Sentinel Lymph Node Mapping in Colon and Rectal Cancer

Its Impact on Staging, Limitations, and Pitfalls
  • Sukamal Saha
  • Adrian G. Dan
  • Carsten T. Viehl
  • Markus Zuber
  • David Wiese
Part of the Cancer Treatment and Research book series (CTAR, volume 127)


Sentinel lymph node (SLN) mapping has been widely applied in the staging of solid neoplasms including colon and rectal cancer. Since the first reported feasibility study in 1997, there have been numerous publications validating SLN mapping as a highly accurate and powerful upstaging technique for colon and rectal cancer. In addition to refining the technical aspects of this procedure, these studies have investigated the use of other tracers and operative techniques, while determining the indications, limitations, and pitfalls of SLN mapping in patients with colorectal cancers. This chapter reviews the rationale for performing SLN mapping for the accurate staging of colon and rectal cancers, and provides a brief review of the historical background of the development of the procedure. Landmark publications, which have contributed to the current status of the technique, are discussed. We will focus on the technical details of the procedure, and on the pathological evaluation of the specimen and the SLNs. The various tracers and techniques of SLN mapping in colon and rectal cancer will be discussed. We have performed SLN mapping in more than 240 consecutive patients over the past 7 years. The success rates for identifying at least one SLN for colon and rectal cancer were 100% and 90.6%, respectively. The accuracy rates were 95.8% and 100%, respectively. In terms of upstaging, 32.3% of colon cancer patients with nodal metastases and 16.7% of rectal patients with nodal metastases were upstaged by the detection of micrometastases found in the SLNs only. Finally, we will also discuss the current role as well as the future research directions for SLN mapping in colon and rectal cancer.


Rectal Cancer Sentinel Lymph Node Lymphatic Mapping Sentinel Lymph Node Mapping AJCC Stage 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bendavid Y, Latulippe J, Younan R, et al. Phase I study on sentinel lymph node mapping in colon cancer: A preliminary report. J Surg Oncol 2002;79:81–84.PubMedCrossRefGoogle Scholar
  2. 2.
    Bilchik A, Giuliano A, Essner R, et al. Universal application of intraoperative lymphatic mapping and sentinel lymphadenectomy in solid neoplasms. Cancer J 1998;4(6): 351–358.Google Scholar
  3. 3.
    Bilchik A, Saha S, Tsioulias G, et al. Aberrant drainage of missed micrometastases: The value of lymphatic mapping and focused analysis of sentinel lymph nodes in gastrointestinal neoplasms. Ann Surg Oncol 2001;8(9S):82–85.Google Scholar
  4. 4.
    Bilchik A, Nora D, Tollenaar R, et al. Ultrastaging of early colon cancer using lymphatic mapping and molecular analysis. Euro J Cancer 2002;38(7):977–985.CrossRefGoogle Scholar
  5. 5.
    Cabanas RM. An approach for treatment of pe1nile carcinoma. Cancer 1977;39(2):456–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Cohen AM, Kelsen D, Saltz L, et al. Adjuvant therapy for colorectal cancer. Curr Probl Cancer 1998;22:5–65.CrossRefGoogle Scholar
  7. 7.
    Coleman RL, Whitten CW, O’Boyle J, Sidhu B. Unexplained decrease in measured oxygen saturation by pulse oxymetry following injection of lymphazurin 1% (isosulfan blue) during a lymphatic mapping procedure. J Surgi Oncol 1999; 70(2): 126–129.CrossRefGoogle Scholar
  8. 8.
    Crucitti F, Doglietto GB, Bellantone R, et al. Accurate specimen preparation and examination is mandatory to detect lymph nodes and avoid understaging in colorectal cancer. J Surg Oncol 1992; 51:153–158.PubMedCrossRefGoogle Scholar
  9. 9.
    Dan A, Saha S, Wiese D, et al. Comparative analysis of Lymphazurin 1% vs. fluorescein 10% in sentinel lymph node (SLN) mapping for colorectal (CR) tumors. Archi Surg 2004 (in press)Google Scholar
  10. 10.
    Essner R, Bostick P, Glass E, Foshag L, Haigh P, Wang H, Morton D. Standardized probe-directed sentinel node dissection in melanoma. Surgery 2000; 127: 26–31.PubMedCrossRefGoogle Scholar
  11. 11.
    Fitzgerald T, Khalifa M, Zahrani M, et al. Ex vivo sentinel lymph node biopsy in colorectal cancer: A feasibility study. J Surg Oncol 2002;80:27–32.PubMedCrossRefGoogle Scholar
  12. 12.
    Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 1994;220(3):391–401.PubMedCrossRefGoogle Scholar
  13. 13.
    Goldstein NS. Lymph node recoveries from 2427 pT3 colorectal resection specimens spanning 45 years: recommendations for a minimum number of recovered lymph nodes based on predictive probabilities. Am J Surg Pathol 2002;26(2): 179–89.PubMedCrossRefGoogle Scholar
  14. 14.
    Gould EA, Winship T, Philbin PH, Hyland, et al. Observations on a “sentinel node” in cancer of the parotid. Cancer 1960;13:77–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Greenson JK, Isenhart CE, Rice R, et al. Identification of occult micrometastases in pericolic lymph nodes of Dukes’ B colorectal cancer patients using monoclonal antibodies against cytokeratin and CC49; correlation with long-term survival. Cancer 1994;73(3):563–569.PubMedCrossRefGoogle Scholar
  16. 16.
    Haboubi NY, Abdalla SA, Amini S, et al. The novel combination of fat clearance and immunohistochemistry improvise prediction of the outcome of patients with colorectal carcinomas: A preliminary study. Int J Colorectal Dis 1998;13(2):99–102.PubMedCrossRefGoogle Scholar
  17. 17.
    Jemal A, Murray T, Samuels A, et al. Cancer statistic, 2003. CA — A Cancer Journal for Clinicians 2003; 53(1): 5–26, 2003.PubMedCrossRefGoogle Scholar
  18. 18.
    Joosten J, Strobbe L, Wauters C, et al. Intraoperative lymphatic mapping and the sentinel node concept in colorectal carcinoma. Br J Surg 1999;86:482–486.PubMedCrossRefGoogle Scholar
  19. 19.
    Keleman PR, van Herle AJ, Giuliano AE. Sentinel lymphadenectomy in thyroid malignant neoplasms. Arch Surg 1998;133(3):288–292.CrossRefGoogle Scholar
  20. 20.
    Keshtgar MR, Amin A, Taylor I, et al. The sentinel node in anal carcinoma. Eur J Surg Oncol 2001;27(1):113–4.PubMedCrossRefGoogle Scholar
  21. 21.
    Kitagawa Y, Fugii H, Mukai M, et al. The role of the sentinel lymph node in gastrointestinal cancer. Surg Clin North Am 2000;80(6):1799–1809.PubMedCrossRefGoogle Scholar
  22. 22.
    Krag DN, Weaver DL, Alex JC, et al. Surgical resection and radiolocalization of the sentinel node in breast cancer using a gamma probe. Surg Oncol 1993; 2(6):335–39.PubMedCrossRefGoogle Scholar
  23. 23.
    Kuerer HM, Wayne JD, Ross MI. Anaphylaxis during breast cancer lymphatic mapping. Surgery 2001; 129(1): 119–120.PubMedCrossRefGoogle Scholar
  24. 24.
    Larsen VH, Freudendal A, Fogh-Andersen N. The influence of patent blue V on pulse oxymetry and haemoximetry. Acta Anaesthesiol Scand Suppl 1995; 107: 53–55.PubMedCrossRefGoogle Scholar
  25. 25.
    Leong SP, Donegan E, Hefferson W, Dean S, Katz JA. Adverse reactions to isosulfan blue during selective sentinel lymph node dissection in melanoma. Ann Surgl Oncol 2000; 7(5): 361–366.CrossRefGoogle Scholar
  26. 26.
    Little AG, DeHoyos, Kirgan DM, et al. Intraoperative lymphatic mapping for non-small cell lung cancer: The sentinel node technique. J Thorac Cardiovasc Surg 1999;117(2):220–34.PubMedCrossRefGoogle Scholar
  27. 27.
    Longnecker SM, Guzzardo MM, Van Voris LP. Life-threatening anaphylaxis following subcutaneous administration of isosulfan blue 1%. Clin Pharmacol 1985; 4(2): 219–221.Google Scholar
  28. 28.
    Mori M, Mimori K, Inoue H, et al. Detection of cancer micrometastases in lymph nodes by reverse transcriptase polymerase chain reaction. Cancer Res 1995;55(25):3417–20.PubMedGoogle Scholar
  29. 29.
    Morton DL, Wen DR, Wong HH, et al. Technical details of intraoperative lymphatic mapping for early stage melanoma. Archi Surg 1992;127(4):392–399.Google Scholar
  30. 30.
    Paramo J, Summerall J, Poppiti R, et al. Validation of sentinel node mapping in patients with colon cancer. Ann Surg Oncol 2002;9(6):550–554.PubMedCrossRefGoogle Scholar
  31. 31.
    Parkin DM, Pisani P, Ferlay J. Global cancer statistics. CA: A Cancer Journal for Clinicians 1999;49(1)33–64.CrossRefGoogle Scholar
  32. 32.
    Pickreen JW. Significance of occult metastases, a study of breast cancer. Cancer 1961;14:1261–1271.CrossRefGoogle Scholar
  33. 33.
    Rodriguez-Bigas MA, Maamoun S, Weber TK, et al. Clinical significance of colorectal cancer: metastases in lymph nodes <5 mm in size. Ann Surg Oncol 1996:3:124–130.PubMedCrossRefGoogle Scholar
  34. 34.
    Rosenberg R, Hoos A, Mueller J, et al. Prognostic significance of cytokeratin-20 RT-PCR reaction in lymph nodes of node-negative colorectal cancer patients. J Clin Oncol 2002:;0(4):1049–1055.CrossRefGoogle Scholar
  35. 35.
    Saha S, Ganatra BK, Gauthier J, et al. Localization of sentinel lymph node in colon cancer. A feasibility study. Society of Surgical Oncology 50th Annual Cancer Symposium. 1997, Chicago, IL. Abstract P-80, page 54.Google Scholar
  36. 36.
    Saha S, Wiese D, Badin J, et al. Technical details of sentinel lymph node mapping in colorectal cancer and its impact on staging. Ann Surg Oncol 2000;7(2): 120–124.PubMedCrossRefGoogle Scholar
  37. 37.
    Saha S, Bilchik A, Wiese D, et al. Ultrastaging of colorectal cancer by sentinel lymph node mapping technique–A multicenter trial. Ann Surg Oncol 2001;8(9S):94–98.Google Scholar
  38. 38.
    Saha S, Dan A, Berman B, et al. Lymphazurin 1% vs. TSC for lymphatic mapping in colorectal tumors — A comparative analysis. Ann Surg Oncol 2004; 11(1): in press.Google Scholar
  39. 39.
    Scott KWM, Grace RH. Detection of lymph node metastases in colorectal carcinoma before and after fat clearance. Br J Surg 1989; 76:1165–1167.PubMedCrossRefGoogle Scholar
  40. 40.
    Tsioulias GJ, Wood TF, Morton DL, et al. Lymphatic mapping and focused analysis of sentinel lymph nodes upstage gastrointestinal neoplasms. Arch Surg 2000; 135: 926–931.PubMedCrossRefGoogle Scholar
  41. 41.
    Turner RR, Ollila DW, Stern S, Giuliano AE. Optimal histopathologic examination of the sentinel lymph node for breast carcinoma staging. Am J Surg Pathol 1999;23(3):263–267.PubMedCrossRefGoogle Scholar
  42. 42.
    Viehl CT, Hamel CT, Marti WR, et al. Identification of sentinel lymph nodes in colon cancer depends on the amount of dye injected relative to tumour size. World J Surg 2003; 27(12): in print.Google Scholar
  43. 43.
    Wawroschek F, Vogt H, Weckermann D, et al. The sentinel lymph node concept in prostate cancer— first results of gamma probe-guided sentinel lymph node identification. Eur Urol 1999;36(6):595–600.PubMedCrossRefGoogle Scholar
  44. 44.
    Wiese D, Saha S, Badin J. Pathologic evaluation of sentinel lymph nodes in colorectal carcinoma. Arch Pathol Lab Med 2000; 124:1759–1763.PubMedGoogle Scholar
  45. 45.
    Wolmark N, Rockette H, Fisher B, et al. The benefit of leucovorin-modulated fluorouracil as postoperative adjuvant therapy for primary colon cancer: Results from National Surgical Adjuvant Breast and Bowel protocol C-03. J Clin Oncol 1993;11(10):1879–1887.PubMedGoogle Scholar
  46. 46.
    Wong JH, Steineman S, Calderia C, et al. Ex vivo sentinel node mapping in carcinoma of the colon and rectum. Ann Surg 2001;233(4):515–521.PubMedCrossRefGoogle Scholar
  47. 47.
    Wood T, Saha S, Morton D, et al. Validation of lymphatic mapping in colorectal cancer: In vivo, ex vivo, and laparoscopic techniques. Dis Colon Rectum 2001;8(2):150–157.Google Scholar

Copyright information

© Springer Science+Business Media, Inc. 2005

Authors and Affiliations

  • Sukamal Saha
    • 1
  • Adrian G. Dan
    • 1
  • Carsten T. Viehl
    • 2
  • Markus Zuber
    • 3
  • David Wiese
    • 1
  1. 1.Michigan State UniversityFlint
  2. 2.University of BaselSwitzerland
  3. 3.Kantonsspital OltenOltenSwitzerland

Personalised recommendations