Ultrastaging of negative pelvic lymph nodes to decrease the true prevalence of isolated paraaortic dissemination in endometrial cancer

Survival outcomes of sentinel lymph node biopsy alone versus back-up systematic lymph node dissection in high-risk endometrial Cancer: A Turkish Gynecologic Oncology group study (TRSGO-SLN-007)

BACKGROUND AND OBJECTIVES

Investigate whether there is an oncological benefit of performing back up systematic lymphadenectomy in addition to bilateral sentinel node biopsy.

METHODS

This multicentre retrospective study included patients with high-risk endometrial cancer treated at four gynaecological oncology clinics in Turkey between 2014 and 2023. Patients were stratified according to both conventional and ESGO risk criteria, and within each category were divided into two groups respectively "Sentinel Lymph Node Biopsy Group (SLN-only)" and "Back-up Lymphadenectomy Group (Back-up LND)". Disease-free survival (DFS) and overall survival (OS) were compared using univariate and multivariable Cox regression analyses.

RESULTS

56 patients in the SLN-only group and 158 patients in the Back-up LND group comprised of the Conventional High-Risk Group (CONV-HR) in the analysis. There was no significant difference statistically in terms of DFS (Log-Rank P = 0.29) and OS (Log-Rank P = 0.99). The European Society of Gynaecologic Oncology (ESGO) High-Risk Group (ESGO-HR) consisted of 44 patients in the SLN-only group and 133 patients in the Back-up LND group were included. The median follow-up periods were 27 months (IQR = 15-38) and 28 (IQR = 16-38) months, respectively. Recurrence rate was 14.1 % and mortality rate was 9.6 %. There was no significant difference statistically in terms of DFS (Log-Rank P = 0.342) and OS (Log Rank P = 0.488).

CONCLUSION

Sentinel lymph node biopsy is a safe and effective method for lymph node assessment in high-risk and clinical early-stage endometrial cancer. The addition of systematic lymphadenectomy did not provide any oncological benefit in terms of survival outcomes.

Ultrasound in endometrial cancer: evaluating the impact of pre-surgical staging

Preoperative staging in endometrial cancer has recently been implied as an important factor in accurately selecting low-risk cases, ultimately avoiding unnecessary lymph node debulking. Transvaginal ultrasound seems promising in clinical staging as it offers the possibility to assess the depth of myometrial infiltration and cervical stromal invasion. This commonly available, non-invasive, and low-cost modality serves as an accurate alternative to MRI, especially in middle- and low-income countries, where MRI may not be promptly available and cost is an important issue. This review aims to summarize the progressive role of clinical implementation of pelvic ultrasonography in the locoregional staging of endometrial carcinoma and to compare its accuracy with other preoperative methods.

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.

Comparison of different tracers in sentinel lymph node detection for endometrial cancer: a systematic review and network meta-analysis

BACKGROUND

In the realm of endometrial cancer (EC) therapeutics and prognostic assessments, lymph nodes' status is paramount. The sentinel lymph node (SLN) detection, recognized for its reliability, has been progressively adopted as a standard procedure, posing a compelling alternative to conventional systematic lymphadenectomy. However, there remains a lack of agreement on the most effective choice of tracers for this procedure.

OBJECTIVE

This investigation was dedicated to a comparative analysis of various tracers to identify the most effective combination that achieves the highest detection rate. This endeavor sought to enhance the efficacy of SLN biopsy in the surgical management of EC.

METHODS

A systematic review was conducted across multiple databases, including the Cochrane Central Register of Controlled Trials, PubMed, Web of Science, Embase, and clinicaltrials.gov, to analyze studies employing different tracers for SLN biopsy during surgery in EC. Using Bayesian network meta-analysis, the authors compared the total and bilateral detection rates of various tracers.

RESULTS

After screening 1431 articles, 11 studies, including 2699 participants, were selected in this network meta-analysis. The combination of radioactive isotopes and indocyanine green (ICG) emerged as the most efficacious method in total and bilateral detection rates, with the Surface Under the Cumulative Ranking Curve (SUCRA) scores of 80.00 and 86.36%, respectively. Additionally, carbon nanoparticles (CNPs) demonstrated superior performance in the detection of para-aortic lymph nodes with an SUCRA score of 97.77%.

CONCLUSION

Network meta-analysis shows that the application of radioactive isotopes and ICG is the optimal tracer combination for SLN biopsy during surgery in EC.

Link between isolated para-aortic lymph node metastasis and intrauterine cancer site in early stage endometrial cancer

OBJECTIVE

Missing occult para-aortic lymph node metastasis is one of the primary concerns of sentinel lymph node biopsy in endometrial cancer. Our study aimed to evaluate the relationship between intrauterine cancer site and isolated para-aortic lymph node metastasis to tailor treatment and reduce the false negative rate of the sentinel lymph node procedure.

METHODS

A retrospective, multicenter, case control study was performed in four international centers. All patients with positive lymph nodes who had complete surgical staging with pelvic and para-aortic lymphadenectomy, between January 2013 and December 2023, were included. Detailed descriptions of the cancer location within the uterine cavity on the cranio-caudal plane and the myometrial wall involvement on the cranio-caudal and ventro-dorsal planes were collected, as were clinical data and cancer histological features. Patients with isolated para-aortic lymph node metastasis were allocated to group 1; patients with pelvic lymph node metastasis and those with both pelvic and para-aortic lymph node metastasis were allocated to group 2. The groups were compared according to the variables collected.

RESULTS

200 preoperative early stage endometrial cancer patients with postoperative International Federation of Gynecology and Obstetrics 2009/2023 stage IIIC1/IIIC2 were included in our study: 42 patients (21%) with isolated para-aortic lymph node metastasis were allocated to group 1 and the remaining patients to group 2. The two groups had comparable clinical and pathological characteristics (p>0.05): mean age was 66.5±10.3 (group 1) and 63.5±11.9 (group 2); endometrioid histotype was the predominant one for both groups (50%); most patients had myometrial infiltration >50% (80.9% and 79.7%), grade 3 (61.9% and 63.9%), and lymph vascular space invasion (78.5% and 82.2%). Cancers involving the fundal uterine cavity, the fundal myometrial wall, or the anterior myometrial wall were 3.11 (1.04-9.27), 3.03 (1.12-8.21), and 2.12 (0.77-5.80) times more likely to metastasize only to para-aortic lymph nodes compared with cancers located in other uterine sites.

CONCLUSIONS

In this study, the intrauterine location of the cancer determined the site of lymph node metastasis. When the tumor involved the fundus (cavity or wall) and infiltrated exclusively the anterior wall, the baseline risk of spreading only into the para-aortic area increased significantly in selected patients at risk of nodal disease.

Evaluation of Different Risk Factors for Metastatic Sentinel Lymph Nodes in Endometrial Cancer

Background/Objectives: This study investigates which demographic, clinical and pathological factors of women with early-stage presurgical EC could be considered risk factors for the presence of different subtypes of metastases in sentinel lymph nodes (SLNs). Methods: This is a retrospective single-center study that collected data between December 2015 and April 2024. EC patients who underwent total hysterectomy with salpingo-oophorectomy and SLN mapping with indocyanine green (ICG) were recorded. Results: Data from 98 women with EC were analyzed. The endometrioid histotype was present in 85 (86%) women, and the non-endometrioid histotype was present in 13 (13%) women. High-grade EC (G3) was present in 21 (21.4%) patients, and low-grade EC (G1-G2) was present in 77 (78.6%) patients. The total number of women with SLN metastasis was 21/98 (21%). Of 21 women, 5 had MAC, 6 had MIC and 10 had ITCs. Conclusions: Preliminary analysis identified three risk factors for nodal involvement: age greater than 67 years, high-grade endometrial carcinomas and myometrial invasion greater than or equal to 50%. Lymphovascular space invasion, histotype 2 and p53 mutation showed a slight, but not statistically significant, tendency to be risk factors for SLN positivity. A deeper analysis with univariate uninominal logistic regression showed that high-grade EC is related to a greater probability of MACs, as shown in other studies, and that low-grade EC (grades 1 and 2) had a strong relationship with low-volume metastasis (LVM); further studies are needed to confirm these results.

Paraaortic lymph node metastasis in endometrial cancer patients: a comprehensive analysis of rates, survival outcomes, and risk factors through systematic review and meta-analysis

Introduction

This study aims to explore the incidence of different metastatic patterns in paraaortic lymph nodes and their corresponding survival outcomes in patients with endometrial cancer, as well as to identify the associated risk factors of such metastasis.

Material and methods

PubMed, Embase, Cochrane Central Register of Controlled Trials, International Clinical Trials Registry Platform, and Clinical Trials.gov were searched from inception to February 10, 2024.The analysis was conducted using R version 4.2.3.

Results

A total of 47 studies involving 33,425 endometrial cancer patients were analyzed. Meta-analysis results revealed that the rate of isolated paraaortic lymph node metastasis, where pelvic lymph nodes were negative but paraaortic lymph nodes were positive (PLN-PAN+), was found to be 2.58% (95% CI 0.0195-0.0329). The rates for PLN+PAN- and PLN+PAN+ were notably higher at 8.54% (95% CI 0.0642-0.1092) and 8.37% (95% CI 0.0613-0.1090), respectively. For clinical stage I EC, the occurrence rate was 5.92% for PLN+PAN- (95% CI 0.0258-0.1032), 1.00% for PLN-PAN+ (95% CI 0.0081-0.0120), and 2.99% for PLN+PAN+ (95% CI 0.0188-0.0431). The survival outcomes indicate a decreasing trend from the PLN-PAN+ and PLN+PAN- groups to the PLN+PAN+ group. Additionally, the survival outcomes of patients with isolated paraaortic lymph node metastasis appear to be comparable to, or not inferior to, those of the PLN+PAN- group. The analysis indicated that pelvic lymph node metastasis (OR 16.72, 95% CI 10.03-27.86), myometrial invasion ≥50% (OR 5.18, 95% CI 3.09-8.69), lymph-vascular space invasion (LVSI) (OR 3.46, 95% CI 2.49-4.81), cervical invasion (OR 4.00, 95% CI 2.09-7.66), and non-endometrioid cancer (OR 2.39, 95% CI 1.17-4.86) were risk factors for paraaortic lymph node metastasis.

Conclusions

Isolated paraaortic lymph node metastasis, though relatively rare, can still occur even in clinical stage I endometrial cancer. The survival outcomes of patients with isolated paraaortic lymph node metastasis appear to be comparable to, or not inferior to, those of the PLN+PAN- group. Even in patients with negative pelvic lymph nodes, careful consideration should be given to the possibility of paraaortic lymph node metastasis, especially in those with high-risk factors.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024503959.

Screening of prognostic factors and survival analysis based on histological type for perimenopausal endometrial carcinoma treated with hysterectomy

PURPOSE

This study aimed to explore the prognostic factors and survival patterns based on the histological type for the perimenopausal endometrial carcinoma (PIPEC) patients treated with hysterectomy.

METHODS

The PIPEC patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database. Methods of random survival forest (RSF) and Cox regression were used to identify the possible prognostic factors of PIPEC patients. Then overall survival (OS) and cancer-specific survival (CSS) of PIPEC data were analyzed by histological types with regional lymph nodes status and SEER-stage to investigate the survival patterns of the PIPEC patients.

RESULTS

A total of 14,178 PIPEC patients were included in the study. We found tumor size, grade, histology, SEER-stage, AJCC-stage, AJCC-T stage, metastasis to distant organs and regional lymph nodes status had a significant survival outcome for PIPEC both for OS and CSS (all p < 0.05). Regardless of regional lymph nodes status and SEER-stage for OS and CSS, the low-grade endometrioid carcinoma had the best prognosis outcome, followed by the mix cell adenocarcinoma and high-grade endometrioid carcinoma, while the carcinosarcoma and undifferentiated carcinoma had relatively poor prognosis outcome. And the survival patterns of different histological types of PIPEC were diverse and changed along with the time.

CONCLUSION

We identified the possible prognostic factors of PIPEC patients treated with hysterectomy. And survival analysis based on the regional lymph nodes status and SEER-stage revealed the different histological types of PIPEC had diverse survival patterns, which will be helpful for guiding clinical practice.

Improvements and challenges in intraperitoneal laparoscopic para-aortic lymphadenectomy: The novel "tent-pitching" antegrade approach and vascular anatomical variations in the para-aortic region

INTRODUCTION

This study introduces and compares a new intraperitoneal laparoscopic para-aortic lymphadenectomy method to reach the level of the renal vein, the "tent-pitching" antegrade approach with the retrograde approach in gynecological malignancy surgeries in terms of success rate, complication incidence, and the number of lymph nodes removed. It focuses on the feasibility, safety, and effectiveness. Meanwhile, this article reports on the vascular anatomical variations discovered in the para-aortic region to enhance surgical safety.

MATERIAL AND METHODS

This was a retrospective cohort study including patients undergone laparoscopic para-aortic lymphadenectomy at a single center from January 2020 to December 2023 for high-risk endometrial and early-stage ovarian cancer. Patient charts were reviewed for mode of operation, perioperative complications, operative details, and histopathology. The patients were divided into anterograde group and retrograde group according to the operation mode. The two groups were further compared based on the success rate of lymph node clearance at the renal vein level, perioperative complications, and the number of removed lymph nodes. Quantitative data were analyzed using the t-test, non-normally distributed data using the rank-sum test, and categorical data using Fisher's exact test and the chi-square test, with statistical significance defined as P < 0.05.

RESULTS

Among 173 patients, the antegrade group showed higher surgery success (97.5% vs 68.82%), more lymph nodes removed (median 14 vs 7), and less median blood loss. The operation time was shorter in the antegrade group. Postoperative complications like lymphocele and venous thrombosis were lower in the antegrade group. Vascular abnormalities were found in 28.9% of patients, with accessory lumbar vein routing anomaly and accessory renal arteries being most common.

CONCLUSIONS

The antegrade approach is feasible, safe, and effective, improving surgical exposure, reducing difficulty without additional instruments or puncture sites, and minimizing organ damage risk. It is effective in achieving better access to the renal vein and removing more para-aortic lymph nodes than the retrograde method. Recognizing and carefully managing the diverse vascular abnormalities in the para-aortic area, including variations in renal arteries, veins, and the inferior vena cava, is essential to reduce intraoperative bleeding and the likelihood of converting to open surgery.

Sentinel Lymph node detection in endometrial cancer - Anatomical and scientific facts

Anatomical and functional aspects of the lymphatic drainage of the uterine corpus in endometrial cancer are demonstrated. Main lymphatic pathway runs along the upper pelvic pathway from the uterine artery first line to the medial external iliac nodes, followed by the lateral external and common iliac node basin. The second important pathway runs along the ovarian vessels directly to the paraaortic nodes. Pathways may visualized best by injection of indocyanine green (ICG) into the uterus. In contrast to the upper pelvic pathway visualized by cervical injection, the paraaortic drainage can only be marked by corporal injection. Lymphatic drainage works downstream (peripheral to central, with respect to vascular valves) only. Clinically, pelvic sentinel node excision replaced systematic lymphadenectomy for diagnostic purposes and even paraaortic node staging can be omitted in most of pelvic node negative patients. For therapeutic purposes compartmental resection of the uterus together with its lymphovascular system and first line nodes "en bloc" could be an option as performed in peritoneal mesometrial resection/targeted compartmental lymphadenctomy (PMMR/TCL).

Therapeutic role of para-aortic lymphadenectomy in patients with intermediate- and high-risk endometrial cancer: a systematic review and meta-analysis

OBJECTIVE

Lymph nodal involvement is a prognostic factor in endometrial cancer. The added value of para-aortic lymphadenectomy compared with pelvic nodal evaluation alone remains a matter of debate in the management of patients with intermediate- and high-risk endometrial cancer. A systematic review and meta-analysis was conducted to assess the prognostic value of para-aortic lymphadenectomy in terms of overall survival and disease-free survival in patients with intermediate- and high-risk endometrial cancer.

METHODS

The study adhered to the PRISMA guidelines. PubMed, Google Scholar and ClinicalTrials.gov were searched from January 2000 to April 2023. Studies on intermediate- and high-risk patients who underwent pelvic versus pelvic and para-aortic dissection were included in the analysis. The Methodological Index for Nonrandomized Studies (MINORS) and the Quality Assessment of Diagnostic Accuracy Studies 2 tool (QUADAS-2) were used for quality assessment of the selected articles.

RESULTS

Fourteen studies were identified, encompassing 9415 patients with a median age of 62 years (IQR 56.5-66.5). The majority had International Federation of Gynecology and Obstetrics stage I-II disease (76%) and endometrioid histology (89%). The 72% of patients who underwent only pelvic nodal evaluation and the 87% who underwent pelvic and para-aortic lymphadenectomy received adjuvant treatment (p=0.44). Pelvic and para-aortic lymphadenectomy was associated with a significant improvement in 5-year overall survival (RR=0.71, 95% CI 0.57 to 0.88, p<0.01), translating to a 41% reduction in the risk of overall death. However, no significant differences were observed in the 5-year risk of recurrence (RR=1.12, 95% CI 0.94 to 1.34, p=0.15). Additionally, patients undergoing pelvic and para-aortic lymphadenectomy experienced a 26% increased risk of post-operative complications (RR=1.26, 95% CI 1.04 to 1.53, p=0.03) and prolonged operative times (MD=56.27, 95% CI 15.94 to 96.60, p<0.01).

CONCLUSION

Pelvic and para-aortic lymphadenectomy appears to confer a prognostic benefit in patients with intermediate- and high-risk endometrial cancer. Robust prospective studies are needed to further validate these findings and elucidate the precise role of para-aortic lymphadenectomy in the optimal management of these patients.

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.

Prognostic Significance of Size, Location, and Number of Lymph Node Metastases in Endometrial Carcinoma

Regional lymph node metastasis is a well-established negative predictive prognostic factor in endometrial carcinomas. Recently, our approach to the pathologic evaluation of lymph nodes in endometrial carcinomas has changed, mainly due to the utilization of immunohistochemical stains in the assessment of sentinel lymph nodes, which may result in the identification of previously unrecognized disease [particularly isolated tumor cells (ITCs)] on hematoxylin and eosin stained slides. However, the clinical significance of this finding is not entirely clear. Following the experience in other organs systems such as breast, the Eight Edition of the American Joint Committee on Cancer's Cancer Staging Manual has recommended utilizing the N0(i+) terminology for this finding, without impact in the final tumor stage. We performed a comparative retrospective multi-institutional survival analysis of 247 patients with endometrial carcinoma with regional lymph node metastasis of various sizes identified in nonsentinel lymphadenectomy, demonstrating that the cumulative survival of patients with isolated tumor cells in regional lymph nodes is not statistically different from patient with negative lymph nodes, and is statistically different from those with lymph nodes showing micrometastasis or larger metastatic deposits. In addition, we evaluated the prognostic implications of the number of involved regional lymph nodes, demonstrating a worsening prognosis as the number of involved lymph nodes increases from none to one, and from one to more than one. Our data suggests that regional lymph nodes with isolated tumor cells in patients with endometrial carcinoma should likely be considered, for staging purposes, as negative lymph nodes, simply indicating their presence with the (i+) terminology.

Predictive factors of sentinel lymph node failed mapping in endometrial carcinoma patients: a systematic review and meta-analysis

OBJECTIVE

In endometrial carcinoma patients, sentinel lymph node bilateral mapping fails in 20-25% of cases, with several factors affecting the likelihood of detection. However, pooled data about predictive factors of failure are lacking. The aim of this systematic review and meta-analysis was to assess the predictive factors of sentinel lymph node failed mapping in endometrial cancer patients undergoing sentinel lymph node biopsy.

METHODS

A systematic review and a meta-analysis was performed searching all studies assessing predictive factors of sentinel lymph node failed mapping in apparent uterine-confined endometrial cancer patients undergoing sentinel lymph node biopsy through the cervical injection of indocyanine green. The associations between sentinel lymph node failed mapping and predictive factors of failure were assessed, calculating the odds ratio (OR) with 95% confidence intervals.

RESULTS

Six studies with a total of 1345 patients were included. Compared with patients with sentinel lymph node bilateral successful mapping, patients with sentinel lymph node failed mapping showed: OR 1.39 (p=0.41) for body mass index >30 kg/m2; OR 1.72 (p=0.24) for menopausal status; OR 1.19 (p=0.74) for adenomyosis; OR 0.86 (p=0.55) for prior pelvic surgery; OR 2.38 (p=0.26) for prior cervical surgery; OR 0.96 (p=0.89) for prior Cesarean section; OR 1.39 (p=0.70) for lysis of adhesions during surgery before sentinel lymph node biopsy; OR 1.77 (p=0.02) for indocyanine green dose <3 mL; OR 1.28 (p=0.31) for deep myometrial invasion; OR 1.21 (p=0.42) for International Federation of Gynecology and Obstetrics (FIGO) grade 3; OR 1.89 (p=0.01) for FIGO stages III-IV; OR 1.62 (p=0.07) for non-endometrioid histotype; OR 1.29 (p=0.25) for lymph-vascular space invasion; OR 4.11 (p<0.0001) for enlarged lymph nodes; and OR 1.71 (p=0.022) for lymph node involvement.

CONCLUSION

Indocyanine green dose <3 mL, FIGO stage III-IV, enlarged lymph nodes, and lymph node involvement are predictive factors of sentinel lymph node failed mapping in endometrial cancer patients.

AORTIC SENTINEL NODE DETECTION IN ENDOMETRIAL CANCER: 6 YEAR PROSPECTIVE STUDY

OBJECTIVE

The aim of this study was to describe our final results using dual cervical and fundal indocyanine green injection for the detection of sentinel lymph nodes (SLNs) in endometrial cancer along parametrial and infundibular drainage pathways.

METHODS

We conducted a prospective observational study between 26 June 2014 and 31 December 2020 enrolling 332 patients that underwent laparoscopic surgery for endometrial cancer at our hospital. In all cases, we performed SLN biopsy with dual cervical and fundal indocyanine green injection identifying pelvic and aortic SLNs. All SLNs were processed with an ultrastaging technique. A total of 172 patients also underwent total pelvic and para-aortic lymphadenectomy.

RESULTS

The detection rates were as follows: 94.0% overall for SLNs; 91.3% overall for pelvic SLNs; 70.5% for bilateral SLNs; 68.1% for para-aortic SLNs, and 3.0% for isolated paraaortic SLNs. We found lymph node involvement in 56 (16.9%) cases, macrometastasis in 22, micrometastasis in 12 and isolated tumor cells in 22. Fourteen patients had isolated aortic nodal involvement, representing 25% of the positive cases. There was one false negative (SLN biopsy negative but lymphadenectomy positive). Applying the SLN algorithm, the sensitivity of the dual injection technique for SLN detection was 98.3% (95% CI 91-99.7), specificity 100% (95% CI 98.5-100), negative predictive value 99.6% (95% CI 97.8-99.9), and positive predictive value 100% (95% CI 93.8-100). Overall survival at 60 months was 91.35%, with no differences between patients with negative nodes, isolated tumor cells and treated nodal micrometastasis.

CONCLUSIONS

Dual sentinel node injection is a feasible technique that achieves adequate detection rates. Additionally, this technique allows a high rate of aortic detection, identifying a non-negligible percentage of isolated aortic metastases. Aortic metastases in endometrial cancer account for as many as a quarter of the positive cases and should be considered, especially in high-risk patients.

Management of Patients Diagnosed with Endometrial Cancer: Comparison of Guidelines

Endometrial cancer is the most common gynecological malignancy in Europe and its management involves a variety of health professionals. In recent years, big discoveries were made concerning the management of patients diagnosed with endometrial cancer, particularly in the field of molecular biology and minimally invasive surgery. This requires the continuous updating of guidelines and protocols over the years. In this paper, we aim to summarize and compare common points and disparities among protocols for management of patients diagnosed with endometrial cancer by leading international gynecological oncological societies. We therefore systematically report the parallel among the guidelines based on the various steps patients with endometrial cancer usually undergo. The comparison between American and European protocols revealed some relevant disparities, in particular regarding surgical staging, molecular biology application as a prognostic tool and follow up regimens. This could possibly cause differences in interpreting and applying protocols in clinical practice in small centers, leading to a lack of adherence to guidelines or even prompting a confusing mix of them.

Therapeutic Benefit of Systematic Lymphadenectomy in Node-Negative Uterine-Confined Endometrioid Endometrial Carcinoma: Omission of Adjuvant Therapy

Simple Summary

Endometrial cancer is the most common gynecological tract malignancy in developed countries. Extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors.

Abstract

Endometrial cancer is the most common gynecological tract malignancy in developed countries, and its incidence has been increasing globally with rising obesity rates and longer life expectancy. In endometrial cancer, extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors. In this review, I discuss the characteristics of lymph node metastasis, the methods of lymph node assessment, and the therapeutic benefits of systematic lymphadenectomy in patients with intermediate- and high-risk endometrioid endometrial carcinoma.

Sentinel lymph node mapping in endometrial cancer to reduce surgical morbidity: always, sometimes, or never

Introduction

Surgical staging of nodal status is of utmost significance to determine the stage of endometrial cancer and construct a targeted treatment plan. Systematic lymphadenectomy has for years been the procedure of choice for staging purposes, enabling thorough assessment of lymph nodes. Nevertheless, it is associated with increased morbidity and severe postoperative complications. In an attempt to avoid the disadvantages of lymphadenectomy, the use of sentinel lymph node (SLN) biopsy has been examined as an alternative staging procedure.The purpose of the present review is to summarize and provide up-to-date evidence about the role of SLN biopsy in the staging and management of endometrial cancer cases in the terms of optimal technique, efficacy, safety, and postoperative morbidity, as an alternative approach to regional lymphadenectomy.

Material and methods

A thorough literature search was conducted in MEDLINE and SCOPUS to identify recent primary research and previous review articles that explore the use of SLN mapping as a staging procedure in patients with endometrial cancer.

Results

There is increasing evidence that SLN mapping is efficient in identifying metastatic nodal disease without compromising oncological safety, achieving comparable or even superior detection rates to those of lymphadenectomy, when optimal technique and careful intraoperative nodal assessment are applied.

Conclusions

Sentinel lymph node mapping can safely replace lymphadenectomy as an acceptable alternative staging method for endometrial cancer; however, future research might further strengthen this suggestion by resolving potential areas of doubt and debate, especially for high-risk endometrial cancer cases.

The Role of Sentinel Lymph Node Mapping in High-grade Endometrial Cancer

OPINION STATEMENT

Total hysterectomy with lymph node assessment is the current standard-of-care for surgical staging in apparent early-stage endometrial cancer. Compared to the traditional complete pelvic lymphadenectomy with or without para-aortic lymphadenectomy, sentinel lymph node (SLN) mapping results in fewer surgical complications, decreased operative time, and lower rates of chronic lymphedema. The technique is endorsed by the National Comprehensive Cancer Network and the Society of Gynecologic Oncology guidelines, and over the past two decades the majority of gynecologic oncologists worldwide have adopted SLN mapping into their practice. However, as the results of the initial SLN studies were mostly based on low-grade tumors, adoption of the technique in high-grade tumors has been slower and more controversial. In this review, we discuss the most recent studies evaluating the SLN mapping in high-grade endometrial cancers. The results of these studies suggest that the SLN detection rate is acceptably high and the negative predictive value is sufficiently low to support the use of SLN mapping in high-grade endometrial tumors to replace complete lymphadenectomy. Validity of SLN mapping techniques does, however, require following a standard algorithm, and success depends also on surgeon expertise. Moreover, the impact of SLN mapping on overall survival in high-grade tumors requires future prospective randomized studies. Finally, a transition toward near-universal SLN mapping techniques for endometrial cancers could significantly impact on the adequacy of gynecologic oncology fellows' surgical training and competency in lymphadenectomy.

Sentinel Lymph Node Biopsy in Surgical Staging for High-Risk Groups of Endometrial Carcinoma Patients

BACKGROUND

In endometrial carcinoma (EC) patients, sentinel lymph node (SLN) biopsy has shown the potential to reduce post-operative morbidity and long-term complications, and to improve the detection of low-volume metastasis through ultrastaging. However, while it has shown high sensitivity and feasibility in low-risk EC patient groups, its role in high-risk groups is still unclear.

AIM

To assess the role of SLN biopsy through the cervical injection of indocyanine green (ICG) in high-risk groups of early-stage EC patients.

MATERIALS AND METHODS

Seven electronic databases were searched from their inception to February 2021 for studies that allowed data extraction about detection rate and accuracy of SLN biopsy through the cervical injection of ICG in high-risk groups of early-stage EC patients. We calculated pooled sensitivity, false negative (FN) rate, detection rate of SLN per hemipelvis (DRh), detection rate of SLN per patients (DRp), and bilateral detection rate of SLN (DRb), with 95% confidence interval (CI).

RESULTS

Five observational cohort studies (three prospective and two retrospective) assessing 578 high risk EC patients were included. SLN biopsy sensitivity in detecting EC metastasis was 0.90 (95% CI: 0.03-0.95). FN rate was 2.8% (95% CI: 0.6-11.6%). DRh was 88.4% (95% CI: 86-90.5%), DRp was 96.6% (95% CI: 94.7-97.8%), and DRb was 80% (95% CI: 75.4-83.9).

CONCLUSION

SLN biopsy through ICG cervical injection may be routinely adopted instead of systematic pelvic and para-aortic lymphadenectomy in surgical staging for high-risk groups of early-stage EC patients, as well as in low-risk groups.

Ultrastaging of 'negative' pelvic lymph nodes in patients with low- and intermediate-risk endometrioid endometrial cancer who developed non-vaginal recurrences

OBJECTIVE

Evidence on micrometastases and isolated tumor cells as factors associated with non-vaginal recurrence in low- and intermediate-risk endometrial cancer is limited. The goal of our study was to investigate risk factors for non-vaginal recurrence in low- and intermediate-risk endometrial cancer.

METHODS

Records of all patients with endometrial cancer surgically managed at the Mayo Clinic before sentinel lymph node implementation (1999-2008) were reviewed. We identified all patients with endometrioid low-risk (International Federation of Gynecology and Obstetrics (FIGO) stage I, grade 1 or 2 with myometrial invasion <50% and negative peritoneal cytology) or intermediate-risk (FIGO stage I, grade 1 or 2 with myometrial invasion ≥50% or grade 3 with myometrial invasion <50% and negative peritoneal cytology) endometrial cancer at definitive pathology after pelvic and para-aortic lymph node assessment. All pelvic lymph nodes of patients with non-vaginal recurrence (any recurrence excluding isolated vaginal cuff recurrences) underwent ultrastaging.

RESULTS

Among 1303 women, we identified 321 patients with low-risk (n=236) or intermediate-risk (n=85) endometrial cancer (median age 65.4 years; 266 (82.9%) stage IA; 55 (17.1%) stage IB). Of the total of 321, 13 patients developed non-vaginal recurrence (Kaplan-Meier rate 4.7% by 60 months; 95% CI 2.1% to 7.2%): 11 hematogenous/peritoneal and two para-aortic and distant lymphatic. Myometrial invasion and lymphovascular space invasion were univariately associated with non-vaginal recurrence. In these patients, the original hematoxylin/eosin slides review confirmed all 646 pelvic and para-aortic removed lymph nodes as negative. The ultrastaging of 463 pelvic lymph nodes did not identify any occult metastases (prevalence 0%; 95% CI 0% to 22.8% considering 13 patients; 95% CI 0% to 0.8% considering 463 pelvic lymph nodes).

CONCLUSION

There were no occult metastases in pelvic lymph nodes of patients with low- or intermediate-risk endometrial cancer with non-vaginal recurrence. Myometrial invasion and lymphovascular space invasion appear to be associated with non-vaginal recurrence.

European Society of Gynaecological Oncology quality indicators for the surgical treatment of endometrial carcinoma

BACKGROUND

Quality of surgical care as a crucial component of a comprehensive multi-disciplinary management improves outcomes in patients with endometrial carcinoma, notably helping to avoid suboptimal surgical treatment. Quality indicators (QIs) enable healthcare professionals to measure their clinical management with regard to ideal standards of care.

OBJECTIVE

In order to complete its set of QIs for the surgical management of gynecological cancers, the European Society of Gynaecological Oncology (ESGO) initiated the development of QIs for the surgical treatment of endometrial carcinoma.

METHODS

QIs were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for the identification of potential QIs and documentation of the scientific evidence, two consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians and patient representatives. QIs were defined using a structured format comprising metrics specifications, and targets. A scoring system was then developed to ensure applicability and feasibility of a future ESGO accreditation process based on these QIs for endometrial carcinoma surgery and support any institutional or governmental quality assurance programs.

RESULTS

Twenty-nine structural, process and outcome indicators were defined. QIs 1-5 are general indicators related to center case load, training, experience of the surgeon, structured multi-disciplinarity of the team and active participation in clinical research. QIs 6 and 7 are related to the adequate pre-operative investigations. QIs 8-22 are related to peri-operative standards of care. QI 23 is related to molecular markers for endometrial carcinoma diagnosis and as determinants for treatment decisions. QI 24 addresses the compliance of management of patients after primary surgical treatment with the standards of care. QIs 25-29 highlight the need for a systematic assessment of surgical morbidity and oncologic outcome as well as standardized and comprehensive documentation of surgical and pathological elements. Each QI was associated with a score. An assessment form including a scoring system was built as basis for ESGO accreditation of centers for endometrial cancer surgery.

Implications of Isolated Para-Aortic Lymph Node Metastasis in Endometrial Cancer: A Large-Scale, Multicenter, and Retrospective Study

Objective: To systematically evaluate lymph node metastasis (LNM) patterns in patients with endometrial cancer (EC) who underwent complete surgical staging, which included systematic pelvic and para-aortic lymphadenectomy.

Methods: Four thousand and one patients who underwent complete surgical staging including systematic pelvic and para-aortic lymphadenectomy for EC were enrolled from 30 centers in China from 2001 to 2019. We systematically displayed the clinical and prognostic characteristics of patients with various LNM patterns, especially the PLN-PAN+ [para-aortic lymph node (PAN) metastasis without pelvic lymph node (PLN) metastasis]. The efficacy of PAN+ (para-aortic lymph node metastasis) prediction with clinical and pathological features was evaluated.

Results: Overall, 431 of the 4,001 patients (10.8%) showed definite LNM according to pathological diagnosis. The PAN+ showed the highest frequency (6.6%) among all metastatic sites. One hundred fourteen cases (26.5%) were PLN-PAN+ (PAN metastasis without PLN metastasis), 167 cases (38.7%) showed PLN+PAN-(PLN metastasis without PAN metastasis), and 150 cases (34.8%) showed metastasis to both regions (PLN+PAN+). There was also 1.9% (51/2,660) of low-risk patients who had PLN-PAN+. There are no statistical differences in relapse-free survival (RFS) and disease-specific survival (DSS) among PLN+PAN-, PLN-PAN+, and PLN+PAN+. The sensitivity of gross PLNs, gross PANs, and lymphovascular space involvement (LVSI) to predict PAN+ was 53.8 [95% confidence interval (CI): 47.6–59.9], 74.2 95% CI: 65.6–81.4), and 45.8% (95% CI: 38.7–53.2), respectively.

Conclusion: Over one-fourth of EC patients with LMN metastases were PLN-PAN+. PLN-PAN+ shares approximate survival outcomes (RFS and DSS) with other LNM patterns. No effective clinical methods were achieved for predicting PAN+. Thus, PLN-PAN+ is a non-negligible LNM pattern that cannot be underestimated in EC, even in low-risk patients.

Recurrence risk of occult micrometastases and isolated tumor cells in early stage endometrial cancer: A case control study

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Ultra-staging INCREASED the identification of low volume lymph node metastasis in EC.

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Occult ITC were not associated with increased odds of recurrent EC.

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Occult ITC were closely associated with known risk factors in early-stage EC.

Objectives

To determine whether previously undetected occult micrometastasis (MM) or isolated tumor cells (ITC) is associated with increased recurrence odds in stage I-II endometrioid adenocarcinoma.

Methods

Women with recurrent stage I/II EC who had complete pelvic and para-aortic were identified as the outcome of interest. A case-control study was designed with the exposure defined as occult MM/ITC not seen on original nodal pathology. Controls were found by frequency-matching in a 1:2 case control ratio. Original nodal slides were re-reviewed, stained and tested with immunohistochemical to detect occult MM/ITC and the odds of associated recurrence was calculated.

Results

Of 153 included, 50 with and 103 without recurrence, there was no difference in age (p = 0.46), race (p = 0.24), stage (p = 0.75), FIGO grade (p = 0.64), lymphovascular space invasion (LVSI); p = 1.00, or GOG 99 high-intermediate risk (HIR) criteria (p = 0.35). A total of 18 ITC (11.8%) and 3 MM (2.0%) not previously identified were found in 19 patients. Finding occult MM/ITC was not associated with more lymph nodes (LN) removed (p = 0.67) or tumor grade (p = 0.48) but was significantly associated with stage (p < 0.01). LVSI (p = 0.09) and meeting high-intermediate risk criteria (p = 0.09), were closely associated but not statistically significant. Isolated ITC were not associated with increased odds for recurrence (OR 0.71, CL: 0.20 – 2.22, p = 0.57), recurrence free survival (RFS) (p = 0.85) or overall survival (OS) (p = 0.92).

Conclusions

In early-stage EC, identification of occult MM or ITC is uncommon and associated with stage. The presence of ITC was not associated with increased odds of recurrence. Adjusting stage or treatment may avoided based on ITC alone. Isolated MM were rare in our population, and further investigation is warranted.

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.

Update on Sentinel Lymph Node Biopsy in Surgical Staging of Endometrial Carcinoma

Sentinel lymph node (SLN) biopsy has emerged as an alternative staging approach in women with assumed early-stage endometrial carcinoma. Through image-guided surgery and pathologic ultrastaging, the SLN approach is introducing “precision medicine” to the surgical management of gynecologic cancers, providing a comprehensive evaluation of high-yield lymph nodes. This approach improves the surgeons’ ability to detect small-volume metastatic disease while reducing intraoperative and postoperative morbidity associated with lymphadenectomy. Although the majority of clinicians in Europe and the USA have recognized the value of SLN biopsy in endometrial carcinoma and introduced this as part of clinical practice, there is ongoing debate regarding its role in very low-risk patients as well as in patients at high risk of nodal metastasis. The significance of low-volume metastasis is not fully understood, and there is no consensus in regard to how the presence of isolated tumor cells should guide adjuvant therapy. Standardized protocols for histopathologic evaluation of SLNs are lacking. In this review article we aim to provide a framework for the introduction of SLN biopsy in endometrial cancer, give an updated overview of the existing literature, as well as discuss potential controversies and unanswered questions regarding this approach and future directions.

Controversies in the Management of Early-stage Serous Endometrial Cancer

BACKGROUND/AIM

Early-stage uterine serous carcinoma (USC) has one of the highest recurrence rates and mortality among early-stage uterine epithelial cancers. Research into the clinical management of USC has begun to progress, guided by surgical and pathological advances. This article summarizes the available literature regarding diagnosis, management, and possible future uses of molecular analysis of women with early-stage USC.

MATERIALS AND METHODS

PubMed was searched for all pertinent English language research articles published from January 1, 2006 through March 1, 2020 which included a study population of women diagnosed with stage 1 USC. Due to the scarcity of prospective or large-scale data, studies were not limited by design or numbers of patients. Studies performed at earlier dates were incorporated to provide context.

RESULTS

A total of 86 studies were included in the review. Multiple well-designed studies have confirmed the safety of a minimally invasive surgical approach for surgical management of USC. The role of sentinel node biopsy has been validated with both prospective and retrospective multi-center data. Stage I USC is associated with a highly variable risk of recurrence, even following completion of adjuvant chemoradiation. This aggressive phenotype has been linked to high numbers of somatic copy number alterations, tumor protein 53, and phosphatidylinositol 3 kinase mutations, which have been shown to be predictive of prognosis.

CONCLUSION

Early-stage USC demonstrates a lack of predictable recurrence patterns, with reports noting distant recurrence in patients with disease confined to polyps. Unless no residual tumor is found on hysterectomy, chemotherapy and radiotherapy should be discussed and individualized by stage and treatment goals.

Sentinel Lymph Nodes and Precision Surgery in Gynecologic Cancer

Besides histologic features, the presence of nodal metastasis is the most crucial prognostic factor for recurrence and survival for patients with gynecologic cancer. Conventionally, lymphadenectomy has been performed routinely to assess lymphatic metastasis. However, lymphadenectomy may be unnecessary in early-stage gynecologic cancer, because the percentage of patients with lymph node involvement is very low. The recent use of sentinel lymph node mapping has provided high feasibility, safety, and accuracy in the assessment of nodal metastasis. The National Comprehensive Cancer Network Clinical Practice Guidelines have incorporated the sentinel lymph node for nodal evaluation in vulvar, endometrial, and cervical cancers.

ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma

A European consensus conference on endometrial carcinoma was held in 2014 to produce multidisciplinary evidence-based guidelines on selected questions. Given the large body of literature on the management of endometrial carcinoma published since 2014, the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) jointly decided to update these evidence-based guidelines and to cover new topics in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide. ESGO/ESTRO/ESP nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of endometrial carcinoma (27 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2014, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 191 independent international practitioners in cancer care delivery and patient representatives. The guidelines comprehensively cover endometrial carcinoma staging, definition of prognostic risk groups integrating molecular markers, pre- and intra-operative work-up, fertility preservation, management for early, advanced, metastatic, and recurrent disease and palliative treatment. Principles of radiotherapy and pathological evaluation are also defined.

Maximizing sentinel node detection in endometrial cancer with dual cervical and transcervical fundal indocyanine green injection: 5-year single-center prospective study

OBJECTIVE

The aim of this study was to describe our latest results using dual cervical and fundal indocyanine green injection for detection of sentinel lymph node (SLN) in endometrial cancer.

METHODS

A prospective observational study was conducted between 26 June 2014 and 31 December 2019 with 278 patients that underwent laparoscopic surgery for endometrial cancer at our institution. In all cases, we performed SLN biopsy with dual cervical and fundal indocyanine green injection. All SLNs were processed with an ultrastaging technique. A total of 128 patients also underwent total pelvic and paraaortic lymphadenectomy.

RESULTS

The detection rates were as follows: 93.5 % (260/278) overall for SLNs; 90.7 % (252/278) overall for pelvic SLNs; 68.0 % (189/278) for bilateral SLNs; 66.9 % (186/278) for paraaortic SLNs, and 2.9 % (8/278) for isolated paraaortic SLNs. We found macroscopic lymph node metastasis in 26 patients (10.0 %) and microdisease in lymph nodes in another 48 patients, raising the overall rate of lymph node involvement to 16.2 %. There was one false negative (negative SLN biopsy but positive lymphadenectomy). Applying the SLN algorithm, the sensitivity of detection was 97.9 % (95 % CI 89.1-99.6), specificity 100 % (95 % CI 98.2-100), negative predictive value 99.5 % (95 % CI 97.4-99.9), and positive predictive value 100 % (95 % CI 92.4-100).

CONCLUSIONS

Dual sentinel node injection is a feasible technique that achieves adequate detection rates. Additionally, this technique allows a high rate of aortic detection, identifying a non-negligible percentage of isolated aortic metastases. Aortic metastases in endometrial cancer are possible and we should not give up actively looking for them.

Avoiding Full Lymphadenectomies in Intermediate- and High-Risk Endometrial Cancer by Sentinel Lymph Node Biopsy Implementation

Objective

To evaluate the role of sentinel lymph node biopsy (SLNB) to avoid staging lymphadenectomies by detecting nodal metastasis in intermediate- and high-risk endometrial cancer (EC).

Methods

A single institutional retrospective study was performed including all patients with intermediate- and high-risk EC who underwent surgical nodal staging between January 2012 and December 2019. Patients with disseminated disease detected on imaging techniques or at the time of surgery were excluded. Patients were evaluable if they underwent nodal staging with SLNB and pelvic (PLD) and paraaortic (PALD) lymph node dissection. We analyzed the accuracy of the sentinel lymph node technique. Only patients with at least one sentinel lymph node (SLN) detected were included in the sensitivity and negative predictive value (NPV) analyses. The tracers used were technetium 99m, blue dye, and indocyanine green.

Results

Eighty-eight patients presented intermediate- and high-risk EC (51 patients and 37 patients respectively) and underwent SLNB with consecutive PLD and PALD. The median (range) number of sentinel nodes retrieved was 2.9 (0–11). The global detection rate of SLN was 96.6% with a bilateral detection of 80.7% when considering all tracers used. However, when combination of indocyanine green and technetium was used the bilateral detection rate was 90.3%. Nodal metastases were detected in 17 (19.3%) cases, 8 (47%) of them corresponded to low volume metastasis (LVM), 7 (87.5%) of them diagnosed at ultrastaging pathologic exam. Finally, we obtained a sensitivity of 90%, a NPV of 97.5%, and a false negative rate (FNR) of 10% in the intermediate-risk EC compared to sensitivity of 85.7%, NPV of 96.6%, and FNR of 14.3% in the high-risk EC group. The only patient with isolated paraaortic nodal metastasis was found at the high-risk group, 1.1%.

Conclusions

According to our results, full lymphadenectomy could be avoided by performing SLNB in patients with intermediate-risk EC because the only false negative case detected was at the beginning of ICG learning curve. For high-risk EC patients we did not find enough evidence to support the systematic avoidance of staging full lymph node dissection. Nevertheless, SLNB should be performed in all cases of EC as it improves LVM diagnosis substantially.

ESGO/ESTRO/ESP Guidelines for the management of patients with endometrial carcinoma

A European consensus conference on endometrial carcinoma was held in 2014 to produce multidisciplinary evidence-based guidelines on selected questions. Given the large body of literature on the management of endometrial carcinoma published since 2014, the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) jointly decided to update these evidence-based guidelines and to cover new topics in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide. ESGO/ESTRO/ESP nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of endometrial carcinoma (27 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2014, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 191 independent international practitioners in cancer care delivery and patient representatives. The guidelines comprehensively cover endometrial carcinoma staging, definition of prognostic risk groups integrating molecular markers, pre- and intra-operative work-up, fertility preservation, management for early, advanced, metastatic, and recurrent disease and palliative treatment. Principles of radiotherapy and pathological evaluation are also defined.

ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma

A European consensus conference on endometrial carcinoma was held in 2014 to produce multi-disciplinary evidence-based guidelines on selected questions. Given the large body of literature on the management of endometrial carcinoma published since 2014, the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy and Oncology (ESTRO), and the European Society of Pathology (ESP) jointly decided to update these evidence-based guidelines and to cover new topics in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.

Comparison of Perioperative Outcomes between Minimally Invasive Sentinel Node Biopsy and Full Lymphadenectomy for Endometrial Cancer

STUDY OBJECTIVE

To review the perioperative differences between patients undergoing a minimally invasive sentinel lymph node dissection and those undergoing a full lymphadenectomy.

DESIGN

Retrospective review.

SETTING

Teaching hospital.

PATIENTS

All patients undergoing a minimally invasive procedure for endometrial cancer that included nodal evaluation.

INTERVENTIONS

Patients who underwent a sentinel lymph node biopsy were compared with those who underwent a full lymphadenectomy at the time of minimally invasive surgery by either laparoscopic or robot-assisted surgery.

MEASUREMENTS AND MAIN RESULTS

A total of 241 minimally invasive surgery procedures for endometrial cancer were performed during the 20-month study period. Nodal dissection was indicated and performed in 156 (65%) of these patients, with 93 undergoing a sentinel lymph node biopsy and 63 a full lymphadenectomy. There was no difference between the sentinel group and the lymphadenectomy group with respect to age, estimated blood loss (p = .23), use of a preoperative enhanced recovery after surgery program (p = .82), or body mass index (34.0 kg/m² vs 33.7 kg/m²; p = .87). The use of full lymphadenectomy was very dependent on the surgeon (p <.001). There was no difference in narcotic use in milligram intravenous equivalents of morphine in surgery (20.9 vs 22.2; p = .37), recovery (4.6 vs 4.9; p = .73), or total dose (25.4 vs 27.0; p = .33). The surgical procedure was longer with lymphadenectomy (185.2 minutes vs 214.2 minutes; p <.001) and the relative risk of discharge from recovery was lower (0.71; 95% confidence interval, 0.51-0.97; p = .03). The hospital stay was longer with lymphadenectomy (16.3 hours vs 25.5 hours; p <.001) and same-day discharge less frequent (48.5% vs 13.8%; p <.001). A multivariate analysis confirmed that sentinel node biopsy was associated with an increased relative risk of discharge of 1.68 (95% confidence interval 1.11-2.53; p = .01) CONCLUSION: Total narcotic requirements are similar between sentinel node biopsy and lymphadenectomy. However, sentinel node biopsy is associated with a shorter surgical time, recovery time, and hospital stay.

Lymph node evaluation in endometrial cancer: how did it change over the last two decades?

Endometrial cancer (EC) is the most common gynecological malignancy in developed countries, and surgery represents the pivotal part of treatment. Hysterectomy and salpingo-oophorectomy allow removing the primary tumor and defining patients at higher risk, who might benefit from adjuvant therapies. Minimally invasive surgery is associated with superior postoperative outcomes and represents a safe and effective approach for surgical staging of EC. The lymph node status evaluation in EC is still a matter of debate. Over the last twenty years much has changed, moving from a full systematic pelvic and paraaortic lymphadenectomy for staging purpose to the removal of the pelvic (with or without paraaortic) lymph nodes only in selected EC classes of risk. Two randomized trials failed to demonstrate survival benefits of lymphadenectomy in case of apparent early stage EC; however, its prognostic role has never been questioned. At present, with the aim of reducing the surgical-related morbidity, sentinel node mapping is emerging as a safe and valid alternative to lymphadenectomy for EC staging, demonstrating high accuracy and an increased detection of lymph nodes metastasis. Here, we performed a review of the most significant studies, which supported the changes in the lymph node status evaluation for EC over the last two decades.

Sentinel lymph node intraoperative analysis in endometrial cancer

PURPOSE

Surgical staging in endometrial cancer has evolved and sentinel lymph node (SLN) mapping has replaced a full pelvic and paraaortic lymphadenectomy in several cases. An intraoperative evaluation of SLN might identify patients who could benefit the most from a full lymphadenectomy. The aim of this study is to evaluate the clinical relevance of frozen section of SLN.

METHODS

A retrospective analysis in patients with endometrial cancer who underwent SLN mapping with intraoperative evaluation at frozen section between February 2016 and September 2019 was performed. In case of metastatic involvement, a full lymphadenectomy was performed.

RESULTS

Fifty-eight patients met the inclusion criteria. Clinical-pathologic characteristics of the patients and surgical data were analyzed. Overall, bilateral and unilateral detection rates were 100% (58/58), 89.7% (52/58), and 10.3% (6/58), respectively. Eight patients had a stage IIIC disease at permanent section. Frozen section detected SLN metastases in four of eight patients. Of these, two were micrometastases and two were macrometastases. At frozen section of the SLNs, no macrometastases were misdiagnosed. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value of frozen section in detecting metastases was 50%, 100%, 93%, 100% and 92.6%, respectively.

CONCLUSION

The intraoperative evaluation of SLN in endometrial cancer accurately identifies patients with macrometastases. This is the cohort that might benefit the most of a full lymphadenectomy for a higher risk of additional lymph node metastases.