Name: sentinel lymph node mapping and biopsy for endometrial cancer at early stage with laparoscopy
Uploaded: 2021-08-19T14:45:00.000+00:00
Duration: 5 min 52 s
Description: Watch this Scientific Journal Video about Sentinel Lymph Node Mapping and Biopsy for Endometrial Cancer at Early Stage with Laparoscopy at JoVE.com

This work was supported in part by grants from the National Natural Science Foundation of China (81772777), Shanghai Science and Technology Commission Medical Guidance Project (18411963700), Clinical Research Plan of SHDC (No. SHDC2020CR4079); Shanghai Pujiang Talents Project (17PJ1401400). We thank the timely help given by Fenghua Ma from radiology department for MR images and Chao Wang from pathology department for pathologic images from Obstetrics and Gynecology Hospital of Fudan University.

All surgery procedures related to the patient described here were approved by the Ethics Committees of Obstetrics &#38; Gynecology Hospital of Fudan University in Shanghai, China. Informed consent was acquired from the patient.
1. Indications for SLN mapping with ICG in EC patients
<ol>
	<li>Ensure that patients are clinically diagnosed with primary EC confined to the uterus with low-risk factors (grade 1 or 2 endometrioid carcinomas, pre-surgical endometrial lesion &#8804;2 cm, and myometrial invasion &#60;50%).</li>
	<li>Ensure that patients are not allergic to the developer (ICG).</li>
	<li>Ensure that patients have not experienced retroperitoneal lymph node dissection for any reason before the disease.</li>
	<li>Ensure that the patients understand the SLN surgical procedures and have signed the surgical consent forms.</li>
	<li>Ensure that the patients cannot perform systematic lymphadenectomy but SLN mapping for surgical staging for any reason.</li>
	<li>Ensure that the patients are enrolled in the clinical trial into the SLN mapping group if they are with intermediate-high risk EC.</li>
</ol>
2. Patient preparation
<ol>
	<li>Preoperative bowel preparation
	<ol>
		<li>Provide laxatives for bowel preparation and enema to patients who have undergone multiple pelvic and abdomen surgeries. 
		NOTE: Intestinal preparation is not required for patients without bowel surgery history.</li>
	</ol>
	</li>
	<li>Preoperative diet preparation
	<ol>
		<li>Avoid solid food for 8 h before the operation, prevent a semi-liquid diet for 6 h before the procedure, and stop drinking for 2 h before the procedure.</li>
	</ol>
	</li>
	<li>Anesthesia
	<ol>
		<li>Use intravenous agents (e.g., propofol) to produce unconsciousness and add some neuromuscular blockers by inhalation or intravenous routes to achieve the needed depth of anesthesia. Use a combination of administrations for anesthetic maintenance to ensure the patient to be unconscious and fully relaxed with stable vital signs throughout the operation. 
		NOTE: The usage of anesthetics will be following the rules of the anesthesiology department of each center.</li>
	</ol>
	</li>
	<li>Position
	<ol>
		<li>Once the patient is anesthetized, allow the patient to be in the lithotomy position with Trendelenburg position.</li>
	</ol>
	</li>
	<li>Prepare the skin at the surgical site. Perform skin preparation with an antiseptic preparation (e.g., povidone-iodine) in an organized fashion from the intended site of the incision radiating out to the edges of the intended area of skin exposure, with the upper boundary of flat xiphoid process, side borders of mid-axillary lines, and lower boundary of the upper thigh (Figure 1).</li>
</ol>
3. Fluorescent dye preparation
<ol>
	<li>Indocyanine green (ICG) preparation
	<ol>
		<li>Dissolve 25 mg of ICG into 20 mL of sterile water for a final concentration of 1.25 mg/mL and shake gently.</li>
	</ol>
	</li>
</ol>
4. ICG injection
<ol>
	<li>Use a 2 mL syringe (with the needle size of 0.6 mm x 32 mm TW LB) to inject 0.5 mL of the prepared ICG at 3 o&#39;clock and 9 o&#39;clock of the ectocervix at the superficial (2-3 mm) and deep (1-2 cm) cervix, respectively (Figure 2). 
	&#8203;NOTE: In some cases, the ectocervix positions of 6 and 12 o&#39;clock can also be selected. ICG should be avoided when injected into Nessler&#39;s cyst.</li>
</ol>
5. Intraoperative SLN identification
<ol>
	<li>Preparation before development
	<ol>
		<li>Grasp the skin around the umbilicus with two towel forceps to elevate the abdominal wall. Make an incision of about 10 mm wide in the skin of the umbilicus and through the fascia and peritoneum.</li>
		<li>Insert a 10 mm trocar through the umbilicus, producing the pneumoperitoneum with intraperitoneal pressure of about 13-14 mmHg. Insert a laparoscope (with light source and cameras) via the trocar.</li>
		<li>Make three other small incisions of ~5 mm wide in the lower abdomen and insert 5 mm trocars through the abdominal wall into the cavity. Insert instruments for manipulation via the other three 5 mm trocars (Figure 1).</li>
		<li>Identify the fallopian tubes under laparoscopy. Grasp and elevate the tubes close to fimbriae and tie a ligature around the tube with a 2-0/T silk suture. 
		NOTE: This step is used to prevent endometrial tumor cells from entering the abdominal cavity along the fallopian tubes from the uterine cavity.</li>
		<li>Take the peritoneal washings with 100 mL of normal saline before any significant handling or manipulation of the uterus. Collect the washing fluid for cytology.</li>
		<li>Open the fluorescence mode of the endoscopic fluorescence imaging system (see step 5.2). Lift unilateral pelvic infundibulum ligament and uterus to reveal the lateral peritoneum and look for the fluorescence lymphatic vessels. 
		&#8203;NOTE: If there are no fluorescence lymphatic vessels identified, it is allowed to inject ICG repeatedly.</li>
	</ol>
	</li>
	<li>SLN mapping
	<ol>
		<li>Endoscopic fluorescence imaging system preparation (PINPOINT).</li>
		<li>Adjust the fluorescence mode to near-infrared laser (excitation light, 805 nm) for the best field of view. 
		NOTE: The endoscopic fluorescence imaging system has several modes, such as HD (High definition) white light, SPY fluorescence, PINPOINT fluorescence, and SPY CSF mode, and the surgeon can switch to another mode if necessary.</li>
	</ol>
	</li>
	<li>Identify SLNs under a fluorescence laparoscopy.
	<ol>
		<li>Hold an ultrasonic scalpel and toothless forceps with each hand (performed by the surgeon). 
		NOTE: The assistant grasps toothless forceps to cooperate with the surgeon.</li>
		<li>Lift and open the peritoneum, separate the sub-peritoneal fat and connective tissues to reveal the necessary structures, including the ureter, internal iliac vessels, and obturator nerves according to the indication of green fluorescence lymphatic lines, as well as to protect them from injury. 
		NOTE: An ultrasonic scalpel with activation is used to cut the tissues, while an inactivated scalpel can be used for blunt dissection.</li>
		<li>Observe the SLNs covered by the peritoneum about 5-10 min after ICG injection. 
		&#8203;NOTE: Typically, SLNs present along with the fluorescence lymphatic vessels from both sides of the cervix to at least the height of the common iliac blood vessel. Occasionally, the SLNs emerge beside the abdominal aorta. PINPOINT equipment has multiple modes, including white light, fluorescence, and black and white modes. Switching between multiple modes helps to determine the location of SLNs.</li>
	</ol>
	</li>
</ol>
6. Intraoperative SLN biopsy
<ol>
	<li>Locate the SLN, the first mapped lymph node along the drainage from parametrium in each hemi-pelvis, and use multiple modes to confirm it. Fully expose the SLNs for complete resection (Figure 3).</li>
	<li>Grasp and elevate the SLN by toothless forceps and perform a complete resection of the lymph node along the periphery of the lymph node in white light. 
	NOTE: Avoid lymph node damage, which might cause contamination with tumor cells.</li>
	<li>Place the removed SLNs in the obturator fossa or put them into a small, simple bag. After the uterus is completely removed and taken out through the vagina, bilateral SLNs are taken out entirely through the vagina rather than through the 5 mm trocar opening to avoid fragmentation.</li>
	<li>Send the removed lymph nodes to the pathology department for pathological ultrastaging.</li>
	<li>During the operation, resect the enlarged or suspicious lymph nodes simultaneously and send them for pathological examination.</li>
	<li>Record the locations of SLNs on standardized intraoperative data collection forms.</li>
	<li>If SLN mapping fails on one or both sides, perform side-specific lymphadenectomy according to the NCCN guidelines. 
	NOTE: If there is no fluorescent node in the hemipelvis, continue to seek the mapped node along the lymphatic vessels until the para-aortic region due to the possibility of mapping in unexpected locations. A failed SLN mapping on either side means that any fluorescent green node is not visible with or without fluorescent green lymphatic vessels under the fluorescence laparoscope system on either side of the pelvis and para-aortic region.</li>
	<li>Perform a total hysterectomy plus bilateral salpingectomy. 
	&#8203;NOTE: Since this was a 28-year-old patient with early-stage endometrioid cancer who had a strong desire for fertility preservation and normal-appearing ovarian cancer and had no apparent family history of breast/ovarian cancer or Lynch Syndrome, ovarian preservation could be considered.</li>
	<li>Indwell a drainage tube for potential residual fluid in the pelvis.</li>
	<li>Remove the laparoscope and release the gas from the abdomen. Close the incisions in the umbilicus and lower abdomen with a single stitch by 2-0/T silk suture.</li>
</ol>
7. Postoperative SLN ultrastaging20
<ol>
	<li>Cut the SLN along the maximum diameter and micro-sectioned 50 &#181;m apart to get three hematoxylin-eosin (H&#38;E) slides and one immunohistochemistry (IHC) slide with anti-cytokeratin antibody (AE1/AE3). 
	NOTE: Ultrastaging entails thin serial sectioning of the gross SLN. Cytokeratin IHC is not essential. No standard protocol is for ultrastaging.</li>
	<li>Lymph node metastases were described as macrometastases (&#62;2 mm), micrometastases (0.2-2.0 mm), or isolated tumor cells (ITCs) according to the classification of the American Joint Committee on Cancer (AJCC)21.</li>
	<li>Report the postoperative pathology with details about the tumor size, histologic type and grade, myometrial invasion, lymphovascular space involvement, cervical stromal involvement, number and status of per lymph nodes, and the cytology of peritoneal washings.</li>
</ol>

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Results of a prospective multicenter study on the factors associated with failure of node mapping with indocyanine green.</a> Gynecologic and Obstetric Investigation. 84 (4), 383-389 (2019).</li><li>Naoura, I., Canlorbe, G., Bendifallah, S., Ballester, M., Dara&#239;, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Relevance+of+sentinel+lymph+node+procedure+for+patients+with+high-risk+endometrial+cancer.">Relevance of sentinel lymph node procedure for patients with high-risk endometrial cancer.</a> Gynecologic Oncology. 136 (1), 60-64 (2015).</li><li>Schiavone, M. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Survival+of+patients+with+uterine+carcinosarcoma+undergoing+sentinel+lymph+node+mapping.">Survival of patients with uterine carcinosarcoma undergoing sentinel lymph node mapping.</a> Annals of Surgical Oncology. 23 (1), 196-202 (2016).</li><li>Soliman, P. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+prospective+validation+study+of+sentinel+lymph+node+mapping+for+high-risk+endometrial+cancer.">A prospective validation study of sentinel lymph node mapping for high-risk endometrial cancer.</a> Gynecologic Oncology. 146 (2), 234-239 (2017).</li></ol>

The authors have nothing to disclose.

SLN mapping and biopsy is a more selective and tailored lymph node dissection approach that has been applied in the clinic for nearly 20 years. In the field of EC, SLN mapping and biopsy have been increasingly recommended by several guidelines due to their high diagnostic efficiency in early-stage EC, achieving overall and bilateral detection rates of 89%-95% and 52%-82%, respectively, with a sensitivity of 84%-100% and negative predictive value of 97%-100%22. The present study reports a typical EC patient who performed SLN mapping and described the SLN protocol in detail from ICG injection to SLN biopsy.
SLN mapping is feasible with various dyes. Previous research on lymph node staging of breast and endometrial cancers applied blue dye (usually methylene blue or isosulfane blue (ISB), radiocolloid, or both23,24,25,26), reaching good performance and accuracy. As shown in white light, the blue dyes mentioned above have been extensively used due to their convenience and the least complex equipment requirement. However, the ICG dye had higher SLN detection rates (83%) than the ISB (64%)26. Thus, ICG is considered a better option for successful detection. Comparison between different dyes is stated in Table 1 according to the SGO consensus27.
In addition to tracker dyes, injection positions also affect detection rates of SLN mapping. Dye injection in the cervix cannot wholly reflect the lymphatic drainage, though the procedure is relatively simple and popular in clinical trials28,29. A hysteroscopic injection requires more skill and is located near the tumor lesion. The myometrial site is challenging to access intraoperatively, resulting in a low negative predictive rate of 87.50% and a false-negative rate of 33.30%30. In studies using cervical injection, the sensitivity range was 62.5%-97.5%, while myometrium injection was 66.70%-94.10%31. A systematic review including 55 eligible studies revealed an overall detection rate of 81% (95% confidence interval is from 77 to 84)32. Double detection works better than single detection, regardless of the injection location33. In the ongoing clinical study (NCT04276532), where 92 EC patients were enrolled, the SLN mapping detection rate was as high as 91.3%, with a total sensitivity of 73.3%. Combining cervical and fundus injections reached a higher para-aortic detection rate (40.4%) than cervical injections alone (4.4%), indicating that the combined injection is more efficient.
There are many possible reasons for insufficient SLN detection. Anatomically, the Naboth cyst and postsurgical abnormal pelvis affect mapping accuracy. Excessive adipose tissue near the cervix and cervical stenosis due to aging also lead to failed mapping. Factors such as body mass index (BMI), ISB dye use, and enlarged nodes are associated with SLN mapping failure34. Controversially, one prospective study including 110 EC patients reported that obesity and the presence of lymph node metastases were not associated with detection failure35. Lymphovascular space invasion might lead to failure of SLN mapping as well.
International guidelines consider SLN mapping and biopsy as necessary procedures10,18. However, there are debates about whether to conduct SLN mapping in intermediate-high risk EC patients. Patients with severe carcinoma, clear cell carcinoma, and carcinosarcoma have a higher risk of node metastasis36. On the contrary, some trials have determined that SLN mapping is a safe alternative to systematic lymphadenectomy because of lower complication occurrence37,38 and equivalent overall survival37. More high-quality clinical trials are required to determine the optimal inclusion standards.
In conclusion, SLN mapping and biopsy are better options than systematic lymphadenectomy to make the operation as simple and minimally invasive as possible. It can even improve the pathological stage of the disease by using a pathological ultrastaging method to guide the postoperative adjuvant therapy more accurately. For maximizing the specificity and sensitivity of SLN detection, this protocol provides tips for SLN mapping and biopsy to ensure a better outcome of the surgery.

Endometrial cancer (EC) is one of the most common diseases in gynecological oncology, and its incidence is rising1,2. Surgery is the first-line treatment for early-stage EC3,4. The evaluation of lymph node metastasis is an essential part of surgical staging in EC. The Gynecologic Oncology Group (GOG) study 33 demonstrated that lymph node metastases are associated with poor prognosis5.
As a new and essential technique for evaluating lymph node metastasis, sentinel lymph node (SLN) mapping and biopsy have emerged in recent years and have been recommended to be employed for patients with apparent uterine-confined EC according to the National Comprehensive Cancer Network (NCCN) guidelines for uterine cancer6,7,8,9,10. SLN mapping has also been extensively applied in tumors such as breast cancer11, lung cancer12, thyroid cancer13, and melanoma14. Pathologic ultrastaging has achieved good performance in colorectal and gynecological cancer15,16,17 and is recommended by the authoritative European guidelines18. Although principles of SLN mapping for EC staging have been provided in international guidelines10,19, there are no detailed manipulations of surgery in other present works.
This work presents the protocol for detailed SLN mapping and biopsy with ICG in a 28-year-old female who had been clinically diagnosed with early-stage EC, thus, improving and promoting the diagnosis of patients.

<table><tbody><tr><td>2-mL syringe</td><td>Becton, Dickinson and Company, USA</td><td>301940</td><td></td></tr><tr><td>Coagulation forceps</td><td>Shanghai Medical Instrument (Group) Co., Ltd. Surgical Instrument Factory</td><td>D0A010</td><td></td></tr><tr><td>Fluorescence microscope</td><td>Olympus</td><td>IX73</td><td></td></tr><tr><td>Harmonic scalpel</td><td>Soering GmbH</td><td>SONOCA190</td><td></td></tr><tr><td>Hematoxylin-eosin staining</td><td>Beyotime Biotechnologies Corporation,CN</td><td>C0107</td><td></td></tr><tr><td>Immunohistochemical cytokeratin staining</td><td>MXB Biotechnologies Corporation, CN</td><td>Kit-0020</td><td></td></tr><tr><td>Indocyanine green (ICG)</td><td>Dandong Medical Innovation Pharmaceutical Corporation.</td><td>3599-32-4</td><td></td></tr><tr><td>Pararaffin</td><td>Sangon biotech Co., Ltd.</td><td>A601889</td><td></td></tr><tr><td>Pinpoint Endoscopic Fluorescence Imaging system</td><td>Novadaq Technoloies Bonita, Springs, FL</td><td>NA</td><td></td></tr><tr><td>Propofol Injection</td><td>Fresenius Kabi Deutschland GmbH D-61346 Bad Homburg v.d.H., Germany</td><td>H20030124</td><td></td></tr><tr><td>Silk Braided non-absorbable suture</td><td>Shanghai Ethicon</td><td>SA854G</td><td></td></tr><tr><td>Silk thread</td><td>Beijing AKIN AIEN International Medical Technology Co.,Ltd.</td><td>VCPP71D</td><td></td></tr><tr><td>Suction-Irrigation Tube</td><td>Shanghai SMAF</td><td>YX980D</td><td></td></tr><tr><td>Toothless forceps</td><td>Shanghai Medical Instrument (Group) Co., Ltd. Surgical Instrument Factory</td><td>J41010</td><td></td></tr><tr><td>Trocar</td><td>ETHICON Co,. Ltd, USA</td><td>B10LT, B5LT</td><td></td></tr></tbody></table>

sentinel lymph node mapping and biopsy for endometrial cancer at early stage with laparoscopy

Sentinel lymph node (SLN) mapping and biopsy is a promising technique for visualizing and evaluating lymph node status in cancer. This approach has been recommended for low-risk endometrial cancer (EC) patients by authoritative international guidelines, but it has not been performed broadly in China and worldwide. This work aims to describe detailed SLN mapping and biopsy procedures to promote the clinical application. SLN mapping and postoperative pathologic ultrastaging were conducted in a patient with low-risk EC using indocyanine green (ICG) dye to track the SLNs under laparoscopy and resecting them completely for ultrastaging. In conclusion, this protocol describes details of ICG injection, and SLN mapping and biopsy in EC patients based on the experiences gained during clinical practice.

The patient in the present case was a 28-year-old female with irregular vaginal bleeding for 2 years, and she was diagnosed with an abnormality of the endometrium 4 months ago. Transvaginal ultrasound examination revealed a heterogeneous endometrial thickness with an adnexal mass. Abdominopelvic magnetic resonance imaging (MRI) demonstrated a 51 mm x 56 mm x 88 mm mass with a clear boundary within the uterine cavity under a high T2WI&#160;signal in a local hospital. Then, she was evaluated by hysteroscopy, and the endometrial lesion was dissected. The pathological results showed grade 1 endometrial cancer. This patient came to the hospital for further treatment with a strong fertility requirement. After a comprehensive evaluation (including another MRI examination that showed an irregular signal of endometrium in hospital, Figure 4) and signing informed consent, she experienced fertility preservation treatment. However, the second hysteroscopy in the hospital revealed&#160;superficial myometrial invasion, a contraindication of fertility preservation. Ultimately, after the patient was informed of her condition, she decided to undergo a total hysterectomy + bilateral salpingectomy + SLN mapping.
The cervix was injected with diluted ICG at 3 and 9 o&#39;clock positions superficially and deeply, respectively (Figure 2). Then, the lymphatic vessels and SLNs were fluorescently labeled, which allowed for their recognition under various color modes (green for fluorescence mode and blue and red for color-segmented mode) in the Pinpoint Endoscopic Fluorescence Imaging system (Figure 3). Subsequently, the pathology department conducted H&#38;E and IHC staining of SLN (Figure 5 and Figure 6) and ultrastaging of SLN. The staging results revealed a negative metastasis output.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/63044/63044fig01.jpg" /> 
Figure 1: Antiseptic preparation scope of SLN mapping in EC with laparoscopy. The black arrow indicates mid-axillary lines. The numbered red circles indicate the places of four trocars on the abdominal wall. Circle No. 2 is for the 10 mm trocar. The rest of the circles are for 5 mm trocars. The distance between circles No. 2 and 3 is around four fingerbreadths. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63044/63044fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/63044/63044fig02.jpg" /> 
Figure 2: Illustration of the SLN mapping in EC. (A) Anatomical diagram of the SLN in the pelvis. The dark green line represents the direction of the lymphatic drainage. Arrows indicate SLN lymph nodes in this case (yellow arrow presents the lymph node located between the right external and internal iliac vessels, brown arrow demonstrates the SLN in the left obturator foramen, and black arrow shows enlarged lymph node on the left iliac vein). Blue flat line indicates clock directions. (B) Injection spot locations in the cervix. ICG = indocyanine green. Green dots indicate the injection spots. The blue square shows the 3 and 9 o&#39;clock positions of the ectocervix. (C) Enlarged cervix diagram: green dots indicate superficial and deep cervical injections. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63044/63044fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/63044/63044fig03.jpg" /> 
Figure 3: Intraoperative imaging of the SLN in EC. (A) Fluorescence mode. The green arrow indicates the SLN under fluorescence mode. (B) Color-segmented fluorescence mode. The yellow arrow indicates the lymph node under color-segmented mode. (C) Florescence mode of sentinel lymph nodes of this case. (D) Color-segmented fluorescence mode of sentinel lymph nodes of this case. HD: High definition; CSF: Color-segmented fluorescence. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63044/63044fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/63044/63044fig04.jpg" /> 
Figure 4: The MRI of EC patient. (A) Irregular signal of the endometrium located in the lower uterus cavity (arrows) on T1WI. (B) Irregular signal of the endometrium (arrows) on T2WI. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63044/63044fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/63044/63044fig05.jpg" /> 
Figure 5: H&#38;E staining of EC and IHC staining of SLN. (A) H&#38;E staining of myoinvasion in EC. (B) H&#38;E staining of SLN. (C) IHC staining of AE1/AE3 (AE1/AE3 may stain myofibroblasts and smooth muscle cells and indicate the residual tumor cells) in SLN. 2.5x and 5x refer to the magnification under the microscope. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63044/63044fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/63044/63044fig06.jpg" /> 
Figure 6:&#160;IHC staining of EC patients. (A) IHC staining of estrogen receptor (ER) with five magnifications. (B) IHC staining of progesterone receptor (PR). (C) IHC staining of P53. (D) IHC staining of Ki67. (E) IHC staining of MLH1. (F) IHC staining of MSH2. (G) IHC staining of PMS2. (H) IHC staining of MSH6. All the images are captured with 5x magnification. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63044/63044fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
Table 1: Comparison between tracers of blue dye, ICG, and Tc99. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/63044/Table 1.xlsx" target="_blank">Please click here to download this Table.</a>

Watch this Scientific Journal Video about Sentinel Lymph Node Mapping and Biopsy for Endometrial Cancer at Early Stage with Laparoscopy at JoVE.com

Sentinel Lymph Node Mapping and Biopsy for Endometrial Cancer at Early Stage with Laparoscopy

This protocol describes the identification and resection of sentinel lymph nodes to make the operation as easy and minimally invasive as possible.

Sentinel lymph node (SLN) mapping and biopsy is a promising technique for visualizing and evaluating lymph node status in cancer. This approach has been ...

sentinel-lymph-node-mapping-biopsy-for-endometrial-cancer-at-early

Nanyang Technological University

Research

JoVE Journal

Cancer Research

11.1K Views.  Obstetrics and Gynecology Hospital of Fudan University. Dit protocol werd samengevat op basis van een cumulatieve ervaring met het in kaart brengen van schildwachtklieren in ten minste 500 gevallen van endometriumcarcinoom om beginners te helpen deze techniek met succes te implementeren. Deze techniek is minimaal invasief, vermindert complicaties en medische kosten en verbetert de detectiesnelheid van lymfekliermetastasen door pathologische ultrastaging. Een leercurve van ongeveer 20 gevallen van SLN-mapping is vereist met ervaring met injectie in...

Video: Sentinel Lymph Node Mapping and Biopsy for Endometrial Cancer at Early Stage with Laparoscopy

Multispectral Real-time Fluorescence Imaging for Intraoperative Detection of the Sentinel Lymph Node in Gynecologic Oncology

The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases.1-3 Surgical treatment most often combines radical excision of the tumor with a full lymphadenectomy in the drainage area of the tumor. However, removal of lymph nodes is associated with increased morbidity due to infection, wound breakdown and lymphedema.4,5 As an alternative, the sentinel lymph node procedure (SLN) was developed several decades ago to detect the first draining lymph node from the tumor.6 In case of lymphogenic dissemination, the SLN is the first lymph node that is affected (Figure 1). Hence, if the SLN does not contain metastases, downstream lymph nodes will also be free from tumor metastases and need not to be removed. The SLN procedure is part of the treatment for many tumor types, like breast cancer and melanoma, but also for cancer of the vulva and cervix.7 The current standard methodology for SLN-detection is by peritumoral injection of radiocolloid one day prior to surgery, and a colored dye intraoperatively. Disadvantages of the procedure in cervical and vulvar cancer are multiple injections in the genital area, leading to increased psychological distress for the patient, and the use of radioactive colloid.
Multispectral fluorescence imaging is an emerging imaging modality that can be applied intraoperatively without the need for injection of radiocolloid. For intraoperative fluorescence imaging, two components are needed: a fluorescent agent and a quantitative optical system for intraoperative imaging. As a fluorophore we have used indocyanine green (ICG). ICG has been used for many decades to assess cardiac function, cerebral perfusion and liver perfusion.8 It is an inert drug with a safe pharmaco-biological profile. When excited at around 750 nm, it emits light in the near-infrared spectrum around 800 nm. A custom-made multispectral fluorescence imaging camera system was used.9.
The aim of this video article is to demonstrate the detection of the SLN using intraoperative fluorescence imaging in patients with cervical and vulvar cancer. Fluorescence imaging is used in conjunction with the standard procedure, consisting of radiocolloid and a blue dye. In the future, intraoperative fluorescence imaging might replace the current method and is also easily transferable to other indications like breast cancer and melanoma.

Fluorescence imaging is a promising innovative modality for image-guided surgery in surgical oncology. In this video we describe the technical procedure for detection of the sentinel lymph node using fluorescence imaging as showcased in gynecologic oncologicy. A multispectral fluorescence camera system, together with the fluorescent agent indocyanine green, is applied.

The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases.1-3 Surgical treatment most often combines radical ...

Medicine

The Application of 1% Methylene Blue Dye As a Single Technique in Breast Cancer Sentinel Node Biopsy

In this study, we injected 1% methylene blue dye (MBD) into the subareolar or peritumoral space of the breast. In the case of breast conserving surgery (BCS), a separate incision in the lower axilla hairline was made to find the sentinel nodes (SNs). In mastectomy, the SNs were identified through the same mastectomy incision. The SNs were described as blue nodes or nodes with lymphatic blue channels. An anatomical landmark in the axilla was used to facilitate SNs identification. The SNs metastases were evaluated by intraoperative frozen section analysis and histopathology examination as it is a gold standard. Here, we described the MBD as the lone technique in breast cancer sentinel node biopsy (SNB) which could be useful when radioisotope tracer or patent or isosulfan blue dye (PBD) cannot be provided.

In Indonesia, sentinel node biopsy (SNB) is not routinely performed for breast cancer surgery because of the limitation to provide radioisotope tracer and isosulfan or patent blue dye (PBD). To overcome this obstacle, we applied 1% methylene blue dye (MBD) as a single agent to map the sentinel nodes (SNs).

In this study, we injected 1% methylene blue dye (MBD) into the subareolar or peritumoral space of the breast. In the case of breast conserving surgery ...

An Orthotopic Endometrial Cancer Model with Retroperitoneal Lymphadenopathy Made From In Vivo Propagated and Cultured VX2 Cells

Endometrial cancer is the most common gynecologic malignancy in North America and the incidence is rising worldwide. Treatment consists of surgery with or without adjuvant therapy depending on lymph node involvement as determined by lymphadenectomy. Lymphadenectomy is a morbid procedure, which has not been shown to have a therapeutic benefit in many patients, and thus a new method to diagnose lymph node metastases is required. To test novel imaging agents, a reliable model of endometrial cancer with retroperitoneal lymph node metastases is needed. The VX2 endometrial cancer model has been described frequently in the literature; however, significant variation exists with respect to the method of model establishment. Furthermore, no studies have reported on the use of cultured VX2 cells to create this model as only cells propagated in vivo have been previously used. Herein, we present a standardized surgical method and post-operative monitoring method for the establishment of the VX2 endometrial cancer model and report on the first use of cultured VX2 cells to create this model.

This protocol presents a standardized method to grow VX2 cells in culture and to create an orthotopic VX2 model of endometrial cancer with retroperitoneal lymph node metastases in rabbits. Orthotopic endometrial cancer models are important for the pre-clinical study of novel imaging modalities for the diagnosis of lymph node metastases.

Endometrial cancer is the most common gynecologic malignancy in North America and the incidence is rising worldwide. Treatment consists of surgery with or ...

Intraoperative Detection of Subtle Endometriosis: A Novel Paradigm for Detection and Treatment of Pelvic Pain Associated with the Loss of Peritoneal Integrity

Endometriosis is a common disease affecting 40 to 70% of reproductive-aged women with chronic pelvic pain (CPP) and/or infertility. The purpose of this study was to demonstrate the use of a blue dye (methylene blue) to stain peritoneal surfaces during laparoscopy (L/S) to detect the loss of peritoneal integrity in patients with pelvic pain and suspected endometriosis. Forty women with CPP and 5 women without pain were evaluated in this pilot study. During L/S, concentrated dye was sprayed onto peritoneal surfaces, then aspirated and rinsed with Lactated Ringers solution. Areas of localized dye uptake were evaluated for the presence of visible endometriotic lesions. Areas of intense peritoneal staining were resected and some fixed in 2.5% buffered gluteraldehyde and examined by scanning (SEM) electron microscopy. Blue dye uptake was more common in women with endometriosis and chronic pelvic pain than controls (85% vs. 40%). Resection of the blue stained areas revealed endometriosis by SEM and loss of peritoneal cell-cell contact compared to normal, non-staining peritoneum. Affected peritoneum was associated with visible endometriotic implants in most but not all patients. Subjective pain relief was reported in 80% of subjects. Based on scanning electron microscopy, we conclude that endometrial cells extend well beyond visible implants of endometriosis and appear to disrupt the underlying mesothelium. Subtle lesions of endometriosis could therefore cause pelvic pain by disruption of peritoneal integrity, allowing menstrual or ovulatory blood and associated pain factors access to underlying sensory nerves. Complete resection of affected peritoneum may provide a better long-term treatment for endometriosis and CPP. This simple technique appears to improve detection of subtle or near invisible endometriosis in women with CPP and minimal visual findings at L/S and may serve to elevate diagnostic accuracy for endometriosis at laparoscopy.

Loss of peritoneal integrity provides a new paradigm to understand and treat chronic pelvic pain in women with mild forms of endometriosis and can be easily detected using intraoperative instillation of dye at the time of laparoscopy.

Endometriosis is a  common disease affecting 40 to 70% of reproductive-aged women with chronic  pelvic pain (CPP) and/or infertility. The purpose of this ...

Modified Laparoscopic Inguinal Lymphadenectomy Using an Abdominal Subcutaneous Approach

Inguinal lymph node metastases significantly impact the prognosis of patients with penile cancer. Therefore, timely inguinal lymph node dissection is essential for the comprehensive treatment of penile cancer. Compared with the traditional open inguinal lymphadenectomy, laparoscopic inguinal lymphadenectomy offers similar tumor control with fewer complications. The current techniques for the laparoscopic surgical approach include L-lymphoid clearance sequence and preservation of the great saphenous vein. In this study, a transabdominal subcutaneous anterograde approach was employed to improve laparoscopic inguinal lymph node dissection and conserve the great saphenous vein, resulting in favorable outcomes. Furthermore, only 2 out of 21 patients experienced wound infections, and only 1 exhibited lymphatic leakage from the drainage orifice. These findings indicate that the use of an innovative subcutaneous transperitoneal retrograde approach is safe for abdominal endoscopic common iliac plexus dissection with fewer complications in patients with penile cancer compared with traditional open surgery. Notably, the postoperative survival rate of penile cancer patients is significantly influenced by the presence or absence of inguinal lymph node metastasis and the extent of metastasis. Timely inguinal lymph node dissection is essential since it significantly impacts the treatment of penile cancer. Besides, laparoscopic inguinal lymphadenectomy offers comparable tumor control to open surgery with significantly reduced complications. Notably, standardized approaches for laparoscopic surgery, cleaning procedures, and preservation of the saphenous vein are crucial for inguinal lymph node dissection. The laparoscopic inguinal lymphadenectomy technique can be improved by employing the abdominal subcutaneous anterograde approach. This article provides a comprehensive account of the procedures and technical improvements associated with the modified laparoscopic inguinal lymphadenectomy using the abdominal subcutaneous approach.

The efficacy of laparoscopic inguinal lymph node dissection is comparable to that of open surgery. It also significantly decreases the incidence of complications. In this study, a modified laparoscopic method was used for inguinal lymph node dissection through the abdominal subcutaneous approach for penile cancer treatment.

Inguinal lymph node metastases significantly impact the prognosis of patients with penile cancer. Therefore, timely inguinal lymph node dissection is ...

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

Tubal Cytology of the Fallopian Tube as a Promising Tool for Ovarian Cancer Early Detection

Currently, it is widely accepted that the vast majority of ovarian high-grade serous carcinoma (HGSC) originate from the fallopian tube. However, due to the lack of markers or tools for the ovarian cancer identification, the early detection of HGSC remains challenging. Direct sampling of the fallopian tube can enhance sensitivity for detection of neoplastic cells when the tumor is not grossly visible. We developed a procedure to collect fallopian tube cells directly from freshly received surgical specimens, which has shown excellent correlation with histological findings. This approach lays a foundation for the future utility of minimally invasive laparoscopic screening in high-risk patient populations.

We explored a tubal cytologic method by sampling the fallopian tube directly post-surgical excision as a tool of ovarian cancer early detection. Here, we present a protocol to collect fallopian tube cells from freshly received surgical specimens.

Currently, it is widely accepted that the vast majority of ovarian high-grade serous carcinoma (HGSC) originate from the fallopian tube. However, due to ...

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex procedures. The high-quality 3-D visual, multijoint arm and natural tremor filtration allow the surgeon to expose and dissect more accurately with minimal invasion. Total mesorectal excision is the standard surgical technique for the treatment of resectable rectal cancer. To reduce the lateral recurrence rate, lateral pelvic lymph node dissection can be performed, as it is a safe and feasible procedure for locally advanced middle-low rectal cancer with a high possibility of metastasis to the lateral lymph nodes. However, the complexity of the anatomic structures and the high postoperative complication rate limit its application. Recently, several surgeons have increasingly used robotic techniques for total mesorectal excision and lateral pelvic lymph node dissection. Compared with open and laparoscopic surgery, the robotic technique has several advantages, such as less blood loss, fewer blood transfusions, minimal trauma, shorter postoperative hospitalization, and quicker recovery. A robotic approach is generally regarded as a reasonable alternative for complicated procedures such as lateral pelvic lymph node dissection, although there are a limited number of high-quality prospective randomized controlled studies reporting direct evidence. Here, we provide the detailed steps of robot-assisted total mesorectal excision and lateral pelvic lymph node dissection performed at the First Affiliated Hospital of Xi&#39;an Jiaotong University.

The robotic technique described herein aims to detail a stepwise approach to robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced (T3/T4) rectal cancer located below the peritoneal reflection.

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex ...

Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this approach makes an innovative improvement in the treatment of G-GISTs that are less than 5 cm in size. Laparoscopy-endoscopy cooperative surgery (LECS) is used to combine endoscopic and laparoscopic surgeries, fully realizing their respective advantages and avoiding their drawbacks. The main steps are as follows. First, gastroscopy and laparoscopy are combined to confirm the location and boundary of the tumor. Tumor resection is carried out laparoscopically, guided by a gastroscope. The specimen is removed orally and the gastric wound closed laparoscopically. Then, gastroscopy and laparoscopy are combined to determine whether there is wound bleeding, if the suture is satisfactory, and if the gastric cavity is deformed.
LECS has natural advantages in the treatment of G-GISTs that are less than 5 cm in size. The accurate estimation of tumor location and boundary greatly improves the complete resection rate of tumors. The risk of tumor rupture is substantially reduced, and the long-term prognosis of patients is significantly improved. The process allows for accurate resection of the tumor, maximum preservation of normal gastric tissue and organ function, and avoids postoperative gastric deformation. The patient's postoperative rehabilitation is greatly accelerated, and oral feeding can resume on the day of the operation. The specimen is taken out through the mouth to avoid the need for an extended abdominal incision. This greatly reduces the patient's postoperative pain and scarring. The method greatly shortens the postoperative hospital stay (i.e., discharge is possible on the day after the operation), increasing the turnover of hospital beds.

Laparoscopy-endoscopy cooperative surgery is appropriate for the treatment of gastric gastrointestinal stromal tumors less than 5 cm in size. It can achieve the respective advantages of endoscopic and laparoscopic surgeries while avoiding their drawbacks.

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this ...

Endoscopic Bilateral Nipple-sparing Mastectomy via a Single Axillary Incision with Immediate Pre-pectoral Implant-based Breast Reconstruction

Oncoplastic breast surgery, with its focus on improving cosmetic outcomes while maintaining oncological safety, has fundamentally transformed the landscape of breast cancer surgical treatment, giving rise to an array of techniques for breast reconstruction. Nipple-sparing mastectomy (NSM) with immediate implant-based breast reconstruction (IBBR) has emerged as a cornerstone in managing early breast cancer. Aligned with the principles of minimally invasive surgery, recent years have witnessed the widespread integration of endoscopic approaches in breast surgery, encompassing procedures like endoscopic breast-conserving surgery (E-BCS) and endoscopic nipple-sparing mastectomy (E-NSM), among others. Capitalizing on the advantages of inconspicuous and shorter incisions, improved visibility, and the avoidance of radiation therapy, the popularity of E-NSM with IBBR is on the rise. However, conventional E-NSM with IBBR often requires two or more incisions, which can result in suboptimal cosmetic outcomes and even prosthesis loss.This paper presents a comprehensive account of the intricate surgical procedures involved in endoscopic bilateral nipple-sparing mastectomy with immediate pre-pectoral implant-based breast reconstruction. The insights shared are drawn from the collective experience of our institution. Notable benefits associated with the described surgical approach encompass enhanced cosmetic outcomes, improved postoperative quality of life, and enhanced physiological functions attributable to the application of pre-pectoral implant-based breast reconstruction through a single incision.

Here, we present detailed surgical procedures for endoscopic bilateral nipple-sparing mastectomy via a single axillary incision with immediate pre-pectoral implant-based breast reconstruction. This procedure is a secure and viable method for breast cancer patients.

Sentinel Lymph Node Mapping and Biopsy for Endometrial Cancer at Early Stage with Laparoscopy

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