Novel preoperative predictive score to evaluate lymphovascular space involvement in endometrial cancer: an aid to the sentinel lymph node algorithm

Advancing Tailored Treatments: A Predictive Nomogram, Based on Ultrasound and Laboratory Data, for Assessing Nodal Involvement in Endometrial Cancer Patients

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.

Role of magnetic resonance imaging in the differentiation of mucinous ovarian carcinoma and mucinous borderline ovarian tumors

OBJECTIVE

This study was carried out to investigate the differentiation of mucinous borderline ovarian tumor from mucinous ovarian carcinoma using magnetic resonance imaging.

METHODS

We evaluated 77 women patients who underwent abdominal magnetic resonance imaging due to pelvic mass. magnetic resonance imaging was reviewed by an experienced radiologist. A total of 70 women patients were included in the study. The magnetic resonance imaging features were retrospectively evaluated and compared between the two pathologies.

RESULTS

There was no difference between the two groups in terms of maximum tumor size. Age at diagnosis was 56.29±11.92 in the mucinous ovarian carcinoma group and 44.74±13.60 in the mucinous borderline ovarian tumor group (p<0.05). A significant difference was found between the two groups, and it was observed that mucinous borderline ovarian tumors appeared in the younger age group compared to mucinous ovarian carcinomas. Presence of ascites, peritoneal dissemination, lymphadenopathy, and mural nodules was found significantly more frequently in mucinous ovarian carcinomas than in mucinous borderline ovarian tumors. Honeycomb appearance was found more frequently in mucinous borderline ovarian tumor patients than in mucinous ovarian carcinoma patients.

CONCLUSION

magnetic resonance imaging findings of these two pathologies overlapped considerably. Compared with mucinous borderline ovarian tumors, mucinous ovarian carcinomas frequently had mural nodules larger than 5 mm, larger tumor size, peritoneal dissemination, and abnormal ascites.

Association of Lymphovascular Space Invasion (LVSI) with Histological Tumor Grade and Myometrial Invasion in Endometrial Carcinoma: A Review Study

Endometrial carcinoma is one of the most frequent gynecological cancers in developed countries. Lymphovascular space invasion (LVSI), histological grade, and myometrial invasion (MMI) are important prognostic factors of endometrial carcinoma. LVSI is considered an independent poor prognostic factor in endometrial carcinoma. Based on the importance of LVSI, this study aimed to discuss the association of LVSI with tumor grade and MMI. A search of PubMed, EMBASE, Web of Science, Scopus, Google Scholar, and Cochrane Library was carried out to collect related studies. Consequently, most studies showed that LVSI is significantly associated with higher histologic grade and deep MMI.

Lymphovascular Space Invasion in Early-Stage Endometrial Cancer (LySEC): Patterns of Recurrence and Predictors. A Multicentre Retrospective Cohort Study of the Spain Gynecologic Oncology Group

The main aim is to compare oncological outcomes and patterns of recurrence of patients with early-stage endometrioid endometrial cancer according to lymphovascular space invasion (LVSI) status. The secondary objective is to determine preoperative predictors of LVSI. We performed a multicenter retrospective cohort study. A total of 3546 women diagnosed with postoperative early-stage (FIGO I-II, 2009) endometrioid endometrial cancer were included. Co-primary endpoints were disease-free survival (DFS), overall survival (OS), and pattern of recurrence. Cox proportional hazard models were used for time-to-event analysis. Univariate and multivariate logistical regression models were employed. Positive LVSI was identified in 528 patients (14.6%) and was an independent prognostic factor for DFS (HR 1.8), OS (HR 2.1) and distant recurrences (HR 2.37). Distant recurrences were more frequent in patients with positive LVSI (78.2% vs. 61.3%, p < 0.01). Deep myometrial invasion (OR 3.04), high-grade tumors (OR 2.54), cervical stroma invasion (OR 2.01), and tumor diameter ≥ 2 cm (OR 2.03) were independent predictors of LVSI. In conclusion, in these patients, LVSI is an independent risk factor for shorter DFS and OS, and distant recurrence, but not for local recurrence. Deep myometrial invasion, cervical stroma invasion, high-grade tumors, and a tumor diameter ≥ 2 cm are independent predictors of LVSI.

Development and Validation of a Nomogram Based on Metabolic Risk Score for Assessing Lymphovascular Space Invasion in Patients with Endometrial Cancer

OBJECTIVE

This study assessed the predictive value of the metabolic risk score (MRS) for lymphovascular space invasion (LVSI) in endometrial cancer (EC) patients.

METHODS

We included 1076 patients who were diagnosed with EC between January 2006 and December 2020 in Peking University People's Hospital. All patients were randomly divided into the training and validation cohorts in a ratio of 2:1. Data on clinicopathological indicators were collected. Univariable and multivariable logistic regression analysis was used to define candidate factors for LVSI. A backward stepwise selection was then used to select variables for inclusion in a nomogram. The performance of the nomogram was evaluated by discrimination, calibration, and clinical usefulness.

RESULTS

Independent predictors of LVSI included differentiation grades (G2: OR = 1.800, 95% CI: 1.050-3.070, p = 0.032) (G3: OR = 3.49, 95% CI: 1.870-6.520, p < 0.001), histology (OR = 2.723, 95% CI: 1.370-5.415, p = 0.004), MI (OR = 4.286, 95% CI: 2.663-6.896, p < 0.001), and MRS (OR = 1.124, 95% CI: 1.067-1.185, p < 0.001) in the training cohort. A nomogram was established to predict a patient's probability of developing LVSI based on these factors. The ROC curve analysis showed that an MRS-based nomogram significantly improved the efficiency of diagnosing LVSI compared with the nomogram based on clinicopathological factors (p = 0.0376 and p = 0.0386 in the training and validation cohort, respectively). Subsequently, the calibration plot showed a favorable consistency in both groups. Moreover, we conducted a decision curve analysis, showing the great clinical benefit obtained from the application of our nomogram. However, our study faced several limitations. Further external validation and a larger sample size are needed in future studies.

CONCLUSION

MRS-based nomograms are useful for predicting LVSI in patients with EC and may facilitate better clinical decision-making.

Data Set for the Reporting of Endometrial Cancer: Recommendations From the International Collaboration on Cancer Reporting (ICCR)

Endometrial cancer is one of the most common cancers among women. The International Collaboration on Cancer Reporting (ICCR) developed a standardized endometrial cancer data set in 2011, which provided detailed recommendations for the reporting of resection specimens of these neoplasms. A new data set has been developed, which incorporates the updated 2020 World Health Organization Classification of Female Genital Tumors, the Cancer Genome Atlas (TCGA) molecular classification of endometrial cancers, and other major advances in endometrial cancer reporting, all of which necessitated a major revision of the data set. This updated data set has been produced by a panel of expert pathologists and an expert clinician and has been subject to international open consultation. The data set includes core elements which are unanimously agreed upon as essential for cancer diagnosis, clinical management, staging, or prognosis and noncore elements which are clinically important, but not essential. Explanatory notes are provided for each element. Adoption of this updated data set will result in improvements in endometrial cancer patient care.

A large multicenter propensity match study of sentinel lymph node biopsy feasibility in endometrioid variants of endometrial cancer

INTRODUCTION

Sentinel lymph node (SLN) biopsy algorithm has been routinely applied in all endometrial endometrioid tumors, however, no studies analyzed the feasibility of SLN mapping in endometrioid variants (EV), which included villoglandular, secretory, ciliated cell, mucinous, and squamous differentiation. This study aimed to demonstrate the feasibility of SLN biopsy in EV of EC.

MATERIALS AND METHODS

All patients undergoing minimally invasive surgical treatment for early-stage EC were included in the study. Patients were divided into 2 study groups: Group 1 which included patients with EV, and Group 2 which included patients with typical endometrioid histology. A propensity match analysis was performed according to age (≥65 years vs. no), BMI (≥30 kg/m² vs. no), and LVSI (present vs. absent).

RESULTS

After a 1:5 propensity-matched analysis, a total of 458 patients were identified (Group 1 n = 77, Group 2 n = 381). Overall detection rate was not statistically significant between the EV and the typical endometrioid group (94.8% vs. 92.4%, p = 0.319). Furthermore, neither bilateral nor unilateral detection rate was different between the two groups (70.1% vs. 74.8%, p = 0.267, and 23.4% vs. 17.8%, p = 0.120). BMI ≥30 kg/m² was the only factor influencing SLN failure (p = 0.013). SLN technique showed excellent sensitivity in both the EV (100% sensitivity, p < 0.001) and the typical endometrioid unit (93.8% sensitivity, p < 0.001).

CONCLUSION

SLN research/detection for EV of endometrial cancer is a feasible and highly sensitive technique. Obesity was confirmed to be a risk factor for SLN failure.

Impact of lymphadenectomy on short- and long-term complications in patients with endometrial cancer

Introduction

Early endometrial cancer is primarily treated surgically via hysterectomy, adenectomy and, depending on tumor stage and subtype, lymphadenectomy. Systematic lymph node dissection is known to cause surgical complications. The aim of the present study was to investigate morbidity and mortality rates associated with lymphadenectomy in patients with endometrial cancer who underwent surgery in a routine clinical setting.

Methods

We collected data from 232 patients who were operated for endometrial carcinoma between 2006 and 2018 at the University of Lubeck, Germany. Surgical complications were viewed in relation to surgical risk factors. Additionally, a questionnaire concerning long-term lymphatic complications and survival was completed. Survival was compared between patients who underwent lymphadenectomy (group I) and those who did not (group II).

Results

Patients in group I needed revision surgery significantly more often due to postoperative complications (such as lymphoceles) compared to those in group II (p = 0.01). The results indicate more serious complications in patients who underwent a systematic lymphadenectomy and in those with lymph node metastases. 15% of patients who underwent a systematic lymphadenectomy had lymph node metastases. Recurrences occurred in 12.5% of cases and were significantly more frequent in patients who had undergone a lymphadenectomy, even if the lymph nodes were negative (p = 0.02). A comparison of survival data during the follow-up period revealed no significant difference. The study highlighted the need for a better preoperative risk stratification and the avoidance of lymphadenectomy for surgical staging alone.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-022-06396-5.

The accuracy and clinical impact of intraoperative frozen section in determining the extent of surgical intervention in patients with early stage endometrial cancer

The aim of this study was to compare intraoperative frozen section (FS) with the final pathology (FP), and determine its clinical impact in clinically apparent early stage endometrial cancer (EC) at the American University of Beirut Medical Center (AUBMC). Data for patients 18 years or older, with clinically apparent early stage, grade 1 or 2, endometrioid EC, who underwent hysterectomy ± lymph node dissection (LND) at AUBMC between January 1^st 1996 and June 30^th 2016 were retrospectively reviewed. 70 patients were included. The overall concordance between FS and FP was 92.3% for histological subtype, 77% for tumour grade, 82% for Myometrial invasion (MI) and 100% for tumour size. At a median follow up of 30 months, 8 recurrences (11.4%) were noted, with a 5-year PFS and OS of 76 and 84% respectively, with a trend towards lower recurrence and improved survival in patients who underwent FS or LND.Impact statementWhat is already known on this subject? Hysterectomy and bilateral salpingo-oophorectomy is the standard surgery for stage I endometrial cancer (EC). Intraoperative frozen section (FS) facilitates the decision on performing lymph node dissection (LND). However, its accuracy and clinical impact have been questioned.What do the results of this study add? Our objective is to compare FS with the final pathology (FP), and determine its clinical impact in clinically apparent early stage EC at the American University of Beirut Medical Center (AUBMC). There is a lack of standardisation regarding FS use and reporting at AUBMC.What are the implications of these findings for clinical practice and/or further research? The strong correlation between FS and FP can serve as a tool to guide decision to perform LND in patients with apparent early stage disease, where use of sentinel LN biopsy technique is not available.

Near-Infrared Imaging With Indocyanine Green for the Treatment of Endometriosis: Results From the Gre-Endo Trial

Introduction

A current challenge for endometriosis surgery is to correctly identify the localizations of disease, especially when small or hidden (occult endometriosis), and to exactly define their real extension. The use of near-infrared radiation imaging (NIR) after injection of indocyanine green (ICG) represents one of the most encouraging method. The aim of this study is to assess the diagnostic value of NIR-ICG imaging in the surgical treatment of endometriosis compared with the standard of treatment.

Material and Methods

The Gre-Endo trial is a prospective, single-arm study (NCT03332004). After exploring the operatory field using the white light (WL) mode, patients were injected with ICG and then observed in NIR mode. All suspected areas were classified and chronicled according to lesions visualized only in WL, NIR-ICG, or in the combination of both. Lesion not visualized in WL was considered as suspect occult lesion (s-OcL). In addition, a random control biopsy from an apparent negative peritoneum visualized in WL and NIR-ICG imaging was taken for all patients (control cases). All lesions removed were considered “suspect endometriosis” until pathology.

Results

Fifty-one patients were enrolled between January 2016 and October 2019. A total of 240 suspected lesions have been identified with both methods (WL + NIR-ICG). Two hundred and seven (86.2%) lesions out of the overall 240 were visualized with WL imaging, and 200 were confirmed to be pathologic (true positive for WL). The remaining 33/240 (13.75%) (false negative for WL) lesions were identified only with NIR-ICG imaging and collected as s-OcL. All 33 s-OcLs removed were confirmed to be pathologic (c-OcL = 100%). NIR-ICG vision showed PPV of 98.5%, NPV of 87.1%, Se of 87%, and Sp of 98.5%, confirming that this kind of imaging is an excellent diagnostic and screening test (p = 0.001 and p = 0.835, according to McNemar’s and Cohen’s kappa tests, respectively).

Conclusions

The use of NIR-ICG vision alone and combined with WL showed good results in intraoperative detection rate and fluorescence-guided surgery of endometriosis. Furthermore, NIR-ICG allowed surgeons to remove occult lesions that otherwise would remain, leading to possible greater postoperative pain and a higher risk of persistence and relapse.

Predictive Score of Nodal Involvement in Endometrial Cancer Patients: A Large Multicentre Series

BACKGROUND

Sentinel lymph node (SLN) biopsy is considered the standard of care in early-stage endometrial cancer (EC). For SLN failure, a side-specific lymphadenectomy is recommended. Nevertheless, most hemipelvises show no nodal involvement. The authors previously published a predictive score of lymphovascular involvement in EC. In case of a negative score (value 3-4), the risk of nodal metastases was extremely low. This multicenter study aimed to analyze a predictive score of nodal involvement in EC patients.

METHODS

The study enrolled patients with EC who had received comprehensive surgical staging with nodal assessment. A preoperative predictive score of nodal involvement was calculated for all the patients before surgery. The score included myometrial infiltration, tumor grading (G), tumor diameter, and Ca125 assessment. The STARD (standards for Reporting Diagnostic accuracy studies) guidelines were followed for score accuracy.

RESULTS

The study analyzed 1038 patients and detected 155 (14.9%) nodal metastases. The score was negative (3 or 4) for 475 patients and positive (5-7) for 563 of these patients. The score had a sensitivity of 83.2%, a specificity of 50.8%, a negative predictive value of 94.5%, and a diagnostic value of 55.7%. The area under the curve was 0.75. The logistic regression showed a significant correlation between a negative score and absence of nodal metastasis (odds ration [OR], 5.133, 95% confidence interval [CI], 3.30-7.98; p < 0.001).

CONCLUSION

The proposed predictive score is a useful test to identify patients at low risk of nodal involvement. In case of SLN failure, the application of the current score in the SLN algorithm could allow avoidance of unnecessary lymphadenectomies.

Association of Myometrial Invasion With Lymphovascular Space Invasion, Lymph Node Metastasis, Recurrence, and Overall Survival in Endometrial Cancer: A Meta-Analysis of 79 Studies With 68,870 Patients

Background

Myometrial invasion has been demonstrated to correlate to clinicopathological characteristics and prognosis in endometrial cancer. However, not all the studies have the consistent results and no meta-analysis has investigated the association of myometrial invasion with lymphovascular space invasion (LVSI), lymph node metastasis (LNM), recurrence, and overall survival (OS). Therefore, a meta-analysis was performed to evaluate the relationship between myometrial invasion and clinicopathological characteristics or overall survival in endometrial cancer.

Materials and Methods

A search of Pubmed, Embase, and Web of Science was carried out to collect relevant studies from their inception until June 30, 2021. The quality of each included study was evaluated using Newcastle–Ottawa scale (NOS) scale. Review Manager version 5.4 was employed to conduct the meta-analysis.

Results

A total of 79 articles with 68,870 endometrial cancer patients were eligible including 9 articles for LVSI, 29 articles for LNM, 8 for recurrence, and 37 for OS in this meta-analysis. Myometrial invasion was associated with LVSI (RR 3.07; 95% CI 2.17–4.35; p < 0.00001), lymph node metastasis (LNM) (RR 4.45; 95% CI 3.29–6.01; p < 0.00001), and recurrence (RR 2.06; 95% CI 1.58–2.69; p < 0.00001). Deep myometrial invasion was also significantly related with poor OS via meta-synthesis of HRs in both univariate survival (HR 3.36, 95% CI 2.35–4.79, p < 0.00001) and multivariate survival (HR 2.00, 95% CI 1.59–2.53, p < 0.00001). Funnel plot suggested that there was no significant publication bias in this study.

Conclusion

Deep myometrial invasion correlated to positive LVSI, positive LNM, cancer recurrence, and poor OS for endometrial cancer patients, indicating that myometrial invasion was a useful evaluation criterion to associate with clinical outcomes and prognosis of endometrial cancer since depth of myometrial invasion can be assessed before surgery. The large scale and comprehensive meta-analysis suggested that we should pay more attention to myometrial invasion in clinical practice, and its underlying mechanism also deserves further investigation.

Can addition of frozen section analysis to preoperative endometrial biopsy and MRI improve identification of high-risk endometrial cancer patients?

Background

Surgeons sometimes have difficulty determining which result to favor when preoperative results (MRI + preoperative endometrial biopsy [pre-op EB]) differ from intraoperative frozen section histology (FS) results. Investigation of how FS can complement ordinary preoperative examinations like MRI and pre-op EB in identification of patients at high risk of lymph node metastasis (high-risk patients) could provide clarity on this issue. Therefore, the aim of this study is to assess the utility of pre-op EB, MRI and FS results and determine how to combine these results in identification of high-risk patients.

Methods

The subjects were 172 patients with endometrial cancer. Patients with a histological high-grade tumor (HGT), namely, grade 3 endometrioid cancer, clear cell carcinoma or serous cell carcinoma, or with any type of cancer invading at least half of the uterine myometrium were considered high-risk. Tumors invading at least half of the uterine myometrium were classified as high-stage tumors (HST). We compared (a) detection of HGT using pre-op EB versus FS, (b) detection of HST using MRI versus FS, and (c) identification of high-risk patients using MRI + pre-op EB versus FS. Lastly, we determined to what degree addition of FS results improves identification of high-risk patients by routine MRI + pre-op EB.

Results

(a) Sensitivity, specificity, and accuracy for detecting HGT were 59.6, 98.4 and 87.8% for pre-op EB versus 55.3, 99.2 and 87.2% for FS (P = 0.44). (b) These figures for detecting HST were 74.4, 83.0 and 80.8% for MRI versus 46.5, 99.2 and 86.0% for FS (P < 0.001). (c) These figures for identifying high-risk patients were 78.3, 85.4 and 82.6% for MRI + pre-op EB versus 55.1, 99.0 and 81.2% for FS (P < 0.001). The high specificity of FS improved the sensitivity of MRI + pre-op EB from 78.3 to 81.2%, but this difference was not statistically significant (P < 0.16).

Conclusion

Frozen section enables identification of high-risk patients with nearly 100% specificity. This advantage can be used to improve sensitivity for identification of high-risk patients by routine MRI + pre-op EB, although this improvement is not statistically significant.

Analysis of Factors Related to Lymph Node Metastasis in Early-Stage Type 1 Endometrial Cancer: Verifying the Clinical Value of Positive Threshold of the Immunohistochemical Parameter Ki67

Objective

Lymph node metastasis (LNM) is an important reference indicator for the prognosis of endometrial cancer (EC). Even in patients with early low-risk EC, many people still have LNM. The purpose of this study was to investigate the related factors influencing LNM in early-stage EC and determine the optimal positive threshold of immunohistochemical parameter Ki67 for predicting LNM, providing auxiliary reference indicators for clinical diagnosis and treatment.

Methods

The clinicopathological data of 651 patients with “apparent” early-stage EC who underwent standard surgical treatment were included. Univariate and multivariate logistics regression were used to analyze the correlation between each clinicopathological factor and LNM. Receiver operating characteristic curve (ROC curve) and Youden index were used to determine the optimal positive threshold of Ki67 for predicting LNM. Finally, correlation between Ki67 and various clinicopathological factors was analyzed, and the predictive value of each prognostic factor was compared.

Results

Multivariate analysis found that histologic grade (P=0.023), lymphatic vessel space invasion (LVSI) (P < 0.001), serological index Ca125 (P=0.002), immunohistochemical parameter Ki67 (P < 0.001), ER (P < 0.001) and P53 (P=0.001) were independent prognostic factors of LNM. ROC curve and Youden index showed that the optimal positive thresholds of Ki67 to predict LNM were 40%. Based on this, ROC curve showed that the area under the curve (AUC) of Ki67 (AUC=0.714) was larger than other single predictors, and Ki67 combined with other predictors can significantly increase the AUC value (AUC= 0.847 and 0.868, respectively).

Conclusion

Ki67 was an important predictor for predicting the LNM in early-stage EC and taking a positive percentage of about 40% can be used as the positive threshold of the immunohistochemical parameter Ki67. On this basis, Ki67 combined with other predictive indicators can significantly improve prediction performance and can be used for segmentally predicting LNM of early-stage EC.

Obesity, an independent predictor of pre and postoperative tumor grading disagreement in endometrial cancer

INTRODUCTION

Obesity is a known independent risk factor for endometrial cancer (EC), and obese patients have a 4.7-fold increased risk compared to the general population to develop the neoplasm. To date, a general pre and postoperative tumor grading agreement from 53 % to 82 % is reported for endometrial analysis, and a consensus on which factors might influence the tumor grading discordance is still absent. Furthermore, although obesity alters the endometrial microenvironment, no studies investigated the role of obesity in the grading agreement of EC patients. This study aims to analyze the role of obesity in the pre and postoperative tumor grading agreement.

MATERIALS AND METHODS

A retrospective analysis was conducted on EC cancer women subjected to surgical treatment. Upgrading discordance was defined as higher tumor grading on final pathological analysis compared to tumor grading on the preoperative examination. Downgrading discordance was defined as a lower tumor grading at the postoperative surgical specimen analysis compared to the preoperative biopsy.

RESULTS

Of the 293 selected patients, 245 were included in the analysis. One hundred and forty nine (60.8 %) patients were tumor grade G1, 52 (21.2 %) G2, and 44 (18.0 %) G3. Grading agreement was 83.9 % for G1 patients, 51.9 % for G2 patients, and 83.3 % for G3 patients. The multivariate analysis showed obesity (BMI > 30 kg/m²) as significant factor influencing pre and postoperative grading agreement (p = 0.014, Odds Ratio 2.036, 95 % Confidence Interval 1.141-3.635).

CONCLUSIONS

Our study for the first time showed obesity as the only factor in the multivariate analysis lowering the pre and postoperative tumor grading concordance. Grade 2 tumor was the factor that most frequently disagreed with the final surgical specimen analysis both in the general and in obese patients.

Assessment of lymphovascular invasion in early stage endometrial carcinoma -a retrospective study

Introduction

Endometrial carcinoma is associated with several known prognostic factors. Recently, lymphovascular invasion (LVI) has gained a prominent position in the risk assessment of early endometrioid endometrial carcinoma, in identifying patients who can benefit from adjuvant radiation therapy. This study aims to assess LVI in early-stage endometrioid endometrial carcinoma accurately with emphasis on its extent /grading. We also propose a few local recommendations for improving LVI reproducibility in endometrial carcinoma to guide future studies.

Methods

The duration of this retrospective study was 2 years. Early-stage I (Ia and Ib), and grade 1 and 2 endometrioid endometrial carcinomas were included. 03 reviewers independently recorded their findings on H&E stained slides. LVI was graded as none, focal and substantial. In discordant cases, immunohistochemical stain CD 31 was used.

All the data was entered in the statistical software SPSS version 26 and analyzed for frequencies. The relationships between various histological parameters assessed and the degree of reproducibility for LVI amongst various observers were also determined.

Results

Out of a total of 70 cases of endometrioid carcinoma diagnosed on hysterectomy specimen, only 32 met our inclusion criteria. The rate of LVI positivity was 6.3 %, 34.4 %, and 37.5 % respectively for reviewers 1, 2, and 3. The degree of reproducibility in LVI assessment and LVI grading was significant amongst reviewers 2 and 3. Also, a significant association was drawn between tumor grade and LVI.

Conclusion

Despite limitations in our study we recommend including both LVI assessment and grading in routine reporting formats locally. By adding a second reviewer in LVI assessment and using CD31 in discrepant cases LVI positivity can be significantly increased.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Lymphovascular space invasion in endometrial carcinoma: Tumor size and location matter

OBJECTIVE

To analyze histological factors possibly associated with lymphovascular space invasion (LVSI) and to determine which of those can act as independent surrogate markers.

METHODS

Retrospective cohort study performed between January 2001 and December 2014. LVSI was defined as the presence of tumor cells inside a space completely surrounded by endothelial cells. Risk factors evaluated included myometrial invasion, tumor grade, size, location, and cervical invasion. Univariate logistical regression models were applied to study any possible association of LVSI with these factors. Values were adjusted by multivariate logistic regression analysis.

RESULTS

A total of 327 patients with endometrial carcinoma treated in our Centre were included. LVSI was observed in 120 patients (36.7%). Lower uterine segment involvement (OR 5.21, 95% CI:2.6-10.4, p < 0.001) and size ≥2 cm (OR 2.62, 95% CI: 1.14-6.1, p < 0.001) were independent factors for LSVI in multivariate analysis. In univariate analysis, LVSI was a surrogate marker in type 1 tumors with deep myometrial invasion (IB, 51.9% vs. IA, 16.0%; p < 0.001), grade 3 (G3 55.8% vs. G1 16.2%; p < 0.001), size ≥2 cm (37.9% vs. 16.1%, p = 0.005), those with involving the lower segment of the uterus (58.9% vs. 22.5%, p < 0.001) and/or with cervical stromal invasion (65.4% vs. 26.1%, p < 0.001), and in type 2 tumors (61.5% vs. 30.5%, p < 0.001). The use of uterine manipulator did not increase the rate of LVSI (35.5% vs. 40.5%, p = 0.612) as compared to no manipulator use.

CONCLUSIONS

Size ≥2 cm and involvement of the lower uterine segment are independent factors for LSVI, in type 1 tumors, which can be used for surgical planning. LVSI is also more common in type 1 tumors with deep myometrial invasion, grade 3 and/or cervical stromal invasion, and also in type 2 tumors. The use of a uterine manipulator does not increase LVSI.

A Lymph Node Count-Based AJCC Staging System Facilitates a More Accurate Prediction of the Prognosis of Patients With Endometrial Cancer

Purpose

Both the International Federation of Gynecology and Obstetrics (FIGO) and the American Joint Committee on Cancer (AJCC) staging system for endometrial cancer (EC) defined the N category by the location of metastatic lymph nodes (LNs) rather than the metastatic LN count. We aimed to compare the accuracy of the AJCC staging system and the LN count-based staging system.

Patients and Methods

EC patients were selected from the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2016. Patients' characteristics were collected, including age, race, marital status, histological type, grade, therapeutic measures, the number of metastatic LNs, the number of dissected LNs, vital status, and survival in months. Overall survival (OS) was analyzed by the Kaplan-Meier (KM) method and the concordance index (C-index) was used to compare the prognostic value of the AJCC staging system and the LN count-based staging system.

Results

We identified 4,276 EC cases from the SEER database, including 2,693 patients with stage IIIC1 and 1,583 patients with stage IIIC2. Multivariate analyses showed that independent prognostic factors for patients with stage IIIC1 included age, race, marital status, grade, histology, chemotherapy, and radiotherapy. Independent prognostic factors for patients with stage IIIC2 included age, marital status, grade, histology, chemotherapy, and radiotherapy. The C-index of the AJCC staging system and the LN count-based staging system were 0.483 and 0.617, respectively. At least six LNs should be dissected to ensure the accuracy of the LN count-based staging system.

Conclusion

A modified AJCC staging system based on the count of metastatic LNs might be superior to the current AJCC staging system, which still had room for improvement and further refinements were required. For accurate staging, we recommended that at least six LNs should be examined in the modified AJCC staging system.

New development on hysteroscopy for endometrial cancer diagnosis: state of the art

Endometrial cancer (EC) is the most common gynecologic cancer diagnosed in developed countries and represents the second most frequent gynecologic cancer-related cause of death following ovarian cancer. There are 2 subtypes of EC. Type I tumors (endometrioid adenocarcinoma) representing 85-90% of the cases. They are likely to be low-grade tumors and are thought to have a link to estrogen exposure. Type II tumors represent 10-15% of EC. They are characterized as high-grade carcinomas, with serous or clear cell histology type, and carry poor prognoses. The benefits of hysteroscopy in achieving a targeted endometrial biopsy under direct visualization over blind biopsy techniques are widely accepted. Hysteroscopic endometrial biopsy is performed under direct visualization and is the only technique that allows for the selective biopsy of targeted areas of the endometrium. There is no screening protocol for the early detection of EC. Among the general population, advanced age, obesity, nulliparity and the use of exogenous hormones are known as risk factors for EC. There are additional situations that portend an increased risk of EC that deserve special consideration such as in patients diagnosed with Lynch Syndrome, using tamoxifen, obese, or the young patient with a desire for future fertility. We presented a narrative review of the current role of hysteroscopy for the diagnosis of endometrial cancer.

Importance of pre-operative ultrasound examination and pathological tumour evaluation in the management of women with endometrial cancer

INTRODUCTION

Endometrial cancer (EC) is the most common gynaecological malignancy in developed countries. Early and accurate diagnostic assessment is crucial for appropriate treatment planning. Information obtained by pre-operative imaging with transvaginal ultrasound (TVUS) and histological endometrial biopsy assessment is often the cornerstone for further management planning. This study aimed to analyse the accuracy of this diagnostic approach for patient management decisions.

MATERIALS AND METHODS

This single-centre retrospective analysis included all patients with endometrial cancer treated between 2015 and 2019. Pre-operative TVUS staging assessment and histopathological endometrial biopsy examination were compared with the final surgical stage and histopathological diagnosis.

RESULTS

Pre-operative and surgical pathological assessment of Type I and Type II tumours was in agreement in 95 % (174/184) and 54 % (12/22) of cases, respectively. The sensitivity and specificity of TVUS assessment of myometrial invasion were 76 % [95 % confidence interval (CI) 66.3-84.2 %] and 81.7 % [95 % CI 73.0-88.6 %], respectively. Diagnostic accuracy was higher for Type I EC (95 %) than Type II EC (54 %). Only presumed ESMO/ESGO/ESTRO risk classification (p < 0.000) and deep myometrial invasion (p < 0.000) were significant for the prediction of lymph node involvement.

CONCLUSION

Pre-operative TVUS examination and pathological endometrial biopsy evaluation enable moderately accurate assessment of the risk of EC. Efforts should be aimed towards the development of novel and more reproducible methods, such as molecular tumour characterization, to improve the pre-operative assessment of risk in patients with EC.

Role of uterine manipulator during laparoscopic endometrial cancer treatment

Endometrial cancer (EC) is the most frequent gynecologic malignancy with 61,000 new cases diagnosed per year in the USA. Gynecologic Oncology Group (GOG) LAP2 randomized study demonstrated a superimposable 5-year overall survival between laparotomic and laparoscopic approaches in EC treatment. In this context the uterine manipulator (UM) represents a valuable tool in order to increase the ergonomics of surgical gesture during a laparoscopic total hysterectomy. Despite the proven safety of the minimally invasive approach in EC treatment, neither the indication whether to use or not, nor the recommendation concerning a specific type of UM are provided by international guidelines. This narrative review aims to collect all the main findings in the literature about UM use to investigate its safety in EC patients. Based on the analysis of the literature research, the main results were categorized into two manipulator-related problems: the iatrogenic LVSI, and the retrograde tumor spillage. LVSI is defined as the presence of tumor cells within an endothelium-lined space. An electronic search was performed using the following keywords: 'uterine manipulator', and 'endometrial cancer'. The electronic database search provided a total of 93 studies. Of whom, 12 case reports, 5 studies not in English language, and 65 works not fitting the review scope were excluded from the analysis. Eleven studies were considered eligible for the purpose of the study. The most recent studies have highlighted the safety of the uterine manipulator in the early-stage EC laparoscopic treatment. All types of manipulators are considered to be fairly safe but its application should be tailored according to tumor dimension and grade of myometrial infiltration.

Sentinel lymph node for endometrial cancer treatment: review of the literature

INTRODUCTION

Endometrial cancer is the most common gynecologic malignancy and in two thirds of patients it is apparently uterine confined at presentation. Lymph nodal status represents one of the main prognostic factors. Nodal evaluation with sentinel lymph node (SLN) mapping has gained more ground in clinical practice after the publication of different studies demonstrating the feasibility and accuracy of this technique. However, at the moment there are no RCTs available evaluating the long-term oncologic safety of SLN technique compared to LND. This review aims at summarizing the available evidence on oncologic outcomes between SLN mapping alone and LND. Differences in operative complications and long-term complications were also analyzed.

EVIDENCE ACQUISITION

The literature search was conducted in the PubMed database and it focused on comparative studies published from inception to September 2020 analyzing differences in oncological outcomes or complications between nodal evaluation with SLN technique alone and nodal evaluation with lymphadenectomy. Comparative studies with more than 10 cases, published in English, were included.

EVIDENCE SYNTHESIS

A total of 5 retrospective comparative studies have been identified reporting data on oncologic outcomes of patients who underwent SLN mapping alone vs. LND. Non significative difference has been reported in terms of overall survival and recurrence free survival between the two groups. Six studies evaluated differences in terms of complications between the two techniques. A total of 2302 patients were identified. Postoperative complications were detected in 9.6% and 7.7% of patients who underwent lymphadenectomy and SLN mapping respectively and no significant difference was noted (P=0.3). Looking at major postoperative complications the rate in the LND group was significantly higher than in the SLN group (3.6% vs. 1.5%, P=0.02). Two of these six studies reported data on lymphatic long-term complications. The prevalence of lymphedema ranged from 0% to 1.3% in the SLN group and from 10% to 18% in the LND group. The absolute difference reported (13.35%) was similar to the one found in literature.

CONCLUSIONS

SLN mapping in apparently uterine confined disease has been demonstrated to be a feasible and accurate technique for nodal evaluation and high-quality evidence support this. Moreover, SLN mapping resulted to be associated with less major postoperative and long-term complications when compared to LDN. Conversely, high-quality evidence is not available on long-term oncologic safety of this technique compared to the standard LND. Randomized trials are requested to provide reliable data on this aspect.

Laparoscopic sentinel node mapping with intracervical indocyanine green injection for endometrial cancer: the SENTIFAIL study – a multicentric analysis of predictors of failed mapping

Objectives

Laparoscopy is commonly used for endometrial cancer treatment, and sentinel lymph node (SLN) mapping has become the standard procedure for nodal assessment. Despite the standardization of the technique, there is no definitive data regarding its failure rate. The objective of this study is to identify factors associated with unsuccessful SLN mapping in endometrial cancer patients undergoing laparoscopic SLN mapping after intracervical indocyanine green (ICG) injection.

Methods

We retrospectively evaluated a consecutive series of endometrial cancer patients who underwent laparoscopic SLN mapping with intracervical ICG injection, in four oncological referral centers from January 2016 to July 2019. Inclusion criteria were biopsy-proven endometrial cancer, total laparoscopic approach, and intracervical ICG injection. Exclusion criteria were evidence of lymph node involvement or extrauterine disease at pre-operative imaging, synchronous invasive cancer, the use of tracers different from ICG, and the use of neoadjuvant treatment. Bilateral and failed bilateral SLN mapping groups were compared for clinical and pathological features. In patients with an unsuccessful procedure, side-specific lymphadenectomy was performed. Logistic regression was used to identify predictors of failure.

Results

A total of 376 patients were included in the study. The overall bilateral and unilateral SLN detection rates were 96.3%, 76.3%, and 20.0% respectively. The failed bilateral mapping detection rate was 23.7%. The median number of sentinel nodes removed was 2.2 (range, 0–5). After multivariate analysis, lymph vascular space involvement [OR 2.4 (1.04–1.12), P=0.003], non-endometrioid histology [OR 3.0 (1.43–6.29), P=0.004], and intraoperative finding of enlarged lymph node [OR 2.3 (1.01–5.31), P=0.045] were identified as independent predictors of failure of SLN mapping.

Conclusion

Lymph vascular space involvement, non-endometrioid histology, and intra-operative finding of enlarged lymph nodes were identified as independent risk factors for unsuccessful mapping in patients undergoing laparoscopic SLN mapping.