Can late lymphoscintigraphy be omitted in the sentinel node procedure in early-stage vulvar cancer?

INTRODUCTION: In the Netherlands, the sentinel lymph node procedure protocol consists of preoperative lymphoscintigraphy combined with intraoperative blue dye for identifying sentinel lymph nodes in early vulvar squamous cell carcinoma. This study aimed at investigating the role of early and late lymphoscintigraphy. MATERIAL AND METHODS: From January 2015 to January 2019, early and late lymphoscintigraphies of 52 women were retrospectively analyzed. Lymphoscintigraphy was performed 30 minutes (early) and 2.5-4 hours (late) after vulvar injection of 99m Tc-labeled nanocolloid. We calculated the concordance correlation coefficient (CCC) between number of sentinel lymph nodes detected on both images using the Lins concordance coefficient and correlated with clinicopathological data. RESULTS: Thirty-four women had a midline tumor and 18 had a lateral tumor. Detection rates with early and late scintigraphy were 88.5% and 98.1%, respectively. Median number of detected nodes was 1.0 (0-7) and 2.0 (0-7). Good statistical correlation between number of sentinel lymph nodes detected on early and late imaging was found (CCC = 0.76) in most patients. In 18 women (35%) a mismatch occurred: a higher number of nodes was detected on late imaging. In 11 of 18 women re-injection was performed because no sentinel lymph nodes were visualized on early images. Late imaging and intraoperative detection showed a good statistical correlation (CCC = 0.61). One woman showed an isolated groin recurrence despite negative sentinel lymph nodes. CONCLUSIONS: This study showed good statistical correlations between early and late scintigraphy in most patients. However, in 35% of women late scintigraphy detected more nodes. In case of poor visualization after the first scintigraphy, re-injection should be considered. Late scintigraphy is probably helpful in confirming successful re-injection and in showing deviating lymph flow in women with failed mapping after the first injection and successful re-injection. Because missing metastatic sentinel lymph nodes often leads to a poor prognosis, we prefer optimal correlations between imaging and intraoperative identification. Hence, late scintigraphy cannot be safely omitted.

Introduction of a dedicated team increases the success rate of external cephalic version: A prospective cohort study.

OBJECTIVE: To investigate the influence of a dedicated team on the success rate of external cephalic version and mode of delivery. STUDY DESIGN: This prospective cohort study included 673 women with a singleton fetus in breech presentation who underwent external cephalic version between January 2013 and December 2017 at Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands. In January 2014, a dedicated team consisting of six gynaecologists and six midwives was introduced at the study clinic. The success rate of external cephalic version and mode of delivery were analysed. In addition, predictors for success were examined by logistic regression analysis. Successful external cephalic version was defined as fetal cephalic presentation immediately following the procedure. RESULTS: Following the introduction of a dedicated team in 2014, the success rate of external cephalic version increased from 39.8% in 2013 to 69.5% in 2017 (p < 0.001), with the greatest increase in nulliparous women (from 23.5% to 58.5%, p = 0.002). Over the 5-year study period, the vaginal delivery rate after external cephalic version increased from 43% in 2013 to 71% in 2017 (p < 0.05). The rate of caesarean section after external cephalic version decreased from 55% to 27% (p < 0.05). Anterior placenta [odds ratio (OR) 0.7, 95% confidence interval (CI) 0.48‒0.97] and complete breech (OR 0.2, 95% CI 0.07‒0.90) were significantly associated with a lower success rate. CONCLUSIONS: This study showed that introduction of a dedicated team led to a significant increase in the success rate of external cephalic version, and a significant decrease in the rate of caesarean section for women presenting with breech in pregnancy.