Future Directions

The data on sentinel node biopsy is accumulating, though this is a rare disease and large studies take time. While it is established as a useful technique, larger studies will help to determine whether, together with ultrasound, it is sufficiently sensitive to exclude tumor in patients with relatively high-risk disease.

MRI is likely to become increasingly used: not only as the best modality for local staging, but also in the characterization of nodes. One small study of lymphotrophic nanoparticles has given impressive results,72 but it is very hard to say whether the technique might be comparable in efficacy to sentinel node biopsy. There is no reason why the two techniques could not be assessed in the same group of patients to answer the question.

PET seems fundamentally compromised in resolution, but the studies in pelvic nodes are encouraging, although it is not yet clear whether early detection of involved pelvic nodes can have a significant impact on prognosis. This question is even more relevant to the detection of distant metastasis: while whole body MRI is emerging as a rival to CT and bone scan,108 and PET could potentially play the same role, the clinical impact may be limited.

A focus on outcome is important: while MRI and sentinel node biopsy are impressive techniques, they are expensive and not available in all centers. They will have to prove their worth, in terms of better survival and reduced morbidity, against simpler techniques such as ultrasound and superficial node dissection.

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