Improving sentinel lymph node detection rates in endometrial cancer: How many cases are needed?

Comparison of laparoscopic vs. robotic sentinel lymph node mapping and biopsy in endometrial cancer

We compare the success of sentinel lymph node (SLN) biopsy between standard laparoscopy and robotic-assisted laparoscopy (RAL) in patients with endometrial cancer. Patients with uterine epithelial tumour types undergoing staging surgery were identified from January 2019 to March 2023. Included patients underwent a total hysterectomy, bilateral salpingo-oophorectomy and attempted bilateral SLN biopsy with indigocyanine green (ICG) dye, utilising either standard laparoscopy or RAL. 298 patients met the inclusion criteria. 211 (70.8%) had standard laparoscopy and 87 (29.2%) underwent RAL. The RAL cohort had significantly higher median body mass index (BMI) compared to standard laparoscopy (37 vs. 28 kg/m2, p < 0.001). The overall rate of successful bilateral SLN biopsy was 66.8% (n = 199), and at least one hemi-pelvis was successfully biopsied in 87.3% (n = 260) of patients. There was no significant difference in bilateral SLN biopsy success between RAL and standard laparoscopy (60.9% vs 69.2%, p = 0.17). RAL was not predictive of bilateral SLN biopsy success in multivariate analysis (OR 1.10, p = 0.76). There was no difference in SLN biopsy location, number of nodes identified, or empty-packet dissections between the surgical approaches. Increasing age (OR 0.96, p = 0.002) and BMI (OR 0.94, p < 0.001) were significantly associated with reduced bilateral SLN biopsy success. Between the learning and experienced periods of the study, the bilateral SLN biopsy success rate improved significantly for RAL (40.6 vs. 72.7%, p = 0.03), which was not found with standard laparoscopy. The decision to perform RAL should consider multiple factors including surgeon experience. Future research should be directed towards prospective, randomised and BMI-matched cohorts.

Global survey on training and practice in sentinel lymph node mapping for endometrial and cervical cancer among early-career gynecologic oncologists

OBJECTIVE

This survey was designed to evaluate exposure to sentinel mapping for cervical and endometrial cancers in addition to the quality and availability of surgical training in sentinel procedures around the world. Furthermore, we aimed to identify obstacles in surgical training in the sentinel procedure to support the adoption of this technique in clinical practice.

METHODS

A 52-item survey was developed and computed using Qualtrics XM and SurveyMonkey software. The target population were members of the European Society of Gynaecological Oncology and the International Gynecological Cancer Society aged ≤40 years. The study invitation was disseminated within both organizations' database. The survey hyperlink was active between September and December 2022. Respondents using the same Internet Protocol address were excluded to avoid duplication of responses. Responses to <50% questions were excluded.

RESULTS

Overall, 238 respondents joined the survey, and 182 (76.5%) provided answers that met the inclusion criteria. Sentinel mapping was implemented for a longer period and used more frequently in endometrial than in cervical carcinoma; 55% of the responders were initially trained in systematic lymph node dissection, and 22% were not yet trained in any lymph node staging. The main challenges in applying sentinel procedure for early-career gynecologic oncologists were no access to hands-on training (n = 22, 12.1%) and no clinical routine in performing systematic pelvic (n = 15, 8.2%) and para-aortic (n = 35, 19.2%) lymph node dissection in case of failed mapping.

CONCLUSIONS

Although sentinel lymph node biopsy is integrated in cervical and endometrial cancer guidelines, a significant number of institutions do not implement this procedure in clinical routine, and 22% of early-career gynecologic oncologists are not trained in any type of surgical lymph node staging. Support for sentinel mapping in national guidelines and guided training opportunities are needed to apply this method globally.

The Assessment of Sentinel Lymph Node Mapping Methods in Endometrial Cancer

Background/Objectives: Sentinel lymph node biopsy (SLNB) is a minimally invasive technique used to assess lymphatic involvement in endometrial cancer (EC), offering reduced surgical morbidity compared to routine lymphadenectomy. Despite its widespread use, the optimal combination of tracers for SLN detection remains a subject of debate. Methods: This retrospective cohort study included 119 patients with early-stage EC treated at the Maria Skłodowska-Curie National Research Institute of Oncology between 2016 and 2021. SLNB was performed using technetium-99m (Tc99m), indocyanine green (ICG), Patent Blue, or combinations of these tracers. Detection rates for unilateral and bilateral SLNs and the accuracy of metastasis identification were analyzed. Results: The overall SLN detection rate was 97.5%. Individual tracer detection rates were 100% for ICG, 100% for Patent Blue, and 96% for Tc99m. Combined tracers achieved detection rates of 96.9% (Tc99m and ICG) and 97.3% (Tc99m and Patent Blue). Bilateral detection was highest with Tc99m and ICG (90.6%) and Patent Blue alone (91%). Metastases were identified in 12% of cases, with combined methods improving metastatic detection. Tc99m yielded no "empty nodes", compared to 1.7% with Patent Blue and 0.8% with ICG. Conclusions: While combining Tc99m with dyes did not significantly improve overall SLN detection rates, it enhanced metastatic identification and reduced false-negative results. These findings suggest that combined tracer methods optimize SLNB accuracy in endometrial cancer. Prospective studies are needed to confirm these results.

Lymphadenectomy in the treatment of sarcomas - indications and technique

Sarcomas are a rare type of malignancy with limited treatment options so far. This analysis aimed to describe the impact of lymphadenectomy on treating sarcoma patients. Sarcomas characterized by lymphatic spread are rare. For this reason, lymphadenectomy is not a procedure that is performed frequently. However, there are histological subtypes that spread more frequently through lymphatic vessels, such as rhabdomyosarcoma (RMS), epithelioid sarcoma (ES), clear cell sarcoma (CCS), and angiosarcoma. On the other hand, synovial sarcoma (SS) is not characterized by an increased tendency to lymphogenous metastases. In our study, we focus on these subtypes of sarcomas. The relationship between lymphadenectomy results and the subsequent prognosis of the patients was investigated. Metastases in the lymph nodes are diagnosed synchronously with distant metastases or when the primary tumor is detected. At the same time, despite lymphadenectomy, sarcoma patients developed further distant metastases. Currently, lymphadenectomy is not a routinely recommended method of treatment for patients with sarcomas. Most often, its potential use is indicated in the case of epithelioid sarcoma, clear cell sarcoma, and rhabdomyosarcoma after a previous positive sentinel lymph node biopsy (SLNB) result. Multicenter randomized prospective clinical trials on the role of lymphadenectomy in the treatment of sarcomas are needed.

Analysis of Predictive Factors Associated with Unsuccessful Sentinel Lymph Node Mapping in Endometrial Carcinoma

BACKGROUND

Sentinel lymph node (SLN) biopsy is recommended over systematic lymphadenectomy in early-stage endometrial cancer due to its lower morbidity and comparable detection rate. The objective of this study was to identify clinical factors associated with unsuccessful mapping.

METHODS

Between April 2020 and June 2024, 120 patients over the age of 18 and diagnosed with early-stage endometrial cancer were enrolled in this prospective study at a single institution. Demographic, clinicopathologic, and treatment data were collected and analyzed using descriptive statistics. Univariate and multiple linear regressions were performed to identify predictors of failed mapping.

RESULTS

The mean age of the patient cohort was 62.5 years (range 33 to 83), and the mean body mass index (BMI) was 32 kg/m2 (range 18 to 50). Patients underwent intracervical injections with methylene blue (MB), indocyanine green (ICG), or a combination of both tracers, with 40 patients in each group. A total of 108 patients (90.0%) were diagnosed with endometrioid carcinoma and 12 (10.0%) with non-endometrioid cancers. Additionally, 110 patients (91.7%) were diagnosed in early stages of the disease. The overall SLN detection rate was 73.4%, with bilateral detection at 49.2% and unilateral detection at 24.2%. Univariate analysis showed that older age (p < 0.001), menopause (p = 0.001), the use of MB as the sole tracer (p = 0.006), a shorter tumor-to-serosa distance (p = 0.048), and bulky lymph nodes (p = 0.18) were associated with unsuccessful mapping. Multiple linear regression model analysis identified age (p = 0.007), tracer type (p = 0.013), and enlarged lymph nodes (p = 0.013) as independent predictors of SLN mapping failure.

CONCLUSIONS

Advanced age, tracer type, and intraoperative detection of enlarged lymph nodes were identified as independent risk factors for unsuccessful mapping in patients undergoing laparoscopic SLN mapping.

Role of sentinel lymph node biopsy with indocyanine green and site of injection in endometrial cancer

PURPOSE OF REVIEW

The aim of the present narrative review is to summarize the state of art on sentinel lymph node biopsy (SLNB) in endometrial cancer, with a special focus on indocyanine green (ICG) as adopted tracer.

RECENT FINDINGS

Over the years, the surgical nodal staging in patients with endometrial cancer has been intensively investigated. Traditionally, systematic pelvic and para-aortic lymphadenectomy represented the gold standard surgical treatment to assess nodal involvement of the tumor. Through the last two decades, SLNB has gradually replaced lymphadenectomy as a more targeted procedure. A great heterogeneity of tracers and injection techniques have been proposed to perform SLNB. However, no universally accepted recommendations are still available.

SUMMARY

SLNB has nowadays almost replaced pelvic lymphadenectomy in low-risk endometrial cancers, offering a better safety profile while being related to a comparable nodal involvement sensitivity. Currently, ICG is considered to be the most used tracer among others. Different injection sites have been proposed, with different detection features. While ICG cervical injection is nowadays the suggested technique for SLNB, noncervical injection techniques, such as hysteroscopic and combined procedures, seem to have a better accuracy in para-aortic nodal assessment, which have a role in high-risk endometrial cancers.

Surgery Advances in Gynecologic Tumors: The Evolution and Outcomes of Robotic Surgery for Gynecologic Cancers in a Tertiary Center

The integration of innovation into routine clinical practice is faced with many challenges. In 2007, we received the mandate to evaluate how the introduction of a robotic program in gynecologic oncology affected patient-centered care by studying its impact on clinical outcomes and hospital resource utilization. Here we summarize the history and experience of developing a robotic surgery program for gynecologic cancers over 16 years. Analysis of the data indicates that robotic surgery improved perioperative patient clinical parameters, decreased blood loss, complications, and hospital stay, maintained the oncologic outcome, and is cost-effective, resulting in it becoming the dominant surgical approach in gynecologic oncology in a tertiary cancer care institution.

Sentinel lymph node biopsy in endometrial cancer: When, how and in which patients

The role of nodal dissection in patients with endometrial cancer has been intensively studied in several studies. Historically, systematic pelvic and para-aortic lymphadenectomy represented the gold standard surgical treatment to assess potential nodal involvement and consequently define the appropriate stage of the tumor. Over the last years, sentinel node biopsy (SLNB) has been introduced as a more targeted alternative to lymph node dissection for lymph node staging and it has become popular among gynecologic oncologists. However, no level A evidence is still available, and several features of the SLNB technique have been matter of discussion among clinicians and a universally accepted methodology is still not currently available. This narrative review aims to summarize the body of knowledge on SLNB to offer the reader a complete picture about the evolution of this technique over the last decades.

Clinical outcomes of sentinel node navigation surgery in patients with preoperatively estimated stage IA endometrial cancer and evaluation of validity for continuing sentinel node navigation surgery based on dispersion of recurrence probability

BACKGROUND

To evaluate the feasibility of the use and continuation of sentinel lymph node navigation surgery (SNNS) as an alternative to pelvic lymph node dissection (PLND) for patients with preoperatively estimated stage IA endometrial cancer.

METHODS

This retrospective study selected the electronic medical records of all patients who had received CT scans and MRI imaging before surgery from April 1, 2009 to March 31, 2021. Sentinel lymph nodes (SLNs) were detected by administrating 99mTc-phytate and/or indocyanine green into the cervix, and the clinical outcomes of the patients who underwent SNNS or PLND were evaluated. Furthermore, in case of nodal recurrence, a new procedure to determine whether the facility should continue with SNNS or not was developed that compares the maximum likelihood hypothesis and an alternative one based on recurrence rates.

RESULTS

Among 137 patients, SLN biopsies with ultrastaging were performed on 91 patients. The SLN detection rate was 95.6%. Over a 59-month median observation period, no statistically significant differences were shown in overall survival, disease-specific survival and disease-free survival between the SNNS and PLND groups when introducing the propensity score method (p-values: 0.06, 0.153, and 0.625, respectively). Our procedure demonstrated that, in our department without recurrence up to the 65th attempt, it was possible to continue SNNS if a recurrence occurs at the 66th attempt.

CONCLUSION

This study suggests the validity of SNNS as an alternative to PLND. Even in the absence of evidence from randomized controlled trials, we can confirm the validity of continuing SNNS using our procedure.

Recent management of endometrial cancer: a narrative review of the literature

Endometrial cancer is a common female gynecological neoplasia and its incidence rate has increased in the past years. Due to its predominant symptoms, most women will present uterine bleeding. It is usually diagnosed at an early stage and surgery has an important role in the treatment plan. The prognosis and quality of life of these patients can be quite favorable, if proper treatment is offered by surgeons. Traditionally, more invasive approaches and procedures were offered to these patients, but recent data suggest that more conservative and minimal invasive choices can be adopted in the treatment algorithm. Minimal invasive surgery, such as laparoscopy and robotic surgery, should be considered as an acceptable alternative, compared to laparotomy with less comorbidities and similar oncological and survival outcomes. Furthermore, sentinel lymph node biopsy has emerged in the surgical staging of endometrial cancer, in order to replace comprehensive lymphadenectomy. It is associated with less intra- and postoperative complications, while preliminary data show no difference in survival rates. However, sentinel lymph node biopsy should be offered within a strict algorithm, to avoid residual metastatic disease. The aim of this review is to analyze all the available data for the application of minimal invasive surgery in early endometrial cancer and especially the role of sentinel lymph node biopsy.

Predictors of Bilateral SLN Radiocolloid Detection in Endometrial Carcinoma

Introduction  Sentinel lymph node (SLN) mapping is an alternative method to conventional lymphadenectomy for nodal status assessment in patients with stage I/II endometrial carcinoma (EC). This study aimed to analyze the potential predictors of unsuccessful bilateral detection of SLN after the application of radiocolloid in EC. Materials and Methods  A prospective, observational, cross-sectional study was performed on 41 patients with EC in preoperative stage I, who underwent SLN mapping after cervical application of 4mCi 99m Tc-SENTI-SCINT. The demographic, clinical, and tumor-related data were obtained from the patient's medical records. Univariate analysis was used to analyze the potential factors associated with an unsuccessful bilateral SLN biopsy. Results  The bilateral SLN detection rate of planar lymphoscintigraphy, single photon emission computed tomography/computed tomography, and gamma probe was 29.26, 41.46, and 26.82%, correspondingly. None of the 16 analyzed risk factors showed statistical significance for nonconclusive bilateral SLN biopsy. Conclusion  Larger scale studies are needed to determine the exact risk factors for unsuccessful bilateral mapping of the lymphatic drainage after cervical application of the radiotracers. This will eventually lead to improvement in bilateral SLN detection in EC patients, so unilateral lymphadenectomy could be avoided.

New techniques versus standard mapping for sentinel lymph node biopsy in breast cancer: a systematic review and meta-analysis

New tracers for sentinel lymph node biopsy (SLNB), as indocyanine green (ICG), superparamagnetic iron oxide (SPIO) and micro bubbles, have been recently introduced in clinical practice showing promising but variable results. We reviewed the available evidence comparing these new techniques with the standard tracers to evaluate their safety. To identify all available studies, a systematic search was performed in all electronic databases. Data regarding sample size, mean number of SLN harvested for patient, number of metastatic SLN and SLN identification rate of all studies were extracted. No significant differences were found in terms of SLNs identification rates between SPIO, RI and BD but with a higher identification rate with the use of ICG. No significant differences were also found for the number of metastatic lymph nodes identified between SPIO, RI and BD and the mean number of SLNs identified between SPIO and ICG versus conventional tracers. A statistically significant differences in favor of ICG was reported for the comparison between ICG and conventional tracers for the number of metastatic lymph nodes identified. Our meta-analysis demonstrates that the use of both ICG and SPIO for the pre-operative mapping of sentinel lymph nodes in breast cancer treatment is adequately effective.

Laparoscopic sentinel lymph node mapping with indocyanine green in endometrial cancer: surgeon's learning curve (cumulative sum analysis)

OBJECTIVES

To evaluate surgeons' learning curves for laparoscopic sentinel lymph node biopsy in endometrial cancer.

METHODS

A prospective observational study was performed at the Oncogynecology Center, Lithuanian University of Health Sciences Hospital, from March 2018 to October 2022. Participating surgeons had no previous experience of laparoscopic sentinel lymph node biopsy with indocyanine green tracer. Cumulative sum analysis was used to create learning curves for the performance of eight surgeons, based on a specific result over a time period. Two different cumulative sum plots were made for each surgeon: successful bilateral sentinel lymph node mapping and removal of sentinel lymph node specimens containing actual lymphatic tissue.

RESULTS

190 patients were included. The overall rate of sentinel lymph node mapping was 89.5%: successful bilateral mapping was achieved in 134 (70.5%) patients, while in 36 (19%) patients sentinel lymph nodes were mapped unilaterally. The bilateral detection rate significantly improved in later study periods (from 59.3% in the first year to 85.0% in the last year; p=0.03). Analysis of the performance of the surgeons for bilateral sentinel lymph node mapping showed that the cumulative sum plot crossed the H0 limit line after 13 consecutive successful bilateral sentinel lymph node biopsies, indicating an acceptable level of competence to achieve the bilateral detection rate of at least 75%. This was accomplished by only one surgeon after 30 surgeries. Analysis of the performance of the surgeons for identification and removal of specimens containing histologically confirmed lymphatic tissue showed that the cumulative sum plots crossed the H0 limit line after six consecutive successful sentinel lymph node removals. This was accomplished by most of the surgeons (5 of 8).

CONCLUSION

At least 30 procedures of indocyanine green traced laparoscopic sentinel lymph node biopsy were needed to reach an acceptable level of competence for a bilateral sentinel lymph node detection rate of at least 75%.

TRIAL REGISTRATION NUMBER

ACTRN12619000979156.

Application of sentinel lymph node mapping in endometrial cancer: A survey among Chinese gynecological oncologists

AIM

To gain a better understanding of the use of sentinel lymph node mapping by Chinese oncologists for endometrial cancer staging and analyze factors influencing its application.

METHODS

Questionnaires were collected online before and by phone after the symposium to evaluate the general characteristics of oncologists who participated in the endometrial cancer seminar and factors associated with the application of sentinel lymph node mapping in endometrial cancer patients.

RESULTS

Gynecologic oncologists from 142 medical centers participated in the survey. 35.4% of doctors employed sentinel lymph node mapping for endometrial cancer staging, 57.3% chose indocyanine green as the tracer. Multivariate analysis revealed that cancer research center (odds ratio = 4.229, 95% CI 1.747-10.237), physician familiarity with sentinel lymph node mapping (odds ratio = 126.188, 95% confidence interval 43.220-368.425) and the use of ultrastaging (odds ratio = 2.657, 95% confidence interval 1.085-6.506) were related to the doctors' selection of sentinel lymph node mapping. There was a significant difference in the surgical procedure for early endometrial cancer, the number of removed sentinel lymph node, and the reason for not adopting sentinel lymph node mapping before and after the symposium.

CONCLUSIONS

The theoretical knowledge of sentinel lymph node mapping, the use of ultrastaging, and cancer research center are related to a higher acceptance of sentinel lymph node mapping. Distance learning is conducive to the promotion of this technology.

Lymphatic Mapping and Sentinel Node Biopsy in High-Grade Uterine Cancers

PURPOSE OF REVIEW

Sentinel lymph node (SLN) mapping has been adopted as an acceptable method of lymph node evaluation in the surgical staging for low-grade endometrial cancer. In this review, we analyze the literature on the utility of SLN mapping in high-grade endometrial cancer.

RECENT FINDINGS

SLN mapping in high-grade endometrial cancer demonstrates similar high detection rates and diagnostic accuracy as seen in low-grade endometrial cancers. However, obtaining sufficient operator experience (at least 30 cases) and following SLN mapping algorithm continues to be essential to preserving diagnostic accuracy. Although limited in retrospective study design and short-term follow-up, current studies have not demonstrated inferior survival outcomes of SLN mapping compared to traditional lymphadenectomy. SLN mapping is an acceptable and accurate method of lymph node evaluation in high-grade endometrial cancer. Future prospective studies are needed to evaluate long-term oncologic outcomes between SLN mapping and systematic lymphadenectomy in this patient population.

Collaborative centralization of gynaecological cancer care

PURPOSE OF REVIEW

To discuss the benefits of centralization of gynaecological cancer care on patients and the healthcare system and how to overcome its barriers.

RECENT FINDINGS

Evidence demonstrates that adherence to clinical practice management guidelines is more likely; the risk of adverse events is lower; survival is improved; in young women fertility preservation is higher; and cost effectiveness is higher; in systems that employ centralized care for women with gynaecological cancer. Barriers to the uptake of centralized models include knowledge, attitude as well as deficient systems and processes, including a lack of governance and leadership. Collaborative centralization refers to a model that sees both elements (centralization and treatment closer to home) utilized at the patient level that addresses some of the barriers of centralized gynaecological cancer care.

SUMMARY

Evidence supports centralized gynaecological cancer care, as it results in reduced risks of adverse events, improved survival and higher fertility rates at lower cost to funders. Collaborative centralization is a process that considers both the value of centralization and collaboration amongst healthcare professionals at primary, secondary and tertiary levels of healthcare to benefit patient outcomes.

Feasibility of Sentinel Lymph Node Sampling in Early-Stage Carcinoma Endometrium: Single-Institution Experience

Introduction

Accurate surgical staging is an essential component in the management of carcinoma endometrium to assess the stage of disease and to tailor adjuvant treatment. Sentinel node technique was introduced as an alternative for extensive lymphadenectomy in early stages to avoid complications associated with lymphadenectomy.

Aims and Objectives

To assess the detection rate and diagnostic accuracy of SLN mapping in patients with early-stage carcinoma endometrium.

Materials and Methods

Prospective validation study involving 30 patients diagnosed to have early-stage carcinoma endometrium. Sentinel nodes were detected by combined methods of radio colloid dye and isosulphan blue dye injection.

Results

Sentinel lymph node was detected in 19 patients (63.4%). 11 patients had no sentinel nodes. Total number of sentinel nodes isolated was 68 with a mean of 2.26 per patient (range 0-4). Ten (33.33%) patients had single sentinel node location, while 9 (30%) had more than 1 sentinel lymph nodes. Twelve patients had bilateral sentinel nodes, and the most frequent location of sentinel node was obturator, 19 (63.3%) especially on right hemi-pelvis. One patient had a hot para-aortic node, while none had blue para-aortic sentinel node. Average number of lymph nodes obtained by lymphadenectomy was 13 per patient (range 7-22). All patients with sentinel node had negative frozen report as well as in histopathology. Two patients in whom no sentinel nodes were detected by either techniques had metastatic nodes in histopathology report.

Conclusion

Detection rate was maximum with radiocolloid dye, and it is better to utilize the technique for less graded tumours and endometrioid variants.

Should Endometrial Cancer Treatment Be Centralized?

Endometrial cancer (EC) is the most common malignancy of the female genital tract in Western and emerging countries. In 2012, new cancer cases numbered 319,605, and 76,160 cancer deaths were diagnosed worldwide. ECs are usually diagnosed after menopause; 70% of ECs are diagnosed at an early stage with a favorable prognosis and a 5-year overall survival rate of 77%. On the contrary, women with advanced or recurrent disease have extremely poor outcomes because they show a low response rate to conventional chemotherapy. EC is generally considered easy to treat, although it presents a 5-year mortality of 25%. Though the guidelines (GLs) recommend treatment in specialized centers by physicians specializing in gynecologic oncology, most women are managed by general gynecologists, resulting in differences and discrepancies in clinical management. In this paper we reviewed the literature with the aim of highlighting where the treatment of EC patients requires gynecologic oncologists, as suggested by the GLs. Moreover, we sought to identify the causes of the lack of GL adherence, suggesting useful changes to ensure adequate treatment for all EC patients.

Predictors for the Recurrence of Clinically Uterine-Confined Endometrial Cancer and the Role of Cytokeratin Immunohistochemistry Stain in the Era of Sentinel Lymph Node Mapping

Simple Summary

Sentinel lymph node (SLN) mapping in women with endometrial cancer is gradually gaining popularity worldwide. The objectives of this retrospective study were to elucidate the predictors for cancer recurrence in the era of SLN mapping, and to compare the clinical outcomes between SLN mapping and traditional lymphadenectomy, as well as to investigate the role of cytokeratin immunohistochemistry stain in detecting lymph node metastases. Para-aortic lymph node metastasis was found to be the sole predictor for cancer recurrence. Cytokeratin immunohistochemistry stain detects more lymph node metastases. In addition, both SLN mapping and traditional lymphadenectomy have similar probabilities of cancer recurrence.

Abstract

Background: The primary objective of this study was to elucidate the predictors for cancer recurrence in women with clinically uterine-confined endometrial cancer in the era of sentinel lymph node (SLN) mapping. Methods: All consecutive women with clinically determined uterine-confined endometrial cancer who had lymph node assessment by either SLN mapping or traditional pelvic lymphadenectomy were reviewed. Results: Women in the SLN mapping group had lower total dissected pelvic nodes, lower incidence of para-aortic lymph node dissection, less intraoperative blood loss and lower complication rates, but a longer operation time compared to the traditional lymphadenectomy group. Para-aortic lymph node metastasis (hazard ratio = 7.60, p = 0.03) was the sole independent predictor for recurrence-free survival. In addition, the utilization of cytokeratin immunohistochemistry stain detected more lymph node metastases (adjusted odds ratio = 3.04, p = 0.03). Recurrence-free survival did not differ between SLN mapping and traditional lymphadenectomy groups (p = 0.24). Conclusions: Para-aortic lymph node metastasis is an important predictor of cancer recurrence. Women with negative hematoxylin and eosin stain should undergo cytokeratin immunohistochemistry stain to increase the detection rate of positive lymph node metastasis. Besides, the probabilities of recurrence seem to be similar between SLN mapping and traditional lymphadenectomy groups in women with clinically uterine-confined endometrial cancer.

Sentinel Lymph Node Mapping in High-Grade Endometrial Cancer

Sentinel lymph node (SLN) mapping is becoming an acceptable alternative to full lymphadenectomy for evaluating lymphatic spread in clinical stage I endometrial cancer (EC). While the assessment of pelvic and para-aortic lymph nodes is part of the surgical staging of EC, there is a long-standing debate over the therapeutic value of full lymphadenectomy in this setting. Although lymphadenectomy offers critical information on lymphatic spread and prognosis, most patients will not derive oncologic benefit from this procedure as the majority of patients do not have lymph node involvement. SLN mapping offers prognostic information while simultaneously avoiding the morbidity associated with an extensive and often unnecessary lymphadenectomy. A key factor in the decision making when planning for EC surgery is the histologic subtype. Since the risk of lymphatic spread is less than 5% in low-grade EC, these patients might not benefit from lymph node assessment. Nonetheless, in high-grade EC, the risk for lymph node metastases is much higher (20–30%); therefore, it is crucial to determine the spread of disease both for determining prognosis and for tailoring the appropriate adjuvant treatment. Studies on the accuracy of SLN mapping in high-grade EC have shown a detection rate of over 90%. The available evidence supports adopting the SLN approach as an accurate method for surgical staging. However, there is a paucity of prospective data on the long-term oncologic outcome for patients undergoing SLN mapping in high-grade EC, and more trials are warranted to answer this question.

Diagnostic accuracy of sentinel node biopsy in non-endometrioid, high-grade and/or deep myoinvasive endometrial cancer: A Turkish gynecologic oncology group study (TRSGO-SLN-006)

INTRODUCTION

This study aimed to evaluate the diagnostic accuracy of the sentinel lymph node (SLN) mapping algorithm in high-risk endometrial cancer patients.

METHODS

Two hundred forty-four patients with non-endometrioid histology, grade 3 endometrioid tumors and/or tumors with deep myometrial invasion were enrolled in this retrospective, multicentric study. After removal of SLNs, all patients underwent pelvic ± paraaortic lymphadenectomy. Operations were performed via laparotomy, laparoscopy or robotic surgery. Indocyanine green (ICG) and methylene blue (MB) were used as tracers. SLN detection rate, sensitivity, negative predictive value (NPV) and false-negative rate (FNR) were calculated.

RESULTS

Surgeries were performed via laparotomy in 132 (54.1%) patients and 152 (62.3%) underwent both bilateral pelvic and paraaortic lymphadenectomy. At least 1 SLN was detected in 222 (91%) patients. Fifty-five (22.5%) patients had lymphatic metastasis and 45 patients had at least 1 metastatic SLN. Lymphatic metastases were detected by side-specific lymphadenectomy in 8 patients and 2 patients had isolated paraaortic metastasis. Overall sensitivity, NPV and FNR of SLN biopsy were 81.8%, 95% and 18.2%, respectively. By applying SLN algorithm steps, sensitivity and NPV improved to 96.4% and 98.9%, respectively. For grade 3 tumors, sensitivity, NPV and FNR of the SLN algorithm were 97.1%, 98.9% and 2.9%.

CONCLUSION

SLN algorithm had high diagnostic accuracy in high-risk endometrial cancer. All pelvic metastases were detected by the SLN algorithm and the isolated paraaortic metastasis rate was ignorable. But long-term survival studies are necessary before this approach becomes standard of care.

Endometrial cancer from early to advanced-stage disease: an update for radiologists

The purpose of this article is to review the current molecular classification of endometrial cancer, the imaging findings in early and advanced disease, and the current management strategies, focusing on the new systemic therapies for advanced EC. In recent years, the management of endometrial cancer has significantly changed. The molecular characterization of endometrial cancer has shed new light into the biologic behavior of this disease, the International Federation of Gynecology and Obstetrics staging system was recently revised, and imaging was formally incorporated in the management of endometrial cancer. Recent genomic analysis of endometrial cancer led to the approval of new molecular-targeted therapies and immune checkpoint inhibitors. Imaging allows assessment of myometrial invasion, cervical stromal extension, lymph node involvement and distant metastases, and has a crucial role for treatment planning. Treatment strategies, which include surgery, radiation and systemic therapies are based on accurate staging and risk stratification.

Advances in management of nonendometrioid endometrial carcinoma, with an emphasis on the sentinel lymph node technique

PURPOSE OF REVIEW

During the last few years there have been important advances in our understanding of endometrial cancer biology, staging, and therapy. In this article, we discuss updates and controversies in the treatment of nonendometrioid endometrial carcinoma (non-EEC), with an emphasis on the role of sentinel lymph node (SLN) biopsy.

RECENT FINDINGS

Lymph node involvement is an important factor in determining prognosis and guiding adjuvant therapy in endometrial carcinoma. SLN biopsy has emerged as a less morbid alternative to lymphadenectomy in surgical staging, and it has generally gained acceptance in the setting of low-grade endometrial carcinoma; however, its role in the setting of high-grade disease remains a topic of debate. Several prospective studies have demonstrated the accuracy of SLN biopsy in detecting nodal metastasis in high-grade endometrial carcinoma. Retrospective series have compared oncologic outcomes of patients with high-grade disease, surgically staged by SLN biopsy, to those staged with lymphadenectomy, and have reported similar survival outcomes. Prospective data on survival is lacking.

SUMMARY

Currently, there is sufficient data to support the diagnostic accuracy of SLN biopsy in the surgical staging of non-EEC. The retrospective evidence demonstrates similar survival for SLN biopsy versus lymphadenectomy.

Sentinel Lymph Node Mapping in Endometrial Cancer: A Comprehensive Review

Endometrial cancer (EC) is known as a common gynecological malignancy. The incidence rate is on the increase annually. Lymph node status plays a crucial role in evaluating the prognosis and selecting adjuvant therapy. Currently, the patients with high-risk (not comply with any of the following: (1) well-differentiated or moderately differentiated, pathological grade G1 or G2; (2) myometrial invasion< 1/2; (3) tumor diameter < 2 cm are commonly recommended for a systematic lymphadenectomy (LAD). However, conventional LAD shows high complication incidence and uncertain survival benefits. Sentinel lymph node (SLN) refers to the first lymph node that is passed by the lymphatic metastasis of the primary malignant tumor through the regional lymphatic drainage pathway and can indicate the involvement of lymph nodes across the drainage area. Mounting evidence has demonstrated a high detection rate (DR), sensitivity, and negative predictive value (NPV) in patients with early-stage lower risk EC using sentinel lymph node mapping (SLNM) with pathologic ultra-staging. Meanwhile, SLNM did not compromise the patient’s progression-free survival (PFS) and overall survival (OS) with low operative complications. However, the application of SLNM in early-stage high-risk EC patients remains controversial. As revealed by the recent studies, SLNM may also be feasible, effective, and safe in high-risk patients. This review aims at making a systematic description of the progress made in the application of SLNM in the treatment of EC and the relevant controversies, including the application of SLNM in high-risk patients.

Sentinel node biopsy for diagnosis of lymph node involvement in endometrial cancer

BACKGROUND

Pelvic lymphadenectomy provides prognostic information for those diagnosed with endometrial (womb) cancer and provides information that may influence decisions regarding adjuvant treatment. However, studies have not shown a therapeutic benefit, and lymphadenectomy causes significant morbidity. The technique of sentinel lymph node biopsy (SLNB), allows the first draining node from a cancer to be identified and examined histologically for involvement with cancer cells. SLNB is commonly used in other cancers, including breast and vulval cancer. Different tracers, including colloid labelled with radioactive technetium-99, blue dyes, e.g. patent or methylene blue, and near infra-red fluorescent dyes, e.g. indocyanine green (ICG), have been used singly or in combination for detection of sentinel lymph nodes (SLN).

OBJECTIVES

To assess the diagnostic accuracy of sentinel lymph node biopsy (SLNB) in the identification of pelvic lymph node involvement in women with endometrial cancer, presumed to be at an early stage prior to surgery, including consideration of the detection rate.

SEARCH METHODS

We searched MEDLINE (1946 to July 2019), Embase (1974 to July 2019) and the relevant Cochrane trial registers.

SELECTION CRITERIA

We included studies that evaluated the diagnostic accuracy of tracers for SLN assessment (involving the identification of a SLN plus histological examination) against a reference standard of histological examination of removed pelvic +/- para-aortic lymph nodes following systematic pelvic +/- para-aortic lymphadenectomy (PLND/PPALND) in women with endometrial cancer, where there were sufficient data for the construction of two-by-two tables.

DATA COLLECTION AND ANALYSIS

Two review authors (a combination of HN, JM, NW, RG, and WH) independently screened titles and abstracts for relevance, classified studies for inclusion/exclusion and extracted data. We assessed the methodological quality of studies using the QUADAS-2 tool. We calculated the detection rate as the arithmetic mean of the total number of SLNs detected out of the total number of women included in the included studies with the woman as the unit of analysis, used univariate meta-analytical methods to estimate pooled sensitivity estimates, and summarised the results using GRADE.

MAIN RESULTS

The search revealed 6259 unique records after removal of duplicates. After screening 232 studies in full text, we found 73 potentially includable records (for 52 studies), although we were only able to extract 2x2 table data for 33 studies, including 2237 women (46 records) for inclusion in the review, despite writing to trial authors for additional information. We found 11 studies that analysed results for blue dye alone, four studies for technetium-99m alone, 12 studies that used a combination of blue dye and technetium-99m, nine studies that used indocyanine green (ICG) and near infra-red immunofluorescence, and one study that used a combination of ICG and technetium-99m. Overall, the methodological reporting in most of the studies was poor, which resulted in a very large proportion of 'unclear risk of bias' ratings. Overall, the mean SLN detection rate was 86.9% (95% CI 82.9% to 90.8%; 2237 women; 33 studies; moderate-certainty evidence). In studies that reported bilateral detection the mean rate was 65.4% (95% CI 57.8% to 73.0%) . When considered according to which tracer was used, the SLN detection rate ranged from 77.8% (95% CI 70.0% to 85.6%) for blue dye alone (559 women; 11 studies; low-certainty evidence) to 100% for ICG and technetium-99m (32 women; 1 study; very low-certainty evidence). The rates of positive lymph nodes ranged from 5.2% to 34.4% with a mean of 20.1% (95% CI 17.7% to 22.3%). The pooled sensitivity of SLNB was 91.8% (95% CI 86.5% to 95.1%; total 2237 women, of whom 409 had SLN involvement; moderate-certainty evidence). The sensitivity for of SLNB for the different tracers were: blue dye alone 95.2% (95% CI 77.2% to 99.2%; 559 women; 11 studies; low-certainty evidence); Technetium-99m alone 90.5% (95% CI 67.7% to 97.7%; 257 women; 4 studies; low-certainty evidence); technetium-99m and blue dye 91.9% (95% CI 74.4% to 97.8%; 548 women; 12 studies; low-certainty evidence); ICG alone 92.5% (95% CI 81.8% to 97.1%; 953 women; 9 studies; moderate-certainty evidence); ICG and blue dye 90.5% (95% CI 63.2.6% to 98.1%; 215 women; 2 studies; low-certainty evidence); and ICG and technetium-99m 100% (95% CI 63% to 100%; 32 women; 1 study; very low-certainty evidence). Meta-regression analyses found that the sensitivities did not differ between the different tracers used, between studies with a majority of women with FIGO stage 1A versus 1B or above; between studies assessing the pelvic lymph node basin alone versus the pelvic and para-aortic lymph node basin; or between studies that used subserosal alone versus subserosal and cervical injection. It should be noted that a false-positive result cannot occur, as the histological examination of the SLN is unchanged by the results from any additional nodes removed at systematic lymphadenectomy.

AUTHORS' CONCLUSIONS

The diagnostic test accuracy for SLNB using either ICG alone or a combination of a dye (blue or ICG) and technetium-99m is probably good, with high sensitivity, where a SLN could be detected. Detection rates with ICG or a combination of dye (ICG or blue) and technetium-99m may be higher. The value of a SLNB approach in a treatment pathway, over adjuvant treatment decisions based on uterine factors and molecular profiling, requires examination in a high-quality intervention study.

Status of Sentinel Lymph Node Biopsy in Endometrial Cancer

The role of lymphadenectomy in surgical staging remains one of the biggest controversies in the management of endometrial cancer. The concept of sentinel lymph node biopsy in endometrial cancer has been evaluated for a number of years, with promising sensitivity rates and negative predictive values. The possibility of adequate staging while avoiding systematic lymphadenectomy leads to a significant reduction in the rate of peri- and postoperative morbidity. Nevertheless, the status of sentinel lymph node biopsy in endometrial cancer has not yet been fully elucidated and is variously assessed internationally. According to current European guidelines and recommendations, sentinel lymph node biopsy in endometrial cancer should be performed only in the context of clinical studies. In this review article, the developments of the past decade are explored concisely. In addition, current data regarding the technical aspects, accuracy and prognostic relevance of sentinel lymph node biopsy are explained and evaluated critically.

Combined use of ICG and technetium does not improve sentinel lymph node detection in endometrial cancer: Results of the COMBITEC study

OBJECTIVE

There is scarce evidence available about the benefit of combining technetium (^99mTc) and indocyanine green (ICG) for sentinel lymph node (SLN) biopsy in endometrial cancer. The aim of this study was to compare the overall and bilateral pelvic detection rates of SLNs in two retrospective cohorts: ICG exclusive vs. combined ICG+^99mTc.

METHODS

The COMBITEC study (COMBined ICG and Technetium for SLN detection in Endometrial Cancer) consisted of a multicentre retrospective study (February 2015-June 2020) including patients diagnosed with endometrial atypical hyperplasia or early-stage endometrial carcinoma who underwent SLN biopsy by cervical injection of ICG with or without ^99mTc in four different referral centers in Spain.

RESULTS

A total of 180 patients were included, 51% (n = 92) in ICG group and 49% (n = 88) in ICG+^99mTc group. Eighty-seven percent of the patients presented endometrioid histology, and over 99% of the procedures were performed by a minimally invasive approach. Both groups were comparable regarding their basal characteristics, except for a higher body mass index in ICG+^99mTc group and a bigger proportion of robotic-assisted procedures in ICG group. Overall detection rate was 92.8% without significant differences between groups (ICG: 94.6% vs ICG+^99mTc: 90.9%, p = .34). No significant differences were observed neither in bilateral pelvic nor aortic mapping rate. When ^99mTc was used, surgical procedures were significantly longer. In 7.3% of mapped patients, at least one positive SLN was found (ICG: 10.3% vs ICG+^99mTc: 3.9%, p = .109). Empty node packet rates and number of SLNs retrieved per patient were also similar between cohorts.

CONCLUSION

Combining preoperative ^99mTc to intraoperative ICG did not improve SLN detection in endometrial cancer, but resulted in longer procedures.

Indocyanine green versus technetium-99m with blue dye for sentinel lymph node detection in early-stage cervical cancer: A systematic review and meta-analysis

Background

The fluorescent dye indocyanine green (ICG) has emerged as a promising tracer for intraoperative detection of sentinel lymph nodes (SLNs) in early‐stage cervical cancer. Although researchers suggest the SLN detection of ICG is equal to the more conventional combined approach of a radiotracer and blue dye, no consensus has been reached.

Aims

We aimed to assess the differences in overall and bilateral SLN detection rates with ICG versus the combined approach, the radiotracer technetium‐99m (^99mTc) with blue dye.

Methods and Results

We searched MEDLINE, Embase, and the Cochrane Library from inception to January 1, 2020 and included studies reporting on a comparison of SLN detection with ICG versus ^99mTc with blue dye in early‐stage cervical cancer. The overall and bilateral detection rates were pooled with random‐effects meta‐analyses.

From 118 studies retrieved seven studies (one cross‐sectional; six retrospective cohorts) were included, encompassing 589 patients. No significant differences were found in the pooled overall SLN detection rate of ICG versus ^99mTc with blue dye. Meta‐analyses of all studies showed ICG to result in a higher bilateral SLN detection rate than ^99mTc with blue dye; 90.3% (95%CI, 79.8‐100.0%) with ICG versus 73.5% (95%CI, 66.4‐80.6%) with 99mTc with blue dye. This resulted in a significant and clinically relevant risk difference of 16.6% (95%CI, 5.3‐28.0%). With sensitivity analysis, the risk difference of the bilateral detection rate maintained in favor of ICG but was no longer significant (13.2%, 95%CI −0.8‐27.3%).

Conclusion

ICG appears to provide higher bilateral SLN detection rates compared to ^99mTc with blue dye in patients with early‐stage cervical cancer. However, in adherence with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines, the quality of evidence is too low to provide strong recommendations and directly omit the combined approach of ^99mTc with blue dye.

Surgical complications occurring during minimally invasive sentinel lymph node detection in endometrial cancer patients. A systematic review of the literature and metanalysis

INTRODUCTION

Endometrial cancer (EC) is the most common gynecological cancer. Sentinel lymph node (SLN) technique has been adopted worldwide and showed lower morbidity and superimposable survival outcomes than the systematic lymphadenectomy (LND). Although these encouraging results, no meta-analyzes were performed on surgical complications during SLN research among patients undergoing laparoscopic (L) versus robotic surgery (R). The present review aims to report surgical complications during laparoscopic versus robotic SLN technique.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyzes (PRISMA) and the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines have been followed for the present meta-analysis.

RESULTS

Six studies, including 769 participants, were included. L-LND resulted in a significantly higher risk of operative complications relative to L-SLN (RR 2.10 [95% CI 1.37 to 3.21]). The risk of complications was comparable between R-SLN and L-SLN (RR 2.32 [95% CI 0.04-121.02]) and between R-LND and L-LND (RR 2.17 [95% CI 0.04-126.69]). According to the SUCRA analysis, L-SLN and R-SLN had the highest chances of being ranked first among proposed surgical procedures (SUCRA 48.9% and 28.4% respectively).

CONCLUSIONS

Our study reported a lower surgical complications rate in patients undergoing L-SLN technique compared to L-LND. A lower rate of surgical complications was also reported for the R-SLN technique compared to the R-LND. Both laparoscopic and robotic SLN surgical techniques were found to be safe surgical procedures.

Sentinel lymph node mapping in high-risk endometrial cancer: a systematic review and meta-analysis

BACKGROUND

In the staging of endometrial cancer (EC), the role of sentinel lymph node (SLN) mapping for high-risk EC is still unclear.

METHODS

Two authors independently reviewed abstracts and full-text articles for inclusion and assessed study quality. English studies published in PubMed, Embase, and Cochrane Library before 20th SEP, 2019 were retrieved to perform a systematic evaluation and meta-analysis which evaluate the detection rate and diagnostic accuracy of SLN mapping in high-risk EC. Statistical analysis was conducted using stata14.0 software.

RESULTS

A total of 12 studies were included, including 758 high-risk EC patients. The detection rate of SLN mapping was 84.8% (95% CI, 79.9-89.6%). The pooled bilateral detection rate was 67.0% (95% CI, 56.8-77.3%). The pooled para-aortic detection rate was 8.4% (95% CI, 1.8-14.9%). The pooled sensitivity was 87% (95% CI, 79-92%), and the pooled specificity was 98% (95% CI, 96-99%). Pooled negative predictive value (NPV) was 97.7% (95% CI, 96.4-99.1%), AUC =0.99 (95% CI, 0.97-0.099).

CONCLUSIONS

SLN mapping still has a high detection rate and diagnostic accuracy in high-risk EC. SLN mapping is a reliable alternative to systematic lymph node dissection, but its prognostic effect on high-risk EC is yet to be further studied and verified by large sample studies.

Sentinel lymph node biopsy in endometrial cancer: state of the art

Endometrial cancer (EC) is the most common gynecological neoplasm in developed countries. In literature, there are discordant data regarding the therapeutic value of systematic lymphadenectomy whereas the importance of lymph node status for determining prognosis and the need for adjuvant treatment is undoubted. Given the low risk of lymph-node metastases in the apparent early-stage disease and the significant surgical and postoperative risks when performing a complete pelvic lymphadenectomy, the surgical approach in these patients is controversial, ranging from no nodal evaluation to comprehensive pelvic and aortic lymphadenectomy. The recent introduction of sentinel node mapping represents the mid-way between the execution and omission of node dissection in EC patients. Indeed, the sentinel node mapping has rapidly emerged as an alternative to complete lymphadenectomy to reduce morbidity. In the present review, we discuss the role of sentinel node mapping in the surgical management of EC evaluating all aspects of this procedure.

Role of carbon nanoparticle suspension in sentinel lymph node biopsy for early-stage cervical cancer: a prospective study

OBJECTIVE

To evaluate the clinical diagnostic validity of carbon nanoparticle suspension (CNS) in sentinel lymph node biopsy (SLNB) for assessing lymphatic spread of early-stage cervical cancer.

DESIGN

A prospective study.

SETTING AND POPULATION

356 cases.

METHODS

We enrolled 356 stage Ia2-IIa2 cervical cancer patients to undergo SLNB using CNS, followed by systematic pelvic lymphadenectomy. All lymph node specimens were assessed using conventional histopathologic ± pathologic ultrastaging analyses.

MAIN OUTCOME MEASURES

Sentinel lymph node detection rate (DR), clinical diagnostic validity and various related factors were analysed.

RESULTS

CNS identified 1456 SLNs in 325 patients. The overall SLN DR was 91.29%. A significantly higher DR was found for patients with tumours <20 mm (97.75% versus 71.91%; P < 0.001). Two patients had false-negative results. SLNB with CNS had sensitivity of 96.65%, false-negative rate (FNR) of 4.35% and negative predictive value (NPV) of 99.29%. Importantly, sensitivity (100%), NPV (100%) and FNR (0%) were improved when testing the subgroup of patients with tumours <20 mm (267 cases). There were no observed differences in DR based on pathological type or grade, stage, depth of stromal invasion, surgical approach, menopausal status or prior treatment with chemotherapy (P > 0.05).

CONCLUSIONS

Sentinel lymph node biopsy with CNS results in favourable DR, sensitivity and NPV for women with early-stage cervical cancer with small tumour sizes. SLNB with CNS is safe, feasible and relatively effective for guiding precise surgical treatment of early-stage cervical cancer.

TWEETABLE ABSTRACT

Sentinel lymph node biopsy with carbon nanoparticle suspension is safe and feasible for early-stage cervical cancer.

Influence of 99m-Tc-Nanocolloid Activity Concentration on Sentinel Lymph Node Detection in Endometrial Cancer: A Quantitative SPECT/CT Study

This study evaluates quantitative combined single photon emission tomography/computed x-ray tomography (SPECT/CT) to assess the influence of radiotracer concentration on detection of sentinel lymph nodes (SLN) in endometrial cancer (EC). Eighty EC patients underwent pericervical 99m-Tc-nanocolloid injection followed by SPECT/CT. The subgroup of patients with failed SLN detection in SPECT/CT (n = 20) was compared to match-paired patients showing at least two SLNs. Results of intraoperative gamma probe measurements and quantitative SPECT/CT were used for comparison. In patients with detection failure, the percentage of injected dose, absolute activity, and volume of the injection site were significantly lower (30 ± 24% vs. 55 ± 19%; p = 0.01, 43 ± 36 MBq vs. 73 ± 33 MBq; p = 0.04, and 183 ± 164 mL vs. 266 ± 164 mL; p = 0.03) while mean activity concentration in liver, spleen, and bone marrow was significantly higher (p = 0.02). Activity concentration (>33 KBq/mL) and absolute activity (>73 MBq) of injection areas correlated with successful intraoperative SLN detection. In a subgroup of 19 SLNs, a correlation between SPECT/CT-derived uptake and intraoperative count rate was found (R² = 0.8; p < 0.001). SLN detection in EC patients depended on high radiotracer activity at the cervical injection site. Quantitative SPECT/CT could predict successful intraoperative SLN detection and may help to optimize injection technique.

The role of sentinel lymph node mapping in endometrial carcinoma

Endometrial cancer is the most commonly diagnosed gynecological malignancy in developing countries, and the second malignancy after cervical cancer in developing countries. The primary treatment is based on surgical and pathologic staging including extrafascial type A radical hysterectomy bilateral salpingo-oophorectomy and pelvic and latero-aortic lymphadenectomy. Minimally invasive surgery is the most widely used technique. Sentinel node biopsy is part of this concept and has reached the management of endometrial cancer. The aim of this review was to describe the history, the different injection techniques and results of sentinel node biopsy, and analyze the future role of this technique in endometrial carcinoma.

Defining the learning curve for successful staging with sentinel lymph node biopsy for endometrial cancer among surgeons at an academic institution

BACKGROUND

Sentinel lymph node (SLN) biopsy is increasingly used in endometrial cancer staging; however, success of the technique is variable, and the learning curve needs to be better understood. Success is defined as identification of a SLN specimen containing nodal tissue in bilateral hemi-pelvises.

OBJECTIVE

To assess the learning curve of surgeons at an academic institution in performing successful SLN mapping and biopsy during robotic staging for endometrial cancer.

METHODS

After institutional review board approval, patients who underwent staging with robotic SLN mapping using indocyanine green at a single academic program between July 2012 and December 2017 were identified. Demographic, pathologic, and surgical data were retrospectively collected from the medical records. Descriptive and comparative statistics were performed. Surgeon rates of successful bilateral SLN mapping and removal of lymphoid-containing SLN specimens were compared. A logistic model was used to analyze the probability of successful SLN mapping and removal of lymph node-containing tissue with increasing number of procedures performed.

RESULTS

Three hundred and seventeen patients met the eligibility criteria. Most had early-stage, low-grade endometrial cancer. A total of 194 (61%) patients had successful bilateral mapping. Among seven surgeons, a plateau in rates of successful bilateral mapping was achieved after 40 cases. No linear correlation was seen between the number of surgeries performed and the rate of removal of lymph node-containing tissue among surgeons. Each additional 10 procedures performed was associated with a 5% and an 11% increase in the odds of successful SLN mapping and removal of lymph node-containing tissue, respectively.

DISCUSSION

The successful removal of lymph node-containing specimens appears to be a surgeon-specific phenomenon. The plateau of the learning curve for successful bilateral mapping seems to be reached at around 40 cases. These first 40 cases offer a time for auditing of individual rates of SLN mapping and removal to identify surgeons who may benefit from procedure-specific remediation.

Value of indocyanine green pelvic lymph node mapping in the surgical approach of cervical cancer

PURPOSE

Lymph node metastasis is a significant predictive factor for disease recurrence and survival in cervical cancer patients and relevant for therapeutic strategies. We evaluated the clinical value of indocyanine green (ICG) by measuring the sensitivity and negative predictive value of sentinel lymph node mapping compared with the gold standard of complete lymphadenectomy in detecting lymph node metastases for cervical cancer.

METHODS

We utilized the near-infrared imaging agent ICG to detect tumor-infested lymph nodes in the pelvis analogue to a classical sentinel lymph node procedure by analyzing data from 20 patients who had undergone surgery for cervical cancer at our institution. A laparoscopic lymph node mapping procedure by means of ICG, followed by a complete pelvic lymphadenectomy with or without paraaortic lymphadenectomy was done in all patients.

RESULTS

Histological examination identified seven patients with tumor-positive pelvic nodes, whereas mapping with ICG identified only five of these patients. Detection rate of positive nodes by ICG mapping and false negative rate was 71.4% and 28.6%, respectively; bilateral detection rate was 83.3%. One of the two false negative patients additionally suffered from deep infiltrating endometriosis.

CONCLUSIONS

Our results indicate that ICG can identify the relevant pelvic nodes independent of tumor size, provided bilateral detection is achieved and additional, related diseases are excluded.

TRIAL REGISTRATION

This trial is registered within the German Clinical Trial Register (DRKS-ID: DRKS00014692).

Risk factors for failure of bilateral sentinel lymph node mapping in early-stage cervical cancer

BACKGROUND

The objective of this study was to determine clinical, tumoral and surgical factors associated with successful bilateral sentinel lymph node mapping (SBM) in early-stage cervical cancer.

METHODS

We performed an ancillary work on the data of two prospective trials on SLN biopsy for FIGO IA-IIA cervical cancer (SENTICOL I & II). Patients having Sentinel lymph node (SLN) mapping for early-stage cervical cancer were included between 2005 and 2012 from 28 French oncologic centers. SLN was detected by a combined labeling technique (blue and isotopic).

RESULTS

405 patients were included for analysis: SLNs were identified on at least one side of the pelvis in 381 patients (94.1%) and bilaterally in 326 patients (80.5%). The mean age was 45.4 years [22-85 years]. Most patients had IB1 pathologic FIGO 2018 stage (81.3%) and squamous cell carcinoma (71%). Surgeries were mainly performed by minimally invasive approach (368 patients - 90.9%). By multivariate analysis, lower SBM rate was significantly associated with Age ≥70 years (ORa = 0.02, 95%CI = [0.001-0.28], p = 0.004), tumor size larger than 20 mm (ORa = 0.46,95%CI = [0.21-0.99], p = 0.048) and Body-mass index higher than 30 kg/m² (ORa = 0.28, 95%CI = [0.12-0.65], p = 0.003). SBM rate was significantly higher in high skills centers (>5patients/year) (ORa = 8.05, 95%CI = [2.06-31.50], p = 0.003) and in SENTICOL II (2009-2012) compared to SENTICOL I (2005-2007) (ORa = 2.6, 95%CI = [1.23-5.51], p = 0.01).

CONCLUSIONS

In early-stage cervical cancer, bilateral SLN detection rates is lower in patients aged more than 70years, patients with BMI≥30 kg/m² and larger tumor ≥20 mm whereas stronger experience of SLN biopsy technique improves bilateral SLN detection.

[Sentinel lymph node biopsy in early-stage cervical cancer: current state of art]

Lymph node status is the most important prognostic factor of survival in women with early stage cervical cancer. Sentinel lymph node (SLN) biopsy is an accurate method for the assessment of lymph nodal involvement in early-stages cervical cancer and has been increasingly used instead of systematic pelvic lymph node dissection (PLND). Less-radical lymph node dissection decreases the associated morbidity of PLND, especially the risk of lower-leg lymphoedema, which affects severely patient quality of life. SLN biopsy allows nodes ultrastaging and provides supplementary histological information by increasing the detection of tumor low-volume (isolated tumors cells and micrometastases). Moreover, SLN biopsy provides accurate anatomical information on pelvic lymphatic drainage pathway by identifying nodes outside of routine lymphadenectomy areas. Selection of a population at low-risk of nodal metastasis, a minimal training, and simple rules may ensure a low false negative rate. Several studies have shown that SLN mapping in these patients is feasible, with excellent detection rates and sensitivity. Combined detection with technetium-99 and blue dye has been widely used but recently, there has been increasing interest in the use of fluorescent dies such as indocyanine green (ICG) which would improve SLN detection. Although recent international guidelines recommend performing SLN biopsy in addition to PLND, SLN biopsy alone is not the gold-standard yet due to lack of prospective evidence, especially on long-term oncological safety. Some points remain controversial such as the low accuracy of intraoperative SLN status assessment by frozen section and the impact of micrometastasis on prognostic. The prospective randomized clinical trial SENTICOL III will answer to these problematics.

Sentinel Lymph Node Ultra-staging as a Supplement for Endometrial Cancer Intraoperative Frozen Section Deficiencies

For endometrial cancer (EC), most surgeons rely on intraoperative frozen section (IFS) to determine the risk of nodal metastasis and necessity of lymphadenectomy. IFS remains a weak link in this practice due to its susceptibility to diagnostic errors. As a less invasive alternative, sentinel lymph node (SLN) mapping and ultra-staging have gradually gained acceptance for EC. We aimed to establish the SLN success rate, negative predictive value, and whether SLNs provide useful information for cases misdiagnosed on IFS. From 2013 to 2017, 100 patients (63 low-risk and 37 high-risk EC) underwent hysterectomy, bilateral salpingo-oophorectomy, and SLN. Among them, 56 had additional pelvic lymphadenectomy. A total of 337 SLNs were obtained in 86 cases: 55 bilaterally and 31 unilaterally. The remaining 14 cases failed because of patient obesity or leiomyoma. Pathology ultra-staging detected 2 positive SLNs from 2 patients (1 with isolated tumor cells, 1 with micrometastases). One of 773 nonsentinel pelvic nodes was positive on the contralateral hemi-pelvis in a patient who was mapped unilaterally, resulting in negative predictive value of 100%. During IFS, tumor grade and/or depth of myometrial invasion was misdiagnosed in 22 cases (22%). These errors would have resulted in under-staging in 10 high-risk patients or over-staging in 4 low-risk patients. SLNs were mapped in these misestimated patients, with one revealing metastases. SLN provides invaluable information on nodal status while detecting occult metastases in cases misdiagnosed on IFS. Our findings justify the incorporation of SLN in initial surgery for EC as an offset to IFS diagnostic errors, minimizing their negative impact on patient care.

Risk of empty lymph node packets in sentinel lymph node mapping for endometrial cancer using indocyanine green

OBJECTIVE

To determine whether the rate of sentinel lymph node (SLN) dissections that do not yield a lymph node on pathological analysis ('empty packet dissection') changes with increasing surgeon experience in the setting of patients undergoing minimally invasive hysterectomy and SLN mapping using indocyanine green dye for endometrial cancer.

METHODS

All patients undergoing SLN mapping using indocyanine green dye at the time of minimally invasive hysterectomy for endometrial cancer or complex atypical hyperplasia were identified between January 2013 and September 2017 at our institution. All surgeons had prior experience performing SLN mapping for endometrial cancer using other methods. The rate of empty packet dissections and SLN counts were evaluated using a logistic regression model analysis.

RESULTS

In total, 236 patients undergoing SLN mapping for either endometrial cancer (85%) or complex atypical hyperplasia (15%) were identified from a prospectively maintained database. When examining all six surgeons together, the percentage of empty packet dissections decreased with increasing number of procedures performed. Each additional procedure was associated with a 3.6% reduction in the odds of an empty packet SLN dissection. After adjusting for individual surgeons, each additional procedure was associated with a 4.9% reduction in the odds of an empty packet. The expected odds of an empty packet after 10 additional procedures decreased by 40.1% (95% CI 12.4% to 58.6%). The addition of two covariates (age and body mass index) did not contribute significantly to the model (likelihood ratio test: X2=2.75, p=0.25). The rate of empty packets appeared to stabilize after approximately 30 procedures. The number of SLNs removed did not change with increasing surgeon experience.

CONCLUSION

The rate of empty packet SLN dissections using indocyanine green dye decreases with increasing number of procedures. This stabilizes after 30 procedures, suggesting completion of a learning curve.

Sentinel lymph node mapping using indocyanine green in patients with uterine and cervical neoplasms: restrictions of the method

Purpose

To establish the surgical, demographic and histopathological factors associated with inaccurate sentinel lymph nodes (SLNs) identification using indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging in uterine and cervical neoplasms during both open and laparoscopic surgery.

Methods

We reviewed patients with atypical endometrial hyperplasia (AEH), clinical stage I and II cervical cancer or uterine malignancies who underwent primary surgery with SLN mapping between September 2015 and January 2018. An analysis of patients’ demographics, tumor factors and surgical approach was conducted. Bilateral and overall detection rates were calculated and univariate analysis was performed to estimate factors associated with failed SLN mapping.

Results

A total of 32 patients with uterine and cervical neoplasms were included in the study. The overall detection rate of the SLN was 84% and bilateral detection rate was 75%. There were no statistically relevant differences in overall and bilateral SLN detection rates by BMI, surgical approach or age. Regarding endometrial cancer, there were no differences in SLN detection rates when comparing tumor grade, histology nor myometrial invasion. For SLN detection failure, only the presence of metastatic lymph nodes and lack of surgical experience significantly increased the disability to detect SLNs (p = 0.03, p = 0.04, respectively).

Conclusions

SLN mapping technique using NIR fluorescence imaging with ICG appears to be accurate method in most of the patients with cervical or endometrial carcinoma, regardless of demographic characteristics, tumor-related features and surgical approach. Surgeons’ expertise in that field allows obtaining excellent detection rates.

Adipose-only sentinel lymph nodes: a finding during the adaptation of a sentinel lymph node mapping algorithm with indocyanine green in women with endometrial cancer

OBJECTIVE

To identify factors that affect successful adaptation of sentinel lymph node mapping and those that lead to unintended adipose-only sentinel lymph node identification.

METHODS

Surgical and pathological data were prospectively collected on patients with endometrial cancer who underwent sentinel lymph node mapping with indocyanine green with or without pelvic and/or para-aortic lymph node dissection between November 2013 and April 2017. All mapping cases were performed with the robotic system. Adipose-only specimens were defined as a sentinel lymph node without a pathologically identified lymph node after ultrastaging.

RESULTS

A total of 202 patients were included: 83% had endometrioid pathology, 12% serous, 3% carcinosarcoma, and 2% clear cell, with mixed pathology noted in 2%. The bilateral sentinel lymph node detection rate was 66%, and the rate of mapping at least a unilateral sentinel lymph node was 86%. Neither the bilateral nor the unilateral sentinel lymph node mapping rate changed with increased surgeon experience. The rate of adipose-only sentinel lymph node identification was more frequent when comparing the first 10 cases (37%), cases 11 - 30 (28%), and > 30 cases (9%) (P = 0.006). Body mass index > 30 kg/m2, uterine fibroids, The International Federation of Gynecology and Obstetrics (FIGO) grade, and histology were not found to have a statistically significant impact on either sentinel lymph node identification or adipose-only sentinel lymph node identification. Adipose-only sentinel lymph nodes were more likely with increased time from cervical injection to identification of the sentinel lymph node in the right hemipelvis. The median range was 28 min (14-73) for true sentinel lymph node identification vs 33 min (23-74) for adipose-only sentinel lymph node identification (P = 0.02).

CONCLUSION

Patient and surgeon factors did not impact the identification of sentinel lymph nodes over time. Adipose-only sentinel lymph nodes were more frequently identified in the initial cases and represent a potential complication to adapting sentinel lymph node biopsy without lymphadenectomy. The increase in adipose-only sentinel lymph node identification that was associated with time from cervical injection may represent delayed or disrupted uptake of indocyanine green.

The impact of different doses of indocyanine green on the sentinel lymph-node mapping in early stage endometrial cancer

INTRODUCTION

Aim of the study is to evaluate the impact of different doses of indocyanine green (ICG) on the sentinel lymph-node (SLN) mapping in endometrial cancer (EC).

MATERIALS AND METHODS

A retrospective analysis of EC patients undergoing a laparoscopic SLN mapping at two institutions was performed. Two different injection protocols were used (protocol # 1: 5 mg/ml and a volume of 8 ml; protocol # 2: 1.25 mg/ml and a volume of 4 ml). In every case, the injection was intracervical. The laparoscopic equipment adopted was the same among both institutions. Overall and bilateral detection rates (DR) and median number of retrieved SLNs were calculated. At uni- and multivariate analysis factors (including ICG dose) associated with DR and number of detected SLNs were investigated.

RESULTS

Overall, 168 patients were included. The overall and bilateral DR were 96.3 and 84.5%. Median number of removed SLNs was 3 (0-18). In 56% of the patients, a median number of 6 (1-93) non-SLNs (NSLNs) were removed. Seventeen (10.1%) patients had metastatic SLNs. At multivariate analysis, no factors were associated with bilateral DR. ICG dose was the only factor associated with number of removed SLNs at multivariate analysis.

CONCLUSION

A larger dose of ICG is associated with a higher number of retrieved SLNs but not with an increased bilateral DR.