the 3, 6, 9, and 12 o’clock posi-
tions the day or morning before surgery. Scintigraphic images
are obtained with a triple-head gamma camera (Irix; Marconi
Corporation, Cleveland, OH, USA) 2 hours after injection and
then every 30 minutes.
In some centers, ICG is preferred over the combination of
other tracers, or is at least as useful as the blue dye and radio-
labeled colloids.22 The results of the FILM study13 served as the
basis for an application to the Food and Drug Administration
(FDA) for on-label use of interstitial injection of ICG com-
bined with near-infrared imaging for lymphatic mapping. It
was the frst prospective, randomized, phase III, multicenter,
noninferiority trial that showed how ICG improved SLN iden-
tifcation rates (74% rate of detection of at least one SLN with
isosulfan blue dye compared with 96% with ICG and 31% rate
of bilateral sentinel nodes with blue dye and 78% with ICG).
There are three different options for direct cervical injection,
although the most commonly used is the two-injection tech-
nique, which is often preferred to the four-quadrant injection
options (Figure 8.1). After general anesthesia is performed,
48
FIGURE 8.2 (a) Most common location of SLNs (blue arrow) following a cervical injection. (b) Less common location of SLNs (green arrow) usu-
ally seen when lymphatic trunks are not crossing over the umbilical ligament but following the mesoureter cephalad to the common iliac and presacral
region. (From Abu-Rustum NR, Rob L, Sentinel lymph node identifcation for early-stage cervical and uterine cancer, in Abu Rustum NR, Barakat
RR, Levine DA, eds, Atlas of Procedures in Gynecologic Oncology 3E, CRC Press, 2013, with permission.)
ICG is injected in the cervix deep (3–4 cm) and superfcially
(2–3 mm cervical submucosa) at 3 and 9 o’clock positions,
for a total of four injections.22 Surgeons should avoid diffuse
smearing. The uterine body lymphatic trunks commonly cross
over the obliterated umbilical artery, with the most common
locations of pelvic SLNs medial to the external iliac, ventral to
the hypogastric, or in the superior part of the obturator region
(Figure 8.2). Surgeons should open the retroperitoneum and
search for the lymph node by activating the infrared button on
the camera head. The primary mode used is the near-infrared
mode, but two additional modes may also be used: spy mode
(black and white mode) or color segmented fuorescence mode
in the form of a color gradient. Surgeons can switch back and
forth between the different modes as often as needed.
Dose of ICG on the SLN mapping
Papadia et al. designed a study to evaluate the impact of dif-
ferent doses of ICG (high dose: 5 mg/mL and a volume of 8
mL and low dose: 1.25 mg/mL and a volume of 4 mL) on the
SLN mapping in endometrial cancer. A higher concentration
and volume of ICG are associated with a larger number of
retrieved SLNs.23
The key to successful SLN mapping is the adherence to an
SLN algorithm. Incorporating an SLN mapping algorithm
reduces the false-negative rate to 2%.24 A reasonable SLN detec-
tion rate varies from practice to practice, but a detection rate of
80%–90% or higher is desired.12 SLN mapping for endometrial
cancer is becoming an established standard of care in many
centers worldwide, while increasing surgeon experience and
a corresponding increase in detection rates of 90% or greater,
in addition to a decrease in false-negative rates as a result of
Clinical Lymphatic Mapping
adherence to the SLN algorithm.25 Moreover, standardization
of surgical technique and surgical-quality assessment tools are
critical to the conduct of clinical trials. Specifc mandatory
and prohibited steps of SLN dissection in endometrial cancer
have been identifed and validated based on consensus among a
large number of international experts.
Cervical cancer
SLN mapping in cervical cancer initially evaluated the util-
ity of blue dye and/or radiocolloid. In this setting, while the
patient is under anesthesia, an injection of isosulfan blue
(Lymphazurin) or methylene blue 1% is administered. With
a spinal needle a total of 4 mL of blue dye is injected directly
into the cervical stroma next to the lesion. A tenaculum may
be used to assist in the stromal injection. Two milliliters per
injection for each side are administered at the 3 and 9 o’clock
positions, which correspond to the position of the parametria.
The 12 o’clock injection may be eliminated in order to avoid
staining the vesicocervicovaginal space. It is recommended
that the injection be performed after the laparotomy has been
performed and the surgical feld exposed. The procedure is
planned through laparotomy, given that the minimally inva-
sive approach is no longer considered after the results of the
LACC trial, which demonstrated worse disease-free survival
for minimally invasive radical hysterectomy when compared
to the open approach.26 The sentinel node identifcation and
removal is performed frst. Preoperative lymphoscintigraphy
is performed using radiolabeled fltered 99mTc. It is injected
directly into two quadrants of the stroma of the cervix using
a spinal needle closest to the area of a normal cervix/tumor
interface. In patients who have undergone a prior cone biopsy,
the injection is given into the bed of the cone on the day before
Modalities of detection
surgery. ICG is increasingly becoming part of the standard of
care, given its high detection rate, higher signal-to-background
ratio, improved cost-effectiveness, and decreased adverse
effects and toxicity. ICG should be injected with a similar
technique as explained earlier for endometrial cancer.
Ovarian cancer
The detection of SLN in ovarian cancer has been evaluated in
the setting of early disease and is currently in the experimental
phase. After the frst publication in 1991,27 there have been a
number of small series with small numbers of patients. Most
studies are exploratory and evaluate the ovarian lymphatic
drainage, although in many cases these have been performed
in patients who had benign,27 borderline, cervical or endome-
trial27 tumors instead of ovarian cancer. The main diffculties
in performing SLN mapping in early ovary cancer include 1)
a large and complex area of lymphatic drainage, 2) the need
for intraoperative injection, and 3) the injection site (it is not
possible to perform a peritumoral or intratumoral injection due
to the risk of tumor rupture). The only systematic review on
the feasibility of SLN in epithelial ovarian cancer has been
published recently.28 The data thus far confrm that the tech-
nique appears feasible with a detection rate of approximately
90%, although there are important limitations, such as low
sample size, injection of the tracer in different anatomical
areas, and the use of different tracers (radiotracer, methylene
blue, and ICG combined or alone). This review concluded that
the best tracer is ICG and the two best injection sites are the
infundibulo-pelvic ligament and the uterovarian ligament.
Five studies have assessed the combination of a radiotracer
and blue dye. The detection rate was 88.1% when a radiocol-
loid (with or without blue dye) was used (N = 109). Three stud-
ies combined patent blue with 99mTc, and the number of SLNs
that have been identifed only with patent blue dye were 100%,
83%, and 20%, respectively.28 When ICG alone was used, the
detection rate was 93.3% (N = 15).29 Based on the published
literature, it appears that, with the exception of patent blue, all
other tracers have resulted in a high detection rate of SLNs.
The utero-ovarian ligament and the infundibulopelvic ligament
have been used as the site of injection in the majority of stud-
ies. Injection of the tracer should be performed, preferably with
the adnexa still in situ, both in the suspensory ligament and the
infundibulopelvic ligament. With this approach, the detection
rate has exceeded 90%. In two studies, an injection into the
ovarian cortex appeared to be less sensitive (71.4%, N = 21).28
Ideally, an interval of 10–15 minutes should be allowed after
injection before starting SLN mapping; this provides the tracer
enough time to spread to the lymph nodes (detection rate >90%).
Safety
Blue dye
Approximately 50% of isosulfan blue in aqueous solution is
weakly bound to serum proteins, leading to its affnity for lym-
phatic channels. Its primary excretion is biliary (90%), and thus
patients with hepatobiliary insuffciency may be at an increased
risk of complications. The overall complication rate should not
49
exceed 1.5%.30 Anaphylaxis during anesthesia is often a clinical
diagnosis presenting, in decreasing frequency, with cardiovas-
cular collapse, erythema, angioedema, bronchospasm (severe
or transient), urticaria and/or rash, gastrointestinal symptoms,
and pulmonary edema.31 It is important to understand that dur-
ing anesthesia, anaphylaxis develops 90% of the time within 10
minutes after intravenous administration of the causal agent.32
However, a time delay of 15–30 minutes may be observed in
cases of anaphylactic reaction to blue dyes, refecting the fact
that these agents are being administered intradermally rather
than intravenously. Adverse reactions to isosulfan blue have
been confrmed as a rare event, less than 2%.33
Another systemic manifestation seen after intradermal injec-
tions of isosulfan blue is an acute transient or a more prolonged
decline in oxygen saturation as measured by pulse oximetry.
Coleman et al. provided a detailed review of the etiology of this
phenomenon.34 Pulse oximetry is a noninvasive modality provid-
ing continuous estimations of peripheral tissue oxygen saturation.
It functions via determination of the concentrations of oxyhemo-
globin and reduced hemoglobin species by measuring the absor-
bance of light at two wavelengths, 660 and 940 nm, respectively.
Isosulfan blue has an absorbance peak of 646 nm. The dye can
also infuence pulse oximetry measurements because it causes
abnormal hemoglobin species.35 Fortunately, this phenomenon is
transient and typically lasts 3–5 minutes. The inaccuracy of the
pulse oximeter in this setting has been confrmed by obtaining
arterial blood sampling during the acute fall in SpO2, a fnding
which confrms adequate and reassuring oxygen saturation.
Technetium
Radiation protection is based on three principles, which
have been described by the International Commission on
Radiological Protection.36 These include the following: justi-
fcation – the application of radiation is justifed only when the
beneft to the exposed individual outweighs the negative con-
sequences; optimization – ensure that the radiation dose to the
patient and the general public is ‘as low as reasonably achiev-
able’; and limitation – boundaries should be placed on risks to
individuals to ensure that the risks do not exceed acceptable
values. The determinant of the radiation dose to which the
patient is exposed is the degree of clearance from the site of
injection and the lymph node. The clearance of radiocolloids
from the interstitial space is very slow; therefore, the largest
dose of radiation is delivered to the site of injection.
It should be emphasized that according to the International
Atomic Energy Agency guidelines, the permitted annual dose
is 1 mSv. The maximal allowed doses of radiation exposure,
according to the National Council on Radiation Protection
(NCRP) recommendations, are 500 mSv for skin per year for
the exposed personnel. Considering this dose limit, a surgeon
could perform more than 9000 sentinel node procedures with-
out exceeding the dose limits.37
Indocyanine green
ICG has an excellent safety profle with a high affnity for albu-
min, and therefore there is almost no leakage of the compound
into surrounding tissue. The liver absorbs and excretes the
50
substance but does not metabolize it into toxic by-products;1
for that reason it exhibits low toxicity with few side effects
(36 out of 21,278 cases; 0.17%), which include shock symp-
toms (0.02%), nausea (0.08%), vascular pain (0.04%), and fever
(0.02%).38 The incidence of mild adverse reactions have been
previously described as 0.15%, and 0.05% for severe adverse
reactions, with no deaths after 1923 procedures.39 One should
note that there are a number of contraindications for the use of
ICG, such as iodine allergy, liver disease, dialysis, renal fail-
ure, uremia, or previously documented anaphylactic reaction
(1 of 42,000 patients). It should also be used with caution in
elderly patients with decreased physiological function.39 There
are no data available describing the signs, symptoms, or labo-
ratory fndings accompanying overdosage.
Mapping in special settings
Pregnancy
SLN mapping procedures are feasible in pregnant patients.
SLN should be considered the standard of care for melanoma
and breast cancer in the clinically negative axilla. Isosulfan
blue should only be given during pregnancy when benefts out-
weigh the risks because it is systemically absorbed after sub-
cutaneous injection.40 Methylene blue has not been found to be
safe and effective in pregnant women according to the FDA,
and this labeling has not been approved. It can cause fetal
harm when administered to a pregnant woman. Intraamniotic
injection during the second trimester has been associated
with neonatal intestinal atresia and fetal death. This drug also
caused adverse developmental outcomes in animals when
administered orally during organogenesis.41
Regarding the use of 99mTc as a widely radioactive tracer
in SLN, the American Society of Clinical Oncology main-
tains pregnancy as a contraindication for this radiotracer.42
However, the European Association of Nuclear Medicine
and the Society of Nuclear Medicine and Molecular Imaging
concluded that the use of 99mTc is justifed by the low risks
of the procedure, considering the limited doses.43 It has been
calculated that when using a nanocolloid with a short half-
life and large particle size, such as 99mTc, and due to the
accumulation of the nanocolloid in the lymph node itself,
the fetal radiation exposure is <5 mGy, even in the inguinal
lymph nodes. It is also recommended that in pregnancy one
should use the single-day protocol, as the administered dose
is lower, the time between admission and surgery is shorter,
and the detection rate does not differ from the 2-day pro-
tocol. Therefore, when maternal outcome may beneft from
an SLN, it should not be withheld because of fear for fetal
radiation exposure.44
It is generally not recommended for pregnant personnel to
perform lymphatic mapping when using radiocolloid, given
that one should always aim for the radiation dose to be ‘as low
as reasonably achievable.’ The distance to maintain for a preg-
nant staff member should be at least 1 meter from the patient.
It is recommended that before introducing the sentinel node
procedure, all personnel should be informed about the proper
handling of material and safety procedures.5 As it pertains to
ICG, although the FDA has classifed it as a category C drug,
Clinical Lymphatic Mapping
ICG SLN mapping seems to be feasible in pregnant cervical
cancer patients, and no adverse events from ICG injection were
recorded.45
Obesity
Two independent studies published by Tanner et al.46 and
Eriksson et al.21 suggested the effect of increased body mass
index (BMI) on SLN detection. The objective of the frst study
was to identify the patient, tumor, and surgeon factors associ-
ated with successful SLN in patients with endometrial cancer
and complex atypical hyperplasia. The authors showed the
decrease of the rate of successful bilateral mapping with blue
for 58% of patients with a BMI ⩾ 30 kg/m2. While this rate
with ICG was always superior to isosulfan blue, the variabil-
ity was more pronounced at higher BMIs. The Eriksson et al.
study21 aimed to determine the impact of obesity on the rate
of successful SLN mapping in patients with endometrial can-
cer undergoing robotic surgery and compared SLN detection
rates using ICG versus blue dye. With increasing BMI, there
was a signifcant decrease in successful bilateral mapping
rates for both the ICG and blue-dye groups; however, the use
of ICG resulted in better bilateral and overall mapping rates
compared with the use of blue dye in all BMI groups. To sum-
marize, these studies concluded that visualization of SLNs is
improved when ICG was used in comparison to blue dye in
obese patients.
Novel modalities
Intraoperative identification techniques
[99mTechnetiumTc] tilmanocept
[99mTechnetiumTc] tilmanocept (trade name Lymphoseek) is
a molecule that binds receptors in reticuloendothelial cells in
the nucleus and can be evaluated via an intraoperative hand-
held gamma detector.47 Lymphoseek has been approved in the
United States and Europe for SLN mapping of breast cancer,48
melanoma,49 and head and neck cancer,50 with sensitivities of
>97% for detecting SLNs. Fluorescent-labeled tilmanocept is
potentially advantageous over sulfur colloids, as it is better tol-
erated by patients and is cleared from the injection site fvefold
faster than sulfur colloid.
Preclinical animal model trials have been successful in
endometrial cancer, with SLN identifcation via robotic sur-
gery, by tagging the [99mTc] tilmanocept to near-infrared fuo-
rescent dye, as well as with gallium-68 to allow for assessment
on positron emission tomography (PET). During robotic or
laparoscopic surgery, fuorescent-labeled tilmanocept does
not require the expertise of radiodetection equipment. Even
though preoperative [99mTc] tilmanocept imaging may not be
regularly used, cross-sectional imagery can be particularly
useful in patients with high BMI.
Carbon nanoparticles
Carbon nanoparticles are 150-nm particles that can be injected
into the anatomical area of interest and drain through the
Modalities of detection
lymphatic vessels (diameter, 120–500 nm). They are then visu-
alized directly as a black stain in the lymphatic channels and
SLN. Carbon nanoparticles are advantageous in that nuclear
medicine is not required, they are relatively inexpensive, and
no special equipment is required. Overall, they are well tol-
erated; a major side effect is skin staining.51 More recently,
carbon nanoparticle use was studied in endometrial cancer in
a prospective single-center trial of 115 patients.52 The tracer
was shown to have a comparable detection rate to those of
currently used methods in endometrial cancer and a safe and
effective profle for SLN mapping. The results revealed that
carbon nanoparticles achieved a total detection rate of 96.5%,
and the cervical injection route was associated with 100% sen-
sitivity and negative predictive value. Although more studies
are needed to confrm these fndings, this colorimetric imag-
ing tracer provides a feasible alternative for centers lacking
fuorescent imaging systems.
India ink
India ink is an injectable colloid suspension of carbon par-
ticles that dyes SLNs black. In a study in early-stage cervical
cancer,53 India ink was used in combination with radiocolloid
and blue dye to determine whether adding this colloid would
help identify parametrial sentinel nodes pathologically. The
authors performed lymphatic mapping and SLN biopsy in 20
women undergoing radical hysterectomy or trachelectomy
using a ‘triple injection’ technique. Pathologic processing of
parametrium and nodal tissue was then performed to identify
India ink in specimens. India ink alone identifed only a single
pelvic sentinel node (0.3%) not detected with blue dye and/or
radiocolloid in this study. However, the addition of this ink
was useful to detect the true sentinel nodes and not second-
echelon nodes detected by blue dye that had already passed
through sentinel nodes.
Superparamagnetic iron
Superparamagnetic iron is a tracer that can be injected pre-
operatively for intraoperative magnetic detection. In 2016,
Karakatsanis54 performed a study aimed to compare the
effcacy of this novel tracer in sentinel node biopsy in breast
cancer with 99mTc and patent blue in a multicenter prospective
trial and performed a meta-analysis of all published studies.
Seven studies were included, with a total of 1118 cases per-
formed and 2300 nodes retrieved. No difference was observed
in the detection rates per case in any of the studies between the
superparamagnetic iron and conventional methods.
Imaging-enhanced modalities
Contrast-enhanced ultrasound
Contrast-enhanced ultrasound is a technique that employs
the injection of perfuorobutane microbubbles to visualize
lymphatic channels on ultrasound and facilitate the identif-
cation of SLNs for subsequent biopsy or resection with skin
marking or wire localization. This method has been studied
in a systematic review and meta-analysis to evaluate whether
51
contrast-enhanced ultrasound-guided core biopsy of the SLN
could identify metastatic nodes preoperatively and reduce the
number of surgical SLN biopsies in patients with breast cancer.
Eleven prospective studies and one retrospective study with
1520 participants were included. The SLN identifcation and
localization rate for contrast-enhanced ultrasound-guided skin
marking had varying success (70%–100% detection rate).55 The
introduction of super-resolution imaging, ultrafast ultrasound
imaging, and improved microbubble transit may improve the
visualization of lymphatics and SLNs with this technique.
Implementing new technology into clinical practice is
challenging. The risk associated with the application of new
techniques or procedures makes it diffcult to replace the
traditional and already accepted surgical technique. To over-
come this scenario, Marcus et al.56 aimed to assess the safety
and effcacy outcomes of an institutional structured evalua-
tion process specifcally focused on the introduction of sur-
gical innovations. A multidisciplinary specialized team of
surgical quality offcers composed the Continuous Quality
Improvement Team (CQIT) and performed structured reviews
of suggested new surgical procedures before being evaluated
by the Value Analysis Team business. The results showed the
review process improved the safety and effciency; no device-
related complications were observed, and the time between
product proposal and trial safety decreased from a mean of
260 to 99 days (P = 0.014).
Conclusion
As we gather additional information in support of the util-
ity of lymphatic mapping and sentinel node detection in the
management of gynecologic cancers, we strive to pursue this
approach to decrease patient morbidity and improve diagnostic
accuracy. While the focus of most perfusion mapping studies
in gynecologic oncology has been on technetium colloids and
blue dye, with the new modality of identifcation of the sen-
tinel nodes, it has improved detection rates while decreasing
cost and side effects. Alternative approaches are actively being
studied in both gynecologic and nongynecologic cancers.
REFERENCES
1. Moukarzel LA, Feinberg J, Levy EJ, et al. Current and
novel mapping substances in gynecologic cancer care. Int J
Gynecol Cancer. 2020;30(3):387–93.
2. Hiram SC. The role of nuclear medicine. Sentinel Lymph
Node Biopsy. Breast Cancer Res. 2001;3(2):104–8.
3. Zalewski K, Benke M, Mirocha B, et al. Technetium-99m-
based radiopharmaceuticals in sentinel lymph node biopsy:
gynecologic oncology perspective. Curr Pharm Des.
2018;24(15):1652–75.
4. Wengenmair KJ. Quality Criteria of Gamma Probes:
Requirements and Future Developments. Berlin,
Heidelberg: Spring; 2005.
5. Giammarile F, Bozkurt MF, Cibula D, et al. The EANM
clinical and technical guidelines for lymphoscintigraphy
and sentinel node localization in gynaecological cancers.
Eur J Nucl Med Mol Imaging. 2014;41(7):1463–77.
52
6. Mount MG, White NR, Nguyen CL, et al. Evaluating one
day versus two days preoperative lymphoscintigraphy pro-
tocols for sentinel lymph node biopsy in breast cancer. Am
Surg. 2015;81(5):454–7.
7. Petersen LJ, Pedersen RD, Skindhoj S, et al. Early dynamic
versus late static lymphoscintigraphy for the identifcation
of sentinel lymph nodes in breast cancer. Clin Nucl Med.
2011;36(12):1098–101.
8. Ferreira H, Smith AV, Wattiez A. Application of indocya-
nine green in gynecology: review of the literature. Surg
Technol Int. 2019;34:282–92.
9. Reinhart MB, Huntington CR, Blair LJ, et al. Indocyanine
green: historical context, current applications, and future
considerations. Surg Innov. 2016;23(2):166–75.
10. Mindt S, Karampinis I, John M, et al. Stability and degrada-
tion of indocyanine green in plasma, aqueous solution and
whole blood. Photochem Photobiol Sci. 2018;17(9):1189–96.
11. Rossi EC, Jackson A, Ivanova A, et al. Detection of sentinel
nodes for endometrial cancer with robotic assisted fuores-
cence imaging: cervical versus hysteroscopic injection. Int
Gynecol Cancer. 2013;23(9):1704–11.
12. Khoury-Collado F, Glaser GE, Zivanovic O, et al.
Improving sentinel lymph node detection rates in endome-
trial cancer: how many cases are needed? Gynecol Oncol.
2009;115(3):453–5.
13. Frumovitz M, Plante M, Lee PS, et al. Near-infrared fuo-
rescence for detection of sentinel lymph nodes in women
with cervical and uterine cancers (FILM): a randomised,
phase 3, multicentre, non-inferiority trial. Lancet Oncol.
2018;19(10):1394–403.
14. Thomaier L, Jager L, Stone R, et al. Risk of empty lymph
node packets in sentinel lymph node mapping for endome-
trial cancer using indocyanine green. Int J Gynecol Cancer.
2019;29(3):513–17.
15. Covens A, Vella ET, Kennedy EB, et al. Sentinel lymph
node biopsy in vulvar cancer: systematic review, meta-
analysis and guideline recommendations. Gynecol Oncol.
2015;137(2):351–61.
16. Puig-Tintoré LM, Ordi J, Vidal-Sicart S, et al. Further data
on the usefulness of sentinel lymph node identifcation and
ultrastaging in vulvar squamous cell carcinoma. Gynecol
Oncol. 2003;88(1):29–34.
17. Crane L, Themelis G, Arts H, et al. Intraoperative near-
infrared fuorescence imaging for sentinel lymph node
detection in vulvar cancer: frst clinical results. Gynecol
Oncol. 2011;120(2):291–5.
18. Koh W-J, Greer BE, Abu-Rustum NR, et al. Vulvar cancer,
version 1.2017, NCCN clinical practice guidelines in oncol-
ogy. J Natl Compr Canc Netw. 2017;15(1):92–120.
19. Schaafsma BE, Verbeek FP, Peters AA, et al. Near-infrared
fuorescence sentinel lymph node biopsy in vulvar cancer:
a randomised comparison of lymphatic tracers. BJOG.
2013;120(6):758–64.
20. Kessous R, How J, Abitbol J, et al. Triple tracer (blue dye,
indocyanine green, and Tc99) compared to double tracer
(indocyanine green and Tc99) for sentinel lymph node detec-
tion in endometrial cancer: a prospective study with ran-
dom assignment. Int J Gynecol Cancer. 2019;29(7):1121–5.
21. Eriksson AGZ, Montovano M, Beavis A, et al. Impact of
obesity on sentinel lymph node mapping in patients with
Clinical Lymphatic Mapping
newly diagnosed uterine cancer undergoing robotic surgery.
Ann Surg Oncol. 2016;23(8):2522–8.
22. National Comprehensive Cancer Network. Uterine
Neoplasms (Version1.2020) [cited 2020 Feb 10]. Available
from: www.nccn.org/professionals/physician_gls/default.
aspx#uterine.
23. Papadia A, Buda A, Gasparri ML, et al. The impact of dif-
ferent doses of indocyanine green on the sentinel lymph-
node mapping in early stage endometrial cancer. J Cancer
Res Clin Oncol. 2018;144(11):2187–91.
24. Barlin JN, Khoury-Collado F, Kim CH, et al. The impor-
tance of applying a sentinel lymph node mapping algorithm
in endometrial cancer staging: beyond removal of blue
nodes. Gynecol Oncol. 2012;125(3):531–5.
25. Abu-Rustum NR. Update on sentinel node mapping
in uterine cancer: 10-year experience at Memorial
Sloan  – Kettering Cancer Center. J Obstet Gynaecol Res.
2014;40(2):327–34.
26. Ramirez PT, Frumovitz M, Pareja R, et al. Minimally inva-
sive versus abdominal radical hysterectomy for cervical
cancer. N Engl J Med. 2018;379(20):1895–904.
27. Vanneuville G, Mestas D, Le Bouedec G, et al. The lym-
phatic drainage of the human ovary in vivo investigated
by isotopic lymphography before and after the menopause.
Surg Radiol Anat. 1991;13(3):221–6.
28. Dell’Orto F, Laven P, Delle Marchette M, et al. Feasibility
of sentinel lymph node mapping of the ovary: a systematic
review. Int J Gynecol Cancer. 2019;29(7):1209–15.
29. Angelucci M, Corrado G, Mancini E, et al. Laparoscopic
indocyanine green sentinel lymph node mapping in early
ovarian cancer. A pilot study and review of the literature.
Ann Surg Oncol. 2016;28:23–8.
30. Ramirez PT, Levenback C. Sentinel nodes in gynecologic
malignancies. Curr Opin Oncol. 2001;13(5):403–7.
31. Fisher M, Baldo B. Anaphylaxis during anaesthesia: current
aspects of diagnosis and prevention. Eur J Anaesthesiol.
1994;11(4):263–84.
32. Moss J. Adverse drug reactions caused by Histamine. ASA
Refr Cours Anesthesiol. 1992;20:155–68.
33. Cimmino VM, Brown AC, Szocik JF, et al. Allergic reac-
tions to isosulfan blue during sentinel node biopsy – a com-
mon event. Surgery. 2001;130(3):439–42.
34. Coleman RL, Whitten CW, O’Boyle J, et al. Unexplained
decrease in measured oxygen saturation by pulse oximetry
following injection of Lymphazurin 1%(isosulfan blue)
during a lymphatic mapping procedure. J Surg Oncol.
1999;70(2):126–9.
35. Scheller MS, Unger RJ, Kelner MJ. Effects of intrave-
nously administered dyes on pulse oximetry readings.
Anesthesiology (Philadelphia).1986;65(5):550–2.
36. Protection ICoR. 1990 recommendations of the interna-
tional commission on radiological protection. Ann ICRP.
1991;21(1–3):1–201.
37. Najaf M, Nedaie H, Lahooti A, et al. Radiation exposure
of the surgeons in sentinel lymph node biopsy. Iran J Radiat
Res. 2012;10(1):53–7.
38. Lecuru FR, McCormack M, Hillemanns P, et al. SENTICOL
III: an international validation study of sentinel node biopsy
in early cervical cancer. A GINECO, ENGOT, GCIG and
multicenter study. Int J Gynecol Cancer. 2019;29(4):829–34.
Modalities of detection
39. Hope-Ross M, Yannuzzi LA, Gragoudas ES, et al. Adverse
reactions due to indocyanine green. Ophthalmology.
1994;101(3):529–33.
40. Khera SY, Kiluk JV, Hasson DM, et al. Pregnancy-
associated breast cancer patients can safely undergo lym-
phatic mapping. Breast J. 2008;14(3):250–4.
41. Drugs.com. Contraindications in Methylene Blue Injection
2018 [updated 2018 Jan 11] [cited 2020 Feb 3]. Available
from: www.drugs.com/pro/methylene-blue-injection.html#
s-34070-32020.
42. Lyman GH, Somerfeld MR, Bosserman LD, et al. Sentinel
lymph node biopsy for patients with early-stage breast can-
cer: American Society of Clinical Oncology clinical prac-
tice guideline update. J Clin Oncol. 2016;35(5):561–4.
43. Giammarile F, Alazraki N, Aarsvold JN, et al. The EANM
and SNMMI practice guideline for lymphoscintigraphy and
sentinel node localization in breast cancer. Eur J Nucl Med
Mol Imaging. 2013;40(12):1932–47.
44. de Haan J, Vandecaveye V, Han SN, et al. Diffculties with
diagnosis of malignancies in pregnancy. Best Pract Res
Clin Obstet Gynaecol. 2016;33:19–32.
45. Papadia A, Mohr S, Imboden S, et al. Laparoscopic indocya-
nine green sentinel lymph node mapping in pregnant cervical
cancer patients. J Minim Invasive Gynecol. 2016;23(2):270–3.
46. Tanner EJ, Sinno AK, Stone RL, et al. Factors associated
with successful bilateral sentinel lymph node mapping in
endometrial cancer. Gynecol Oncol. 2015;138(3):542–7.
47. Surasi DS, O’Malley J, Bhambhvani P. 99mTc-tilmanocept:
a novel molecular agent for lymphatic mapping and sen-
tinel lymph node localization. J Nucl Med Technol.
2015;43(2):87–91.
48. Wallace AM, Han LK, Povoski SP, et al. Comparative
evaluation of [99m Tc] tilmanocept for sentinel lymph node
mapping in breast cancer patients: results of two phase 3
trials. Ann Surg Oncol. 2013;20(8):2590–9.
49. Sondak VK, King DW, Zager JS, et al. Combined analysis
of phase III trials evaluating [99m Tc] tilmanocept and vital
53
blue dye for identifcation of sentinel lymph nodes in clini-
cally node-negative cutaneous melanoma. Ann Surg Oncol.
2013;20(2):680–8.
50. Agrawal A, Civantos FJ, Brumund KT, et al. [99m Tc]
Tilmanocept accurately detects sentinel lymph nodes
and predicts node pathology status in patients with oral
squamous cell carcinoma of the head and neck: results
of a phase III multi-institutional trial. Ann Surg Oncol.
2015;22(11):3708–15.
51. Zhang L, Huang Y, Yang C, et al. Application of a carbon
nanoparticle suspension for sentinel lymph node mapping
in patients with early breast cancer: a retrospective cohort
study. World J Surg Oncol. 2018;16(1):112.
52. Zuo J, Wu LY, Cheng M, et al. Comparison study of
laparoscopic sentinel lymph node mapping in endome-
trial carcinoma using carbon nanoparticles and lym-
phatic pathway verifcation. J Minim Invasive Gynecol.
2019;26(6):1125–32.
53. Frumovitz M, Euscher ED, Deavers MT, et al. ‘Triple injec-
tion’ lymphatic mapping technique to determine if parame-
trial nodes are the true sentinel lymph nodes in women with
cervical cancer. Gynecol Oncol. 2012;127(3):467–71.
54. Karakatsanis A, Christiansen PM, Fischer L, et al. The
Nordic SentiMag trial: a comparison of super paramagnetic
iron oxide (SPIO) nanoparticles versus Tc99 and patent blue
in the detection of sentinel node (SN) in patients with breast
cancer and a meta-analysis of earlier studies. Breast Cancer
Res Treat. 2016;157(2):281–94.
55. Moody AN, Bull J, Culpan A-M, et al. Preoperative sen-
tinel lymph node identifcation, biopsy and localization
using contrast enhanced ultrasound (CEUS) in patients with
breast cancer: a systematic review and meta-analysis. Clin
Radiol. 2017;72(11):959–71.
56. Marcus RK, Lillemoe HA, Caudle AS, et al. Facilitation of
surgical innovation: is it possible to speed the introduction
of new technology while simultaneously improving patient
safety? Ann Surg. 2019;270(6):937–41.
9
Ultrastaging of the sentinel node

Celien P.H. Vreuls, Ate G.J. van der Zee, and Paul J. van Diest

CONTENTS
Introduction .................................................................................................................................................................................... 55
Frozen section ................................................................................................................................................................................ 55
Imprint cytology............................................................................................................................................................................. 56
Serial sectioning............................................................................................................................................................................. 57
Immunohistochemistry .................................................................................................................................................................. 57
Fine-needle aspiration cytology ..................................................................................................................................................... 58
Flow cytometry .............................................................................................................................................................................. 58
Molecular techniques ..................................................................................................................................................................... 59
The optimal standard protocol ....................................................................................................................................................... 60
Summary remarks .......................................................................................................................................................................... 60
References...................................................................................................................................................................................... 61

investigation, immunohistochemistry (IHC), imprint cytology,

Introduction
The main task for the pathologist is to examine sentinel nodes
(SNs) for possible metastasis.1–5 This examination has to be
done with more attention (‘ultrastaging’) than examination of
routinely removed lymph nodes with the usual central hema-
toxylin and eosin (H&E) section. A false-negative SN assess-
ment leading to omission of lymph node dissection may lead
to untreatable locoregional tumor outgrowth in tumor-bearing
lymph nodes that have been left behind. The SN evaluation
will usually be done postoperatively. If indicated, a complete
lymph node dissection would then be performed in a second
session. However, it is advantageous for the patient and sur-
geon if the regional lymph node dissection, when necessary,
could be performed in the same operating session as the SN
procedure and the excision of the primary tumor. This requires
accurate and effcient intraoperative assessment of the SN by
the pathologist.
Size measurement of SN metastases in gynecologic cancer
follows the thresholds of breast cancer and melanoma. This
means that metastases smaller than 0.2 mm are denoted iso-
lated tumor cells (ITCs), those 0.2–2 mm are micrometastases,
and those >2 mm in size are macrometastases. In breast cancer
cells may be displaced by biopsy procedures and transported
to the SN, leading to epithelial groups in SNs that do not rep-
resent true metastases.6,7 Displacement in gynecologic cancers
has not been studied so far. Measuring the size of metastases
may be diffcult when multiple smaller separate but neighbor-
ing clusters are present, for which Gabor Cserni has provided
guidelines.8
There are several ways for postoperative and intraopera-
tive SN evaluation. These include traditional histopathologic
fne-needle aspiration cytology, fow cytometry, and molecular
analysis. Several review papers on the pathology of the SN
have been published.1,5,9–11 The aim of this chapter is to provide
an up-to-date discussion of the virtues and faws of these dif-
ferent methods and to present practical guidelines for the SN
investigation in gynecologic cancers.
Frozen section
As just briefy mentioned, it would be an advantage to the
patient and surgeon if the regional lymph node dissection,
when necessary, could be performed in the same operating
session as the SN procedure and the excision of the primary
tumor, obviating the need for a second operation. However,
there is also a logistic drawback: the time for possible sub-
sequent lymph node dissection needs to be reserved in all
patients, while it will be used in only some of the patients.
Accurate and effcient intraoperative assessment of the SN
by the pathologist may be done by frozen-section analysis,
usually a single H&E frozen section. The next paragraphs will
make clear that without step sections and IHC, up to 15%–20%
of metastases may be missed in patients with breast cancer or
cutaneous melanoma. Therefore, the theoretical sensitivity for
detection of metastases by single H&E frozen section analysis
is (under optimal conditions) probably not higher than 80%–
85% and lower in more diffcult conditions, as is often the case
with frozen sections.
In our initial study on 54 breast cancer patients,12 27/31 SN
metastases were detected by the frozen section procedure.
Sensitivity was 87%, specifcity 100%, positive predictive
value 100%, and negative predictive value (NPV) 91%. These

DOI: 10.1201/9781003255536-9 55
56
data compare very well with some other early studies.13–15
However, in a larger follow-up study, sensitivity dropped to
about 60% in our hands when the percentage of lobular carci-
nomas had increased, and frozen sections were also routinely
analyzed by less experienced pathologists, leading to some
judgment errors.16 These observations have been confrmed
by others.17,18 Obviously, the ability of the frozen sections to
detect metastases is higher for macrometastases than micro-
metastases, let alone ITCs.18 Smaller metastases undetected by
frozen section that appear in the fnal paraffn H&E or IHC
sections will usually necessitate lymph node dissection in a
second operation.
Veronesi et al.19 described a combination of intraoperative
step frozen sections with rapid IHC to arrive at an intraop-
erative fnal diagnosis in breast cancer, correctly predicting a
metastasis-free SN in 95.4% of cases.20 This procedure was,
however, very labor-intensive and led to a signifcant increase
in the operating time (up to 1 h). Zurrida et al.21 devised a
similar but quicker intraoperative method, requiring about 40
min, in which pairs of sections were taken every 50 µm for
the frst 15 sections and every 100 µm thereafter, sampling the
entire node. This extensive intraoperative frozen examination
correctly predicted an uninvolved axilla in 95.3% of cases.
Ultraquick IHC protocols are mandatory for this.22 In another
study using extensive intraoperative sampling taking up to 60
sections per SN,14 H&E section analysis by an experienced
pathologist proved more important than IHC, and this method
had the accuracy of a defnitive histologic examination. The
frozen-section procedure should not be essentially different
for cervical adenocarcinomas and vulvar and cervical squa-
mous cell carcinomas.23
In frozen-section analysis, care must be taken that the tis-
sue is frozen fat (as by freezing it with a cooled fat weight on
top of it) and that cutting is performed cautiously to prevent
inadvertent tissue loss as much as possible. Intraoperative step
sections are time-consuming and lead to excessive tissue loss,
and extra sections for the different levels need to be cut imme-
diately for IHC.19 Nevertheless, it is unavoidable that some SN
material will be lost; theoretically, this may lead to missing
some smaller SN metastases. The chance of this occurring
will naturally depend on the size and the distribution of these
metastases. However, since the likelihood of second-echelon
lymph nodes containing metastases usually correlates to the
size of the SN metastasis,24,25 this risk may be acceptable. The
percentage of SN metastases discarded during tissue process-
ing is probably quite low when proper measures to prevent
tissue loss are taken, since the percentage of SN metastases
found in our initial breast cancer study12 was comparable to
that in other breast cancer studies without an intraoperative
procedure.26–28 Moreover, it has to be realized that for the aver-
age lymph node, only about 1% of the total node volume is
actually looked at under the microscope, even when making
step sections and performing IHC.
The value of the frozen section has especially been studied
in cervical cancer. In the recent SENTIX trial, frozen sections
failed to detect 54% of positive lymph nodes (pN1), including
28% of cases with macrometastases and 90% with microme-
tastases.29 In the cervical cancer study of Roy et al., frozen
section analysis missed 42% of the SL metastases.30 In more
Clinical Lymphatic Mapping
recent studies, results were comparable. Rychlik et al. reported
a sensitivity of 81% and NPV of 98% (excluding ITC).31 Balaya
et al. described a sensitivity of 42% and NPV of 90%, or 56%
and 94% if ITCs were excluded.32 Dostalek et al. reported a
sensitivity of 47% and NPV of 93% (excluding ITCs).33 These
studies indicate that the yield of frozen section analysis in cer-
vical cancer is not optimal.
In our view, the disadvantage of potentially missing some
smaller metastases due to loss of tissue can be outweighed
by the advantage of performing full lymph node dissection
during the initial operation in SN-positive cancer patients
and by the increased number of lymph node metastases
found by the more detailed investigation of the SN compared
to usual locoregional lymph nodes. The operative delay of
15–20 min caused by the frozen-section investigation may
be acceptable, since during this time the primary tumor can
be excised.
Imprint cytology
Imprint slides can simply be produced from lymph nodes by
frmly pressing the cut surface to a glass slide. In a postopera-
tive and intraoperative setting, the May-Grünwald-Giemsa and
Quickdiff stains, respectively, allow detection of metastatic
cells. Imprint cytology has previously been described as help-
ful in the detection of lymph node metastases of prostate34 and
breast cancer35,36 Fisher et al.36 detected breast cancer axillary
lymph node metastases intraoperatively in imprints of 18/21
(86%) patients. In an intraoperative study in breast cancer,12
imprints were prepared from all cut SN surfaces, showing a
sensitivity of imprints for detection of SN metastases of 62%
with a specifcity of 100%. The sensitivity of the imprints was
signifcantly lower than that of frozen sections. In addition,
there were no SNs in which the imprints convincingly showed
metastases while the frozen sections did not. Therefore, we
found that imprints did not have more value than the intraop-
erative, frozen-section SN investigation.
However, other authors have had much better experience.
Motomura et al.37 described a sensitivity of intraoperative
imprint cytology of breast cancer SNs of 91%, a result which
was better than H&E frozen-section analysis. Turner et al.38
used a combination of frozen-section analysis and imprints,
resulting in a high sensitivity. Ratanawichitrasin et al.39
observed an imprint sensitivity of 82% compared to H&E fnal
sections (no IHC), a result which is comparable to the experi-
ence of Cserni.40 The imprint method therefore seems to be
reasonably useful for intraoperative SN evaluation.
Interestingly, the perception of the surgeon of the impor-
tance of false-negative and false-positive results appears to
be changing. Reasoning from the fact that, traditionally, the
complete lymph node dissection is the standard therapy, one
could argue that false-positive results are not really a prob-
lem and that false-negative results are practically a bigger
problem since a second operation will then be necessary.
However, the growing reliability and importance of the SN
procedure has put more emphasis on the impact of false-
positive results, since they would lead to an ‘unnecessary’
lymph node dissection.
Ultrastaging of the sentinel node 57

From the average lymph node, several thousand sections can

Serial sectioning
The SNs are fxed in neutral buffered formaldehyde and com-
pletely embedded after lamellating them according to their
size. Various protocols for lamellating have been advocated.
Our preferred way is as follows: SNs smaller than 0.5 cm are
processed and paraffn-embedded intact, those between 0.5
and 1 cm are halved, and those larger than 1 cm are lamel-
lated into pieces of approximately 0.5 cm in size (Figure 9.1). It
has been suggested that tumor cells preferentially enter the SNs
through the contralateral side of the hilum of lymph nodes.38
If true, this would have important consequences, since bisect-
ing the long axis of the SN from the outer capsule to the hilum
would produce two cut surfaces of the midline region where the
frst single tumor cell or small groups of tumor cells would be
readily visible. However, experimental evidence for this theory
is lacking, and, in practice, it is quite diffcult to identify the
hilum. Therefore, in our opinion, there is suffcient evidence to
recommend this as the current optimal protocol (see Table 9.3).
Future studies may help to make SN sampling more effcient
when the hilum approach is better validated. It remains there-
fore common practice to lamellate perpendicular to the long
axis to allow for maximum visualization of the SN surface.11,41
be produced. As this obviously confronts the pathologist with
an unacceptably high workload, a compromise has to be found
between workload and sensitivity, which will unavoidably lead
to missing some tumor cells. This compromise is best achieved
by taking step sections at regular intervals, increasing the
percentage of metastases found in SNs with about 8%,42,43
depending on the protocol used (Table 9.1). In vulvar squa-
mous cell cancer,23,44–47 the yield of step sectioning and IHC
seems to be lower. In vulvar cancer, De Hullu et al.44 detected
by step sectioning and IHC in 102 sentinel lymph nodes that
were negative on routine examination 4 additional metastases
(4%; 95% confdence interval [CI], 1%–9%). Three of the four
metastases were observed in patients whose lymph nodes were
negative on routine examination. One additional metastasis
was found in a patient who already had another SN with meta-
static disease. In squamous cell cervical cancer, Levenback et
al.23 detected in 31 patients with no positive SNs on routine
H&E processing no micrometastases with serial step section-
ing. Ten patients with negative SNs on routine H&E and serial
step sectioning had their SNs submitted to cytokeratin IHC
analysis. No metastases were identifed with this technique.
One patient with a positive SN on routine H&E staining had a
micrometastasis found by serial sectioning of the contralateral
sentinel node.23
In endometrial cancer, ‘ultrastaging’ protocols increased the
number of patients with lymph node metastases from 10.6% to
15.2%, not dissecting the yield from step sections and IHC.48
Step sections are obviously necessary only when the frst
section appears to be tumor negative. In cutting the step rib-
bons, one section of each ribbon should be mounted for
H&E staining, while the rest of the ribbon should be saved
for eventual IHC (see later). Although mucin histochemical
stains (periodic acid–Schiff [PAS] and Alcian blue) may be
useful for detecting adenocarcinoma metastases, especially in
primary lobular breast cancer, IHC is a much more sensitive
method (see later).

Immunohistochemistry
FIGURE 9.1 Lymph node metastasis at routine histopathologic exami-
nation (hematoxylin and eosin staining, ×200 microscope magnifcation). IHC is a generally applicable and cost-effective technique that
has proven to be very useful for detection of tumor cells in
TABLE 9.1 lymph nodes (especially micrometastases and ITCs) by dem-
onstration of proteins that are, within the context of the tissue
Cumulative Number of Patients with Breast Cancer Sentinel Node
analyzed, tumor specifc (Figures 9.2 and 9.3). Overall, IHC
Metastases Found with Each Additional Level (250-mm Intervals)
increases the percentage of metastases found in non-SN lymph
in a Total of 86 Patients
nodes by, on average, 20%,1 the gain being highest in lobular
H&E % H&E IHC % IHC breast cancer. For the SN, the range of conversion of the SN
  positive positive positive positive
to positive by ultrastaging (however, with quite varying proto-
Level 1 69 80 74 86 cols) is 2%–20%, with an average of 11% (Table 9.2).
Level 2 71 83 77 90 Different antibodies have been used for breast cancer, of
Level 3 73 85 81 94 which CAM5.2 seems to be the one most widely used. In gen-
Level 4 75 87 84 98 eral, little background staining is seen with this antibody, and
Level 5 76 88 86 100 its sensitivity is about 100%. Caveats are epithelial and meso-
thelial inclusions and macrophages that have eaten keratin.
Abbreviations: HE, hematoxylin/eosin staining; IHC, CAM5.2 immunohisto- Staining of sinus-lining (dendritic) cells may sometimes be
chemistry.
observed, especially when using automated immunostainers,
Source: Adapted from Torrenga et al.42 but sinus-lining cells are easily recognized by their dendritic
58 Clinical Lymphatic Mapping

TABLE 9.2
Overview of Different Gynecologic Cancer Studies Evaluating
the Conversion Rate of SNs to Positive by IHC
No. of % Converted to
patients positive by
Study Organ converted IHC
de Hullu 2000 44 36 vulva 3/23 13
Terada 200049 73 vulva 2/14 4
Molpus 200150 75 vulva 2/18 11
Levenback 200047 21 cervix 0/31 0
Moore 2003 51 29 vulva 0/29 0
Van der Zee 200852 403 vulva 68/163 42
Euscher 200853 48 cervix 1/33 19
FIGURE 9.2 Lymph node metastasis confrmed with immunohisto- Devaja 201154 60 vulva 0/5 0
pathologic examination (AE1/3 immunohistochemical staining ×100 Ballester 201155 125 endometrium 8/16 50
microscope magnifcation).
Levenback 201256 418 vulva 30/132 23
Koskas 201357 187 endometrium 18/38 47
Kim 201358 508 endometrium 23/64 36
Naoura 201559 180 endometrium 17/41 41
Touhami 2015 60 268 endometrium 19/43 44
Salvo 201761 188 cervix 6/27 22
Overall 197/677 29%

Fine-needle aspiration cytology

FIGURE 9.3 Scattered keratin-positive cells in a sentinel lymph node. The
clinical signifcance of this fnding in gynecologic cancers is not known
(AE1/3 immunohistochemical staining ×400 microscope magnifcation).
morphology. CAM5.2 is also useful for metastases of adeno-
carcinomas from most other sites. EMA and other MUC1 anti-
bodies have too low a specifcity, since they may also stain
plasma cells and macrophages, and the sensitivity of EMA is
also low, since breast cancers and other adenocarcinomas can
well be EMA negative. CEA and NCRC11 are specifc but not
very sensitive.
In the overview of Dundr et al. on cervical cancer, lymph
node involvement was detected only after ultrastaging in 21%
of patients.62
For squamous cell carcinoma metastases, AE1/3 is a reli-
able antibody. It has high specifcity and sensitivity. Van den
Brekel et al.63 found additional non-SN lymph node metasta-
ses in 3/13 head and neck squamous cell carcinoma patients
(23%) with this antibody. This antibody can also be used for
squamous gynecologic cancer; however, its yield appears
to be modest, as described in the previous paragraph. For
melanoma, a combination of a sensitive marker (S100) and
a specifc marker (Melan A, MART1, tyrosinase) can be
recommended.
A few studies have explored the possibility of ultrasonographi-
cally guided fne-needle aspiration biopsy (FNAB) to detect SN
metastases. Motomura et al.64 examined the axillae of 60 patients
with breast cancer, in whom a hot spot was detected by gamma
probe, by ultrasonography. Preoperative diagnosis of SN metasta-
sis by gamma probe and ultrasonographically guided FNAB was
compared with the histologic results of SN. SNs were visualized
by ultrasonography in 29 of 60 patients (48%). The sensitivity,
specifcity, and overall accuracy of ultrasonography in the diag-
nosis of SN metastasis were 50%, 92%, and 77%, respectively.
Of 14 patients with positive results by ultrasonography, 4 had
positive and 2 had negative cytology. The combination of ultra-
sonography and ultrasonographically guided FNAB for visu-
alized nodes had a sensitivity of 79%, specifcity of 93%, and
overall accuracy of 86%. Blind FNAB in the hot spot was not
useful in the detection of SN metastasis in patients whose SNs
failed to be detected by ultrasonography. Gamma probe and ultra-
sonographically guided FNAB is therefore a potentially useful
method for preoperative detection of SN metastasis. In patients
with positive SN FNAB, further SN biopsy is no longer indicated,
and complete axillary lymph node dissection can be performed as
a primary procedure. One feasibility study on ultrasound-guided
FNAB in vulvar cancer was recently published showing agree-
ment with fnal histology in 37 of 43 cases (86%), with sensitivity
and specifcity 77% and 100%, respectively.65
Flow cytometry
Flow cytometry (FCM) is a technique of measuring the proper-
ties of cells in suspension after staining with a fuorescent dye.
Ultrastaging of the sentinel node
It is a fast technique in which thousands of cells can be
screened in minutes. The frst FCM approach for the detection
of metastases in lymph nodes is with the same antibodies as
for IHC, coupled with a fuorescent tag. However, such FCM
is not very suitable for detecting rare events, so the additional
value to extensive histopathology is probably very limited. The
second approach is DNA FCM, in which a clone of cells with
abnormal DNA content or a high percentage of S-G2M-phase
cells may indicate metastatic cells. Joensuu et al.66 found the
diagnostic accuracy of such DNA FCM analysis of fne-needle
aspirations of lymph nodes to be 92%, with a sensitivity of
91% and a specifcity of 95%. DNA FCM suggested the cor-
rect diagnosis in fve of the seven cytologically false-negative
cases and in nine of the twelve cytologically indeterminate or
suspicious cases.
A more sophisticated approach is a DNA/cytokeratin
double-staining procedure, as described by Leers et al.67 In
this study, the breast cancer paraffn pieces that were left over
between step ribbons were used to prepare single-cell suspen-
sions with preservation of the cytoplasm, so that epithelial
cells could then be identifed by cytokeratin staining.
The presence of 1% epithelial cells was very indicative of
metastases, but cell cycle parameters of the epithelial fraction
(DNA aneuploidy or a high percentage of S-phase) provided
further evidence. By this approach, metastases were found that
were not detected by H&E and IHC.
Molecular techniques
An even more refned molecular biologic approach to the
detection of micrometastases is amplifcation by reverse-
transcriptase polymerase chain reaction (RT-PCR) of messen-
ger RNA (mRNA), which is expressed in the cancer cells of
interest, but not by other lymph node cells. By dilution experi-
ments,68,69 it has been estimated that a single cancer cell can
be detected by RT-PCR among 106 –107 normal cells. This
indicates that RT-PCR is by far the most sensitive method for
detection of metastases in SNs.
Different studies have evaluated the usefulness of RT-PCR
for detecting SN metastases. Schoenfeld et al.70 compared ker-
atin 19 RT-PCR with histopathologic results (H&E and IHC)
in axillary lymph nodes of breast cancer patients and found all
18 histopathologically involved lymph nodes to be positive by
RT-PCR. Of the 39 lymph nodes that were histologically nega-
tive, 14 were positive by RT-PCR. Noguchi et al.68,71 compared
MUC1 and keratin 19 RT-PCR and found all ten lymph nodes
that were histopathologically positive to be also positive by
RT-PCR and that three (6%) and fve (9%) of histopathologi-
cally negative (H&E only) lymph nodes expressed MUC1 and
keratin 19, respectively, indicating the presence of metastases.
Hoon et al.69 found occult metastases by beta–human chori-
onic gonadotropin (ß-HCG) RT-PCR in 25% of patients that
were histopathologically lymph node negative, and Kataoka
et al.72 found conversion percentages of 25% for CEA and 21%
for mammoglobin in an H&E-only study. In this last study,
RT-PCR improved the prediction of axillary lymph node sta-
tus to 98.5%. In a study on breast and gastrointestinal cancer,
Mori et al.73 detected metastases by CEA RT-PCR in 47/87
59
(54%) lymph nodes that were negative on regular histology.
Wascher et al.,74 using MAGE-A3 RT-PCR, found 28 of 73
(38%) histopathologically negative SNs to be RT-PCR positive.
Manzotti et al.75 found a high prevalence of positive RT-PCR in
histologically uninvolved SNs when considering single mark-
ers, but when at least two of three markers (maspin, cytokera-
tin 19, and mammaglobin) were expressed, the concordance
with either SN or axillary lymph node status was highest.75
Some authors76 use RT-PCR routinely. For vulvar cancer, there
are at present no data on the value of RT-PCR. Van Trappen
et al.77 applied a fully quantitative, real-time RT-PCR assay
to document absolute copy numbers of the epithelial marker
cytokeratin 19 in primary tumors, 156 lymph nodes from 32
patients with cervical cancer (stages IA2, IB1, and IB2), and
32 lymph nodes from nine patients with benign disease. All
primary tumors and histologically involved lymph nodes (six)
had increased expression of cytokeratin 19 mRNA, while
lower expression of cytokeratin 19 was detected in 66 (44%)
of 150 histologically uninvolved lymph nodes and in nodes
from 16 of 32 patients with cervical cancer. Fifteen of these
16 patients with evidence of micrometastases had the highest
cytokeratin 19 transcription level in a frst lymph node drain-
age station. Transcription of cytokeratin 19 was found at a low
level in just 1 of 32 lymph nodes obtained from nine patients
with benign disease. The median copy number of cytokeratin
19 transcription was signifcantly higher in association with
adverse prognostic features. These results suggest that about
50% of early-stage cervical cancers shed tumor cells to the
pelvic lymph nodes, and the amount of cytokeratin 19 expres-
sion was related to clinicopathologic features. However, fur-
ther studies are required to document the clinical implications
of molecular micrometastases.77
These studies underline the great promise of RT-PCR for
detecting SN metastases. However, several comments have
to be made. First, a clear drawback of all of these studies is
that those pieces that were examined had not been subjected
to the usual histopathologic investigation with H&E and IHC.
If this had been done, more metastases might well have been
detected with these conventional methods as well. Concluding
that the molecular analysis is superior is therefore tricky. A
better approach seems to be to subject those pieces to molecu-
lar analysis that would normally be thrown away: the pieces
between the step sections. However, this requires that RNA
be successfully extracted from paraffn-embedded tissue. This
appears to be possible, as was shown by Palmieri et al. for mel-
anoma,78 although the sensitivity of paraffn RT-PCR may be
lower than that of frozen tissue. Second, contamination is a big
potential problem, and histopathologic control of specimens
homogenized for blind assays such as RT-PCR will always
be necessary. A pitfall is epithelial or mesothelial inclusions
and displaced benign cells.6 Third, healthy volunteers appear
to express presumed specifc markers, such as CEA, CK-19,
GA733.2, and MUC-1,79 in their blood and lymph nodes,
meaning that these markers can yield false-positive results.
Fourth, one must ask whether the high sensitivity of RT-PCR
has clinical signifcance. As shown in several studies, second-
echelon breast cancer metastases are hardly ever found when
the true SN is negative by extensive histopathologic investiga-
tion with step sections and IHC.28 It remains to be proven that
60
RT-PCR may identify those few patients who escape extensive
histopathologic investigation, but, especially for melanoma,
there is promise.
However, overall, RT-PCR may be a relatively quick and
cheap alternative,80 so further studies are necessary to develop
combinations of primers that are specifc enough to estab-
lish the role of RT-PCR in detecting metastases in SNs and
to assess the clinical value of RT-PCR. Promising frst results
have been described.81
One-step nucleic acid amplifcation (OSNA) is a rapid CK19
mRNA PCR that can be applied intraoperatively.82 Fanfani et
al. studied OSNA for the detection of SN metastasis in women
with endometrial cancer. OSNA detected a higher rate of
micrometastasis and a lower rate of macrometastasis and ITC
when compared with standard ultrastaging, not allowing for
conclusions on the validity of this technique in endometrial
cancer.83
The optimal standard protocol
Lamellate perpendicular to the long axis allows for maximum
visualization of the SN surface.11,41 Further, there is not much
consensus among different groups as to how many step sec-
tions are needed and what the step size should be.41 Breast
cancer studies have provided SN data that are useful to arrive
at evidence-based guidelines in this respect.28,38,42,43 Turner et
al.38 examined 60 SNs by step H&E sections and cytokeratin
IHC at ten levels separated by 40 µm, following the hilum
approach. Levels 1 and 2 yielded additional micrometas-
tases in nine SNs (15%), but in levels 3–10, only two (3%)
further metastases were found. They therefore recommended
the study of only two levels separated by 40 µm. However,
their SN slices were 2–3 mm thick, so even with ten levels at
40 µm, only 400 µm would be investigated, accounting for
no more than 13%–20% of the SN slices. This seems to be
insuffcient and may explain the disappointing yield of this
procedure. Rather than taking many sections at small inter-
vals, it may be more effcient to take fewer sections at larger
step intervals. In the study of Cserni,4 SNs were serially sec-
tioned and every 10th to 20th level was examined by H&E
and/or IHC. A central cross-section through the SN would
have failed to detect metastases in 8/26 lymph nodes (31%),
leading to a false-negative SN status in 6/21 patients (29%).
The percentage of metastases found increased from 69% with
only a central cross-section to 77% with 5 further steps, to
81% with 10 steps, and to 96% with 15 steps. Only at 45 steps
was a 100% sensitivity found. Cserni stated that with a three-
level approach at 25%, 50%, and 75% of the block, metastases
would have been missed in 15% of patients. A previous non-
SN study by Zhang et al.84 found almost all metastases with
such a three-level approach. Our own SN protocol includes
step sectioning at fve levels with an interval of 250 µm with
H&E and IHC when the frst-level H&E section is nega-
tive.1,2,10,12,42,43,85–88 Since we perform frozen-section analysis
routinely, leading to some loss of material, this ensures sam-
pling through the better part of the SN. In practice, this has
proven to provide an acceptable workload. The yield per level
has been detailed, as shown in Table 9.1.42
Clinical Lymphatic Mapping
When we take the cumulative total of detected metastases
at level 5 to be 100%, the percentage of SN-positive patients
increased from 80%, 83%, 85%, 87% to 88% in the H&E
sections through levels 1–5, and with IHC from 86%, 90%,
94%, 98% to 100%. With a similar protocol, an even higher
conversion rate was found by Dowlatshahi et al.89 The clini-
cal relevance of fnding micrometastases on the higher levels
is underlined by the fact that three of nine patients in whom
single-cell metastases were detected only at levels 3–5 had
metastases in the subsequent axillary lymph node dissec-
tion. Besides, we have seen several breast cancer cases with
only a few metastatic cells in the SN detected by IHC, while
second-echelon lymph nodes contained signifcant meta-
static deposits.24,90 This is probably due to rerouting of the
lymph drainage because of lymph obstruction of the ‘real’
SN by the heavy tumor load. Others have also reported rela-
tively high percentages of involved non-SNs in SN microme-
tastases.91 IHC is therefore essential when the initial H&E
SN (step) sections are all negative, and ribbons must be kept
when step-cutting.
Summary remarks
Ultrastaging, including step H&E-stained sections and IHC,
is mandatory for reliable detection of metastases in SNs of
gynecologic cancers. Intraoperative single H&E frozen-
section and imprint cytologic analysis of SNs has been
shown to be reasonably reliable for the detection of breast
cancer metastases, but a false-negative rate of 30%–40%
will have to be accepted. These are all standard techniques
that are available in each pathology laboratory, so nothing
special, except the dedication of the pathologist, is required.
Although the workload for an SN is high for the pathologist,
it should be kept in mind that there will be fewer axillary
lymph node dissection specimens to handle, saving time.
Altogether, the SN procedure may save costs.13 Further stud-
ies are necessary to establish the role of FCM and sophis-
ticated molecular biologic techniques such as RT-PCR in
detecting SN metastases. Table 9.3 summarizes our current
recommendations for the SN evaluation and ultrastaging in
gynecologic cancers.
TABLE 9.3
Recommendations for the SN Evaluation (IHC:
immunohistochemistry) [see further 1,41]
Adenocarcinoma Single H&E frozen-section analysis and/or
(cervix) imprint cytology. H&E step sections (fve with
200–250 µm interval) with CAM5.2 IHC.
Squamous cell cancer Single H&E frozen-section analysis with
(vulva, cervix, vagina) imprint cytology. H&E step sections (fve
with 200–250 µm interval) with AE1/3 IHC.
Melanoma (vulva) Single H&E frozen-section analysis with
imprint cytology. H&E step sections (two to
fve with 150 µm interval) with S100/Melan
A or IHC.
Ultrastaging of the sentinel node 61

REFERENCES 21. Zurrida S, Mazzarol G, Galimberti V, et al. The problem of

the accuracy of intraoperative examination of axillary senti-
1. Van Diest PJ, Peterse HL, Borgstein PJ, et al. Pathologic
nel nodes in breast cancer. Ann Surg Oncol. 2001;8:817–20.
investigation of sentinel lymph nodes. Eur J Nuclear Med.
22. Richter T, Nährig J, Komminoth P, et al. Protocol for ultra-
1999;26:S43–A9.
rapid immunostaining of frozen sections. J Clin Pathol.
2. Van Diest PJ. Histopathologic workup of sentinel lymph
1999;52:461–3.
nodes: how much is enough? J Clin Pathol. 1999;52:871–3.
23. Levenback C, Coleman RL, Burke TW, et al. Lymphatic
3. Cserni G. How to improve low lymph node recovery rates
mapping and sentinel node identifcation in patients with
from axillary clearance specimens of breast cancer. A
cervix cancer undergoing radical hysterectomy and pelvic
short-term audit. J Clin Pathol. 1998;51:846–9.
lymphadenectomy. J Clin Oncol. 2002;20:688–93.
4. Cserni G. The reliability of sampling three to six nodes for
24. Rahusen FD, Van Diest PJ, Meijer S. Re: Chu et al; Do all
staging breast cancer. J Clin Pathol. 1999;52:681–3.
patients with sentinel node metastasis from breast carci-
5. Cserni G. Axillary staging of breast cancer and the sentinel
noma need complete axillary node dissection? Ann Surg.
node. J Clin Pathol. 2000;53:733–41.
2000;231:615–16.
6. van Deurzen CH, de Bruin PC, Koelemij R, et al. Isolated
25. Chu KU, Turner RR, Hansen NM, et al. Do all patients with
tumor cells in breast cancer sentinel lymph nodes: displace-
sentinel node metastasis from breast carcinoma need com-
ment or metastases? An immunohistochemical study. Hum
plete axillary node dissection? Ann Surg. 1999;229:536–41.
Pathol. 2009;40:778–82.
26. Giuliano AE. Sentinel lympadenectomy in primary breast
7. Liebens F, Carly B, Cusumano P, et al. Breast cancer seed-
carcinoma: an alternative to routine axillary dissection. J
ing associated with core needle biopsies: a systematic
Surg Oncol. 1996;62:75–6.
review. Maturitas. 2009;62:113–23.
27. Veronesi U, Paganelli G, Galimberti V, et al. Sentinel-node
8. Cserni G, Bianchi S, Boecker W, et al. European Working
biopsy to avoid axillary dissection in breast cancer with
Group for Breast Screening Pathology Improving the
clinically negative lymph-nodes. Lancet. 1997;349:1864–7.
reproducibility of diagnosing micrometastases and isolated
28. Turner RR, Ollila DW, Krasne DL, et al. Histopathologic
tumor cells. Cancer. 2005;103(2):358–67.
validation of the sentinel lymph node hypothesis for breast
9. Cserni G. Histopathologic examination of the sentinel
carcinoma. Ann Surg. 1997;226:271–8.
lymph nodes. Breast J. 2006;12(5 Suppl 2):S152–6.
29. Cibula D, Kocian R, Plaikner A et al. Sentinel lymph node
10. Van Diest PJ, Torrenga H, Meijer S, et al. Pathologic
mapping and intraoperative assessment in a prospective, inter-
analysis of sentinel lymph nodes. Semin Surg Oncol.
national, multicentre, observational trial of patients with cervi-
2001;20:238–45.
cal cancer: the SENTIX trial. Eur J Cancer. 2020;137:69–80.
11. Burg LC, Hengeveld EM, In‘t Hout J, et al. Ultrastaging
30. Roy M, Bouchard-Fortier G, Popa I, et al. Value of senti-
methods of sentinel lymph nodes in endometrial cancer –
nel node mapping in cancer of the cervix. Gynecol Oncol.
a systematic review. Int J Gynecol Cancer. 2020: Online
2011;122:269–74.
ahead of print.
31. Rychlik A, Angeles MA, Migliorelli F, et al. Frozen sec-
12. Van Diest PJ, Torrenga H, Borgstein PJ, et al. Reliability
tion examination of sentinel lymph nodes can be used as a
of intra-operative frozen section and imprint cytologi-
decisional tool in the surgical management of early cervical
cal investigation of sentinel lymph nodes in breast cancer.
cancer. Int J Gynecol Cancer. 2020;30(3):358–63.
Histopathology. 1999;35:14–18.
32. Balaya V, Guani B, Benoit L, et al. Diagnostic value of fro-
13. Flett MM, Going JJ, Stanton PD, et al. Sentinel node localiza-
zen section examination of sentinel lymph nodes in early-
tion in patients with breast cancer. Br J Surg. 1998;85:991–3.
stage cervical cancer at the time of ultrastaging. Gynecol
14. Galimberti V, Zurrida S, Intra M, et al. Sentinel node biopsy
Oncol. 2020;158(3):576–83.
interpretation: the Milan experience. Breast J. 2000;6:306–9.
33. Dostalek L, Slama J, Fisherova D, et al. Impact of sentinel
15. Viale G, Bosari S, Mazzarol G, et al. Intraoperative exami-
lymph node frozen section evaluation to avoid combined
nation of axillary sentinel lymph nodes in breast carcinoma
treatment in early-stage cervical cancer. Int J Gynecol
patients. Cancer. 1999;85:2433–8.
Cancer. 2020;30(6):744–8.
16. Rahusen FD, Pijpers R, Van Diest PJ, et al. The implemen-
34. Gentry JF. Pelvic lymph node metastases in prostatic car-
tation of the sentinel node biopsy as a routine procedure for
cinoma. The value of touch imprint cytology. Am J Surg
patients with breast cancer. Surgery. 2000;128:6–12.
Pathol. 1986;10:718–27.
17. Gulec SA, Su J, O’Leary JP, et al. Clinical utility of frozen
35. Hadjiminas DJ, Burke M. Intraoperative assessment of
section in sentinel node biopsy in breast cancer. Am Surg.
nodal status in the selection of patients with breast cancer
2001;67:529–32.
for axillary clearance. Br J Surg. 1994;81:1615–16.
18. Weiser MR, Montgomery LL, Susnik B, et al. Is routine
36. Fisher CJ, Boyle S, Burke M, et al. Intraoperative assess-
intraoperative frozen-section examination of sentinel
ment of nodal status in the selection of patients with breast
lymph nodes in breast cancer worthwhile? Ann Surg Oncol.
cancer for axillary clearance. Br J Surg. 1993;80:457–8.
2000;7:651–5.
37. Motomura K, Inaji H, Komoike Y, et al. Intraoperative
19. Veronesi U, Zurrida S, Galimberti V. Consequences of
sentinel lymph node examination by imprint cytology
sentinel lymph node in clinical decision making in breast
and frozen sectioning during breast surgery. Br J Surg.
cancer and prospects for future studies. Eur J Surg Oncol.
2000;87:597–601.
1998;24:93–5.
38. Turner RR, Ollila DW, Stern S, et al. Optimal histopatho-
20. Veronesi U, Zurrida S, Mazzarol G, et al. Extensive frozen
logic examination of the sentinel lymph node for breast car-
section examination of axillary sentinel nodes to determine
cinoma staging. Am J Surg Pathol. 1999;23:263–7.
selective axillary dissection. World J Surg. 2001;25:806–8.
62
39. Ratanawichitrasin A, Biscotti CV, Levy L, et al. Touch
imprint cytological analysis of sentinel lymph nodes for
detecting axillary metastases in patients with breast cancer.
Br J Surg. 1999;86:1346–8.
40. Cserni G. The potential value of intraoperative imprint
cytology of axillary sentinel lymph nodes in breast cancer
patients. Am Surg. 2001;67:86–91.
41. Euscher ED, Malpica A. Gynaecological malignancies and
sentinel lymph node mapping: an update. Histopathology.
2020;76:139–50.
42. Torrenga H, Rahusen FD, Meijer S, et al. Sentinel node
in breast cancer: detailed analysis of the yield from step
sectioning and immunohistochemistry. J Clin Pathol.
2001;54:553–5.
43. Torrenga H, Diest PJ van, Meijer S. Sentinel-node biopsy in
breast cancer. Lancet. 2001;358:1814.
44. de Hullu JA, Hollema H, Piers DA, et al. Sentinel lymph
node procedure is highly accurate in squamous cell carci-
noma of the vulva. J Clin Oncol. 2000;18:2811–16.
45. de Hullu JA, Doting E, Piers DA, et al. Sentinel lymph
node identifcation with technetium-99m-labeled nano-
colloid in squamous cell cancer of the vulva. J Nucl Med.
1998;39:1381–5.
46. de Hullu JA, Piers DA, Hollema H, et al. Sentinel lymph
node detection in locally recurrent carcinoma of the vulva.
Br J Obstet Gynaecol. 2001;108:766–8.
47. Levenback C. Intraoperative lymphatic mapping and sen-
tinel node identifcation: gynecologic applications. Recent
Results Cancer Res. 2000;157:150–8.
48. Euscher E, Sui DW, Soliman P, et al. Ultrastaging of sentinel
lymph nodes in endometrial carcinoma according to use of
2 different methods. Int J Gynecol Pathol. 2018;37:242–51.
49. Terada KY, Shimizu DM, Wong JH. Sentinel node dissec-
tion and ultrastaging in squamous cell cancer of the vulva.
Gynecol Oncol. 2000;76:40–4.
50. Molpus KL, Kelley MC, Johnson JE, et al. Sentinel lymph
node detection and micro-staging in vulvar carcinoma. J
Reprod Med. 2001;46:863–9.
51. Moore RG, Granai CO, Gajewski W, et al. Pathologic eval-
uation of inguinal sentinel lymph nodes in vulvar cancer
patients: a comparison of immunohistochemical staining
versus ultrastaging with hematoxylin and eosin staining.
Gynecol Oncol. 2003;91(2):378–82.
52. Van der Zee AG, Oonk MH, De Hullu JA, et al. Sentinel
node dissection is safe in the treatment of early-stage vulvar
cancer. J Clin Oncol. 2008;26;884–9.
53. Euscher ED, Malpica A, Atkinson EN, et al. Ultrastaging
improves detection of metastases in sentinel lymph nodes of
uterine cervix squamous cell carcinoma. Am J Surg Pathol.
2008;32:1336–43.
54. Devaja O, Mehra G, Coutts M, et al. A prospective study
of sentinel lymph node detection in vulval carcinoma: is it
time for a change in clinical practice? Int J Gynecol Cancer.
2011;21:559–64.
55. Ballester M, Dubernard G, Lecuru F, et al. Detection rate
and diagnostic accuracy of sentinel-node biopsy in early
stage endometrial cancer: a prospective multicentre study
(SENTIENDO). Lancet Oncol. 2011;12:469–76.
56. Levenback CF, Ali S, Coleman RL, et al. Lymphatic
mapping and sentinel lymph node biopsy in women with
Clinical Lymphatic Mapping
squamous cell carcinoma of the vulva: a Gynecologic
Oncology Group study. J Clin Oncol. 2012;30:3786–91.
57. Koskas M, Chereau E, Ballester M, et al. Accuracy of
a nomogram for prediction of lymph-node metastasis
detected with conventional histopathology and ultrastaging
in endometrial cancer. Br J Cancer. 2013;108:1267–72.
58. Kim CH, Soslow RA, Park KJ, et al. Pathologic ultrastag-
ing improves micrometastasis detection in sentinel lymph
nodes during endometrial cancer staging. Int J Gynecol
Cancer. 2013;23:964–70.
59. Naoura I, Canlorbe G, Bendifallah S, et al. Relevance of
sentinel lymph node procedure for patients with high-risk
endometrial cancer. Gynecol Oncol. 2015;136:60–4.
60. Touhami O, Trinh XB, Gregoire J, et al. Predictors of non-
sentinel lymph node (non-SLN) metastasis in patients with
sentinel lymph node (SLN) metastasis in endometrial can-
cer. Gynecol Oncol. 2015;138:41–5.
61. Salvo G, Ramirez PT, Levenback CF, et al. Sensitivity and
negative predictive value for sentinel lymph node biopsy in
women with early-stage cervical cancer. Gynecol Oncol.
2017;145:96–101.
62. Dundr P, Cibula D, Němejcová K, et al. Pathologic proto-
cols for sentinel lymph nodes ultrastaging in cervical can-
cer. Arch Pathol Lab Med. 2020;144(8):1011–20.
63. Van den Brekel MWM, Stel HV, van der Valk P, et al.
Micrometastases from squamous cell carcinoma in
neck dissection specimens. Eur Arch Otorhinolaryngol.
1992;249:349–53.
64. Motomura K, Inaji H, Komoike Y, et al. Gamma probe and
ultrasonographically-guided fne-needle aspiration biopsy
of sentinel lymph nodes in breast cancer patients. Eur J
Surg Oncol. 2001;27:141–5.
65. Angelico G, Santoro A, Inzani F, et al. Ultrasound-guided
FNA cytology of groin lymph nodes improves the manage-
ment of squamous cell carcinoma of the vulva: results from
a comparative cytohistological study. Cancer Cytopathol.
2019;127:514–20.
66. Joensuu H, Klemi PJ, Eerola E. Flow cytometric DNA
analysis combined with fne needle aspiration biopsy in
the diagnosis of palpable metastases. Analy Quant Cytol
Histol. 1988;10:256–60.
67. Leers M, Schoffelen R, Theunissen P, et al. Multiparameter
fow cytometry (MP-FCM) as a tool for the detection of
micrometastatic tumour cells in the sentinel lymph node
procedure. J Clin Pathol. 2002;55:359–66.
68. Noguchi S, Aihara T, Motomura K, et al. Detection of
breast cancer micrometastases in axillary lymph nodes by
means of reverse transcriptase-polymerase chain reaction.
Comparison between MUC1 mRNA and keratin 19 mRNA
amplifcation. Am J Pathol. 1996;148:649–56.
69. Hoon DSB, Sarantou T, Doi F, et al. Detection of metastatic
breast cancer by ß-hcg polymerase chain reaction. Int J
Cancer. 1996;69:369–74.
70. Schoenfeld A, Luqmani Y, Smith D, et al. Detection of breast
cancer micrometastases in axillary lymph nodes by using
polymerase chain reaction. Cancer Res. 1994;54:2986–90.
71. Noguchi S, Tomohiko A, Motomura K, et al. Detection of
breast cancer micrometastases in axillary lymph nodes by
means of reverse transcriptase-polymerase chain reaction.
Cancer. 1994;74:1595–600.
Ultrastaging of the sentinel node
72. Kataoka A, Mori M, Sadanaga N, et al. RT-PCR detection
of breast cancer cells in sentinel lymph nodes. Int J Oncol.
2000;16:1147–52.
73. Mori M, Mimori K, Inoue H, et al. Detection of cancer
micrometastases in lymph nodes by reverse transcriptase-
polymerase chain reaction. Cancer Res. 1995;55:3417–20.
74. Wascher RA, Bostick PJ, Huynh KT, et al. Detection of
MAGE-A3 in breast cancer patients’ sentinel lymph nodes.
Br J Cancer. 2001;85:1340–6.
75. Manzotti M, Dell’Orto P, Maisonneuve P, et al. Reverse
transcription-polymerase chain reaction assay for multiple
mRNA markers in the detection of breast cancer metastases
in sentinel lymph nodes. Int J Cancer. 2001;95:307–12.
76. Ishida M, Kitamura K, Kinoshita J, et al. Detection of
micrometastasis in the sentinel lymph nodes in breast can-
cer. Surgery. 2002;131(1 Pt 2):S211–16.
77. Van Trappen PO, Gyselman VG, Lowe DG, et al. Molecular
quantifcation and mapping of lymph-node micrometasta-
ses in cervical cancer. Lancet. 2001;357:15–20.
78. Palmieri G, Ascierto PA, Cossu A, et al. Detection of occult
melanoma cells in paraffn-embedded histologically nega-
tive sentinel lymph nodes using a reverse transcriptase poly-
merase chain reaction assay. J Clin Oncol. 2001;19:1437–43.
79. Bostick PJ, Chatterjee S, Chi DD, et al. Limitations of
specifc reverse-transcriptase polymerase chain reac-
tion markers in the detection of metastases in the lymph
nodes and blood of breast cancer patients. J Clin Oncol.
1998;16:2632–40.
80. van der Velde-Zimmermann D, Schipper ME, de Weger
RA, et al. Sentinel node biopsies in melanoma patients: a
protocol for accurate, effcient, and cost-effective analysis
by preselection for immunohistochemistry on the basis of
Tyr-PCR. Ann Surg Oncol. 2000;7:51–4.
81. Bostick PJ, Huynh KT, Sarantou T, et al. Detection
of metastases in sentinel lymph nodes of breast can-
cer patients by multiple-marker RT-PCR. Int J Cancer.
1998;79:645–51.
82. Visser M, Jiwa M, Horstman A, et al. Intra-operative rapid
diagnostic method based on CK19 mRNA expression for
63
the detection of lymph node metastases in breast cancer. Int
J Cancer. 2008;122(11):2562–7.
83. Fanfani F, Monterossi G, Di Meo ML, et al. Standard ultra-
staging compared to one-step nucleic acid amplifcation for
the detection of sentinel lymph node metastasis in endome-
trial cancer patients: a retrospective cohort comparison. Int
J Gynecol Cancer. 2020;30(3):372–7.
84. Zhang PJ, Reisner RM, Nangia R, et al. Effectiveness of
multiple level sectioning in detecting axillary nodal micro-
metastasis in breast cancer. A retrospective study with
immunohistochemical analysis. Arch Pathol Lab Med.
1998;122:687–90.
85. Borgstein PJ, Pijpers R, Comans EF, et al. Sentinel lymph
node biopsy in breast cancer: guidelines and pitfalls of lym-
phoscintigraphy and gamma probe detection. J Am Coll
Surg. 1998;186:275–83.
86. Borgstein PJ, Meijer S, Pijpers R, et al. Functional lym-
phatic anatomy for sentinel node biopsy in breast cancer:
echoes from the past and the periareolar blue method. Ann
Surg. 2000;232:81–9.
87. Pijpers R, Meyer S, Hoekstra OS, et al. Impact of lympho-
scintigraphy on sentinel node identifcation with techne-
tium-99m-colloidal albumin in breast cancer. J Nucl Med.
1997;38:366–8.
88. Pijpers R, Borgstein PJ, Meijer S, et al. Sentinel node biopsy
in melanoma patients: dynamic lymphoscintigraphy fol-
lowed by intraoperative gamma probe and vital blue guid-
ance. World J Surg. 1997;21:788–92.
89. Dowlatshahi K, Fan M, Bloom KJ, et al. Occult metas-
tases in the sentinel lymph nodes of patients with early
stage breast carcinoma: a preliminary study. Cancer.
1999;86:990–6.
90. Rahusen FD, Torrenga H, van Diest PJ, et al. Predictive
factors for metastatic involvement of nonsentinel nodes in
patients with breast cancer. Arch Surg. 2001;136:1059–63.
91. Turner RR, Chu KU, Qi K, et al. Pathologic features asso-
ciated with nonsentinel lymph node metastases in patients
with metastatic breast carcinoma in a sentinel lymph node.
Cancer. 2000;89:574–81. Run ning Head Right- y of the vulva
10
Sentinel lymph node biopsy of the vulva

Maaike Oonk and Ate G.J. van der Zee

CONTENTS
Introduction .................................................................................................................................................................................... 65
Safety of the sentinel node procedure ............................................................................................................................................ 65
Can we extend the indication for sentinel node biopsy in vulvar cancer? ..................................................................................... 67
New directions in sentinel lymph node detection .......................................................................................................................... 68
Sentinel node metastasis ................................................................................................................................................................ 68
Conclusions .................................................................................................................................................................................... 69
References...................................................................................................................................................................................... 69

morbidity. The sentinel lymph node procedure was frst intro-

Introduction
With an annual incidence of 2–3 per 100,000 women, vulvar
cancer is the fourth most common gynecologic malignancy.
Squamous cell carcinoma is the most common histological
type, comprising about 80% of all vulvar malignancies. Other
types, like melanomas, adenocarcinomas, and basal cell can-
cers, are much less common. In this chapter we will focus on
squamous cell carcinoma of the vulva. For the last few decades
the incidence of squamous cell carcinoma of the vulva has
been increasing, with a more rapid rise in the rates seen in
women aged <60 years at diagnosis.1
Over the last few decades, many modifcations have been
made in the standard treatment of vulvar cancer, all with the aim
to reduce treatment-related morbidity without compromising
survival rates. However, morbidity remained a serious problem
and was especially related to the inguinofemoral lymphadenec-
tomy. In 1977 Cabanas was the frst to introduce the sentinel
node technique in the treatment of patients with penile can-
cer.2 Vulvar cancer seemed an ideal candidate for sentinel node
biopsy for a variety of reasons. First, most patients present
with early-stage disease and only 30%–35% of them will have
inguinofemoral lymph node involvement.3–5 Second, because
of the absence of noninvasive imaging techniques that reliably
exclude lymph node metastases,6 all patients with macroinva-
sive disease require staging of the groin by sentinel node pro-
cedure or lymphadenectomy. The morbidity of this procedure
is signifcant, with frequent wound breakdown, lymphocysts,
lymphedema of the legs, and recurrent infections.7,8 And last,
since vulvar cancer is a cutaneous malignancy, the lesions are
easily accessible for peritumoral tracer injection and also the
pattern of lymph drainage from the vulva is fairly predictable;
the frst draining lymph nodes are located in the groins.
Of all modifcations in standard treatment in the last decades,
the introduction of the sentinel node procedure has prob-
ably been the one with the most impact on treatment-related
duced in vulvar cancer in 1994. Levenback et al. published the
frst feasibility study on sentinel lymph node biopsy with only
isosulfan blue as a tracer and always followed by an inguino-
femoral lymphadenectomy.9 After that many small single-center
studies were published in which the sentinel node procedure
was always followed by inguinofemoral lymphadenectomy to
investigate the feasibility and accuracy of this procedure. They
found the procedure was feasible, with a high detection rate,
especially with the combined technique (radioactive tracer and
blue dye) (Figure 10.1). These studies also showed a high nega-
tive predictive value of a negative sentinel node.10,11
Safety of the sentinel node procedure
The Groningen International Study on Sentinel Nodes in Vulvar
cancer (GROINSS-V I) was the frst large study on the safety of
the sentinel node procedure in vulvar cancer and was published
in 2008. In this multicenter international study only patients with
a metastatic sentinel node underwent an inguinofemoral lymph-
adenectomy. In patients with a negative sentinel node, it was
observed whether omission of inguinofemoral lymphadenec-
tomy was safe. The eligibility criteria for this study were unifocal
squamous cell carcinoma of the vulva less than 4 cm in diameter,
without suspicious nodes at clinical examination. In 2.3% of the
sentinel node–negative patients, groin recurrences were diag-
nosed during follow-up.3 In the same period, the Gynecological
Oncology Group published their results of the GOG173 study,
in which the sentinel node biopsy was routinely followed by
an inguinofemoral lymphadenectomy. They found 2% of false
negatives in patients with tumors <4 cm.4 After the publication
of these trials, the sentinel node procedure was included in many
national and international treatment guidelines.
In 2015 Covens et al. published the results of their meta-
analysis which assessed the harms and benefts of the sentinel

DOI: 10.1201/9781003255536-10 65
66 Clinical Lymphatic Mapping

FIGURE 10.1 Sentinel node detection with the combined technique. (a) Preoperative lymposcintigram shows bilateral lymph drainage, with one
sentinel node located in each groin. (b) Just before the start of surgery, injection with blue dye to visualize the sentinel node and afferent lymph vessels.
(c) Using the gamma probe, the sentinel node is localized. (d) The blue afferent lymph vessels and radioactivity lead us to the sentinel node. (e) The
sentinel node is localized. (f) The sentinel node is sent for pathological evaluation with ultrastaging.
Sentinel lymph node biopsy of the vulva
node procedure. In this paper they showed the groin recurrence
rates after a negative sentinel node biopsy were not signifcantly
higher than after a negative inguinofemoral lymphadenec-
tomy. These were, respectively, 3% (95% confdence interval
[CI] 2%–4%) and 1% (95% CI 0%–3%).12 In the AGO-CaRE-1
study, 487 lymph node–negative patients who had undergone
inguinofemoral lymphadenectomy were compared with 69 sen-
tinel lymph node–negative patients who had undergone sentinel
node biopsy only. Only those with tumors <4 cm were included.
The authors found similar results for both groups with regard
to recurrence rates and survival.13 A recent nationwide study in
Denmark in 286 early-stage vulvar cancer patients confrmed
these results for the sentinel node procedure. Isolated groin
recurrences after a negative sentinel node were observed in
2.1% of the patients, all within 2 years after primary treatment.14
Standard sentinel node detection can be performed with a
radioactive tracer (usually 99mTechnetium-labeled nanocolloid)
and a blue dye. Blue dye enables the surgeon to directly visualize
the lymph vessels and the sentinel node, and thereby it facilitates
the detection of the sentinel node. A meta-analysis of studies
on the sentinel node procedure in vulvar cancer showed that the
combination of technetium Tc99 and blue dye provides the best
detection rate: a detection rate of 97.7% for technetium Tc99 with
blue dye, 94.0% for technetium Tc99 alone, and 68.7% for blue
dye alone.15 Based on these results and the experience that the
learning curve is shorter with the combined technique, we advise
performing the sentinel node procedure with both a radioactive
tracer and blue dye. In a model-based economic evaluation of the
sentinel node procedure using a radioactive tracer and blue dye
with ultrastaging, Sutton et al. concluded that this may be con-
sidered the most cost-effective strategy, based on survival free
of morbidity.16 Other studies confrmed these fndings and stated
that the key factor in this was the lower incidence of lymphedema
in women who underwent sentinel node biopsy only.17,18
The morbidity of sentinel node biopsy alone is much
lower compared with an inguinofemoral lymphadenectomy.
GROINSS-V showed that lymphedema and recurrent erysip-
elas occurred in, respectively, 1.9% and 0.4% after sentinel
node biopsy alone, compared to 25.2% and 16.2%, respectively,
after inguinofemoral lymphadenectomy.3 Hospital stay is also
shorter after sentinel node biopsy. Patients today usually can
leave the hospital 1–2 days after the surgical intervention.
However, the morbidity for patients with a metastatic senti-
nel node is still high, as they all require additional inguinofem-
oral lymphadenectomy. Different studies have reported on the
incidence of lower extremity lymphedema after vulvar cancer
surgery, and the range is wide: 14%–50%.19,20 Lower extremity
lymphedema has shown to be detrimental to quality of life,
daily functioning, and body image.21 Therefore, trials focusing
on prevention and management of this condition are needed.
Can we extend the indication for sentinel
node biopsy in vulvar cancer?
The criteria for application of the sentinel node procedure
in vulvar cancer have been the same since the introduc-
tion in our treatment guidelines:22 unifocal squamous cell
67
carcinoma smaller than 4 cm in maximum diameter, without
suspicious nodes at clinical examination and imaging. These
criteria are based on the inclusion criteria of GROINSS-V I.
In the GOG173 study, tumors with a maximum diameter of
6 cm could be included. In this study the false-negative rate
was much higher for patients with tumors ≥4 cm compared to
those with tumors <4 cm (7.4% versus 2%).4 A multicenter
German study in 127 women with primary T1–T3 vulvar
cancer published no separate analysis for tumors ≥4 cm.
However, three patients had false-negative sentinel nodes,
and two of them had primary tumors ≥4 cm.23 Nica et al.
described 20 patients with a tumor ≥4 cm who had undergone
sentinel node biopsy. Eleven of them had a negative sentinel
node, and thus no adjuvant treatment. One of these patients
had an isolated groin recurrence (9%). Based on this fnd-
ing, the authors conclude that the sentinel node procedure
in larger tumors might have a higher risk in terms of groin
recurrences.24 Data on the sentinel node procedure in mul-
tifocal tumors are lacking. The GROINSS-V protocol was
amended after 3 years of inclusion because of the high num-
ber of groin recurrences in patients with multifocal tumors
and a negative sentinel node (11.8% at the moment it was
decided to amend the protocol and multifocal disease was
made an exclusion criterion).3 Other studies did not include
multifocal disease or did not describe these patients sepa-
rately.4,23 A study by Garganese et al. investigated the role
of sentinel node biopsy in patients without clinically suspect
groin nodes who were not eligible for the sentinel node pro-
cedure according to current treatment guidelines. They sug-
gest that sentinel lymph node biopsy can be accurate and safe
even in clinically N0 patients who are currently excluded
from this procedure, providing that a careful preoperative
selection is performed with a negative positron emission
tomography–computed tomography (PET-CT).25 A Swedish
study by Zach et al. is currently investigating the sentinel
node procedure in four groups of patients: frst, patients with
a primary tumor ≥4 cm; second, patients with multifocal dis-
ease; third, patients with a local recurrence without previous
inguinofemoral lymphadenectomy or radiation to the groins;
and fourth, patients with a local recurrence with previous
inguinofemoral lymphadenectomy and/or radiation to the
groins. All patients in this study will undergo inguinofemo-
ral lymphadenectomy after the sentinel node biopsy.26 In a
retrospective analysis of 27 patients with local recurrence
who underwent a repeat sentinel node procedure, van Doorn
et al. showed the procedure is feasible in locally recurrent
disease. However, the detection rate is 78% lower compared
to the sentinel node procedure in the primary setting.27 This
group is currently prospectively investigating the sentinel
node procedure without subsequent inguinofemoral lymph-
adenectomy in case of a negative sentinel node in patients
with locally recurrent disease. In summary, several studies
are investigating whether the inclusion criteria for sentinel
node biopsy can be extended so more vulvar cancer patients
can be spared the negative consequences of an inguinofemo-
ral lymphadenectomy. Until now, we advise strictly adhering
to the criteria as formulated earlier in order to prevent (often
fatal) groin recurrences.
68
New directions in sentinel lymph
node detection
Near-infrared fuorescence imaging has emerged as a new
method for intraoperative visualization of sentinel nodes.
Peritumoral injection of this tracer allows for real-time sen-
tinel node imaging. Near-infrared light is invisible to the
naked eye and therefore does not color the surgical feld when
applied. Furthermore, it has a penetration depth of approxi-
mately 5–8 mm, allowing identifcation of structures even if
they are not yet directly exposed to the surface.28 Several stud-
ies have shown good feasibility of the method in identifying
the sentinel node in vulvar cancer patients.29–31
A recent randomized controlled trial by Deken et al. com-
pared standard sentinel node detection with a hybrid tracer
ICG-99Tc nanocolloid in 48 patients.32 They found that the
percentage of blue sentinel nodes was lower compared with the
percentage of fuorescent sentinel nodes (65.3% versus 92.5%,
P < 0.001). The rate of successful sentinel node procedures
was not different between both groups (92.1% for the standard
group, 97.2% for blue dye, P = 0.33). There are several advan-
tages of near-infrared fuorescence imaging over blue dye.
First, the penetration depth of the fuorescence emission. Blue
dye cannot be seen through the skin or soft tissue, whereas
indocyanine green (ICG) has a penetration depth of up to 8
mm. Second, blue dye and has a lower sensitivity for sentinel
node detection. Furthermore, blue dye has a small risk of ana-
phylaxis, which is much lower for ICG.33 On the other hand,
near-infrared fuorescence imaging requires a fuorescent
camera system, training in near-infrared imaging, and conve-
nience with the technique. Also, there are some shortcomings
of this procedure. Because of its molecular size, ICG migrates
through the lymph vessels without specifcity for the frst
draining lymph nodes compared to the higher-echelon nodes.
Because of this feature, it also induces spillage during surgi-
cal manipulation.34 There are only a few contraindications for
ICG: iodine allergy (since indocyanine green contains sodium
iodide), pregnancy or breastfeeding, liver disease, dialysis or
renal failure, and previous anaphylactic reaction.33
The use of near-infrared imaging alone would have the
potential advantage of becoming a one-step procedure, avoid-
ing preoperative injection of a radioactive tracer and perform-
ing a lymphoscintigram. However, body weight is a limitation
for the use of ICG alone, since the penetrance is max 8 mm.29
No other prospective studies have shown a single-tracer strat-
egy using ICG alone. The combination with 99mTc appears to
be the optimal combination. The best of both was combined
in the development of a hybrid tracer: ICG-99mTc-nanocolloid.
With this procedure, the sentinel node procedure can become
more accurate and independent of the use of blue dye.34
In conclusion, the use of near-infrared imaging appears to
be of added value because of its high sensitivity, which outper-
forms blue dye and is comparable to 99mTechnetium-labeled
nanocolloid. Advantages might be that near-infrared imaging
is not disturbed by the background signal, as sometimes is the
case with radiocolloid. Since the penetration depth is limited
to approximately 8 mm, the concurrent use of a radioactive
tracer is still needed.
Clinical Lymphatic Mapping
More recently, a superparamagnetic iron oxide has been
introduced as an alternative tracer for sentinel lymph node
detection. Superparamagnetic iron oxide particles have been
shown to be suitable for lymph node mapping using a mag-
netic probe for nodal detection. The sentinel node can also
be visualized since the particles are carboxydextran-coated,
giving the sentinel node a blackish-brown appearance. A
meta-analysis and randomized controlled trial in breast can-
cer patients showed noninferiority to the standard technique
for sentinel node biopsy with technetium-labeled colloid and
blue dye.35,36 Therefore, it could be a viable alternative for a
radioactive tracer with blue dye or ICG. The advantages of this
procedure are that the injection of the tracer can be done up
to 7 days before surgery, allowing more fexibility in schedul-
ing surgery. Also, intraoperative injection can be performed,
allowing for a one-step procedure. Surgeons reported they
felt comfortable with the magnetic technique after perform-
ing three to fve cases.36 Only one study investigated this tech-
nique in vulvar cancer in a series of 20 patients. In this study
the superparamagnetic iron oxide tracer was combined with
99mTc, both injecting them a day before surgery. This study
showed that the use of superparamagnetic iron oxide tracer
was not inferior to the standard approach with a radioactive
tracer.37 When this technique would show similar results in
a 1-day protocol, this could provide a great advantage, since
preoperative peritumoral tracer injection is a painful proce-
dure for patients.
Sentinel node metastasis
Sentinel node biopsy allows the application of ultrastaging.
Ultrastaging consists of multiple sectioning and immunohis-
tochemistry. Different protocols for multiple sectioning have
been applied, but usually sentinel nodes are cut at 400- to
500-um intervals. At every level one slide is stained with
standard hematoxylin-eosin staining and one with immu-
nohistochemical staining for cytokeratin. Ultrastaging of
sentinel nodes allows detection of smaller metastases, which
can easily be missed with standard hematoxylin-eosin stain-
ing (2- to 5-mm slides). In GROINSS-V I 41% of the meta-
static sentinel nodes were detected only by ultrastaging.3 In
the GOG173 study this percentage was 23%.4 An interesting
result is the publication of the interim fndings of an audit
on the outcomes of sentinel node biopsy in routine clinical
practice in Australia and New Zealand. Two isolated groin
recurrences were observed after a negative sentinel node,
and in both cases, analysis showed the pathology protocol for
sentinel node workup was not followed. This report shows
that strict adherence to the pathology protocol is an essential
component in the utilization of the sentinel node procedure
in vulvar cancer.38
We know that the risk of non–sentinel node metastases
increases with the size of the sentinel node metastasis.
Analysis of metastatic sentinel nodes from GROINSS-V I
showed that the risk of additional metastasis was 4.2% for
patients with isolated tumor cells in the sentinel node and
increased to 62.5% for patients with sentinel node metasta-
ses >10 mm. There was no threshold below which the risk
Sentinel lymph node biopsy of the vulva
of additional metastases was so low that inguinofemoral
lymphadenectomy could be safely omitted.39 Therefore, all
sentinel node metastases, even those with isolated tumor
cells, should be regarded as a metastatic sentinel, and
therefore have an indication for adjuvant treatment. At this
moment, standard treatment for a metastatic sentinel node is
an inguinofemoral lymphadenectomy of the affected groin.
A study by Nica et al. suggests an inguinofemoral lymph-
adenectomy can be omitted and replaced by inguinofemoral
radiotherapy when the sentinel node contains metastasis ≤2
mm. However, these observations are based on retrospec-
tive analysis in a small number of patients.24 Therefore,
we believe further prospective data should be awaited.
GROINSS-V II investigated whether radiotherapy is a safe
alternative for patients with a micrometastasis in the senti-
nel node. Patients with sentinel node metastasis ≤2 mm were
treated with inguinofemoral radiotherapy (50 Gy) instead of
an inguinofemoral lymphadenectomy. Stopping rules were
constructed to monitor groin recurrence rate. This study
included patients from 2005 to 2016, and the results will
soon become available. GROINSS-V III will investigate
whether chemoradiation is a safe alternative for an inguino-
femoral lymphadenectomy in patients with a macrometasta-
sis (>2 mm) in the sentinel node.
Conclusions
Sentinel node biopsy is part of the standard of care today in
early-stage vulvar cancer treatment. The procedure can be per-
formed with a radioactive tracer in combination with blue dye
or ICG. The sentinel node procedure is cost-effective. Standard
treatment in case of a metastatic sentinel node (metastasis of
any size) is an inguinofemoral lymphadenectomy. Studies on
radio(chemo)therapy instead of a lymphadenectomy might
change future treatment guidelines.
REFERENCES
1. Bray F, Laversanne M, Weiderpass E, et al. Geographic and
temporal variations in the incidence of vulvar and vaginal
cancer. In J Cancer. 2020;147(10):2764–71.
2. Cabanas RM. An approach for the treatment of penile car-
cinoma. Cancer. 1977;39(2):456–66.
3. Van der Zee AG, Oonk MH, De Hullu JA, et al. Sentinel
node dissection is safe in the treatment of early-stage vulvar
cancer. J Clin Oncol. 2008;26(6):884–9.
4. Levenback CG, Ali S, Coleman RL, et al. Lymphatic map-
ping and sentinel lymph node biopsy in women with squa-
mous cell carcinoma of the vulva: a gynecologic oncology
group study. J Clin Oncol. 2012;30(31):3786–91.
5. Froeding LP, Høgdall C, Kristensen E, et al. Recurrence
and survival rates in node negative patients after sentinel
node biopsy for early-stage vulva cancer – a nationwide
study. Gynecol Oncol. 2020;156(1):124–30.
6. Selman TJ, Luesley DM, Acheson N, et al. A systematic
review of the accuracy of diagnostic tests for inguinal lymph
node status in vulvar cancer. Gynecol Oncol. 2005:206–14.
7. Pouwer AW, Hinten F, van der Velden J, et al. Volume-
controlled versus short drainage after inguinofemoral
69
lymphadenectomy in vulvar cancer patients: a Dutch nation-
wide prospective study. Gynecol Oncol. 2017;146(3):580–7.
8. Carlson JW, Kauderer J, Hutson A, et al. GOG 224 – the
lymphedema and gynecologic cancer (LEG) study: inci-
dence and risk factors in newly diagnosed patients. Gynecol
Oncol. 2020;156(2):467–74.
9. Levenback C, Burke TW, Gershenson DM, et al.
Intraoperative lymphatic mapping for vulvar cancer. Obstet
Gynecol. 1994;84(2):163–7.
10. Hassanzade M, Attaran M, Treglia G, et al. Lymphatic
mapping and sentinel node biopsy in squamous cell carci-
noma of the vulva: a systematic review and meta-analsysi of
the literature. Gynecol Oncol. 2013;130(1):237–45.
11. Lawrie TA, Patel A, Martin-Hirsch PP, et al. Sentinel node
assessment for diagnosis of groin lymph node involve-
ment in vulval cancer. Cochrane Database Syst Rev.
2014;2014(6):CD10409.
12. Covens A, Vella ET, Kennedy EB, et al. Sentinel lymph
node biopsy in vulvar cancer: systematic review, meta-
analysis and guideline recommendations. Gynecol Oncol.
2015;137(2):351–61.
13. Klapdor R, Hillemans P, Wölber L, et al. Outcome after
sentinel lymph node dissection in vulvar cancer: a sub-
group analysis of the AGO-CaRE-1 study. Ann Surg Oncol.
2017;24:1314–21.
14. Froeding LP, Høgdall C, Kristensen E, et al. Recurrence
and survival rates in node negative patients after sentinel
node biopsy for early-stage vulva cancer – a nationwide
study. Gynecol Oncol. 2020;156:124–30.
15. Meads C, Sutton AJ, Rosenthal AN, et al. Sentinel lymph
node biopsy in vulval cancer: systematic review and meta-
analysis. Br J Cancer. 2014;110(12):2837–46.
16. Sutton AJ, Barton P, Sundar S, et al. Cost-effectiveness
of sentinel lymph node biopsy vs inguinofemoral lymph-
adenectomy in women with vulval cancer. Br J Cancer.
2013;109(10):2533–47.
17. Erickson BK, Divine LM, Leath CA, et al. Cost-
effectiveness analysis of sentinel lymph node biopsy in the
treatment of early-stage vulvar cancer. In J Gynecol Cancer.
2014;24(8):1480–5.
18. McCann GA, Cohn DE, Jewell EL, et al. Lymphatic mapping
and sentinel lymph node dissection compared to complete
lymphadenectomy in the management of early-stage vulvar can-
cer: a cost-utility analysis. Gynecol Oncol. 2015;136(2):300–4.
19. Wills A, Obermair A. A review of complications associ-
ated with the surgical treatment of vulvar cancer. Gynecol
Oncol. 2013;131:467–79.
20. Huang J, Ye N, Wang Z, et al. Incidence of lower limb
lymphedema after vulvar cancer: a systemic review and
meta-analysis. Medicine. 2017;96(46):e8722.
21. Carter J, Huang HQ, Armer J, et al. GOG244 – the lymph-
edema and gynecologic cancer (LeG) study: the impact of
lower-extremity lymphedema on quality of life, psycho-
logical adjustment, physical ability, and function. Gynecol
Oncol. 2020; Epub ahead of print.
22. Oonk MHM, Planchamp F, Baldwin P, et al. European soci-
ety of gynaecological oncology guidelines for the manage-
ment of patients with vulvar cancer. In J Gynecol Cancer.
2017;27:832–7.
23. Hampl M, Hantschmann P, Michels P, et al. Validation
of the accuracy of the sentinel lymph node procedure in
70
patients with vulvar cancer: results of a multicenter study in
Germany. Gynecol Oncol. 2008;111(2):282–8.
24. Nica A, Covens A, Vicus D, et al. Sentinel lymph nodes in
vulvar cancer: management dilemmas in patients with posi-
tive nodes and larger tumors. Gynecol Oncol. 2019;94–100.
25. Garganese G, Collarino A, Fragomeni SM, et al. Groin senti-
nel node biopsy and 18F-FDG PET/CT-supported preoperative
lymph node assessment in cN0 patients with vulvar cancer
currently unft for minimally invasive inguinal surgery: the
GroSNaPET study. Eur J Surg Oncol. 2017;43(9):1776–83.
26. Zach D, Kannisto P, Bohlin KS, et al. Can we extend the
indication for sentinel node biopsy in vulvar cancer? A
nationwide feasibility study from Sweden. Int J Gynecol
Cancer. 2020;30:402–5.
27. Van Doorn HC, Van Beekhuizen HJ, Gaarenstroom KN,
et al. Repeat sentinel lymph node procedure in patients
with recurrent vulvar squamous cell carcinoma is feasible.
Gynecol Oncol. 2016;140(3):415–19.
28. Handgraaf HJ, Verbeek FP, Tummer QR, et al. Real-time
near-infrared fuorescence guided surgery in gynecologic
oncology: a review of the current state of the art. Gynecol
Oncol. 2014;135(3):606–13.
29. Crane LM, Themelis G, Arts HJ, et al. Intraoperative near-
infrared fuorescence imaging for sentinel lymph node
detection in vulvar cancer: frst clinical results. Gynecol
Oncol. 2011;120:291–5.
30. Schaafsma BE, Verbeek FP, Peters AA, et al. Near-infrared
fuorescence sentinel lymph node biopsy in vulvar cancer:
a randomised comparison of lymphatic tracers. BJOG.
2013;120:758–64.
31. Hutteman M, van der Vorst JR, Gaarenstroom KN, et al.
Optimization of near-infrared fuorescent sentinel lymph
node mapping for vulvar cancer. Am J Obstet Gynecol.
2012;206:89.e1–5.
Clinical Lymphatic Mapping
32. Deken MM, van Doorn HC, Verver D, et al. Near-infrared
fuorescence imaging compared to standard sentinel lymph
node detection with blue dye in patients with vulvar can-
cer – a randomized controlled trial. Gynecol Oncol. 2020;
Article in Press.
33. Zapardiel I, Alvarez J, Barahona M, et al. Utility of intra-
operative fuorescence imaging in Gynecologic surgery:
systematic review and consensus statement. Ann Surg
Oncol. 2020; Online Ahead of Print.
34. KleinJan GH, Van Werkhoven E, van den Berg NS, et al.
The best of both worlds: a hybrid approach for optimal pre-
and intraoperative identifcation of sentinel lymph nodes.
Euro J Nucl Med Mol Imaging. 2018;45(11):1915–25.
35. Teshome M, Wei C, Hunt KK, et al. Use of a magnetic
tracer for sentinel lymph node detection in early-stage
breast cancer patients: a meta-analysis. Ann Surg Oncol.
2016;23(5):1508–14.
36. Alvarado MD, Mittendorf EA, Teshome M, et al.
SentimagIC: a non-inferiority trial comparing superpara-
magnetic iron oxide versus technetium-99m and blue dye in
the detection of axillary sentinel nodes in patients with early-
stage breast cancer. Ann Surg Oncol. 2019;26(11):3510–16.
37. Jedryka MA, Klimczak P, Kryszpin M, et al.
Superparamagnetic iron oxide: a novel tracer for senti-
nel lymph node detection in vulvar cancer. Int J Gynecol
Cancer. 2020;30(9):1280–4.
38. Sykes P, Eva L, van der Griend R, et al. Pathological pro-
cess has a crucial role in sentinel node biopsy for vulvar
cancer. Gynecol Oncol. 2019;153:292–6.
39. Oonk MH, van Hemel BM, Hollema H, et al. Size of
sentinel-node metastasis and chances on non-sentinel-
node involvement and survival in early stage vulvar can-
cer: results from GROINSS-V, a multicentre observational
study. Lancet Oncol. 2010;11(7):646–52. Runa ping
11
Sentinel lymph node mapping in cervical cancer

David Cibula and Martina Borcinova

CONTENTS
Sentinel lymph node mapping in the pelvis................................................................................................................................... 71
Lymphatic drainage from the cervix .................................................................................................................................... 71
Lymphatic drainage in the pelvis ......................................................................................................................................... 71
Pelvic dissection and SLN removal technique ..................................................................................................................... 71
SLN localization in the pelvis .............................................................................................................................................. 72
SLN detection rate................................................................................................................................................................ 73
Sensitivity of SLN for pelvic lymph node staging ............................................................................................................... 74
SLN biopsy in clinical management .............................................................................................................................................. 74
Acceptance of SLN in current routine practice .................................................................................................................... 74
International recommendations ............................................................................................................................................ 74
SLN frozen section and intraoperative triage of patients ..................................................................................................... 75
Pathologic ultrastaging and prognostic role of micrometastases ......................................................................................... 75
SLN in fertility-sparing treatment ........................................................................................................................................ 77
SLN and lower leg lymphedema .......................................................................................................................................... 78
Ongoing clinical trials on the safety of SLN biopsy only .................................................................................................... 78
Summary ........................................................................................................................................................................................ 78
References...................................................................................................................................................................................... 79

Sentinel lymph node mapping in the pelvis
Lymphatic drainage from the cervix
The cervix is an optimal anatomical structure for SLN use.
This organ is easily accessible transvaginally for a tracer appli-
cation, and, in early stages, the metastatic spread is almost
always lymphogenic. It is very unlikely that, given the rich
network of lymph nodes (LNs) in the pelvis, lymph drainage
would bypass the pelvic basin completely so that tumor cells
would be caught in the paraaortic region and all pelvic nodes
would remain negative. This is the main reason that pelvic LN
involvement is the most signifcant prognostic factor in early-
stage cervical cancer. And this is also why LN staging is such
a signifcant step in disease management.
As the cervix is the central pelvic organ, lymphatic drainage
is bilateral, and so each pelvic side must be staged separately.
A negative sentinel lymph node (SLN) on one side of the pelvis
does not guarantee LN negativity on the other side. If SLN is
detected only unilaterally, systematic pelvic lymph node dis-
section (PLND) must be performed on the other side.1
vessels on the pelvic side wall, do not only carry lymph from
the central pelvic organs. Their main purpose is to drain the
lymph from the lower extremities cranially to the paracaval
and paraaortic lymphatic systems. These trunks receive multi-
ple channels from the midline gynecologic organs. Two major
lymphatic trunks can be identifed on the lateral pelvic walls,
with multiple connections between them (https://surgery4u.eu/
video-41).2 A ‘superfcial’ trunk enters the pelvis through the
femoral canal; it runs on the ventral walls of the external iliac
vessels, receives lymphatic channels from parametria, and
continues on the ventral wall of the common iliac artery crani-
ally (Figure 11.1).
The ‘deep’ trunk enters the pelvis medially to the external
iliac vessels and creates a bundle of fatty lymphatic tissue
surrounding the obturator nerve. From the obturator fossa, it
continues cranially to the space between the superior gluteal
vessels and the psoas muscle, where it splits into two parts.
The frst one creates a deep common iliac branch that runs
between the psoas muscle and the common iliac vein, while
the deeper one, often overlooked, runs medially via a tun-
nel below the common iliac vessels to the presacral region
(Figure 11.2).

Lymphatic drainage in the pelvis Pelvic dissection and SLN removal technique
It is important to keep in mind that the lymphatic trunks, The goal of replacing systematic PLND by SLN biopsy
which are interrupted when LNs are harvested alongside large is to decrease postoperative morbidity, mainly the risk of

DOI: 10.1201/9781003255536-11 71
72
FIGURE 11.1 Superfcial lymphatic trunk on the right pelvic side wall.
EIA, external iliac artery; EIV, external iliac vein; IIV, internal iliac vein;
IIA, internal iliac artery; CIA, common iliac artery; CIV, common iliac
vein; GN, genitofemoral nerve; PM, psoas muscle; A, aortic bifurcation;
SLT, superfcial lymphatic trunk; EI, external iliac region; SCI, superf-
cial common iliac region. (From Ref. 2 with permission.)
FIGURE 11.2 Deep lymphatic trunk on the right pelvic side wall. EIV,
external iliac vein; EIA, external iliac artery; IIV, internal iliac vein; IIA,
internal iliac artery; CIA, common iliac artery; CIV, common iliac vein;
GN, genitofemoral nerve; PM, psoas muscle; A, lymphatic passage below
common iliac vessels; DLT, deep lymphatic trunk; OBT, obturator region;
II, internal iliac region; DCI, deep common iliac region. (From Ref. 2
with permission.)
Clinical Lymphatic Mapping
developing lower leg lymphedema. The technique of pelvic
space dissection and SLN removal must therefore correspond
with this intention. If too many SLNs are removed and both
main lymphatic trunks running on the pelvic side wall are
disrupted, this will inevitably compromise drainage from the
lower extremities. Pelvic dissection should thus be as consider-
ate as possible and aim to preserve the lymphatic channels that
do not transport lymph to the SLN. When tracer-marked lym-
phatic channels are visible through the peritoneum, pelvic dis-
section can be targeted to one region only. If the channels are
not visible, however, regions with the most frequent SLN pres-
ence should be approached frst, namely the interiliac (obtura-
tor) and external iliac regions, by opening the paravesical and
lateral pararectal spaces. Other retroperitoneal spaces in the
level II should only be dissected if SLNs have not been found.
SLN localization in the pelvis
A familiarity with the regions in which SLNs are most fre-
quently found is crucial for their successful detection. For clin-
ical practice, it is useful to divide the pelvic lymphatic basin
into two levels, with a horizontal boundary at the level of the
common iliac vessels’ bifurcation (Figure 11.3). It has been
proven in large retrospective studies that the localization of all
detected SLNs corresponds with the localization of positive
FIGURE 11.3 Anatomical distribution of SLN and positive SLN in the
pelvis in the SENTIX prospective trial (N = 395). SLN, sentinel lymph
node. (From data in Ref. 5.)
Sentinel lymph node mapping in cervical cancer 73

SLNs. The majority of SLNs are typically found in level I, cau- patients in the SENTIX trial, paraaortic localization of SLN
dally to the common iliac vessel bifurcation. In level II, two has not been reported in any case.5
main anatomical regions are usually described on both sides
of the pelvis: the external iliac region around the external iliac
SLN detection rate
vessels and the interiliac region, which is anatomically identi-
cal with the obturator region. In the frst large retrospective Pelvic LN staging must be performed separately for both pel-
analysis on SLN mapping by Rob in 183 patients, 91% of SLNs vic side walls. SLN detection frequency is therefore reported
were detected in level I.3 In a combined analysis of two pro- as side-specifc, or separately for unilateral and bilateral detec-
spective French studies (SENTICOL I and II) in 405 patients,4 tion. The success rate for bilateral detection oscillates in the lit-
83% of SLNs were found in level I, and in a recent paper from erature between 55% and 100%, depending on the tracer used,
the SENTIX prospective study in 351 patients, it was 90%.5 size of the cohort, and experience of the surgeon – but mainly
Both spaces are well-defned by stable anatomical landmarks.6 on the year of publication.3–5,7,12–16 Lower detection frequency
SLNs are detected much less frequently in level II, between was reported in older studies in patients with larger tumors.12,13
the vena cava bifurcation cranially and the common iliac In a literature review published in 2013, the difference in side-
bifurcation caudally. On this level, typically three regions specifc detection was 25% between the groups with tumor
are distinguished: the common iliac region around the com- sizes of <2 cm (n = 768) and ≥2 cm (n = 724).17 However, with
mon iliac vessels on both sides of the pelvis and one central better standardization of SLN biopsy techniques, the differ-
presacral space between the common iliac vessels. These ences in detection between smaller and larger tumors have
regions also have clearly defned anatomical borders.6 In the progressively decreased.5,15 In a large retrospective study cov-
SENTIX trial positive SLNs in level II were detected only in ering 350 patients with stages pT1a–pT2, the detection rate
4% of patients, with 1.8% of cases with isolated positive SLNs was compared in three groups of different tumor sizes: <2 cm,
in level II only.5 All these results prove the fact that cervical 2–3.9 cm, and ≥4 cm.18 Unilateral and bilateral detection was
cancer in most patients progresses predictably, and so the most achieved in 93% and 80% of patients, respectively, without any
attention should always be paid to exploring the two regions major differences among groups. Successful SLN detection,
below the common iliac bifurcation, where the majority of however, requires adjustment of the technique of tracer appli-
SLNs and positive SLNs are located. cation in large tumors.18,19 Tracer cannot be applied superf-
Diverse data can be found in the literature about the pres- cially and submucosally; rather, it needs to be inserted into the
ence of SLN in so-called ‘atypical’ localizations. This is residual cervical stroma behind the tumor using a long needle
mainly because in the past some authors considered even (Figure 11.4).
level II or parametria ‘atypical’ regions.4,7,8 However, the pres-
ence of SLN in level II, including the presacral region, should
be considered typical for cervical cancer. Also, the parametria,
which are located between the cervix and pelvic side walls, are
a typical area for localization of cervical lymphatic drainage.
Back in 2000, Benedetti-Panici, who submitted isolated para-
metria for pathological ultrastaging, found LNs in the ventral
parametria in 12% and in lateral parametria in 38% of cases.9
It is likely that the detection of LNs in the parametria is seri-
ously underreported. Parametria are usually an integral part of
the surgical specimen after radical hysterectomy. Also, due to
the leak of color, fuorescent tracer, or radiation from the cer-
vix to the adjacent tissue, our ability to reliably detect subtle
parametrial LNs as SLNs is limited. This fact may gain impor-
tance in the future if simple hysterectomy is performed instead
of radical and, at the same time, systematic PLND is replaced
by SLN biopsy only. A combination of these recent trends may
increase the risk that positive parametrial LNs will be left in
situ and the patient will not receive adjuvant treatment if the
SLN is negative.
It seems, however, that another factor in the more frequent
atypical SLN localization in the past, mainly in the paraaortic
region, was the SLN biopsy learning curve. The more experi-
ence with SLN biopsy the surgeon has, the smaller the risk that
SLN is not identifed within the seven standard pelvic regions.
This historical trend is apparent in two consecutive studies
from France. While the paraaortic localization of SLN was
reported in 5% of patients in the earlier study, it was described
in only 1.5% of patients in a combined analysis of both tri- FIGURE 11.4 Tracer application into the residual cervical stroma in
als.10,11 In a recent paper from a large prospective cohort of 395 larger tumors.
74
Overall, it appears that the main factor for successful bilat-
eral detection is the learning curve. A signifcantly higher
detection rate was reported in both multicenter prospective
studies, SENTIX and SENTICOL, in centers with a higher
number of patients.4,5 More experience is likely the reason why
the more recent study SENTICOL II reached a better detec-
tion rate in comparison with the older study SENTICOL I.4
The SENTIX study, which commenced in 2016, is the frst
multicenter trial that recently reported a bilateral detection
rate higher than 90%.5 Data from 395 patients were analyzed.
The success rate of the detection was unaffected by tumor
size, tumor stage, or body mass index. On the other hand,
an interesting factor, which worsened the detection success
in both prospective studies, was the higher age of patients,
determined as 60 years in the SENTIX study and ≥70 years
in the SENTICOL study.4,5 The median number of removed
SLNs in large studies consistently oscillates between two and
three.5,10,15
Sensitivity of SLN for pelvic lymph node staging
Sensitivity is the key parameter in assessing the reliability of
the SLN concept for pelvic LN staging. It indicates the portion
of patients in whom SLN status is negative and yet there is a
metastasis detected in other pelvic LNs. Therefore, sensitivity
can only be assessed when SLN is combined with systematic
PLND.
Similarly, the detection rates in earlier studies presented a
lower sensitivity of SLN biopsy in patients with larger tumors.
In the frst multicenter study from Germany, the sensitivity
was 91% in tumors <2 cm, while only 73% in tumors ≥2 cm.13
A review of 15 publications with more than 50 cases from
2013 showed that tumors smaller than 2 cm had a sensitivity
of 100%, whereas in larger tumors it was 10% lower.20 With
growing experience and improved SLN biopsy technique stan-
dards, the signifcance of tumor size decreases and the number
of patients with falsely negative SLNs constantly stays very
low. In the frst French prospective study, SENTICOL I, in
which SLN biopsy was followed by a systematic PLND, the
sensitivity in patients with tumors <4 cm and bilateral SLN
detection reached 100%.7 In the largest retrospective study so
far, in which there were 645 patients enrolled and disease stage
varied from IA1 to IIB, the sensitivity reached 97%.21
Taking into consideration such a consistently reported low
SLN false-negative rate for pelvic LN staging, one could
take the safety of SLN biopsy in cervical cancer for granted.
There are, however, a few caveats in the available evidence.
First, the sensitivity is very high, partially thanks to the fact
that the presence of any type of metastasis in SLN, includ-
ing micrometastases or isolated tumor cells, is considered a
positive fnding. The classifcation of metastases was adopted
from breast cancer, and it recognizes three groups based on
size of metastasis as follows: macrometastases (MAC) >2 mm,
micrometastases (MIC) >0.2 mm up to 2 mm, and isolated
tumor cells (ITCs) up to 0.2 mm.
As an example, in a large retrospective study, metastatic
involvement was detected in non-SLN pelvic LNs in 23
cases (3.6%) in whom only MIC or ITC were found in SLN
by ultrastaging.22 These cases were not considered false
Clinical Lymphatic Mapping
negative despite the detection of MAC in non-SLN, but only
MIC or ITC in SLN. A conventional SLN evaluation (with-
out ultrastaging) would fail to detect pelvic LN involvement
in these patients, which would cause a drop of sensitivity
to 80% and make SLN biopsy without additional PLND an
unreliable and unsafe method of LN staging. Second, there
has always been a methodological bias when comparing SLN
and non-SLN status. While SLNs are mostly assessed using
an ultrastaging protocol, other pelvic LNs are processed con-
ventionally. So far, only a few studies on a limited number
of patients assessed both SLNs and all other pelvic LNs by
ultrastaging.23–27 Although the risk of MIC in non-SLNs with
negative SLNs is low, all available evidence comes from a
cumulative group of 90 patients in which the methodology
of pathological evaluation was not identical and the risk of
LN involvement was low (12 cases). These limitations in our
knowledge justify the current ongoing trials, which both are
designed to address the safety of the replacement of PLND
by SLN biopsy only.
SLN biopsy in clinical management
Acceptance of SLN in current routine practice
Even though there is robust evidence from retrospective stud-
ies about the high SLN detection rate and high sensitivity of
SLN ultrastaging for pelvic LN staging, results from several
surveys indicate that the acceptance of SLN biopsy in routine
clinical practice is still quite low.28
For example, in a 2016 survey of 63 German institutions, SLN
biopsy was reported to be performed in vulvar cancer in 73% of the
institutions, but in cervical cancer only in 29%.29 And only 11%
of the centers performed SLN biopsy without additional PLND.
In an ESGO survey from 2018, which provided answers from 566
respondents, SLN biopsy in cervical cancer was reported to be
used in stage T1a1 by 17%, in stage T1a2 by 19%, and in stage
T1b1 in tumors <2 cm by just 9% of the respondents.30
There are probably multiple reasons for this apparent hesi-
tation to avoid performing traditional systematic PLND and
rely on the SLN concept. First of all, LN involvement is the
most signifcant prognostic factor for an adjuvant treatment
decision in cervical cancer patients. While the prognosis in
patients with positive LNs after a standard treatment includ-
ing adjuvant radiotherapy is still very good, leaving positive
LN without administering adjuvant treatment likely has fatal
consequences for the patient. Second, the majority of the data
on SLN biopsy in cervical cancer comes from retrospective
studies, which do have their limitations. This may be why
many surgeons keep on performing systematic PLND – until
the oncological safety of SLN biopsy without systemic PLND
has been proven in prospective studies.
International recommendations
Current international recommendations for the clinical man-
agement of patients with cervical cancer have already opened
the possibility of performing SLN biopsy only, without sys-
tematic PLND, but they vary in their indications.
Sentinel lymph node mapping in cervical cancer
European guidelines that were jointly developed by three
European medical societies (European Society Gynecologic
Oncology-European Society for Radiotherapy and Oncology-
European Society of Pathology [ESGO-ESTRO-ESP]) con-
sider SLN biopsy alone suffcient only in stage IA;31 SLN
biopsy is suggested in patients with stage T1a1 LVSI–positive
or T1a2 LVSI–negative patients, and it is recommended in
T1a2 LVSI–positive patients. On the other hand, in patients
with stage T1b, SLN biopsy is highly recommended, though
it should be performed in combination with systematic PLND.
The aim of SLN biopsy in these patients is not to avoid sys-
tematic staging, but to detect selected SLN for intraoperative
assessment and increase the detection of smaller metasta-
ses thanks to SLN ultrastaging. Published guidelines of the
European Society for Medical Oncology are in agreement
with the European guidelines,32 as well as guidelines of the
Spanish Society of Medical Oncology.33
In National Comprehensive Cancer Network (NCCN)
guidelines, SLN biopsy is considered an alternative to PLND
in all tumors ≤4 cm except for stage IA1 without LVSI.1,34
These guidelines emphasize that the best mapping results are
obtained in tumors below 2 cm and that side-specifc LN stag-
ing requires performance of a systematic PLND on the pelvic
side where SLNs were not found.
Other societies worldwide also adopted the NCCN guide-
lines, such as the International Gynecologic Cancer Society,35
or reference both NCCN and European guidelines, such as
Cancer Australia.36 Published guidelines of individual soci-
eties of Asian states are varying. In general, societies are in
agreement that SLN biopsy represents an option to PLND up to
stage T1a2.37,38 In contrast, the Korean Society of Gynecologic
Oncology does not cover SLN biopsy in the guidelines and rec-
ommend PLND as the standard of care for all disease stages.39
SLN frozen section and intraoperative
triage of patients
One of the advantages of the SLN concept is that it provides
the opportunity to identify a small number of LNs at the high-
est risk of metastatic involvement and send these for intra-
operative pathological assessment. The literature, however, is
discrepant when it comes to the reliability of intraoperative
SLN assessment.40 The frozen section technique is fairly uni-
form and usually involves the assessment of one slice from
each SLN or from each half of one SLN. A higher number of
sections would prolong the surgery, and it could result in the
loss of a substantial part of the SLN tissue for further ultra-
staging. Therefore, the key factor that infuences the sensitiv-
ity of the frozen section technique is the quality of the fnal
SLN processing. The less intensive the ultrastaging protocol,
the lower the chance for detecting smaller metastases. We
can hypothesize that this phenomenon explains why some,
mostly smaller, studies reported a fairly low false negativ-
ity of the frozen section technique for the fnal pelvic LN
status.41
More recent studies, however, consistently showed that fro-
zen section assessment fails to detect small metastases. In the
French prospective study, SLN frozen section was performed
in 102 patients, and it failed to detect 70% of patients with
75
MAC (4/9), all MIC (4/4), and all ITC (9/9).42 A Canadian
study on 211 patients reported 10 of 13 cases with positive
SLN found falsely negative by frozen section, including 7
MIC, 2 ITC cases, and 1 MAC with a size of 2.9 mm.43 In a
large retrospective cohort of 309 cases, frozen section identi-
fed 67% of cases with MAC (16/24), but only 14% with MIC
(2/14) and 0% with ITC (0/10).44 Similar results were con-
frmed recently from the SENTIX prospective study, which,
for the frst time in cervical cancer, included a central pathol-
ogy quality control algorithm.45 In the group of 395 patients,
MAC, MIC, and ITC were detected by frozen section in 72%
(21/29), 10% (19/21), and 0% (0/12), respectively.5 The sensi-
tivity of frozen section assessment for fnal SLN status reached
76% for MAC and 46% for N1 (MAC and MIC together). In
summary, there is ample evidence that frozen section does not
detect almost any MIC and ITC, but even more importantly, it
also fails to detect about 30% of MAC, usually slightly above
2 mm in size.
The main purpose of SLN frozen section is to get an oppor-
tunity to change the management during the course of the sur-
gery. If positive SLNs are found intraoperatively, any radical
procedure, including systematic PLND and radical hysterec-
tomy, can be abandoned and the patient can be referred for
defnitive chemoradiation. The goal is to decrease extra mor-
bidity due to the combination of radical surgery and pelvic
radiotherapy. A one-step approach is even more important in
fertility-sparing management (trachelectomy or conization).
This management is recommended by the European guide-
lines,46 which claim that one key objective in the management
of early-stage disease should be avoiding combined treat-
ment.47 A one-step protocol like this is obviously limited by
the high false-negative rate of intraoperative SLN evaluation.44
Both the clinician and the patient must be aware that about
50% of LN metastases will be diagnosed only after the surgery
by fnal ultrastaging, and therefore, a combined treatment can-
not be avoided in these cases.
Pathologic ultrastaging and prognostic
role of micrometastases
As discussed earlier, it is generally accepted that SLN biopsy
increases the accuracy of pelvic LN staging.43,48,49 More fre-
quent detection of positive LNs is a result of an intensive
pathological assessment of a small number of SLNs. However,
pathologic ultrastaging is a demanding and time-consuming
technique, which cannot be applied to all pelvic LNs after sys-
tematic PLND, even though it increases the probability of fnd-
ing metastases, especially smaller ones.
Moreover, the role of SLN ultrastaging is still controversial.
The criticism stems mostly from experiences in other tumors,
predominantly breast cancer, in which the presence of MIC
was not confrmed to be a signifcant prognostic factor. It is,
however, important to emphasize that experiences from one
tumor cannot be fully extrapolated to a different one. While in
breast cancer there is an array of different prognostic factors,
in cervical cancer, LN involvement is the decisive factor for
adjuvant treatment. Hematogenous and lymphogenous spread
is typical for breast cancer, while cervical cancer in the early
stages spreads solely to pelvic lymph nodes.
76
Critical arguments assume that ultrastaging detects only
metastases smaller than 2 mm, MIC and ITC, whose prog-
nostic signifcance has not yet been conclusively confrmed.
However, this is not entirely true. Let us use a comparison
between frozen section and ultrastaging as an analogy. The
intensity of pathological assessment by frozen section is fairly
similar to a standard assessment of pelvic LN. It has been
well documented that ultrastaging is able to detect up to 30%
more MAC than frozen section. That is also a reason why SLN
biopsy is recommended as the method to increase the accuracy
of detection of positive pelvic LNs in the management of all
early stages in combination with PLND.
Nonetheless, a recent review article demonstrated how cur-
rent approaches to ultrastaging protocols vary and how insuf-
fcient the protocol descriptions that have appeared in the
literature were.50 Among studies that reported results from
SLN biopsy, 27% (27/97) did not give any details about the
ultrastaging protocol and, even more surprisingly, SLNs were
completely processed in only 8 of them! Even if information
about intervals between slices and the use of immunohisto-
chemistry (IHC) is given, the key parameter is the number
of levels (series), and this is mostly absent. It is important to
emphasize that the number of levels is a key parameter for
ultrastaging, since if only one or two levels are processed com-
pletely, which is frequently the case, the remaining SLN tissue
is left in paraffn unprocessed.
Minimal requirements for the description of the protocol
include the following items: 1) approach to gross process-
ing (slicing and thickness of slices), 2) number and distance
between levels (series), 3) number of sections (slides) per level,
and 4) use of IHC. A complete processing of all SLNs at a
few micrometer intervals would result in hundreds of slides
per node, which would not be sustainable in routine practice.
So, it is necessary to fnd a reasonable compromise between
sensitivity, expense, and labor intensity. Recently a protocol
was suggested that is designed to pick up the majority of all
MICs (Figure 11.5).51 This protocol consists of slicing SLNs at
2-mm intervals and cutting the node into four sections (slides)
at 200-μm levels (one hematoxylin-eosin [H&E], one IHC
pan-cytokeratin antibody, and two unstained sections that can
be used for assessing whether the tumor focus is becoming
larger) (Figure 11.5b). It results in approximately 20 pairs of
H&E and IHC-stained slides per SLN. Such a protocol is more
intensive than the ‘average’ protocol described in the literature
(Figure 11.5a), and it represents a compromise that enables the
detection of the majority of MAC and MIC.
It has been consistently shown that pathological ultrastag-
ing detects about 5%–10% of patients with early-stage cervical
cancer with only MIC in their SLN.5,15,21,52 Numerous papers
presented data on the prevalence of MIC; very few of them,
however, evaluated the impact of MIC on the prognosis, and
the data are not consistent. For the frst time, the potential
signifcance of MIC was suggested by the French group.23 In
a case-control study, they compared a group of 26 recurred
patients with the same number of matched controls without
recurrence. The relative risk of recurrence was 2.44 (p < 0.01)
for MIC and 2.64 (p < 0.01) for LVSI. Since the frst French
publication, another six retrospective studies have presented
data about the risk of recurrence in patients with MIC; all but
Clinical Lymphatic Mapping
one showed a negative impact on the prognosis.23,53–58 In the
largest retrospective study published so far, data from 645
cases were collected from seven institutions.21 All patients had
an SLN biopsy followed by PLND, and SLNs were processed
by pathologic ultrastaging. Both MAC and MIC were associ-
ated with similar and signifcantly decreased overall survival
(MAC: hazard ratio [HR] = 6.85; 95% confdence interval
[CI]: 2.59–18.05; MIC: HR = 6.86; 95% CI: 2.09–22.61). The
only retrospective study that failed to show MIC as a negative
prognostic factor was a multi-institutional retrospective study,
which submitted tissue blocks for reevaluation in a group of
129 patients who were LN-negative at the time of primary
treatment.57 Any immunoreactive tumor cells were classifed
as MIC, and the results indicated that the presence of MIC was
not associated with a negative outcome. There were, however,
only 11 recurrences in this group (8.5%), and patients with
MIC were more likely to receive adjuvant radiotherapy than
those with negative LNs (39% vs. 18%). Recently, data from
two prospective French studies (SENTICOL I and II) were
analyzed for the impact of MIC on prognosis.52 Positive LNs
were found in 41 out of 321 patients (13%), and 22 (54%) of
them were low-volume metastases (MIC or ITC). The authors
did not fnd any negative impact of the presence of MIC on
disease-free survival. It should be emphasized that the gen-
eral prognosis of patients was superior to any of the previous
prospective trials, with only 6.5% of recurrences at 3 years,
and neither low-volume disease nor the presence of MAC was
associated with lower disease-free survival.
Multiple reasons may explain discrepant results in the lit-
erature. First, the risk of recurrence is low in the early stages
of cervical cancer, even in patients with positive pelvic LN,
so it requires a large cohort to demonstrate any signifcant
impact on the prognosis. Second, and more importantly, in the
absence of any universal protocol for SLN ultrastaging, patho-
logic processing is so different that such discrepancies inevi-
tably affect the accuracy of detection of not only MIC but also
small MAC. Third, the designs of the studies differed consid-
erably. In some of them, SLNs were prospectively assessed by
ultrastaging, while other pelvic LNs were processed by stan-
dard H&E evaluation. In others, tissue blocks from all pelvic
LNs were reevaluated retrospectively from patients who were
LN-negative at the time of the treatment. There are substantial
differences in cohort sizes, disease stages, and the proportion
of cases that received adjuvant therapy. And fnally, studies
differed substantially in the strategy of adjuvant treatment, and
some of them did not even report what proportion of patients
with MAC or MIC received adjuvant radiotherapy.
Three ongoing international prospective trials planning
to accrue 600, 475, and 500 patients who will undergo SLN
biopsy only should bring new evidence on the signifcance of
MIC for the prognosis. Estimating a 10% rate of MIC in SLNs,
these studies should result in cumulative data on about 150
cases with MIC. However, data on the oncological outcome
will not be available until 2022 and 2027. Furthermore, many
of the patients with MIC will likely receive adjuvant treatment,
so any comparison with the LN-negative group will be biased.
Concerning ITC, available data are even more inconclu-
sive, and we must accept the fact that their impact on the
prognosis will likely never be proven. The main reason is that
Sentinel lymph node mapping in cervical cancer 77

FIGURE 11.5 Comparison between a commonly used ultrastaging protocol composed of two levels only (a) and a suggested protocol processing
SLN tissue completely (b). FFPE, formalin-fxed, paraffn-embedded; HE, hematoxylin-eosin stain; IHC, immunohistochemistry. (From Ref. 39 under
Creative Commons license.)

pathological processing will never be so intensive that it will

be able to reliably detect all ITCs – ITC detection will always
be relative to the protocol for ultrastaging.
In summary, although available data are inconsistent, for
the safety of our patients, it is reasonable to consider the pres-
ence of MIC as a negative prognostic factor. We should apply
the same strategy to MIC patients as for patients with MAC,
at least until the data from ongoing prospective trials proves
that patients with MIC have an equal prognosis to LN-negative
patients, without adjuvant treatment.
SLN in fertility-sparing treatment
The negative status of pelvic LNs is a key prerequisite for
fertility-sparing management. Metastatic LN involvement
shifts the patient to a high-risk group in which adjuvant treat-
ment is indicated. With the current treatment options, we are
unable to offer a safe option for fertility-sparing treatment to
LN-positive patients. The only available alternative is the pres-
ervation of the ovaries for assisted reproductive techniques
and surrogate pregnancy.
78
Surgical LN staging should always be the frst step in the
fertility-sparing algorithm. The advantages of SLN biopsy are
even more important in those cases than in nonfertility-sparing
management. Dispatching SLN for ultrastaging increases
the chances of detecting small metastases and improves the
safety of fertility-sparing management. In cases with a posi-
tive result, intraoperative SLN assessment allows one to step
away from the planned fertility-sparing procedure and instead
perform paraaortic LN staging concomitantly with the trans-
position of ovaries.
Given the fact that fertility-sparing candidates are patients
with small tumors, the frequency of LN positivity in this
population is fortunately low. Despite that, the result of frozen
section can be falsely negative, and the presence of a small-
size metastasis can be reported as late as with defnite pathol-
ogy.59 It is important to inform the patient about such an option
before the surgery.
SLN and lower leg lymphedema
Lower leg lymphedema (LLL) is the most prevalent postopera-
tive morbidity following the treatment of gynecologic cancer.
Lymphedema is a manifestation of lymphatic system insuff-
ciency and deranged lymph transport.29 It is characterized by
the swelling of one or both lower limbs caused by excess accu-
mulation of water, plasma proteins, extravascular blood cells,
and parenchymal/stromal cell products in the limb tissues.60
LLL signifcantly decreases the quality of life of gyneco-
logic cancer survivors, negatively affecting daily activities
as well as their social and sexual life.61 Since the worldwide
median of cervical cancer diagnosis is in the patients’ mid-
to-late 40s, minimizing the long-term risk of LLL in this
relatively young population is of particular importance, and
it is the main reason for an effort to replace PLND by SLN
biopsy only.62
The most signifcant risk factor for LLL development after
cervical cancer treatment is the performance of PLND.63–66
Radical hysterectomy (RH) followed by PLND was described
to have an LLL incidence ranging between 20% and 56%.67–72
It was shown that the extent of PLND and the number of
removed LNs are factors directly related to the risk of LLL
development; however, the critical number of removed LNs
described in the literature varies between 10 and 31.72–77
Multiple randomized studies have demonstrated that the
implementation of SLN biopsy reduces the risk of LLL devel-
opment after gynecologic cancer treatment, including the
treatment of endometrial or vulvar cancer.78–81 However, data
on lymphedema in cervical cancer patients after SLN biopsy
only are still scarce.
In the prospective pilot paper of Niikura et al.,82 new symp-
tomatic LLL was identifed in 2 (8.7%) of the 23 cervical can-
cer patients who underwent RH with SLN biopsy only and in
5 (42%) of 12 patients who underwent RH with PLND. A ret-
rospective review of 167 cervical cancer patients showed that
among 70 patients after RH with SLN biopsy only, none of
them developed LLL as compared to 13.4% of patients who
underwent RH with full PLND.83 Such a promising outcome
was confrmed by another retrospective study in which lymph-
edema was identifed in 22.4% (15/ 67) of patients in the PLND
Clinical Lymphatic Mapping
group as compared to no occurrence among 139 patients after
SLN removal only.84 Finally, the SLN-only group of cervical
cancer patients in the prospective randomized SENTICOL II
study also self-reported less severe symptoms when compared
to the group who underwent full PLND.85
All available literature, mostly based on retrospective data,
consistently document that the risk of LLL is reduced to a min-
imum after RH in combination with SLN biopsy. Currently
ongoing prospective trials should bring fnal evidence to con-
frm these expectations.
Ongoing clinical trials on the
safety of SLN biopsy only
Three prospective trials are currently registered at clinicaltrials.
gov with safety of SLN biopsy in cervical cancer treatment
as the primary endpoint and have been actively recruiting
patients. The frst study, SENTIX (NCT02494063), was reg-
istered in July 2015 and is a prospective observational single-
arm study with the aim of enrolling 600 cases with tumors
≤4 cm, who will undergo SLN biopsy only.44 Enrollment is
estimated to complete by the end of 2020, with the survival
data maturing 2 years later. A Chinese trial was registered by
Sun Yat-Sen University in December 2015 (NCT02642471).
It is enrolling patients with tumors up to 3 cm and randomiz-
ing separately those with negative or positive SLN by frozen
section to four arms, with and without additional PLND. An
update in 2020 reported that the target enrollment has been
increased from 800 to 1080 cases, with the study comple-
tion date remaining December 2022. Another randomized
trial, ARGACY/GINECO (NCT03386734), was registered
in 2017 by a French group, with the aim of randomizing 950
patients with tumors ≤4 cm into two arms: 1) SLN in combi-
nation with PLND and 2) SLN biopsy only, with estimated
completion in May 2026.86 These three trials should bring
practice-changing evidence about the safety of the SLN con-
cept in cervical cancer, if, hopefully, they deliver affrmative
results.
Summary
Our knowledge about the SLN concept in cervical cancer has
grown substantially since the frst edition of this book. The
technique of tracer application and SLN detection in the pelvis
is currently well standardized, and we have robust data on the
SLN detection rate, as well as on the most frequent localiza-
tion of SLN in the pelvis. We have gathered data from many
retrospective studies showing that SLN biopsy signifcantly
increases the sensitivity of pelvic LN staging thanks to inten-
sive pathologic processing, which is able to detect more metas-
tases of small dimensions, which would not be detected by a
conventional pathological assessment. We have confrmed that
SLN biopsy can be consistently used in all patients with early-
stage disease, irrespective of tumor size or patient body mass
index (BMI). We know that SLN frozen section can be used to
adjust the management intraoperatively, but we have to accept
that approximately 50% of positive LNs will be detected as
late as by fnal ultrastaging. Finally, available data confrm
Sentinel lymph node mapping in cervical cancer
that replacing PLND with SLN biopsy can nearly eradicate
the occurrence of LLL.
However, after 20 years of clinical research, we still have
some questions that remain unanswered. Discussions continue
about the signifcance of micrometastases for the prognosis
because the evidence is not conclusive and is based on very
small numbers of recurrences in these cases. Solving this puz-
zle will also enable standardization of an international ultrast-
aging protocol. Foremost, we can expect to soon get evidence
from prospective studies about the safety of replacing tradi-
tional systematic PLND with SLN biopsy.
REFERENCES
1. Wui-Jin K, Nadeem RA-R, Sarah B, et al. Cervical can-
cer, version 3.2019, NCCN clinical practice guidelines in
Oncology. J Natl Compr Canc Netw. 2019;17(1):64–84.
2. Cibula D, Abu-Rustum NR. Pelvic lymphadenectomy in
cervical cancer – surgical anatomy and proposal for a new
classifcation system. Gynecol Oncol. 2010;116(1):33–7.
3. Rob L, Strnad P, Robova H, et al. Study of lymphatic map-
ping and sentinel node identifcation in early stage cervical
cancer. Gynecol Oncol. 2005;98(2):281–8.
4. Balaya V, Bresset A, Guani B, et al. Risk factors for failure
of bilateral sentinel lymph node mapping in early-stage cer-
vical cancer. Gynecol Oncol. 2020;156(1):93–9.
5. Cibula D, Kocian R, Plaikner A, et al. Sentinel lymph node
mapping and intraoperative assessment in a prospective,
international, multicentre, observational trial of patients
with cervical cancer: the SENTIX trial. Eur J Cancer.
2020;137:69–80.
6. Cibula D, Abu-Rustum NR. Classifcation system for pel-
vic lymphadenectomy in cervical cancer. Gynecol Oncol.
2010;118(1):94–5.
7. Lecuru F, Mathevet P, Querleu D, et al. Bilateral nega-
tive sentinel nodes accurately predict absence of lymph
node metastasis in early cervical cancer: results of the
SENTICOL study. J Clin Oncol. 2011;29(13):1686–91.
8. Frumovitz M, Euscher ED, Deavers MT, et al. ‘Triple injec-
tion’ lymphatic mapping technique to determine if parame-
trial nodes are the true sentinel lymph nodes in women with
cervical cancer. Gynecol Oncol. 2012;127(3):467–71.
9. Benedetti-Panici P, Maneschi F, D’Andrea G, et al. Early
cervical carcinoma. Cancer. 2000;88(10):2267–74.
10. Bats AS, Mathevet P, Buenerd A, et al. The sentinel node
technique detects unexpected drainage pathways and
allows nodal ultrastaging in early cervical cancer: insights
from the multicenter prospective SENTICOL study. Ann
Surg Oncol. 2013;20(2):413–22.
11. Balaya V, Mathevet P, Magaud L, et al. Predictive factors
of unexpected lymphatic drainage pathways in early-stage
cervical cancer. Gynecol Oncol. 2019;154(1):102–9.
12. Wydra D, Sawicki S, Wojtylak S, et al. Sentinel node iden-
tifcation in cervical cancer patients undergoing transperi-
toneal radical hysterectomy: a study of 100 cases. Int J
Gynecol Cancer. 2006;16(2):649–54.
13. Altgassen C, Hertel H, Brandstadt A, et al. Multicenter
validation study of the sentinel lymph node concept
in cervical cancer: AGO Study Group. J Clin Oncol.
2008;26(18):2943–51.
79
14. Slama J, Dundr P, Dusek L, et al. Sentinel lymph node
status in patients with locally advanced cervical cancers
and impact of neoadjuvant chemotherapy. Gynecol Oncol.
2012;125(2):303–6.
15. Salvo G, Ramirez PT, Levenback CF, et al. Sensitivity and
negative predictive value for sentinel lymph node biopsy in
women with early-stage cervical cancer. Gynecol Oncol.
2017;145(1):96–101.
16. Beavis AL, Salazar-Marioni S, Sinno AK, et al. Sentinel
lymph node detection rates using indocyanine green in
women with early-stage cervical cancer. Gynecol Oncol.
2016;143(2):302–6.
17. Rob L, Robova H, Halaska MJ, et al. Current status of sen-
tinel lymph node mapping in the management of cervical
cancer. Expert Rev Anticancer Ther. 2013;13(7):861–70.
18. Dostalek L, Zikan M, Fischerova D, et al. SLN biopsy in
cervical cancer patients with tumors larger than 2cm and
4cm. Gynecol Oncol. 2018;148(3):456–60.
19. Cibula D, Kuzel D, Slama J, et al. Sentinel node (SLN)
biopsy in the management of locally advanced cervical can-
cer. Gynecol Oncol. 2009;115(1):46–50.
20. Rob L, Robova H, Chmel R, et al. Surgical options in early
cervical cancer. Int J Hyperthermia. 2012;28(6):489–500.
21. Cibula D, Abu-Rustum NR, Dusek L, et al. Bilateral ultra-
staging of sentinel lymph node in cervical cancer: lower-
ing the false-negative rate and improving the detection of
micrometastasis. Gynecol Oncol. 2012;127(3):462–6.
22. Cibula D, Abu-Rustum NR, Fischerova D, et al. Surgical
treatment of ‘intermediate risk’ lymph node negative cervi-
cal cancer patients without adjuvant radiotherapy: a retro-
spective cohort study and review of the literature. Gynecol
Oncol. 2018;151(3):438–43.
23. Marchiole P, Buenerd A, Benchaib M, et al. Clinical sig-
nifcance of lympho vascular space involvement and lymph
node micrometastases in early-stage cervical cancer: a
retrospective case-control surgico-pathological study.
Gynecol Oncol. 2005;97(3):727–32.
24. Barranger E, Cortez A, Commo F, et al. Histopathological
validation of the sentinel node concept in cervical cancer.
Ann Oncol. 2004;15(6):870–4.
25. Popa I, Plante M, Renaud MC, et al. Negative sentinel
lymph node accurately predicts negative status of pelvic
lymph nodes in uterine cervix carcinoma. Gynecol Oncol.
2006;103(2):649–53.
26. Okamoto S, Niikura H, Nakabayashi K, et al. Detection of
sentinel lymph node metastases in cervical cancer: assess-
ment of KRT19 mRNA in the one-step nucleic acid amplif-
cation (OSNA) method. Gynecol Oncol. 2013;130(3):530–6.
27. Cibula D, Zikan M, Slama J, et al. Risk of micrometasta-
ses in non-sentinel pelvic lymph nodes in cervical cancer.
Gynecol Oncol. 2016;143(1):83–6.
28. Vercellino GF, Erdemoglu E, Lichtenberg P, et al. A GCIG
international survey: clinical practice patterns of sentinel
lymph node biopsies in cervical cancer. Arch Gynecol
Obstet. 2019;300(1):191–9.
29. The diagnosis and treatment of peripheral lymphedema:
2016 consensus document of the international society of
lymphology. Lymphology. 2016;49(4):170–84.
30. Dostalek L, Avall-Lundqvist E, Creutzberg CL, et al. ESGO
survey on current practice in the management of cervical
cancer. Int J Gynecol Cancer. 2018;28(6):1226–31.
80
31. Cibula D, Potter R, Planchamp F, et al. The European
Society of Gynaecological Oncology/European Society
for Radiotherapy and Oncology/European Society of
Pathology guidelines for the management of patients with
cervical cancer. Virchows Archiv. 2018;472(6):919–36.
32. Marth C, Landoni F, Mahner S, et al. Cervical cancer:
ESMO Clinical Practice Guidelines for diagnosis, treatment
and follow-up. Ann Oncol. 2017;28(Suppl 4):iv72–iv83.
33. de Juan A, Redondo A, Rubio MJ, et al. SEOM clinical
guidelines for cervical cancer (2019). Clin Transl Oncol.
2020;22(2):270–8.
34. NCCN guidelines version 2.2020; 2020. Available from:
www.nccn.org/professionals/physician_gls/pdf/cervical.pdf.
35. International Gynecologic Cancer Society. Available from:
https://igcs.org/education-resources/clinical-resources/.
36. Cancer Australia. Available from: www.canceraustralia
.gov.au/affected-cancer/cancer-types/cervical-cancer/
health-professionals.
37. National Health Commission of the People’s Republic of
C. Chinese guidelines for diagnosis and treatment of cer-
vical cancer 2018 (English version). Chin J Cancer Res.
2019;31(2):295–305.
38. Ebina Y, Mikami M, Nagase S, et al. Japan Society of
Gynecologic Oncology guidelines 2017 for the treatment of
uterine cervical cancer. Int J Clin Oncol. 2019;24(1):1–19.
39. Lim MC, Lee M, Shim SH, et al. Practice guidelines for
management of cervical cancer in Korea: a Korean Society
of Gynecologic Oncology Consensus Statement. J Gynecol
Oncol. 2017;28(3):e22.
40. Holman LL, Levenback CF, Frumovitz M. Sentinel lymph
node evaluation in women with cervical cancer. J Minim
Invasive Gynecol. 2014;21(4):540–5.
41. Martinez A, Mery E, Filleron T, et al. Accuracy of intra-
operative pathological examination of SLN in cervical can-
cer. Gynecol Oncol. 2013;130(3):525–9.
42. Bats AS, Buenerd A, Querleu D, et al. Diagnostic value of
intraoperative examination of sentinel lymph node in early
cervical cancer: a prospective, multicenter study. Gynecol
Oncol. 2011;123(2):230–5.
43. Roy M, Bouchard-Fortier G, Popa I, et al. Value of senti-
nel node mapping in cancer of the cervix. Gynecol Oncol.
2011;122(2):269–74.
44. Dostalek L, Slama J, Fisherova D, et al. Impact of sentinel
lymph node frozen section evaluation to avoid combined
treatment in early-stage cervical cancer. Int J Gynecol
Cancer. 2020;30(6):744–8.
45. Nemejcova K, Kocian R, Kohler C, et al. Central pathol-
ogy review in SENTIX, a prospective observational inter-
national study on sentinel lymph node biopsy in patients
with early-stage cervical cancer (ENGOT-CX2). Cancers.
2020;12(5).
46. Cibula D, Potter R, Planchamp F, et al. The European
Society of Gynaecological Oncology/European Society
for Radiotherapy and Oncology/European Society of
Pathology guidelines for the management of patients with
cervical cancer. Radiother Oncol. 2018;127(3):404–16.
47. Cibula D, Potter R, Planchamp F, et al. The European
Society of Gynaecological Oncology/European Society
for Radiotherapy and Oncology/European Society of
Pathology guidelines for the management of patients with
cervical cancer. Int J Gynecol Cancer. 2018;28(4):641–55.
Clinical Lymphatic Mapping
48. Bats AS, Clement D, Larousserie F, et al. Sentinel lymph
node biopsy improves staging in early cervical cancer.
Gynecol Oncol. 2007;105(1):189–93.
49. Brar H, Hogen L, Covens A. Cost-effectiveness of sentinel
node biopsy and pathological ultrastaging in patients with
early-stage cervical cancer. Cancer. 2017;123(10):1751–9.
50. Dundr P, Cibula D, Nemejcova K, et al. Pathologic proto-
cols for sentinel lymph nodes ultrastaging in cervical can-
cer. Arch Pathol Lab Med. 2020;144(8):1011–20.
51. Cibula D, McCluggage WG. Sentinel lymph node (SLN)
concept in cervical cancer: current limitations and unan-
swered questions. Gynecol Oncol. 2019;152(1):202–7.
52. Guani B, Balaya V, Magaud L, et al. The clinical impact
of low-volume lymph nodal metastases in early-stage cer-
vical cancer: the senticol 1 and senticol 2 trials. Cancers.
2020;12(5).
53. Fregnani JH, Latorre MR, Novik PR, et al. Assessment of
pelvic lymph node micrometastatic disease in stages IB
and IIA of carcinoma of the uterine cervix. Int J Gynecol
Cancer. 2006;16(3):1188–94.
54. Horn LC, Hentschel B, Fischer U, et al. Detection of micro-
metastases in pelvic lymph nodes in patients with carci-
noma of the cervix uteri using step sectioning: frequency,
topographic distribution and prognostic impact. Gynecol
Oncol. 2008;111(2):276–81.
55. Cibula D, Abu-Rustum NR, Dusek L, et al. Prognostic signif-
icance of low volume sentinel lymph node disease in early-
stage cervical cancer. Gynecol Oncol. 2012;124(3):496–501.
56. Colturato LF, Signorini Filho RC, Fernandes RC, et al.
Lymph node micrometastases in initial stage cervical
cancer and tumoral recurrence. Int J Gynaecol Obstet.
2016;133(1):69–75.
57. Stany MP, Stone PJ, Felix JC, et al. Lymph node microme-
tastases in early-stage cervical cancer are not predictive of
survival. Int J Gynecol Pathol. 2015;34(4):379–84.
58. Kocian R, Slama J, Fischerova D, et al. Micrometastases
in sentinel lymph nodes represent a signifcant negative
prognostic factor in early-stage cervical cancer: a single-
institutional retrospective cohort study. Cancers. 2020;12(6).
59. Sonoda K, Yahata H, Okugawa K, et al. Value of intra-
operative cytological and pathological sentinel lymph node
diagnosis in fertility-sparing trachelectomy for early-stage
cervical cancer. Oncology. 2018;94(2):92–8.
60. Grada AA, Phillips TJ. Lymphedema: pathophysiol-
ogy and clinical manifestations. J Am Acad Dermatol.
2017;77(6):1009–20.
61. Dunberger G, Lindquist H, Waldenstrom AC, et al. Lower
limb lymphedema in gynecological cancer survivors –
effect on daily life functioning. Support Care Cancer.
2013;21(11):3063–70.
62. Torre LA, Islami F, Siegel RL, et al. Global cancer in
women: burden and trends. Cancer Epidemiol Biomarkers
Prev. 2017;26(4):444–57.
63. Hareyama H, Hada K, Goto K, et al. Prevalence, classif-
cation, and risk factors for postoperative lower extremity
lymphedema in women with gynecologic malignancies: a
retrospective study. Int J Gynecol Cancer. 2015;25(4):751–7.
64. Todo Y, Yamamoto R, Minobe S, et al. Risk factors for
postoperative lower-extremity lymphedema in endometrial
cancer survivors who had treatment including lymphad-
enectomy. Gynecol Oncol. 2010;119(1):60–4.
Sentinel lymph node mapping in cervical cancer
65. Roman MM, Barbieux R, Nogaret JM, et al. Use of lympho-
scintigraphy to differentiate primary versus secondary lower
extremity lymphedema after surgical lymphadenectomy: a
retrospective analysis. World J Surg Oncol. 2018;16(1):75.
66. Halaska MJ, Novackova M, Mala I, et al. A prospective
study of postoperative lymphedema after surgery for cervi-
cal cancer. Int J Gynecol Cancer. 2010;20(5):900–4.
67. Kim SI, Lim MC, Lee JS, et al. Comparison of lower
extremity edema in locally advanced cervical cancer: pre-
treatment laparoscopic surgical staging with tailored radio-
therapy versus primary radiotherapy. Ann Surg Oncol.
2016;23(1):203–10.
68. Kuroda K, Yamamoto Y, Yanagisawa M, et al. Risk factors
and a prediction model for lower limb lymphedema following
lymphadenectomy in gynecologic cancer: a hospital-based ret-
rospective cohort study. BMC Women’s Health. 2017;17(1):50.
69. Ohba Y, Todo Y, Kobayashi N, et al. Risk factors for lower-
limb lymphedema after surgery for cervical cancer. Int J
Clin Oncol. 2011;16(3):238–43.
70. Biglia N, Librino A, Ottino MC, et al. Lower limb lymph-
edema and neurological complications after lymphad-
enectomy for gynecological cancer. Int J Gynecol Cancer.
2015;25(3):521–5.
71. Yoshihara M, Shimono R, Tsuru S, et al. Risk factors for
late-onset lower limb lymphedema after gynecological can-
cer treatment: a multi-institutional retrospective study. Eur
J Surg Oncol. 2020;46(7):1334–8.
72. Mendivil AA, Rettenmaier MA, Abaid LN, et al. Lower-
extremity lymphedema following management for endome-
trial and cervical cancer. Surg Oncol. 2016;25(3):200–4.
73. Abu-Rustum NR, Alektiar K, Iasonos A, et al. The inci-
dence of symptomatic lower-extremity lymphedema fol-
lowing treatment of uterine corpus malignancies: a 12-year
experience at Memorial Sloan-Kettering Cancer Center.
Gynecol Oncol. 2006;103(2):714–18.
74. Todo Y, Yamazaki H, Takeshita S, et al. Close relationship
between removal of circumfex iliac nodes to distal exter-
nal iliac nodes and postoperative lower-extremity lymph-
edema in uterine corpus malignant tumors. Gynecol Oncol.
2015;139(1):160–4.
75. Fuller J, Guderian D, Kohler C, et al. Lymph edema
of the lower extremities after lymphadenectomy and
81
radiotherapy for cervical cancer. Strahlenther Onkol.
2008;184(4):206–11.
76. Kunitake T, Kakuma T, Ushijima K. Risk factors for lower
limb lymphedema in gynecologic cancer patients after ini-
tial treatment. Int J Clin Oncol. 2020;25(5):963–71.
77. Togami S, Kawamura T, Fukuda M, et al. Risk factors
for lymphatic complications following lymphadenec-
tomy in patients with cervical cancer. Jpn J Clin Oncol.
2018;48(12):1036–40.
78. Huang J, Yu N, Wang X, et al. Incidence of lower limb
lymphedema after vulvar cancer: a systematic review and
meta-analysis. Medicine. 2017;96(46):e8722.
79. Geppert B, Lonnerfors C, Bollino M, et al. Sentinel
lymph node biopsy in endometrial cancer: Feasibility,
safety and lymphatic complications. Gynecol Oncol.
2018;148(3):491–8.
80. Accorsi GS, Paiva LL, Schmidt R, et al. Sentinel lymph
node mapping vs systematic lymphadenectomy for endo-
metrial cancer: surgical morbidity and lymphatic complica-
tions. J Minim Invasive Gynecol. 2020;27(4):938–45.e2.
81. Biglia N, Zanfagnin V, Daniele A, et al. Lower body lymph-
edema in patients with gynecologic cancer. Anticancer Res.
2017;37(8):4005–15.
82. Niikura H, Okamoto S, Otsuki T, et al. Prospective study of
sentinel lymph node biopsy without further pelvic lymph-
adenectomy in patients with sentinel lymph node-negative
cervical cancer. Int J Gynecol Cancer. 2012;22(7):1244–50.
83. Togami S, Kubo R, Kawamura T, et al. Comparison of lym-
phatic complications between sentinel node navigation sur-
gery and pelvic lymphadenectomy in patients with cervical
cancer. Jpn J Clin Oncol. 2020;50(5):543–7.
84. Yahata H, Kobayashi H, Sonoda K, et al. Prognostic out-
come and complications of sentinel lymph node navigation
surgery for early-stage cervical cancer. Int J Clin Oncol.
2018;23(6):1167–72.
85. Gianoni M, Mathevet P, Uzan C, et al. Does the sentinel
lymph node sampling alone improve quality of life in early
cervical cancer management? Front Surg. 2020;7:31.
86. Lecuru FR, McCormack M, Hillemanns P, et al. SENTICOL
III: an international validation study of sentinel node biopsy
in early cervical cancer. A GINECO, ENGOT, GCIG and
multicenter study. Int J Gynecol Cancer. 2019;29(4):829–34. Run n ing
12
Sentinel lymph node mapping in breast cancer

Angelena Crown and Mary L. Gemignani

CONTENTS
Introduction.................................................................................................................................................................................... 83
Breast cancer.................................................................................................................................................................................. 83
Patterns of nodal metastasis ................................................................................................................................................. 83
Pathology.............................................................................................................................................................................. 83
Ductal carcinoma in situ .......................................................................................................................................... 83
Lobular carcinoma in situ ........................................................................................................................................ 84
Invasive ductal carcinoma........................................................................................................................................ 84
Infltrating lobular carcinoma............................................................................................................................................... 85
Staging for breast cancer................................................................................................................................................................ 85
The axilla ....................................................................................................................................................................................... 87
SLNB.................................................................................................................................................................................... 87
Pathologic analysis of the SLN...................................................................................................................................................... 89
Intraoperative techniques ............................................................................................................................................................... 90
Blue dye ......................................................................................................................................................................................... 90
Radioisotope/nuclear medicine...................................................................................................................................................... 90
Indocyanine green .......................................................................................................................................................................... 90
The SLN mapping procedure......................................................................................................................................................... 90
Management of the clinically negative axilla....................................................................................................................... 93
SLNB after NAC............................................................................................................................................................................ 93
Follow-up after SLNB ................................................................................................................................................................... 95
Conclusion ..................................................................................................................................................................................... 95
References...................................................................................................................................................................................... 95

Introduction Breast cancer

Breast cancer is the most common malignancy among women Patterns of nodal metastasis
in the United States. In 2019, an estimated 268,600 new cases
The ipsilateral axilla is the most common site of metastatic
of breast cancer were diagnosed in American women, compris-
spread of breast cancer. In contrast, metastasis to the internal
ing 15.2% of all new cancer cases.1 Women have a 12.8% (1 in
mammary nodal basin occurs less frequently and is an inde-
8) lifetime risk of developing breast cancer.1 Although breast
pendent predictor of poor outcomes.2 Spread to the internal
cancer poses a serious health concern, increased screening and
mammary nodes is most commonly observed in the setting of
early detection of breast cancer, coupled with advances in sys-
inner quadrant lesions and in the presence of axillary nodal
temic therapies, have led to dramatic improvements in relative
metastasis.
survival rates, which now approach 90% at 5 years.1
Despite an increasing role for genomics, axillary lymph
node status remains one of the most important prognos- Pathology
tic indicators in breast cancer. Sentinel lymph node biopsy
(SLNB) in breast cancer evolved out of efforts to minimize
Ductal carcinoma in situ
the morbidity associated with axillary lymph node dissection Ductal carcinoma in situ (DCIS) comprises a heterogeneous
(ALND) while still providing important staging information. group of lesions with distinct growth patterns and cytologic
Sentinel lymph node (SLN) mapping with the use of blue dye features. Classifcation is based on an architectural pattern
and/or radioisotope allows selective resection of representa- and includes comedo, cribriform, and micropapillary patterns
tive nodes to provide accurate axillary staging in patients (Figure 12.1). These noninvasive lesions range from low grade
with breast cancer. to high grade and are thought to be nonobligate precursors to

DOI: 10.1201/9781003255536-12 83
84
FIGURE 12.1 Ductal carcinoma in situ, intermediate grade (H&E,
100×). (Courtesy of Dr. Dilip Giri from the Department of Pathology at
Memorial Sloan Kettering Cancer Center.)
FIGURE 12.2 (a) Lobular carcinoma in situ, classical type, demonstrating the characteristic distended acini flled with small monomorphic cells with
round nuclei (H&E, 100×). (b) Arrow points to typical fried egg morphology of the neoplastic cells (H&E, 200×). (Courtesy of Dr. Dilip Giri from the
Department of Pathology at Memorial Sloan Kettering Cancer Center.)
Clinical Lymphatic Mapping
invasive cancer with the potential to degenerate into invasive
carcinoma over time.
Lobular carcinoma in situ
Lobular carcinoma in situ (LCIS) is a noninvasive lesion char-
acterized by solid proliferation of small cells with round to
oval nuclei and distention of the terminal duct–lobular units.
It is a marker for increased breast cancer risk in either breast
and is associated with a 2% annual incidence of breast cancer
(Figure 12.2).3
Invasive ductal carcinoma
The category of invasive ductal carcinoma makes up the major-
ity of malignant mammary tumors (65%–80%) (Figure 12.3).
This category also includes a group of lesions termed ‘special
histologic subtypes,’ which is composed of tubular, medullary,
metaplastic, mucinous, papillary, and adenoid cystic carcino-
mas, all of which are associated with favorable outcomes.4
Sentinel lymph node mapping
FIGURE 12.3 Well to moderately differentiated invasive ductal carci-
noma, tubular type. The tumor is exclusively composed of well-formed
tubular glands (arrows) (H&E, 100×). (Courtesy of Dr. Dilip Giri from the
Department of Pathology at Memorial Sloan Kettering Cancer Center.)
FIGURE 12.4 (a and b) Invasive lobular carcinoma, classical type. Arrow denotes characteristic Indian-fle linear arrangement (H&E, 200×).
(Courtesy of Dr. Dilip Giri from the Department of Pathology at Memorial Sloan Kettering Cancer Center.)
85
Infiltrating lobular carcinoma
Infltrating lobular carcinomas constitute 10%–14% of inva-
sive breast carcinomas (Figure 12.4). These tumors tend to
grow circumferentially around ducts and lobules, with a lin-
ear, ‘Indian fle,’ targetoid growth pattern.
Staging for breast cancer
The American Joint Committee on Cancer (AJCC) assigns
clinical and pathologic stages according to the tumor–node–
metastasis (TNM) system. The eighth edition of the AJCC
staging system for breast cancer incorporates SLNB results
into the anatomic stage and distinguishes micrometastases
from isolated tumor cells (ITCs) on the basis of size and his-
tologic evidence of malignant activity.5 In this most recent
edition, the AJCC assigns both anatomic stage groups and
prognostic stage groups that rely both on the anatomic
extent of disease and on biomarkers. The AJCC requires
that cancer registries in the United States use the prognostic
stage groups for case reporting. These biomarkers include
86
FIGURE 12.5 (a) Well to moderately differentiated invasive ductal car-
cinoma with well-formed glandular structures (H&E, 100×). (b) Tumor
is strongly positive for ER with >95% of tumor cells exhibiting strong
nuclear staining (6F11, Leica, 100×). (c) Tumor is strongly positive for
PR with >95% of tumor cells exhibiting strong nuclear staining (Clone
16, Leica, 100×). (Courtesy of Dr. Dilip Giri from the Department of
Pathology at Memorial Sloan Kettering Cancer Center.)
Clinical Lymphatic Mapping
expression of estrogen receptor (ER) and progesterone
receptor (PR), both of which are considered positive if ≥1%
of tumor cells stain for the receptor on immunohistochemi-
cal (IHC) evaluation regardless of staining intensity (Figure
12.5). Human epidermal growth factor receptor 2 (HER2) is
evaluated by immunohistochemistry or, in equivocal cases,
by fuorescent in situ hybridization (Figure 12.6). Histologic
grade is calculated as the sum of values assigned to mor-
phologic features, including tubule formation, mitotic count,
and nuclear pleomorphism. The Oncotype DX (Genomic
Health, Redwood City, CA) genetic assay assigns recurrence
scores (RSs) that are incorporated into staging for patients
with ER/PR-positive, HER2-negative tumors that are >5
mm and ≤50 mm in size.
FIGURE 12.6 (a) Moderately differentiated invasive ductal carcinoma
with micropapillary features (H&E, 100×). (b) The tumor is HER2+ with
3+ staining in 100% of tumor cells (4B5, Ventana, 100×). (Courtesy of
Dr. Dilip Giri from the Department of Pathology at Memorial Sloan
Kettering Cancer Center.)
Sentinel lymph node mapping 87

node metastasis may be present in >10% of patients and that

The axilla
The axilla is a pyramidal space between the arm and thoracic
wall. It contains the axillary vessels and their branches, the
brachial plexus and its branches, and lymph nodes embedded
in fatty tissue. The primary route of lymphatic drainage of the
breast is through the ipsilateral axillary lymph nodes (Figure
12.7a). The boundaries of a level I and II ALND include the
axillary vein superiorly, the serratus medially, and the latis-
simus dorsi laterally. The inferior extent is defned by the con-
vergence of the latissimus dorsi and serratus anterior muscles.
Care is taken to avoid injury to the long thoracic neurovascular
bundle, which travels medially and inserts into the serratus
anterior at approximately T4, and to the thoracodorsal neuro-
vascular bundle, which innervates the latissimus dorsi.
At the time of Halsted’s radical mastectomy, complete
ALND, including levels I–III, was routine, given the impor-
tance of nodal status for prognostication. The status of the
axilla remains one of the most important prognostic factors
today. Although valuable, clinical examination of the axilla
is neither sensitive nor specifc, and a negative clinical exam
does not guarantee absence of metastatic disease. Multiple
studies have shown that even in tumors <1 cm in size, lymph
the incidence of lymph node metastasis increases with larger
tumor size.6
A complete level I and II ALND provides excellent regional
control, with axillary recurrence occurring in <1% of patients,
but comes at the expense of signifcant morbidity, with 10%–
15% of patients developing lymphedema.7–9 Additionally, arm
numbness and tingling, pain, shoulder abduction defcits, and
weakness are well-documented sequelae of this procedure.9
SLNB
Metastatic involvement of lymph nodes is thought to occur in
a stepwise manner. The SLN concept was frst introduced by
Cabanas in penile carcinoma.10 He postulated that the SLN,
the frst lymph node in a regional lymphatic basin to receive
lymph fow from a primary tumor, would accurately refect the
status of the remainder of the nodes in that regional lymphatic
basin (Figure 12.7b). Rosen demonstrated the incidence of
“skip metastasis” (nodal disease present in level 3 but in nei-
ther level 1 nor level 2) to be <2%.11 Given the predictable pat-
tern of metastasis, SLNB emerged as an alternative to ALND
for axillary staging.

FIGURE 12.7 (a) Axillary lymph nodes. The axillary and substernal lymph nodes that drain the breast are shown. The lymph nodes are also divided
into levels by location relative to the pectoralis minor. Level I (low) lymph nodes lie lateral to the lateral border of the pectoralis minor muscle. Level
II (mid) nodes lie behind the pectoralis minor muscle, and level 3 (high) nodes are medial (deep) to the medial border of this muscle. (From Gemignani
ML, Sentinel lymph node mapping in breast cancer and melanoma, Operative Techniques in Gynecologic Surgery [2001] 6:16–20, with permission.)
88 Clinical Lymphatic Mapping

FIGURE 12.7 (b) The sentinel lymph node is the frst lymph node that receives direct drainage from the primary tumor. Because it is the frst site of
drainage, it should be the frst site of lymphatic spread. A tumor-free sentinel lymph node implies the absence of lymph node metastases in the entire
lymphatic basin.

Initial studies in melanoma by Morton and colleagues dem- TABLE 12.1

onstrated the feasibility of the SLNB concept in patients with Selected Large Validation Studies of SLNB in Breast Cancer
cutaneous melanoma.12 This initial study reported success-
False negative
ful identifcation of the SLN in 82% of the 237 patients who
Trial N Treatment arms rate
received intradermal injections of blue dye. SLNB accurately
predicted the regional nodal status in 99% of successful proce- Louisville 1436 Group 1: SLNB with blue 8.3%
Sentinel Node dye -> ALND (range,
dures and in 95% of cases with positive nodes.
Trial17 Group 2: SLNB with colloid 4.3%–14.3%)
The validity of the SLN concept hinges upon the accurate (2001) -> ALND
prediction of the status of the regional lymphatic basin based Group 3: SLNB with dual
on the SLN status. Studies have shown that successful iden- mapping -> ALND
tifcation of the SLN occurs 92%–98% of the time, with the Milan16 516 Group 1: SLNB + ALND 8.8%
combination of blue dye and radioisotope improving the rate (2003) Group 2: SLNB with ALND
of detection of SLNs. The positive predictive value of the tech- only if SLN+
nique approaches 100%, with a negative predictive value close ALMANAC14 1031 SLNB with blue dye + 6.7%
to 95% when both blue dye and radioisotope are used. The (2006) colloid followed by ALND
false-negative rate (FNR) is approximately 5%–10% in most NSABP B-3215 5611 Group 1: SLNB + ALND 9.8%
studies (Table 12.1).13–17 (2007) Group 2: SLNB with ALND
The positive predictive value of SLNB increases with the only if SLN+
number of sentinel nodes retrieved, with positive predictive SNAC13 1088 Group 1: SLNB with ALND 5.5%
(2009) only if SLN+
values ranging from 75% for a single sentinel node to 98% for
Group 2: SLNB + ALND
three sentinel nodes.18 Resection of non-SLNs does not appear
to add value to the SLNB procedure. Turner et al. performed Note: These trials all demonstrated false-negative rates between 5% and 10%.
IHC staining of all lymph nodes removed, sentinel and nonsen- Abbreviations: SLNB, sentinel lymph node biopsy; ALND, axillary
tinel, in a series of women undergoing standard ALND with lymph node dissection; SLN, sentinel lymph node; ALMANAC, Axillary
clinically negative nodes (cN0).19 A total of 157 SLNs were Lymphatic Mapping Against Nodal Axillary Clearance; NSABP,
examined; 10 (6%) demonstrated IHC positivity compared National Sentinel Adjuvant Breast and Bowel Project; SNAC, Sentinel
with only 1 of 1087 non-SLNs (0.09%). They concluded that Node Biopsy vs. Axillary Clearance
the probability of non-SLNs containing metastases was <0.1%
when both hematoxylin-eosin (H&E) and IHC stains of the
SLN were negative, indicating that resection of SLNs does not the management of any cN0 patients with invasive breast can-
signifcantly increase the positive predictive value of SLNB. cer. SLNB should be performed by a team that can proceed to
SLNB can be performed in conjunction with either mastec- ALND in the event that the SLN procedure is unsuccessful.
tomy or breast-conserving surgery (BCS) and is standard in It is not routinely indicated for DCIS and should be reserved
Sentinel lymph node mapping
for cases in which there is a suspicion of microinvasion, as
the rate of positive nodes approaches 6%, or in the setting of
mastectomy, where occult invasive disease is found in 20% of
mastectomy specimens.20–22
Because of the paramount importance of nodal status in
the prognosis of breast cancer, fndings on SLNB inform sys-
temic therapy recommendations. Nodal metastasis is currently
an indication for adjuvant chemotherapy in all breast cancer
subtypes.23 The RxPONDER trial is evaluating whether low-
volume nodal disease in the setting of a low RS should remain
an indication for adjuvant chemotherapy in women with cN0
ER/PR+, HER2− breast cancer.24
Use of SNLB in elderly patients is more nuanced. Hughes
et al. reported a 12-year follow-up on 636 women age ≥70
years with cT1N0M0 tumors who were randomized to
lumpectomy and tamoxifen or to lumpectomy, tamoxifen,
and adjuvant radiation therapy (RT) and found that omission
of RT was not associated with a deleterious effect on sur-
vival.25 Breast cancer–specifc survival at 10 years was 97%
in the tamoxifen group compared to 98% in the tamoxifen
plus radiation group.25 The majority of patients in the study,
64%, did not undergo axillary surgery.26 After 12 years of
follow-up, only six patients (1% of those who did not undergo
axillary surgery) in the entire study had an axillary recur-
rence – all in patients who did not undergo ALND and did
not receive RT.25 Given these reassuring fndings, this study
provided level 1 evidence for selective use of axillary surgery
in patients age ≥70 years. Indeed, the Society of Surgical
Oncology issued a “Choosing Wisely” recommendation that
SLNB be omitted in cN0 women age ≥70 years with early-
stage ER/PR+, HER2– breast cancers; however, this recom-
mendation allows for individual consideration of axillary
staging in cases in which a positive result would affect sys-
temic therapy recommendations.27
Historically, SLN mapping was thought be compromised
in cases of disrupted or aberrant lymphatic drainage pat-
terns, which may be caused by large tumors, previous RT,
multicentric tumors, or the presence of a large cavity pro-
duced from a prior excision. With modern mapping tech-
niques, these conditions do not constitute contraindications
to SLNB, and we routinely perform SLNB in these cases.
Pregnancy was also considered a relative contraindication
to SLNB due to concerns for radiation exposure to the fetus
from the radioisotope and for allergic reactions to blue dye;
however, modern series quantifying radiation dose to the
fetus have demonstrated that fetal exposure is negligible and
have suggested that technetium colloid use for SLNB is safe
during pregnancy.28–30
Pathologic analysis of the SLN
In contrast to ALND, SLNB has the advantage of facilitating
the use of enhanced pathologic techniques, such as IHC, for
the evaluation of the SLNs. Overall, greater scrutiny is paid to
SLNs through serial sectioning and IHC staining. Serial sec-
tioning improves the detection of metastases and increases the
yield (up to 30%) in H&E analysis over single sectioning.31,32
The addition of IHC staining further increases the detection of
89
nodal metastases and is possible because only a few SLNs are
obtained at the time of the procedure. Neither serial sectioning
nor IHC would be practical or cost-effective in a conventional
ALND, which yields an average of 20 nodes.33
IHC stains used in breast cancer are monoclonal antibod-
ies against the cytokeratins AE1/AE3 and CAM 5.2. Several
studies have demonstrated an increase in the diagnostic yield
of occult nodal metastases with the use of IHC analysis in
patients thought to have negative nodes through standard
histologic analysis using H&E stains. Use of IHC stains can
increase the yield of detection of tumor cells by 10%–20%
over standard histopathologic analysis.34,35
According to AJCC staging, metastases <2 mm in size are
classifed as micrometastases.5 The question of whether the
presence of isolated micrometastases on SLNB necessitates
full ALND was initially controversial; however, two prospec-
tive national trials found that micrometastases are associated
with minimal changes in prognosis. The American College of
Surgeons Oncology Group (ACOSOG) Z0010 trial evaluated
the impact of occult lymph node metastases on survival in
women undergoing breast-conserving therapy (BCT); it found
that 10.5% of women who had negative SLNs on H&E had
positive fndings on IHC.34 There was no difference in overall
survival (OS) or disease-free survival (DFS) in women who
were found to have micrometastases compared to women
whose lymph nodes were negative on both H&E and IHC.
The National Surgical Adjuvant Breast and Bowel Project
(NSABP) B-32 study randomized women with cT1–2N0
undergoing BCT or mastectomy with negative SLNs on H&E
to SLNB alone or full ALND. The study found that occult
metastases were present in 15.9% of women and that the pres-
ence of occult nodal metastases was associated with a 1.2%
reduction in OS, a 2.8% decrease in DFS, and a 2.8% reduction
in distant DFS at 60 months.7
Galimberti and colleagues reported results from
International Breast Cancer Study Group 23–01, a random-
ized control trial that confrmed the oncologic safety of the
omission of ALND in patients with cT1–2N0 tumors undergo-
ing BCT or mastectomy with fndings of micrometastases on
SNLB.36 In this trial, women with early-stage breast cancer
with no palpable adenopathy who were found to have micro-
metastases on SLNB were randomized to completion ALND
or no further axillary surgery. After a median follow-up of
9.7 years, they found no difference in DFS between groups:
76.8% in the no further axillary surgery group and 74.9% in
the completion axillary dissection group.37 However, lymph-
edema rates were 13% in the completion ALND group, com-
pared to 5% in the no further axillary surgery group, again
highlighting the increased morbidity associated with conven-
tional ALND.
These prospective trials support the current practice of
omitting ALND in patients with isolated micrometastases.
Additionally, together with the landmark ACOSOG Z0011
trial that confrmed the oncologic safety of omitting ALND
in patients with fewer than three nodes with macrometastases,
these trials have led to more selective use of IHC staining, as
the presence of isolated micrometastases has been shown to
have minimal prognostic value outside of the neoadjuvant che-
motherapy setting.38
90
Intraoperative techniques
Frozen-section H&E analysis allows visualization of the
nodal architecture and can be used to inform operative deci-
sion making. It has been reported to have an FNR of 6%–24%
compared with fnal analysis on paraffn and is more reliable
for detection of macrometastatic disease.31,32 Disadvantages of
this technique include frozen-tissue artifact, the consumption
of tissue, and intraoperative delay.
The use of imprint cytology has also been reported in SLN
mapping. Imprint cytology uses touch preparations, which can
provide excellent cytologic detail and allow rapid analysis, as
well as increased tissue preservation for use in paraffn sec-
tions; however, there are inherent limitations to imprint cytol-
ogy, including the smaller number of cells examined compared
with frozen-section analysis and an increased incidence of
indeterminate results.39
In the era of ACOSOG Z0011, we reserve frozen-section
nodal analysis for women undergoing mastectomy and for
women who received neoadjuvant chemotherapy (NAC),
as the chance of fnding more than two positive nodes in
women with cT1–2N0 disease undergoing up-front surgery
is very low.
Blue dye
Isosulfan blue dye (Lymphazurin, Hirsch Industries,
Richmond, VA) is a monosodium salt of a 2,5-disulfonated tri-
phenyl methane dye.40 It binds weakly to albumin and is taken
up selectively by the lymphatics. Incidence of severe allergic
reaction is <1%. Allergic reactions include urticaria, rashes,
and ‘blue hives’; however, anaphylactic reactions with cardio-
vascular collapse have also been reported.
A study from Memorial Sloan Kettering Cancer Center
(MSKCC) reported an allergic reaction rate of 1.6% among
2392 patients who received isosulfan blue dye as part of
the SLNB procedure.41 The majority of the reactions (69%)
were blue hives and urticaria. The incidence of hypotensive
reaction was 0.5%. Other severe allergic reactions included
bronchospasm and respiratory compromise; these events
required short-term pressor support but did not require
emergency intubation. No cross-sensitivity between sulfa
allergy and isosulfan blue dye was observed. A subse-
quent prospective series reported by King and colleagues
from MSKCC demonstrated a similar rate of allergic reac-
tions, 1.8%, among 1728 patients.42 Hypotensive reactions
comprised 0.2% of events, with 0.1% of patients requiring
pressor support. Additionally, a nonsignifcant trend toward
fewer allergic reactions with smaller volumes of dye was
noted.
Patent blue-V dye is a triphenyl methane dye similar to iso-
sulfan blue that is used in Europe. Patent blue-V dye has been
used in lymphangiography longer than isosulfan blue dye. The
frequency of allergic reactions to patent blue dye has been esti-
mated to be 0.2%–2.7%.43,44
Clinical Lymphatic Mapping
Radioisotope/nuclear medicine
In the United States, the majority of the published experience
has been with technetium-99m sulfur colloid (99mTc-SC),
while in Europe, 99mTc colloidal albumin is used. Filtration of
the colloid produces uniformity of particle size and is standard
in lymphatic mapping in melanoma, whereas the unfltered
colloid is suffcient in breast cancer.45 In melanoma, lympho-
scintigraphy reveals anomalous drainage patterns and iden-
tifes the lymphatic basin to be investigated. Because the
ipsilateral axilla is the primary focus of SLNB in breast can-
cer, a negative lymphoscintigram does not preclude successful
intraoperative localization of the SLN.
A number of studies have found that SLNs identifed by
intraparenchymal, subdermal, intradermal, or subareolar
injection stage the axilla with comparable accuracy.46 It is
thought that the entire breast and overlying skin function as
one, with drainage to an identifable SLN in most patients.47
This may explain why such a wide variation in isotope tech-
niques, including dosage, medium location, and timing of
injection, produces similar SLN identifcation rates.
Indocyanine green
A novel tracer, indocyanine green (ICG), was developed in
2005.48 Advantages of ICG include delineating lymphatic
channels and real-time fow of lymph. Initial studies reported
an SLN detection rate of 94%, with subsequent studies report-
ing SLN detection rates approaching 100%, providing increas-
ing support for the use of ICG.49–51 In a study of 821 women
with cN0 breast cancer who underwent SLNB, Sugie et al.
compared SLNB using ICG to SLNB using traditional radio-
isotope.52 Rates of SLN detection were equivalent (both 97%),
and use of both methods together led to a SLN detection rate
of 99.8%. ICG detected more SLNs (2.3 nodes vs. 1.7 nodes
for radioisotope) and increased the detection of positive nodes
(7.2% of positive nodes were fuorescent but not radioactive).
No ICG hypersensitivity reactions were observed. The use of
ICG requires a special camera to allow visualization and is
less readily accessible than current techniques used for SLNB
(blue dye and radioisotope). Further study defning the role of
ICG in SLNB in breast cancer is necessary.
The SLN mapping procedure
Our current approach at MSKCC includes both isotope and
blue dye for lymphatic mapping for the majority of up-front
cases and for all cases following NAC.53 The morning of the
operation, the patient receives 0.1 mCi of unfltered 99mTc-SC
(CIS-U.S. Inc., Bedford, MA) intradermally overlying the site of
the tumor. Alternatively, mapping may be performed the night
before surgery; this has not been demonstrated to have a clini-
cally meaningful impact on successful SLN identifcation.54 A
lymphoscintigram is obtained preoperatively (Figure 12.7c).
Sentinel lymph node mapping 91

FIGURE 12.7 (c) Intraoperative identifcation of the sentinel lymph node. The use of lymphoscintigraphy to identify the sentinel lymph node in
melanoma is well documented. The value of the preoperative lymphoscintigram in sentinel lymph node mapping in breast cancer is controversial.
Injection of radioisotope in conjunction with blue dye has been shown to increase the success of fnding the sentinel lymph node and thus decrease the
learning curve associated with the procedure.

FIGURE 12.8 (a) Injection of the blue dye at the time of surgery is
helpful in the sentinel lymph node procedure. Adverse reactions occur
in approximately 1% of sentinel lymph node biopsies. The use of the blue
dye in conjunction with radioisotope increases the success rate of lym-
phatic mapping compared to either technique alone.
FIGURE 12.8 (c) Injection of the blue dye can also be performed intra-
dermally, but will require a smaller volume.

One to two hours after the isotope injection, the patient is

FIGURE 12.8 (b) The gamma probe (C-Trak, Care Wise, Inc., Morgan
Hill, CA) can be used to identify intraoperatively the ‘hot’ sentinel lymph
node during dissection. The gamma probe provides an auditory signal that
can help direct the dissection toward the location of the sentinel lymph node.
taken to the operating room. Under either local or general
anesthesia, the breast and axilla are prepped and draped in
the usual manner, an intraparenchymal injection of 2–8 mL
of isosulfan blue dye is injected into the subareolar plexus,
and the breast is massaged for 5 minutes (Figure 12.8a–e).
Within 5–10 minutes, the axilla is explored through a small
transverse incision (Figure 12.8f). Identifcation and removal
of all hot and blue nodes are done with the aid of a hand-
held gamma probe and identifcation of the blue lymphatic
channels (Figure 12.9a–d). In cases of mastectomy or follow-
ing NAC, the SLNs are submitted for frozen-section analy-
sis, and if metastases are identifed, an immediate ALND is
performed.
92
FIGURE 12.8 (d) The radioactive counts help to determine the amount
of radioisotope that is present in the injection site.
FIGURE 12.8 (e) The area of maximum radioactivity is noted. Surgical
exploration will begin directly over this area to have the greatest potential
in identifcation of the sentinel lymph node.
FIGURE 12.8 (f) Careful dissection is performed so as not to disrupt
the blue lymphatics, which will lead to the sentinel lymph node.
Clinical Lymphatic Mapping
FIGURE 12.9 (a) The gamma probe is dressed with a sterile cover and
is used to help localize the direction to proceed for identifcation of the
sentinel lymph node.
FIGURE 12.9 (b) Identifcation of the ‘blue’ sentinel lymph node is noted.
FIGURE 12.9 (c) The use of both radioisotope and blue dye will ensure
success for the SLN procedure. An average of two nodes is usually found
during this procedure. However, any blue or hot node will need to be
removed to decrease the false-negative procedure rate. Nodes that emit
10% or more of the strongest signal that was detected in a sentinel node
require resection as sentinel nodes.
Sentinel lymph node mapping
FIGURE 12.9 (d) After removal of the blue nodes, the gamma probe
is introduced into the axilla to check for any residual radioactivity
hotspots, which may indicate an additional sentinel lymph node. A four-
fold decrease in counts is considered a successful radiolocalization. This
reduced count is recorded.
It is important to perform careful intraoperative palpation
of the axilla, as uptake of both isotope and blue dye can be
impaired by gross tumor involvement of nodes. Cody and col-
leagues reported that clinically suspicious nodes were present
in more than 50% of false-negative SLNB procedures.53,55 In
these cases, gross tumor involvement of the nodes may com-
promise the identifcation of the true sentinel node, and these
palpable nodes should be resected as sentinel nodes.
Management of the clinically negative axilla
Until the ACOSOG Z0011 trial, standard of care mandated
completion ALND in the setting of a positive SLN. The Z0011
trial originated from the observation that the SLN is the only
positive lymph node in the majority of women and from a
desire to spare women the morbidity of an operation that, in the
setting of a single positive node, would be unlikely to provide
signifcant oncologic beneft.56–59 This landmark randomized
study assigned women undergoing BCS and whole-breast RT
(WBRT) with cT1-T2N0M0 breast cancer with one or two pos-
itive SLNs to one of two treatment arms: completion ALND or
no ALND.38 Of note, 27% of women in the ALND group were
found to have additional positive nodes in their axillary speci-
mens. Women who underwent SLNB alone presumably had a
similar rate of residual disease; despite no targeted therapy to
the axilla, there was no difference in locoregional recurrence,
OS, or DFS between groups after a median follow-up of 9.3
years.60 Results of this trial were practice changing and led to
the routine omission of ALND for women with cT1-2N0 breast
cancer undergoing BCT who were found to have one to two
positive SLNs.
Of note, women undergoing mastectomy were not included
in the Z0011 trial; consequently, results of the trial cannot be
extrapolated to them. Targeted treatment of the axilla is still
warranted in women who elect mastectomy and are found
to have one to two positive SLNs. Because standard breast
93
radiation tangents cover low-level axillary nodes, it is thought
that some axillary treatment occurs during WBRT. Unless
they met criteria for postmastectomy RT, most women under-
going mastectomy would not receive RT and therefore risk
undertreatment of their axillae. Additionally, although nodal
tangents were explicitly disallowed in the Z0011 protocol, post
hoc review of available radiation plans revealed that approxi-
mately 19% of patients received axillary RT.61 These fndings
raised questions regarding the optimal radiation treatment
approach to patients with low-volume axillary disease treated
with SNLB alone.
The AMAROS study provided additional data to guide
axillary management in women with low-volume axillary
disease.62 In this prospective randomized study, women with
cT1-2N0 undergoing mastectomy or BCT with positive fnd-
ings on SLNB were randomized to ALND or axillary RT.
Locoregional recurrence, OS, and DFS were similar between
groups. Additional fndings of the study included lower rates
of lymphedema and shoulder dysfunction in the axillary RT
group. This study provided the data to support axillary RT as
a potential alternative to ALND in patients undergoing mas-
tectomy that were found to have positive SLNs.
The National Cancer Institute of Canada MA.20 study
evaluated whether the addition of regional nodal irradiation
(RNI) to WBRT would improve survival outcomes in patients
with node-positive or high-risk node-negative breast cancers.63
Addition of RNI did not result in any difference in OS, but
DFS was 5% higher in the RNI group: 82% compared to 77%
in the WBRT-only group. Benefts were seen in both loco-
regional recurrence and distant recurrence with the addition
of RNI. Despite nearly ubiquitous use of ALND (96%), the
results of this trial may apply to Z0011 patients who are treated
with SNLB for low-volume axillary disease. This reasoning
is predicated on the assumption that SNLB likely resects the
majority of the disease burden in the axilla, as well as the
observation of similar locoregional recurrence rates regardless
of whether an ALND was performed in Z0011.
SLNB after NAC
Although adjuvant chemotherapy was frmly established as
the backbone of systemic therapy for breast cancer treatment,
there was interest in elucidating the ideal timing of chemo-
therapy. NAC, which is delivered prior to surgery, may allow
locally advanced primary tumors to become amenable to
breast conservation, as well as facilitate downstaging of the
axilla. The NSABP explored the role of chemotherapy in the
neoadjuvant setting in two large randomized trials, B-18 and
B-27, and found no difference in OS or DFS between women
who received NAC and those who received adjuvant chemo-
therapy.64,65 Pathologic complete response (pCR) was a predic-
tor of OS and DFS in both studies. In B-27, pCR following
NAC was a prognostic factor for survival independent of the
response in the breast. These fndings led to interest in defn-
ing a role for SLNB in women undergoing NAC.
Given concern for potential fbrosis of lymphatic channels,
the accuracy of SLNB following NAC was evaluated in mul-
tiple studies. The GANEA study prospectively evaluated the
94 Clinical Lymphatic Mapping

feasibility of SLNB after NAC; in cN0 women, the identifca- Building on the fndings in Z1071, Caudle and the University
tion rate was 95% with an FNR of 9% – comparable to rates of Texas MD Anderson Cancer Center group described a
that have been reported for cN0 women undergoing up-front novel technique, the TArgeted lymph node Dissection (TAD),
surgery.66 With the ability to perform an accurate SLNB after in which the biopsy-proven positive node was clipped prior
NAC confrmed, the next series of questions focused on opti- to NAC and then targeted at the time of surgery in addition
mal timing of axillary staging for women receiving NAC. to a standard SNLB.72 Multiple groups reported outcomes of
The SENTInel NeoAdjuvant (SENTINA) study demon- this technique and found that the combination of SLNB and
strated that SLNB prior to NAC and after NAC (repeat SLNB) excision of the biopsy-proven node reduced the FNR to below
was associated with an identifcation rate of 61% and an FNR 10% and had the potential to tailor axillary management.
of 52%, indicating that repeat SLNB was not an appropriate Additionally, they demonstrated that the clipped node was not
option.67 Knowing that axillary staging can only be performed an SLN in up to 24% of cases, suggesting that SLNB alone
once and that confrmation of nodal pCR could obviate the may miss the initially positive node in up to a quarter of cases.
need for ALND, performing SLNB after NAC became the pre- Frozen-section analysis is of paramount importance in the
ferred approach. Hunt et al. evaluated the oncologic safety of setting of NAC, as metastases of any size, including ITCs
this approach with a series of 3746 women with cT1-3N0 who and micrometastases, indicate residual disease and warrant
underwent SLNB at the University of Texas MD Anderson ALND (Figure 12.10a–c). Indeed, it was with the inclusion
Cancer Center. Patients who were found to be pN0 follow-
ing NAC and underwent SLNB alone had a 4-year regional
recurrence rate of 1.2%, similar to the 0.9% observed among
patients who had negative SLNs and underwent SLNB alone
in the up-front surgery setting.68
Having verifed the oncologic safety of SLNB following
NAC in cN0 patients, attention then turned to evaluating the
feasibility and accuracy of SLNB in clinically node-positive
(cN+) patients who convert to cN0 following NAC. The
ACOSOG Z1071 trial evaluated results of SLNB in 649 biopsy-
proven cN+ women; 83% converted to cN0 after NAC.69 The
SLN identifcation rate was 93%, and the FNR in women who
had two or more SLNs resected was 13%. This FNR failed
to meet the predefned threshold of 10% to consider SLNB
appropriate in this population. A similar study, Sentinel Node
Biopsy Following Neoadjuvant Chemotherapy (SN FNAC),
also examined the technical success and accuracy of SLNB
in biopsy-proven cN+ women. This study reported comparable
results, with an SLN identifcation rate of 88% and an FNR of
8% when ITCs were considered node positive and 13% when
ITCs were considered node negative.70
Although the FNRs in these studies failed to meet the pre-
determined threshold to indicate oncologic appropriateness
of SLN in cN+ women undergoing NAC, unplanned explor-
atory analyses in Z1071 suggested strategies to help reduce the
unacceptably high FNR. These strategies included use of dual
tracer (11% false negative vs. 20% FNR with single agent) and
removal of three or more SLNs (FNR 9% vs. 21% with two
SLNs). With FNRs so close to the predetermined threshold
and a signal in Z1071 suggesting that the FNR could reach
acceptable range with some technical modifcations, the next
series of studies focused on refning the SLN technique and
generating clinical criteria to ensure oncologic safety in this
population.
In an early study assessing the feasibility and clinical impact
of fnding three or more SLNs after NAC, Mamtani et al.
reported on a prospective cohort of 132 women who presented
with cN+ disease and converted to cN0 after NAC. They found
that the probability of fnding three or more SLNs was 86%
FIGURE 12.10 (a) Frozen section of a sentinel lymph node involved
and that 47% of women in this population were spared ALND with metastatic carcinoma (H&E, 200×). Arrows demonstrate clusters of
after NAC, suggesting that fnding three or more SLNs was tumor cells in the background of lymphoid tissue (star). (b) Lymph node
both feasible in most women and that the results affected sur- with treatment effect following NAC with accumulation of macrophages
gical management in almost half of these women.71 (H&E, 50×).
Sentinel lymph node mapping
FIGURE 12.10 (c) Arrow denotes pale-appearing macrophages embedded
in a background of fbrosis (H&E, 200×). (Courtesy of Dr. Dilip Giri from
the Department of Pathology at Memorial Sloan Kettering Cancer Center.)
of micrometastases that the SN FNAC study was able to
achieve an FNR <10%. To elucidate the relationship between
low-volume axillary disease on SLNB and additional disease
within the axilla, Moo and colleagues at MSKCC evaluated
702 women who underwent SLNB after NAC. They found that
23% of women with micrometastases and 63% of women with
macrometastases on frozen section had one or more additional
positive lymph nodes on ALND.73 Additionally, 17% of women
with ITCs had one or more additional positive nodes on ALND.
Together, these results indicate that low-volume SLN disease
does not identify women who are at low risk for additional axil-
lary metastases and confrm the role for ALND in this setting.
Although there is a large volume of data to guide manage-
ment of the axilla after NAC, there is a paucity of data defn-
ing best practices for axillary management after neoadjuvant
endocrine therapy, and this will be an area of intense research
activity in the coming years.
Follow-up after SLNB
Local recurrence after SLNB for melanoma has been
reported.74 Recent reports have found that the rates of isolated
axillary relapse after a negative SLNB are comparable to a
conventional ALND; indeed, long-term follow up of the B-32
trial and Milan trials demonstrated similar rates of regional
nodal recurrence – all under 1%.7,8 Madsen et al. reported the
MSKCC experience: among 1529 women with negative SLNs
at the time of SLNB, cumulative incidence of axillary recur-
rence as a frst breast event was 1% at 15 years.75
Importantly, there are no long-term data assessing the onco-
logic safety of SLNB alone for patients who convert from cN+
to pN0. Galimberti and colleagues reported zero axillary fail-
ure events at 61 months among 70 patients who converted from
cN+ to pN0 and were treated with SLNB alone.76 Reports on
oncologic safety and rates of regional recurrence are highly
anticipated as the data from Z1071 mature.
95
The long-term morbidities of SLNB require ongoing long-
term follow-up. A prospective trial comparing sensory mor-
bidity after SLNB and ALND found that sensory defcits
occurred twice as frequently in women who underwent ALND
as they did in women who underwent SLNB.77 In a study of 187
women who underwent BCS with either SLNB or ALND, the
rates of subjective arm numbness, chest or axillary numbness,
arm or hand swelling, and objective neurosensory changes in
the axilla and arm were signifcantly higher in women who
underwent ALND.78
Studies demonstrate a lower rate of lymphedema in women
who undergo SLNB compared to those who undergo ALND.
McLaughlin et al. reported a series of 936 women who under-
went axillary surgery at MSKCC; women who required ALND
had a 16% rate of lymphedema at 5 years follow-up compared
to 5% in women who required SLNB alone.79 Risk factors
associated with the development of lymphedema included
higher body mass index and infection or injury of the ipsilat-
eral arm. Studies exploring the incidence and management of
lymphedema are ongoing, with additional work focusing on
prevention and early detection.
Conclusion
SLNB allows accurate staging in patients with breast cancer
and identifcation of patients who require ALND to optimize
locoregional control. SLNB also helps guide systemic therapy
recommendations and affords decreased morbidity by avoid-
ing ALND in appropriate patients.
REFERENCES
1. Surveillance Epidemiology and End Results (SEER)
Program, SEER Stat Fact Sheet: Female Breast Cancer
[cited 2020 Mar 17]. Available from: http://seer.cancer.gov/
statfacts/html/breast.html.
2. Shen J, et al. Intramammary lymph node metastases are
an independent predictor of poor outcome in patients with
breast carcinoma. Cancer. 2004;101(6):1330–7.
3. King TA, et al. Lobular carcinoma in situ: a 29-year lon-
gitudinal experience evaluating clinicopathologic fea-
tures and breast cancer risk. J Clin Oncol. 2015;33(33):
3945–52.
4. Tadros AB, Wen HY, Morrow M. Breast cancers of spe-
cial histologic subtypes are biologically diverse. Ann Surg
Oncol. 2018;25(11):3158–64.
5. Amin MB, et al. The eighth edition AJCC cancer staging
manual: continuing to build a bridge from a population-
based to a more ‘personalized’ approach to cancer staging.
CA Cancer J Clin. 2017;67(2):93–9.
6. Bevilacqua JLB, et al. Doctor, what are my chances of hav-
ing a positive sentinel node? A validated nomogram for risk
estimation. J Clin Oncol. 2007;25(24):3670–9.
7. Krag DN, et al. Sentinel-lymph-node resection compared
with conventional axillary-lymph-node dissection in clini-
cally node-negative patients with breast cancer: overall sur-
vival fndings from the NSABP B-32 randomised phase 3
trial. Lancet Oncol. 2010;11(10):927–33.
96
8. Veronesi U, et al. Sentinel lymph node biopsy in breast can-
cer: ten-year results of a randomized controlled study. Ann
Surg. 2010;251(4):595–600.
9. Ashikaga T, et al. Morbidity results from the NSABP B-32
trial comparing sentinel lymph node dissection versus axil-
lary dissection. J Surg Oncol. 2010;102(2):111–18.
10. Cabanas RM. An approach for the treatment of penile car-
cinoma. Cancer. 1977;39(2):456–66.
11. Rosen PP, et al. Discontinuous or ‘skip’ metastases in breast
carcinoma. Analysis of 1228 axillary dissections. Ann
Surg. 1983;197(3):276–83.
12. Morton DL, et al. Technical details of intraoperative lym-
phatic mapping for early stage melanoma. Arch Surg.
1992;127(4):392–9.
13. Gill G, S.T.G.o.t.R.A.C.o. Surgeons, and N.C.T. Centre,
Sentinel-lymph-node-based management or routine axil-
lary clearance? One-year outcomes of sentinel node biopsy
versus axillary clearance (SNAC): a randomized controlled
surgical trial. Ann Surg Oncol. 2009;16(2):266–75.
14. Goyal A, et al. Factors affecting failed localisation and
false-negative rates of sentinel node biopsy in breast
cancer – results of the ALMANAC validation phase. Breast
Cancer Res Treat. 2006;99(2):203–8.
15. Krag DN, et al. Technical outcomes of sentinel-lymph-node
resection and conventional axillary-lymph-node dissec-
tion in patients with clinically node-negative breast cancer:
results from the NSABP B-32 randomised phase III trial.
Lancet Oncol. 2007;8(10):881–8.
16. Veronesi U, et al. A randomized comparison of sentinel-
node biopsy with routine axillary dissection in breast can-
cer. N Engl J Med. 2003;349(6):546–53.
17. Wong SL, et al. Sentinel lymph node biopsy for breast can-
cer: impact of the number of sentinel nodes removed on the
false-negative rate. J Am Coll Surg. 2001;192(6):684–9;
discussion 689–91.
18. McCarter MD, et al. The breast cancer patient with mul-
tiple sentinel nodes: when to stop? J Am Coll Surg.
2001;192(6):692–7.
19. Turner RR, et al. Histopathologic validation of the senti-
nel lymph node hypothesis for breast carcinoma. Ann Surg.
1997;226(3):271–6; discussion 276–8.
20. Flanagan MR, et al. Is sentinel lymph node biopsy required
for a core biopsy diagnosis of ductal carcinoma in situ with
microinvasion? Ann Surg Oncol. 2019;26(9):2738–46.
21. Pilewskie M, et al. Is sentinel lymph node biopsy indicated
at completion mastectomy for ductal carcinoma in situ?
Ann Surg Oncol. 2016;23(7):2229–34.
22. Mittendorf EA, et al. Core biopsy diagnosis of ductal carci-
noma in situ: an indication for sentinel lymph node biopsy.
Curr Surg. 2005;62(2):253–7.
23. National Comprehensive Cancer Network, Breast Cancer
(Version 3.2019), in NCCN Clinical Practice Guidelines in
Oncology; 2019.
24. Southwest Oncology Group, A phase III, randomized
clinical trial of standard adjuvant endocrine therapy +/−
chemotherapy in patients with 1–3 positive nodes, hormone-
responsive and HER2-negative breast cancer according
to Recurrence Score [cited 2020 Feb 1]. Available from:
www.swog.org/clinical-trials/s1007.
Clinical Lymphatic Mapping
25. Hughes KS, et al. Lumpectomy plus tamoxifen with or
without irradiation in women age 70 years or older with
early breast cancer: long-term follow-up of CALGB 9343. J
Clin Oncol. 2013;31(19):2382–7.
26. Hughes KS, et al. Lumpectomy plus tamoxifen with or
without irradiation in women 70 years of age or older
with early breast cancer. N Engl J Med. 2004;351(10):
971–7.
27. Oncology, S.o.S. Don’t routinely use sentinel node biopsy
in clinically node negative women ≥70 years of age with
early stage hormone receptor positive, HER2 negative inva-
sive breast cancer. Choosing Wisely; 2016 [2020 Feb 29].
Available from: www.choosingwisely.org/clinician-lists/
sso-sentinel-node-biopsy-in-node-negative-women-70-and-
over/.
28. Gentilini O, et al. Safety of sentinel node biopsy in pregnant
patients with breast cancer. Ann Oncol. 2004;15(9):1348–51.
29. Pandit-Taskar N, et al. Organ and fetal absorbed dose esti-
mates from 99mTc-sulfur colloid lymphoscintigraphy and
sentinel node localization in breast cancer patients. J Nucl
Med. 2006;47(7):1202–8.
30. Spanheimer PM, et al. Measurement of uterine radiation
exposure from lymphoscintigraphy indicates safety of
sentinel lymph node biopsy during pregnancy. Ann Surg
Oncol. 2009;16(5):1143–7.
31. Turner RR, Giuliano AE. Intraoperative pathologic
examination of the sentinel lymph node. Ann Surg Oncol.
1998;5(8):670–2.
32. Turner RR, et al. Intraoperative examination of the sentinel
lymph node for breast carcinoma staging. Am J Clin Pathol.
1999;112(5):627–34.
33. Boughey JC, et al. Number of lymph nodes identifed at
axillary dissection: effect of neoadjuvant chemotherapy
and other factors. Cancer. 2010;116(14):3322–9.
34. Giuliano AE, et al. Association of occult metastases in sen-
tinel lymph nodes and bone marrow with survival among
women with early-stage invasive breast cancer. JAMA.
2011;306(4):385–93.
35. Weaver DL, et al. Effect of occult metastases on sur-
vival in node-negative breast cancer. N Engl J Med.
2011;364(5):412–21.
36. Galimberti V, et al. Axillary dissection versus no axillary
dissection in patients with sentinel-node micrometastases
(IBCSG 23–01): a phase 3 randomised controlled trial.
Lancet Oncol. 2013;14(4):297–305.
37. Galimberti V, et al. Axillary dissection versus no axil-
lary dissection in patients with breast cancer and sentinel-
node micrometastases (IBCSG 23–01): 10-year follow-up
of a randomised, controlled phase 3 trial. Lancet Oncol.
2018;19(10):1385–93.
38. Giuliano AE, et al. Axillary dissection vs no axillary dis-
section in women with invasive breast cancer and senti-
nel node metastasis: a randomized clinical trial. JAMA.
2011;305(6):569–75.
39. Tew K, et al. Meta-analysis of sentinel node imprint cytol-
ogy in breast cancer. Br J Surg. 2005;92(9):1068–80.
40. Hirsch JI, et al. Use of isosulfan blue for identifcation of
lymphatic vessels: experimental and clinical evaluation.
AJR Am J Roentgenol. 1982;139(6):1061–4.
Sentinel lymph node mapping
41. Montgomery LL, et al. Isosulfan blue dye reactions dur-
ing sentinel lymph node mapping for breast cancer. Anesth
Analg. 2002;95(2):385–8.
42. King TA, et al. A prospective analysis of the effect of blue-
dye volume on sentinel lymph node mapping success and
incidence of allergic reaction in patients with breast cancer.
Ann Surg Oncol. 2004;11(5):535–41.
43. Kalimo K, Saarni H. Immediate reactions to patent blue
dye. Contact Dermatitis. 1981;7(3):171–2.
44. Mortazavi SH, Burrows BD. Allergic reaction to patient blue
dye in lymphangiography. Clin Radiol. 1971;22(3):389–90.
45. Linehan DC, et al. Sentinel lymph node biopsy in breast
cancer: unfltered radioisotope is superior to fltered. J Am
Coll Surg. 1999;188(4):377–81.
46. Martin RC, et al. Highest isotope count does not predict
sentinel node positivity in all breast cancer patients. Ann
Surg Oncol. 2001;8(7):592–7.
47. Borgstein PJ, et al. Functional lymphatic anatomy for senti-
nel node biopsy in breast cancer: echoes from the past and
the periareolar blue method. Ann Surg. 2000;232(1):81–9.
48. Kitai T, et al. Fluorescence navigation with indocyanine
green for detecting sentinel lymph nodes in breast cancer.
Breast Cancer. 2005;12(3):211–15.
49. Sugie T, et al. Comparison of the indocyanine green fuo-
rescence and blue dye methods in detection of sentinel
lymph nodes in early-stage breast cancer. Ann Surg Oncol.
2013;20(7):2213–18.
50. Tagaya N, et al. A novel approach for sentinel lymph node
identifcation using fuorescence imaging and image over-
lay navigation surgery in patients with breast cancer. World
J Surg. 2011;35(1):154–8.
51. Tagaya N, et al. Intraoperative identifcation of senti-
nel lymph nodes by near-infrared fuorescence imaging
in patients with breast cancer. Am J Surg. 2008;195(6):
850–3.
52. Sugie T, et al. Evaluation of the clinical utility of the ICG
fuorescence method compared with the radioisotope
method for sentinel lymph node biopsy in breast cancer.
Ann Surg Oncol. 2016;23(1):44–50.
53. Cody HS. Sentinel lymph node mapping in breast cancer.
Oncology (Williston Park). 1999;13(1):25–34; discussion
35–6, 39, 43.
54. Dodia N, El-Sharief D, Kirwan CC. The use of isotope
injections in sentinel node biopsy for breast cancer: are
the 1- and 2-day protocols equally effective? Springerplus.
2015;4:495.
55. Hill AD, et al. Lessons learned from 500 cases of lymphatic
mapping for breast cancer. Ann Surg. 1999;229(4):528–35.
56. Albertini JJ, et al. Lymphatic mapping and sentinel
node biopsy in the patient with breast cancer. JAMA.
1996;276(22):1818–22.
57. Giuliano AE, et al. Lymphatic mapping and sentinel lymph-
adenectomy for breast cancer. Ann Surg. 1994;220(3):391–
8; discussion 398–401.
58. Krag D, et al. The sentinel node in breast cancer – a multi-
center validation study. N Engl J Med. 1998;339(14):941–6.
59. O’Hea BJ, et al. Sentinel lymph node biopsy in breast can-
cer: initial experience at Memorial Sloan-Kettering Cancer
Center. J Am Coll Surg. 1998;186(4):423–7.
97
60. Giuliano AE, et al. Effect of axillary dissection vs no axil-
lary dissection on 10-year overall survival among women
with invasive breast cancer and sentinel node metastasis:
the ACOSOG Z0011 (Alliance) randomized clinical trial.
JAMA. 2017;318(10):918–26.
61. Jagsi R, et al. Radiation feld design in the ACOSOG Z0011
(Alliance) Trial. J Clin Oncol. 2014;32(32):3600–6.
62. Donker M, et al. Radiotherapy or surgery of the axilla after a
positive sentinel node in breast cancer (EORTC 10981–22023
AMAROS): a randomised, multicentre, open-label, phase 3
non-inferiority trial. Lancet Oncol. 2014;15(12):1303–10.
63. Whelan TJ, et al. Regional nodal irradiation in early-stage
breast cancer. N Engl J Med. 2015;373(4):307–16.
64. Bear HD, et al. Sequential preoperative or postoperative
docetaxel added to preoperative doxorubicin plus cyclo-
phosphamide for operable breast cancer: National Surgical
Adjuvant Breast and Bowel Project Protocol B-27. J Clin
Oncol. 2006;24(13):2019–27.
65. Fisher B, et al. Effect of preoperative chemotherapy on
local-regional disease in women with operable breast can-
cer: fndings from National Surgical Adjuvant Breast and
Bowel Project B-18. J Clin Oncol. 1997;15(7):2483–93.
66. Classe JM, et al. Sentinel lymph node biopsy after neo-
adjuvant chemotherapy for advanced breast cancer: results
of Ganglion Sentinelle et Chimiotherapie Neoadjuvante,
a French prospective multicentric study. J Clin Oncol.
2009;27(5):726–32.
67. Kuehn T, et al. Sentinel-lymph-node biopsy in patients with
breast cancer before and after neoadjuvant chemotherapy
(SENTINA): a prospective, multicentre cohort study.
Lancet Oncol. 2013;14(7):609–18.
68. Hunt KK, et al. Sentinel lymph node surgery after neoadjuvant
chemotherapy is accurate and reduces the need for axillary dis-
section in breast cancer patients. Ann Surg. 2009;250(4):558–66.
69. Boughey JC, et al. Sentinel lymph node surgery after
neoadjuvant chemotherapy in patients with node-positive
breast cancer: the ACOSOG Z1071 (Alliance) clinical trial.
JAMA. 2013;310(14):1455–61.
70. Boileau JF, et al. Sentinel node biopsy after neoadjuvant
chemotherapy in biopsy-proven node-positive breast cancer:
the SN FNAC study. J Clin Oncol. 2015;33(3):258–64.
71. Mamtani A, et al. How often does neoadjuvant chemother-
apy avoid axillary dissection in patients with histologically
confrmed nodal metastases? Results of a prospective study.
Ann Surg Oncol. 2016;23(11):3467–74.
72. Caudle AS, et al. Improved axillary evaluation following
neoadjuvant therapy for patients with node-positive breast
cancer using selective evaluation of clipped nodes: imple-
mentation of targeted axillary dissection. J Clin Oncol.
2016;34(10):1072–8.
73. Moo T-A, et al. Is low-volume disease in the sentinel node
after neoadjuvant chemotherapy an indication for axillary
dissection? Ann Surg Oncol. 2018;25(6):1488–94.
74. Gershenwald JE, et al. Patterns of recurrence following a
negative sentinel lymph node biopsy in 243 patients with
stage I or II melanoma. J Clin Oncol. 1998;16(6):2253–60.
75. Matsen C, et al. Late axillary recurrence after negative sen-
tinel lymph node biopsy is uncommon. Ann Surg Oncol.
2016;23(8):2456–61.
98
76. Galimberti V, et al. Sentinel node biopsy after neoadjuvant
treatment in breast cancer: fve-year follow-up of patients
with clinically node-negative or node-positive disease
before treatment. Eur J Surg Oncol. 2016;42(3):361–8.
77. Temple LK, et al. Sensory morbidity after sentinel lymph
node biopsy and axillary dissection: a prospective study of
233 women. Ann Surg Oncol. 2002;9(7):654–62.
Clinical Lymphatic Mapping
78. Crane-Okada R, et al. Long-term morbidity of sentinel node
biopsy versus complete axillary dissection for unilateral
breast cancer. Ann Surg Oncol. 2008;15(7):1996–2005.
79. McLaughlin SA, et al. Prevalence of lymphedema in
women with breast cancer 5 years after sentinel lymph node
biopsy or axillary dissection: objective measurements. J
Clin Oncol. 2008;26(32):5213–19.
13
Sentinel lymph node biopsy of the endometrium

Jennifer J. Mueller and Nadeem R. Abu-Rustum

CONTENTS
Epidemiology of the disease .......................................................................................................................................................... 99
Historical perspective on lymph node status in endometrial cancer .............................................................................................. 99
Early sentinel lymph node mapping feasibility studies in endometrial cancer .............................................................................. 99
SLN mapping patterns in endometrial cancer .............................................................................................................................. 100
SLN mapping: techniques and examples ..................................................................................................................................... 102
SLN detection using an algorithm ............................................................................................................................................... 103
SLN detection: false-negative rates.............................................................................................................................................. 103
SLN mapping versus lymphadenectomy: the great debate .......................................................................................................... 104
SLN mapping and oncologic outcomes ....................................................................................................................................... 104
Endometrioid histology ...................................................................................................................................................... 104
High-risk histology............................................................................................................................................................. 105
Future directions .......................................................................................................................................................................... 106
References.................................................................................................................................................................................... 106

Epidemiology of the disease
Endometrial cancer is the fourth most common malignancy
among women in the United States. As the annual incidence
rate continues to rise from year to year, an estimated 65,620
new cases will be diagnosed in 2020 and 12,590 women will
die from this disease.1 Endometrial cancer most often presents
at an early stage, and in the absence of concerns such as medi-
cal frailty or fertility preservation, is managed surgically with
hysterectomy, bilateral oophorectomy, and lymph node evalu-
ation.2 Compared to patients with extrauterine disease spread,
particularly nodal disease, the vast majority of women with
early-stage disease have an excellent prognosis.3
Historical perspective on lymph node
status in endometrial cancer
The historical management of apparent early-stage endome-
trial cancer was discussed more thoroughly in an earlier pub-
lished edition of this chapter4 and will be briefy reviewed here.
Prior to the 1980s, the approach to endometrial cancer therapy
included primary radiation followed by surgery. This was per-
formed to sterilize extrauterine spread of disease and spare
extensive surgery, including lymph node evaluation. In 1987,
Creasman et al.5 published the fndings of a clinicopathologic
study (Gynecologic Oncology Group [GOG] 33) that examined
occult nodal involvement in surgically staged early endome-
trial cancer and related nodal involvement to pathologic uter-
ine factors, including International Federation of Gynecology
and Obstetrics (FIGO) grade and myometrial invasion. The
study’s results revealed that lymph node involvement increases
with increasing FIGO grade and depth of myometrial inva-
sion, which has been reproduced in modern patient cohorts.6–8
This helped catalyze a change in endometrial cancer manage-
ment, with patients stratifed based on clinical and pathologic
risk factors for recurrence to help determine who would most
beneft from radiation therapy. Prospective trials conducted
by the GOG and the Post-Operative Radiation Therapy in
Endometrial Cancer (PORTEC) groups9–11 examined the
oncologic beneft of adjuvant radiation therapy in patients with
high-to-intermediate-risk endometrial cancer, and although
these studies did not show an improvement in survival, they
did provide justifcation for postoperative radiation therapy to
reduce the risk of recurrence.
Around that time, surgical strategies began to incorporate
lymph node dissection (pelvic and paraaortic) to tailor therapy
based on uterine risk factors and nodal positivity. Two land-
mark prospective trials examined the oncologic impact of
lymphadenectomy as part of surgical staging in patients with
early-stage endometrial cancer. These randomized trials dem-
onstrated lymphadenectomy was signifcantly associated with
prognosis (e.g., detecting node-positive disease) but not with
survival.12,13 Furthermore, lymphadenectomy carries added
surgical morbidity, including leg lymphedema, higher rates of
intraoperative blood loss, and vascular and nerve injury.14–17
Early sentinel lymph node mapping
feasibility studies in endometrial cancer
The concept of sentinel lymph node (SLN) mapping was
described in the literature as early as the 1970s,18 although
2 decades would pass before its application in endometrial

DOI: 10.1201/9781003255536-13 99
100
cancer was frst reported.19 Endometrial tumors present many
challenges for SLN mapping, including a tumor not clinically
or radiographically visible to inject and complex, bilateral lym-
phatic drainage pathways. Early reports and studies of SLN
mapping in endometrial cancer consisted of small numbers
of patients and looked at various injection sites (e.g., myome-
trium, uterine serosa, cervix, and endometrium) or combina-
tions of these sites to determine optimal injection location.
The ultimate goal of these initial studies was to determine an
injection method that would incorporate both the ovarian and
pelvic drainage pathways. Investigators who have incorporated
a fundal and cervical injection to optimize dye uptake in the
pelvic and ovarian lymphatic drainage pathways have reported
mapping success rates in the range of 80%.20 Hysteroscopic
endometrial injection, with the advantage that a peritumoral
injection maps to the most relevant drainage pathways of the
primary tumor site, including the paraaortic (ovarian) drain-
age route, has been proposed as an alternative approach. This
approach, however, has not been broadly adopted, possibly
due to its associated technical challenges and poor reproduc-
ibility.21 The Memorial Sloan Kettering Cancer Center (MSK)
group pioneered and standardized the cervical injection tech-
nique for SLN mapping in endometrial cancer.2 Although ini-
tially met with resistance from gynecologic surgeons, many
institutions eventually realized the value of this simple injec-
tion approach, and adoption rates have increased.22,23 Rossi et
al. compared a cervical versus hysteroscopic injection using
indocyanine green (ICG) in patients with endometrial cancer
and demonstrated higher SLN detection rates with a cervi-
cal injection, as well as comparable drainage patterns, which
included aortic regions, suggesting cervical injection alone is
suffcient for lymphatic mapping.24
Cervical injection has been widely adopted for SLN map-
ping in endometrial cancer and has been shown in two meta-
analysis studies to enhance pelvic SLN detection compared
with alternative sites of injection.25,26 In one study, SLNs
detected with cervical injection were three times more likely
to harbor metastatic disease than non-SLNs, even without
ultrastaging, demonstrating increased intraoperative surgical
precision.21,27 The technique consists of injecting 1 cc of dye
superfcially (1–2 mm) and deep (1–2 cm) at the 3 and 9 o’clock
positions of the cervix for a total of 4 cc of dye. This is the most
common approach in current practice2 and was also used in the
Fluorescence Imaging for Lymphatic Mapping (FILM) ran-
domized trial of blue dye versus ICG.28 These early studies are
discussed in greater detail in excellent literature reviews.20,29,30
A variety of tracers and dyes, including technetium-99 and
colored dyes such as vital blue (isosulfan blue, methylene blue,
Lymphazurin) and ICG, have been studied in SLN mapping
for endometrial cancer. Bilateral SLN detection rates range
from 31% to 100%, depending on the study and injection agent
used.31 Clinical practice has shifted to the use of ICG with
near-infrared (NIR) imaging due to its consistent and supe-
rior bilateral mapping success rates, including in morbidly
obese patients, and excellent safety profle.32–36 The random-
ized, controlled FILM study compared both blue dye and ICG
within each of the 180 patients with clinical stage I endome-
trial or early-stage cervical cancer undergoing laparoscopic
staging that included SLN mapping. Patients were randomized
Clinical Lymphatic Mapping
to receive either ICG followed by blue dye or blue dye followed
by ICG. Higher rates of bilateral mapping were seen with ICG
(77%–80%) over blue dye (29%–32%) in both groups.28
SLN mapping patterns in endometrial cancer
The lymphatic drainage of the uterus is reviewed in detail in
Chapter 2. The uterus follows three general lymphatic drain-
age pathways.37,38 The frst drainage pathway is the main target
for pelvic SLN mapping in endometrial cancer. This pathway
drains the cervical plus mid/lower uterine lymphatics and
empties to pelvic nodal basins along the iliac and obtura-
tor vessels. Lymphatic trunks will condense in the paracer-
vix and cross medial to lateral over the cranial part of the
obliterated umbilical ligament (upper or ventral paracervical
pathway). Less commonly, these trunks condense in the para-
cervix and traverse dorsally in the meso-ureter to drain the
presacral common iliac nodes (lower or dorsal paracervical
pathway). The second drainage pathway is the fundal portion
of the uterus, including the serosa, which joins with the ovar-
ian vessels and drains to paraaortic nodal basins. The third
(and least dominant) pathway is the mid-uterine lymphatics,
which travel within the round ligament to the inguinal nodal
basins. Following a cervical injection of dye, the most com-
mon SLN locations in the pelvis are found along external
iliac, internal iliac, and obturator vessels and, less frequently,
along the common iliac vessels and presacral region of the
pelvis. A subset of patients (10%–15%) will map to the para-
aortic nodal regions. When these nodes are encountered, they
are frequently found above the level of the inferior mesenteric
artery (IMA).39,40
Understanding the two well-established mapping patterns
of paracervical lymphatic channel fow leading to SLNs41 can
help surgeons reliably locate true SLNs and reduce the risk
of false-negative nodes. The most common pelvic mapping
pattern occurs when lymphatic channels travel through the
paracervix and cross over the obliterated umbilical ligament
to an SLN located medial to the external iliac vessels, ven-
tral to the internal iliac vessels, or in the superior portion of
the obturator space. This is the upper or ventral paracervical
pathway. SLNs are frequently found along the dorsal cranial
surface of external iliac vessels, but the obturator space is
also a common location. If the retroperitoneal spaces are not
opened and explored, the surgeon may remove a secondary
echelon node and mistake it for the true SLN. The less com-
mon pelvic mapping pattern will demonstrate dye uptake
in lymphatic channels that do not cross over the obliterated
umbilical ligament and instead course cephalad within the
dorsal meso-ureter to drain to a common iliac or presacral
node. This is the lower or dorsal paracervical pathway. These
lymph nodes can be more challenging to identify, especially
in obese patients. Awareness of this less common map-
ping pattern can enable the surgeon to locate atypical SLN
locations and reduce rates of failed mapping (Figure 13.1).
Uncommon or atypical SLN mapping examples in endome-
trial cancer are depicted in Figure 13.2, as variability can
exist within a patient. Figure 13.3 provides technical pointers
for pelvic SLN mapping success.
Biopsy of the endometrium 101

FIGURE 13.1 Pelvic lymphatic mapping patterns in endometrial cancer using a cervical injection technique. (a) This illustrates the most common
lymphatic drainage pattern following an intracervical injection of colored dye. Channels condense in the paracervix and cross medial to lateral over
the obliterated umbilical ligament, draining to external iliac and obturator nodal basins. (c) A patient with endometrial cancer has mapped via the
more common mapping pattern. Channels have crossed over the umbilical ligament (arrow) and lead to a right external iliac sentinel lymph node. (b)
This illustrates the less common lymphatic drainage pattern following an intracervical injection of colored dye. Channels condense in the paracervix
and travel cranially in the meso-ureter to drain common iliac and presacral nodal basins. (d) A patient with endometrial cancer has mapped via the
less common mapping pattern. Channels are seen traveling cephalad in the meso-ureter (arrow) and leading to a right presacral common iliac sentinel
lymph node. In both patient examples (c and d), the sentinel node (star in each image) appears bright white in a black background using the ‘spy’ mode
(Stryker, Kalamazoo, MI) perfusion assessment mode (side panel, middle images), fuoresces bright green using indocyanine green with near-infrared
imaging (side panel, lower images), and bright red with heat map assessment using color-segmented fuorescence in which gray-blue is least intense
and red is most intense (main images).
102 Clinical Lymphatic Mapping

FIGURE 13.2 Uncommon and atypical sentinel lymph node mapping examples in endometrial cancer following a cervical injection of dye. Top row:
(a) Indocyanine green (ICG) uptake within a left external iliac lymph node (double star) initially labeled as the sentinel node was actually a secondary
echelon node. (b) Retroperitoneal spaces opened and explored, and the true sentinel lymph node was located in the obturator space, which is bright
green using near-infrared imaging (star). (c) Lymphatics are seen crossing over the obliterated umbilical ligament (arrows in a and b) and leading to
a node in the obturator space (star). Efferent channels are seen traveling from this obturator sentinel lymph node to the previously seen external iliac
node (a). Surgeons may miss the true sentinel lymph node if the retroperitoneal spaces are not opened and explored. (d) Example of an empty nodal
packet. Dilated lymphatic channels mapping to the left pelvic sidewall consolidated to create a more intense signal (medial to the umbilical ligament)
on both perfusion and heat-based mapping (seen as red using color-segmented fuorescence mode and bright white using ‘spy’ mode). No nodal tis-
sue was palpated upon removal. Palpating excised tissue bedside during surgery can improve sentinel node retrieval and reduce false-negative cases.
Middle row: (a) Example of methylene blue dye uptake in a single lymphatic channel (arrow) in the left pelvis, which is coursing cranially parallel
with the iliac vessels to the presacral region and leads to a common iliac sentinel lymph node. (b and c) Cervical injection site locations for sentinel
lymph node mapping in endometrial cancer. Our preference is to inject dye 1 cc superfcially and 1 cc deep at the 3 and 9 o’clock positions for a total
of 4 cc of dye. (d) ICG uptake in the right pelvis within the dominant lymphatic channel traveling within the meso-ureter to a subaortic sentinel lymph
node (star). Lower row: (a) ICG fuorescing lymphatic channel in the left pelvis crosses the obliterated umbilical ligament and travels along the iliac
vessels past the common iliac vessels (arrow), with no sentinel nodes seen in the pelvis. This channel led to a left paraaortic sentinel lymph node. (b)
A lymphatic channel with methylene blue uptake (arrow) is seen terminating adjacent to a grossly enlarged precaval lymph node (star). Nodes flled
with tumor may block uptake of dye coming from lymphatic channels. Suspicious or enlarged lymph nodes must be removed regardless of mapping. (c)
A right pelvic primary lymphatic channel seen crossing over the obliterated umbilical ligament (common mapping pattern) and bifurcated, leading to
two true sentinel lymph nodes (both were removed and underwent pathologic ultrastaging). (d) A right-sided internal iliac sentinel lymph node mapped
with isosulfan blue. (*Several panels courtesy of Drs. Mario M. Leitao Jr and Nadeem R. Abu-Rustum.)

• Inject dye slowly into the cervix using a good injection technique
• Perform sentinel lymph node mapping first
• You can reinject the cervix if there is no dye uptake
• Keep your surgical field clean, avoid disrupting lymphatic channels
• Take it slow and be precise with your movements
• Find the obliterated umbilical ligament then trace it cranially
• Follow the lymphatic channels as they cross the umbilical ligament (this will lead to
the sentinel node in most cases)
• Do not remove the first green node you see
• Open the retroperitoneal spaces and trace the channels
• Remember the less common mapping pattern

FIGURE 13.3 Tips for fnding the pelvic sentinel lymph node

the MSK group estimated that 30 cases were needed to achieve

SLN mapping: techniques and examples
Although a learning curve is associated with SLN mapping
in endometrial cancer, there is no consensus on the number
of cases needed to declare mastery. In their initial experience,
good detection rates and low false-negative rates.42 Another
single-institution surgical group used a logistic model to assess
the probability of successful SLN mapping and noted 40 cases
were needed to consistently achieve successful bilateral SLN
mapping.43 The Society of Gynecologic Oncology (SGO)
Biopsy of the endometrium
recommends a minimum of 20 SLN mapping procedures with
concurrent lymphadenectomy or a <5% false-negative rate.44
Given the potential for variability, it is important for each sur-
geon to analyze the pathologic and clinical outcomes of all
their SLN mapping cases in order to reduce the risk of false-
negative nodes and empty nodal packets.
SLN mapping can be performed via laparotomy or a mini-
mally invasive approach. If blue dye is used, special equip-
ment is not required. There are multiple laparoscopic imaging
systems (e.g., PINPOINT from Stryker, Kalamazoo, MI and
Visera System from Olympus Medical Systems, Hamburg,
Germany), as well as a robotic platform (DaVinci Surgical
System from Intuitive Surgical, Sunnyvale, CA), that incor-
porate ICG with NIR imaging. There are also handheld and
mountable NIR imaging systems (e.g., Stryker and Olympus
Medical Systems). Some imaging systems include a trimodal
view of NIR, white light (perfusion-based assessment), and
color-segmented fuorescence (a heat map showing intensity
of ICG uptake). The addition of color-segmented fuorescence
may enable surgeons to better differentiate lymphatic channels
from SLNs and SLNs from secondary echelon nodes.45
SLN detection using an algorithm
Early reports of SLN mapping in endometrial cancer focused
on the feasibility of the technique. Later work sought to deter-
mine whether SLN mapping was a reasonable alternative to
lymphadenectomy in apparent early-stage disease.
Numerous publications have demonstrated the technical fea-
sibility of SLN mapping in endometrial cancer; however, the
high false-negative rates reported in these early papers raised
concern. MSK incorporated a surgical staging algorithm for
endometrial cancer and applied it retrospectively to a cohort
of women staged with SLN plus lymphadenectomy. The appli-
cation of the algorithm reduced the false-negative rate in the
cohort from 15% to 2%.46 The MSK surgical staging algorithm
FIGURE 13.4 Memorial Sloan Kettering Cancer Center surgical algorithm for endometrial cancer. (Adopted by the National Comprehensive Cancer
Center; from Ref. 46, with permission.)
103
has provided a valuable framework for surgeons to move
beyond simply removing the SLN to considering important
factors such as clinically enlarged nodes, peritoneal spread
of disease, and management standards for failed mapping
in one or both hemipelvis. Beginning in 2014, the National
Comprehensive Cancer Network (NCCN) guidelines incor-
porated the MSK surgical staging algorithm for endometrial
cancer as an option for surgical staging (Figure 13.4).
SLN detection: false-negative rates
Acceptable false-negative rates for SLN mapping in endome-
trial cancer are derived from profciency metrics in SLN map-
ping for early-stage breast cancer. Based upon these metrics,
surgeons should meet a <5% false-negative rate threshold to
be considered profcient in the technique.47 False-negative
rates for SLN mapping in endometrial cancer range widely
in the literature, refecting surgeon experience, tracer selec-
tion, body mass index (BMI) of the patient population, and
whether a surgical staging algorithm was used. The contempo-
rary literature reports false-negative rates of less than 5% and
negative predictive values of 97%–100%.39,44,46 Holloway et
al. retrospectively compared patients with endometrial cancer
(n = 780) who had undergone lymphadenectomy alone com-
pared with SLN mapping plus lymphadenectomy. The two
groups were similar across all comparisons, except patients
who had undergone SLN mapping demonstrated a signifcant
increase in the detection of lymph node metastasis, which was
associated with an increase in the use of adjuvant therapy. In
SLN-positive cases, the SLN was the only positive node 50%
of the time and the SLN false-negative rate was 2.8%.48 The
FIRES trial was a single-arm prospective cohort study of 340
patients undergoing surgical staging with SLN mapping fol-
lowed by lymphadenectomy for apparent early-stage endome-
trial cancer (any grade or histology). Investigators performed
site visits to observe surgeons performing SLN mapping as
104
a quality metric prior to patient enrollment. The investiga­
tors reported a high rate of successful mapping to at least one
hemipelvis (86%), a low false-negative rate (3%), and a high
negative predictive value (99.6%).39 These results support SLN
mapping in endometrial cancer as an acceptable alternative to
lymphadenectomy.2,44,49
SLN mapping versus lymphadenectomy:
the great debate
Lymphadenectomy is associated with increased periopera­
tive risk, including bleeding, operative injury, lymphocele
development, and chronic leg lymphedema, which can have
a dramatic impact on quality of life. Prospective trials con­
ducted in patients with apparent early-stage endometrial can­
cer undergoing comprehensive nodal staging demonstrated
that nodal evaluation is prognostic but not associated with a
survival advantage,12,13 providing the impetus for the explo­
ration of SLN techniques in endometrial cancer. SLN map­
ping is associated with decreased morbidity and increased
precision in detecting nodal disease and provides valuable
prognostic information. Leitao et al. used a mailed survey to
describe the first patient-reported outcomes on postoperative
leg lymphedema in surgically staged patients with endome­
trial cancer, with encouraging results in support of SLN versus
lymphadenectomy.16
SLN mapping in endometrial cancer has concerned some in
the field, given the risk of missing a positive paraaortic SLN.50
Work by the Mayo Clinic showed that in women with apparent
early-stage endometrial cancer found to have a positive pel­
vic node, approximately 50% will have a positive paraaortic
node, most often located above the IMA.51 Conversely, in the
setting of negative pelvic nodes, an isolated positive paraaor­
tic node will be found in 2%–3% of patients.51,52 The value of
paraaortic lymphadenectomy to capture this small percentage
of patients is unclear. Pathologic ultrastaging of pelvic lymph
nodes was not performed in these frequently cited studies;
thus, micrometastatic disease may have gone undetected. In a
recent paper from the Mayo Clinic, ultrastaging of presumably
TABLE 13.1
Incidence of Sentinel Lymph Node Metastases Reported by Grade and Depth of Myometrial Invasion in Endometrioid Endometrial
Carcinoma (n = 959)
Grade 1
n (%)
Depth of invasion ITC Micro/macro
None 2/449 (<1) 0/449 (0)
Inner half 20/202 (10) 9/202 (4.5)
Outer half 19/62 (31) 6/62 (10)
Total 41/713 (6) 15/713 (2)
Notes: Depth of invasion: inner half defined as <50% myoinvasion; outer half defined as ≥50% myoinvasion; Grade: Refers to the International Federation
of Gynecology and Obstetrics (FIGO) grading system for endometrial carcinoma.
Abbreviation: ITC, isolated tumor cells.
Source: Reprinted from Ref. 8, with permission from Elsevier.
Clinical Lymphatic Mapping
negative pelvic nodes in a cohort of patients with isolated
positive paraaortic nodes led to an approximate 30% detec­
tion rate of pelvic nodal metastasis, previously undetected,
which reduced the rate of isolated paraaortic nodal metastases
to 1.5% in this series.53 Mueller et al.8 from MSK published a
clinical and pathologic study of 1044 patients with endome­
trial cancer staged with bilateral SLN mapping over a 10-year
period and reported that 6% (61 of 1044 patients) had isolated
tumor cells (ITCs) that would be missed with routine hema­
toxylin and eosin pathologic nodal processing (Table 13.1).8
Kim et al. from MSK reported on a cohort of 508 patients with
clinical stage I endometrial cancer retrospectively subjected to
pathologic SLN ultrastaging and detected an additional 4.5%
incidence of nodal metastases with the use of ultrastaging.54
However, this remains an area of debate in the field, particu­
larly in high-risk endometrial histology. For now, we accept
the small percentage of patients (1%–3%) with potentially
missed isolated paraaortic nodal metastasis using SLN map­
ping in endometrial cancer and leave the decision of whether to
proceed with a paraaortic lymphadenectomy to the surgeon’s
discretion after careful consideration of the surgical staging
algorithm (Figure 13.4). It is important to note that this is not
a unique, recent clinical scenario and that paraaortic metas­
tases were unfortunately missed even in the pre-SLN era. In
fact, the findings of an SGO survey by Soliman et al. showed
that only 11% of gynecologic oncologists routinely performed
a paraaortic dissection to renal vessels as part of staging.55
SLN mapping and oncologic outcomes
Endometrioid histology
There are limited publications comparing oncologic outcomes
between patients who have undergone SLN mapping and
those who have undergone lymphadenectomy. The literature
regarding oncologic safety is limited to observational data,
and there have not been any high-level prospective trials com­
paring the two techniques.56,57 As a reminder, pelvic lymph­
adenectomy for staging did not become a standard of care
Grade 2 Grade 3
n (%) n (%)
ITC Micro/macro ITC Micro/macro
0/61 (0) 0/61 (0) 0/20 (0) 1/20 (5)
4/76 (5) 3/76 (4) 2/31 (6) 1/31 (3)
7/41 (17) 8/41 (20) 3/17 (18) 4/17 (24)
11/178 11/178 (6) 5/68 (7) 6/68 (9)
(6)
Biopsy of the endometrium
based on prospective randomized trials showing an oncologic
beneft. For SLN mapping, the best available data we have for
now come from the collaborative work of the Mayo Clinic and
MSK, who have reported on the staging, treatment, and onco-
logic outcomes of two different low-grade endometrial cancer
populations. The Mayo Clinic used data from a period when
surgical practice was to perform a comprehensive pelvic and
aortic node dissection for high-risk uterine factors; MSK used
data from a period when surgical practice was to perform SLN
mapping. In the pooled results of 1135 women with endome-
trioid endometrial cancer with <50% myoinvasion, metasta-
ses to pelvic nodes were detected in 5.1% of MSK patients
compared with 2.6% of Mayo patients (p = 0.03). A similar
number of positive paraaortic nodal metastases were detected
in both groups despite fewer paraaortic nodes removed in
the MSK-staged patients. The 3-year disease-free survival
rates were not signifcantly different (94.9% [95% confdence
interval (CI), 92.4–97.5] for SLN-mapped patients compared
with 96.8% [95% CI, 95.2–98.5] for lymphadenectomy-staged
patients).58
This same collaboration between the Mayo Clinic and MSK
studied 176 patients with endometrioid endometrial cancer with
outer-half myoinvasion. On multivariable analysis, stage  III
disease and receipt of adjuvant treatment were associated with
overall survival in the combined cohort. When analyzing node-
negative patients, there was no association between overall sur-
vival and the method of nodal assessment if patients received
adjuvant therapy. The adjusted hazard ratios for progression-
free survival, nonvaginal progression-free survival, and overall
survival were 0.69 (95% CI, 0.23–2.03), 0.67 (95% CI, 0.19–
2.33), and 0.81 (95% CI, 0.16–4.22), respectively.59
A Canadian research group retrospectively compared 275
patients with surgically staged endometrial cancer who had
undergone SLN mapping with 197 patients who had undergone
lymphadenectomy. They observed no difference in survival
between the groups but reported a pelvic sidewall recurrence
rate of 30% in SLN-staged patients compared with 71% in
lymphadenectomy-staged patients. The authors concluded that
the SLN mapping approach was the most accurate method in
detecting nodes at greatest risk for disease.56
High-risk histology
Some question the oncologic safety of SLN mapping in high-
risk endometrial cancers, given the increased risk of recur-
rence and death compared with low-risk disease, even when
uterine confned. There is concern that the false-negative rates
in these high-risk cancers may be higher than reported in the
literature, as most studies report from experience with low-
grade histologic subtypes. There is also concern that endome-
trial cancers of high-risk histology may harbor occult aortic
nodal metastasis with a higher frequency than cancers of low-
risk histology.60
Researchers at the MD Anderson Cancer Center conducted
a prospective study of 101 patients with clinical stage I high-
grade endometrial subtypes who underwent staging surgery,
including SLN mapping using a surgical staging algorithm,
followed by pelvic and aortic lymphadenectomy.61 At least
one SLN was removed in 89% of patients. There was a 23%
105
node-positivity rate (the only positive node in 40% of cases),
and the false-negative rate was 4.3%. The authors concluded
SLN mapping was a safe alternative to lymphadenectomy,
with an acceptable false-negative rate in this patient popu-
lation. The prospective FIRES trial included a substantial
number (n = 100) of patients with endometrial cancer of high-
grade histology and reported an overall false-negative rate
of 3%.39 The SENTOR trial62 was a prospective study of 156
patients with clinical stage I endometrial cancer with inter-
mediate- and high-risk histologic subtypes that examined
the sensitivity of the SLN algorithm in this high-risk popula-
tion. Patients underwent minimally invasive staging surgery,
including SLN mapping, followed by pelvic lymphadenec-
tomy in patients with FIGO grade 2 histology and pelvic and
paraaortic lymphadenectomy for all other subtypes, with a
median of 16 pelvic and 5 paraaortic lymph nodes removed.
An SLN was detected in 97% of patients (78% bilateral detec-
tion rate), the false-negative rate was 4% (95% CI, 0.1–1–19),
and the negative predictive value was 99% (95% CI, 96–100).
Of the 27 node-positive patients in the study, 52% had metas-
tases in the SLN alone. The authors concluded that SLN map-
ping in intermediate- and high-grade endometrial cancer has
excellent diagnostic accuracy and may be a suitable replace-
ment for lymphadenectomy in low- and high-grade endome-
trial cancer. No oncologic outcomes were reported in these
prospective trials.
A group from Johns Hopkins University published a retro-
spective study of 52 patients with clinical stage I high-grade
endometrial cancer undergoing surgical staging with SLN
mapping using a staging algorithm, followed by lymphad-
enectomy.63 The authors reported a false-negative rate of 22%
(two of nine node-positive patients) but also reported that
SLN mapping did not affect adjuvant therapy choice or risk of
recurrence in the node-positive patients.
The MSK and Mayo groups published their retrospective
experience on staging, treatment, and oncologic outcomes in
high-risk endometrial cancer histologies with SLN mapping
(MSK) compared with lymphadenectomy (Mayo Clinic).
Ducie et al. published on patients with deeply invasive FIGO
grade 3 plus any serous or clear cell histology with any myo-
invasion, with approximately 200 patients from each institu-
tion.64 The authors reported no difference in FIGO stage IIIC
detection (21.7% SLN versus 19.4% lymphadenectomy; p =
0.68) and similar rates of paraaortic lymph node metastases
in their high-risk cohort (8.3% SLN versus 12.6% lymph-
adenectomy; p = 0.29). Schiavone et al. published the MSK
experience of 248 patients with serous endometrial cancer; 95
were staged with lymphadenectomy and 153 with SLN map-
ping.65 Similar rates of FIGO stage IIIC detection, receipt of
adjuvant therapy, and oncologic outcomes were noted among
the two groups. The 2-year progression-free survival rate was
77% (CI 68%–83%) for SLN-staged patients and 71% (95%
CI, 61%–79%) for lymphadenectomy-staged patients. In 2019,
Basaran et al. published results from a retrospective cohort
of 245 patients with serous endometrial carcinoma surgically
staged according to the ‘ideal use’ of the MSK surgical stag-
ing algorithm (bilateral SLN retrieval without lymphadenec-
tomy, n = 79) versus lymphadenectomy alone (n = 166).66 The
2-year overall survival rates were 96.6% for the SLN group
106 Clinical Lymphatic Mapping

FIGURE 13.5 Representative example of clinical positron lymphography (PLG) with positron emission tomography/computed tomography (PET/
CT) and intracervical injection of 18F-fuoro-2-deoxy-D-glucose (18F-FDG) in a patient with uterine carcinosarcoma. (a and b) PLG demonstrated three
sentinel lymph nodes (SLNs) in the right pelvis, (b) one of which demonstrated a prolonged and delayed uptake pattern, as shown in the time-activity
curves (c). (d) Intraoperative measurements of counts per minute (CPM) of the excised lymph nodes demonstrated higher uptake in the suspicious
node even 5 hours after tracer injection. (e) 3D surface reconstruction of the PET/CT at 25 minutes showing the higher uptake in the suspicious node
(blue circle) and the same node shown on the axial CT (f). (g) Intraoperative view of the node stained by vital blue dye. Histology – low (h) and
high magnifcation (i and j) confrming the presence of metastatic carcinoma within the suspicious node. (This research was originally published in
JNM. Mueller JJ, Dauer LT, Murali R, Iasonos A, Pandit-Taskar N, Abu-Rustum N, Grimm J. Positron Lymphography via Intracervical 18 F-FDG
Injection for Pre-Surgical Lymphatic Mapping in Cervical and Endometrial Malignancies. J Nucl Med. 2020 Jan 10:jnumed.119.230714. doi: 10.2967/
jnumed.119.230714. Online ahead of print.)

versus 89.6% for the lymphadenectomy group in stage I and II
patients (p = 0.8) and 73.6% for the SLN group versus 77.3%
for the lymphadenectomy group in stage III patients (p = 0.8).
In a study of 136 patients with endometrial carcinosarcoma
staged with SLN mapping or lymphadenectomy,67 Schiavone
et al. reported that node-positive disease detection was similar
between the two groups, and the 2-year progression-free sur-
vival was 23 months for each group.
No prospective trials have examined oncologic outcomes
in patients staged with SLN mapping. Some have raised con-
cern for nodal recurrences either in the aortic region or pel-
vis due to false-negative SLNs at initial surgery. Aloisi et al.
published on patterns of frst recurrence in a cohort of 207
stage IIIC1 patients staged with SLN mapping alone (no aortic
nodal dissection) and reported a 30% recurrence rate. Of these
frst recurrences, only 8% were pure node, of which 4% were
isolated aortic disease.68 There are limited data on this topic.
At this time, SLN mapping using the MSK NCCN surgical
staging algorithm for endometrial cancer is deemed a reason-
able alternative to lymphadenectomy, with predominantly ret-
rospective, observational research to support this practice.44
Future directions
Investigators are focused on improving SLN mapping tech-
niques using novel approaches to radiotracers and imaging
modalities. For example, positron lymphography uses the
widely available radiotracer 18F-fuorodeoxyglucose (18F-
FDG) to locally inject the cervix, followed by dynamic posi-
tron emission tomography/computed tomography imaging
(Figure 13.5). This technique has been shown to not only map
to the SLN on imaging but has also been able to delineate an
SLN that harbors metastasis. Mueller et al. from MSK pub-
lished the frst in-human results from 20 patients with endome-
trial and cervical cancers using this technique and detected all
cases (3 patients) with pathologically confrmed SLN metasta-
ses, including 2 patients with micrometastatic disease.69
Use of novel imaging modalities may enhance metastatic
node detection. MSK is currently looking at clinical applica-
tions of Cerenkov luminescence imaging. Cerenkov light is
emitted by many different radiopharmaceuticals, including 18F-
FDG. When these charged particles travel through a nondialec-
tric medium (such as water in a cell), they emit light within the
visible blue spectrum, which can be captured with Cerenkov
imaging systems. Grimm and colleagues published their work
using integrated positron lymphography with Cerenkov imag-
ing in a melanoma murine model and showed a clear delin-
eation of normal versus malignant nodal tissue confrmed on
histopathology.70 Technological advances such as these may
help add even more value to SLN mapping for our patients.
REFERENCES
1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA
Cancer J Clin. 2020;70(1):7–30.
Biopsy of the endometrium
2. Koh WJ, Abu-Rustum NR, Bean S, et al. Uterine Neoplasms,
Version 1.2018, NCCN clinical practice guidelines in oncol-
ogy. J Natl Compr Canc Netw. 2018;16(2):170–99.
3. Surveillance, Epidemiology, and End Results Program.
Cancer Stat Facts: Uterine Cancer [cited 2020 May 22].
Available from: https://seer.cancer.gov/statfacts/html/corp.
html.
4. Levenback C, van der Zee AGJ, Coleman RL. Clinical
Lymphatic Mapping of Gynecologic Cancers. London:
CRC Press; 2004.
5. Creasman WT, Morrow CP, Bundy BN, et al. Surgical patho-
logic spread patterns of endometrial cancer. A Gynecologic
Oncology Group Study. Cancer. 1987;60(8 Suppl):2035–41.
6. Chi DS, Barakat RR, Palayekar MJ, et al. The incidence of
pelvic lymph node metastasis by FIGO staging for patients
with adequately surgically staged endometrial adenocar-
cinoma of endometrioid histology. Int J Gynecol Cancer.
2008;18(2):269–73.
7. Creasman WT, Ali S, Mutch DG, et al. Surgical-
pathological fndings in type 1 and 2 endometrial cancer:
an NRG Oncology/Gynecologic Oncology Group study on
GOG-210 protocol. Gynecol Oncol. 2017;145(3):519–25.
8. Mueller JJ, Pedra Nobre S, Braxton K, et al. Incidence of
pelvic lymph node metastasis using modern FIGO staging
and sentinel lymph node mapping with ultrastaging in sur-
gically staged patients with endometrioid and serous endo-
metrial carcinoma. Gynecol Oncol. 2020;157(3):619–23.
9. Creutzberg CL, van Putten WL, Koper PC, et al. Surgery
and postoperative radiotherapy versus surgery alone for
patients with stage-1 endometrial carcinoma: multicentre
randomised trial. PORTEC Study Group. Post Operative
Radiation Therapy in Endometrial Carcinoma. Lancet.
2000;355(9213):1404–11.
10. Nout RA, Smit V, Putter H, et al. Vaginal brachytherapy
versus pelvic external beam radiotherapy for patients with
endometrial cancer of high-intermediate risk (PORTEC-2):
an open-label, non-inferiority, randomised trial. Lancet.
2010;375:816–23.
11. Keys HM, Roberts JA, Brunetto VL, et al. A phase III
trial of surgery with or without adjunctive external pelvic
radiation therapy in intermediate risk endometrial adeno-
carcinoma: a Gynecologic Oncology Group study. Gynecol
Oncol. 2004;92:744–51.
12. Benedetti Panici P, Basile S, Maneschi F, et al. Systematic
pelvic lymphadenectomy vs. no lymphadenectomy in early-
stage endometrial carcinoma: randomized clinical trial. J
Natl Cancer Inst. 2008;100(23):1707–16.
13. Barton DP, Naik R, Herod J. Effcacy of systematic pel-
vic lymphadenectomy in endometrial cancer (MRC
ASTEC Trial): a randomized study. Int J Gynecol Cancer.
2009;19(8):1465.
14. Abu-Rustum NR, Alektiar K, Iasonos A, et al. The inci-
dence of symptomatic lower-extremity lymphedema fol-
lowing treatment of uterine corpus malignancies: a 12-year
experience at Memorial Sloan-Kettering cancer center.
Gynecol Oncol. 2006;103:714–18.
15. Dessources K, Aviki E, Leitao Jr MM. Lower extremity
lymphedema in patients with gynecologic malignancies. Int
J Gyecol Cancer. 2020;30(2):252–60.
16. Leitao MM Jr, Zhou QC, Gomez-Hidalgo NR, et al. Patient-
reported outcomes after surgery for endometrial carcinoma:
107
prevalence of lower-extremity lymphedema after sentinel
lymph node mapping versus lymphadenectomy. Gynecol
Oncol. 2020;156(1):147–53.
17. Accorsi GS, Paiva LL, Schmidt R, et al. Sentinel lymph
node mapping vs systematic lymphadenectomy for endo-
metrial cancer: surgical morbidity and lymphatic complica-
tions. J Minim Invasive Gynecol. 2020;27(4):938–45.
18. Cabanas RM. An approach for the treatment of penile car-
cinoma. Cancer. 1977;39(2):456–66.
19. Burke TW, Levenback C, Tornos C, et al. Intraabdominal
lymphatic mapping to direct selective pelvic and para-
aortic lymphadenectomy in women with high-risk endo-
metrial cancer: results of a pilot study. Gynecol Oncol.
1996;62(2):169–73.
20. Abu-Rustum NR, Khoury-Collado F, Gemignani ML.
Techniques of sentinel lymph node identifcation for
early-stage cervical and uterine cancer. Gynecol Oncol.
2008;111(2 Suppl):S44–50.
21. Buda A, Lissoni A, Milani R. Sentinel lymph node detec-
tion in endometrial cancer: hysteroscopic peritumoral ver-
sus cervical injection. J Gynecol Oncol. 2016;27(1):e11.
22. Renz M, Diver E, English D, et al. Sentinel lymph node
biopsies in endometrial cancer: practice patterns among
gynecologic oncologists in the United States. J Minim
Invasive Gynecol. 2020;27(2):482–8.
23. Casarin J, Multinu F, Abu-Rustum NR, et al. Factors
infuencing the adoption of the sentinel lymph node tech-
nique for endometrial cancer staging: an international
survey of gynecologic oncologists. Int J Gynecol Cancer.
2019;29(1):60–7.
24. Rossi EC, Jackson A, Ivanova A, et al. Detection of sentinel
nodes for endometrial cancer with robotic assisted fuores-
cence imaging: cervical versus hysteroscopic injection. Int
J Gynecol Cancer. 2013;23(9):1704–11.
25. Bodurtha Smith AJ, Fader An, Tanner EJ. Sentinel
lymph node assessment in endometrial cancer: a sys-
tematic review and metaanalysis. AM J Obstet Gynecol.
2017;216(5):459–76.
26. Kang S, Yoo HJ, Hwang JH, et al. Sentinel lymph node
biopsy in endometrial cancer: meta analysis of 26 studies.
Gynecol Oncol. 2011;123(3):522–7.
27. Khoury-Collado F, Murray MP, Hensley ML, et al. Sentinel
lymph node mapping for endometrial cancer improves the
detection of metastatic disease to regional lymph nodes.
Gynecol Oncol. 2011;122(2):251–4.
28. Frumovitz M, Plante M, Lee PS, et al. Near-infrared fuo-
rescence for detection of sentinel lymph nodes in women
with cervical and uterine cancers (FILM): a randomised,
phase 3, multicentre, non-inferiority trial. Lancet Oncol.
2018;19(10):1394–403.
29. Khoury-Collado F, Abu-Rustum NR. Lymphatic map-
ping in endometrial cancer: a literature review of current
techniques and results. Int J Gynecol Cancer. 2008;18(6):
1163–8.
30. Papadia A, Gasparri ML, Buda A, et al. Sentinel lymph
node mapping in endometrial cancer: comparison of
fuorescence dye with traditional radiocolloid and blue. J
Cancer Res Clin Oncol. 2017;143(10):2039–48.
31. Rossi EC. Current state of sentinel lymph nodes for
women with endometrial cancer. Int J Gynecol Cancer.
2019;29(3):613–21.
108
32. Eriksson AG, Beavis A, Soslow RA, et al. A comparison
of the detection of sentinel lymph nodes using indocyanine
green and near-infrared fuorescence imaging versus blue
dye during robotic surgery in uterine cancer. Int J Gynecol
Cancer. 2017;27(4):743–7.
33. Eriksson AG, Montovano M, Beavis A, et al. Impact of obe-
sity on sentinel lymph node mapping in patients with newly
diagnosed uterine cancer undergoing robotic surgery. Ann
Surg Oncol. 2016;23(8):2522–8.
34. Rozenholc A, Samouelian V, Warkus T, et al. Green versus
blue: randomized controlled trial comparing indocyanine
green with methylene blue for sentinel lymph node detection
in endometrial cancer. Gynecol Oncol. 2019;153(3):500–4.
35. Plante M, Touhami O, Trinh XB, et al. Sentinel node
mapping with indocyanine green and endoscopic near-
infrared fuorescence imaging in endometrial cancer. A
pilot study and review of the literature. Gynecol Oncol.
2015;137(3):443–7.
36. Buda A, Bussi B, Di Martino G, et al. Sentinel lymph node
mapping with near-infrared fuorescent imaging using
indocyanine green: a new tool for laparoscopic platform
in patients with endometrial and cervical cancer. J Minim
Invasive Gynecol. 2016;23(2):265–9.
37. Henriksen E, Murrieta T. Adenocarcinoma of the cor-
pus uteri; a clinicopathological study. West J Surg Obstet
Gynecol. 1950;58(7):331–43.
38. Masubuchi S, Fujimoto I, Masubuchi K. Lymph node
metastasis and prognosis of endometrial carcinoma.
Gynecol Oncol. 1979;7(1):36–46.
39. Rossi EC, Kowalski LD, Scalici J, et al. A comparison of
sentinel lymph node biopsy to lymphadenectomy for endo-
metrial cancer staging (FIRES trial): a multicentre, pro-
spective, cohort study. Lancet Oncol. 2017;18(3):384–92.
40. Jewell EL, Huang JJ, Abu-Rustum NR, et al. Detection of
sentinel lymph nodes in minimally invasive surgery using
indocyanine green and near-infrared fuorescence imag-
ing for uterine and cervical malignancies. Gynecol Oncol.
2014;133(2):274–7.
41. Abu-Rustum NR. Sentinel lymph node mapping for endo-
metrial cancer: a modern approach to surgical staging. J
Natl Compr Canc Netw. 2014;12(2):288–97.
42. Khoury-Collado F, Glaser GE, Zivanovic O, et al
Improving sentinel lymph node detection rates in endome-
trial cancer: how many cases are needed? Gynecol Oncol.
2009;115(3):453–5.
43. Tucker K, Staley SA, Gehrig PA, et al. Defning the learn-
ing curve for successful staging with sentinel lymph node
biopsy for endometrial cancer among surgeons at an aca-
demic institution. Int J Gynecol Cancer. 2020;30(3):346–51.
44. Holloway RW, Abu-Rustum NR, Backes FJ, et al. Sentinel
lymph node mapping and staging in endometrial can-
cer: a Society of Gynecologic Oncology literature review
with consensus recommendations. Gynecol Oncol.
2017;146(2):405–15.
45. Lopez Labrousse MI, Frumovitz M, Guadalupe Patrono M,
et al. Sentinel lymph node mapping in minimally invasive
surgery: role of imaging with color-segmented fuorescence
(CSF). Gynecol Oncol. 2017;146(3):676–7.
46. Barlin JN, Khoury-Collado F, Kim CH, et al. The impor-
tance of applying a sentinel lymph node mapping algorithm
Clinical Lymphatic Mapping
in endometrial cancer staging: beyond removal of blue
nodes. Gynecol Oncol. 2012;125(3):531–5.
47. Lyman GH, Giuliano AE, Somerfeld MR, et al. American
Society of Clinical Oncology guideline recommendations
for sentinel lymph node biopsy in early-stage breast cancer.
J Clin Oncol. 2005;23(30):7703–20.
48. Holloway RW, Gupta S, Stavitzski NM, et al. Sentinel
lymph node mapping with staging lymphadenectomy for
patients with endometrial cancer increases the detection of
metastasis. Gynecol Oncol. 2016;141(2):206–10.
49. SGO Clinical Practice Statement: The Role of Sentinel
Lymph Node Mapping in Endometrial Cancer; 2015 [cited
2020 Feb 10]. Available from: www.sgo.org/clinical-prac-
tice/guidelines/the-role-of-sentinel-lymph-node-mapping-
in-endometrial-cancer/.
50. Frumovitz M, Coleman RC, Soliman PT, et al. A case for
caution in the pursuit of the sentinel node in women with
endometrial carcinoma. Gynecol Oncol. 2014;132(2):275–9.
51. Kumar S, Podratz KC, Bakkum-Gamez JN, et al.
Prospective assessment of the prevalence of pelvic, para-
aortic and high paraaortic lymph node metastasis in endo-
metrial cancer. Gynecol Oncol. 2014;132(1):38–43.
52. James JA, Rakowski JA, Jeppson CN, et al. Robotic transperi-
toneal infra-renal aortic lymphadenectomy in early-stage
endometrial cancer. Gynecol Oncol. 201;136(2):285–92.
53. Multinu F, Casarin J, Cappuccio S, et al. Ultrastaging of
negative pelvic lymph nodes to decrease the true prevalence
of isolated paraaortic dissemination in endometrial cancer.
Gynecol Oncol. 2019:154(1):60–4.
54. Kim CH, Soslow RA, Park KJ, et al. Pathologic ultrastag-
ing improves micrometastasis detection in sentinel lymph
nodes during endometrial cancer staging. Int J Gynecol
Cancer. 2013;23(5):964–70.
55. Soliman PT, Frumovitz M, Spannuth W, et al.
Lymphadenectomy during endometrial cancer staging:
practice patterns among gynecologic oncologists. Gynecol
Oncol. 2010;119(2):291–4.
56. How J, Gauthier C, Abitbol J, et al. Impact of sentinel
lymph node mapping on recurrence patterns in endometrial
cancer. Gynecol Oncol. 2017;144(3):503–9.
57. Buda A, Restaino S, Di Martino G, et al. The impact of
the type of nodal assessment on prognosis in patients with
high-intermediate and high-risk ESMO/ESGO/ESTRO
group endometrial cancer. A multicenter Italian study. Eur
J Surg Oncol. 2018;44(10):1562–7.
58. Eriksson AGZ, Ducie J, Ali N, et al. Comparison of a
sentinel lymph node and a selective lymphadenectomy
algorithm in patients with endometrioid endometrial car-
cinoma and limited myometrial invasion. Gynecol Oncol.
2016;140(3):394–9.
59. Schlappe BA, Weaver AL, Ducie JA, et al. Multicenter
study comparing oncologic outcomes between two nodal
assessment methods in patients with deeply invasive endo-
metrioid endometrial carcinoma: a sentinel lymph node
algorithm versus a comprehensive pelvic and paraaortic
lymphadenectomy. Gynecol Oncol. 2018;151(2):235–42.
60. Mariani A, Dowdy SC, Cliby WA, et al Prospective assess-
ment of lymphatic dissemination in endometrial can-
cer: a paradigm shift in surgical staging. Gynecol Oncol.
2008;109(1):11–18.
Biopsy of the endometrium
61. Soliman PT, Westin SN, Dioun S, et al. A prospective vali-
dation study of sentinel lymph mapping for high-risk endo-
metrial cancer. Gynecol Oncol. 2017;146(2):234–9.
62. Cusimano MC, Vicus D, Pulman K, et al. Assessment
of sentinel lymph node biopsy vs lymphadenectomy for
intermediate- and high-grade endometrial cancer staging.
JAMA Surg. 2021;156(2):157–64. https://doi.org/10.1001/
jamasurg.2020.5060.
63. Tanner EJ, Ojalvo L, Stone RL, et al. The utility of senti-
nel lymph mapping in high-grade endometrial cancer. Int J
Gynecol Cancer. 2017;27(7):1416–21.
64. Ducie JA, Eriksson AGZ, Ali N, et al. Comparison of a sen-
tinel lymph node mapping algorithm and comprehensive
lymphadenectomy in the detection of stage IIIC endome-
trial carcinoma at higher risk for nodal disease. Gynecol
Oncol. 2017;147(3):541–8.
65. Schiavone MB, Scelzo C, Straight C, et al. Survival
of patients with serous uterine carcinoma undergo-
ing sentinel lymph node mapping. Ann Surg Oncol.
2017;24(7):1965–71.
109
66. Basaran D, Bruce S, Aviki EM, et al. Sentinel lymph node
mapping alone compared to more extensive lymphadenec-
tomy in patients with uterine serous carcinoma. Gynecol
Oncol. 2020;156(1):70–6.
67. Schiavone MB, Zivanovic O, Zhou Q, et al. Survival of
patients with uterine carcinosarcoma undergoing sentinel
lymph node mapping. Ann Surg Oncol. 2016;23(1):196–202.
68. Aloisi A, Casanova JM, Tseng JH, et al. Patterns of
FIRST recurrence of stage IIIC1 endometrial cancer with
no PARAAORTIC nodal assessment. Gynecol Oncol.
2018;151(3):395–400.
69. Mueller JJ, Dauer LT, Murali R, et al. Positron lymphog-
raphy via intracervical 18F-FDG injection for pre-surgical
lymphatic mapping in cervical and endometrial malig-
nancies. J Nucl Med. 2020;61(8);1123–30. https://doi.
org/10.2967/jnumed.119.230714.
70. Lockau H, Neuschmelting V, Ogirala A, et al. Dynamic
18F-FDG PET lymphography for in vivo identifcation of
lymph node metastases in murine melanoma. J Nucl Med.
2018;59(2):210–15.
14
Impact of sentinel lymph node mapping on quality of life

Mariana Antonella Nigra, Pedro T. Ramirez, and Larissa Meyer

CONTENTS
Quality of life in gynecologic cancer ........................................................................................................................................... 111
Sentinel lymph node mapping and lymphedema ......................................................................................................................... 112
Vulvar cancer: quality of life after sentinel lymph node mapping ............................................................................................... 112
Endometrial cancer: quality of life after sentinel lymph node mapping ...................................................................................... 113
Cervical cancer: quality of life after sentinel lymph node mapping ............................................................................................ 113
Patient-reported outcomes in gynecologic cancer ....................................................................................................................... 114
Conclusion ................................................................................................................................................................................... 115
References.................................................................................................................................................................................... 115

Quality of life in gynecologic cancer
Early detection and novel therapies in the management of
patients with gynecologic cancers have led to signifcant
improvements in survival. As a result, there are an increas-
ing number of cancer survivors for whom quality of life (QoL)
is a major determinant on return to normal daily activities.1
QoL is defned as overall general well-being, which comprises
objective descriptions and subjective evaluations of physical,
material, social, and emotional well-being, together with the
extent of personal development, all weighted by a personal set
of values.2 The principle of QoL has been studied since the
1960s, and it has been routinely associated with the discussion
of numerous items ranging from the relative ‘liveability’ and
effects of social policy, to the benefts of different models of
human service providers, to the individualized outcomes of a
vast number of medical and psychotherapeutic practices.3
Currently, it is possible to quantify QoL to establish numeri-
cal parameters for the evaluation of medical interventions. In
order to measure QoL, several questionnaires have been cre-
ated to obtain data on physical functioning, role limitations
due to physical problems, social functioning, bodily pain, gen-
eral mental health, role limitations due to emotional problems,
and vital and general health perceptions.4 A frst-generation
core questionnaire, the European Organization for Research
and Treatment of Cancer (EORTC) QLQ-C36, was developed
in 1987.5 This 36-item questionnaire was designed to be cancer
specifc and applicable across cultural settings. The only scale
that required substantial revision, due to inadequate reliabil-
ity, was the eight-item emotional functioning scale. In the next
generation of the instrument, this scale was replaced by a four-
item emotional functioning scale previously used in EORTC
clinical trials. A second-generation core questionnaire, the
frst version of the 30-item EORTC QLQ-C30, was subse-
quently developed.6 The QLQ-C30 version 1.0 incorporates
fve functional scales (physical, role, cognitive, emotional,
and social), three symptom scales (fatigue, pain, and nausea/
vomiting), a global health status, and a number of single items
assessing additional symptoms commonly reported by cancer
patients (dyspnea, loss of appetite, insomnia, constipation, and
diarrhea) and perceived fnancial impact of the disease.7
QoL assessments are a key factor in assessing cancer bur-
den and the effect of treatment.4 The literature has extensively
described the toxicities and side effects related to such treat-
ments, as is the case of lower limb lymphedema. This is a
condition, often irreversible, that affects many patients after
lymphadenectomy for gynecologic cancer, and it has been con-
sistently shown to affect multiple QoL metrics.8 The overall
incidence of treatment-related lymphedema is approximately
25% in endometrial or cervical cancer, but it may be as high
as 70% in vulvar cancer if a lymphadenectomy is performed.9
The clinical presentations of lower limb lymphedema are usu-
ally chronic and progressive, leading to a reduction in QoL.10
Ryan et al. showed in a retrospective study that among patients
with vulva, endometrial, and cervical cancer, 17% had lower
extremity lymphedema and 51% reported alterations in their
daily activities.11 A cohort study evaluated QoL of women
treated with either pelvic lymphadenectomy and pelvic radia-
tion therapy or pelvic radiation alone for gynecologic cancer
(endometrial, ovarian, cervical, vulvar).12 The authors used a
questionnaire addressing physical symptoms that originated
in the pelvis, demographic, psychological, and QoL factors. A
total of 616 gynecologic cancer survivors answered the ques-
tionnaire, and 36% reported lower limb lymphedema. Overall
QoL was signifcantly lower among cancer survivors with
lower limb lymphedema. They were also less satisfed with
their sleep, more concerned with the recurrence of cancer, and
more likely to interpret the body’s symptoms as recurrence.
Cancer survivors reported that lymphedema of the lower
extremities prevented them from physical activity (45%) and

DOI: 10.1201/9781003255536-14 111

112
housework (29%) and affected their ability to participate in
social activities (27%) or meet friends (20%). The authors thus
showed a negative impact of lymphedema on QoL and activi-
ties of daily living.
Aesthetic and functional changes secondary to surgical
treatment can lead to depression, anxiety, and a negative body
image. In its severe stages, lymphedema can affect a patient’s
ability to perform the functions of daily living.13 In a retro-
spective study, 152 patients who underwent lymphadenec-
tomy for endometrial, cervical, or ovarian cancer reported the
incidence of lower limb lymphedema and neurological com-
plications collected by questionnaire for three months after
surgery.14 The incidence of lower limb lymphedema and neu-
rological complications after lymphadenectomy was 36%.
Sentinel lymph node mapping and
lymphedema
For the purpose of reducing the morbidity associated with
lymphadenectomy, less invasive operative techniques, such as
lymphatic mapping and sentinel lymph node (SLN) mapping,
have been developed.15 A prospective study of patients with
stage I–IIIA melanoma of the extremities, trunk, or neck who
underwent SLN mapping evaluated the development of lymph-
edema and QoL 6 months after surgery using a functional
evaluation questionnaire for breast cancer therapy (FACT-B).16
A total of 14 (2%) of 694 patients had lymphedema. Stage I–II
patients with complete QoL data demonstrated that weighted
QoL was strongly associated with perceived changes rather
than actual changes in limb size. Subsequently, the sentinel
node was implemented in other cancers, such as breast cancer,
where a signifcant reduction in the prevalence of lymphedema
(<10%) was shown when patients underwent SLN mapping
without lymphadenectomy.17 Furthermore, its implementation
in gynecologic cancer patients has been described in several
studies.9,18,22,25
In gynecologic cancers, QoL has been evaluated as it per-
tains to the presence of lymphedema. A study of 789 women
treated with either pelvic radiotherapy alone or with surgery
and diagnosed with endometrial cancer, cervical cancer, vagi-
nal cancer, or ovarian cancer evaluated the impact of lower
limb lymphedema on overall QoL, sleep, sexuality, and daily
life activities reported by gynecologic cancer survivors.18
Vulvar cancer: quality of life after
sentinel lymph node mapping
Treatment for vulvar cancer has been associated with sig-
nifcant QoL disruption, including sexual dysfunction, vulvar
pain or numbness, and lymphedema.19 Patients with vulvar
cancer after inguinofemoral lymphadenectomy had shown a
rate of lower extremity lymphedema of 10% in retrospective
reports and 73% in studies assessing patient-reported symp-
toms.20 GROINSS V is a multicenter observational study that
evaluated the detection of sentinel nodes using a radioactive
marker and blue dye in patients with T1–T2 squamous cell
Clinical Lymphatic Mapping
cancer of the vulva and studied the safety and clinical util-
ity of this procedure.21 When the sentinel node was found to
be negative in the pathological ultrastaging, inguinofemoral
lymphadenectomy was omitted. The patients were observed
with follow-up for 2 years at intervals of every 2 months.
Short-term morbidity decreased in patients after sentinel node
dissection compared to patients with a positive sentinel node
who underwent inguinofemoral lymphadenectomy (groin
wound rupture: 11.7% vs. 34.0%, respectively, and cellulite:
4.5% vs. 21.3%, respectively). Long-term morbidity was also
observed less frequently after sentinel node removal compared
to sentinel node removal and inguinofemoral lymphadenec-
tomy (recurrent erysipelas: 0.4% vs. 16.2%, respectively, and
lymphedema of legs: 1.9% vs. 25.2%, respectively). However,
an evaluation of QoL in the GROINSS V study was not
reported in the initial publication. Oonk et al. performed a ret-
rospective study in patients who participated in GROINSS-V
to compare QoL in vulvar cancer patients who were treated
with SLN mapping only to those who underwent inguino-
femoral lymphadenectomy.22 Patients were invited to fll out
three questionnaires: the EORTC QLQ-C30, a vulvar-specifc
questionnaire, and a questionnaire regarding the opinion of
patients on new treatment options 33 weeks after surgery. With
a response rate of 85%, 35 patients after SLN mapping and
27 patients after inguinofemoral lymphadenectomy flled out
the questionnaires. No difference in overall QoL was observed
between the two groups. Reasons for not fnding an improve-
ment in QoL was the limitation of the small study population
that underpowered the result. The major difference was the
increase in complaints of lymphedema of the lower extremities
after inguinofemoral lymphadenectomy.
Conversely, other publications have shown a change in QoL,
such as a retrospective study, where the QoL was measured
in women after a complete lymphadenectomy or SLN map-
ping for early-stage vulvar cancer.23 The severity of lymph-
edema symptoms was recorded. The QoL-adjusted survival
was measured using the Utility-Based Questionnaire-Cancer,
a cancer-specifc validated QoL instrument. Sixty-three per-
cent of women reported lymphedema after complete lymph-
adenectomy (48%) or sentinel node biopsy (15%). The activity
most affected in all women was physical function, especially
the ability to perform vigorous activities such as running and
climbing stairs. Social life and self-care activities were the
least affected. Thirty-six women (60%) identifed themselves
as being sexually active. Of these women, 18 (50%) reported
that their health did not affect their sex life, whereas the same
number of women reported that it did. When comparing those
who reported lymphedema or leg pain with those who did not
experience these symptoms, QoL scores were signifcantly
lower in the symptomatic group. In women reporting lymph-
edema, the greatest negative effects were on sex life, physical
function, and social activities. The women who experienced
leg pain had higher levels of emotional distress and loss of
ability to perform self-care activities.
Furthermore, in a retrospective study of 21 patients with
vulvar carcinoma FIGO stage I–IIIA who underwent vulvec-
tomy or wide excision with sentinel node biopsy or inguinal
lymphadenectomy, the authors investigated factors infuenc-
ing QoL and sexual function.24 All patients were interviewed
Impact of sentinel lymph node mapping
according to the Female Sexual Function Index questionnaire
(FSFI) and the Short Form 12 questionnaire (SF12). This ques-
tionnaire uses 12 items to describe a summary scale for QoL.
It is divided into eight subscales, providing two partial scores:
the Mental Component Summary and the Physical Component
Summary. In total, 10 patients had undergone an inguinal
lymphadenectomy, 5 patients a sentinel node biopsy, and 6
without lymph node evaluation. Of the patients who underwent
a lymphadenectomy, 90% scored low on the FSFI, but only
45% scored low without this procedure. Lymphadenectomy
was the only factor infuencing sexual function. Patients who
did not undergo lymphadenectomy or sentinel node biopsy
scored better in terms of sexual function.
Endometrial cancer: quality of life
after sentinel lymph node mapping
The implementation of the sentinel node in endometrial can-
cer has been evaluated extensively, including in two prospec-
tive studies. The SENTI-ENDO study demonstrated that SLN
biopsy adequately predicts lymph node status, especially in
patients with stage I endometrial cancer and increased detec-
tion of lymph node involvement when ultrastaging was per-
formed.25 In another key study, the FIRES trial evaluated
the use of the indocyanine green–labeled sentinel nodes, and
86% of patients had successful mapping, and nodal metasta-
ses were detected in 97% of endometrial cancer metastasis.26
In that study, a signifcant decrease in morbidity associated
with complete lymphadenectomy was observed. In addition,
a prospective study compared the rate of lymphatic complica-
tions in 188 patients with endometrial cancer undergoing SLN
biopsy versus a full pelvic and infrarenal paraaortic lymphad-
enectomy. SLN biopsy alone resulted in a lower incidence of
leg lymphedema than lymphadenectomy (1.3% vs. 18.1%, p =
0.0003).27 However, none of these prospective trials evaluated
patient QoL.
A number of investigators have explored QoL as it pertains
to the use of SLN mapping. Rowlands et al. assessed and com-
pared QoL 3–5 years after surgery for endometrial cancer in
women with lower limb lymphedema, lower limb swelling, or
without.28 The patients underwent either pelvic lymphadenec-
tomy or SLN. The Medical Outcomes Study Short Form-12
(SF-12) Health Survey was used to assess physical and mental
QoL. The scale is made up of eight subscales (physical func-
tioning, bodily pain, general health, physical and emotional
role limitations, vitality, social functioning, and mental health),
which are combined to form two summary scores: physical
and mental QoL. In total, 639 women were categorized as
women with lower limb lymphedema (n = 68), women with
lower limb swelling (n = 177), or women without (n = 394).
Women with lower limb lymphedema had clinically lower
physical QoL than women without; however, their mental QoL
was within the normal range. Women with lower limb swelling
had signifcantly lower physical and mental QoL than women
without lower limb lymphedema or lower limb swelling.
A prospective study was performed in 97 women who
underwent minimally invasive staging for endometrial cancer
113
with a primary aim to measure the incidence of lower limb
lymphedema.29 Secondary objectives included observation
of changes in lower extremity function and QoL with the
FACT-G questionnaire and the Lower Extremity Functional
Scale (LEFS). The FACT-G was used to evaluate the impact of
staging surgery and lymphedema on QoL. The LEFS is a vali-
dated survey that consists of 20 questions that assess the effect
of a lower limb condition on a person’s ability to perform
everyday tasks. The rate of lower limb lymphedema was 25%
at 4–6 weeks, 19% at 6–9 months, and 27% at 12–18 months
postoperatively. The presence of lower limb lymphedema
was associated with a signifcant worsening from baseline
LEFS scores at 4–6 weeks (−27.0% vs. −3.7%, p = 0.02) and
6–9 months (−13.0% vs. 0%, p = 0.01). Lower limb lymph-
edema was not associated with a change in patient-reported
global QoL.
Another retrospective study in patients who underwent pri-
mary surgery for endometrial cancer evaluated the impact of
lymphadenectomy on QoL. Women were mailed a survey that
included a validated 13-item lower limb lymphedema screening
questionnaire and QoL questionnaire QLQ-C30 and EORTC
QLQ-EN24 for a minimum of 44 months after surgery.30
This measured fve functional scales, three symptom scales,
global health status, and a number of single items assessing
additional symptoms commonly reported by cancer patients.
Of 1275 potential participants, 599 were evaluable (180 SLN,
352 lymphadenectomy, and 67 hysterectomies alone). Self-
reported lower limb lymphedema prevalence was 27% in the
SLN group (49/180) and 41% in the lymphadenectomy group
(144/352). Lymphadenectomy retained an independent associ-
ation with an increased prevalence of lower limb lymphedema
over SLN (p < 0.003). Patients with self-reported lower limb
lymphedema had signifcantly worse QoL compared to those
without self-reported lower limb lymphedema.
Cervical cancer: quality of life after
sentinel lymph node mapping
SLN biopsy in cervical cancer was validated in the SENTICOL I
study, a retrospective study that determined sensitivity when
this technique was implemented.30 However, this study did
not evaluate morbidity of patients undergoing surgery or their
subsequent QoL. With the need to learn about the impact of
different treatment approaches on the QoL of patients, Park et
al. aimed to identify problems related to long-term QoL and
sexual function in cervical cancer survivors.31 A total of 860
women with a history of cervical cancer (stage I–IVa) and 494
controls were selected randomly. Subjects flled out a question-
naire that included the European Organization for Research
and Treatment of Cancer (EORTC) QLQ-C30, its Cervical
Cancer Module, and additional sexual function items. Cervical
cancer survivors had clinically signifcant worse problems
with social functioning, constipation, diarrhea, and diffcul-
ties with their fnances than controls (p < 0.01). Survivors also
reported more severe lymphedema and menopausal symptoms
and worse body image, sexual and/or vaginal functioning, and
sexual worry (p < 0.01). Anxiety about sexual performance
114
was more problematic in survivors than in controls (p < 0.01),
as was dyspareunia for women who received radiotherapy
(p < 0.01).
In another study, the QoL of patients was evaluated regard-
less of the approach of lymph node evaluation. Le Borgne et al.
prospectively evaluated long-term QoL in cervical cancer sur-
vivors 5, 10, and 15 years after diagnosis.32 Five QoL question-
naires (SF-36, EORTC QLQ-C30, the cervical cancer-specifc
module [EORTC QLQ-CX24], the MFI fatigue questionnaire,
and the STAI for anxiety) and a life condition questionnaire
were used. A total of 173 patients (42% treated with surgery
alone and 58% with a combination of treatments) and 594 con-
trols participated in the study. Compared to controls, patients
had an overall good QoL, except the psycho-emotional decline
of survivors after 15-years was worse (p < 0.01). Worsening of
some symptoms was observed over time; 15-year survivors,
in particular, reported signifcantly more lymphedema than
5-year survivors (p = 0.009) and 10-year cervical cancer sur-
vivors (p = 0.002). Compared with cervical cancer survivors
treated by surgery alone, QoL of cervical cancer survivors
who underwent radiotherapy was signifcantly more affected
in terms of cervical cancer–specifc problems, such as sexual
dysfunction (p = 0.002), voiding and abdominal symptoms
(p = 0.01), and lymphedema (p = 0.01).
Currently, the SENTIX trial is designed to determine
the oncological safety and postoperative morbidity of SLN
biopsy, only without subsequent pelvic lymph node dissec-
tion in women with early-stage cervical cancer. However,
this study does not include a formal evaluation of QoL.33 The
SENTICOL III study is currently underway as a prospective,
multicenter, randomized trial examining the oncologic out-
comes of sentinel lymph node mapping vs. complete lymphad-
enectomy in patients with cervical cancer. One of its objectives
will be the evaluation of QoL using the questionnaires QLQ-
C30 and QLQ-CX24, measuring three specifc dimensions:
pain, global health score, and physical functioning scores at 3
years. However, one of the potential limitations of this study is
that patients will be aware as to which surgery they had based
on lymph node count in the fnal pathology report and may be
biased to report higher rates of lymphedema and worse QoL if
knowing that they were randomized to the full lymphadenec-
tomy group.34 Therefore, at this time there is a paucity of data
evaluating QoL of patients after the implementation of sentinel
node mapping in cervical cancer.
Patient-reported outcomes in
gynecologic cancer
Patient-reported outcomes (PROs) are defned by the Food
and Drug Administration (FDA) and National Quality Forum
(NQF) as “a report that comes directly from the patient about
the status of a patient’s health condition without amend-
ment or interpretation of the patient’s response by a clini-
cian or anyone else.”35,36 PRO instruments aim to measure
one or more aspects of PROs, which can include topics such
as symptom burden to more complex, multidimensional con-
cepts, such as QoL.37
Clinical Lymphatic Mapping
PROs have the potential to improve the quality and patient-
centeredness of medical care in a variety of ways. They can
be used at the patient level to improve interactions between
patients and clinicians and can also be used in research to
identify benefts and harms of interventions. Finally, they
have a role in policy making and population surveillance,
including contributing to guideline development, inform-
ing coverage and reimbursement decisions, evaluating care
quality, and identifying the impacts of policy options. This
initiative of the Patient-Reported Outcomes Measurement
Information System (PROMIS) establishes a national
resource for precise and effcient measurement of PROs.
The main goal of the PROMIS initiative is to develop and
evaluate to the clinical research community a set of publicly
available, effcient, and fexible PRO measurements, includ-
ing QoL.38 The PROMIS Network has developed a compre-
hensive repository of electronic patient-reported outcomes
measures (ePROs) of major symptom domains that have been
validated in cancer patients.
With the growing focus on patient-centered care, PROs are
becoming an important component to clinical trials and quality
metrics. Tools have been studied to measure PROs in gyne-
cologic cancer patients. A prospective study performed over 6
months in a gynecologic oncology outpatient clinic evaluated
the feasibility and acceptability of PROMIS and assessed if it
can identify severely symptomatic patients and increase refer-
ral to supportive services.39 Of the 336 patients who completed
the study, 35% had a current cancer and 19% had experienced
at least one disease recurrence. Sixty-nine percent demon-
strated moderate to severe physical dysfunction (60%), pain
(36%), fatigue (28%), anxiety (9%), depression (8%), and sexual
dysfunction (32%). Thirty-nine (12%) severely symptomatic
patients were referred to services such as psychiatry, pallia-
tive care, pain management, social work, or integrative oncol-
ogy care. Most survey respondents identifed ePROs as helpful
(78%) and easy to complete (92%). Concluding that outpatient
PROMIS administration is feasible and acceptable to gyneco-
logic oncology patients and can help identify severely symp-
tomatic patients for referral to ancillary support services.
The PRO measure has been implemented in different felds of
oncological gynecology. In a study by Meyer et al., the authors
evaluated patient symptom burden in 29 patients.40 Women
were undergoing laparotomy in the gynecologic oncology
department. Symptoms were assessed using the MD Anderson
Symptom Inventory (MDASI-OC), a validated 27-item tool
used in patients with ovarian cancer. The MDASI-OC was
administered as a preoperative reference daily while admitted
to the hospital after surgery, twice a week in the frst week after
discharge, and then weekly for up to 8 weeks after the opera-
tion. Seventy-fve percent of patients had a diagnosis of ovarian
cancer. Of these patients, half underwent primary cytoreduction
surgery and the other half received neoadjuvant chemotherapy
prior to cytoreductive interval surgery. In the postoperative hos-
pital setting, the fve symptoms with the highest overall burden
were fatigue, pain, abdominal pain, dry mouth, and drowsiness.
The study concluded that PROs are a crucial component of
patient-centered research and longitudinal compilation and that
analysis of symptom burden may allow for more meaningful
comparisons of surgical technique and preoperative care.
Impact of sentinel lymph node mapping
Other tools have been used in studies to measure PROs. In
a systematic review aiming to summarize the existing litera-
ture related to PROs among endometrial cancer survivors, the
investigators included articles according to exposures or spe-
cifc PROs.41 Of 1722 unique studies, 102 full-text articles were
reviewed, of which a total of 27 studies fulflled the inclusion
criteria. The most commonly used PRO questionnaires were
the European Organization for Research and Treatment of
Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-
C30) (n = 9), Short Form 36 Questionnaire (SF-36, n = 8), the
Functional Assessment of Cancer Therapy-General (FACT-G,
n = 5), and the Female Sexual Function Index (FSFI, n = 4).
Obesity was associated with lower QoL and physical function-
ing. Treatment type affected several outcomes. Laparoscopy
generally resulted in better QoL outcomes when compared to
laparotomy. Sexual function outcomes were dependent on age,
time since diagnosis, and having consulted a physician before
engaging in sexual activities. In addition, a physical activity
intervention was associated with improved sexual interest but
not sexual function. This review provides insight into the expe-
rience of endometrial cancer survivors. Factors that contribute
to QoL, such as pain, fatigue, and emotional and social func-
tioning, should be monitored following an endometrial cancer
diagnosis. To our knowledge, there are no studies evaluating
PROs after the implementation of SLN mapping in gyneco-
logic cancer.
Conclusion
The evaluation of QoL and PROs in patients with cancer has
become a topic of increasing relevance both in the clinical
management of patients and in research. The increase in the
survival of patients secondary to new therapies requires the
evaluation of its impact on patient recovery and daily activi-
ties. With the integration of SLN mapping, the most frequent
and disabling complications, such as lymphedema of the lower
limbs, have decreased signifcantly, allowing an improvement
in the functional capacity of patients. Although there are data
on QoL in survivors of gynecologic cancers, there is very
limited information regarding assessment of QoL specifc
to patients who have undergone SLN mapping alone. Future
studies should aim to prospectively evaluate QoL and PROs in
patients undergoing SLN mapping.
REFERENCES
1. Beesley VL, Eakin EG, Janda M, et al. Gynecological can-
cer survivors health behaviors and their associations with
quality of life. Cancer Causes Control. 2008;19(7):775–82.
2. Antaki C, Rapley M. Quality of life talk: the liberal paradox
of psychological testing. Discourse Soc. 1996;7(3):293–316.
3. Rapley M. Quality of Life Research: A Critical Introduction.
London: Springer; 2004. pp. 1021–1024.
4. Mooney A. Quality of life: questionnaires and questions. J
Health Commun. 2006;11(3):327–41.
5. Aaronson NK, Bullinger M, Ahmedzai S. A modular
approach to quality-of-life assessment in cancer clinical tri-
als. Recent Results Cancer Res. 1988;111:231–49.
115
6. Aaronson NK, Ahmedzai S, Bergman B, et al. The
European Organization for Research and Treatment of
Cancer QLQ-C30: a quality-of-life instrument for use in
international clinical trials in oncology. J Nat Cancer Inst.
1993;85(5):365–76.
7. The EORTC QLQ-C30 Manuals, Reference Values and
Bibliography. EORTC Quality of Life Group. Belgium:
Brussels EORTC; 2002.
8. Dunberger G, Lindquist H, Waldenström A, et al. Lower
limb lymphedema in gynecological cancer survivors –
effect on daily life functioning. Support Care Cancer.
2013;21(11):3063–70.
9. Dessources K, Aviki E, Leitao MM Jr. Lower extremity
lymphedema in patients with gynecologic malignancies. Int
J Gynecol Cancer. 2020;30(2):252–60.
10. Rowlands IJ, Beesley VL, Janda M, et al. Quality of life
of women with lower limb swelling or lymphedema 3–5
years following endometrial cancer. Gynecol Oncol.
2014;133(2):314–18.
11. Ryan M, Stainton MC, Slaytor EK, et al. A etiology and
prevalence of lower limb lymphedema following treatment
for gynaecological cancer. Aust N Z J Obstet Gynecol.
2003;43(2):148–51.
12. Dunberger G, Lindquist H, Waldenström A, et al. Lower
limb lymphedema in gynecological cancer survivors –
effect on daily life functioning. Support Care Cancer.
2013;21(11):3063–70.
13. Fu MR, Ridner SH, Hu SH, et al. Psychosocial impact of
lymphedema: a systematic review of literature from 2004
to 2011. Psychooncology. 2013;22(7):1466–84.
14. Biglia N, Librino A, Ottino M, et al. Lower limb lymph-
edema and neurological complications after lymphad-
enectomy for gynecological cancer. Int J GynecolCancer.
2015;25(3):521–5.
15. Morton RL, Wen DR, Wong JH, et al. Technical details
of intraoperative lymphatic mapping for early stage mela-
noma. Arch Surg. 1992;127(4):392–9.
16. Morton RL, Tran A, Vessey J, et al. Quality of life fol-
lowing sentinel node biopsy for primary cutaneous mela-
noma: health economic implications. Ann Surg Onco.
2017;24(8):2071–9.
17. Cormier JN, Askew RL, Mungovan KS, et al. Lymphedema
beyond breast cancer: a systematic review and meta-
analysis of cancer-related secondary lymphedema. Cancer.
2010;116(22):5138–49.
18. Dunberger G, Lindquist H, Waldenström A, et al. Lower
limb lymphedema in gynecological cancer survivors –
effect on daily life functioning. Support Care Cancer.
2013;21(11):3063–70.
19. Wenzel L. Patient-reported outcomes in sentinel lymph
node procedure versus inguinofemoral lymphadenectomy –
what is the next step? Gynecol Oncol. 2009;113(3):299–300.
20. Berger J, Scott E, Sukumvanich P, et al. The effect of groin
treatment modality and sequence on clinically signifcant
chronic lymphedema in patients with vulvar carcinoma. Int
J Gynecol Cancer. 2015;25(1):119–24.
21. Van der Zee AG, Oonk MH, De Hullu JA, et al. Sentinel
node dissection is safe in the treatment of early stage vulvar
cancer. J Clin Oncol. 2008;26(6):884–9.
22. Oonk MH, Van Os MA, De Bock GH, et al. A compari-
son of quality of life between vulvar cancer patients after
116
sentinel lymph node procedure only and inguinofemoral
lymphadenectomy. Gynecol Oncol. 2009;113(3):301–5.
23. Farrell R, Gebski V, Hacker NF. Quality of life after com-
plete lymphadenectomy for vulvar cancer: do women pre-
fer sentinel lymph node biopsy? Int J Gynecol Cancer.
2014;24(4):813–19.
24. Forner DM, Dakhil R, Lampe B. Quality of life and sexual
function after surgery in early stage vulvar cancer. Eur J
Surg Oncol. 2015;41(1):40–5.
25. Daraï E, Dubernard G, Bats AS, et al. Sentinel node biopsy
for the management of early stage endometrial cancer: long-
term results of the SENTI-ENDO study. Gynecol Oncol.
2015;136(1):54–9.
26. Rossi EC, Kowalski LD, Scalici J, et al. A comparison of
sentinel lymph node biopsy to lymphadenectomy for endo-
metrial cancer staging (FIRES trial): a multicentre, pro-
spective, cohort study. Lancet Oncol. 2017;18(3):384–92.
27. Geppert B, Lönnerfors C, Bollino M, et al. Sentinel lymph
node biopsy in endometrial cancer-feasibility, safety and lym-
phatic complications. Gynecol Oncol. 2018;148(3):491–8.
28. Rowlands IJ, Beesley VL, Janda M. Quality of life of
women with lower limb swelling or lymphedema 3–5
years following endometrial cancer. Gynecol Oncol.
2014;133(2):314–18.
29. Watson CH, Lopez-Acevedo M, Broadwater G, et al. A
pilot study of lower extremity lymphedema, lower extrem-
ity function, and quality of life in women after minimally
invasive endometrial cancer staging surgery. Gynecol
Oncol. 2019;153(2):399–404.
30. Leitao MM Jr, Gomez-Hidalgo NR, Abu-Rustum NR, et
al. Patient-reported outcomes after surgery for endometrial
carcinoma: prevalence of lower-extremity lymphedema
after sentinel lymph node mapping versus lymphadenec-
tomy. Gynecol Oncol. 2020;156(1):147–53.
31. Lécuru F, Mathevet P, Querleu D, et al. Bilateral nega-
tive sentinel nodes accurately predict absence of lymph
node metastasis in early cervical cancer: results of the
SENTICOL study. J Clin Oncol. 2011;29(13):1686–91.
Clinical Lymphatic Mapping
32. Park SY, Bae DS, Nam JH, et al. Quality of life and
sexual problems in disease-free survivors of cervical
cancer compared with the general population. Cancer.
2007;110(12):2716–25.
33. Cibula D, Dusek J, Jarkovsky J, et al. A prospective mul-
ticenter trial on sentinel lymph node biopsy in patients
with early-stage cervical cancer (SENTIX). Int J Gynecol
Cancer. 2019;29(1):212–15.
34. Lecuru FR, McCormack M, Hillemanns P, at el.
SENTICOL III: an international validation study of sen-
tinel node biopsy in early cervical cancer. A GINECO,
ENGOT, GCIG and multicenter study. Int J Gynecol
Cancer. 2019;29(4):829–34.
35. U.S. Food and Drug Administration. Guidance for Industry.
Patient reported outcome measures: use in medical product
development to support labeling claims. Federal Register.
2009;74:65132–3.
36. National Quality Forum. Patient-Reported Outcomes [2012
Dec 10]. Available from: www.qualityforum.org/Projects/
n-r/ Patient-Repor ted_Outcomes/ Patient-Repor ted _
Outcomes.aspx.
37. Snyder CF, Jensen RE, Segal JB, et al. Patient-reported out-
comes (PROs). Med Care. 2013;51:S73–9.
38. Ahmed S, Berzon RA, Revicki DA, et al. The use of patient-
reported outcomes (PRO) within comparative effectiveness
research: implications for clinical practice and health care
policy. Med Care. 2012;50(12):1060–70.
39. Gressel GM, Dioun SM, Richley M, et al. Utilizing the
Patient Reported Outcomes Measurement Information
System (PROMIS®) to increase referral to ancillary sup-
port services for severely symptomatic patients with gyne-
cologic cancer. Gynecol Oncol. 2019;152(3):509–13.
40. Meyer LA, Nick AM, Shi Q, et al. Perioperative trajectory
of patient reported symptoms: a pilot study in gynecologic
oncology patients. Gynecol Oncol. 2015;136(3):440–5.
41. Shisler R, Sinnott JA, Wang V, et al. Life after endometrial
cancer: a systematic review of patient-reported outcomes.
Gynecol Oncol. 2018;148(2):403–13.
15
Radiation oncology considerations

Gwendolyn Joyce McGinnis and Anuja Jhingran

CONTENTS
Introduction .................................................................................................................................................................................. 117
Radiation therapy targets ............................................................................................................................................................. 117
Nodal target delineation ..................................................................................................................................................... 117
Pelvic nodes........................................................................................................................................................................ 117
Paraaortic nodes ................................................................................................................................................................. 118
Inguinal nodes .................................................................................................................................................................... 118
Radiation therapy techniques....................................................................................................................................................... 118
3D conformal radiation therapy and intensity-modulated radiation therapy ..................................................................... 118
Image-guided radiotherapy ................................................................................................................................................ 120
Literature review by disease site .................................................................................................................................................. 120
Vulva .................................................................................................................................................................................. 120
Endometrium...................................................................................................................................................................... 121
Early stage ............................................................................................................................................................. 121
Advanced stage ...................................................................................................................................................... 123
Conclusion ................................................................................................................................................................................... 124
References.................................................................................................................................................................................... 124

Introduction endometrial, and cervical cancers. We will also discuss the

Radiation therapy has been used to treat cancer for over a cen-
tury. In recent years, radiation has become a more sophisti-
cated tool through technological advancements that allow for
improved effectiveness and minimized side effects. Radiation
therapy is employed in the treatment of approximately 60% of
cancer patients1 – often to complement surgical or systemic
approaches to minimize the chance of microscopic residual
disease. As surgical approaches become more nuanced, so
must our understanding of how to best incorporate radiation
therapy to maximize oncologic outcomes while minimizing
short- and long-term toxicity from treatment.
Radiation therapy is often employed in the adjuvant setting
with the goal of eradicating microscopic disease. For this rea-
son, increased utilization of sentinel lymph node biopsy will
introduce new adjuvant treatment decisions in the manage-
ment of many cancers. In some disease sites, like the breast
or vulva, there are relatively robust data to support the role of
adjuvant radiation, depending on fndings at the time of sen-
tinel lymph node biopsy. However, in other cases, like uterine
or cervical cancer, there are less high-level data on which to
base treatment recommendations and, instead, expert opinion
prevails.
In this chapter, we will offer a brief overview of modern
external beam radiation techniques and targets relevant to
patients undergoing postoperative radiation after sentinel
lymph node biopsy for gynecologic cancers, including vulvar,
data available to inform decision making regarding adjuvant
radiation for these disease sites. While adjuvant radiation fol-
lowing sentinel lymph node biopsy is important to understand
in the context of breast cancer, it is outside the scope for this
chapter. When considering the use of radiation therapy in the
treatment of gynecologic cancer patients after surgical inter-
vention, it is frst important to understand the most common
techniques used to plan and deliver radiation therapy for these
disease sites.
Radiation therapy targets
Nodal target delineation
Deciding on target volumes of interest when planning radia-
tion treatment is often a nuanced decision. Regional lymph
nodes are often included as targets of interest when treating
gynecologic cancers with radiation therapy. Which lymph
node basins to include depends on the primary site and likeli-
hood of regional spread in the context of individual patients.
Pelvic nodes
Pelvic nodes, including obturator, internal iliac, external iliac,
presacral, and common iliac basins, are commonly included in
radiation felds, given the propensity for gynecologic cancers

DOI: 10.1201/9781003255536-15 117

118
to spread to lymph nodes in these regions. Radiation felds are
designed to encompass all sites of primary drainage, including
lymph nodes found at the junction between the external iliac,
internal iliac, and common iliac vessels to the level of the com-
mon iliac bifurcations. Presacral nodes are usually covered in
patients with cervical cancer and upper vaginal involvement
but are not routinely covered in patients with lower vaginal
cancer, vulvar cancer unless the apex of the vagina is involved,
or endometrial cancer unless there is cervical stromal involve-
ment. Perirectal lymph nodes are included for posterior
involvement, including the rectovaginal septum, cul-de-sac,
or rectum. Typical pelvic felds have a superior border at the
level of the aortic bifurcation, or approximately at the L4/L5
interspace.
Paraaortic nodes
Paraaortic nodes are often treated in cases of uterine fundus,
fallopian tube, or ovarian involvement. They are also included
if there are any grossly involved paraaortic lymph nodes. The
term ‘extended felds’ is used when paraaortic lymph nodes
are included. Radiation felds are extended approximately to
the level of T12, or 1.5–2 cm above the level of the most supe-
rior grossly involved lymph node. Lower paraaortic nodes are
covered prophylactically when there is positive common iliac
nodes up to the level of L2.
Inguinal nodes
Inguinal lymph nodes are routinely treated in cases of vulvar
cancer. They are usually included in the treatment of cervi-
cal, vaginal, or endometrial cancer when the tumor involves
the distal one-third of the vagina or there are grossly involved
inguinal lymph nodes.
FIGURE 15.1 A volumetric modulated arc (VMAT) IMRT plan prescribed to 45 Gy (blue isodose line) with a 50 Gy simultaneous integrated boost
(SIB; red isodose line) (a) and a four-feld 3D CRT plan prescribed to 50 Gy with hotspots blocked (b) that could be used to treat a patient with vulvar
cancer. Target volumes include primary (flled red), nodal clinical target volume (flled pink), and nodal planning target volume (flled aquamarine).
Clinical Lymphatic Mapping
Radiation therapy techniques
3D conformal radiation therapy and
intensity-modulated radiation therapy
Conformal radiation therapy refers to radiotherapy treat-
ment designed to deliver high doses to areas of interest while
minimizing doses to normal structures. Within the category
of conformal techniques, both 3D conformal radiation ther-
apy (3D-CRT) and intensity-modulated radiation therapy
(IMRT) have been used in the treatment of gynecologic can-
cers. 3D-CRT became a standard for treating pelvic felds in
gynecologic cancers by utilizing four beams (anterior, poste-
rior, right lateral, and left lateral) to create a four-feld ‘box’ to
cover volumes at risk within the pelvis. While this technique
adequately covers the pelvic targets as described earlier, it fre-
quently includes a substantial volume of bowel, which contrib-
utes to acute and chronic diarrhea seen with radiation therapy.
In IMRT, the dose is shaped around target structures, with
multiple converging beams or arcs utilizing dose-calculation
algorithms. Precise delineation of volumes at risk and consid-
eration of internal organ motion within the pelvis are critical.
IMRT allows for a signifcantly more nuanced treatment plan
design, which has repeatedly demonstrated improved dosim-
etry2–5 as well as decreased patient-reported toxicity.6,7 RTOG
1203 was a randomized trial of 278 women with cervical or
endometrial cancer undergoing either standard pelvic radia-
tion or IMRT.8 Pelvic IMRT was found to be associated with
much lower rates of gastrointestinal (GI) and urinary toxicity.
Figures 15.1 and 15.2 show two different plans for a patient
with vulvar cancer comparing the 3D conformal technique
to IMRT. Figures 15.3 and 15.4 show typical IMRT felds for
patients treated with pelvic felds, as well as patients treated
with paraaortic felds.
Radiation oncology considerations 119

FIGURE 15.2 A comparison of the dose volume histogram (DVH) for IMRT (solid lines) as compared to 3D-CRT (dashed lines). Note lower doses
delivered to bladder, rectum, sigmoid, bowel, and femoral heads without sacrifcing dose to target volumes.

FIGURE 15.3 An example of the target volumes and dose delivered for a postoperative patient prescribed to 45 Gy (red isodose line) to the pelvis.
Target contours include vaginal internal target volume (flled maroon) and nodal clinical target volume (flled blue).
120 Clinical Lymphatic Mapping

FIGURE 15.4 An example of the target volumes and dose delivered for a postoperative patient dispositioned to extended feld coverage. Dose is
prescribed to 45 Gy (blue isodose line) to the pelvis and extended nodal regions with a simultaneous integrated boost to the involved lymph node (flled
pink) to 50 Gy (red isodose line). In addition to the grossly involved lymph node, target contours include vaginal internal target volume (flled red) and
nodal clinical target volume (flled yellow).

Image-guided radiotherapy
An essential element of high-quality radiation treatment is
accurate patient positioning and treatment delivery. A num-
ber of factors introduce uncertainty in this process, includ-
ing imprecise patient positioning, inherent organ motion, and
technical variation. In order to compensate for this uncertainty
inherent in the patient setup and treatment process, radiation
oncologists use an additional margin when designing target
volumes in excess of the volumes of clinical interest. However,
the use of real-time image guidance can allow for the use of
smaller margins, as the treating radiation oncologist can be
certain of the position of the treatment target and organs at risk
at the time of treatment. Image guidance may include x-rays
aligning to bone or cone beam computed tomography (CT)
scans aligning to soft tissue, or even just looking at positions
of target organs or a combination of both.
The use of image-guided IMRT to patients receiving adju-
vant cervical radiation was investigated in the PARCER trial,
and preliminary results have been presented in abstract form.9
This study of 300 patients found that image-guided IMRT
resulted in signifcantly lower late grade 2 or higher bowel tox-
icity (2.0% versus 8.7%), likely driven by signifcantly lower
doses delivered to the bowel.
Literature review by disease site
Vulva
Lymph node status is the most important predictor for overall
survival in patients with vulvar cancer.10–12 Thorough lymph
node evaluation is necessary for patient selection for radia-
tion therapy. Sentinel node biopsy in addition to radical local
excision has become the standard of care in the treatment
of early-stage vulvar cancer.13 The sentinel node has gained
popularity because it has been shown to have low groin
recurrence and low morbidity and prevents overtreatment.14
Adjuvant radiation therapy may play a role in the manage-
ment of patients with vulvar cancer in several scenarios,
including prophylactic irradiation and management of micro-
metastatic disease.
Radiation oncology considerations
Patient selection for defnitive radiation treatment to the
groin in place of groin lymphadenectomy remains an area of
controversy.15 Past efforts have aimed to investigate differ-
ences between groin dissection versus groin radiation. GOG
37 found that radiation after radical vulvectomy and inguinal
lymphadenectomy signifcantly reduced local relapses and
cancer-related deaths.16,17 Retrospective data suggested that
inguinofemoral irradiation could be a viable alternative to
lymphadenectomy for squamous cell carcinoma of the vulva.
18 However, GOG 88 randomized patients undergoing radical
vulvectomy for T1–T3/N0–N1 (FIGO, 1971) vulvar cancer to
bilateral groin dissection or bilateral groin radiation therapy.19
The study was closed early after interim analysis revealed
signifcantly higher rates of groin failure in patients receiving
radiation (18.5% versus 0%).19 However, subsequent analyses
have demonstrated that the groin radiation felds prescribed to
3 cm did not adequately treat groin lymph nodes, which can
range in depth from 2 to 18.5 cm.20 It is also notable that 20%
of patients in the surgical arm were found to have involved
groin nodes and subsequently received adjuvant groin and pel-
vic radiation. Subsequent retrospective data suggest that pro-
phylactic inguinofemoral irradiation may be an alternative to
primary lymphadenectomy with similar oncologic outcomes.21
The data for the role of adjuvant radiation following the
discovery of metastatic groin nodes are more robust. It has
been established that patients with increased nodal burden
have increased risk of cancer recurrence. Patients with more
than two involved lymph nodes have signifcantly higher risk
of recurrence, and overall survival declines with each positive
node.18 The impact of lymph node involvement differs signif-
cantly by adjuvant treatment. In patients without adjuvant radi-
ation, the number of involved lymph nodes has been highly
correlated with prognosis; however, this difference is dimin-
ished in the setting of adjuvant radiation.22 AGO-CaRE-1 was
a multicenter retrospective cohort study that showed a beneft
in progression-free survival (PFS) and a trend in overall sur-
vival (OS) with adjuvant radiation in node-positive patients.
This beneft was seen regardless of the number of positive
nodes, grade, or depth of invasion.23 There was a subgroup
analysis of patients undergoing sentinel lymph node dissection
(SLND).24
At present, there are no established guidelines for the man-
agement of SLN micrometastasis (≤2 mm deposit) or isolated
tumor cells (ITCs) (≤0.2 mm). In the GROINSS-V study, the
rate of positive non-SLNs was found to be low in patients with
ITCs (4.2%) and in patients with micrometastasis (11.1%);
however, the authors concluded that no cutoff size was found
below which the chance of non-SLN metastasis was close to
zero, emphasizing the role of adjuvant treatment.25 Current
National Cancer Comprehensive Network (NCCN) guidelines
recommend adjuvant radiation with or without concurrent che-
motherapy for a single positive sentinel lymph node measuring
2 mm or less.26
GROINSS-VIII is a prospective phase II trial designed
to test the effcacy and safety of adjuvant chemoradiation in
patients with a groin metastasis over 2 mm in a sentinel node
in patients with unifocal, squamous cell carcinomas of the
vulva with a primary tumor less than 4 cm. The primary out-
come is the groin recurrence rate, and the secondary outcome
121
is treatment-related morbidity. Chemoradiation will be 48–50
Gy to the groin clinical target volume (CTV) with simultane-
ously integrated boost (SIB) to 56 Gy delivered with weekly
cisplatin. The outcome of this study will be very useful to see if
radiation therapy can replace lymph node dissection in patients
with micrometatasis. Figure 15.5 shows a CT scan of a patient
who had sentinel lymph node biopsy that was negative; how-
ever, a node was present on the preoperative scan that was not
a sentinel node and was not removed and later was found to be
positive—one of the major concerns about just using sentinel
node data. Postoperative scans should usually be done to make
sure that all suspicious nodes are removed, even with SLND.
Endometrium
Surgical staging is a cornerstone in the management of endo-
metrial cancer and often historically included systematic
lymphadenectomy. Much of the beneft of lymph node dis-
section appears to come from surgical staging rather than
therapeutic effect.27,28 It is known that metastatic lymph node
involvement is a signifcant prognostic factor.29,30 Detection of
lymph node involvement often substantially changes adjuvant
treatment recommendations, including the utilization of post-
operative radiation therapy. This is especially important for
patients with grade 2–3 endometrioid endometrial, clear cell,
or papillary serous tumors. However, the optimal management
of patients with grade 1 endometrioid endometrial cancer is a
subject up for greater debate. In recent years, sentinel lymph
node biopsy has become a favored alternative to lymph node
dissection.31
Current guidelines provide a framework for conceptualiz-
ing adjuvant treatment of endometrial cancer, including the
infuence of lymph node involvement.32–34 Women with low-
risk disease defned as surgical specimens with no or mini-
mal grade 1–2 residual disease (<50% myometrial invasion)
without additional risk factors (age over 60 or lymphovascu-
lar space involvement [LVSI]). Women who are found to have
grade 1–2 disease with more substantial myometrial invasion
(>50%) or women with less invasive (<50% myometrial inva-
sion) but high-grade disease are typically recommended for
vaginal brachytherapy. Pelvic radiation is typically reserved
for women with high-grade disease with >50% myometrial
invasion, deep cervical stromal invasion, or positive nodes.
Lymph node involvement is a relatively common fnding
upon surgical staging, though the involvement is commonly
low volume (qualifying as either ITCs or micrometastatic dis-
ease).35,36 Many patients who have low-volume lymph node
involvement have otherwise favorable disease.36 Therefore,
adjuvant treatment recommendations after discovery of low-
volume lymph node involvement can require nuanced decision
making. Likely, there is no role for additional surgery after
positive sentinel lymph node biopsy. Rather, some combina-
tion of radiation and chemotherapy should be utilized.
Early stage
Multiple large trials, including PORTEC 137 and GOG 9938,
seem to suggest that adjuvant radiation does not improve
overall survival in early-stage, low-risk disease. However,
122 Clinical Lymphatic Mapping

FIGURE 15.5 An example of an inguinal node recurrence after partial radical vulvectomy and negative sentinel node biopsies. The patient was a
70-year-old woman who underwent initial radical partial vulvectomy with sentinel lymph node biopsy. Bilateral sentinel lymph nodes were mapped
and three additional groin nodes were dissected; all were negative for metastatic disease. However, a left groin lymph node, which measured 1.5 × 0.8
cm on initial scan (a) and subsequently enlarged to 1.5 × 1.2 cm (b), was not removed. The lymph node was appreciated on postoperative restaging
imaging (c and d) at 5 months, and fne needle aspiration (FNA) confrmed metastatic squamous cell carcinoma. The patient went on to undergo salvage
left inguinal lymphadenectomy showing 5 mm focus of squamous cell carcinoma, followed by adjuvant external beam radiation therapy (EBRT) to the
left inguinal operative bed and distal left pelvic lymph nodes. She had no evidence of disease and minimal toxicity at 5 years after initial diagnosis.
(From Eiffel P, Klopp AH, Gynecologic Radiation Oncology: A Practical Guide, Wolters Kluwer Health, Inc., 2016, with permission.)

in patients with high risk disease or those with metastatic
involvement of the lymph nodes, data show a beneft to adju-
vant therapy.
A large retrospective review of patients who underwent
sentinel node biopsy showed patients with low-volume lymph
node disease frequently received adjuvant treatment and had
improved oncologic outcomes compared to patients with mac-
rometastatic lymph node disease.39 In this study, 844 patients
were included, 44 of whom had low-volume metastatic lymph
node disease (LVM; defned as ITCs or micrometastatic dis-
ease) and 47 had macrometastatic lymph node involvement
(MM); 753 patients were lymph node negative. In terms of
adjuvant therapy, 82% of patients with LVM, 89% of patients
with MM, and 14% of patients without lymph node involve-
ment received adjuvant therapy. Recurrence-free survival was
90% for N0, 86% for N0(i+), 86% for N1(mic), and 71% for
N1+ patients.
It appears that the risk of recurrence with ITCs alone is low,
regardless of adjuvant therapy. In a retrospective review of
519 patients undergoing surgical management for endometrial
cancer, including sentinel lymph node mapping, outcomes
for patients with ITCs alone appeared excellent regardless
of adjuvant treatment. A total of 31 patients with ITCs alone
were included. Eleven (35%) patients with ITCs received
adjuvant chemotherapy ± whole pelvic radiation therapy
(WPRT), 10 (32%) received WPRT, and 10 (32%) received
either no adjuvant treatment or vault brachytherapy (VBT)
only. At 3 years, PFS in ITC patients (95.5%) was similar to
node-negative (87.6%) and micrometastatic (85.5%) disease,
but signifcantly better than patients with macrometastases
(58.5%). Only 1 of the 31 patients with ITCs had a recurrence
(FIGO stage IB, carcinosarcoma histology) despite adjuvant
treatments.
Another multi-institutional retrospective study of 175
patients with early-stage endometrial cancer (9% had stage IA,
39% stage IB, and 12% stage II disease) found to have ITCs
on SLNB confrmed similar fndings.40 Completion lymphad-
enectomy was performed in 49% of patients. Many patients
(43%) received either no adjuvant treatment or VBT alone,
12% had EBRT, and 45% had chemotherapy with or without
radiation therapy. Nine recurrences were noted (fve distant,
three retroperitoneal, one vaginal). Chemotherapy, external
beam radiation, and type of lymph node dissection were not
associated with recurrence-free survival.
Radiation oncology considerations
Among higher-risk patients, another retrospective review
found a higher risk of recurrence with any lymph node dis-
ease, including ITC or micrometastatic disease.41 A total of
61 patients were included, with 9 patients with LVM and 52
without lymph node disease. Presence of ITC/MM was found
to be an independent risk factor for recurrence, and 8-year OS
and RFS were lower in the ITC/MM group when compared to
the N0 group.
Advanced stage
Patients with advanced disease are at a higher risk of local
recurrence42 and the use of adjuvant radiation therapy is more
established.43,44 Patients are also at increased risk of distant
failure, which is why chemotherapy is a mainstay of adjuvant
treatment.
Several studies have compared radiation alone versus che-
motherapy. GOG 122 demonstrated that OS was improved in
patients receiving chemotherapy versus whole-abdomen radia-
tion therapy.45 Another randomized phase III trial of advanced
endometrial cancer comparing adjuvant chemotherapy versus
pelvic radiation therapy showed PFS and OS were higher with
chemotherapy versus pelvic radiation.46 However, in Maggi
et al., there was no signifcant difference in survival between
high-risk endometrial cancer patients treated with chemother-
apy as compared to pelvic radiation.47
Subsequent trials examined the combination of chemother-
apy and radiation. PORTEC 3 was a randomized trial between
radiation alone versus chemoradiation and showed no differ-
ence in OS with the addition of chemotherapy, but did show
an improvement in RFS (75% vs. 68%), especially in stage
III patients.48 The NSGO/EORTC/MaNGO trial compared
sequential chemotherapy with external beam radiation versus
radiation alone and found an improvement in PFS.49 In GOG
258, 707 patients with stage III or IVA endometrial carcinoma
were randomized to receive either chemoradiotherapy or che-
motherapy alone. Patients with stage I or II clear-cell or serous
endometrial carcinoma and positive peritoneal washings were
also included. Patients underwent hysterectomy and bilateral
salpingo-oophorectomy with optional pelvic and paraaortic
lymph node dissection. Patients were randomized to either
cisplatin plus EBRT followed by carboplatin/paclitaxel or car-
boplatin/paclitaxel only. EBRT was delivered to the pelvis,
with or without paraaortic felds, with a planned total dose of
45 Gy in 25 fractions. IMRT and VBT were allowed only in
the chemoradiation group. Recurrence-free survival at 5 years
was almost identical: 59% in the chemoradiation group versus
58% in radiation alone. There were no signifcant subgroup
differences. Chemoradiation was associated with a lower rate
of vaginal recurrences at 5 years (2% vs. 7%) and paraaortic
node recurrence at 5 years (11% vs. 20%). However, distant
recurrence was more common in the chemoradiation group
(27% vs. 21%). In quality-of-life analysis, chemoradiation
demonstrated poorer outcomes, though this did not exceed the
‘clinically signifcant’ threshold.50
Cervix
Surgical management is the mainstay of treatment of early-
stage cervical cancer. Adjuvant therapy is indicated for patients
123
undergoing a primary surgical approach if pathologic fnd-
ings indicate a high risk of disease recurrence. Many of these
factors focus on the nature of the primary disease, including
clinical tumor size, LVSI, and depth of tumor invasion into the
cervical stroma.51,52 However, lymph node involvement is also
a strong prognostic indicator in cervical cancer and therefore
an item of importance when considering adjuvant treatment
recommendations.53,54 OS has repeatedly been found to be sig-
nifcantly shorter in patients with lymph node involvement.55
According to current guidelines by the NCCN, full pelvic
lymphadenectomy remains the standard of care for early-stage
cervical cancer patients except for those with IA1 disease with-
out LVSI.56 However, sentinel lymph node biopsy is becom-
ing increasingly popular and is the recommended approach
for pelvic lymph node staging by the European Society of
Gynecological Oncology.57,58 Patients may beneft from a more
minimal surgical approach, given morbidity after pelvic and/
or paraaortic lymphadenectomy.59–61 Toxicity after lymphad-
enectomy is further increased in the setting of adjuvant radia-
tion.62 Sentinel lymph node biopsy appears to be a reasonable
alternative, with high-quality data showing bilateral detection
rates in more than 90% of patients, even with small cervical
cancers.63,64
Although sentinel lymph node biopsy is becoming a more
popular approach in early-stage cervical cancer, there are lim-
ited data to guide optimal adjuvant therapy based on the patho-
logical fndings in sentinel lymph nodes. Nevertheless, these
fndings are currently being used to shape treatment decisions.
In a 2017 survey of the European Society of Gynaecological
Oncology, macrometastases, micrometastases, and ITCs in
lymph nodes were considered indications for adjuvant treat-
ment by 96%, 93%, and 68% of respondents, respectively.57
Currently, postoperative chemoradiation therapy is recom-
mended for all patients at high risk for recurrence.65,66 Patients
are considered high risk if surgical pathology demonstrates
positive margins, positive pelvic or paraaortic lymph nodes,
and positive parametrium.67,68
Data for adjuvant management of early-stage cervical can-
cer patients at high risk for recurrence include SWOG 8797/
RTOG 9112/GOG 109. This was a prospective randomized
trial that investigated the role of adding concurrent chemo-
therapy to adjuvant pelvic radiation in women with FIGO
stage IA2, IB, or IIA cervical cancer at high risk of recur-
rence after radical hysterectomy and pelvic lymph node dis-
section based on pathological features. A total of 127 patients
with pelvic nodal metastases, positive parametrial invasion, or
positive surgical margins were randomized to radiation versus
radiation with the addition of chemotherapy, delivered every
3 weeks as four cycles of cisplatin (CDDP) at 70 mg/m2 intra-
venous (IV) infusion and 5-fuorouracil (5-FU) at 4000 mg/
m2 over a 4-day continuous infusion beginning on day 1 of
radiation. Postoperative radiation was delivered as 49.3 Gy
in 1.7-Gy fractions to at least the whole pelvis, with elective
paraaortic extended nodal feld irradiation to 45 Gy in 30 frac-
tions if common iliac nodes were found to be involved. On
long-term update, both PFS and OS were improved with the
addition of chemotherapy.69
Another study of high-risk patients was a retrospective
review of patients with FIGO stage IB–IIB cervical cancer
124
with at least two positive pelvic lymph nodes and/or metastatic
common iliac nodes who received adjuvant chemotherapy in
addition to postoperative radiation and showed consistent fnd-
ings.70 Of the 25 patients included, 64% were disease free at
30 months from treatment and no paraaortic node recurrences
were observed.
Finally, a retrospective review examined adjuvant che-
motherapy alone for patients with FIGO stage IB and IIA
cervical cancer with features increasing risk of recurrence,
including deep cervical stromal invasion (> 50%; DCSI), posi-
tive surgical margin, parametrial involvement, and/or pelvic
nodal metastases following radical hysterectomy and pel-
vic lymphadenectomy. A total of 65 patients were included.
Chemotherapy consisted of bleomycin (5 mg IV continuous
infusion for 7 days), vincristine (0.7 mg/m2 IV bolus on day
7), mitomycin C (7 mg/m2 IV bolus on day 7), and CDDP (10
mg IV continuous infusion for 7 days). Patients with DCSI as
their only risk factor received only four cycles of chemother-
apy, while others received fve cycles. Results showed 5-year
disease-free survival of 100% for patients with squamous cell
cancers (SCCs) with DCSI alone, 71.4% for adenosquamous
histology and DCSI alone, 89.3% for SCC and at least one
other risk factor, and 71.4% for adenosquamous histology with
at least one other risk factor.71 A phase III trial is undergo-
ing evaluating the advantage of additional chemotherapy to
chemoradiation for these high-risk patients, and the results
should be ready by 2022.
Patients with intermediate risk factors for recurrence,
including large tumor size, DCSI, and LVSI, also beneft
from adjuvant therapy. This was demonstrated in GOG 92, a
phase III randomized trial of 277 patients with FIGO stage IB
cervical cancer with the risk factors previously mentioned.52,72
Patients were randomized to postoperative radiation therapy
versus no further treatment. Radiation was delivered as
46–50.4 Gy at 1.8–2.0 Gy per fraction over 4.5–6 weeks to
the pelvis. Results showed that local (13.9% vs. 20.7%) and
distant (2.9% vs. 8.6%) relapse rates were lower in the radia-
tion therapy arm. On long-term follow-up, the radiation arm
demonstrated longer PFS; however, no difference was seen in
OS. After controlling for prognostic factors, patients in the
radiation therapy arm were 44% less likely to fail. This fnd-
ing was especially dramatic in patients with nonsquamous
histologies (8.8% vs. 44% experiencing recurrences). A 2012
meta-analysis, which also includes the data from GOG 92,
also demonstrated the beneft of radiation for intermediate
risk factors.72
Additionally, GOG 0263 is a phase III prospective trial cur-
rently accruing and designed to determine if postoperative
adjuvant chemoradiation can signifcantly improve recurrence-
free survival when compared to radiation alone in stage I–IIA
cervical cancer patients with intermediate risk factors after
treatment with radical hysterectomy. However, the bigger
question is that with no beneft in OS with adjuvant radiation
therapy, whether there is a need anyhow for adjuvant therapy
with modern imaging and surgery. Therefore, a new phase III
will start enrolling in 2022 randomizing patients with inter-
mediate risk factors to surgery plus or minus VBT versus sur-
gery plus pelvic radiation therapy.
Clinical Lymphatic Mapping
Conclusion
Radiation therapy plays an important role in the treatment of
gynecologic cancers, both as a defnitive treatment and as an
adjuvant to surgery. Continuous improvements in radiation
planning and techniques coupled with surgical strategies like
sentinel node biopsy appear to result in better local tumor con-
trol and reduced acute and long-term toxicity.
The integration of sentinel node biopsy into the routine care
of women with gynecologic cancer raises new questions for
study. Do all micrometastases and ITCs require adjuvant radi-
ation therapy? Should patients with regional macrometastases
undergo lymphadenectomy prior to regional radiation therapy?
When should radiation felds be extended? What is the role for
new strategies like targeted therapy and immunotherapy with
existing combinations? Radiation oncologists have decades-
long experience with the treatment of women with gyneco-
logic cancers and must remain as fully engaged members of
multidisciplinary teams in the continuous effort to develop
safer and more effective combinations.
REFERENCES
1. Slotman BJ, Cottier B, Bentzen SM, et al. Overview of
national guidelines for infrastructure and staffng of radio-
therapy. ESTRO-QUARTS: work package 1. Radiother
Oncol. 2005;75(3):349–54.
2. Luo H-C, Lin G-S, Liao S-G, et al. Cervical cancer treated
with reduced-volume intensity-modulated radiation therapy
base on Sedlis criteria (NCCN VS RTOG). Br J Radiol.
2018;91(1081):20170398.
3. Du X-L, Tao J, Sheng X-G, et al. Intensity-modulated radia-
tion therapy for advanced cervical cancer: a comparison of
dosimetric and clinical outcomes with conventional radio-
therapy. Gynecol Oncol. 2012;125(1):151–7.
4. Gandhi AK, Sharma DN, Rath GK, et al. Early clinical out-
comes and toxicity of intensity modulated versus conven-
tional pelvic radiation therapy for locally advanced cervix
carcinoma: a prospective randomized study. Int J Radiat
Oncol Biol Phys. 2013;87(3):542–8.
5. Naik A, Gurjar OP, Gupta KL, et al. Comparison of dosi-
metric parameters and acute toxicity of intensity-modulated
and three-dimensional radiotherapy in patients with cer-
vix carcinoma: a randomized prospective study. Cancer/
Radiothérapie. 2016;20(5):370–6.
6. Mell LK, Sirák I, Wei L, et al. Bone marrow-sparing inten-
sity modulated radiation therapy with concurrent cisplatin
for stage IB-IVA cervical cancer: an international multi-
center Phase II Clinical Trial (INTERTECC-2). Int J Radiat
Oncol Biol Phys. 2017;97(3):536–45.
7. Wang X, Shen Y, Zhao Y, et al. Adjuvant intensity-
modulated radiotherapy (IMRT) with concurrent paclitaxel
and cisplatin in cervical cancer patients with high risk fac-
tors: a phase II trial. Eur J Surg Oncol. 2015;41(8):1082–8.
8. Klopp AH, Yeung AR, Deshmukh S, et al. Patient-
reported toxicity during pelvic intensity-modulated radia-
tion therapy: NRG oncology – RTOG 1203. J Clin Oncol.
2018;36(24):2538.
Radiation oncology considerations
9. Chopra S, Dora T, Gupta S, et al. Phase III randomized trial
of postoperative adjuvant conventional radiation (3DCRT)
versus image guided intensity modulated radiotherapy
(IG-IMRT) in cervical cancer (PARCER): fnal analysis.
Int J Radiat Oncol Biol Phys. 2020;108(3):S1–S2.
10. Canlorbe G, Rouzier R, Bendifallah S, et al. Impact sur la
survie de la procédure du ganglion sentinelle dans le cancer
de la vulve : analyse de la SEER database. Gynécol Obstét
Fertil. 2012;40(11):647–51.
11. Burger MP, Hollema H, Emanuels AG, et al. The importance
of the groin node status for the survival of T1 and T2 vulval
carcinoma patients. Gynecol Oncol. 1995;57(3):327–34.
12. Farias-Eisner R, Cirisano FD, Grouse D, et al. Conservative
and individualized surgery for early squamous carcinoma
of the vulva: the treatment of choice for stage I and II (T1–2
N0–1 M0) disease. Gynecol Oncol. 1994;53(1):55–8.
13. Covens A, Vella ET, Kennedy EB, et al. Sentinel lymph
node biopsy in vulvar cancer: systematic review, meta-
analysis and guideline recommendations. Gynecol Oncol.
2015;137(2):351–61.
14. Van der Zee AGJ, Oonk MH, De Hullu JA, et al. Sentinel
node dissection is safe in the treatment of early-stage
vulvar cancer. J Clin Oncol Off J Am Soc Clin Oncol.
2008;26(6):8884–9.
15. Jolly S, Soni P, Gaffney DK, et al. ACR Appropriateness
Criteria® adjuvant therapy in vulvar cancer. Oncology.
2015;29(11). Available from: www.cancernetwork.com/
oncology-journal/acr-appropriateness-criteria-adjuvant-
therapy-vulvar-cancer/page/0/1.
16. Homesley HD, Bundy BN, Sedlis A, et al. Radiation therapy
versus pelvic node resection for carcinoma of the vulva with
positive groin nodes. Obstet Gynecol. 1986;68(6):733–40.
17. Kunos C, Simpkins F, Gibbons H, et al. Radiation therapy
compared with pelvic node resection for node-positive vul-
var cancer: a randomized controlled trial. Obstet Gynecol.
2009;114(3):537–46.
18. Petereit DG, Mehta MP, Buchler DA, et al. Inguinofemoral
radiation of N0,N1 vulvar cancer may be equivalent to
lymphadenectomy if proper radiation technique is used. Int
J Radiat Oncol Biol Phys. 1993;27(4):963–7.
19. Stehman FB, Bundy BN, Thomas G, et al. Groin dissec-
tion versus groin radiation in carcinoma of the vulva: a
Gynecologic Oncology Group study. Int J Radiat Oncol
Biol Phys. 1992;24(2):389–96.
20. Koh WJ, Chiu M, Stelzer KJ, et al. Femoral vessel depth
and the implications for groin node radiation. Int J Radiat
Oncol Biol Phys. 1993;27(4):969–74.
21. Hallak S, Ladi L, Sorbe B. Prophylactic inguinal-
femoral irradiation as an alternative to primary lymphad-
enectomy in treatment of vulvar carcinoma. Int J Oncol.
2007;31(5):1077–85.
22. Woelber L, Eulenburg C, Choschzick M, et al. Prognostic
role of lymph node metastases in vulvar cancer and impli-
cations for adjuvant treatment. Int J Gynecol Cancer.
2012;22(3):503–8.
23. Mahner S, Jueckstock J, Hilpert F, et al. Adjuvant ther-
apy in lymph node – positive vulvar cancer: the AGO-
CaRE-1 study. J Natl Cancer Inst. 2015;107(3). https://doi.
org/10.1093/jnci/dju426.
125
24. Klapdor R, Hillemanns P, Wölber L, et al. Outcome after
sentinel lymph node dissection in vulvar cancer: a sub-
group analysis of the AGO-CaRE-1 study. Ann Surg Oncol.
2017;24(5):1314–21.
25. Oonk MH, van Hemel BM, Hollema H, et al. Size of
sentinel-node metastasis and chances of non-sentinel-
node involvement and survival in early stage vulvar can-
cer: results from GROINSS-V, a multicentre observational
study. Lancet Oncol. 2010;11(7):646–52.
26. NCCN Clinical Practice Guidelines in Oncology: Vulvar
Cancer (Squamous Cell Carcinoma); 2020. Available from:
www.nccn.org/professionals/physician_gls/pdf/vulvar_
blocks.pdf.
27. Kitchener H, Swart AM, Qian Q, et al. Effcacy of sys-
tematic pelvic lymphadenectomy in endometrial can-
cer (MRC ASTEC trial): a randomised study. Lancet.
2008;373(9658):125–36.
28. Panici PB, Basile S, Maneschi F, et al. Systematic pelvic
lymphadenectomy vs no lymphadenectomy in early-stage
endometrial carcinoma: randomized clinical trial. J Natl
Cancer Inst. 2008;100(23):1707–16.
29. DiSaia PJ, Creasman WT, Boronow RC, et al. Risk factors
and recurrent patterns in Stage I endometrial cancer. Am J
Obstet Gynecol. 1985;151(8):1009–15.
30. Barlin JN, Zhou Q, St Clair CM, et al. Classifcation and
regression tree (CART) analysis of endometrial carci-
noma: seeing the forest for the trees. Gynecol Oncol.
2013;130(3):452–6.
31. Soliman PT, Westin SN, Dioun S, et al. A prospective vali-
dation study of sentinel lymph node mapping for high-risk
endometrial cancer. Gynecol Oncol. 2017;146(2):234–9.
32. Meyer LA, Bohlke K, Powell MA, et al. Postoperative radi-
ation therapy for endometrial cancer: American Society of
Clinical Oncology clinical practice guideline endorsement
of the American Society for Radiation Oncology evidence-
based guideline. J Clin Oncol. 2015;33(26):2908–13.
33. Klopp A, Smith BD, Alektiar K, et al. The role of post-
operative radiation therapy for endometrial cancer: execu-
tive summary of an American Society for Radiation
Oncology evidence-based guideline. Pract Radiat Oncol.
2014;4(3):137–44.
34. Jones E, Beriwal S, Beyer D, et al. An analysis of appropriate
delivery of postoperative radiation therapy for endometrial
cancer using the RAND/UCLA appropriateness method:
executive summary. Adv Radiat Oncol. 2016;1(1):26–34.
35. Plante M, Stanleigh J, Renaud M-C, et al. Isolated tumor
cells identifed by sentinel lymph node mapping in endo-
metrial cancer: does adjuvant treatment matter? Gynecol
Oncol. 2017;146(2):240–6.
36. Clinton LK, Kondo J, Carney ME, et al. Low-volume lymph
node metastases in endometrial carcinoma. Int J Gynecol
Cancer. 2017;27(6):1165–70.
37. Creutzberg CL, van Putten WLJ, Koper PCM, et al. Surgery
and postoperative radiotherapy versus surgery alone for
patients with stage-1 endometrial carcinoma: multicentre
randomised trial. Lancet. 2000;355(9213):1404–11.
38. Keys HM, Roberts JA, Brunetto VL, et al. A phase III
trial of surgery with or without adjunctive external pel-
vic radiation therapy in intermediate risk endometrial
126
adenocarcinoma: a Gynecologic Oncology Group study.
Gynecol Oncol. 2004;92(3):744–51.
39. St. Clair CM, Eriksson AGZ, Ducie JA, et al. Low-volume
lymph node metastasis discovered during sentinel lymph
node mapping for endometrial carcinoma. Ann Surg Oncol.
2016;23(5):1653–9.
40. Backes FJ, Felix AS, Grégoire J, et al. Sentinel lymph node
(SLN) isolated tumor cells (ITCs) in otherwise stage I/II
endometrioid endometrial cancer: to treat or not to treat?
Gynecol Oncol. 2018;149:7–8.
41. Todo Y, Kato H, Okamoto K, et al. Isolated tumor cells and
micrometastases in regional lymph nodes in stage I to II
endometrial cancer. J Gynecol Oncol. 2016;27(1):e1.
42. Mundt AJ, McBride R, Rotmensch J, et al. Signifcant pel-
vic recurrence in high-risk pathologic stage I – IV endome-
trial carcinoma patients after adjuvant chemotherapy alone:
implications for adjuvant radiation therapy. Int J Radiat
Oncol Biol Phys. 2001;50(5):1145–53.
43. Stewart KD, Martinez AA, Weiner S, et al. Ten-year out-
come including patterns of failure and toxicity for adjuvant
whole abdominopelvic irradiation in high-risk and poor
histologic feature patients with endometrial carcinoma. Int
J Radiat Oncol Biol Phys. 2002;54(2):527–35.
44. Mundt AJ, Murphy KT, Rotmensch J, et al. Surgery and
postoperative radiation therapy in FIGO Stage IIIC
endometrial carcinoma. Int J Radiat Oncol Biol Phys.
2001;50(5):1154–60.
45. Randall ME, Filiaci VL, Muss H, et al. Randomized phase
III trial of whole-abdominal irradiation versus doxorubicin
and cisplatin chemotherapy in advanced endometrial carci-
noma: a Gynecologic Oncology Group Study. J Clin Oncol.
2006;24(1):36–44.
46. Susumu N, Sagae S, Udagawa Y, et al. Randomized phase III
trial of pelvic radiotherapy versus cisplatin-based combined
chemotherapy in patients with intermediate- and high-risk
endometrial cancer: a Japanese Gynecologic Oncology
Group study. Gynecol Oncol. 2008;108(1):226–33.
47. Maggi R, Lissoni A, Spina F, et al. Adjuvant chemotherapy
vs radiotherapy in high-risk endometrial carcinoma: results
of a randomised trial. Br J Cancer. 2006;95(3):266–71.
48. de Boer SM, Powell ME, Mileshkin L, et al. Adjuvant
chemoradiotherapy versus radiotherapy alone for women
with high-risk endometrial cancer (PORTEC-3): fnal
results of an international, open-label, multicentre, ran-
domised, phase 3 trial. Lancet Oncol. 2018;19(3):295–309.
49. Hogberg T, Signorelli M, de Oliveira CF, et al. Sequential
adjuvant chemotherapy and radiotherapy in endometrial
cancer – results from two randomised studies. Eur J Cancer.
2010;46(13):2422–31.
50. Matei D, Filiaci V, Randall ME, et al. Adjuvant chemother-
apy plus radiation for locally advanced endometrial cancer.
N Engl J Med. 2019;380(24):2317–26.
51. Delgado G, Bundy B, Zaino R, et al. Prospective surgical-
pathological study of disease-free interval in patients
with stage IB squamous cell carcinoma of the cervix:
a Gynecologic Oncology Group study. Gynecol Oncol.
1990;38(3):352–7.
52. Sedlis A, Bundy BN, Rotman MZ, et al. A randomized
trial of pelvic radiation therapy versus no further therapy
in selected patients with stage IB carcinoma of the cervix
after radical hysterectomy and pelvic lymphadenectomy:
Clinical Lymphatic Mapping
a Gynecologic Oncology Group Study. Gynecol Oncol.
1999;73(2):177–83.
53. Creasman WT, Kohler MF. Is lymph vascular space
involvement an independent prognostic factor in early cer-
vical cancer? Gynecol Oncol. 2004;92(2):525–9.
54. Biewenga P, van der Velden J, Mol BWJ, et al. Prognostic
model for survival in patients with early stage cervical can-
cer. Cancer. 2011;117(4):768–76.
55. Fuller AF Jr, Elliott N, Kosloff C, et al. Determinants of
increased risk for recurrence in patients undergoing radical
hysterectomy for stage IB and IIA carcinoma of the cervix.
Gynecol Oncol. 1989;33(1):34–9.
56. NCCN clinical practice guidelines in Oncology (NCCN
Guidelines) cervical cancer. National Comprehensive
Cancer Network. Published 2020 [cited 2020 Oct 8].
Available from: www.nccn.org/professionals/physician_
gls/pdf/cervical_blocks.pdf.
57. Dostalek L, Åvall-Lundqvist E, Creutzberg CL, et al. ESGO
survey on current practice in the management of cervical
cancer. Int J Gynecol Cancer. 2018;28(6):1226–31.
58. Cibula D, Pötter R, Planchamp F, et al. The European
Society of Gynaecological Oncology/European Society for
Radiotherapy and Oncology/European Society of pathol-
ogy guidelines for the management of patients with cervical
cancer. Virchows Arch. 2018;472(6):919–36.
59. Beesley V, Janda M, Eakin E, et al. Lymphedema after
gynecological cancer treatment: prevalence, correlates, and
supportive care needs. Cancer. 2007;109(12):2607–14.
60. Mathevet P, Lecuru F. Effect of sentinel lymph-node
biopsy alone on the morbidity of the surgical treatment
of early cervical cancer: results from the prospective
randomized study Senticol2. J Clin Orthod. 2015;33
(15_suppl):5521.
61. Niikura H, Okamoto S, Otsuki T, et al. Prospective study of
sentinel lymph node biopsy without further pelvic lymph-
adenectomy in patients with sentinel lymph node – negative
cervical cancer. Int J Gynecol Cancer. 2012;22(7):1244–
50. Published online 2012. https://ijgc.bmj.com/content/
22/7/1244.abstract.
62. Landoni F, Maneo A, Colombo A, et al. Randomised study
of radical surgery versus radiotherapy for stage Ib-IIa cervi-
cal cancer. Lancet. 1997;350(9077):535–40.
63. Cibula D, Kocian R, Plaikner A, et al. Sentinel lymph node
mapping and intraoperative assessment in a prospective,
international, multicentre, observational trial of patients
with cervical cancer: the SENTIX trial. Eur J Cancer.
2020;137:69–80.
64. Altgassen C, Hertel H, Brandstädt A, et al. Multicenter
validation study of the sentinel lymph node concept
in cervical cancer: AGO Study Group. J Clin Oncol.
2008;26(18):2943–51.
65. Wolfson AH, Varia MA, Moore D, et al. ACR
Appropriateness Criteria® role of adjuvant therapy in the
management of early stage cervical cancer. Gynecol Oncol.
2012;125(1):256–62.
66. Chino J, Annunziata CM, Beriwal S, et al. Radiation
therapy for cervical cancer: executive summary of an
ASTRO clinical practice guideline. Pract Radiat Oncol.
2020;10(4):220–34.
67. Peters WAI, Liu PY, Barrett RJII, et al. Concurrent chemo-
therapy and pelvic radiation therapy compared with pelvic
Radiation oncology considerations
radiation therapy alone as adjuvant therapy after radical
surgery in high-risk early-stage cancer of the cervix. Obstet
Gynecol Surv. 2000;55(8):491.
68. Rotman M, Sedlis A, Piedmonte MR, et al. A phase III ran-
domized trial of postoperative pelvic irradiation in stage IB
cervical carcinoma with poor prognostic features: follow-
up of a gynecologic oncology group study. Int J Radiat
Oncol Biol Phys. 2006;65(1):169–76.
69. Monk BJ, Wang J, IMS, et al. Rethinking the use of radiation
and chemotherapy after radical hysterectomy: a clinical-
pathologic analysis of Gynecologic Oncology Group/
Southwest Oncology Group/Radiation Therapy Oncology
Group trial. Gynecol Oncol. 2005;96(3):721–8.
127
70. Cheng X, Cai SM, Li ZT, et al. Concurrent chemotherapy
and adjuvant extended feld irradiation after radical surgery
for cervical cancer patients with lymph node metastases. Int
J Gynecol Cancer. 2008;18(4):779–84.
71. Takeshima N, Umayahara K, Fujiwara K, et al. Treatment
results of adjuvant chemotherapy after radical hysterectomy
for intermediate- and high-risk stage IB – IIA cervical can-
cer. Gynecol Oncol. 2006;103(2):618–22.
72. Rogers L, Siu SSN, Luesley D, et al. Radiotherapy and
chemoradiation after surgery for early cervical cancer.
Cochrane Database Syst Rev. 2012;5. Available from:
www.cochranelibrary.com/cdsr/doi/10.1002/14651858.
CD007583.pub3/abstract.
16
Special considerations

Michael Frumovitz

CONTENTS
Introduction .................................................................................................................................................................................. 129
Vaginal cancer .............................................................................................................................................................................. 129
Ovarian cancer ............................................................................................................................................................................. 130
Vulvar melanoma ......................................................................................................................................................................... 131
References.................................................................................................................................................................................... 133

Introduction lymphatic system of the female reproductive tract, Plentl and

As lymphatic mapping and sentinel lymph node biopsy have
become part of the standard of care in the treatment of women
with vulvar cancer and are options frequently utilized in the
surgical treatment of cervical and uterine cancers, gyneco-
logic oncologists are exploring their utility and validity in
other malignancies of the female reproductive tract. Although
the diagnosis is exceedingly rare, women with vaginal can-
cer may beneft from lymphatic mapping even when radiation
therapy is being considered instead of surgery. For patients
with clinically early ovarian cancer, lymphatic mapping and
sentinel lymph node biopsy may allow for less extensive sur-
gery while still obtaining important prognostic information.
The application of lymphatic mapping and sentinel lymph
nodes will be reviewed in the frst part of this chapter. Finally,
vulvar melanoma presents an interesting intersection of muco-
sal squamous cancer and cutaneous melanoma. The manage-
ment of sentinel nodes in cutaneous melanoma has evolved
signifcantly over the last decade, and how those lessons may
be applied to vulvar melanoma will be explored at the end of
this chapter.
Vaginal cancer
Many clinicians assume that lymphatic drainage from the
upper vagina follows cervical routes into the pelvis, while
drainage from the lower vagina and introitus follow vulvar
routes to the inguinofemoral triangle. The middle portion
of the vagina may therefore drain to either basin. These pat-
terns, however, are inconsistent, and lymphatic drainage of
the vagina may actually follow ventral and dorsal routes more
commonly than drainage based on the regions of the proximal,
mid, and distal vagina (or upper, middle, and lower thirds).1
In this ventral/dorsal model, lymphatics from the ventral por-
tion of the vagina drain to the pelvis, while the dorsum of the
vagina may drain to rectal nodes. In their defnitive text on the
Friedman admit that the lymphatic drainage of the vagina is
complex and uncertain and that “unusual variations” are fre-
quently reported.1
As reliable pathways for lymphatic drainage of the vagina
are lacking, lymphatic mapping may be an essential part of
therapeutic planning for treating women with vaginal cancer.
Typically vaginal cancers located in the upper and middle
vagina are treated with radiation therapy. With the variable
drainage patterns of the vagina, lymphatic mapping may be
very useful in these patients prior to radiation planning to
assure adequate coverage of potential metastatic sites in drain-
ing basins. For women with vaginal cancers in the lower third
or introitus and felt to be surgically resectable, lymphatic
mapping may help surgeons plan the surgical approach and
whether to sample inguinofemoral or pelvic nodes (or possibly
rectal nodes) as part of their surgery.
Multiple case reports have detailed the location of sentinel
nodes after lymphatic mapping of a primary vaginal cancer.
These publications typically report traditional pathways of
lymphatic drainage of the vagina, with the upper vagina drain-
ing to the pelvis and the lower vagina draining to the groin.2–6
In a study of seven patients by Hertel and colleagues, lymphatic
drainage also seemed to follow the more traditional routes.7
Patients with disease exclusively in the upper or middle third
had drainage to the pelvis, while the one patient with disease
limited to only the lower third had drainage to the groin. One
patient had disease along the entire vagina, and lymphatic
mapping revealed sentinel nodes in both the groin and pel-
vis. The last patient had disease in the lower and middle third
and had lymphatic drainage to the pelvis only with no map-
ping in the groin. Other prospective studies have confrmed
the unpredictable lymphatic pathways draining the vagina. In
the largest study of lymphatic mapping in women with vaginal
cancer, Frumovitz et al. identifed at least one sentinel node in
11 (79%) of 14 women who underwent lymphatic mapping.8
When tumors were located in the lower third or at the introitus,
sentinel nodes were detected in the groin 50% of the time, in

DOI: 10.1201/9781003255536-16 129

130
TABLE 16.1
Lymph Node Basins Draining the Vagina by Tumor Location
Location of sentinel node(s)
Tumor location (by thirds) Groin Pelvis Groin and pelvis
Lower/introitus (n = 11) 64% 22% 22%
Middle (n = 1) 0% 100% 0%
Upper (n = 8) 25% 75% 0%
Note: *Tumors that crossed one or more regions were excluded.
the pelvis 17% of the time, and in both the groin and pelvis
33% of the time. Tumors in the upper third drained to the groin
50% of the time and to the pelvis in the other half of cases.
The one case with disease in the middle third drained to the
pelvis. When assessing tumor location by anterior or posterior,
anterior lesions drained to the groin in 25% of cases and to the
pelvis in 75% of cases. Posterior lesions drained to the groin
in 50% of cases, to the pelvis in 17% of cases, and to both
the groin and pelvis in 33%. Other authors have also reported
cases of vaginal cancer located in the lower third of the vagina
mapping to both groin and pelvic basins.9 Table 16.1 summa-
rizes the location of sentinel nodes based on tumor location in
the vagina.
Ovarian cancer
The main lymphatic drainage of the ovary follows the ovar-
ian vessels to the aortocaval region to the vena cava and aorta
as high as the cisterna chyli.1 However, nodal basins drain-
ing the ovary may also be found in multiple locations in the
deep pelvis and along the iliac vessels. The right ovary fre-
quently drains to the right and anterior to the vena cava above
the inferior mesenteric artery, while the lymphatic basins of
the left ovary are more often found overlying the aorta and a
bit more cephalad. Occasionally the lymphatic channels found
in the infundibulopelvic ligament will terminate lower along
the vena cava and aorta (below the inferior mesenteric artery)
and even below the bifurcation of the aorta along the sacral
promontory. There are also lymphatic channels that fow down
the posterolateral aspects of the uterus to join the cervical
channels leading deep into the pelvis to the obturator space
and external iliac vessels. In addition, the ovary has lymphatic
drainage directly to the pelvis through channels in the folds
of the broad ligament terminating near the bifurcation of the
internal and external iliac vessels.1 These channels may also
continue into the inguinal triangle. Although rare, women with
ovarian cancer do occasionally present with metastatic disease
in the groin nodes as disease progresses past the pelvic nodes
through these channels.
Complete lymphadenectomy in patients with stage III/
IV ovarian cancer has been shown to be unnecessary,10 but
its role in clinically early-stage disease remains unclear. In
women with disease grossly limited to the ovary, lymphad-
enectomy will confrm metastatic disease to lymph nodes in
as many as 15% of cases.11 Although the therapeutic value of
resecting these lymph nodes is likely minimal, the presence of
Clinical Lymphatic Mapping
disease spread to lymph nodes may affect recommendations
* for observation or adjuvant chemotherapy in certain histologic
subtypes. Similar to performing complete lymphadenectomy
in other gynecologic cancers, removing all at-risk nodes in
women with gross ovary-confned disease adds surgical mor-
bidity and operative time and is overtreatment for the 85% of
women who will ultimately have node-negative disease. For
these reasons, investigators have started to explore the role of
lymphatic mapping and sentinel nodes in women with early-
stage ovarian cancer.
In order to apply mapping principles to ovarian cancer, early
investigators frst had to work out the location and timing of
injections. Injection of mapping substances directly into the
ovarian cortex was fraught with risk of rupture and upstaging
of disease, so this approach was quickly abandoned. Some of
the initial studies injected dyes into the mesovarium, myome-
trium, and uterine cervix, but ultimately leading researchers
adopted injection in the subcuticular tissue of the infundibu-
lopelvic and utero-ovarian ligaments as the areas most likely
to accurately map the ovary.12 Utilizing this technique, at least
one sentinel node will be identifed in approximately 94% of
cases. Sentinel nodes will be found in the aortocaval region
alone 66% of the time, in the pelvis only 12% of the time, and
in both regions 22% of the time13 (Figure 16.1). Surprisingly,
sentinel nodes along the vena cava and aorta were more fre-
quently detected below the inferior mesenteric artery than
above it (57% vs. 43%).14–18 Although injecting the infundib-
ulopelvic and utero-ovarian ligaments seems to be the best
option for lymphatic mapping ovarian cancer, one of the limi-
tations of this technique in ovarian cancer is the lack of drain-
ing basins detected in the contralateral pelvis even though
metastatic disease to lymph nodes can be found in those nodes
in 3.2% of cases.12
The timing of injections is still not entirely worked out. As
the decision to perform lymph node sampling is typically made
after a frozen section has established malignancy, there are two
possibilities of when to inject the dyes. One option is to inject
all cases with a suspicion of malignancy at the beginning of the
case and then explore for sentinel nodes only after the frozen
section returns cancer. One problem with this approach is that
blue dye and indocyanine green only stay in the sentinel node
for a limited time, so they may not be found if the frozen sec-
tion takes a long time. Radiocolloid will stay in the sentinel
node for hours, so this tracer may be more appropriate for this
approach. Another potential problem with this approach is that
it may be diffcult to safely access the infundibulopelvic and/or
utero-ovarian ligaments for injection if the pelvic tumor is large
or fxed. The other technique is to remove the adnexal mass, and
once a frozen section reveals malignancy, then inject the rem-
nants of the infundibulopelvic and utero-ovarian ligaments. This
timing protocol will have a sentinel node detection rate in 90%–
100% of cases.17,18 Frequently a diagnosis of cancer is made post-
operatively requiring a staging surgery as a second procedure.
Attempts have been made in these circumstances to perform
lymphatic mapping by injecting the infundibulopelvic and utero-
ovarian ligament stumps/remnants, but detection rates go down
signifcantly when this is done. In one study, the sentinel node
detection rate in these delayed staging cases was 42% compared
to 89% when performed during the initial surgery (p = 0.003).17
Special considerations 131

FIGURE 16.1 Sentinel lymph nodes of the right ovary identifed by injection of blue dye in the hilum of the ovary. The nodes are anterior to the
inferior vena cava (IVC) and between the IVC and aorta. Left ovarian sentinel nodes are typically at level of the left renal vein.

There are very few prospective validation studies for senti- (ESMO) and the National Comprehensive Cancer Network
nel nodes in women with ovarian cancer. The Sentinel Nodes (NCCN) recommend a wide excision with 0.5-cm margins for
in Early Stage Ovarian Cancer (SELLY) trial performed lym- in situ lesions, 1 cm for tumors <2 mm thick, and obtaining a
phatic mapping and sentinel lymph node biopsy followed by margin of 2 cm for lesions ≥ 2 mm thick22 (Figure 16.3). For
complete lymphadenectomy in women with histologically tumors >1 mm thick, sentinel lymph node biopsies are also
confrmed ovarian cancer. The authors reported on the frst
31 patients in a preliminary report.17 The overall detection rate
was 68% (21 of 31 patients). Four patients had metastatic dis-
ease to lymph nodes, and the sentinel node identifed all of
them (sensitivity 100%, false-negative rate 0%). In addition,
the negative predictive value was 100%.17 The SELLY trial
continues to accrue and ultimately will enroll 176 patients,
which will provide more robust data on the validity of the
technique.19

Vulvar melanoma
Although vulvar melanoma is the most common nonsqua-
mous malignancy of the vulva, it is an exceedingly rare dis-
ease, accounting for only 5% of vulvar cancers. In the United
States there are only 0.136 cases per 100,000 women.20 Vulvar
melanoma is an aggressive disease with a 5-year survival rate
of approximately 33%.21 The disease occurs most frequently in
Caucasian women at an average age of 60, and older age has
been shown to be an independent prognostic factor for sur-
vival. Tumors are most frequently found on the labia minora
and clitoris (Figure 16.2).
Much of the treatment recommendations for vulvar mela-
noma have been extrapolated from the literature for the more
common cutaneous melanoma. Surgical resection is the pre-
ferred primary management for patients with vulvar melanoma.
In their guidelines, the European Society for Medical Oncology FIGURE 16.2 Vulvar melanoma involving the clitoris.
132
FIGURE 16.3 Surgical resection of clitoral melanoma with adequate
margins.
recommended. In addition, sentinel lymph node biopsy is rec-
ommended for lesions 0.75–1 mm thick that have additional
risk factors such as ulceration or high mitotic rate.
With efforts led by Dr. Donald Morton in the early 1990s,
surgeons began to investigate the safety of sentinel lymph node
biopsy alone as a replacement for complete regional lymph-
adenectomy in patients with cutaneous melanoma.23 The
Multicenter Selective Lymphadenectomy Trial-I (MSLT-I)
randomized 2001 patients with cutaneous melanoma with a
Breslow thickness >1 mm to either wide excision and observa-
tion with regional lymphadenectomy only at the time of recur-
rence (observation group) or wide excision and sentinel lymph
node biopsy followed by observation if the sentinel node was
negative (biopsy group). In those patients with positive sen-
tinel nodes, complete regional lymphadenectomy was per-
formed in a second surgery (biopsy group).24 For patients with
intermediate-thickness melanomas (1.2–3.5 mm), there was no
difference in melanoma-specifc survival for the entire biopsy
group compared to the observation group (81% vs. 78% at 10
years, p = 0.18). However, there was a signifcant improvement
in melanoma-specifc survival in those patients who had a pos-
itive sentinel lymph node compared to those in the observation
group who developed clinical disease in a regional lymph node
basin (62% vs. 42%, p = 0.006). For patients with thick mela-
nomas (>3.5 mm), similarly there was no difference in survival
for the entire group, including for those patients with positive
nodes (33%) who had sentinel lymph node biopsy as compared
to those who had regional nodes observed and only managed at
the time of clinical presentation for the disease (48% vs. 46%,
Clinical Lymphatic Mapping
p = 0.78). This study established sentinel lymph node biopsy
as the standard of care in patients with cutaneous melanoma.
As immediate regional lymphadenectomy after detection
of a positive sentinel node was part of the MSLT-I protocol,
this, too, became part of the standard of care for cutaneous
melanoma. However, at that time there were no prospective
studies showing that completion lymphadenectomy improved
oncologic outcomes, although it was well known that it greatly
increased adverse events and morbidity.
The second Multicenter Selective Lymphadenectomy Trial
(MSLT-II) evaluated the utility of completion lymphadenec-
tomy in patients with cutaneous melanoma who were found
to have a positive sentinel node. Patients with metastatic dis-
ease to sentinel nodes were randomly assigned to completion
regional lymphadenectomy or an observation group entailing
clinical exam and nodal ultrasonography assessment with
completion lymph node dissection if the patient developed a
regional lymph node recurrence. As expected, regional lymph
node recurrence was higher in the observation group as com-
pared to the completion group (23% vs. 8%, p < 0.001), but
this did not translate into a survival difference. At a median
follow-up of 43 months, the 3-year melanoma-specifc sur-
vival rate was equivalent between the two groups (86% for
both groups, p = 0.42).25 The DeCOG-SLT study also found
completion lymphadenectomy did not improve survival over
observation with exam and ultrasound after a positive senti-
nel node was detected in patients with cutaneous melanoma.26
Although the recurrence rate was lower than predicted in both
groups, leading to a study that was ultimately underpowered,
the study showed no difference in survival between the two
groups (3-year survival 82% in the observation group com-
pared to 81% in the completion group, p = 0.87). Again, nodal
recurrences were higher in the observation group (16%) than
they were in the completion group (11%).
Based on these studies, the American Society of Clinical
Oncology (ASCO) and the Society for Surgical Oncology
(SSO) recommend wide excision and sentinel lymph node
biopsy alone for patients with intermediate-thickness cutane-
ous melanoma (1–4 mm) and for those with thin lesions (<1
mm thick) with risk factors such as ulceration.27 For patients
with thick melanomas (>4 mm), sentinel lymph node biopsy
may be considered for prognostic purposes and to aid in guid-
ing adjuvant therapy, even though MSLT-1 and other studies
have not shown a survival beneft in these patients. Based on
the MSLT-II and DeCOG-SLT studies, the NCCN states that
observation after a positive sentinel node is preferred, although
completion lymphadenectomy may be considered.28
Lymphatic mapping and sentinel lymph node biopsy for
vulvar melanoma follow the same techniques described ear-
lier in this book (see Chapter 5). Wechter et al. reported on
ten patients with vulvar melanoma who underwent sentinel
lymph node biopsy.29 Two patients had positive sentinel nodes,
but there was no description of long-term follow-up in these
patients. In another retrospective study, De Hullu et al. treated
33 patients with vulvar melanoma in whom 9 underwent
lymphatic mapping and sentinel lymph node biopsy.30 Two
(22%) of the 9 patients who had a sentinel lymph node biopsy
recurred in the groin compared to 0 of the 24 who had full
inguinofemoral lymphadenectomies. However, both of these
Special considerations
patients had lesions >4 mm thick, which made them exceed-
ingly high risk for recurrence. Other than an additional few
case reports, there are no other publications on outcomes for
women with vulvar melanoma after sentinel node biopsy.
REFERENCES
1. Plentl AA, Friedman EA. Lymphatic System of the Female
Genitalia. Philadelphia: W.B. Saunders Company; 1971.
2. Ishida H, Nagai T, Sato S, et al. Concomitant sentinel lymph
node biopsy leading to abbreviated systematic lymphad-
enectomy in a patient with primary malignant melanoma of
the vagina. Springerplus. 2015;4;102.
3. Nakagawa S, Koga K, Kugu K, et al. The evaluation of
the sentinel node successfully conducted in a case of malig-
nant melanoma of the vagina. Gynecol Oncol. 2002;86;
387–9.
4. Dhar KK, Das N, Brinkman DA, et al. Utility of sentinel
node biopsy in vulvar and vaginal melanoma: report of two
cases and review of the literature. Int J Gynecol Cancer.
2007;17:720–3.
5. Abramova L, Parekh J, Irvin WP Jr, et al. Sentinel node
biopsy in vulvar and vaginal melanoma: presentation
of six cases and a literature review. Ann Surg Oncol.
2002;9:840–6.
6. Rodier JF, Janser JC, David E, et al. Radiopharmaceutical-
guided surgery in primary malignant melanoma of the
vagina. Gynecol Oncol. 1999;75:308–9.
7. Hertel H, Soergel P, Muecke J, et al. Is there a place for
sentinel technique in treatment of vaginal cancer?: feasibil-
ity, clinical experience, and results. Int J Gynecol Cancer.
2013;23:1692–8.
8. Frumovitz M, Gayed IW, Jhingran A, et al. Lymphatic
mapping and sentinel lymph node detection in women with
vaginal cancer. Gynecol Oncol. 2008;108:478–81.
9. van Dam P, Sonnemans H, van Dam PJ, et al. Sentinel
node detection in patients with vaginal carcinoma. Gynecol
Oncol. 2004;92:89–92.
10. Harter P, Sehouli J, Lorusso D, et al. A randomized trial of
lymphadenectomy in patients with advanced ovarian neo-
plasms. N Engl J Med. 2019;380:822–32.
11. Piver MS, Barlow JJ, Lele SB. Incidence of subclinical
metastasis in stage I and II ovarian carcinoma. Obstet
Gynecol. 1978;52:100–4.
12. Uccella S, Zorzato PC, Lanzo G, et al. The role of sentinel
node in early ovarian cancer: a systematic review. Minerva
Med. 2019;110:358–66.
13. Dell’Orto F, Laven P, Delle Marchette M, et al. Feasibility
of sentinel lymph node mapping of the ovary: a systematic
review. Int J Gynecol Cancer. 2019;29:1209–15.
14. Kleppe M, Brans B, Van Gorp T, et al. The detection of
sentinel nodes in ovarian cancer: a feasibility study. J Nucl
Med. 2014;55:1799–804.
15. Buda A, Passoni P, Corrado G, et al. Near-infrared
fuorescence-guided sentinel node mapping of the ovary
133
with indocyanine green in a minimally invasive setting: a
feasible study. J Minim Invasive Gynecol. 2017;24:165–70.
16. Nyberg RH, Korkola P, Maenpaa JU. Sentinel node and
ovarian tumors: a series of 20 patients. Int J Gynecol
Cancer. 2017;27:684–9.
17. Uccella S, Nero C, Vizza E, et al. Sentinel-node biopsy in
early-stage ovarian cancer: preliminary results of a pro-
spective multicentre study (SELLY). Am J Obstet Gynecol.
2019;221:324e1–e10.
18. Lago V, Bello P, Montero B, et al. Sentinel lymph node
technique in early-stage ovarian cancer: a phase II clinical
trial. Int J Gynecol Cancer. 2020;30(9):1390–6.
19. Scambia G, Nero C, Uccella S, et al. Sentinel-node biopsy
in early stage ovarian cancer: a prospective multicentre
study (SELLY). Int J Gynecol Cancer. 2019;29:1437–9.
20. Boer FL, Ten Eikelder MLG, Kapiteijn EH, et al. Vulvar
malignant melanoma: pathogenesis, clinical behaviour and
management: review of the literature. Cancer Treat Rev.
2019;73:91–103.
21. Weinstock MA. Malignant melanoma of the vulva and
vagina in the United States: patterns of incidence and pop-
ulation-based estimates of survival, Am J Obstet Gynecol.
1994;171:1225–30.
22. Dummer R, Hauschild A, Lindenblatt N, et al. Cutaneous
melanoma: ESMO Clinical Practice Guidelines for diag-
nosis, treatment and follow-up. Ann Oncol. 2015;26(Suppl
5):126–32.
23. Morton DL, Cochran AJ, Thompson JF, et al. Sentinel node
biopsy for early-stage melanoma: accuracy and morbidity
in MSLT-I, an international multicenter trial. Ann Surg.
2005;242:302–11; discussion 311–13.
24. Morton DL, Thompson JF, Cochran AJ, et al. Final trial
report of sentinel-node biopsy versus nodal observation in
melanoma. N Engl J Med. 2014;370:599–609.
25. Faries MB, Thompson JF, Cochran AJ, et al. Completion
dissection or observation for sentinel-node metastasis in
melanoma. N Engl J Med. 2017;376:2211–22.
26. Leiter U, Stadler R, Mauch C, et al. Complete lymph node
dissection versus no dissection in patients with sentinel
lymph node biopsy positive melanoma (DeCOG-SLT):
a multicentre, randomised, phase 3 trial. Lancet Oncol.
2016;17:757–67.
27. Wong SL, Balch CM, Hurley P, et al. Sentinel lymph
node biopsy for melanoma: American Society of Clinical
Oncology and Society of Surgical Oncology joint clinical
practice guideline. J Clin Oncol. 2012;30:2912–18.
28. Network NCC. Cutaneous Melanoma (Version 3.2020)
[2020 Jun 10]. Available from: www.nccn.org/professionals/
physician_gls/pdf/cutaneous_melanoma.pdf.
29. Wechter ME, Gruber SB, Haefner HK, et al. Vulvar mela-
noma: a report of 20 cases and review of the literature. J Am
Acad Dermatol. 2004;50:554–62.
30. de Hullu JA, Hollema H, Hoekstra HJ, et al. Vulvar mel-
anoma: is there a role for sentinel lymph node biopsy?
Cancer. 2002;94:486–91.
17
Clinical trial design

Scott Jordan and Brian M. Slomovitz

CONTENTS
Introduction .................................................................................................................................................................................. 135
Endometrial cancer ...................................................................................................................................................................... 135
Cervical cancer............................................................................................................................................................................. 136
Vulvar cancer ............................................................................................................................................................................... 138
Summary ...................................................................................................................................................................................... 139
References.................................................................................................................................................................................... 139

Introduction Endometrial cancer

Since frst being described for use in penile cancer in 1977,
sentinel lymph node (SLN) evaluation has slowly become the
standard-of-care surgical approach to staging across multiple
cancer sites.1 Acceptance among gynecologic oncologists has
been dependent on clinical trials demonstrating SLN evalua-
tion to have a low false-negative rate, noninferior survival out-
comes, and an improvement in long- and short-term surgical
morbidity.
In order to accomplish this, a stepwise progression from
reports of a novel surgical approach to large randomized con-
trolled trials is required. The approach to this has differed
among disease sites due to unique challenges present in each
cancer, but the basic principles are similar. Initially, small
case series are published, demonstrating the technical ability
of radiocolloid or dye to identify sentinel nodes in patients who
are planned for complete lymphadenectomy. Larger retrospec-
tive series and smaller prospective studies describe institutional
experience with technique, further refning a standard proto-
col for use in practice-changing trials. The primary objective
of traditional phase III trials is to establish prospectively the
sensitivity of SLNevaluation, often using the patient herself as
the control group, by comparing excised sentinel nodes to the
standard of complete lymphadenectomy. A second objective
is to establish the safety of the technique by reporting short-
and long-term procedural morbidity, recurrence rate, and
recurrence-free survival data in patients undergoing sentinel
node biopsy compared with full lymphadenectomy. Because
of the rarity of some of the gynecologic cancers, the variety of
endpoints that we deem to be most clinically appropriate, and
the strong views of experts in our feld, carrying out phase III
trials is not always possible, and we need to use novel study
designs to demonstrate meaningful data that will change the
standard of care.
The frst report of sentinel node injection in endometrial can-
cer was published in 1996 by Burke et al., a single-institution
pilot study with 15 patients who underwent myometrial injec-
tion of isosulfan blue dye at the time of abdominal hysterec-
tomy for endometrial cancer.2 Statistical endpoints were not
defned, and neither sensitivity nor negative predictive value
(NPV) were reported. Multiple small prospective case series
followed, investigating the feasibility of sentinel node identi-
fcation and the sensitivity and NPV for cancer detection.3–16
Many of these pilot studies also reported the most common
locations for mapping as part of feasibility.
Early studies were divided in surgical methodology between
uterine injection of tracer (either into the fundus or directly
into the tumor via hysteroscopy) and cervical injection. Due
to the relative ease of cervical injection compared to hystero-
scopic or fundal injection, small trials were designed compar-
ing the two injection sites with the goal of comparing node
detection rates. In 2008, Perrone et al. compared sentinel node
detection rates between two cohorts. The frst received techni-
cium-99 (Tc-99m) injected preoperatively into the cervix, and
the second cohort received hysteroscopically Tc-99m directly
into the tumor. Detection rates between the cohorts did not
differ signifcantly.17 In 2013, Rossi et al. compared cervical
versus hysteroscopic injection of indocyanine green (ICG) dye
prior to robotic sentinel lymph node biopsy, demonstrating a
signifcantly higher detection rate in the cervical group.18 A
study incorporating single photon emission computed tomog-
raphy (SPECT) rather than surgical detection methods con-
frmed cervical injection to yield an improved detection rate
compared with hysteroscopic peritumoral injection.19 Two
large meta-analyses have confrmed these results.20,21
While initial studies utilized either Tc-99m, blue dye, or a
combination of the two, the addition of near-infrared imaging

DOI: 10.1201/9781003255536-17 135

136
technology has allowed the inclusion of ICG tracer to be com-
pared as well. Sinno et al. compared detection rates between
ICG and isosulfan blue dye cohorts of patients undergoing
robotic-assisted SLN biopsy, demonstrating signifcantly
higher rates of sentinel node identifcation in the ICG cohort
compared with isosulfan blue dye.22 A comparison by How et
al. utilizing all three tracers injected into the cervical stroma of
the same patient demonstrated poorer performance of isosul-
fan blue dye compared with either ICG or Tc-99m, which per-
formed similarly.23 In a randomized controlled trial of sentinel
node detection in endometrial and cervical cancer powered for
noninferiority, ICG demonstrated a signifcantly higher detec-
tion rate compared with isosulfan blue, leading the authors to
suggest ICG to in fact be the superior agent.24
Two large phase III, prospective, multisite studies demon-
strated acceptable sensitivity and NPV values (Table 17.1). The
SENTI-ENDO study, frst published in 2011, evaluated sensitiv-
ity and NPV in SLN evaluation using each hemipelvis as a unit
of analysis, as well as by using the patient as a unit of analysis.
Tc-99m and isosulfan blue cervical injections were utilized for
identifcation. Completion pelvic lymphadenectomies were per-
formed following sentinel lymph node excision for calculation
of NPV and sensitivity. The study demonstrated 100% NPV and
100% sensitivity in each hemipelvis, with a 97% NPV and 84%
sensitivity in each patient.25 A survival analysis was published
in 2015, showing no difference in recurrence-free survival
between patients with and without detected SLN or between
those with and without positive SLN. Adjuvant therapy was also
given more frequently in patients with positive SLN, demon-
strating the impact on therapeutic decision making.26
The FIRES trial, published in 2017, was similarly designed,
utilizing ICG as a tracer. The primary endpoints were sensi-
tivity and NPV, and with 356 patients enrolled, it is the larg-
est prospective endometrial SLN study to date. Sensitivity
was reported as 97.2% with an NPV of 99.6%.27 The fndings
of these large prospective studies corroborate the published
results of the three largest meta-analyses on endometrial SLN
biopsy.20,21,28
Initially, due to controversy surrounding the utility of com-
prehensive universal lymphadenectomy in the surgical man-
agement of early-stage endometrial cancer, SLN evaluation
presented an attractive alternative due to decreased surgical
intervention but equivalent detection rates.29 With increasing
adoption of the technique, retrospective and prospective data
were published demonstrating the utility of SLN in high-risk
histologies. Schiavone et al. published the results of an analysis
of a prospectively maintained database including 136 patients
with carcinosarcoma. No difference in progression-free or
overall survival was seen between patients who underwent
complete lymphadenectomy or SLN biopsy alone.30 The rate
of positive nodes was also equivalent between the two groups.
Soliman et al. published a prospective trial of 123 patients with
high-grade endometrial cancers, demonstrating 95% sensitiv-
ity and a false-negative rate of 4.3%.31
Given the prevalence of endometrial cancer, the stepwise
demonstration of safety and effcacy, and the confrmation
in phase III prospective trials, SLN for endometrial cancer
is considered the standard of care for patients with presumed
early-stage endometrial cancer.
Clinical Lymphatic Mapping
Cervical cancer
SLN mapping in cervical cancer was frst reported in 1999, in
a prospective series by Echt et al., demonstrating a subopti-
mal identifcation rate of 15.4% in 13 cervical cancer patients
injected with lymphazurine.32 In the following years, similar
to endometrial cancer, many small case series were published
demonstrating the sensitivity of SLN mapping in cervical can-
cer, including sensitivity and NPV. These small studies were
included in meta-analyses by van de Land et al. in 2007 (sen-
sitivity 92%) and by Frumovitz et al. in 2008 (sensitivity 92%,
NPV 97%).33,34
The frst multicenter study was published in 2008 by
Altagassen et al. (Table 17.1). It included 590 prospectively
registered patients, with endpoints of detection rate (88.6%),
sensitivity (77.4%), and NPV (94.3%) calculated after SLN
excision followed by systematic pelvic and paraaortic lymph
node dissection. Despite a low sensitivity in the total cohort,
a post hoc analysis demonstrated higher sensitivity and NPV
in patients with tumors under 2 cm, suggesting that patients
with smaller tumors are the most appropriate for SLN biopsy.35
The multicenter SENTICOL study was similarly designed, but
explicitly included up to stage IB1 disease. The protocol also
included ultrastaging of sentinel nodes, which was not done in
the previous study. Sensitivity of this study was higher at 92%,
and NPV was 98.2%.36
In an effort to further increase sensitivity and NPV while
minimizing surgical morbidity, Cormier et al. published a
prospective study evaluating the sensitivity and NPV of SLN
mapping within a single institution compared with the theo-
retical sensitivity and specifcity had the proposed algorithm
been applied. This algorithm included excision of all mapped
SLNs (with ultrastaging), removal of all suspicious nodes,
side-specifc pelvic lymph node dissection (LND) perfor-
mance in a nonmapping hemipelvis, and en block paramet-
rectomy being performed with resection of the primary tumor.
This analysis demonstrated an increase in patient-specifc
specifcity of 87.5% and NPV of 96.8% to 100% and 100%,
respectively, while avoiding bilateral complete LND in all but
6.6% of patients.37
Unique to the surgical management of cervical cancer is the
potential for abandoning the surgical approach in the setting of
positive lymph nodes in order to reduce treatment-related mor-
bidity and provide optimal anatomy to permit maximum radi-
ation dose delivery. Thus, additional studies were designed to
determine the utility of SLN evaluation intraoperatively. Fader
et al. published a prospective series evaluating 38 patients’
SLN excision specimens intraoperatively via frozen section
and postoperatively via ultrastaging. Comparison of these two
methods demonstrated frozen section to correctly identify
lymph node metastases in only 33% of cases.38 Retrospective
evaluation of the SENTICOL study, which only performed
intraoperative examination in the case of macroscopic nodal
enlargement, similarly demonstrated sensitivity of intraop-
erative evaluation to be 21%.39 A larger retrospective trial in
2013, including 225 patients, compared results of intraopera-
tive SLN frozen section to postoperative ultrastaging, again
showing a poor sensitivity result of only 56%.40
Clinical trial design 137

TABLE 17.1
Study Details
Trial name Disease site Population Study design Endpoints Enrollment Result
How 2012 23 Endometrium All histologies Cervical Tc-99 and patent blue Detection rate, 100 Detection 92%,
dye injection, robotic SLN sensitivity, specifcity, sensitivity 89%,
excision, PLND +/− PALND NPV NPV 99%
Rossi (FIRES) Endometrium Clinical stage I, Cervical ICG injection, robotic 1) Sensitivity of sentinel 340 patients Sensitivity to detect
201727 all histologies SLN excision, followed by lymph node specimen in metastatic disease:
complete PLND +/− PALND detecting metastatic 97.2%. NPV 99.6%
disease, 2) NPV for
lymph node involvement
Ballester Endometrium Clinical stage Cervical Tc-99 and patent blue Negative predictive 125 patients NPV for each
(SENTI-ENDO) I–II, all injection, open or laparoscopic value in 1) each hemipelvis: 100%;
201125 histologies SLN excision, followed by hemipelvis and 2) each NPV for each patient:
PLND +/− PALND patient 97%
Darai (SENTI- Endometrium Clinical stage Cervical Tc-99 and patent blue Recurrence-free survival 125 patients No difference in RFS
ENDO) 201526 I–II, all injection, open or laparoscopic between patients with
histologies SLN excision, followed by and without detected
PLND +/− PALND SLN, or between
patients with and
without LN
metastases
Tanner 201746 Endometrium Early stage, Cervical ICG injection, Side-specifc PLND rate 113 patients Side-specifc PLND:
grade 1–2 laparoscopic SLN excision, and nodal metastases 5.3%, overall PLND
endometrioid followed by TLH/BSO; in identifcation rate rate: 7.1%; nodal
nonbilaterally mapping metastases rate: 8%
patients, only those that met
high-risk criteria underwent
completion PLND on the
nonmapping side
Paley 201647 Endometrium Early stage, all ICG injection, SLN excision, Evaluate feasibility and 85 patients SLN sensitivity of
histologies PPALND in serous, clear cell, accuracy of SLN in 100%, specifcity of
carcinosarcoma, tumor size >2 women at high risk for 100%
cm, >50% myometrial wall LN involvement
invasion, grade 3 histology,
grossly suspicious nonsentinel
nodes, or positive SLN on
touch prep
Soliman 201731 Endometrium Stage I: Injection with ICG, T99, or False-negative rate, 101 Hemipelvis:
High-risk blue dye, SLN excision, sensitivity, and negative False-negative rate:
histologies or followed by PLND and predictive value by 7.1%, NPV 98%,
deep PALND patient and by sensitivity 92.9%,
myometrial hemipelvis Patient: False-
invasion; negative rate: 5%,
stage II: any NPV 98.6%,
histology Sensitivity 95%
Sawicki 201548 Endometrium Stage I–II, all Injection Tc99 to cervix and Compare SLN detection 188 Detection rate in
histologies methylene blue to fundus rates after cervical and Tc-99/methylene
versus methylene blue injected subserosal blue group: 95.1%,
into cervix and fundus, open administration of two methylene blue only
SLN biopsy, followed by tracers, sensitivity of group: 87.7%,
PLND + PALND in high-risk SLN biopsy sensitivity: 87.5%,
tumors NPV 97.7%
Lecuru Cervix Stage IA1 with T99 and patent blue injection, Determine sensitivity 139 patients Sensitivity 92%,
(SENTICOL) LVSI-IB1 SLN excision, PLND and NPV of SLN biopsy NPV 98.2%
201136 +/− PALND
Altgassen 200835 Cervix All stages T99 or blue dye injection, SLN Sensitivity and NPV in 507 patients Sensitivity 77.4%,
planned for excision, PLND +/− PALND total population NPV 94.3%
surgical staging

(Continued )
138 Clinical Lymphatic Mapping

TABLE 17.1
(Continued)
Trial name Disease site Population Study design Endpoints Enrollment Result
Cormier 2011 37 Cervix Stage IAI with Blue dye +/− Tc-99m Sensitivity and NPV 122 Patient specifc:
LVI to IIA injection, SLN excision, rates by patient and by Sensitivity 87.5%,
PLND +/− PALND hemipelvis; NPV 96.8%; side
retrospective evaluation specifc: sensitivity
of SLN excision 92.6%, NPV 98.9%,
algorithm algorithm: Sensitivity
100%, NPV 100%
Frumovitz 201824 Cervix and Clinical stage I Isosulfan blue + ICG dye Effcacy of 163 patients 97% of excised
uterus cervical or injection, SLN identifcation intraoperative ICG lymph nodes
uterine cancer, and excision versus isosulfan blue identifed with ICG,
all histologies (noninferiority) 47% of excised
lymph nodes
identifed with
blue dye
Van der Zee Vulva T1 or T2, less T99 and isosulfan injection, Evaluate safety of 403 In SLN group, 2-year
(GROINS VI) than 4 cm, groin SLN excision, if omitting inguinofemoral recurrence rate of
200842 squamous cell positive, inguinofemoral lymphadenectomy in 2.3%, 3-year survival
carcinoma of lymphadenectomy was patients with negative 97%, improved
the vulva, with performed; if more than one sentinel lymph node, short- and long-term
>1 mm DOI nodal metastases was evaluate short- and operative morbidity
and clinically identifed, postoperative RT long-term morbidity of
nonsuspicious was recommended sentinel node removal
LN and complete
inguinofemoral
lymphadenectomy
Levenback Vulva Squamous cell Isosulfan blue +/− T99 Establish negative 452 patients NPV 96.3% by
(GOG 173) carcinoma, >1 injection, groin SLN excision, predictive value and patient, 97.4% by
201244 mm invasion, followed by inguinofemoral sensitivity of groin SLN groin, sensitivity
tumor size lymphadenectomy evaluation 91.7% by patient,
between 2 and 92.1% by groin
6 cm clinically
nonsuspicious
LN
GROINS VII45 Vulva T1 or T2, less Isosulfan blue + T99 injection,
than 4 cm, groin SLN excision
squamous cell
carcinoma of
the vulva, with
>1 mm DOI
and clinically
nonsuspicious
LN

Similar to studies in uterine cancer, the optimal radiotracer
was also investigated. In a meta-analysis combining six studies
that compared indocyanine green (ICG) dye to blue dye, Tc99-m,
or a combination, ICG was demonstrated to be superior to blue
dye but equivalent to the combination of Tc-99m and blue dye.41
The FILM study by Frumovitz et al. comparing blue dye to ICG
uptake rates in patients who received both tracers was powered
for noninferiority, but 97% of excised nodes were ICG positive,
compared to just 47% of nodes with blue dye positivity.24
Similar to endometrial cancer, SLN detection in cervical
cancer patients has been studied prospectively and may be
incorporated into the standard of care. One issue indirectly
related to this procedure relates to performing it during an
exploratory laparotomy, not during minimally invasive sur-
gery. The principles of SLN detection are the same regardless
of the approach and should be performed regardless of open or
minimally invasive surgery.
Vulvar cancer
SLN mapping in vulvar cancer was the frst gynecologic
malignancy studied. This was due to the predictable lym-
phatic drainage of the vulva, the ease of tracer injection, and
the morbidity associated with complete groin lymphadenec-
tomy. Given the rarity of this disease, traditional clinical trial
design (phase I, II, III) is not possible. Instead, large coopera-
tive group observational trials were designed to best answer
the question of whether the sentinel node procedure could be
incorporated into the standard of care.
Clinical trial design
The GROINSS-V1 study (GROnigen INternational Study on
Sentinel nodes in Vulvar cancer) was an observational study of
276 women with early-stage vulvar cancer who had a primary
tumor smaller than 4 cm and no metastases detected on SLN
biopsy. The primary objective of this observational study was
to investigate the safety of omitting inguinofemoral lymphade-
nectomy in patients with a negative sentinel node. For patients
with unifocal disease, these investigators found a groin recur-
rence rate of 2.3% over a median follow-up time of 35 months.
The false-negative rate was 5.9%, and the false-negative pre-
dictive value was 2.9%.42
At the same time, GOG protocol 173, a multi-institutional
observational trial of 452 women with early-stage vulvar
cancer, was performed. Unlike the GROINS-V1 trial, in
this study, all of the patients underwent an SLN biopsy fol-
lowed by a complete inguinofemoral lymph node dissection
(IFLD). The primary objective of this study was to estimate
the negative predictive value of a sentinel groin lymph node
(i.e., the probability of all unilateral groin lymph nodes from
a dissection being negative when the unilateral sentinel node
is negative). The study also utilized the false-negative predic-
tive value, incorporating the false-negative identifcation rate
in affected groins and the true negative rate in unaffected dis-
sected groins, calculated by 1 – the NPV. The study results
yielded a false-negative predictive value of 3.7%. There was
an improved false-negative SLN biopsy rate (2.0 vs. 7.4%) in
patients with tumors 2–3.9 cm compared to tumors 4–6 cm,
respectively.43,44
The results of these two large prospective trials were enough
to incorporate the sentinel node procedure into the standard of
care for women with apparent early-stage squamous cell vul-
var cancer with unifocal lesions that were less than 4 cm. In
these patients, a negative sentinel lymph node was enough to
abandon a complete lymphadenectomy and to avoid radiother-
apy. However, further research needed to be done to improve
the care for women with a positive sentinel node.
One limitation to both of these initial trials was the time
it took to enroll patients. To overcome this barrier, the third
large observational trial for early-stage vulvar cancer brought
together two large cooperative groups to perform one study.
GROINSS-V II/GOG 270 was a prospective multicenter
phase II trial, including patients with early-stage squamous
cell carcinoma (SCC) of the vulva (diameter <4 cm) with-
out suspicious lymph nodes at imaging, who had primary
surgical treatment with a sentinel node procedure. In case
of a metastatic sentinel node (metastasis of any size), radio-
therapy was given to the groin(s) (50 Gy). In case of a nega-
tive sentinel node, patients were followed up for ≥2 years.
Stopping rules were defned for both groups to monitor groin
recurrence rate. These rules pertained to the occurrence of
groin recurrences in those patients with metastatic SLN(s).
The rules were based on grouped sequential analysis, with
alpha and beta spending properties. The maximum num-
ber of patients needed was 150: when the upper and lower
boundary of the stopping rule would not be passed, the study
would close when 150 patients with a metastatic SLN had
completed 2 years of follow-up.45
After activation of the stopping-rule in June 2010, interim
analysis showed an increased risk for groin recurrence in
139
case of sentinel node metastasis >2 mm. The protocol was
amended, with only patients with metastasis ≤2 mm receiving
radiotherapy and those >2 mm undergoing complete lymph-
adenectomy. Final analysis after ≥2 years revealed an accept-
able groin recurrence rate; six isolated groin recurrences in
160 patients with a sentinel node micrometastasis (3.8%).
Two developed recurrence in the contralateral (sentinel node–
negative) groin and two had refused radiotherapy.45
With the completion of GROINSSV1, GOG173, and
GROINSSV2/GOG270, the standard of care has been changed
to incorporate SLN biopsy in all patients with unifocal vulvar
cancer 4 cm or less. For patients with negative nodes, obser-
vation is safe. For patients with positive nodes less than 2
mm and without extracapsular spread, radiotherapy to 50 Gy
yields an acceptable treatment option without full lymph node
dissection.
GROINSV3/CV2020 is a NCI cancer therapy evaluation
program (CTEP)-approved study to investigate prospectively
if increasing radiotherapy to 56 Gy and adding chemosen-
sitization can adequately treat patients with greater than 2
mm of lymph node involvement or with extracapsular spread.
This is a prospective phase II trial only enrolling patients
after SLN biopsy. Similar to the other GROINS studies,
early stopping rules are incorporated to prevent an ineffec-
tive treatment.
Based on three large prospective studies, the SLN procedure
has become the standard of care for women with early-stage
vulvar cancer.
Summary
Prospective phase II treatment trials and randomized trials
have been performed to demonstrate the safety and effcacy of
the SLN procedure in patients with endometrial, cervical, and
vulvar cancer. Future trials will continue to investigate areas
of high unmet need and further evaluate newer modalities for
these advanced procedures.
REFERENCES
1. Cabanas RM. An approach for the treatment of penile
carcinoma. Cancer. 1977;39(2):456–66. https://doi.org/10.
1002/1097-0142(197702)39:23.0.CO;2-I.
2. Burke TW, Levenback C, Tornos C, et al. Intraabdominal
lymphatic mapping to direct selective pelvic and para-
aortic lymphadenectomy in women with high- risk endo-
metrial cancer: results of a pilot study. Gynecol Oncol.
1996;62(2):169–73. http://doi.org/10.1006/gyno.1996.0211.
3. Allameh T, Hashemi V, Mohammadizadeh F, et al. Sentinel
lymph node mapping in early stage of endometrial and cer-
vical cancers. J Res Med Sci. 2015;20(2):169–73. https://
pubmed.ncbi.nlm.nih.gov/25983771. Available from: www.
ncbi.nlm.nih.gov/pmc/articles/PMC4400713/.
4. Altgassen C, Pagenstecher J, Hornung D, et al. A new
approach to label sentinel nodes in endometrial cancer.
Gynecol Oncol. 2007;105(2):457–61. Available from:
www.sciencedirect.com.ezproxy.fu.edu/science/article/pii/
S0090825807000054.
140
5. Bats A, Clément D, Larousserie F, et al. Does sentinel node
biopsy improve the management of endometrial cancer?
data from 43 patients. J Surg Oncol. 2008;97(2):141–5.
https://doi.org/10.1002/jso.20857.
6. Delaloye J, Pampallona S, Chardonnens E, et al.
Intraoperative lymphatic mapping and sentinel node biopsy
using hysteroscopy in patients with endometrial cancer.
Gynecol Oncol. 2007;106(1):89–93. Available from: www.
sciencedirect.com.ezproxy.fiu.edu/science/article/pii/
S0090825807001825.
7. Favero G, Pfffer T, Ribeiro A, et al. Laparoscopic senti-
nel lymph node detection after hysteroscopic injection of
technetium-99 in patients with endometrial cancer. Int J
Gynecol Cancer. 2015;25(3):423–30. https://doi.org/10.1097/
IGC.0000000000000387.
8. Gien LT, Kwon JS, Carey MS. Sentinel node mapping
with isosulfan blue dye in endometrial cancer. J Obstet
Gynaecol Can. 2005;27(12):1107–12. Available from:
www.sciencedirect.com.ezproxy.fu.edu/science/article/pii/
S1701216316303930.
9. Kataoka F, Susumu N, Yamagami W, et al. The importance
of para-aortic lymph nodes in sentinel lymph node mapping
for endometrial cancer by using hysteroscopic radio-isotope
tracer injection combined with subserosal dye injection:
prospective study. Gynecol Oncol. 2016;140(3):400–4.
Available from: www.sciencedirect.com.ezproxy.fu.edu/
science/article/pii/S0090825815302250.
10. Kuru Oğ, Topuz S, Sen S, et al. Sentinel lymph node
biopsy in endometrial cancer: description of the tech-
nique and preliminary results. J Turk Ger Gynecol Assoc.
2011;12(4):204–8. Available from: www.ncbi.nlm.nih.
gov/pmc/articles/PMC3939250/. https://doi.org/10.5152/
jtgga.2011.52.
11. Laios A, Volpi D, Tullis IDC, et al. A prospective pilot
study of detection of sentinel lymph nodes in gynaecologi-
cal cancers using a novel near infrared fuorescence imag-
ing system. BMC Res Notes. 2015;8(1):608. https://doi.
org/10.1186/s13104-015-1576-z.
12. Lopes LAF, Nicolau SM, Baracat FF, et al. Sentinel
lymph node in endometrial cancer. Int J Gynecol
Cancer. 2007;17(5):1113–17. https://doi.org/10.1111/j.1525-
1438.2007.00909.x.
13. López-De la Manzanara Cano C, Cordero García JM,
Martín-Francisco C, et al. Sentinel lymph node detection
using 99mTc combined with methylene blue cervical injec-
tion for endometrial cancer surgical management: a pro-
spective study. Int J Gynecol Cancer. 2014;24(6):1048–53.
https://doi.org/10.1097/IGC.0000000000000158.
14. Mücke J, Klapdor R, Schneider M, et al. Isthmocervical
labelling and SPECT/CT for optimized sentinel detection
in endometrial cancer: technique, experience and results.
Gynecol Oncol. 2014;134(2):287–92. Available from:
www.sciencedirect.com.ezproxy.fu.edu/science/article/pii/
S0090825814009561.
15. Solima E, Martinelli F, Ditto A, et al. Diagnostic accu-
racy of sentinel node in endometrial cancer by using hys-
teroscopic injection of radiolabeled tracer. Gynecol Oncol.
2012;126(3):419–23. Available from: www.sciencedirect.
com.ezproxy.fu.edu/science/article/pii/S0090825812003988.
16. Valha P, Kucera E, Sak P, et al. Intraoperative subserosal
approach to label sentinel nodes in intermediate and high-risk
Clinical Lymphatic Mapping
endometrial cancer. Eur J Gynaecol Oncol. 2015;36(6):
643–6. http://europepmc.org/abstract/MED/26775344.
17. Perrone AM, Casadio P, Formelli G, et al. Cervical and hys-
teroscopic injection for identifcation of sentinel lymph node
in endometrial cancer. Gynecol Oncol. 2008;111(1):62–7.
Available from: www.sciencedirect.com.ezproxy.fu.edu/
science/article/pii/S0090825808004277.
18. Rossi EC, Jackson A, Ivanova A, et al. Detection of sen-
tinel nodes for endometrial cancer with robotic assisted
fuorescence imaging: cervical versus hysteroscopic injec-
tion. Int J Gynecol Cancer. 2013;23(9):1704–11. https://doi.
org/10.1097/IGC.0b013e3182a616f6.
19. Sahbai S, Taran F, Fiz F, et al. Pericervical injection of
99mTc-nanocolloid is superior to peritumoral injection for
sentinel lymph node detection of endometrial cancer in
SPECT/CT. Clin Nucl Med. 2016;41(12). Available from:
https://journals.lww.com/nuclearmed/Fulltext/2016/12000/
Pericervical_Injection_of_99mTc_Nanocolloid_Is.3.aspx.
20. Kang S, Yoo HJ, Hwang JH, et al. Sentinel lymph node
biopsy in endometrial cancer: meta-analysis of 26 studies.
Gynecol Oncol. 2011;123(3):522–7. https://doi.org/10.1016/j.
ygyno.2011.08.034.
21. Bodurtha Smith AJ, Fader AN, Tanner EJ. Sentinel lymph
node assessment in endometrial cancer: a systematic review
and meta-analysis. Obstet Gynecol. 2017;216(5):459–76.
e10. Available from: www.sciencedirect.com.ezproxy.fu.
edu/science/article/pii/S0002937816320579. https://doi.
org/10.1016/j.ajog.2016.11.1033.
22. Sinno AK, Fader AN, Roche KL, et al. A comparison
of colorimetric versus fuorometric sentinel lymph node
mapping during robotic surgery for endometrial can-
cer. Gynecol Oncol. 2014;134(2):281–6. https://doi.org/
S0090-8258(14)00982-2.
23. How J, Gotlieb WH, Press JZ, et al. Comparing indo-
cyanine green, technetium, and blue dye for sentinel
lymph node mapping in endometrial cancer. Gynecol
Oncol. 2015;137(3):436–42. Available from: www.
sciencedirect.com.ezproxy.fiu.edu/science/article/pii/
S0090825815007945. https://doi.org/10.1016/j.ygyno.2015
.04.004.
24. Frumovitz M, Plante M, Lee PS, et al. Near-infrared
fuorescence for detection of sentinel lymph nodes in
women with cervical and uterine cancers (FILM): a ran-
domised, phase 3, multicentre, non-inferiority trial.
Lancet Oncol. 2018;19(10):1394–403. Available from:
www.sciencedirect.com.ezproxy.fiu.edu/science/article/
pii/S1470204518304480. https://doi.org/10.1016/S1470
-2045(18)30448-0.
25. Ballester M, Dubernard G, Lécuru F, et al. Detection rate
and diagnostic accuracy of sentinel-node biopsy in early
stage endometrial cancer: a prospective multicentre study
(SENTI-ENDO). Lancet Oncol. 2011;12(5):469–76. https://
doi.org/10.1016/S1470-2045(11)70070-5.
26. Daraï E, Dubernard G, Bats A, et al. Sentinel node biopsy
for the management of early stage endometrial cancer: long-
term results of the SENTI-ENDO study. Gynecol Oncol.
2015;136(1):54–9. Available from: www.sciencedirect.com.
ezproxy.fiu.edu/science/article/pii/S0090825814013389.
https://doi.org/10.1016/j.ygyno.2014.09.011.
27. Rossi EC, Kowalski LD, Scalici J, et al. A comparison
of sentinel lymph node biopsy to lymphadenectomy for
Clinical trial design
endometrial cancer staging (FIRES trial): a multicentre,
prospective, cohort study. Lancet Oncol. 2017;18(3):384–
92. Available from: www.sciencedirect.com.ezproxy.fu.
edu/science/article/pii/S1470204517300682. https://doi.org/
10.1016/S1470-2045(17)30068-2.
28. Ansari M, Rad MA, Hassanzadeh M, et al. Sentinel node
biopsy in endometrial cancer: systematic review and
meta-analysis of the literature. Eur J Gynaecol Oncol.
2013;34(5):387–401.
29. NCCN.org. NCCN Clinical Practice Guidelines in
Oncology (NCCN Guidelines ®) Uterine Neoplasms
Continue NCCN Guidelines for Patients ®; 2021. Available
from: www.nccn.org/patients.
30. Schiavone MB, Zivanovic O, Zhou Q, et al. Survival of
patients with uterine carcinosarcoma undergoing sentinel
lymph node mapping. Ann Surg Oncol. 2016;23(1):196–
202. https://doi.org/10.1245/s10434-015-4612-2.
31. Soliman PT, Westin SN, Dioun S, et al. A prospective vali-
dation study of sentinel lymph node mapping for high-risk
endometrial cancer. Gynecol Oncol. 2017;146(2):234–9.
https://doi.org/10.1016/j.ygyno.2017.05.016.
32. Echt ML, Finan MA, Hoffman MS, et al. Detection of sen-
tinel lymph nodes with lymphazurin in cervical, uterine,
and vulvar malignancies. South Med J. 1999;92(2):204–8.
https://doi.org/10.1097/00007611-199902000-00008.
33. van de Lande J, Torrenga B, Raijmakers PGHM, et al.
Sentinel lymph node detection in early stage uterine cer-
vix carcinoma: a systematic review. Gynecol Oncol.
2007;106(3):604–13. Available from: www.sciencedirect
.com/science/article/pii/S0090825807003381. https://doi
.org/10.1016/j.ygyno.2007.05.010.
34. Frumovitz M, Ramirez PT, Levenback CF. Lymphatic
mapping and sentinel lymph node detection in women with
cervical cancer. Gynecol Oncol. 2008;110(3, Suppl 2):S17–
S20. Available from: www.sciencedirect.com.ezproxy.fu
.edu/science/article/pii/S0090825808002059. https://doi
.org/10.1016/j.ygyno.2008.03.012.
35. Altgassen C, Hertel H, Brandstädt A, et al. Multicenter vali-
dation study of the sentinel lymph node concept in cervi-
cal cancer: AGO study group. JCO. 2008;26(18):2943–51.
https://doi.org/10.1200/JCO.2007.13.8933.
36. Lécuru F, Mathevet P, Querleu D, et al. Bilateral nega-
tive sentinel nodes accurately predict absence of lymph
node metastasis in early cervical cancer: results of the
SENTICOL study. JCO. 2011;29(13):1686–91. https://doi.
org/10.1200/JCO.2010.32.0432.
37. Cormier B, Diaz JP, Shih K, et al. Establishing a sentinel
lymph node mapping algorithm for the treatment of early
cervical cancer. Gynecol Oncol. 2011;122(2):275–80.
https://doi.org/10.1016/j.ygyno.2011.04.023.
38. Fader AN, Edwards RP, Cost M, et al. Sentinel lymph node
biopsy in early-stage cervical cancer: utility of intraop-
erative versus postoperative assessment. Gynecol Oncol.
2008;111(1):13–17. Available from: www.sciencedirect.com
.ezproxy.fu.edu/science/article/pii/S009082580800437X.
https://doi.org/10.1016/j.ygyno.2008.06.009.
141
39. Bats A, Buénerd A, Querleu D, et al. Diagnostic value
of intraoperative examination of sentinel lymph node in
early cervical cancer: a prospective, multicenter study.
Gynecol Oncol. 2011;123(2):230–5. Available from:
www.sciencedirect.com.ezproxy.fiu.edu/science/article/
pii/S0090825811006950. https://doi.org/10.1016/j.ygyno.2011
.08.010.
40. Slama J, Dundr P, Dusek L, et al. High false negative rate of
frozen section examination of sentinel lymph nodes in patients
with cervical cancer. Gynecol Oncol. 2013;129(2):384–8.
Available from: www.sciencedirect.com.ezproxy.fu.edu/
science/article/pii/S0090825813000723. https://doi.org/10
.1016/j.ygy2013.02.001.
41. Ruscito I, Gasparri ML, Braicu EI, et al. Sentinel node
mapping in cervical and endometrial cancer: indocyanine
green versus other conventional dyes-A meta-analysis. Ann
Surg Oncol. 2016;23(11):3749–56. https://doi.org/10.1245/
s10434-016-5236-x.
42. Van der Zee AGJ, Oonk MH, De Hullu JA, et al. Sentinel
node dissection is safe in the treatment of early-stage vul-
var cancer. JCO. 2008;26(6):884–9. https://doi.org/10.1200/
JCO.2007.14.0566.
43. Coleman RL, Ali S, Levenback CF, et al. Is bilateral lymph-
adenectomy for midline squamous carcinoma of the vulva
always necessary? An analysis from gynecologic oncol-
ogy group (GOG) 173. Gynecol Oncol. 2013;128(2):155–9.
https://doi.org/10.1016/j.ygyno.2012.11.034.
44. Levenback CF, Ali S, Coleman RL, et al. Lymphatic map-
ping and sentinel lymph node biopsy in women with squa-
mous cell carcinoma of the vulva: a gynecologic oncology
group study. J Clin Oncol. 2012;30(31):3786–91. Available
from: www.ncbi.nlm.nih.gov/pmc/articles/PMC3478573/.
https://doi.org/10.1200/JCO.2011.41.2528.
45. Slomovitz B, Oonk M, Monk BJ, et al. Validation of sen-
tinel lymph biopsy in patients with early stage vulvar
cancer: a prospective trial of 1552 women (GROINSS-V
II/GOG270). Gynecol Oncol. 2020;159:2–3. https://doi
.org/10.1016/j.ygyno.2020.06.004.
46. Tanner E, Puechl A, Levinson K, et al. Use of a novel sen-
tinel lymph node mapping algorithm reduces the need for
pelvic lymphadenectomy in low-grade endometrial can-
cer. Gynecol Oncol. 2017;147(3):535–40. Available from:
www.sciencedirect.com.ezproxy.fiu.edu/science/article/
pii/S0090825817314233. https://doi.org/10.1016/j.ygyno
.2017.10.020.
47. Paley PJ, Veljovich DS, Press JZ, et al. A prospective inves-
tigation of fuorescence imaging to detect sentinel lymph
nodes at robotic-assisted endometrial cancer staging.
Obstet Gynecol. 2016;215(1):117.e1–.e7. Available from:
www.sciencedirect.com.ezproxy.fiu.edu/science/article/
pii/S0002937815026502. https://doi.org/10.1016/j.ajog.2015.
12.046.
48. Sawicki S, Lass P, Wydra D. Sentinel lymph node biopsy
in endometrial Cancer – Comparison of 2 detection meth-
ods. Int J Gynecol Cancer. 2015;25(6):1044–50. https://doi
.org/10.1097/IGC.0000000000000447.
Index
Note: Page numbers in italics indicate a fgure and page numbers in bold indicate a table on the corresponding page.
99mTc colloidal albumin, 90
99mTc-labeled radiopharmaceuticals, 44
99mTechnetium-labeled nanocolloid, 68
[99mTechnetiumTc] tilmanocept, 50
A blue dye, 90, 91
abdomen and pelvis, lymphatics, 1, 2
adenocarcinoma metastases, 26, 57
adjuvant chemotherapy, 41, 89, 93,
122–124, 130
adjuvant radiation therapy (RT), 89, 99, 120,
123–124
AJCC Cancer Staging Manual for breast
cancer, 7
Alcian blue, 57
American College of Surgeons Oncology
Group 2001 Trial, 41
American Joint Committee on Cancer (AJCC),
7, 85–86
American Society of Clinical Oncology
(ASCO), 132
anaphylaxis, 44, 49, 68
anastomosis of Poirier channel, 30
anterior trunk, 25–26
antigen-presenting cells (APCs), 11
ARGACY/GINECO randomized trial, 78
ascites, 9
automated immunostainers, 57–58
axillary sheath, breast and axilla, 39
B
BCS, see breast-conserving surgery (BCS)
beta-human chorionic gonadotropin (β-HCG)
RT-PCR, 59
bilateral efferent drainage, 18
bilateral inguinal femoral lymphadenectomy,
3, 5–6
bilateral lymph drainage, 66
bilateral pelvic lymphadenectomy, 7
bilateral sentinel lymph nodes, 122
blind FNAB, 58
blue dye agents/tracer, 4, 44, 47
breast cancer, 90, 91
ICG dose on SLN mapping, 49
mapping tracers, 44
breast and axilla
axillary sheath, 39
internal mammary artery medially, 39
internal mammary nodes, 40–41
lymphatic system, 39
lymph nodes draining, classifcation, 41
nodes level, 41
pectoralis major muscle, 39
primary blood supply, 40
primary lymph nodes of, 40
Rotter’s interpectoral group, 40
sentinel lymph node (SLN), 41, 41–42
unidirectional lymphatics fow, 39
breast cancer, 7
AMAROS study, 93
axilla, 87, 87–89, 88, 88
clinically negative axilla, management, 93
ductal carcinoma in situ (DCIS), 83, 84
follow-up after SLNB, 95
gamma probe, 91
imprint cytology, 56
indocyanine green, 90
infltrating lobular carcinoma, 85, 85
intraoperative techniques, 90, 91
invasive ductal carcinoma, 84, 85–86
lobular carcinoma in situ (LCIS), 84, 84
nodal metastasis, patterns, 83
paraffn pieces, 59
pathology, 83, 84
radioisotope/nuclear medicine, 90, 92
sentinel lymph node mapping, 83–95
SLN, pathologic analysis, 89
SLNB after NAC, 93–95, 94–95
SLN mapping procedure, 90–93, 91–93
staging, 85–86, 86
breast-conserving surgery (BCS), 88
C contrast-enhanced ultrasound, 51
Cancer Australia, 75
Cancer Care Ontario group, 46
cancer-specifc validated QoL instrument, 112
carbon nanoparticles, 50–51
cardinal ligaments, 24
caveats, 57, 74
Cerenkov luminescence imaging, endometrial
cancers, 106
cervical cancers, 6, 26, 31
biopsy in clinical management, 74–78
clinical trial design, 136–138
natural history of, 26, 26
in pelvis, 71–74
quality of life, sentinel lymph node
mapping on, 113–114
sentinel lymph node mapping in, 71–78
cervical injection, 100
of dye, 102
technique, 101
cervix/cervical
anterior trunk, 25–26
cervical lymphatics, topographic anatomy
of, 24–26
cervix cancer, natural history of, 26, 26
lateral trunk, 24–25, 25
lymphatic drainage, 1, 2, 4
lymphatics, topographic anatomy of, 24–26
lymphatics of, 23–26
midbody uterine drainage pathway, 30
posterior trunk, 25, 26
topographic anatomy, 23, 23–24
tracer injection, 31
chemoradiation, 75, 121, 123, see also
radiation oncology
circumfex vasculature, 17
clinical management, SLN biopsy
acceptance in current routine practice, 74
in fertility-sparing treatment, 77–78
frozen section and intraoperative triage of
patients, 75
international recommendations, 74–75
lower leg lymphedema (LLL), 78
micrometastases, pathologic ultrastaging
and prognostic, 75–77, 77
ongoing clinical trials, 78
clinical target volume (CTV), 121
clinical trial design
cervical cancer, 136–138
endometrial cancer, 135–136
study details, 137–138
vulvar cancer, 138–139
clitoral lymphatics to pelvis, 18
colloids and lymphoscintigraphy, 44–45
color-segmented fuorescence, 103
complete lymphadenectomy, 130–131, 135
contralateral lymph node metastases, 36
Cooper’s ligaments, 39
counts per minute (CPM), 106
cribriform fascia, 17, 20
cribriform lamina, 17
cutaneous lymphatics, 3–4
cutaneous melanoma, 6
cytokeratin 19 transcription, 59
cytoreductive interval surgery, 114
D
dendritic cells, 11
direct lymphatic drainage, 41
disease-free survival (DFS) in women, 89
distal interiliac nodal basins, 25–26
DNA aneuploidy, 59
DNA/cytokeratin double-staining procedure,
59
DNA FCM, 59
dose volume histogram (DVH), 119
E
edema, 9–10
electronic patient-reported outcomes measures
(ePROs), 114
empty lymph node packet syndrome, 45–46
en bloc tumor resections, 19
endometrial adenocarcinomas, 11
endometrial cancers, 10, 31, 60, 101
143
144
Cerenkov luminescence imaging, 106
cervical injection of dye, 102
clinical trial design, 135–136
detection using an algorithm, 103
early studies in, 99–100
endometrioid histology, 104–105
false-negative rates, 103–104
high-risk histology, 105–106
lymphadenectomy vs., 104
lymph node status in, 99
patterns in, 100, 101–102
positron lymphography, 106
quality of life, sentinel lymph node
mapping on, 113
survivors, 115
technique by disease site, 47–48
techniques and examples, 102–103
ultrastaging protocols, 57
endometrial lymphatic anatomy, 29
endometrioid endometrial carcinoma, 104
endometrioid histology, 104–105
endometrium
endometrial cancer, early studies in, 99–100
endometrial cancer, lymph node status in, 99
epidemiology, 99
Memorial Sloan Kettering Cancer Center
surgical algorithm, 103
pelvic lymphatic mapping patterns, 101
radiation oncology, 121–124
sentinel lymph node biopsy of, 99–106
superfcial lymphatics, 29
energy discrimination, 45
epithelial marker cytokeratin, 19, 59
epithelial ovarian cancer (EOC), 36
estrogen receptor (ER), 86
European Organization for Research and
Treatment of Cancer (EORTC), 113
European Organization for Research and
Treatment of Cancer Quality of Life
Questionnaire-Core 30 (EORTC
QLQ-C30), 115
European Society for Medical Oncology
(ESMO), 131
European Society of Gynecological
Oncology, 123
exocervix, 23
extravisceral trunks, 24
F
FACT-B, see functional evaluation
questionnaire for breast cancer therapy
(FACT-B)
false-negative rate (FNR), 88, 103–104
false-negative sentinel node, 7
FCM, see fow cytometry (FCM)
Federation of Gynecologists and Obstetricians
(FIGO), 35, 99
female genitalia, 16
female genitalia, external, 16
Female Sexual Function Index questionnaire
(FSFI), 113
femoral (deep) inguinal lymphatics, 17–18
FIGO, see Federation of Gynecologists and
Obstetricians (FIGO)
fltered lymph, 45
fne-needle aspiration biopsy (FNAB), 58
fne-needle aspiration cytology, 58
FIRES trial, 136
fow cytometry (FCM), 58–59
Fluorescence Imaging for Lymphatic Mapping
(FILM) randomized trial, 100
FNAB, see fne-needle aspiration biopsy
(FNAB)
Food and Drug Administration (FDA), 47
frozen section, sentinel node, 55–56, 75
functional evaluation questionnaire for breast
cancer therapy (FACT-B), 112
fundus lymphatic channels, 29
G
Gamma photon emission energy, 44
gamma probe, 41, 44–47, 51, 58, 66, 91–92
generator-produced radioisotopes, 44
glands sentinel, 9
groin anatomy, 16
cribriform fascia, 20
cross-sectional anatomy, 20
lymphatic anatomy, 19
operative and cross-sectional anatomy, 21
sentinel lymph nodes and inguinal femoral
anatomy, 20
superfcial inguinal nodes, 20
vulvar and inguinal lymphatic anatomy, 21
GROINSS-VII/GOG 270, 139
GROINSS-VIII, 121
GROINSV3/CV2020, 139
Groningen International Study on Sentinel
Nodes in Vulvar cancer (GROINSS-V I),
65, 67, 69, 121, 139
Gynecological Oncology Group, 65
gynecologic cancers/malignancies, 12
management, 7
quality of life, sentinel lymph node
mapping on, 111–112
SN evaluation and ultrastaging in, 60, 60
gynecologic oncology, 1, 11–12
Gynecologic Oncology Group (GOG), 6, 20
gynecologic tumors, 1, see also gynecologic
cancers/malignancies
H Protection, 49
Halstedian principles, 5
hematogenous spread, breast cancer, 75
hematoxylin-eosin (H&E) stain, 88
hepatobiliary insuffciency, 49
high-reliability organizations (HROs), 7
history
abdomen and pelvis, lymphatics, 1, 2
cervix, lymphatic drainage, 1, 2, 4
inguinal nodes and pelvic nodes, 3
lymphatic anatomy, Cadaver studies of, 1
lymphatic mapping concept, 6, 6–7
penile lymphography, Cabanas’s technique
for, 5
safety and surgical innovation, 7
sentinel node identifcation, early efforts
at, 4–6
solid tumors, Halsted model for surgical
management, 3
in vivo injection of dyes, 3–4
vulvar lymphatics, 1, 2
Index
hot node, 44
human epidermal growth factor receptor 2
(HER2), 86
human papillomavirus (HPV) infection, 26
hybrid tracer, 68
I
ICG dye, see indocyanine green (ICG) dye
iliac lymph nodes, 26
image-guided radiotherapy, 120
imaging-enhanced modalities, 51
immunohistochemical (IHC) evaluation,
57–58, 86
imprint cytology, 56
India ink, 4, 51
indocyanine green (ICG) dye, 45–46, 68, 90, 100,
113, 135, see also blue dye agents/tracer
blue dye, 49
cervical cancer, 48–49
indocyanine green, 49–50
ovarian cancer, 49
safety, 49–50
on SLN mapping, 48–50
technetium, 49
inferior mesenteric artery (IMA), 100
infundibulopelvic ligament, 4, 49
inguinal lymphatics, topography of, 15–17, 17
inguinal lymph nodes, radiation
oncology, 118
inguinal nodes
and pelvic nodes, 3
radiation oncology, 118
recurrence, 122
inguinofemoral lymphadenectomy, 12–13,
65, 112
inguinofemoral lymph node dissection
(IFLD), 139
internal mammary artery medially, 39
internal mammary nodes, 40–41
International Atomic Energy Agency
guidelines, 49
International Breast Cancer Study Group
23–01, 89
International Commission on Radiological
International Gynecologic Cancer Society, 75
International Sentinel Node Society, 7
intraoperative identifcation techniques
carbon nanoparticles, 50–51
India ink, 51
[99mTechnetiumTc] tilmanocept, 50
superparamagnetic iron, 51
intraoperative lymphatic mapping, 6
intraoperative near-infrared fuorescence
imaging, 46
intraoperative probes, 45
intravenous and submucosal
administration, 45
in vivo injection of dyes, 3–4
isolated micrometastases, 89
isolated tumor cells (ITCs), 85, 104, 123
ITCs, see isolated tumor cells (ITCs)
K
Korean Society of Gynecologic Oncology, 75
Index 145

L empty lymph node packet syndrome, optimal standard protocol, sentinel node, 60
45–46 ovarian cancer, 35, 130–131, 131
labial-crural fold, 5 indocyanine green, 45–46 ovarian drainage pathway, 30
lateral trunk, 24–25, 25 MD Anderson Symptom Inventory ovary
Lower Extremity Functional Scale (LEFS), 113 (MDASI-OC), 114 and fallopian tube, lymphatic drainage, 36
lower leg lymphedema (LLL), 78 Medical Outcomes Study Short Form-12 lymphatic anatomy, 35
lymphadenectomy, 12, 99, 113 (SF-12) Health Survey, 113 ovarian cancer, sentinel node detection
bilateral inguinal femoral, 3, 5–6 melanoma, 7 in, 36
bilateral pelvic, 7 Memorial Sloan Kettering Cancer Center pelvic and aortic lymph node metastasis
complete, 130–131, 135 (MSKCC), 4–5, 90 distribution, 35–36
vs. endometrial cancers, 104 group, 100 studies, 35
inguinofemoral, 12–13, 65, 112 surgical algorithm, 103 overall survival (OS), 89
paraaortic, 104 metastable isotope, 44
pelvic, 1 metastatic carcinoma, sentinel lymph node
regional, 6–7 P
involved in, 94–95
lymph and lymphatic vessels, 10 metastatic lymph nodes, 31 paraaortic lymphadenectomy, 104
lymphangiogenesis, 10–11 methylene blue, 44 paraaortic nodes, 118
lymphangiography, 17 microanatomy and physiology, lymphatic paraffn-embedded tissue, 59
lymphangions, 10 anatomy parametrium, 48, 51, 71, 73, 123–124
lymphatic anatomy, Cadaver studies of, 1 lymph and lymphatic vessels, 10 parotid cancer, 4
lymphatic capillaries, blind terminal sacs lymph nodes, 10–11 patent blue-V dye, 90
of,  10 physiology, 10 pathologic complete response (pCR), 93
lymphatic channels, 29 regional lymph nodes, immunology, 11–12 Patient-Reported Outcomes Measurement
lymphatic drainage, 17–18 studies, 9 Information System (PROMIS), 114
fuid, 10 surgical anatomy, 12–13 patient-reported outcomes (PROs), 114–115
patterns, 4 micrometastases (MIC), 74–77, 123 pectoralis major muscle, breast and axilla, 39
routes, 29–30, 30 minimally invasive radical hysterectomy, 48 pelvic lymphadenectomy, 1
lymphatic dysfunction, 9 molecular techniques, sentinel node, 59–60 pelvic lymphatic mapping patterns, 101
lymphatic mapping monoclonal antibodies, breast cancer, 89 pelvic nodes, radiation oncology, 117–118
concept, 6, 6–7 morbidity, 112 pelvis, sentinel lymph node mapping in
studies in women, 18 Morton, D., 6 anatomical distribution, 72
for tumors, 1 Multicenter Selective Lymphadenectomy atypical localizations, 73
lymphatic spread of breast cancer, 9 Trial-I (MSLT-I), 132 cervix, lymphatic drainage from, 71
lymphatic system Multicenter Selective Lymphadenectomy deep lymphatic trunk, 72
breast and axilla, 39 Trial-II (MSLT-II), 132 detection rate, 73–74
studies of, 9 localization, 72–73
surgical anatomy, 12–13 lymphatic drainage, 71
lymphatic trunks, 12 N
pelvic dissection and SLN removal
lymphatic vessel endothelial hyaluronan National Cancer Comprehensive Network technique, 71–72
receptor 1 (LYVE1), 10 (NCCN), 75, 121, 131 pelvic lymph node staging, sensitivity
lymphedema, 10, 12–13, 112 National Cancer Institute of Canada MA.20 of, 74
lymph node dissection (LND), 136 study, 93 residual cervical stroma, tracer
lymph nodes, 10–11 National Council on Radiation Protection application, 73
anatomy, 11 (NCRP) recommendations, 49 SENTIX study, 74
draining, breast and axilla, 41 National Quality Forum (NQF), 114 superfcial lymphatic trunk, 72
involvement, 121 National Surgical Adjuvant Breast and Bowel penile carcinoma, 4–5, 87
metastases, 11 Project (NSABP) B-32 study, 89 penile lymphography, 4, 5
metastasis, 57–58 National Surgical Quality Improvement periodic acid-Schiff (PAS), 57
sampling, 130 Database (NSQIP), 7 perirectal lymph nodes, radiation oncology, 118
status in endometrial cancers, 99 negative predictive value (NPV), 135 PORTEC 3, 123
lymphocytes, 11 neoadjuvant chemotherapy (NAC), 90 positron emission tomography (PET), 50
from lymph nodes, 11 nodal metastases, 31, 89 positron lymphography, endometrial cancers, 106
tumor antigens, 11 nodal target delineation, radiation oncology, 117 posterior trunk, 25, 26
lymphogenous spread, breast cancer, 75 node of Cloquet, 3 postoperative chemoradiation therapy, 123
lymphoscintigram, 9, 90 nodes level, breast and axilla, 41 Post-Operative Radiation Therapy in
lymphoscintigraphy, 6, 10, 44 nonkeratinizing squamous epithelium, 23 Endometrial Cancer (PORTEC)
Lymphoseek, 50 non-sentinel node metastases, 68–69 groups, 99
lymphovascular space involvement (LVSI), 121 NSGO/EORTC/MaNGO trial, 123 pregnancy, mapping in, 50
lymphovascular systems, 45 nuclear medicine, 44–45, 51, 90 preoperative lymphoscintigraphy, 45–46
primary blood supply, breast and axilla, 40
M O primary lobular breast cancer, 57
primary lymph nodes of breast and axilla, 40
macrometastases (MAC), 60, 74–77, 123 obesity, mapping in, 50 progesterone receptor (PR), 86
MAGE-A3 RT-PCR, 59 oncotic proteins, 44 prospero homeobox protein (PROX1), 10
mapping tracers Oncotype DX genetic assay, 86 prostate, lymph node metastases of, 56
blue dye agents, 44 one-step nucleic acid amplifcation psycho-emotional decline, 113
colloids and lymphoscintigraphy, 44–45 (OSNA), 60 pulse oximetry, 49
146 Index

Q sentinel node, 1, 4, 7 cervical cancers, 31

quality of life, sentinel lymph node mapping on
cervical cancer, 113–114
endometrial cancer, 113
gynecologic cancer, 111–112
lymphedema, 112
patient-reported outcomes (PROs),
114–115
vulvar cancer, 112–113
R serial sectioning, 57
radiation oncology
dose volume histogram (DVH), 119
endometrium, 121–124
image-guided radiotherapy, 120
inguinal lymph nodes, 118
inguinal nodes, 118
nodal target delineation, 117
paraaortic nodes, 118
pelvic nodes, 117–118
perirectal lymph nodes, 118
protection, 49
radiation therapy techniques, 118–120,
119–120
therapy techniques, 118–120, 119–120
volumetric modulated arc (VMAT) IMRT
plan, 118, 119
vulva, 120–121
radical hysterectomy (RH), 78
radical vulvectomy, 3, 5–6
radiocolloid tracers, 46
radiolabeled compounds, 6
radionuclides injection, 6
real-time RT-PCR assay, 59
regional lymphadenectomy, 6–7
regional lymph nodes, immunology, 11–12
regional nodal irradiation (RNI), 93
reverse-transcriptase polymerase chain
reaction (RT-PCR), 59
Rotter’s interpectoral group, breast and axilla, 40
Rotter’s nodes, 40
RxPONDER trial, 89
S technetium-labeled colloid, 68
Sappey’s illustration, vulvar lymphatics, 1, 2
scattered keratin-positive cells, sentinel lymph
node, 58
second-echelon regional nodes, 3
sensitivity, 45
SENTICOL study, 136
SENTI-ENDO study, 113, 136
sentinel lymph node biopsy (SLNB), 1, 11–12
endometrium, 99–106
vulva, 65–69
Sentinel Lymph Nodes in Early-Stage Ovarian
Cancer trial (SELLY), 36
sentinel lymph node (SLN) mapping, 99–100
breast and axilla, 41, 41–42
breast cancer, 83–95
cervical cancer, 71–79
cervical injection, location for, 48
endometrium, 99–106
mapping, 31, 32
sentinel lymph node technique, 46–47
SENTInel NeoAdjuvant (SENTINA) study, 93
biopsy, 1, 112
fne-needle aspiration cytology, 58
fow cytometry (FCM), 58–59
frozen section, 55–56
identifcation, 4–7
immunohistochemistry, 57–58
imprint cytology, 56
molecular techniques, 59–60
optimal standard protocol, 60
recommendations for the SN Evaluation, 60
ultrastaging of, 56–60
Sentinel Node Biopsy Following Neoadjuvant
Chemotherapy (SN FNAC), 93
Sentinel Nodes in Early Stage Ovarian Cancer
(SELLY) trial, 131
serial sectioning, sentinel node, 57
shielding, 45
Short Form 12 questionnaire (SF12), 113
simultaneously integrated boost (SIB), 121
single photon emission computed tomography
(SPECT), 44, 135
sinus-lining (dendritic) cells, 57–58
skip metastasis, 87
sky-blue dye, 4
Society for Surgical Oncology (SSO), 132
Society of Gynecologic Oncology (SGO),
102–103
solid tumors, Halsted model for surgical
management, 3
spatial resolution, 44–45
squamous cell carcinomas, 1, 11, 65
stromal chemokines, 11
superfcial inguinal lymphatics, 17
superfcial inguinal nodes, 5, 20
superfcial intermediate group (Sf-IM), 17
superfcial lateral group (Sf-L), 17
superfcial medial group (Sf-M), 17
superparamagnetic iron, 51
superparamagnetic iron oxide, 68
surgical oncologist, lymphatic mapping, 1
T
technique by disease site
endometrial cancer, 47–48
vulvar cancer, 46–47
terminal lymphatics, 10
triple injection technique, 51
tumor metastases, 30–31
tumor-node- metastasis (TNM) system, 85
tumor-secreted factors, 11
U
ultrastaging protocols, endometrial cancers, 57
unidirectional lymphatics fow, breast and
axilla, 39
uterine cancer
carcinosarcoma, positron lymphography
(PLG), 106
cervical injection sites for mapping, 47
uterosacral and cardinal ligaments, 24
uterosacral ligament, 25
uterus, lymphatics of
body lymphatic trunks, 48
cervical/midbody uterine drainage
pathway, 30
cervical tracer injection, 31
endometrial cancers, 31
endometrial lymphatic anatomy, 29
endometrium, superfcial lymphatics, 29
fundus lymphatic channels, 29
lymphatic channels, 29
lymphatic drainage routes, 29–30, 30
metastatic lymph nodes, 31
nodal metastases, 31
ovarian drainage pathway, 30
sentinel lymph node (SLN) mapping, 31, 32
tumor metastases, 30–31
uterine corpus, lymphatic drainage
patterns, 29
utero-ovarian ligament, 49
Utility-Based Questionnaire-Cancer, 112
V
vaginal cancer, 129, 129–130
vaginal epithelium, 23
vascular endothelial growth factor receptor-3
(VEGFR3), 10
vascular endothelial growth factor (VEGF), 11
vault brachytherapy (VBT), 122
vesicocervicovaginal space, 48
volumetric modulated arc (VMAT) IMRT
plan, 118, 119
vulvar cancer, 7
clinical trial design, 138–139
quality of life, sentinel lymph node
mapping on, 112–113
radiation oncology, 120–121
technique by disease site, 46–47
vulva/vulvar
detection with combined technique, 66
embryology, 15
external female genitalia, 16
femoral (deep) inguinal lymphatics,
17–18
groin, topographic anatomy, 16
GROINSS-V protocol, 67, 69
indication for, 67
inguinal lymphatics, topography of,
15–17, 17
inguinofemoral lymphadenectomy, 67
lymphatic drainage, 6, 17–18
lymphatics, 1, 2, 5, 15–19
melanoma, 131, 131–133, 132
natural history and patterns of spread,
18–19
near-infrared fuorescence imaging, 68
radioactive tracer, 67
sentinel lymph node biopsy of, 65–69
sentinel node metastasis, 68–69
sentinel node procedure, safety,
65–67, 66
superfcial inguinal lymphatics, 17
tissues, 16
topography, 15
vulvar tissues, 16
W
whole pelvic radiation therapy (WPRT), 122