{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T12:50:54Z","timestamp":1765889454637,"version":"build-2065373602"},"reference-count":32,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2025,2,19]],"date-time":"2025-02-19T00:00:00Z","timestamp":1739923200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Cervical cancer primarily disseminates through the lymphatic system, with the metastatic involvement of pelvic and para-aortic lymph nodes significantly impacting prognosis and treatment decisions. Sentinel lymph node (SLN) mapping is critical in guiding surgical management. However, resource-limited settings often lack advanced detection tools like indocyanine green (ICG). This study evaluated the feasibility and effectiveness of SLN biopsy using alternative techniques in a high-risk population with a high prevalence of large tumours. Methods: This prospective, observational study included 42 patients with FIGO 2018 stage IA1\u2013IIA1 cervical cancer treated between November 2019 and April 2024. SLN mapping was performed using methylene blue alone or combined with a technetium-99m radiotracer. Detection rates, sensitivity, and false-negative rates were analysed. Additional endpoints included tracer technique comparisons, SLN localization patterns, and factors influencing detection success. Results: SLNs were identified in 78.6% of cases, with bilateral detection in 57.1%. The combined technique yielded higher detection rates (93.3% overall, 80% bilateral) compared to methylene blue alone (70.4% overall, 40.7% bilateral, p &lt; 0.05). The sensitivity and negative predictive values were 70% and 93.87%, respectively. Larger tumours (&gt;4 cm), deep stromal invasion, and prior conization negatively impacted detection rates. False-negative SLNs were associated with larger tumours and positive lymphovascular space invasion. Conclusions: SLN biopsy is feasible in resource-limited settings, with improved detection rates using combined tracer techniques. However, sensitivity remains suboptimal due to a steep learning curve and challenges in high-risk patients. Until a high detection accuracy is achieved, SLN mapping should complement, rather than replace, pelvic lymphadenectomy in high-risk cases.<\/jats:p>","DOI":"10.3390\/jcm14041381","type":"journal-article","created":{"date-parts":[[2025,2,19]],"date-time":"2025-02-19T05:34:26Z","timestamp":1739943266000},"page":"1381","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Sentinel Lymph Node Detection in Cervical Cancer: Challenges in Resource-Limited Settings with High Prevalence of Large Tumours"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6511-682X","authenticated-orcid":false,"given":"Szil\u00e1rd Le\u00f3","family":"Kiss","sequence":"first","affiliation":[{"name":"First Obstetrics and Gynaecology Clinic, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2535-509X","authenticated-orcid":false,"given":"Mihai","family":"Stanca","sequence":"additional","affiliation":[{"name":"First Obstetrics and Gynaecology Clinic, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dan Mihai","family":"C\u0103p\u00eelna","sequence":"additional","affiliation":[{"name":"Faculty of General Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tudor Emil","family":"C\u0103p\u00eelna","sequence":"additional","affiliation":[{"name":"Faculty of General Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maria","family":"Pop-Suciu","sequence":"additional","affiliation":[{"name":"Department of Nuclear Medicine, Emergency County Hospital Targu Mures, 540136 Targu Mures, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Botond Istvan","family":"Kiss","sequence":"additional","affiliation":[{"name":"Second Surgery Clinic, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"suffix":"Sr.","given":"Szil\u00e1rd Le\u00f3","family":"Kiss","sequence":"additional","affiliation":[{"name":"First Obstetrics and Gynaecology Clinic, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5661-2514","authenticated-orcid":false,"given":"Mihai Emil","family":"C\u0103p\u00eelna","sequence":"additional","affiliation":[{"name":"First Obstetrics and Gynaecology Clinic, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 540142 Targu Mures, Romania"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,2,19]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1600","DOI":"10.1007\/s10147-021-01980-2","article-title":"The role of lymph nodes in cervical cancer: Incidence and identification of lymph node metastases\u2014A literature review","volume":"26","author":"Olthof","year":"2021","journal-title":"Int. J. Clin. Oncol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"567","DOI":"10.1007\/s11596-018-1915-0","article-title":"Progress in the Study of Lymph Node Metastasis in Early-stage Cervical Cancer","volume":"38","author":"Huang","year":"2018","journal-title":"Curr. Med. Sci."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"485","DOI":"10.21037\/atm.2020.03.27","article-title":"Validation of the prognostic value of various lymph node staging systems for cervical squamous cell carcinoma following radical surgery: A single-center analysis of 3732 patients","volume":"8","author":"Guo","year":"2020","journal-title":"Ann. Transl. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1002\/ijgo.12749","article-title":"Revised FIGO staging for carcinoma of the cervix uteri","volume":"145","author":"Bhatla","year":"2019","journal-title":"Int. J. Gynecol. Obstet."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1136\/ijgc-2023-004429","article-title":"ESGO\/ESTRO\/ESP Guidelines for the management of patients with cervical cancer\u2014Update 2023*","volume":"33","author":"Cibula","year":"2023","journal-title":"Int. J. Gynecol. Cancer"},{"key":"ref_6","unstructured":"(2024, December 18). Cancer Today. Available online: https:\/\/gco.iarc.fr\/today\/en\/dataviz\/bars?types=0&mode=population&sort_by=value0&sexes=2&cancers=23&populations=100_112_191_196_203_208_233_246_250_276_300_348_352_372_380_40_428_440_442_470_498_499_528_56_578_616_620_642_643_688_70_703_705_724_752_756_8_804_807_826&key=total."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Stanca, M., C\u0103p\u00eelna, D.M., Tr\u00e2mbi\u021ba\u0219, C., and C\u0103p\u00eelna, M.E. (2022). The Overall Quality of Life and Oncological Outcomes Following Radical Hysterectomy in Cervical Cancer Survivors Results from a Large Long-Term Single-Institution Study. Cancers, 14.","DOI":"10.3390\/cancers14020317"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1016\/j.ejca.2020.06.034","article-title":"Sentinel lymph node mapping and intraoperative assessment in a prospective, international, multicentre, observational trial of patients with cervical cancer: The SENTIX trial","volume":"137","author":"Cibula","year":"2020","journal-title":"Eur. J. Cancer"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"546","DOI":"10.1016\/j.ygyno.2021.06.018","article-title":"Sentinel lymph node mapping in early-stage cervical cancer\u2014A national prospective multicenter study (SENTIREC trial)","volume":"162","author":"Sponholtz","year":"2021","journal-title":"Gynecol. Oncol."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Amengual Vila, J., Torrent Colomer, A., Sampol Bas, C., Quintero Duarte, A., Ruiz Coll, M., Rioja Merlo, J., and Cordoba, O. (2024). Detecting Atypical Sentinel Lymph Nodes in Early-Stage Cervical Cancer Using a Standardized Technique with a Hybrid Tracer. Cancers, 16.","DOI":"10.3390\/cancers16152626"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1016\/j.ygyno.2019.11.026","article-title":"Combining Indocyanine Green and Tc99-nanocolloid does not increase the detection rate of sentinel lymph nodes in early stage cervical cancer compared to Indocyanine Green alone","volume":"156","author":"Ekdahl","year":"2020","journal-title":"Gynecol. Oncol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"954","DOI":"10.1016\/j.jmig.2017.05.011","article-title":"Indocyanine Green versus Radiotracer with or without Blue Dye for Sentinel Lymph Node Mapping in Stage >IB1 Cervical Cancer (>2 cm)","volume":"24","author":"Crivellaro","year":"2017","journal-title":"J. Minim. Invasive Gynecol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"4198","DOI":"10.1245\/s10434-015-4701-2","article-title":"A Comparison of Radiocolloid and Indocyanine Green Fluorescence Imaging, Sentinel Lymph Node Mapping in Patients with Cervical Cancer Undergoing Laparoscopic Surgery","volume":"22","author":"Imboden","year":"2015","journal-title":"Ann. Surg. Oncol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1016\/j.ygyno.2017.02.005","article-title":"Sensitivity and negative predictive value for sentinel lymph node biopsy in women with early-stage cervical cancer","volume":"145","author":"Salvo","year":"2017","journal-title":"Gynecol. Oncol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1016\/j.jmig.2017.10.002","article-title":"Real-Time Fluorescent Sentinel Lymph Node Mapping with Indocyanine Green in Women with Previous Conization Undergoing Laparoscopic Surgery for Early Invasive Cervical Cancer: Comparison with Radiotracer\u2009\u00b1\u2009Blue Dye","volume":"25","author":"Buda","year":"2018","journal-title":"J. Minim. Invasive Gynecol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2959","DOI":"10.1245\/s10434-016-5227-y","article-title":"From Conventional Radiotracer Tc-99m with Blue Dye to Indocyanine Green Fluorescence: A Comparison of Methods Towards Optimization of Sentinel Lymph Node Mapping in Early Stage Cervical Cancer for a Laparoscopic Approach","volume":"23","author":"Buda","year":"2016","journal-title":"Ann. Surg. Oncol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"456","DOI":"10.1016\/j.ygyno.2018.01.001","article-title":"SLN biopsy in cervical cancer patients with tumors larger than 2 cm and 4 cm","volume":"148","author":"Zikan","year":"2018","journal-title":"Gynecol. Oncol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2590","DOI":"10.1002\/cam4.3645","article-title":"Sentinel lymph node biopsy in early stage cervical cancer: A meta-analysis","volume":"10","author":"Zhang","year":"2021","journal-title":"Cancer Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1247","DOI":"10.1007\/s10147-022-02178-w","article-title":"Sentinel node navigation surgery in cervical cancer: A systematic review and metaanalysis","volume":"27","author":"Chiyoda","year":"2022","journal-title":"Int. J. Clin. Oncol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e27035","DOI":"10.1097\/MD.0000000000027035","article-title":"Sentinel lymph node mapping in early-stage cervical cancer: Meta-analysis","volume":"100","author":"Wang","year":"2021","journal-title":"Medicine"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"13","DOI":"10.3802\/jgo.2017.28.e13","article-title":"The detection of sentinel lymph nodes in laparoscopic surgery for uterine cervical cancer using 99m-technetium-tin colloid, indocyanine green, and blue dye","volume":"28","author":"Tanaka","year":"2016","journal-title":"J. Gynecol. Oncol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"2943","DOI":"10.1200\/JCO.2007.13.8933","article-title":"Multicenter Validation Study of the Sentinel Lymph Node Concept in Cervical Cancer: AGO Study Group","volume":"26","author":"Altgassen","year":"2008","journal-title":"J. Clin. Oncol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1016\/S1040-8428(03)00129-X","article-title":"Laparoscopic assessment of the sentinel lymph nodes in early cervical cancer. Technique\u2014Preliminary results and future developments","volume":"48","author":"Dargent","year":"2003","journal-title":"Crit. Rev. Oncol. Hematol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1016\/j.ygyno.2009.06.017","article-title":"Sentinel node (SLN) biopsy in the management of locally advanced cervical cancer","volume":"115","author":"Cibula","year":"2009","journal-title":"Gynecol. Oncol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"559","DOI":"10.1016\/j.ygyno.2015.09.076","article-title":"The sentinel node procedure in early stage cervical cancer, taking the next step; a diagnostic review","volume":"139","author":"Tax","year":"2015","journal-title":"Gynecol. Oncol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1686","DOI":"10.1200\/JCO.2010.32.0432","article-title":"Bilateral negative sentinel nodes accurately predict absence of lymph node metastasis in early cervical cancer: Results of the SENTICOL study","volume":"29","author":"Mathevet","year":"2011","journal-title":"J. Clin. Oncol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"599","DOI":"10.1002\/jso.25853","article-title":"Learning curve for sentinel lymph node mapping in gynecologic malignancies","volume":"121","author":"Kim","year":"2020","journal-title":"J. Surg. Oncol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"298","DOI":"10.1016\/j.ejso.2009.06.009","article-title":"The lymphatic drainage of the uterine cervix in adult fresh cadavers: Anatomy and surgical implications","volume":"36","author":"Ercoli","year":"2010","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"256","DOI":"10.1016\/j.ygyno.2017.02.018","article-title":"A study on uterine lymphatic anatomy for standardization of pelvic sentinel lymph node detection in endometrial cancer","volume":"145","author":"Geppert","year":"2017","journal-title":"Gynecol. Oncol."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Bizzarri, N., Arciuolo, D., Certelli, C., Pedone Anchora, L., Gallotta, V., Teodorico, E., Carbone, M.V., Piermattei, A., Fanfani, F., and Fagotti, A. (2023). Ultrastaging of the Parametrium in Cervical Cancer: A Clinicopathological Study. Cancers, 15.","DOI":"10.3390\/cancers15041099"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1016\/j.ygyno.2021.08.031","article-title":"Resection of the upper paracervical lymphovascular tissue should be an integral part of a pelvic sentinel lymph node algorithm in early stage cervical cancer","volume":"163","author":"Ekdahl","year":"2021","journal-title":"Gynecol. Oncol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"467","DOI":"10.1016\/j.ygyno.2012.08.015","article-title":"\u201cTriple injection\u201d lymphatic mapping technique to determine if parametrial nodes are the true sentinel lymph nodes in women with cervical cancer","volume":"127","author":"Frumovitz","year":"2012","journal-title":"Gynecol. Oncol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/4\/1381\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T16:37:36Z","timestamp":1760027856000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/4\/1381"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,2,19]]},"references-count":32,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2025,2]]}},"alternative-id":["jcm14041381"],"URL":"https:\/\/doi.org\/10.3390\/jcm14041381","relation":{},"ISSN":["2077-0383"],"issn-type":[{"type":"electronic","value":"2077-0383"}],"subject":[],"published":{"date-parts":[[2025,2,19]]}}}