title: Detection of sentinel lymph nodes in patients with endometrial cancer undergoing robotic-assisted staging: a comparison of colorimetric and fluorescence imaging.
abstract: OBJECTIVE
  To retrospectively compare results from lymphatic mapping of pelvic sentinel lymph nodes (SLN) using fluorescence near-infrared (NIR) imaging of indocyanine green (ICG) and colorimetric imaging of isosulfan blue (ISB) dyes in women with endometrial cancer (EC) undergoing robotic-assisted lymphadenectomy (RAL). A secondary aim was to investigate the ability of SLN biopsies to increase the detection of metastatic disease.
  
  
  METHODS
  Thirty-five patients underwent RAL with hysterectomy. One mL ISB was injected submucosally in four quadrants of the cervix, followed by 0.5 mL ICG [1.25mg/mL] immediately prior to placement of a uterine manipulator. Retroperitoneal spaces were dissected for colorimetric detection of lymphatic pathways. The da Vinci(®) camera was switched to fluorescence imaging and results recorded. SLN were removed for permanent analysis with ultra-sectioning, H&E, and IHC staining. Hysterectomy with RAL was completed.
  
  
  RESULTS
  Twenty-seven (77%) and 34 (97%) of patients had bilateral pelvic or aortic SLN detected by colorimetric and fluorescence, respectively (p=0.03). Considering each hemi-pelvis separately, 15/70 (21.4%) had "weak" uptake of ISB in SLN confirmed positive with fluorescence imaging. Using both methods, bilateral detection was 100%. Ten (28.6%) patients had lymph node (LN) metastasis, and 9 of these had SLN metastasis (90% sensitivity, one false negative SLN biopsy). Seven of nine (78%) SLN metastases were ISB positive and 100% were ICG positive. Twenty-five had normal LN, all with negative SLN biopsies (100% specificity). Four (40%) with LN metastasis were detected only by IHC and ultra-sectioning of SLN.
  
  
  CONCLUSIONS
  Fluorescence imaging with ICG detected bilateral SLN and SLN metastasis more often than ISB, and the combination resulted in 100% bilateral detection of SLN. Ultra-sectioning/IHC of SLN increased the detection of lymph node metastasis.
authors.affiliation: Florida Hospital Gynecologic Oncology, Florida Hospital Cancer Institute and the Global Robotics Institute, Orlando, FL 32804, USA. robhollowaymd@gmail.com
authors.forename: Robert W
authors.initials: RW
authors.lastname: Holloway
authors.forename: Ricardo A Molero
authors.initials: RA
authors.lastname: Bravo
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Rakowski
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: James
authors.forename: Corinne N
authors.initials: CN
authors.lastname: Jeppson
authors.forename: Susan B
authors.initials: SB
authors.lastname: Ingersoll
authors.forename: Sarfraz
authors.initials: S
authors.lastname: Ahmad
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003124:Colorimetry / Q000379:methods; D016889:Endometrial Neoplasms / Q000473:pathology* / Q000601:surgery; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008198:Lymph Nodes / Q000473:pathology* / Q000601:surgery; D008856:Microscopy, Fluorescence / Q000379:methods; D008875:Middle Aged; D009367:Neoplasm Staging; D012189:Retrospective Studies; D012371:Robotics / Q000379:methods; D021701:Sentinel Lymph Node Biopsy / Q000379:methods*