Objective: To investigate the application of sentinel lymph node biopsy (SLNB) in early-staged cervical cancer by laparoscopy. Methods: It was a prospective, single-arm, single-center clinical study. Seventy-eight cases of cervical cancer patients were collected from July 2015 to December 2018 at the Fourth Hospital of Hebei Medical University. All the patients were injected with tracer into the disease-free block of cervical tissue after anesthesia by the same surgeon who learned sentinel lymph node (SLN) mapping technique in Memorial Sloan-Kettering Cancer Center, and underwent SLN mapping followed by complete pelvic lymphadenectomy. Moreover, all the dissected lymph nodes were stained with hematoxylin eosin staining (HE) pathological examination. Besides, the negative SLN on hematoxylin-eosin staining were detected by immunohistochemistry cytokeratin staining micro-metastasis. To analyze the distribution, detection rate, false negative rate the sensitivity and negative predictive value of the SLN in early-staged cervical cancer by laparoscopy, and explore the value of SLN mapping in predicting the lymph nodes metastasis in early-staged cervical cancer. Results: The overall detection rate of SLN in cervical cancer was 99% (77/78), bilateral detection rate was 87% (68/78). The average of 12.4 lymph node (LN) and 3.6 SLN were dissected for each patients each side. SLN of cervical cancer were mainly distributed in the obturator space (61.5%, 343/558), followed by external iliac (23.5%, 131/558), common iliac (7.3%, 41/558), para-uterine (3.8%, 21/558), internal iliac (2.2%, 12/558), para abdominal aorta (1.1%, 6/558), and anterior sacral lymphatic drainage area (0.7%, 4/558). Fourteen cases of LN metastasis were found among all 78 cases. There were a total of 38 positive LN, including 26 SLN metastasis and 12 none sentinel LN metastasis. Through immunohistochemical staining and pathological ultra-staging, 1 SLN was found to be isolated tumor cells (ITC), and 5 SLNs were found to be micro-metastases (MIC), accounting for 23% (6/26) of positive SLN. SLN mapping with pathological ultra-staging improved the prediction of LN metastasis in cervical cancer (2/14). Metastatic SLN mainly distributed in the obturator space (65%, 17/26), peri-uterine region (12%, 3/26), common iliac region (15%, 4/26), and external iliac region (8%, 2/26). The consistency of the diagnosis of lymph node metastasis by SLN biopsy and postoperative retroperitoneal lymph node metastasis showed that the Kappa value was 1.000 (P<0.001), indicated that the metastasis status of SLN and retroperitoneal lymph node were completely consistent. The sensitivity, specificity, accuracy, false-negative rate, and negative predictive value of SLN biopsy in the diagnosis of lymph node metastasis were 100%, 100%, 100%, 0, and 100%, respectively. Conclusions: SLN in early-staged cervical cancer patients were mainly distributed in the obturator and external iliac space, pathalogical ultra-staging of SLN could improve the prediction of LN metastasis. Intraoperative SLN mapping is safe, feasible and could predict the state of retroperitoneal LN metastasis in early-staged cervical cancer. SLNB may replace systemic pelvic lymphadenectomy.
目的： 探讨前哨淋巴结（SLN）活检技术在早期子宫颈癌腹腔镜手术中的应用。 方法： 本研究是一项前瞻性、单臂、单中心的临床研究，入组时间为2015年7月，截止时间为2018年12月，共入组了在河北医科大学第四医院诊治的78例初治的早期子宫颈癌患者，其年龄为（50.2±9.3）岁。所有患者均于麻醉后在无瘤块的子宫颈组织处采用浅注射（2~3 mm）、深注射（1~2 cm）法注射示踪剂（亚甲蓝或纳米炭），随后在腹腔镜下先行蓝染或黑染的SLN切除，再行子宫广泛性切除+系统性盆腔淋巴结切除±腹主动脉旁淋巴结切除术，术后对常规病理检查（HE染色）阴性的SLN行连续切片联合免疫组化法细胞角蛋白检测进行病理超分期检查。分析SLN的检出率、SLN的分布、SLN与非SLN的病理检查结果，评价SLN活检诊断淋巴结转移的效能。 结果： （1）SLN的检出率：78例子宫颈癌患者中，77例检出SLN，SLN总检出率为99%（77/78），其中SLN双侧检出率为87%（68/78）、单侧检出率为12%（9/78）。（2）SLN的分布：78例子宫颈癌患者共切除盆腔淋巴结1 930枚，平均每例患者每侧切除盆腔淋巴结12.4枚；其中77例检出SLN的患者共切除SLN 558枚，平均每例患者每侧切除SLN 3.6枚。子宫颈癌SLN主要分布于闭孔区（61.5%，343/558），其后依次为髂外（23.5%，131/558）、髂总（7.3%，41/558）、宫旁（3.8%，21/558）、髂内（2.2%，12/558）、腹主动脉旁（1.1%，6/558）和骶前区（0.7%，4/558）。（3）SLN与非SLN的病理检查结果：78例子宫颈癌患者中，术后淋巴结转移患者14例（18%，14/78），共38枚转移淋巴结，其中SLN转移26枚、非SLN转移12枚。26枚转移SLN中，6枚为SLN低体积转移，包括1枚孤立肿瘤细胞转移（ITC）、5枚微小转移（MIC），占转移SLN的23%（6/26）；其余20枚为宏转移。14例术后淋巴结转移患者中，12例术后通过HE染色检测到淋巴结转移，2例通过病理超分期检测到淋巴结MIC，病理超分期检查后淋巴结转移检出率提高了2/14。转移SLN主要分布在闭孔（65%，17/26）、髂总（15%，4/26）、宫旁（12%，3/26）、髂外区（8%，2/26）。（4）SLN活检技术诊断淋巴结转移与术后腹膜后淋巴结转移状态的一致性Kappa检验显示，Kappa值为1.000（P<0.001），表示SLN活检结果与腹膜后淋巴结的转移状态完全一致。SLN活检技术诊断淋巴结转移的敏感度为100%，特异度为100%，准确率为100%，假阴性率为0，阳性预测值为100%，阴性预测值为100%。 结论： 早期子宫颈癌SLN主要分布在闭孔及髂外区域，SLN的病理超分期检查可提高淋巴结低体积转移的检出率。早期子宫颈癌腹腔镜手术中行SLN活检是安全、可行的，SLN活检可代替系统性淋巴结切除术。.