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Narva S, Polo-Kantola P, Oksa S, Kallio J, Huvila J, Rissanen T, Hynninen J, Hietanen S, Joutsiniemi T. Is it safe to operate selected low-risk endometrial cancer patients in secondary hospitals? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108317. [PMID: 38581756 DOI: 10.1016/j.ejso.2024.108317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/23/2024] [Accepted: 03/30/2024] [Indexed: 04/08/2024]
Abstract
INTRODUCTION The aim of this study was to assess the accuracy of a preoperative screening algorithm in identifying low-risk endometrial cancer (EC) patients to ensure optimal care. METHODS A total of 277 patients with primary EC confirmed through biopsy underwent magnetic resonance imaging (MRI). Patients with risk factors for advanced high-risk EC, such as non-endometrioid histology, high-grade differentiation status, deep myometrial invasion, or spread beyond the uterine corpus, were systematically excluded. The remaining preoperatively screened patients with stage IA low-grade endometrioid EC (EEC) (n = 93) underwent surgery in a tertiary hospital. The accuracy of the preoperative diagnosis was evaluated by comparing the findings with the postoperative histopathological results. Disease-free survival (DFS) and overall survival (OS) were analyzed using 8-year follow-up data. RESULTS Postoperative histopathological analysis revealed that all patients had grade 1-2 EEC localized to the corpus uteri. Only three patients had deep myometrial invasion (stage IB), but they remained disease-free after 6-9 years of follow-up. The median follow-up time for all patients was 8.7 years. The DFS was 7.6 years, and the OS was 8.6 years. Two patients with stage IA grade 1 EEC experienced relapse and, despite treatment, died of EC. No other EC-related deaths occurred. CONCLUSIONS The screening algorithm accurately identified low-risk EC patients without compromising survival. Therefore, the algorithm appears to be feasible for selecting patients for surgery in secondary hospitals.
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Affiliation(s)
- Sara Narva
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland; TYKS Cancer Centre, FICAN West, Organization of EU Cancer Institutes, Finland.
| | - Päivi Polo-Kantola
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland
| | - Sinikka Oksa
- Department of Obstetrics and Gynecology, Satasairaala Hospital, Pori, Finland
| | - Johanna Kallio
- Department of Radiology, Turku University Hospital and University of Turku, Turku, Finland; TYKS Cancer Centre, FICAN West, Organization of EU Cancer Institutes, Finland
| | - Jutta Huvila
- Department of Pathology, Turku University Hospital and University of Turku, Turku, Finland; TYKS Cancer Centre, FICAN West, Organization of EU Cancer Institutes, Finland
| | - Tiia Rissanen
- Department of Biostatistics, Turku University Hospital and University of Turku, Turku, Finland
| | - Johanna Hynninen
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland; TYKS Cancer Centre, FICAN West, Organization of EU Cancer Institutes, Finland
| | - Sakari Hietanen
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland; TYKS Cancer Centre, FICAN West, Organization of EU Cancer Institutes, Finland
| | - Titta Joutsiniemi
- Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland; TYKS Cancer Centre, FICAN West, Organization of EU Cancer Institutes, Finland
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Akdöner A, Kurt S, Yavuz O, Bayram E, Üresin M, Ulukuş EÇ. Effect of low uterine segment involvement on prognosis of early stage endometrial cancer. J Obstet Gynaecol Res 2024; 50:991-1001. [PMID: 38575743 DOI: 10.1111/jog.15933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 03/14/2024] [Indexed: 04/06/2024]
Abstract
AIM Our aim is to investigate the effect of uterine lower segment involvement on prognosis of early-stage endometrial cancer cases diagnosed and treated in our clinic. MATERIALS AND METHODS The file records of 316 cases reviewed retrospectively.Only stage I (a and b, n=209) cases were investigated, because they were more homogeneous group. RESULTS The lymphovascular invasion rate was found to be higher in patients with stage Ia and uterine lower segment involvement (p < 0.001). Adjuvant treatment requirement was higher in patients with stage Ia and uterine lower segment involvement (p < 0.001). Among stage Ia cases, the recurrence rate between 1 and 3 years was found to be higher in cases with uterine lower segment involvement (p = 0.001). Among the stage Ib cases, lymphovascular invasion was found to be higher in cases with uterine lower segment involvement (p < 0.001). The recurrence rate between 1 and 3 years was found to be higher in stage Ib compared to Ia (p = 0.01). Uterine lower segment involvement was found to be associated with high lymphovascular invasion rate in all stage I cases (p < 0.001). It was determined that the need for adjuvant treatment was higher in cases with uterine lower segment involvement (p < 0.001). It was determined that the probability of recurrence between 1 and 3 years was higher in cases with uterine lower segment involvement (p = 0.007). CONCLUSION Uterine lower segment involvement is associated with increased lymphovascular invasion even in the early stages. It is an important risk factor for systemic spread such as lymphovascular invasion, myometrial invasion, and lymph node involvement.
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Affiliation(s)
- Aslı Akdöner
- Gynecology and Obstetrics Department, Medical School, Dokuz Eylül University, İzmir, Turkey
| | - Sefa Kurt
- Gynecology and Obstetrics Department, Medical School, Dokuz Eylül University, İzmir, Turkey
| | - Onur Yavuz
- Gynecology and Obstetrics Department, Medical School, Dokuz Eylül University, İzmir, Turkey
| | - Emre Bayram
- Gynecology and Obstetrics Department, Medical School, Dokuz Eylül University, İzmir, Turkey
| | - Merve Üresin
- Gynecology and Obstetrics Department, Medical School, Dokuz Eylül University, İzmir, Turkey
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Insalaco G, Incognito GG, Genovese F, Gulino FA, Rivoli L, Ciancio F, Valenti G, Incognito D, Carbone L, Palumbo M. Impact of obesity in the identification of the sentinel lymph node in endometrial cancer: a retrospective, monocentric study and literature review. Arch Gynecol Obstet 2024; 309:2779-2788. [PMID: 38400908 DOI: 10.1007/s00404-024-07386-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/09/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE To evaluate the sentinel lymph node (SLN) protocol for staging endometrial carcinomas, assessing its impact on surgical management, and determining indications for adjuvant therapies. The study also examines factors that may influence SNL mapping, particularly focusing on the failure of the technique due to obesity. METHODS A retrospective analysis was conducted on the medical records of patients with a histological diagnosis of endometrial carcinoma, who underwent surgical staging with SLN biopsy. The lymph node status was compared between non-obese (group 1) and obese (group 2) patients. RESULTS 71 women were included in the study, of which 33 were non-obese (46.5%) and 38 were obese (53.5%). The failure detection rate was higher in obese patients (14, 36.8%) compared to non-obese patients (5, 15.2%) (p = 0.039). The risk of mapping failure increased by 1.6 times for every 5-unit increase in body mass index (BMI) (OR 1.672, 95% CI 1.024-2.730, p = 0.040). BMI was confirmed as an independent risk factor for mapping failure in both univariate (OR 3.267, 95% CI 1.027-10.395, p = 0.045) and multivariate analyses (OR 5.779, 95% CI 1.320-25.297, p = 0.020). CONCLUSION SLN detection in obese patients requires great care, as obesity may alter the sensitivity of the technique.
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Affiliation(s)
| | - Giosuè Giordano Incognito
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.
| | - Fortunato Genovese
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Ferdinando Antonio Gulino
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adults and Developmental Age, "G. Martino" University Hospital, Messina, Italy
| | - Luca Rivoli
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | | | | | - Dalila Incognito
- Medical Oncology Unit, Department of Human Pathology "G. Barresi", University of Messina, Messina, Italy
| | - Ludovico Carbone
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Marco Palumbo
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
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Bollino M, Geppert B, Lönnerfors C, Persson J. A selective anatomically based lymph node sampling can replace a side specific pelvic lymphadenectomy in endometrial cancer with failed sentinel node mapping. Eur J Cancer 2024; 204:114049. [PMID: 38657525 DOI: 10.1016/j.ejca.2024.114049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/26/2024] [Accepted: 04/04/2024] [Indexed: 04/26/2024]
Abstract
AIM To evaluate the locations of metastatic pelvic sentinel nodes (SLN) and the proportion of SLNs outside and within defined typical anatomical positions along the upper paracervical lymphatic pathway (UPP). PATIENTS AND METHODS Consecutive women with endometrial cancer (EC) of all risk groups underwent pelvic SLN-detection using cervically injected indocyanine green (ICG). A strict anatomically based algorithm and definitions of SLNs was adhered to. The positions of ICG-defined SLNs were intraoperatively depicted on an anatomical chart. All SLNs were examined using ultrastaging and immunohistochemistry. The proximal third of the obturator fossa and the interiliac area were defined as typical positions. The parauterine lymphovascular tissue (PULT) was separately removed. The proportions of metastatic SLNs, overall and isolated, typically, and atypically positioned were analyzed per woman. RESULTS A median of two (range 1-12) SLN metastases along the UPP including the PULT were found in 162 women. 41 of 162 women (25.3 %) had isolated metastases in the obturator fossa harboring 49.1 % of all SLN metastases. Three women (1,9 %) had isolated PULT metastases. SLN metastases outside typical positions were identified in 28/162 women (17.3 %); isolated metastases were seen in seven women (4.3 %), so 95.7 % of pelvic node positive women had at least one metastatic SLN located at a typical position. CONCLUSION A selective removal of lymph nodes at typical proximal obturator and interiliac positions and the PULT can replace a full side specific pelvic LND when SLN mapping is unsuccessful. The obturator fossa is the predominant location for metastatic disease.
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Affiliation(s)
- Michele Bollino
- Department of Obstetrics and Gynaecology, Division of Gynaecologic Oncology, Skåne University Hospital Lund, Lund University Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology, Lund, Sweden
| | - Barbara Geppert
- Department of Obstetrics and Gynaecology, Division of Gynaecologic Oncology, Skåne University Hospital Lund, Lund University Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology, Lund, Sweden
| | - Celine Lönnerfors
- Department of Obstetrics and Gynaecology, Division of Gynaecologic Oncology, Skåne University Hospital Lund, Lund University Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology, Lund, Sweden
| | - Jan Persson
- Department of Obstetrics and Gynaecology, Division of Gynaecologic Oncology, Skåne University Hospital Lund, Lund University Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology, Lund, Sweden.
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Rambow AC, Nikolai M, Jansen P, Rogmans C, Tribian N, Bauerschlag DO, Maass N, van Mackelenbergh MT. Laparoscopic surgery for endometrial cancer is oncologically safe and improves hospital stay duration: a retrospective single-center study over a 16-year period. Arch Gynecol Obstet 2024:10.1007/s00404-024-07550-x. [PMID: 38789852 DOI: 10.1007/s00404-024-07550-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE To investigate changes in surgical procedures and patient outcomes of patients diagnosed with endometrial cancer (EC) at a German university hospital between 1998 and 2014. METHODS A monocentric, retrospective review was conducted to identify patients diagnosed and treated with EC during the aforementioned period at the Department of Gynecology and Obstetrics at the University Hospital Kiel, Germany. RESULTS 303 patients were identified. Patient demographics, risk factors, histological subtypes and stages of EC remained consistent over time. The most common surgical procedure was total abdominal hysterectomy (TAH) (81.9%). In 2011, the institution carried out its first total laparoscopic hysterectomy (TLH) for EC, resulting in a significant increase in laparoscopic surgical procedures (2011-2014: N = 70; TAH 44.2%; TLH 51.4%). Although the total number of lymph node stagings remained consistent over time, there was a significant increase in the performance of simultaneous pelvic and para-aortic lymphonodectomy (LNE) compared to pelvic LNE alone (2.6 in 2001-2005 vs. 18.0% in 2011-2014, p ≤ 0.001). The duration of hospital stays significantly decreased over time, with a mean of 20.9 days in the first and 8.5 days in the last period. When comparing surgical procedures, TLHs resulted in significantly shorter postoperative stays with an average of 6.58 vs. 13.92 days for TAH. The surgical procedure performed did not affect 5-year overall survival rates in this study (84.9% for TAH and 85.3% for TLH, p = 0.85). CONCLUSIONS Our retrospective single-center study demonstrates that laparoscopic surgery for endometrial cancer is oncologically safe and shortens hospital stays.
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Affiliation(s)
- Anna-Christina Rambow
- Department of Gynecology and Obstetrics, University Hospital Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany.
| | - Moritz Nikolai
- Department of Gynecology and Obstetrics, University Hospital Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Peer Jansen
- Department of Gynecology and Obstetrics, University Hospital Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Christoph Rogmans
- Department of Gynecology and Obstetrics, University Hospital Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Nils Tribian
- Department of Gynecology and Obstetrics, University Hospital Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Dirk O Bauerschlag
- Department of Gynecology and Obstetrics, University Hospital Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Nicolai Maass
- Department of Gynecology and Obstetrics, University Hospital Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Marion T van Mackelenbergh
- Department of Gynecology and Obstetrics, University Hospital Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
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Rios-Doria E, Abu-Rustum NR, Alektiar KM, Makker V, Liu YL, Zamarin D, Friedman CF, Aghajanian C, Ellenson LH, Chiang S, Weigelt B, Mueller JJ, Leitao MM. Prognosis of isolated tumor cells and use of molecular classification in early stage endometrioid endometrial cancer. Int J Gynecol Cancer 2024:ijgc-2024-005522. [PMID: 38782452 DOI: 10.1136/ijgc-2024-005522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Abstract
OBJECTIVE We assessed the prognosis and molecular subtypes of early stage endometrioid endometrial cancer with isolated tumor cells within sentinel lymph nodes (SLNs) compared with node negative disease. METHODS Patients diagnosed with stage IA, IB, or II endometrioid endometrial cancer and primary surgical management were identified from January 1, 2007 to December 31, 2019. All SLNs underwent ultrastaging according to the institutional protocol. Patients with cytokeratin positive cells, micrometastases, and macrometastases were excluded. Clinical, pathology, and molecular subtype data were reviewed. RESULTS Overall, 1214 patients with early stage endometrioid endometrial cancer met the inclusion criteria, of whom 1089 (90%) had node negative disease and 125 (10%) had isolated tumor cells. Compared with node negative disease, the presence of isolated tumor cells had a greater association with deep myometrial invasion, lymphovascular space invasion, receipt of adjuvant therapy, and adjuvant chemotherapy with or without radiation (p<0.01). There was no significant difference in survival rates between patients with isolated tumor cells and node negative disease (3 year progression free survival rate 94% vs 91%, respectively, p=0.21; 3 year overall survival rate 98% vs 96%, respectively, p=0.45). Progression free survival did not significantly differ among patients with isolated tumor cells who received no adjuvant therapy or chemotherapy with or without radiation (p=0.31). There was no difference in the distribution of molecular subtypes between patients with isolated tumor cells (n=28) and node negative disease (n=194; p=0.26). Three year overall survival rates differed significantly when stratifying the entire cohort by molecular subtype (p=0.04). CONCLUSIONS Patients with isolated tumor cells demonstrated less favorable uterine pathologic features and received more adjuvant treatment with similar survival compared with patients with nodenegative disease. Among the available data, molecular classification did not have a significant association with the presence of isolated tumor cells, although copy number-high status was a poor prognostic indicator in early stage endometrioid endometrial cancer.
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Affiliation(s)
- Eric Rios-Doria
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nadeem R Abu-Rustum
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of OB/GYN, Weill Cornell Medical College, New York, New York, USA
| | - Kaled M Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vicky Makker
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Ying L Liu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Dmitriy Zamarin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Claire F Friedman
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Carol Aghajanian
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Lora H Ellenson
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sarah Chiang
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Britta Weigelt
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jennifer J Mueller
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of OB/GYN, Weill Cornell Medical College, New York, New York, USA
| | - Mario M Leitao
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of OB/GYN, Weill Cornell Medical College, New York, New York, USA
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Matsuura M, Nagao S, Kurokawa S, Tamate M, Akimoto T, Saito T. Surgical Outcomes of da Vinci Xi™ and da Vinci SP™ for Early-Stage Endometrial Cancer in Patients Undergoing Hysterectomy. J Clin Med 2024; 13:2864. [PMID: 38792405 PMCID: PMC11122509 DOI: 10.3390/jcm13102864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
Objectives: This study aimed to evaluate and compare the feasibility and outcomes of two robotic hysterectomy (da Vinci Xi™ vs. da Vinci SP™) systems without lymph node dissection in patients with early-stage endometrial cancer, and assess the postoperative recurrence rate and overall survival of patients. Methods: A retrospective review of 84 patients who underwent robotic hysterectomy for endometrial cancer (stage 1A) was conducted. Surgical procedures, patient characteristics, intraoperative measures, and postoperative outcomes were statistically analyzed. A single gynecologist performed all surgeries. Results: Patient characteristics, average age, and body mass index showed no significant differences between the two models. The total operative time was significantly shorter with da Vinci SP™. Recurrence was identified in only one patient operated on with da Vinci Xi™. All patients were alive during analysis, with a median overall survival of 38 and 9 months for da Vinci Xi™ and da Vinci SP™, respectively. Conclusions: Robotic hysterectomy without lymph node dissection appears to be a safe and effective approach for patients with early-stage endometrial cancer. The da Vinci SP offers the advantage of shorter operative times than the da Vinci Xi™. These findings support the consideration of robotic surgery as a viable option for selected patients.
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Affiliation(s)
- Motoki Matsuura
- Department of Obstetrics and Gynecology, Sapporo Medical University, Sapporo 060-8556, Japan; (S.N.); (S.K.); (M.T.); (T.A.); (T.S.)
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Horala A, Szubert S, Nowak-Markwitz E. Range of Resection in Endometrial Cancer-Clinical Issues of Made-to-Measure Surgery. Cancers (Basel) 2024; 16:1848. [PMID: 38791927 PMCID: PMC11120042 DOI: 10.3390/cancers16101848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/20/2024] [Accepted: 04/24/2024] [Indexed: 05/26/2024] Open
Abstract
Endometrial cancer (EC) poses a significant health issue among women, and its incidence has been rising for a couple of decades. Surgery remains its principal treatment method and may have a curative, staging, or palliative aim. The type and extent of surgery depends on many factors, and the risks and benefits should be carefully weighed. While simple hysterectomy might be sufficient in early stage EC, modified-radical hysterectomy is sometimes indicated. In advanced disease, the evidence suggests that, similarly to ovarian cancer, optimal cytoreduction improves survival rate. The role of lymphadenectomy in EC patients has long been a controversial issue. The rationale for systematic lymphadenectomy and the procedure of the sentinel lymph node biopsy are thoroughly discussed. Finally, the impact of the molecular classification and new International Federation of Gynecology and Obstetrics (FIGO) staging system on EC treatment is outlined. Due to the increasing knowledge on the pathology and molecular features of EC, as well as the new advances in the adjuvant therapies, the surgical management of EC has become more complex. In the modern approach, it is essential to adjust the extent of the surgery to a specific patient, ensuring an optimal, made-to-measure personalized surgery. This narrative review focuses on the intricacies of surgical management of EC and aims at summarizing the available literature on the subject, providing an up-to-date clinical guide.
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Affiliation(s)
- Agnieszka Horala
- Division of Gynaecological Oncology, Department of Gynaecology, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (S.S.); (E.N.-M.)
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Qi L, Zhao M, Li W, Mu N, Yang Y, Yang Z, Lin A. Development and validation of a nomogram for predicting specific mortality risk: A study of competing risk model based on real endometrial cancer patients. J Obstet Gynaecol Res 2024. [PMID: 38710649 DOI: 10.1111/jog.15957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 04/10/2024] [Indexed: 05/08/2024]
Abstract
OBJECTIVE This study aimed to construct a competing risk prediction model for predicting specific mortality risks in endometrial cancer patients from the SEER database based on their demographic characteristics and tumor information. METHODS We collected relevant clinical data on patients with histologically confirmed endometrial cancer in the SEER database between 2010 and 2015. Univariate and multivariate competing risk models were used to analyze the risk factors for endometrial cancer-specific death, and a predictive nomogram was constructed. C-index and receiver operating characteristic curve (ROC) at different time points were used to verify the accuracy of the constructed nomogram. RESULTS There were 26 109 eligible endometrial cancer patients in the training cohort and 11 189 in the validation cohort. Univariate and multivariate analyses revealed that Age, Marriage, Grade, Behav, FIGO, Size, Surgery, SurgOth, Radiation, ParaAortic_Nodes, Peritonea, N positive, DX_liver, and DX_lung were independent prognostic factors for specific mortality in endometrial cancer patients. Based on these factors, a nomogram was constructed. Internal validation showed that the nomogram had a good discriminative ability (C-index = 0.883 [95% confidence interval [CI]: 0.881-0.884]), and the 1-, 3-, and 5-year AUC values were 0.901, 0.886 and 0.874, respectively. External validation indicated similar results (C-index = 0.883 [95%CI: 0.882-0.883]), and the 1-, 3-, and 5- AUC values were 0.908, 0.885 and 0.870, respectively. CONCLUSION We constructed a competing risk model to predict the specific mortality risk among endometrial cancer patients. This model has favorable accuracy and reliability and can provide a reference for the development and update of endometrial cancer prognostic risk assessment tools.
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Affiliation(s)
- Lin Qi
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong Province, People's Republic of China
| | - Manyin Zhao
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong Province, People's Republic of China
| | - Wenshu Li
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong Province, People's Republic of China
| | - Nan Mu
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong Province, People's Republic of China
| | - Yukun Yang
- HongQi Hospital Affiliated to Mudanjiang Medical University, China
| | - Zhaojie Yang
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong Province, People's Republic of China
| | - Aimin Lin
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong Province, People's Republic of China
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Jeong S, Jeon OH, Hong JH, Kim K, Kim BM, Park JY, Kim K, Cho HW, Kim HK. Detection of metastatic lymph node and sentinel lymph node mapping using mannose receptor targeting in in vivo mouse footpad tumor models and rabbit uterine cancer models. Int J Surg 2024; 110:2692-2700. [PMID: 38377062 DOI: 10.1097/js9.0000000000001227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/13/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND This study aimed to evaluate the effectiveness of neo-mannosyl human serum albumin-indocyanine green (MSA-ICG) for detecting metastatic lymph node (LN) and mapping sentinel lymph node (SLN) using mouse footpad uterine tumor models. Additionally, the authors assessed the feasibility of MSA-ICG in SLN mapping in rabbit uterine cancer models. MATERIALS AND METHODS The authors compared the LN targeting ability of MSA-ICG with ICG. Six mouse footpad tumor models and two normal mice were each assigned to MSA-ICG and ICG, respectively. After the assigned tracers were injected, fluorescence images were taken, and the authors compared the signal-to-background ratio (SBR) of the tracers. A SLN biopsy was performed to confirm LN metastasis status and CD206 expression level. Finally, an intraoperative SLN biopsy was performed in rabbit uterine cancer models using MSA-ICG. RESULTS The authors detected 14 groin LNs out of 16 in the MSA-ICG and ICG groups. The SBR of the MSA-ICG group was significantly higher than that of the ICG group. The metastatic LN subgroup of MSA-ICG showed a significantly higher SBR than that of ICG. CD206 was expressed at a high level in metastatic LN, and the signal intensity difference increased as the CD206 expression level increased. SLN mapping was successfully performed in two of the three rabbit uterine cancer models. CONCLUSIONS MSA-ICG was able to distinguish metastatic LN for an extended period due to its specific tumor-associated macrophage-targeting property. Therefore, it may be a more distinguishable tracer for identifying metastatic LNs and SLNs during uterine cancer surgery. Further research is needed to confirm these results.
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Affiliation(s)
- Sohyeon Jeong
- Department of Obstetrics and Gynecology, Korea University Guro Hospital
| | - Ok Hwa Jeon
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine
- Department of Biomedical Sciences, Korea University College of Medicine
| | - Jin Hwa Hong
- Department of Obstetrics and Gynecology, Korea University Guro Hospital
| | - Kyungsu Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine
- Department of Biomedical Sciences, Korea University College of Medicine
| | | | - Ji Yong Park
- Department of Nuclear Medicine, College of Medicine, Seoul National University
| | - Kweon Kim
- Cellbion Co., Ltd., Seoul, Republic of Korea
| | - Hyun-Woong Cho
- Department of Obstetrics and Gynecology, Korea University Guro Hospital
| | - Hyun Koo Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine
- Department of Biomedical Sciences, Korea University College of Medicine
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11
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Jaafar E, Gaultier V, Wohrer H, Estevez JP, Gonthier C, Koskas M. Impact of sentinel lymph node mapping on survival in patients with high-risk endometrial cancer in the early stage: A matched cohort study. Int J Gynaecol Obstet 2024; 165:677-684. [PMID: 38226675 DOI: 10.1002/ijgo.15315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/06/2023] [Indexed: 01/17/2024]
Abstract
OBJECTIVE The aim of this study was to compare patient survival using sentinel lymph node (SLN) procedure and pelvic lymphadenectomy for stating early-stage high risk endometrial cancer. METHODS Patients who underwent surgery for early-stage high risk endometrial cancer between 2010 and 2017 were extracted from the incidence registry of the SEER program. We identified patients who underwent SLN mapping. Patients who initially underwent pelvic lymphadenectomy were selected as the comparison group. One-to-one matching was performed according to age, ethnicity, histology, extension and grade. The primary outcome was disease-specific survival. The secondary outcome was overall survival. RESULTS A total of 326 patients who underwent SLN mapping and 326 who underwent pelvic lymphadenectomy initially were included in the study. The three-year analysis did not find a significant difference between the SLN and lymphadenectomy groups on disease-specific survival probability (88.2% vs 82.7, P = 0.07) and on overall survival probability (82.7% vs 78.2%, P = 0.57). Patients who underwent SLN mapping had a lower mean number of lymph nodes removed (mean 3 vs 16, P < 0.001) and there was a higher rate of patients with positive pelvic lymph nodes (18% vs 14%, P = 0.04). Following adjustment for confounding factors, disease-specific survival did not vary according to the lymph node intervention performed (P = 0.056), but the SLN group had better overall survival than those in the lymphadenectomy group (P = 0.047). CONCLUSION The SLN technique was not associated with poorer disease-specific survival than pelvic lymphadenectomy even after adjustment. These results suggest that SLN is an acceptable and safe procedure in surgical staging for early-stage high-risk endometrial cancer.
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Affiliation(s)
- Eya Jaafar
- Gynecological Department, Bichat Hospital, Paris Diderot University, Paris, France
| | - Victor Gaultier
- Gynecological Department, Bichat Hospital, Paris Diderot University, Paris, France
- Gynecological Department, University Paris Cité, Paris, France
| | - Henri Wohrer
- Gynecological Department, Bichat Hospital, Paris Diderot University, Paris, France
- Gynecological Department, University Paris Cité, Paris, France
| | - Juan Pablo Estevez
- Gynecological Department, Bichat Hospital, Paris Diderot University, Paris, France
| | - Clementine Gonthier
- Gynecological Department, Bichat Hospital, Paris Diderot University, Paris, France
| | - Martin Koskas
- Gynecological Department, Bichat Hospital, Paris Diderot University, Paris, France
- Gynecological Department, University Paris Cité, Paris, France
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12
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Matsumoto YK, Himoto Y, Nishio M, Kikkawa N, Otani S, Ito K, Yamanoi K, Kato T, Fujimoto K, Kurata Y, Moribata Y, Yoshida H, Minamiguchi S, Mandai M, Kido A, Nakamoto Y. Nodal infiltration in endometrial cancer: a prediction model using best subset regression. Eur Radiol 2024; 34:3375-3384. [PMID: 37882835 DOI: 10.1007/s00330-023-10310-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 07/17/2023] [Accepted: 08/17/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVES To build preoperative prediction models with and without MRI for regional lymph node metastasis (r-LNM, pelvic and/or para-aortic LNM (PENM/PANM)) and for PANM in endometrial cancer using established risk factors. METHODS In this retrospective two-center study, 364 patients with endometrial cancer were included: 253 in the model development and 111 in the external validation. For r-LNM and PANM, respectively, best subset regression with ten-time fivefold cross validation was conducted using ten established risk factors (4 clinical and 6 imaging factors). Models with the top 10 percentile of area under the curve (AUC) and with the fewest variables in the model development were subjected to the external validation (11 and 4 candidates, respectively, for r-LNM and PANM). Then, the models with the highest AUC were selected as the final models. Models without MRI findings were developed similarly, assuming the cases where MRI was not available. RESULTS The final r-LNM model consisted of pelvic lymph node (PEN) ≥ 6 mm, deep myometrial invasion (DMI) on MRI, CA125, para-aortic lymph node (PAN) ≥ 6 mm, and biopsy; PANM model consisted of DMI, PAN, PEN, and CA125 (in order of correlation coefficient β values). The AUCs were 0.85 (95%CI: 0.77-0.92) and 0.86 (0.75-0.94) for the external validation, respectively. The model without MRI for r-LNM and PANM showed AUC of 0.79 (0.68-0.89) and 0.87 (0.76-0.96), respectively. CONCLUSIONS The prediction models created by best subset regression with cross validation showed high diagnostic performance for predicting LNM in endometrial cancer, which may avoid unnecessary lymphadenectomies. CLINICAL RELEVANCE STATEMENT The prediction risks of lymph node metastasis (LNM) and para-aortic LNM can be easily obtained for all patients with endometrial cancer by inputting the conventional clinical information into our models. They help in the decision-making for optimal lymphadenectomy and personalized treatment. KEY POINTS •Diagnostic performance of lymph node metastases (LNM) in endometrial cancer is low based on size criteria and can be improved by combining with other clinical information. •The optimized logistic regression model for regional LNM consists of lymph node ≥ 6 mm, deep myometrial invasion, cancer antigen-125, and biopsy, showing high diagnostic performance. •Our model predicts the preoperative risk of LNM, which may avoid unnecessary lymphadenectomies.
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Affiliation(s)
- Yuka Kuriyama Matsumoto
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yuki Himoto
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Mizuho Nishio
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Nao Kikkawa
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Otani
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Kimiteru Ito
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Yamanoi
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoyasu Kato
- Department of Gynecology, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Fujimoto
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yasuhisa Kurata
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yusaku Moribata
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Hiroshi Yoshida
- Department of Diagnostic Pathology, National Cancer Center Hospital, Tokyo, Japan
| | - Sachiko Minamiguchi
- Department of Diagnostic Pathology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masaki Mandai
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Aki Kido
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
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13
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Molnar O, Straciuc OM, Mihuțiu S, Lazăr L. Impact of PET/CT Imaging with FDG in Locally Advanced Cervical Carcinoma-A Literature Review. Curr Oncol 2024; 31:2508-2526. [PMID: 38785469 PMCID: PMC11119194 DOI: 10.3390/curroncol31050188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 04/27/2024] [Accepted: 04/28/2024] [Indexed: 05/25/2024] Open
Abstract
Positron emission tomography (PET) and computed tomography (CT) have evolved as a pivotal diagnostic modality in the field of oncology. With its increasing application in staging and ready availability, it becomes imperative for committed radiation oncologists to possess a complete analysis and understanding of integration of molecular imaging, which can be helpful for radiation planning, while also acknowledging its possible limitations and challenges. A significant obstacle lies in the synthesis and design of tumor-specific bmolecules for diagnosing and treating cancer. The utilization of radiation in medical biochemistry and biotechnology, encompassing diagnosis, therapy, and control of biological systems, is encapsulated under the umbrella term "nuclear medicine". Notably, the application of various radioisotopes in pharmaceutics has garnered significant attention, particularly in the realm of delivery systems for drugs, DNA, and imaging agents. The present article provides a comprehensive review of use of novel techniques PET and CT with major positron-emitting radiopharmaceuticals currently in progress or utilized in clinical practice with their integration into imaging and radiation therapy.
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Affiliation(s)
- Ottó Molnar
- Doctoral Studies Department, Biomedical Science, 410087 Oradea, Romania
| | - Oreste Mihai Straciuc
- Doctoral Studies Department, Biomedical Science, 410087 Oradea, Romania
- Centrul PET/CT Pozitron Diagnosztika, 410035 Oradea, Romania
| | - Simona Mihuțiu
- Department of Medicine-Psycho-Neuroscience and Recovery, Faculty of Medicine and Pharmacy, 410073 Oradea, Romania
- Oncology Department, Pelican Hospital, 410469 Oradea, Romania
| | - Liviu Lazăr
- Doctoral Studies Department, Biomedical Science, 410087 Oradea, Romania
- Department of Medicine-Psycho-Neuroscience and Recovery, Faculty of Medicine and Pharmacy, 410073 Oradea, Romania
- Băile Felix Medical Rehabilitation Hospital, 417500 Băile Felix, Romania
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14
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Bizoń M, Olszewski M, Grabowska A, Siudek J, Mawlichanów K, Pilka R. Efficacy of Single- and Dual-Docking Robotic Surgery of Paraaortic and Pelvic Lymphadenectomy in High-Risk Endometrial Cancer. J Pers Med 2024; 14:441. [PMID: 38793024 PMCID: PMC11122409 DOI: 10.3390/jpm14050441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/07/2024] [Accepted: 04/15/2024] [Indexed: 05/26/2024] Open
Abstract
(1) The surgical method of choice for the treatment of endometrial cancer is minimally invasive surgery. In cases of high-risk endometrial cancer, completed paraaortic and pelvic lymphadenectomy are indicated. The aim of this study was to analyze the types of docking during robotic surgery assisted with the da Vinci X system while performing paraaortic and pelvic lymphadenectomy. (2) Methods: A total of 25 patients with high-risk endometrial cancer, with a mean age of 60.07 ± 10.67 (range 34.69-83.23) years, and with a mean body mass index (BMI) of 28.4 ± 5.62 (range 18-41.5) kg/m2, were included in this study. The analyzed population was divided into groups that underwent single or dual docking during surgery. (3) Results: No statistical significance was observed between single and dual docking during paraaortic and pelvic lymphadenectomy and between the type of docking and the duration of the operation. However, there was a statistically significant correlation between the duration of the operation and previous surgery (p < 0.005). The number of removed lymph nodes was statistically associated with BMI (p < 0.005): 15.87 ± 6.83 and 24.5 ± 8.7 for paraaortic and pelvic lymph nodes, respectively, in cases of single docking, and 18.05 ± 7.92 and 24.88 ± 11.75 for paraaortic and pelvic lymph nodes, respectively, in cases of dual docking. (4) Conclusions: The robot-assisted approach is a good surgical method for lymphadenectomy for obese patients, and, despite the type of docking, there are no differences in the quality of surgery.
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Affiliation(s)
- Magdalena Bizoń
- LUX MED Oncology Hospital, św. Wincentego 103, 03-291 Warsaw, Poland;
- Faculty of Medicine, Lazarski University, 02-662 Warsaw, Poland
- Neo Hospital, Kostrzewskiego 47, 30-437 Cracow, Poland
| | - Maciej Olszewski
- LUX MED Oncology Hospital, św. Wincentego 103, 03-291 Warsaw, Poland;
- Faculty of Medicine, Lazarski University, 02-662 Warsaw, Poland
- Neo Hospital, Kostrzewskiego 47, 30-437 Cracow, Poland
| | | | - Joanna Siudek
- Neo Hospital, Kostrzewskiego 47, 30-437 Cracow, Poland
- Faculty of Mechanical Engineering, Cracow University of Technology, Al. Jana Pawła II 37, 31-864 Cracow, Poland
| | - Krzysztof Mawlichanów
- Neo Hospital, Kostrzewskiego 47, 30-437 Cracow, Poland
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Cracow, Poland
| | - Radovan Pilka
- Neo Hospital, Kostrzewskiego 47, 30-437 Cracow, Poland
- Department of Obstetrics and Gynecology, University Hospital, Palacky University Olomouc, 779 00 Olomouc, Czech Republic
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15
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Sun Y, Han P, Wang Y, Cheng X, Wu W, Liu Q, Ren F. Risk assessment of extra-uterine involvement and prognosis in young type I endometrial carcinoma with high or moderate differentiation and less than 1/2 myometrial invasion. Aging (Albany NY) 2024; 16:6445-6454. [PMID: 38575312 PMCID: PMC11042967 DOI: 10.18632/aging.205714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/27/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE The aim of this study was to investigate whether young patients with endometrial carcinoma can preserve adnexa and lymph nodes to improve their quality of life without compromising their prognosis. METHODS A total of 319 patients with type I endometrial carcinoma (high or moderate differentiation and less than 1/2 myometrial invasion) hospitalized in the First Affiliated Hospital of Zhengzhou University from May 2012 to July 2021 were included. The patients were divided into four groups: high differentiation without myometrial invasion group (G1MI-), high differentiation with superficial myometrial invasion group (G1MI+), moderate differentiation without myometrial invasion group (G2MI-), and moderate differentiation with superficial myometrial invasion group (G2MI+). Logistic regression analysis was conducted to identify risk factors for extra-uterine involvement. Kaplan-Meier method was used to draw the survival curve to compare the prognosis in subgroups and rates of extra-uterine involvement were also compared using Chi-square test or Fisher's exact test. RESULTS Multivariable logistic regression revealed that differentiation (HR = 14.590, 95%CI = 1.778-119.754, p = 0.013) and myometrial invasion (HR = 10.732, 95%CI = 0.912-92.780, p = 0.037) were the independent risk factors for extra-uterine involvement. The overall difference was statistically significant (p < 0.001). In the subgroups analysis, both adnexal metastasis and lymph node metastasis were statistically significant in the G2MI+ group compared with G1MI- (p = 0.007, p = 0.008). There were no significant differences in the overall survival (OS) rate and progression free survival (PFS) rate among the four subgroups (p > 0.05). CONCLUSIONS Surgery with adnexal preservation and without systematic lymphadenectomy could be employed for the patients who are high differentiation with less than 1/2 myometrial invasion or moderate differentiation without myometrial invasion, but not recommended to the patients with moderate differentiation and superficial myometrial invasion.
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Affiliation(s)
- Yi Sun
- Deparment of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Pin Han
- Deparment of Gynecology, The Luoyang Maternal and Child Health Care Hospital, Luoyang 471000, China
| | - Yuanpei Wang
- Deparment of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Xiaoran Cheng
- Deparment of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Weijia Wu
- Deparment of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Qianwen Liu
- Deparment of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Fang Ren
- Deparment of Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
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16
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Fan MS, Qiu KX, Wang DY, Wang H, Zhang WW, Yan L. Risk factors associated with false negative rate of sentinel lymph node biopsy in endometrial cancer: a systematic review and meta-analysis. Front Oncol 2024; 14:1391267. [PMID: 38634055 PMCID: PMC11021692 DOI: 10.3389/fonc.2024.1391267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 03/19/2024] [Indexed: 04/19/2024] Open
Abstract
Objective Currently, sentinel lymph node biopsy (SLNB) is increasingly used in endometrial cancer, but the rate of missed metastatic lymph nodes compared to systemic lymph node dissection has been a concern. We conducted a systematic review and meta-analysis to evaluate the false negative rate (FNR) of SLNB in patients with endometrial cancer and to explore the risk factors associated with this FNR. Data sources Three databases (PubMed, Embase, Web of Science) were searched from initial database build to January 2023 by two independent reviewers. Research eligibility criteria Studies were included if they included 10 or more women diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I or higher endometrial cancer, the study technique used sentinel lymph node localization biopsy, and the reported outcome metrics included false negative and/or FNR. Study appraisal and synthesis methods Two authors independently reviewed the abstracts and full articles. The FNR and factors associated with FNR were synthesized through random-effects meta-analyses and meta-regression. The results We identified 62 eligible studies. The overall FNR for the 62 articles was 4% (95% CL 3-5).There was no significant difference in the FNR in patients with high-risk endometrial cancer compared to patients with low-risk endometrial cancer. There was no difference in the FNR for whether frozen sections were used intraoperatively. The type of dye used intraoperatively (indocyanine green/blue dye) were not significantly associated with the false negative rate. Cervical injection reduced the FNR compared with alternative injection techniques. Indocyanine green reduced the FNR compared with alternative Tc-99m. Postoperative pathologic ultrastaging reduced the FNR. Conclusions Alternative injection techniques (other than the cervix), Tc-99m dye tracer, and the absence of postoperative pathologic ultrastaging are risk factors for a high FNR in endometrial cancer patients who undergo SLNB; therefore, we should be vigilant for missed diagnosis of metastatic lymph nodes after SLNB in such populations. Systematic review registration http://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023433637.
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Affiliation(s)
- Meng-si Fan
- Department of Gynecology, Shandong Provincial Qianfoshan Hospital, Shandong Second Medical University, Key Laboratory of Laparoscopic Technology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Ke-xin Qiu
- Department of Gynecology, Shandong Provincial Qianfoshan Hospital, Shandong Second Medical University, Key Laboratory of Laparoscopic Technology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Dong-yue Wang
- School of Clinical Medicine, Shandong First Medical University, Jinan, China
| | - Hao Wang
- School of Clinical Medicine, Shandong First Medical University, Jinan, China
| | - Wei-wei Zhang
- Department of Gynecology, Tengzhou Maternal and Child Health Hospital, Tengzhou, Shandong, China
| | - Li Yan
- Department of Gynecology, Shandong Provincial Qianfoshan Hospital, Shandong Second Medical University, Key Laboratory of Laparoscopic Technology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
- Department of Gynecology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
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Pavone M, Jochum F, Lecointre L, Fanfani F, Scambia G, Querleu D, Akladios C. Therapeutic role of para-aortic lymphadenectomy in patients with intermediate- and high-risk endometrial cancer: a systematic review and meta-analysis. Int J Gynecol Cancer 2024; 34:519-527. [PMID: 38296516 DOI: 10.1136/ijgc-2023-005134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
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.
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Affiliation(s)
- Matteo Pavone
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- Dipartimento di Scienze per la Salute della Donna e del Bambino e di Sanità Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Floriane Jochum
- Department of Gynecology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Lise Lecointre
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- Department of Gynecology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Francesco Fanfani
- Dipartimento di Scienze per la Salute della Donna e del Bambino e di Sanità Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Giovanni Scambia
- Dipartimento di Scienze per la Salute della Donna e del Bambino e di Sanità Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Denis Querleu
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- Dipartimento di Scienze per la Salute della Donna e del Bambino e di Sanità Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Chérif Akladios
- Department of Gynecology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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18
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Fumagalli D, De Vitis LA, Caruso G, Occhiali T, Palmieri E, Guillot BE, Pappalettera G, Langstraat CL, Glaser GE, Reynolds EA, Fruscio R, Landoni F, Mariani A, Grassi T. Low-Volume Metastases in Apparent Early-Stage Endometrial Cancer: Prevalence, Clinical Significance, and Future Perspectives. Cancers (Basel) 2024; 16:1338. [PMID: 38611016 PMCID: PMC11011093 DOI: 10.3390/cancers16071338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Endometrial cancer (EC) is the most diagnosed gynecologic malignancy, and its incidence and mortality are increasing. The prognosis is highly dependent on the disease spread. Surgical staging includes retroperitoneal evaluation to detect potential lymph node metastases. In recent years, systematic lymphadenectomy has been replaced by sentinel lymph node (SLN) biopsy and ultrastaging, allowing for the detection of macrometastases, micrometastases, and isolated tumor cells (ITCs). Micrometastases and ITCs have been grouped as low-volume metastases (LVM). The reported prevalence of LVM in studies enrolling more than one thousand patients with apparent early-stage EC ranges from 1.9% to 10.2%. Different rates of LVM are observed when patients are stratified according to disease characteristics and their risk of recurrence. Patients with EC at low risk for recurrence have low rates of LVM, while intermediate- and high-risk patients have a higher likelihood of being diagnosed with nodal metastases, including LVM. Macro- and micrometastases increase the risk of recurrence and cause upstaging, while the clinical significance of ITCs is still uncertain. A recent meta-analysis found that patients with LVM have a higher relative risk of recurrence [1.34 (95% CI: 1.07-1.67)], regardless of adjuvant treatment. In a retrospective study on patients with low-risk EC and no adjuvant treatment, those with ITCs had worse recurrence-free survival compared to node-negative patients (85.1%; CI 95% 73.8-98.2 versus 90.2%; CI 95% 84.9-95.8). However, a difference was no longer observed after the exclusion of cases with lymphovascular space invasion. There is no consensus on adjuvant treatment in ITC patients at otherwise low risk, and their recurrence rate is low. Multi-institutional, prospective studies are warranted to evaluate the clinical significance of ITCs in low-risk patients. Further stratification of patients, considering histopathological and molecular features of the disease, may clarify the role of LVM and especially ITCs in specific contexts.
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Affiliation(s)
- Diletta Fumagalli
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (R.F.); (F.L.)
| | - Luigi A. De Vitis
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy
| | - Giuseppe Caruso
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy
| | - Tommaso Occhiali
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Clinic of Obstetrics and Gynecology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy
| | - Emilia Palmieri
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Gynecologic Oncology Unit, Department of Women, Children and Public Health Sciences, , Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00136 Roma, Italy
| | - Benedetto E. Guillot
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy
| | - Giulia Pappalettera
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy
| | - Carrie L. Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
| | - Gretchen E. Glaser
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
| | - Evelyn A. Reynolds
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
| | - Robert Fruscio
- Department of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (R.F.); (F.L.)
- Division of Gynecologic Surgery, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy
| | - Fabio Landoni
- Department of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (R.F.); (F.L.)
- Division of Gynecologic Surgery, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
| | - Tommaso Grassi
- Department of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (R.F.); (F.L.)
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Wang Y, Liu W, Lu Y, Ling R, Wang W, Li S, Zhang F, Ning Y, Chen X, Yang G, Zhang H. Fully Automated Identification of Lymph Node Metastases and Lymphovascular Invasion in Endometrial Cancer From Multi-Parametric MRI by Deep Learning. J Magn Reson Imaging 2024. [PMID: 38471960 DOI: 10.1002/jmri.29344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Early and accurate identification of lymphatic node metastasis (LNM) and lymphatic vascular space invasion (LVSI) for endometrial cancer (EC) patients is important for treatment design, but difficult on multi-parametric MRI (mpMRI) images. PURPOSE To develop a deep learning (DL) model to simultaneously identify of LNM and LVSI of EC from mpMRI images. STUDY TYPE Retrospective. POPULATION Six hundred twenty-one patients with histologically proven EC from two institutions, including 111 LNM-positive and 168 LVSI-positive, divided into training, internal, and external test cohorts of 398, 169, and 54 patients, respectively. FIELD STRENGTH/SEQUENCE T2-weighted imaging (T2WI), contrast-enhanced T1WI (CE-T1WI), and diffusion-weighted imaging (DWI) were scanned with turbo spin-echo, gradient-echo, and two-dimensional echo-planar sequences, using either a 1.5 T or 3 T system. ASSESSMENT EC lesions were manually delineated on T2WI by two radiologists and used to train an nnU-Net model for automatic segmentation. A multi-task DL model was developed to simultaneously identify LNM and LVSI positive status using the segmented EC lesion regions and T2WI, CE-T1WI, and DWI images as inputs. The performance of the model for LNM-positive diagnosis was compared with those of three radiologists in the external test cohort. STATISTICAL TESTS Dice similarity coefficient (DSC) was used to evaluate segmentation results. Receiver Operating Characteristic (ROC) analysis was used to assess the performance of LNM and LVSI status identification. P value <0.05 was considered significant. RESULTS EC lesion segmentation model achieved mean DSC values of 0.700 ± 0.25 and 0.693 ± 0.21 in the internal and external test cohorts, respectively. For LNM positive/LVSI positive identification, the proposed model achieved AUC values of 0.895/0.848, 0.806/0.795, and 0.804/0.728 in the training, internal, and external test cohorts, respectively, and better than those of three radiologists (AUC = 0.770/0.648/0.674). DATA CONCLUSION The proposed model has potential to help clinicians to identify LNM and LVSI status of EC patients and improve treatment planning. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Yida Wang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
| | - Wei Liu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Yuanyuan Lu
- Department of Radiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Rennan Ling
- Department of Radiology, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, First Affiliated Hospital of Southern University of Science and Technology, Shanghai, China
| | - Wenjing Wang
- Department of Radiology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shengyong Li
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
| | - Feiran Zhang
- Department of Pathology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Yan Ning
- Department of Pathology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xiaojun Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Guang Yang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
| | - He Zhang
- Department of Radiology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
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Glaser GE, Dowdy SC. Sentinel lymph node biopsy in high-risk endometrial cancer: The dénouement. Gynecol Oncol 2024; 182:A1-A2. [PMID: 38521580 DOI: 10.1016/j.ygyno.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Affiliation(s)
- Gretchen E Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Healthcare Deliver, Mayo Clinic, Rochester, MN, USA.
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Leone Roberti Maggiore U, Spanò Bascio L, Alboni C, Chiarello G, Savelli L, Bogani G, Martinelli F, Chiappa V, Ditto A, Raspagliesi F. Sentinel lymph node biopsy in endometrial cancer: When, how and in which patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107956. [PMID: 38286085 DOI: 10.1016/j.ejso.2024.107956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/27/2023] [Accepted: 01/08/2024] [Indexed: 01/31/2024]
Abstract
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.
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Affiliation(s)
| | - Ludovica Spanò Bascio
- Obstetrics and Gynecology, Policlinico Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Carlo Alboni
- Obstetrics and Gynecology, Policlinico Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Chiarello
- Department of Biomedical Sciences and Human Oncology, University of Bari, Italy
| | - Luca Savelli
- Obstetrics and Gynecology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Giorgio Bogani
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Fabio Martinelli
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Valentina Chiappa
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Antonino Ditto
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Francesco Raspagliesi
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
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Rosati A, Vargiu V, Capozzi VA, Giannarelli D, Palmieri E, Baroni A, Perrone E, Berretta R, Cosentino F, Scambia G, Fanfani F. Concurrent endometrial cancer in atypical endometrial hyperplasia and the role of sentinel lymph nodes: clinical insights from a multicenter experience. Int J Gynecol Cancer 2024:ijgc-2023-005202. [PMID: 38431287 DOI: 10.1136/ijgc-2023-005202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
OBJECTIVE This study aimed to evaluate the prevalence of concurrent endometrial cancer in patients pre-operatively diagnosed with atypical endometrial hyperplasia undergoing hysterectomy. Additionally, we assessed the occurrence of high to intermediate-risk and high-risk tumors according to the ESGO-ESTRO-ESP classification. The study also compared surgical outcomes and complications between patients undergoing simple hysterectomy and those undergoing hysterectomy with sentinel lymph node biopsy. METHODS In this multicenter retrospective study, patients with a pre-operative diagnosis of atypical endometrial hyperplasia were identified and divided into two groups: Group 1, which included patients treated with total hysterectomy with or without bilateral salpingo-oophorectomy, and Group 2, where sentinel lymph node biopsy was incorporated into the standard surgical treatment. RESULTS Among 460 patients with atypical endometrial hyperplasia, 192 received standard surgical management (Group 1) and 268 underwent sentinel lymph node biopsy (Group 2). A total of 47.2% (95% CI 42.6% to 51.7%) of patients were upgraded to endometrial cancer on final histopathological examination. High to intermediate-risk and high-risk tumors constituted 12.3% and 9.2% in Group 2 and 7.4% and 3.7% in Group 1. Lymph node metastases were identified in 7.6% of patients with concurrent endometrial cancer who underwent nodal assessment with at least unilateral mapping. Of the 12 sentinel lymph node metastases, 75.0% were micrometastases, 16.7% macrometastases, and 8.3% isolated tumor cells. No significant differences were found in estimated blood loss, operative time, and intra-operative and post-operative complications between the two groups. The rate of patients undergoing sentinel lymph node biopsy doubled every 2 years (OR 2.010, p<0.001), reaching 79.1% in the last 2 years. CONCLUSION This study found a prevalence of concurrent endometrial cancer of 47.2%, and sentinel lymph node biopsy provided prognostic and therapeutic information in 60.8% of cases. It also allowed for the adjustment of adjuvant therapy in 12.3% of high to intermediate-risk patients without increasing operative time or complication rates.
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Affiliation(s)
- Andrea Rosati
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Virginia Vargiu
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | | | - Diana Giannarelli
- Facility of Epidemiology and Biostatistics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | | | - Emanuele Perrone
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Roberto Berretta
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Cosentino
- Department of Medicine and Health Sciences "Vincenzo Tiberio", Università degli Studi del Molise, Campobasso, Molise, Italy
| | - Giovanni Scambia
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Fanfani
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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Kim JH, Kim DY, Kim J, Noh JJ, Hwang WY, Baek MH, Choi MC, Joo WD, Lee YJ, Suh DH, Kim YB. Practice guidelines for management of uterine corpus cancer in Korea: a Korean Society of Gynecologic Oncology consensus statement. J Gynecol Oncol 2024; 35:e45. [PMID: 38216137 PMCID: PMC10948989 DOI: 10.3802/jgo.2024.35.e45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 12/16/2023] [Accepted: 12/20/2023] [Indexed: 01/14/2024] Open
Abstract
The Korean Society of Gynecologic Oncology (KSGO) had been making an effort to standardize and enhance the quality of domestic uterine corpus cancer treatment by developing updated clinical practice guidelines in 2021. The KSGO revised the guidelines based on a literature search using 4 key elements: Population, Intervention, Comparison, and Outcome framework. These elements include the evaluation of the efficacy and safety of immune checkpoint inhibitor treatment in recurrent/advanced endometrial cancer patients who have failed platinum-based chemotherapy, as well as the effect of combined treatment with trastuzumab in patients with HER2/neu-positive endometrial cancer. Additionally, the guideline assessed the efficacy and safety of omitting lymph node dissection in low-risk endometrial cancer patients, investigated the effect of sentinel lymph node mapping in early-stage endometrial cancer surgery, addressed the outcome of chemoradiation therapy as a postoperative treatment in patients with advanced (stage III-IVA) endometrial cancer, and explored the impact of initial treatment with immune checkpoint inhibitors on survival in patients with advanced or recurrent endometrial cancer patients.
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Affiliation(s)
- Ju-Hyun Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dae-Yeon Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Junhwan Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Joseph J Noh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Yeon Hwang
- Department of Obstetrics and Gynecology, School of Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Min-Hyun Baek
- Center for Gynecologic Cancer, National Cancer Center, Goyang, Korea
| | - Min Chul Choi
- Comprehensive Gynecologic Cancer Center, CHA Bundang Medical Center, College of Medicine, CHA University, Seongnam, Korea
| | - Won Duk Joo
- Comprehensive Gynecologic Cancer Center, CHA Bundang Medical Center, College of Medicine, CHA University, Seongnam, Korea
| | - Yong Jae Lee
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yong Beom Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
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Recio F, Scalise CB, Loar P, Lumish M, Berman T, Peddada A, Kalashnikova E, Rivero-Hinojosa S, Beisch T, Nicosia B, Farmer T, Dutta P, Malhotra M, ElNaggar AC, Liu MC, Vaccarello L, Holloway RW. Post-surgical ctDNA-based molecular residual disease detection in patients with stage I uterine malignancies. Gynecol Oncol 2024; 182:63-69. [PMID: 38262240 DOI: 10.1016/j.ygyno.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/20/2023] [Accepted: 12/25/2023] [Indexed: 01/25/2024]
Abstract
INTRODUCTION Among uterine malignancies, endometrial cancer (EC) is the most common cancer of the female reproductive tract. Traditionally, risk stratification in EC is determined by standard clinicopathological risk factors. Although circulating tumor DNA (ctDNA) has emerged as a prognostic biomarker in various malignancies, its clinical validity in EC remains to be established. METHODS In this analysis of real-world data, 267 plasma samples from 101 patients with stage I EC were analyzed using a tumor-informed ctDNA assay (Signatera™ bespoke mPCR-NGS). Patients were followed post-surgically and monitored with ctDNA testing for a median of 6.8 months (range: 0.37-19.1). RESULTS Patients who tested ctDNA-positive at both their first time point and longitudinally experienced inferior recurrence-free survival (RFS) (HR = 6.2; p = 0.0006 and HR = 15.5; p < 0.0001, respectively), and showed a recurrence rate of 58% and 52%, vs. 6% and 0%, respectively for the ctDNA-negative patients. Most ctDNA-positive patients had high-risk histologies or sarcoma, versus low-risk and high-intermediate risk (H-IR) EC. Furthermore, patients with high-risk histologies who were ctDNA-positive showed shorter RFS compared to those who tested negative (HR = 9.5; p = 0.007), and those who tested positive in the low/H-IR cohort (HR = 0.25; p = 0.04). Post-surgically, detectable ctDNA was highly prognostic of clinical outcome and remained the only significant risk factor for recurrence when adjusted for clinicopathological risk factors, such as histologic risk group, mismatch repair (MMR), and p53 status. CONCLUSION Incorporating ctDNA monitoring along with traditional known risk factors may aid in identifying patients with stage I EC who are at highest risk of recurrence, and possibly aid in treatment stratification.
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Affiliation(s)
- Fernando Recio
- AdventHealth Orlando Gynecologic Oncology, Orlando, FL, USA
| | | | | | | | - Tara Berman
- Inova Schar Cancer Institute, Fairfax, VA, USA
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Yamashita T, Itoh T, Asano T, Suina A, Nishimori M, Munakata S, Satoh H. 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. Int J Clin Oncol 2024; 29:222-231. [PMID: 38177623 PMCID: PMC10808438 DOI: 10.1007/s10147-023-02449-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/25/2023] [Indexed: 01/06/2024]
Abstract
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.
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Affiliation(s)
- Tsuyoshi Yamashita
- Department of Obstetrics and Gynecology, Hakodate Municipal Hospital, 1-10-1 Minato-Cho, Hakodate, Hokkaido, 041-8680, Japan.
| | - Takahiro Itoh
- Department of Obstetrics and Gynecology, Hakodate Municipal Hospital, 1-10-1 Minato-Cho, Hakodate, Hokkaido, 041-8680, Japan
| | - Takuya Asano
- Department of Obstetrics and Gynecology, Hakodate Municipal Hospital, 1-10-1 Minato-Cho, Hakodate, Hokkaido, 041-8680, Japan
| | - Asuka Suina
- Department of Obstetrics and Gynecology, Hakodate Municipal Hospital, 1-10-1 Minato-Cho, Hakodate, Hokkaido, 041-8680, Japan
| | - Mitsutaka Nishimori
- Department of Obstetrics and Gynecology, Hakodate Municipal Hospital, 1-10-1 Minato-Cho, Hakodate, Hokkaido, 041-8680, Japan
| | - Satoru Munakata
- Department of Pathology, Hakodate Municipal Hospital, 1-10-1 Minato-Cho, Hakodate, Hokkaido, 041-8680, Japan
| | - Hideki Satoh
- Department of Media Architecture, School of Systems Information Science, Future University Hakodate, 116-2 Kamedanakano-Cho, Hakodate, Hokkaido, 041-8655, Japan
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de Souza Nobrega F, Alvarenga-Bezerra V, Barbosa GB, Salim RC, Martins LM, de Cillo PE, de Moura Queiroz P, Moretti-Marques R. Vaginal hysterectomy for the treatment of low-risk endometrial cancer: Surgical technique, costs, and perioperative and oncologic results. Gynecol Oncol 2024; 181:76-82. [PMID: 38141534 DOI: 10.1016/j.ygyno.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVES This study aimed to describe an operative technique for vaginal hysterectomy (VH) and assess the costs, perioperative, and oncological outcomes for this procedure when used in the treatment of patients with low-risk endometrial cancer (LREC). METHODS A retrospective analysis of medical records was conducted on patients who underwent VH to treat precursor and invasive endometrial lesions between April 2019 and November 2021 at a single center in São Paulo, Brazil. RESULTS Thirty-four patients met the inclusion criteria. The mean patient age was 61.9 years, and the mean body mass index (BMI) was 34. Obese patients (BMI ≥ 30) accounted for 77% of the sample. Preoperative functional capacity measures were Eastern Cooperative Oncology Group (ECOG) 0-1 and ECOG-2 for 91% and 9% of the patients, respectively. The mean operative time and length of hospital stay were 109 min and 1.2 days, respectively. Four patients had a conversion of the surgical route to laparotomy. No major intraoperative complications were observed. Patients who underwent surgical conversion had a greater uterine volume (227 versus 107 mL, p = 0.006) and longer operative time (177 versus 96 min, p = 0.001). The total cost associated with VH was, on average, US$ 2058.77 (R$ 10,925.91), representing 47% of the cost associated with non-vaginal routes. Twenty-eight patients received a definitive diagnosis of endometrial carcinoma; of these, three received adjuvant radiotherapy. The mean follow-up period was 34.6 months for the patients diagnosed with cancer. One case of disease recurrence occurred 16.6 months after surgery, with one death at 28.6 months of follow-up. CONCLUSIONS These findings suggest that VH could be a feasible and cost-effective alternative for selected patients with LREC in low-resource settings.
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Affiliation(s)
- Fernando de Souza Nobrega
- Hospital Municipal Vila Santa Catarina; Hospital Israelita Albert Einstein, Ginecologia Oncológica, São Paulo, SP, Brazil
| | - Vanessa Alvarenga-Bezerra
- Hospital Municipal Vila Santa Catarina; Hospital Israelita Albert Einstein, Ginecologia Oncológica, São Paulo, SP, Brazil.
| | - Guilherme Bicudo Barbosa
- Hospital Municipal Vila Santa Catarina; Hospital Israelita Albert Einstein, Ginecologia Oncológica, São Paulo, SP, Brazil
| | - Rafael Calil Salim
- Hospital Municipal Vila Santa Catarina; Hospital Israelita Albert Einstein, Ginecologia Oncológica, São Paulo, SP, Brazil
| | - Luísa Marcella Martins
- Hospital Municipal Vila Santa Catarina; Hospital Israelita Albert Einstein, Ginecologia Oncológica, São Paulo, SP, Brazil
| | - Pedro Ernesto de Cillo
- Hospital Municipal Vila Santa Catarina; Hospital Israelita Albert Einstein, Ginecologia Oncológica, São Paulo, SP, Brazil
| | - Priscila de Moura Queiroz
- Hospital Municipal Vila Santa Catarina; Hospital Israelita Albert Einstein, Ginecologia Oncológica, São Paulo, SP, Brazil
| | - Renato Moretti-Marques
- Hospital Municipal Vila Santa Catarina; Hospital Israelita Albert Einstein, Ginecologia Oncológica, São Paulo, SP, Brazil
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Pino I, Gozzini E, Radice D, Boveri S, Iacobone AD, Vidal Urbinati AM, Multinu F, Gullo G, Cucinella G, Franchi D. Advancing Tailored Treatments: A Predictive Nomogram, Based on Ultrasound and Laboratory Data, for Assessing Nodal Involvement in Endometrial Cancer Patients. J Clin Med 2024; 13:496. [PMID: 38256630 PMCID: PMC10816430 DOI: 10.3390/jcm13020496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/12/2024] [Accepted: 01/13/2024] [Indexed: 01/24/2024] Open
Abstract
Assessing lymph node metastasis is crucial in determining the optimal therapeutic approach for endometrial cancer (EC). Considering the impact of lymphadenectomy, there is an urgent need for a cost-effective and easily applicable method to evaluate the risk of lymph node metastasis in cases of sentinel lymph node (SLN) biopsy failure. This retrospective monocentric study enrolled EC patients, who underwent surgical staging with nodal assessment. Data concerning demographic, clinicopathological, ultrasound, and surgical characteristics were collected from medical records. Ultrasound examinations were conducted in accordance with the IETA statement. We identified 425 patients, and, after applying exclusion criteria, the analysis included 313 women. Parameters incorporated into the nomogram were selected via univariate and multivariable analyses, including platelet count, myometrial infiltration, minimal tumor-free margin, and CA 125. The nomogram exhibited good accuracy in predicting lymph node involvement, with an AUC of 0.88. Using a cutoff of 10% likelihood of nodal involvement, the nomogram displayed a low false-negative rate of 0.04 (95% CI 0.00-0.19) in the training set. The adaptability of this straightforward model renders it suitable for implementation across diverse clinical settings, aiding gynecological oncologists in preoperative patient evaluations and facilitating the design of personalized treatments. However, external validation is mandatory for confirming diagnostic accuracy.
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Affiliation(s)
- Ida Pino
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (D.F.)
| | - Elisa Gozzini
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy;
| | - Davide Radice
- Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Sara Boveri
- Laboratory of Biostatistics and Data Management, Scientific Directorate, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy;
| | - Anna Daniela Iacobone
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (D.F.)
| | - Ailyn Mariela Vidal Urbinati
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (D.F.)
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy;
- Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy;
- Laboratory of Biostatistics and Data Management, Scientific Directorate, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy;
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy
| | - Francesco Multinu
- Department of Gynecologic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy;
| | - Giuseppe Gullo
- Department of Obstetrics and Gynecology, Villa Sofia Cervello Hospital, University of Palermo, 90146 Palermo, Italy; (G.G.); (G.C.)
| | - Gaspare Cucinella
- Department of Obstetrics and Gynecology, Villa Sofia Cervello Hospital, University of Palermo, 90146 Palermo, Italy; (G.G.); (G.C.)
| | - Dorella Franchi
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (D.F.)
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Ueno Y, Yoshida E, Nojiri S, Kato T, Ohtsu T, Takeshita T, Suzuki S, Yoshida H, Kato K, Itoh M, Notomi T, Usui K, Sozu T, Terao Y, Kawaji H, Kato H. Use of clinical variables for preoperative prediction of lymph node metastasis in endometrial cancer. Jpn J Clin Oncol 2024; 54:38-46. [PMID: 37815156 PMCID: PMC10773201 DOI: 10.1093/jjco/hyad135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/19/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE Endometrial cancer is the most common gynaecological cancer, and most patients are identified during early disease stages. Noninvasive evaluation of lymph node metastasis likely will improve the quality of clinical treatment, for example, by omitting unnecessary lymphadenectomy. METHODS The study population comprised 611 patients with endometrial cancer who underwent lymphadenectomy at four types of institutions, comprising seven hospitals in total. We systematically assessed the association of 18 preoperative clinical variables with postoperative lymph node metastasis. We then constructed statistical models for preoperative lymph node metastasis prediction and assessed their performance with a previously proposed system, in which the score was determined by counting the number of high-risk variables among the four predefined ones. RESULTS Of the preoperative 18 variables evaluated, 10 were significantly associated with postoperative lymph node metastasis. A logistic regression model achieved an area under the curve of 0.85 in predicting lymph node metastasis; this value is significantly higher than that from the previous system (area under the curve, 0.74). When we set the false-negative rate to ~1%, the new predictive model increased the rate of true negatives to 21%, compared with 6.8% from the previous one. We also provide a spreadsheet-based tool for further evaluation of its ability to predict lymph node metastasis in endometrial cancer. CONCLUSIONS Our new lymph node metastasis prediction method, which was based solely on preoperative clinical variables, performed significantly better than the previous method. Although additional evaluation is necessary for its clinical use, our noninvasive system may help improve the clinical treatment of endometrial cancer, complementing minimally invasive sentinel lymph node biopsy.
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Affiliation(s)
- Yuta Ueno
- Department of Gynecology, Kanagawa Cancer Center, Yokohama, Japan
- Department of Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan
- Department of Obstetrics and Gynecology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Emiko Yoshida
- Department of Obstetrics and Gynecology, Juntendo University, Tokyo, Japan
- Medical Technology Innovation Center, Juntendo University, Tokyo, Japan
| | - Shuko Nojiri
- Clinical Research and Trial Center, Juntendo University, Tokyo, Japan
| | - Tomoyasu Kato
- Department of Gynecology, National Cancer Center, Tokyo, Japan
| | - Takashi Ohtsu
- Division of Advanced Cancer Therapeutics, Kanagawa Cancer Center Research Institute, Yokohama, Japan
- Center for Cancer Genome Medicine, Kanagawa Cancer Center, Yokohama, Japan
| | - Toshiyuki Takeshita
- Department of Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan
| | - Shunji Suzuki
- Department of Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Yoshida
- Department of Diagnostic Pathology, National Cancer Center, Tokyo, Japan
| | - Ken Kato
- Clinical Research Support Office, Biobank Translational Research Support Section, National Cancer Center Hospital, Tokyo, Japan
| | - Masayoshi Itoh
- Laboratory for Advanced Genomics Circuit, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Tsuguto Notomi
- Department of Obstetrics and Gynecology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Kengo Usui
- Medical Technology Innovation Center, Juntendo University, Tokyo, Japan
| | - Takashi Sozu
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Tokyo, Japan
| | - Yasuhisa Terao
- Department of Obstetrics and Gynecology, Juntendo University, Tokyo, Japan
| | - Hideya Kawaji
- Research Center for Genome and Medical Sciences, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Hisamori Kato
- Department of Gynecology, Kanagawa Cancer Center, Yokohama, Japan
- Kanagawa Health Service Association, Yokohama, Japan
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Pados G, Zouzoulas D, Tsolakidis D. Recent management of endometrial cancer: a narrative review of the literature. Front Med (Lausanne) 2024; 10:1244634. [PMID: 38235267 PMCID: PMC10792696 DOI: 10.3389/fmed.2023.1244634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 11/23/2023] [Indexed: 01/19/2024] Open
Abstract
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.
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Affiliation(s)
- George Pados
- Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, “Papageorgiou” Hospital, Thessaloniki, Greece
- Center for Endoscopic Surgery “Diavalkaniko” Hospital, Thessaloniki, Greece
| | - Dimitrios Zouzoulas
- Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, “Papageorgiou” Hospital, Thessaloniki, Greece
| | - Dimitrios Tsolakidis
- Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, “Papageorgiou” Hospital, Thessaloniki, Greece
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30
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Salman L, Cusimano MC, Marchocki Z, Ferguson SE. Sentinel lymph node mapping in endometrial cancer: Current evidence and practice. J Surg Oncol 2024; 129:117-119. [PMID: 38059317 DOI: 10.1002/jso.27550] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 11/15/2023] [Indexed: 12/08/2023]
Abstract
Surgical staging with total hysterectomy, bilateral salpingo-oophorectomy, and lymph node assessment is the standard of care for patients with clinical early-stage endometrial cancer. Traditionally, complete pelvic and para-aortic lymphadenectomy (LND) was performed to assess for nodal metastases; however, numerous prospective studies have demonstrated that sentinel lymph node biopsy has similar diagnostic accuracy, and is an acceptable alternative to complete LND. This has led to a paradigm shift in endometrial cancer staging.
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Affiliation(s)
- Lina Salman
- Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/Sinai Health Systems, Toronto, Ontario, Canada
| | - Maria C Cusimano
- Department of Gynecology, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
| | - Zibi Marchocki
- Department of Obstetrics and Gynaecology, University College Cork, Cork University Maternity Hospital, Cork, Ireland
| | - Sarah E Ferguson
- Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/Sinai Health Systems, Toronto, Ontario, Canada
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Higashi Y, Togami S, Kobayashi H. Para-aortic lymphadenectomy in endometrial cancer patients with left-sided inferior vena cava: A case report and literature review. Taiwan J Obstet Gynecol 2024; 63:98-102. [PMID: 38216280 DOI: 10.1016/j.tjog.2023.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2023] [Indexed: 01/14/2024] Open
Abstract
OBJECTIVE The incidence of left-sided inferior vena cava (IVC) is extremely low. However, without a preoperative diagnosis of left-sided IVC, the risk of intraoperative vascular injury during para-aortic lymph node (PAN) lymphadenectomy is high. CASE REPORT Herein, we present two cases in which left-sided IVCs were diagnosed using preoperative imaging. PAN lymphadenectomies were safely performed in these patients with endometrial cancer. In the first case, the left-sided IVC crossed the abdominal aorta after the left renal and gonadal veins had drained into it and joined the right renal vein. In the second case, the left-sided IVC crossed the abdominal aorta after the left renal and gonadal veins flowed into it and the ascending lumbar vein flowed into the right side. CONCLUSION These cases demonstrate that even in the presence of vascular malformations, PAN lymphadenectomy can be performed safely by employing preoperative anatomical imaging analysis and judicious intraoperative surgical maneuvers to avoid vascular injury.
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Affiliation(s)
- Yuriko Higashi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
| | - Shinichi Togami
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan.
| | - Hiroaki Kobayashi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
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Imai K, Hirooka-Nakama J, Hotta Y, Shigeta H. A Review of Laparoscopic Para-aortic Lymphadenectomy for Early-stage Endometrial Cancer: Extraperitoneal Approach May Have the Advantage over Intraperitoneal Approach. Gynecol Minim Invasive Ther 2024; 13:10-18. [PMID: 38487605 PMCID: PMC10936721 DOI: 10.4103/gmit.gmit_25_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/29/2023] [Accepted: 09/21/2023] [Indexed: 03/17/2024] Open
Abstract
The importance of lymphadenectomy, including para-aortic nodes, for the accurate staging of endometrial cancer, is well established. Although the therapeutic role of lymph node resection in endometrial cancer is still under debate, some studies support its usefulness for survival benefit. To predict the necessity of lymphadenectomy, several preoperative scoring systems have been proposed as being effective. For endometrial cancer, there is a trend towards minimally invasive surgery, including para-aortic lymphadenectomy. For para-aortic lymphadenectomy, there are two different approaches: the extraperitoneal approach and the transperitoneal approach. The extraperitoneal approach has advantages over the transperitoneal approach in terms of better access to the left aortic nodes, no interference of the bowel, and possibly better options for obese or elderly patients. However, the extraperitoneal approach may have a longer learning curve than the transperitoneal approach. Robot-assisted extraperitoneal para-aortic lymphadenectomy is feasible and safe and may be suitable for patients irrespective of their baseline characteristics.
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Affiliation(s)
- Kazuaki Imai
- Department of Obstetrics and Gynecology, Yokohama Municipal Citizen’s Hospital, Japan
| | - Junko Hirooka-Nakama
- Department of Obstetrics and Gynecology, Yokohama Municipal Citizen’s Hospital, Japan
| | - Yuichiro Hotta
- Department of Obstetrics and Gynecology, Yokohama Municipal Citizen’s Hospital, Japan
| | - Hiroyuki Shigeta
- Department of Obstetrics and Gynecology, Yokohama Municipal Citizen’s Hospital, Japan
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Sharon A, Aiob A, Kais M, Apel-Sarid L, Tendler R, Dourleshter G, Bornstein J. Detection and dissection of sentinel nodes in endometrial endometrioid cancer with indocyanine green using PinPoint laparoscopy: Analysis of the learning curve. Eur J Obstet Gynecol Reprod Biol 2024; 292:91-96. [PMID: 37988798 DOI: 10.1016/j.ejogrb.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/01/2023] [Accepted: 11/12/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVE Early-stage endometrial endometrioid adenocarcinoma is managed through laparoscopic total hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy. Detection of positive nodes is rare, and lymphadenectomy may involve complications. Pelvic sentinel lymph node dissection can prevent complete dissection. Herein, we evaluated the learning curve of sentinel lymph node dissection using indocyanine green. STUDY DESIGN All surgeries for endometrial endometrioid adenocarcinoma were performed laparoscopically with indocyanine green to detect sentinel nodes. The primary outcome was the ability to identify and resect sentinel lymph nodes on each side. The secondary outcome was correspondence between the frozen section histology of the nodes with the final histology. RESULTS Among 31 patients with endometrial endometrioid adenocarcinoma treated between October 2018 and August 2020, 29 who underwent laparoscopy using indocyanine green were enrolled. Complete lymphadenectomy was performed in 16 patients. Failure to recognize sentinel nodes on right and left sides occurred in 10.34% and 0% of cases, respectively. The median number of recognized and dissected sentinel nodes was 1 on both sides (range 0-5). One patient had a lymph node positive for malignancy on histology (3.45%) on both sides. There were 13 and 14 cases of negative frozen sections on the right and left sides, respectively, and 1 case of a positive frozen section with positive whole pelvic lymph nodes. CONCLUSION Sentinel node dissection using indocyanine green in endometrial endometrioid adenocarcinoma has a distinct learning curve; however, it is practical and achievable for skilled surgeons.
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Affiliation(s)
- Avishalom Sharon
- Department of Gynecology and Obstetrics, Galilee Medical Center, Nahariya and Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Ala Aiob
- Department of Gynecology and Obstetrics, Galilee Medical Center, Nahariya and Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Mohammad Kais
- Department of Gynecology and Obstetrics, Galilee Medical Center, Nahariya and Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Liat Apel-Sarid
- Department of Pathology, Galilee Medical Center, Nahariya, Israel
| | - Renee Tendler
- Department of Gynecology and Obstetrics, Galilee Medical Center, Nahariya and Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Grigory Dourleshter
- Department of Gynecology and Obstetrics, Galilee Medical Center, Nahariya and Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Jacob Bornstein
- Department of Gynecology and Obstetrics, Galilee Medical Center, Nahariya and Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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Buechi CA, Siegenthaler F, Sahli L, Papadia A, Saner FAM, Mohr S, Rau TT, Solass W, Imboden S, Mueller MD. Real-World Data Assessing the Impact of Lymphovascular Space Invasion on the Diagnostic Performance of Sentinel Lymph Node Mapping in Endometrial Cancer. Cancers (Basel) 2023; 16:67. [PMID: 38201495 PMCID: PMC10778553 DOI: 10.3390/cancers16010067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND SLN mapping has emerged as a standard of care in endometrial cancer due to its high sensitivity and significant reduction in morbidity. Although lymphovascular space invasion (LVSI) is a known risk factor for lymph node metastasis and recurrence, evidence on the reliability of SLN mapping in LVSI-positive patients is scarce. The aim of this study was to determine the impact of LVSI on the diagnostic performance of SLN mapping. METHODS This retrospective cohort study included patients with endometrial cancer who underwent primary surgical treatment at the Bern University Hospital, Switzerland, between 2012 and 2022. RESULTS LVSI was present in 22% of patients and was significantly associated with lymph node metastasis (p < 0.001) and recurrence (p < 0.001). In node-negative patients with only SLN mapping performed, LVSI was an independent predictor of recurrence during multivariable Cox regression analysis (p = 0.036). The negative predictive value of SLN mapping was 91.5% and was significantly lower in tumors with LVSI (75.0%) compared to LVSI-negative tumors (95.6%, p = 0.004). CONCLUSION The presence of LVSI was significantly associated with worse oncological outcomes. LVSI was an independent predictor of recurrence in node-negative patients with only SLN mapping performed. Furthermore, the negative predictive value of SLN mapping was significantly lower in LVSI-positive tumors.
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Affiliation(s)
- Carol A. Buechi
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, 3010 Bern, Switzerland; (C.A.B.)
| | - Franziska Siegenthaler
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, 3010 Bern, Switzerland; (C.A.B.)
| | - Laura Sahli
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, 3010 Bern, Switzerland; (C.A.B.)
| | - Andrea Papadia
- Department of Gynecology and Obstetrics, Ente Ospedaliero Cantonale of Lugano, 6900 Lugano, Switzerland
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Flurina A. M. Saner
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, 3010 Bern, Switzerland; (C.A.B.)
| | - Stefan Mohr
- Department of Gynecology and Obstetrics, Bürgerspital Solothurn, 4500 Solothurn, Switzerland;
| | - Tilman T. Rau
- Institute of Pathology, Universitätsklinikum Düsseldorf, 40225 Düsseldorf, Germany
| | - Wiebke Solass
- Institute of Tissue Medicine and Pathology, University of Bern, 3008 Bern, Switzerland
| | - Sara Imboden
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, 3010 Bern, Switzerland; (C.A.B.)
| | - Michael D. Mueller
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, 3010 Bern, Switzerland; (C.A.B.)
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Ignatov A, Mészáros J, Ivros S, Gennari P, Ignatov T. Oncologic Outcome of Robotic-Assisted and Laparoscopic Sentinel Node Biopsy in Endometrial Cancer. Cancers (Basel) 2023; 15:5894. [PMID: 38136438 PMCID: PMC10741694 DOI: 10.3390/cancers15245894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Recently, sentinel lymph node biopsy (SLNB) has been introduced in the surgical staging of endometrial cancer as an alternative to systematic lymph node dissection (LND). However, the survival impact of SLNB is not yet well characterised. METHODS We performed a retrospective study of 419 patients with endometrial cancer treated with SLNB alone or with pelvic and para-aortic LND. For SLNB mapping, indocyanine green was used. RESULTS Median follow-up was 66 months. After exclusions, 337 patients were eligible for analysis. Of them, 150 underwent SLNB and 187 LND. During the follow-up time, 27 (24.7%) of the 150 who underwent SLNB and 54 (28.9%) of the 187 who underwent LND were diagnosed with recurrent disease (p = 0.459). The estimated 5-year disease-free survival (DFS) rate was 76.7% and 72.2% for patients in the SLNB and LND group, respectively (p = 0.419). The 5-year overall survival (OS) rates were 80.7% and 77.0% in the SLNB and LND group, respectively (p = 0.895). Survival rates were similar in both groups independent of lymph node status. Multivariable analysis confirmed that the staging approach was not associated with oncological outcome. For patients without lymph node metastases, patient outcome was worsened by advanced tumour stage and non-endometrioid tumour histology. In the group of patients with confirmed lymph node metastases, advanced tumour stage and inadequate adjuvant treatment significantly reduced DFS and OS. CONCLUSION Our data suggested that SLNB did not compromise the oncological outcome of patients with endometrial cancer compared to LND.
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Affiliation(s)
- Atanas Ignatov
- Department of Gynecology and Obstetrics, Otto-von-Guericke University, 39108 Magdeburg, Germany; (J.M.); (S.I.); (P.G.); (T.I.)
| | - József Mészáros
- Department of Gynecology and Obstetrics, Otto-von-Guericke University, 39108 Magdeburg, Germany; (J.M.); (S.I.); (P.G.); (T.I.)
| | - Stylianos Ivros
- Department of Gynecology and Obstetrics, Otto-von-Guericke University, 39108 Magdeburg, Germany; (J.M.); (S.I.); (P.G.); (T.I.)
- Gynecologic Oncology Unit, Metropolitan Hospital, 18547 Athens, Greece
| | - Paolo Gennari
- Department of Gynecology and Obstetrics, Otto-von-Guericke University, 39108 Magdeburg, Germany; (J.M.); (S.I.); (P.G.); (T.I.)
| | - Tanja Ignatov
- Department of Gynecology and Obstetrics, Otto-von-Guericke University, 39108 Magdeburg, Germany; (J.M.); (S.I.); (P.G.); (T.I.)
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36
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Guo Y, Sun L, Chen X, Wen Q, Shao Z, Tang X, Shi X, Wang J, Zhang Y, Zhu T. A multicenter noninferior randomized controlled study of sentinel lymph node biopsy alone versus sentinel lymph node biopsy plus lymphadenectomy for patients with stage I endometrial cancer, INSEC trial concept. BMC Cancer 2023; 23:1184. [PMID: 38041023 PMCID: PMC10693105 DOI: 10.1186/s12885-023-11226-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 07/25/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Up to the present time, there has remained a lack of strong evidence as to whether sentinel lymph node biopsy can replace lymphadenectomy for early endometrial cancer. The traditional surgery for endometrial cancer includes pelvic lymphadenectomy and paraaortic lymph node resection, but complications often seriously affect patients' quality of life. Two randomized controlled trials with large samples have proved that lymphadenectomy does not improve the overall recurrence rate and survival rate of patients. On the contrary, it increases the incidence of complications and even mortality. The current trial is designed to clarify whether sentinel lymph node biopsy can replace lymphadenectomy for early endometrial cancer patients with negative lymph nodes. METHODS This study is a randomized, open-label, multicenter and non-inferiority controlled clinical trial in China. Potential participants will be patients with pathologically confirmed endometrial cancer at the Zhejiang Cancer Hospital, Jiaxing Maternity and Child Health Care Hospital, and the First Hospital of Jiaxing in China. The total sample size for this study is 722. Patients will be randomly assigned in a 1:1 ratio to two groups. Patients in one group will undergo sentinel lymph node biopsy + total hysterectomy + bilateral salpingo-oophorectomy ± paraaortic lymph node resection. Patients in the other group will undergo sentinel lymph node biopsy + total hysterectomy + bilateral salpingo-oophorectomy + pelvic lymphadenectomy ± paraaortic lymph node resection. The 3-year disease-free survival rate, overall survival rate, quality of life (use EORTC QLQ-C30 + QLQ-CX24), and perioperative related indexes of the two groups will be compared. RESULTS We expect to find that for patients with early endometrial cancer, the 3-year disease-free survival rate following sentinel lymph node biopsy with indocyanine green combined with near-infrared fluorescence imaging is similar to that following lymphadenectomy. The operation time, as well as incidence of pelvic lymphocyst, lymphedema of lower limb, and edema of vulva in patients who only undergo sentinel lymph node biopsy are expected to be significantly lower than in patients who undergo lymphadenectomy. The quality of life of patients who undergo sentinel lymph node biopsy alone will be significantly better than that of patients who undergo lymph node dissection. CONCLUSION This will prove that the prognosis of sentinel lymph node biopsy alone with indocyanine green combined with near-infrared fluorescence imaging is not inferior to that of sentinel lymph node biopsy plus lymphadenectomy for early stage endometrial cancer with negative nodal assessment intraoperatively. In addition, sentinel lymph node biopsy alone with indocyanine green combined with near-infrared fluorescence imaging results in fewer surgical complications and gives patients better quality of life. TRIAL REGISTRATION chictr.org.cn, ChiCTR1900023161. Registered 14 May 2019, http://www.chictr.org.cn/edit.aspx?pid=38659&htm=4 .
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Affiliation(s)
- Yanglong Guo
- Department of Gynecologic Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Lu Sun
- Department of Gynecologic Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Xi Chen
- Department of Gynecologic Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Qiang Wen
- Department of Gynecologic Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Zhuyan Shao
- Department of Gynecologic Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Xuedong Tang
- Department of Gynecologic Oncology, Jiaxing Maternity and Child Health Care Hospital, Jiaxing, Zhejiang, People's Republic of China
| | - XiaoJun Shi
- Department of Gynecologic Oncology, The First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, People's Republic of China
| | - Jinyu Wang
- Department of Medical Records Statistics, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China
| | - Yingli Zhang
- Department of Gynecologic Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China.
| | - Tao Zhu
- Department of Gynecologic Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, Zhejiang, 310022, China.
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Ghanem AI, Bhatnagar A, Elshaikh M, Hijaz M, Elshaikh MA. Recurrence Risk Stratification for Women With FIGO Stage I Uterine Endometrioid Carcinoma Who Underwent Surgical Lymph Node Evaluation. Am J Clin Oncol 2023; 46:537-542. [PMID: 37679878 DOI: 10.1097/coc.0000000000001043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVE The aim of this study was to estimate the recurrence risk based on the number of prognostic factors for patients with stage I uterine endometrioid carcinoma (EC) who underwent surgical lymph node evaluation (SLNE) and were managed with observation. METHODS We queried our database for women with FIGO-2009 stage I EC who underwent surgical staging including SLNE. Multivariate analysis with stepwise model selection was used to determine independent risk factors for 5-year recurrence-free survival (RFS). Study groups based on risk factors were compared for RFS, disease-specific survival, and overall survival. RESULTS A total of 706 patients were identified: median age was 60 years (range, 30 to 93 y) and median follow-up was 120 months. Median number of examined lymph nodes was 8 (range, 1 to 66). 91% were stage IA, 75% had grade 1 and lymphovascular space invasion was detected in 6%. Independent predictors of 5-year RFS included age 60 years and above ( P =0.038), grade 2 ( P =0.003), and grade 3 ( P <0.001) versus grade 1. Five-year RFS for group 0 (age less than 60 y and grade 1) was 98% versus 92% for group 1 (either: age 60 y and older or grade 2/3) versus 84% for group 2 (both: age 60 y and above and grade 2/3), respectively ( P <0.001). Five-year disease-specific survival was 100% versus 98% versus 95%, ( P =0.012) and 5-year overall survival was 98% versus 90% versus 81%, for groups 0, 1, and 2, respectively ( P <0.001). CONCLUSIONS In patients with stage I EC who received SLNE and no adjuvant therapy, only age 60 years and above and high tumor grade were independent predictors of recurrence and can be used to quantify individualized recurrence risk, whereas lymphovascular space invasion was not an independent prognostic factor in this cohort.
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Affiliation(s)
- Ahmed I Ghanem
- Department of Radiation Oncology, Henry Ford Cancer Institute
- Clinical Oncology Department, University of Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Aseem Bhatnagar
- Department of Radiation Oncology, Henry Ford Cancer Institute
| | - Muneer Elshaikh
- Department of Radiation Oncology, Henry Ford Cancer Institute
| | - Miriana Hijaz
- Department of Women's Health Services, Division of Gynecologic Oncology, Henry Ford Cancer Institute, Detroit, MI
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Ponce J, Fernández S, Barahona M, Martínez JM, Ortega C, Martí L. Robotic-assisted para-aortic lymphadenectomy: Technique and indications in gynecological oncology. Best Pract Res Clin Obstet Gynaecol 2023; 91:102401. [PMID: 37678062 DOI: 10.1016/j.bpobgyn.2023.102401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/21/2023] [Accepted: 07/27/2023] [Indexed: 09/09/2023]
Abstract
The benefits of minimally-invasive surgeries have been documented, and they have been established as the preferred approach for gynecological surgeries. With the development of robotic surgery, many highly complex surgeries can benefit from these advantages. Due to the complexity of aortocaval lymphadenectomy, surgical technique protocols have been described to reduce risks by maximizing benefits. We describe the technique using five ports (4 robotic arms and an assistant) to work the upper abdominal field, and different instruments recommended in each of their positions to reduce errors and optimize surgical time. After the "step by step" description, we summarize indications of aortocaval lymphadenectomy for every gynecological cancer in different stages.
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Affiliation(s)
- Jordi Ponce
- Gynecologic Department, University Hospital of Bellvitge (IDIBELL), University of Barcelona, Spain.
| | - Sergi Fernández
- Gynecologic Department, University Hospital of Bellvitge (IDIBELL), University of Barcelona, Spain.
| | - Marc Barahona
- Gynecologic Department, University Hospital of Bellvitge (IDIBELL), University of Barcelona, Spain.
| | - José Manuel Martínez
- Gynecologic Department, University Hospital of Bellvitge (IDIBELL), University of Barcelona, Spain.
| | - Carlos Ortega
- Gynecologic Department, University Hospital of Bellvitge (IDIBELL), University of Barcelona, Spain.
| | - Lola Martí
- Gynecologic Department, University Hospital of Bellvitge (IDIBELL), University of Barcelona, Spain.
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Zhang X, Chen S, Li G, Zheng L, Shang S, Li J, Guan X, Yang J. Investigating the influence of primary uterine tumor site on pelvic and para-aortic lymph node metastatic pattern and evaluating the risk factors for lymph node metastases in endometrial carcinoma: A retrospective study. Medicine (Baltimore) 2023; 102:e36100. [PMID: 38013262 PMCID: PMC10681575 DOI: 10.1097/md.0000000000036100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 10/23/2023] [Indexed: 11/29/2023] Open
Abstract
To assess the metastatic pattern in pelvic and para-aortic lymph nodes in relation with the primary uterine tumor site and to evaluate risk factors for lymph node metastases. 212 patients with endometrial cancer who underwent surgical treatment from December 2014 to December 2019 were selected. The clinical and pathological data were retrospectively analyzed. The factors and uterine primary tumor site related to lymph node metastasis were analyzed by univariate and multivariate analysis. Among the 212 patients with endometrial cancer, 17 cases had lymph node metastasis, and thus the metastasis rate was 8.02%. Univariate analysis revealed that lymph node metastasis was significantly correlated with Federation of Gynecology and Obstetrics stage, depth of myometrial invasion, tumor size, pathological grade, and lymphovascular space invasion (P < .05) and was not correlated with age, pathological type, and cervical involvement (P > .05). Primary uterine tumor site (fundus, horns, body or lower uterine segment) with or without cervical involvement was associated with different lymph nodes' metastatic sites. The lymph node metastatic pathways of endometrial cancer mainly include obturator lymph nodes and para-aortic lymph nodes, and skip metastasis may occur; endometrial carcinoma may jump and metastasize to para-aortic lymph nodes, specially when the lesion is located in the uterine fundus and uterine horns (cornua of uterus); there is a significant correlation between the location of lymph node metastasis and the location of primary uterine malignant tumor.
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Affiliation(s)
- Xiao Zhang
- Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, School of Medicine, Zhejiang University, Hangzhou, China
| | - Saihua Chen
- Department of Gynecology, Zhejiang People’s Hospital, Tiantai Branch, Taizhou, China
| | - Guangxiao Li
- Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, School of Medicine, Zhejiang University, Hangzhou, China
| | - Limei Zheng
- Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shanliang Shang
- Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianqiong Li
- Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaojing Guan
- Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianhua Yang
- Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, School of Medicine, Zhejiang University, Hangzhou, China
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Liu T, Zhang H, Han C, Kong W. Construction and validation of nomograms for predicting the prognosis of elderly patients with uterine serous carcinoma: a SEER-based study. J Cancer Res Clin Oncol 2023; 149:14475-14492. [PMID: 37567988 DOI: 10.1007/s00432-023-05174-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/09/2023] [Indexed: 08/13/2023]
Abstract
PURPOSE To investigate the prognostic indicators, develop and verify nomograms for predicting overall survival (OS) and cancer-specific survival (CSS) in elderly patients with uterine serous carcinoma (USC). METHODS Data of eligible USC patients aged ≥ 65 years from 2004 to 2015 in the Surveillance, Epidemiology and End Results (SEER) database were collected for retrospective analysis. X-tile software was used to assess the optimal cut-off values. Univariate and multivariate Cox regression analyses were performed to explore the prognostic factors. Nomograms were developed to predict the probability of 1-, 3- and 5-year OS and CSS. Concordance indexes (c-index), receiver operating characteristic analysis and calibration curves were used to evaluate the model. Decision curve analysis (DCA) was introduced to examine the clinical value of the models. RESULTS Age, Federation International of Gynecology and Obstetrics stage, N stage, tumor size, number of lymph nodes resected, and adjuvant therapy were independent prognostic factors for OS and CSS. The C-indexes were 0.736 (OS), 0.754 (CSS) in the training set and 0.731 (OS), 0.759 (CSS) in the validation set. The area under the curve (AUCs) of OS and CSS for 1-, 3-, and 5-years all exceeded 0.75. The calibration plots for the probability of survival were in good agreement. As shown in DCA curves, the nomograms showed better discrimination power and higher net benefits than the 6th American Joint Committee on Cancer staging system. CONCLUSIONS The nomograms constructed based on prognostic risk factors could individually predict the prognosis of elderly USC patients and provide a reference for clinical decision-making.
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Affiliation(s)
- Tingting Liu
- Department of Gynecological Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No. 17 Qihelou Street, Dongcheng District, Beijing, 100006, China
| | - He Zhang
- Department of Gynecological Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No. 17 Qihelou Street, Dongcheng District, Beijing, 100006, China
| | - Chao Han
- Department of Gynecological Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No. 17 Qihelou Street, Dongcheng District, Beijing, 100006, China
| | - Weimin Kong
- Department of Gynecological Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No. 17 Qihelou Street, Dongcheng District, Beijing, 100006, China.
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Togami S, Fukuda M, Mizuno M, Yanazume S, Kobayashi H. Efficacy and prognosis of robotic surgery with sentinel node navigation surgery in endometrial cancer. J Gynecol Oncol 2023; 34:e68. [PMID: 37293801 PMCID: PMC10627747 DOI: 10.3802/jgo.2023.34.e68] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/16/2023] [Accepted: 05/01/2023] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVE This study aimed to validate the surgical and oncologic outcomes of robotic surgery with sentinel node navigation surgery (SNNS) in endometrial cancer. METHODS This study included 130 patients with endometrial cancer, who underwent robotic surgery, including hysterectomy, bilateral salpingo-oophorectomy, and pelvic SNNS at the Department of Obstetrics and Gynecology of Kagoshima University Hospital. Pelvic sentinel lymph nodes (SLNs) were identified using the uterine cervix 99m Technetium-labeled phytate and indocyanine green injections. Surgery-related and survival outcomes were also evaluated. RESULTS The median operative and console times and volume of blood loss were 204 (range: 101-555) minutes, 152 (range: 70-453) minutes, and 20 (range: 2-620) mL, respectively. The bilateral and unilateral pelvic SLN detection rates were 90.0% (117/130) and 5.4% (7/130), respectively, and the identification rate (the rate at which at least one SLN could be identified on either side) was 95% (124/130). Lower extremity lymphedema occurred in only 1 patient (0.8%), and no pelvic lymphocele occurred. Recurrence occurred in 3 patients (2.3%), and the recurrence site was the abdominal cavity, with dissemination in 2 patients and vaginal stump in one. The 3-year recurrence-free survival and 3-year overall survival rates were 97.1% and 98.9%, respectively. CONCLUSION Robotic surgery with SNNS for endometrial cancer showed a high SLN identification rate, low occurrence rates of lower extremity lymphedema and pelvic lymphocele, and excellent oncologic outcomes.
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Affiliation(s)
- Shinichi Togami
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
| | - Mika Fukuda
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
| | - Mika Mizuno
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
| | - Shintaro Yanazume
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
| | - Hiroaki Kobayashi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan.
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Jiang Y, Wang C, Zhou S. Artificial intelligence-based risk stratification, accurate diagnosis and treatment prediction in gynecologic oncology. Semin Cancer Biol 2023; 96:82-99. [PMID: 37783319 DOI: 10.1016/j.semcancer.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 08/27/2023] [Accepted: 09/25/2023] [Indexed: 10/04/2023]
Abstract
As data-driven science, artificial intelligence (AI) has paved a promising path toward an evolving health system teeming with thrilling opportunities for precision oncology. Notwithstanding the tremendous success of oncological AI in such fields as lung carcinoma, breast tumor and brain malignancy, less attention has been devoted to investigating the influence of AI on gynecologic oncology. Hereby, this review sheds light on the ever-increasing contribution of state-of-the-art AI techniques to the refined risk stratification and whole-course management of patients with gynecologic tumors, in particular, cervical, ovarian and endometrial cancer, centering on information and features extracted from clinical data (electronic health records), cancer imaging including radiological imaging, colposcopic images, cytological and histopathological digital images, and molecular profiling (genomics, transcriptomics, metabolomics and so forth). However, there are still noteworthy challenges beyond performance validation. Thus, this work further describes the limitations and challenges faced in the real-word implementation of AI models, as well as potential solutions to address these issues.
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Affiliation(s)
- Yuting Jiang
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE and State Key Laboratory of Biotherapy, West China Second Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, Sichuan 610041, China; Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Chengdi Wang
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE and State Key Laboratory of Biotherapy, West China Second Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, Sichuan 610041, China; Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Shengtao Zhou
- Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE and State Key Laboratory of Biotherapy, West China Second Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, Sichuan 610041, China; Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China.
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Cabrera S, Gómez-Hidalgo NR, García-Pineda V, Bebia V, Fernández-González S, Alonso P, Rodríguez-Gómez T, Fusté P, Gracia-Segovia M, Lorenzo C, Chacon E, Roldan Rivas F, Arencibia O, Martí Edo M, Fidalgo S, Sanchis J, Padilla-Iserte P, Pantoja-Garrido M, Martínez S, Peiró R, Escayola C, Oliver-Pérez MR, Aghababyan C, Tauste C, Morales S, Torrent A, Utrilla-Layna J, Fargas F, Calvo A, Aller de Pace L, Gil-Moreno A. Accuracy and Survival Outcomes after National Implementation of Sentinel Lymph Node Biopsy in Early Stage Endometrial Cancer. Ann Surg Oncol 2023; 30:7653-7662. [PMID: 37633852 PMCID: PMC10562309 DOI: 10.1245/s10434-023-14065-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/23/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Sentinel lymph node (SLN) biopsy has recently been accepted to evaluate nodal status in endometrial cancer at early stage, which is key to tailoring adjuvant treatments. Our aim was to evaluate the national implementation of SLN biopsy in terms of accuracy to detect nodal disease in a clinical setting and oncologic outcomes according to the volume of nodal disease. PATIENTS AND METHODS A total of 29 Spanish centers participated in this retrospective, multicenter registry including patients with endometrial adenocarcinoma at preoperative early stage who had undergone SLN biopsy between 2015 and 2021. Each center collected data regarding demographic, clinical, histologic, therapeutic, and survival characteristics. RESULTS A total of 892 patients were enrolled. After the surgery, 12.9% were suprastaged to FIGO 2009 stages III-IV and 108 patients (12.1%) had nodal involvement: 54.6% macrometastasis, 22.2% micrometastases, and 23.1% isolated tumor cells (ITC). Sensitivity of SLN biopsy was 93.7% and false negative rate was 6.2%. After a median follow up of 1.81 years, overall surivial and disease-free survival were significantly lower in patients who had macrometastases when compared with patients with negative nodes, micrometastases or ITC. CONCLUSIONS In our nationwide cohort we obtained high sensitivity of SLN biopsy to detect nodal disease. The oncologic outcomes of patients with negative nodes and low-volume disease were similar after tailoring adjuvant treatments. In total, 22% of patients with macrometastasis and 50% of patients with micrometastasis were at low risk of nodal metastasis according to their preoperative risk factors, revealing the importance of SLN biopsy in the surgical management of patients with early stage EC.
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Affiliation(s)
- Silvia Cabrera
- Gynecologic Oncology Unit, Hospital Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
| | - Natalia R Gómez-Hidalgo
- Gynecologic Oncology Unit, Hospital Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | | | - Vicente Bebia
- Gynecologic Oncology Unit, Hospital Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | | | - Paula Alonso
- Department of Obstetrics and Gynecology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Tomás Rodríguez-Gómez
- Department of Obstetrics and Gynecology, Hospital Virgen de la Victoria, Málaga, Spain
| | - Pere Fusté
- Gynecologic Oncology Unit, Hospital Clínic i Provincial de Barcelona, Barcelona, Spain
| | | | - Cristina Lorenzo
- Department of Obstetrics and Gynecology, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - Enrique Chacon
- Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, Pamplona, Spain
| | - Fernando Roldan Rivas
- Department of Obstetrics and Gynecology, Hospital Clínico Universitario de Zaragoza, Zaragoza, Spain
| | - Octavio Arencibia
- Department of Obstetrics and Gynecology, Hospital Universitario Gran Canarias Dr. Negrín, Las Palmas, Spain
| | - Marina Martí Edo
- Department of Obstetrics and Gynecology, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Soledad Fidalgo
- Department of Obstetrics and Gynecology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Josep Sanchis
- Gynecologic Oncology Unit, Instituto Valenciano de Oncologia (IVO), Valencia, Spain
| | - Pablo Padilla-Iserte
- Gynecologic Oncology Unit, Hospital Politécnico Universitario La Fe, Valencia, Spain
| | - Manuel Pantoja-Garrido
- Department of Obstetrics and Gynecology, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Sergio Martínez
- Department of Gynecology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Ricard Peiró
- Department of Obstetrics and Gynecology, Hospital General de Catalunya, Barcelona, Spain
| | - Cecilia Escayola
- Department of Obstetrics and Gynecology, El Pilar Quiron, Barcelona, Spain
| | - M Reyes Oliver-Pérez
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, 12 de Octubre Research Institute (i+12), Complutense University of Madrid, Madrid, Spain
| | - Cristina Aghababyan
- Department of Obstetrics and Gynecology, Hospital General Universitario de Valencia, Valencia, Spain
| | - Carmen Tauste
- Department of Obstetrics and Gynecology, Hospital Universitario de Navarra, Pamplona, Spain
| | - Sara Morales
- Department of Obstetrics and Gynecology, Hospital Infanta Leonor, Madrid, Spain
| | - Anna Torrent
- Department of Obstetrics and Gynecology, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Jesus Utrilla-Layna
- Department of Obstetrics and Gynecology, Fundación Jimenez Diaz, Madrid, Spain
| | - Francesc Fargas
- Department of Obstetrics and Gynecology, Hospital Universitari Quirón Dexeus, Barcelona, Spain
| | - Ana Calvo
- Department of Obstetrics and Gynecology, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Laura Aller de Pace
- Department of Obstetrics and Gynecology, Hospital Marqués de Valdecilla, Santander, Spain
| | - Antonio Gil-Moreno
- Gynecologic Oncology Unit, Hospital Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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Chen J, Liang S, He M, Wang Z, Deng H, Zhang G, Yang X, Liang X, Sun X, Zhou R, Li X, Li Y, Wang J. Comparison of sentinel lymph node distribution and lymphatic drainage pathway between high- and low-risk endometrial cancers. Arch Gynecol Obstet 2023; 308:1641-1647. [PMID: 37430177 DOI: 10.1007/s00404-023-07111-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 06/13/2023] [Indexed: 07/12/2023]
Abstract
PURPOSE This study aimed to compare the distribution and drainage pathway of sentinel lymph nodes between high- and low-risk endometrial cancers. METHODS In total, 429 patients with endometrial cancer who underwent sentinel lymph node biopsy in Peking University People's Hospital from July 2015 to April 2022 were retrospectively enrolled. There were 148 patients in the high-risk group and 281 patients in the low-risk group. RESULTS The unilateral and bilateral detection rates of sentinel lymph nodes were 86.5% and 55.9%, respectively. The highest detection rate was achieved in the subgroup with a combined use of indocyanine green (ICG) and carbon nanoparticles (CNP) (94.4% for unilateral detection and 66.7% for bilateral detection). The upper paracervical pathway (UPP) was detected in 93.3% of cases in the high-risk group and 96.0% of cases in the low-risk group (p = 0.261). The lower paracervical pathway (LPP) was detected in 10.0% of cases in the high-risk group and 17.9% of cases in the low-risk group (p = 0.048). Remarkably increased detection rates of SLN in the common iliac (7.5%) and para-aortic or precaval areas (2.9%) were observed in the high-risk group. In contrast, a markedly decreased detection rate of SLN in the internal iliac area (1.9%) was observed in the high-risk group. CONCLUSION The highest detection rate of SLN was observed in the subgroup with a combined use of ICG and CNP. The detection of UPP is important for both high-risk and low-risk cases, while LPP detection plays a more important role in the low-risk group. Lymphadenectomy in the common iliac and para-aortic or precaval areas is essential for patients with high-risk EC. Removal of internal iliac lymph nodes is essential for patients with low-risk EC, in case of ineffective SLN mapping.
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Affiliation(s)
- Jiayu Chen
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
- Department of Obstetrics and Gynecology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
| | - Sichen Liang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Miao He
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Zhiqi Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Hao Deng
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Guo Zhang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Xin Yang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Xudong Liang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Xiuli Sun
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Rong Zhou
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Xiaowei Li
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Yi Li
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Jianliu Wang
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China.
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Park J, Bak S, Song JY, Chung YJ, Yuki G, Lee SJ, Mun J, Kim MR. Robotic surgery in Gynecology: the present and the future. Obstet Gynecol Sci 2023; 66:518-528. [PMID: 37465847 PMCID: PMC10663391 DOI: 10.5468/ogs.23132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/23/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023] Open
Abstract
Since its introduction, laparoscopic surgery has been often preferred over open surgery in obstetrics and gynecology due to its advantages, such as less bleeding, lower incidence of adhesions, reduced postoperative pain, short hospital stay, and quick return to daily life. However, in the case of complex surgeries, laparoscopy presented some limitations. Nonetheless, since the 1980s, medical robots have been introduced to overcome the technical limitations of laparoscopy and start a new age for minimally invasive surgery. In this review, we explore the indications and advantages and disadvantages of robotic surgery in the field of gynecology, and try to assess the recent trend of robotic surgery.
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Affiliation(s)
- JungYoon Park
- Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - SeongEun Bak
- Department of Obstetrics and Gynecology, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Jae-Yen Song
- Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Youn-Jee Chung
- Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Gen Yuki
- Department of Obstetrics and Gynecology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Su Jeong Lee
- Department of Obstetrics and Gynecology, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Jisu Mun
- Department of Obstetrics and Gynecology, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Mee-Ran Kim
- Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
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Guo W, Wang T, Lv B, Jiang J, Liu Y, Zhao P. Advances in Radiomics Research for Endometrial Cancer: A Comprehensive Review. J Cancer 2023; 14:3523-3531. [PMID: 38021155 PMCID: PMC10647186 DOI: 10.7150/jca.89347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/08/2023] [Indexed: 12/01/2023] Open
Abstract
Endometrial cancer (EC) is a common gynecologic malignancy, with a rising trend in related mortality rates. The assessment based on imaging examinations contributes to the preoperative staging and surgical management of EC. However, conventional imaging diagnosis has limitations such as low accuracy and subjectivity. Radiomics, utilizing advanced feature analysis from medical images, extracts more information, ultimately establishing associations between imaging features and disease phenotypes. In recent years, radiomic studies on EC have emerged, employing radiomic features combined with clinical characteristics to model and predict histopathological features, protein expression, and clinical prognosis. This article elaborates on the application of radiomics in EC research and discusses its implications.
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Affiliation(s)
- Wenxiu Guo
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, 250021, China
| | - Tong Wang
- Department of Gynecology and Obstetrics, Qilu Hospital of Shandong University, 250012, Jinan, China
| | - Binglin Lv
- Department of Gynecology and Obstetrics, Qilu Hospital of Shandong University, 250012, Jinan, China
| | - Jie Jiang
- Department of Gynecology and Obstetrics, Qilu Hospital of Shandong University, 250012, Jinan, China
| | - Yao Liu
- Department of Gynecology and Obstetrics, Qilu Hospital of Shandong University, 250012, Jinan, China
| | - Peng Zhao
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, 250021, China
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Koh KML, Ng ZY, Chin FHX, Wong WL, Wang J, Lim YK. Comparing Surgical and Oncological Outcomes between Indocyanine Green (ICG) Sentinel Lymph Node Mapping with Routine Lymphadenectomy in the Surgical Staging of Early-Stage Endometrioid Endometrial Cancer. Obstet Gynecol Int 2023; 2023:9949604. [PMID: 37881680 PMCID: PMC10597725 DOI: 10.1155/2023/9949604] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/17/2023] [Accepted: 10/07/2023] [Indexed: 10/27/2023] Open
Abstract
Methods A retrospective single-centre cohort study of patients with early-stage endometrioid endometrial cancer undergoing staging surgery (total hysterectomy, bilateral salpingo-oophorectomy with/without pelvic lymph node, and/or para-aortic lymph node dissection (PLND)) with either SLN mapping or routine lymphadenectomy between July 2017 and December 2018. Results 203 cases with clinical and radiological International Federation of Gynaecology and Obstetrics (FIGO) stage I endometrioid endometrial cancer were included, out of which 109 cases underwent SLN mapping and 94 cases complete lymphadenectomy. Compared to the PLND group, the SLN group had shorter operative time (129 vs. 162 minutes), less blood loss (100 vs. 300 ml), and decreased length of postoperative hospital stay (3 vs. 4 days) (p < 0.001). The lymph node metastases detection rate was 4.6% and 7.4% for the SLN and PLND groups, respectively (p = 0.389). With a median follow-up of 14 months for the SLN and 15 months for the PLND group, the disease-free (DFS) and overall survival (OS) were comparable for both at 13 months (p = 0.538 and p = 0.333, respectively). Conclusion SLN mapping has been shown to be an acceptable alternative to routine lymphadenectomy in the surgical staging of early-stage endometrial cancer in our centre, with a comparable lymph node metastases detection rate, DFS and OS, and reduction in operative morbidity. Our results with SLN mapping reproduce comparable outcomes to those reported in the literature.
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Affiliation(s)
- Krystal Miao Lin Koh
- Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, 100 Bukit Timah Road 229899, Singapore
| | - Zheng Yuan Ng
- Department of Gynaecological Oncology, KK Women's and Children's Hospital, 100 Bukit Timah Road 229899, Singapore
| | - Felicia Hui Xian Chin
- Department of Gynaecological Oncology, KK Women's and Children's Hospital, 100 Bukit Timah Road 229899, Singapore
| | - Wai Loong Wong
- Department of Gynaecological Oncology, KK Women's and Children's Hospital, 100 Bukit Timah Road 229899, Singapore
| | - Junjie Wang
- Department of Gynaecological Oncology, KK Women's and Children's Hospital, 100 Bukit Timah Road 229899, Singapore
| | - Yong Kuei Lim
- Department of Gynaecological Oncology, KK Women's and Children's Hospital, 100 Bukit Timah Road 229899, Singapore
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Capozzi VA, Scarpelli E, Berretta R. Response to: Correspondence on 'Long-term survival outcomes in high-risk endometrial cancer patients undergoing sentinel lymph node biopsy alone versus lymphadenectomy' by Buda et al. Int J Gynecol Cancer 2023; 33:1670-1671. [PMID: 37666524 DOI: 10.1136/ijgc-2023-004890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023] Open
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Capozzi VA, Armano G, Maglietta G, Rosati A, Vargiu V, Scarpelli E, Sozzi G, Chiantera V, Cosentino F, Gioè A, Catena U, Scambia G, Fanfani F, Di Spiezio Sardo A, Ghi T, Berretta R. Hysteroscopic endometrial tumor localization and sentinel lymph node mapping. An upgrade of the hysteroscopic role in endometrial cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106952. [PMID: 37328309 DOI: 10.1016/j.ejso.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Given the growing interest in sentinel node mapping (SLN) biopsy in Endometrial Cancer (EC) patients, many efforts have been made to maximize the SLN bilateral detection rate. However, at present, no previous research assessed the potential correlation between primary EC location in the uterine cavity and SLN mapping. In this context, this study aims to investigate the possible role of intrauterine EC hysteroscopic localization in predicting SLN nodal placement. MATERIALS AND METHODS EC patients surgically treated from January 2017 to December 2021 were retrospectively analyzed. All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and SLN mapping. During hysteroscopy, the location of the neoplastic lesion was described as follows: uterine fundus (comprising the most cranial portion of the uterine cavity up to the tubal ostium including the cornual areas), corpus uteri (from the tubal ostium to the inner uterine orifice), and diffuse (when the tumor invades more than 50% of the uterine cavity). RESULTS Three hundred ninety patients met the inclusion criteria. The tumor pattern diffused to the whole uterine cavity was statistically associated with SLN uptake on common iliac lymph nodes (OR 2.4, 95%CI 1-5.8, p = 0.05). Patients'age is an independent factor associated with SLN failure (OR: 0.95, 95%CI 0.93-0.98, p < 0.001). CONCLUSIONS The study showed a statistically significant association between EC hysteroscopically spread throughout the whole uterine cavity and SLN uptake at the common iliac lymph nodes. Furthermore, patient age negatively affected the SLN detection rate.
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Affiliation(s)
- Vito Andrea Capozzi
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy.
| | - Giulia Armano
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Giuseppe Maglietta
- Clinical and Epidemiological Research Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Andrea Rosati
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Virginia Vargiu
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Oncology, Gemelli Molise Spa, Campobasso, Italy
| | - Elisa Scarpelli
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Giulio Sozzi
- Department of Gynecologic Oncology, University of Palermo, Palermo, Italy
| | - Vito Chiantera
- Department of Gynecologic Oncology, University of Palermo, Palermo, Italy
| | - Francesco Cosentino
- Department of Oncology, Gemelli Molise Spa, Campobasso, Italy; Dipartimento di Medicina e Scienze della Salute "Vincenzo Tiberio", Università del Molise, Campobasso, Italy
| | - Alessandro Gioè
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ursula Catena
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Scambia
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Fanfani
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Attilio Di Spiezio Sardo
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Tullio Ghi
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Roberto Berretta
- Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
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Huang SY, Fu HC, Wu CH, Wang SC, Ou YC, Tsai CC, Chen YY, Huang SW, Wang YW, Lin H. Pretreatment carcinoembryonic antigen combined with cancer antigen-125 for predicting lymph node metastasis in endometrial carcinoma: a retrospective cohort study. J Cancer Res Clin Oncol 2023; 149:11807-11813. [PMID: 37405474 DOI: 10.1007/s00432-023-05087-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/29/2023] [Indexed: 07/06/2023]
Abstract
PURPOSE To investigate whether the cost-effective, pretreatment tumor markers carcinoembryonic antigen (CEA) and carbohydrate antigen-125 (CA-125) can be used to predict lymph node metastasis (LNM) in endometrioid-type endometrial cancer (EC) and to develop a predictive model. METHODS This was a single-center retrospective study of patients with endometrioid-type EC who underwent complete staging surgery between January 2015 and June 2022. We identified the optimal cut-off values of CEA and CA-125 for predicting LNM using receiver operating characteristic (ROC) curves. Stepwise multivariate logistic regression analysis was used to identify independent predictors. A nomogram for predicting LNM was constructed and validated by bootstrap resampling. RESULTS The optimal cut-off values of CEA and CA-125 were 1.4 ng/mL (area under the ROC curve (AUC) 0.62) and 40 U/mL (AUC 0.75), respectively. Multivariate analysis showed that CEA (odds ratio (OR) 1.94; 95% confidence interval (CI) 1.01-3.74) and CA-125 (OR 8.75; 95% CI 4.42-17.31) were independent predictors of LNM. Our nomogram showed adequate discrimination with a concordance index of 0.78. Calibration curves for the probability of LNM showed optimal agreement between the predicted and actual probabilities. The risk of LNM for markers below the cut-offs was 3.6%. The negative predictive value and negative likelihood ratio were 96.6% and 0.26, respectively, with moderate ability to rule out the possibility of LNM. CONCLUSION We report a cost-effective method of using pretreatment CEA and CA-125 levels to identify patients with endometrioid-type EC who are at a low risk for LNM, which may guide decision-making regarding aborting lymphadenectomy.
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Affiliation(s)
- Szu-Yu Huang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City, Taiwan, R.O.C
| | - Hung-Chun Fu
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City, Taiwan, R.O.C
| | - Chen-Hsuan Wu
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City, Taiwan, R.O.C
| | - Shao-Chi Wang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City, Taiwan, R.O.C
| | - Yu-Che Ou
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City, Taiwan, R.O.C
- Department of Obstetrics and Gynecology, Chia-Yi Chang Gung Memorial Hospital, Chia-Yi, Taiwan
| | - Ching-Chou Tsai
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City, Taiwan, R.O.C
| | - Ying-Yi Chen
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City, Taiwan, R.O.C
| | - Szu-Wei Huang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City, Taiwan, R.O.C
| | - Ying-Wen Wang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City, Taiwan, R.O.C
| | - Hao Lin
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, Kaohsiung City, Taiwan, R.O.C..
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