Maximizing Sentinel Lymph Node Detection: Aortic Sentinel Lymph Node Detection in Endometrial Cancer

Study Objective: To determine the importance of a dual (cervical and fundal) indocyanine green (ICG) injection and thorough dissection for the detection of sentinel lymph nodes (SLNs). Design: Description and step-by-step demonstration of the surgical procedure using video (Canadian Task Force classification III). Setting: Hospital Universitario Donostia, San Sebastian, Spain. Patients: A 60-year-old woman with a diagnosis of IAG1 endometrial adenocarcinoma (EC). Interventions: The patient received a cervical and transcervical fundal ICG injection for para-aortic and pelvic SLN detection in the setting of a research protocol, followed by a total hysterectomy and bilateral salpingo-oophorectomy with a frozen section of the uterus as a standard approach [1]. Institutional Review Board approval was obtained for the research protocol of this study. Measurements and Main Results: Dual ICG injection [2] adds the benefit of a cervical injection (that best evaluates the pelvic region [3]) to the fundal injection, with better spread to the lumboaortic pathway [4] so as not to lose the aortic drainage and aortic SLN, whose relevance is still discussed due to its low incidence of metastasis [5]. This search does not add to the associated morbidity but is associated with increased operative time. For pelvic SLN dissection, patience and good training are key; the surgeon must always be on the lookout for uncommon pathways if no SLN is detected in the classical areas. The final histological classification was upgraded to a grade IIIC2 (ie, micrometastasis in the aortic and pelvic-right pararectal space) EC, 3 cm G1 with no lymphovascular invasion. Conclusion: Dual ICG injection allows comprehensive mapping not only of pelvic SLNs, but also of para-aortic SLNs, in EC, maximizing the identification of all possible affected areas. Nonetheless, the relevance of its added benefit requires further evaluation. (C) 2018 AAGL. All rights reserved.