Lymph node evaluation in high-risk early stage endometrial cancer: A multi-institutional retrospective analysis comparing the sentinel lymph node (SLN) algorithm and SLN with selective lymphadenectomy

Buda, Alessandro; Gasparri, Maria Luisa; Puppo, Andrea; Mereu, Liliana; Ponti, Elena De; Martino, Giampaolo Di; Novelli, Antonia; Tateo, Saverio; Müller, Michael; Landoni, Fabio; Papadia, Andrea

doi:10.1016/j.ygyno.2018.06.003

Cited by 43 publications

(34 citation statements)

References 29 publications

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“…Conversely, eight studies reported promising results . The most convincing results were demonstrated by the FIRES trial, with an overall sensitivity, FN rate, and NPV of 97.2%, 2.7%, and 99.6% respectively.…”

Section: Discussionmentioning

confidence: 99%

A Prospective Study of Sentinel Lymph Node Mapping for Endometrial Cancer: Is It Effective in High-Risk Subtypes?

et al. 2019

The Oncologist

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Background. The efficacy of sentinel lymph node (SLN) mapping for high-risk endometrial cancer remains unclear. This prompted us to evaluate the sensitivity, negative predictive value (NPV), and false-negative (FN) rate of cervical injection of indocyanine green (ICG) SLN mapping in patients with endometrial cancer. Materials and Methods. This prospective interventional study was performed at a single university teaching hospital. Consecutive patients with early-stage endometrial cancer who underwent laparoscopic surgical staging were included. Cervical injection of ICG and near-infrared SLN identification and biopsy were performed for all study patients followed by systematic pelvic lymphadenectomy, whereas para-aortic lymphadenectomy was performed in all patients with high-risk histologies. SLN detection rates, sensitivity, NPV, and FN rates were calculated. Results. Between July 2016 and July 2018, 131 patients were enrolled. The overall SLN detection rate was 93.1%, with a bilateral detection rate of 61.8%. Four positive SLNs were identified in four patients. Lymph node metastasis was observed in four additional patients without positive SLNs. These four patients belonged to a group of patients with a high-risk subtype. Three of the four patients had isolated para-aortic node metastases. In low-risk endometrial cancers, the sensitivity of the SLN technique to identify nodal metastatic disease was 100% (95% confidence interval [CI] 31.0-100), with an NPV and FN rate of 100% (95% CI 95.1-100) and 0%, respectively. In high-risk endometrial cancers, the sensitivity, NPV, and FN rate were 20% (95% CI 1.0-70.1), 83.3% (95% CI 61.8-94.5), and 80%, respectively. Conclusion. Cervical injection of ICG and SLN mapping yielded a low sensitivity and a high FN rate for the identification of node metastasis in endometrial cancer with high-risk histologies. The Oncologist 2019;24:e1381-e1387 Implications for Practice: The efficacy of sentinel lymph node (SLN) mapping for high-risk endometrial cancer remains unclear. This study enrolled 131 patients with early-stage endometrial cancer who underwent cervical injection of indocyanine green SLN mapping followed by systematic pelvic lymphadenectomy and para-aortic lymphadenectomy. The key result was that SLN mapping yielded a low sensitivity and a high false-negative rate for the identification of node metastasis in endometrial cancer with high-risk histologies. The SLN strategy in these patients may increase the risk of missed diagnosis of isolated para-aortic node metastases and seems to be unacceptable in clinical practice.

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Section: Discussionmentioning

confidence: 99%

A Prospective Study of Sentinel Lymph Node Mapping for Endometrial Cancer: Is It Effective in High-Risk Subtypes?

et al. 2019

The Oncologist

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“…Whether aortic lymphadenectomy could have a therapeutic role is a debatable point, as well as what is the best adjuvant therapy for node-positive patients. Multicenter retrospective series have not identified differences in survival in women with endometrial cancer treated with an SLN mapping procedure or full staging lymphadenectomy 26 27. Undoubtedly having aortic nodal involvement (FIGO stage IIIC2) has a prognostic impact.…”

Section: Discussionmentioning

confidence: 99%

Sentinel lymph node mapping in endometrial cancer: performance of hysteroscopic injection of tracers

Martinelli

Ditto

Bogani

et al. 2020

Int J Gynecol Cancer

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ObjectiveTo report on the performance of hysteroscopic injection of tracers (indocyanine green (ICG) and technetium-99m (Tc-99m)) for sentinel lymph node (SLN) mapping in endometrial cancer.MethodsSingle-center retrospective evaluation of consecutive patients who underwent SLN mapping following hysteroscopic peritumoral injection of tracer. Detection rate (overall/bilateral/aortic) diagnostic accuracy, and oncologic outcomes were evaluated.ResultsA total of 221 procedures met the inclusion criteria. Mean patient age was 60 (range 28–84) years and mean body mass index was 26.9 (range 15–47) kg/m2 . In 164 cases (70.9%) mapping was performed laparoscopically. The overall detection rate of the technique was 94.1% (208/221 patients). Bilateral pelvic mapping was found in 62.5% of cases with at least one SLN detected and was more frequent using ICG than with Tc-99m (73.8% vs 53.3%; p<0.001). In 47.6% of cases SLNs mapped in both pelvic and aortic nodes, and in five cases (2.4%) only in the aortic area. In eight patients (3.8%) SLNs were found in aberrant (parametrial/presacral) areas. Mean number of detected SLNs was 3.7 (range 1–8). In 51.9% of cases at least one node other than SLNs was removed. Twenty-six patients (12.5%) had nodal involvement: 12 (46.2%) macrometastases, six (23.1%) micrometastases, and eight (30.7%) isolated tumor cells. In 12 cases (46.8%) the aortic area was involved. Overall, 6/221 (2.7%) patients had isolated para-aortic nodes. Three false-negative results were found, all in the Tc-99m group. All had isolated aortic metastases. Overall sensitivity was 88.5% (95% CI 71.7 to 100.0) and overall negative predictive value was 96.5% (95% CI 86.8 to 100.0). There were 10 (4.8%) recurrences: five abdominal/distant, four vaginal, and one nodal (in the aortic area following a unilateral mapping plus side-specific pelvic lymphadenectomy). Most recurrences (9/10 cases) were patients in whom a completion lymphadenectomy was performed. No deaths were reported after a mean follow-up of 47.7 months.ConclusionsHysteroscopic injection of tracers for SLN mapping in endometrial cancer is as accurate as cervical injection with a higher detection rate in the aortic area. ICG improves the bilateral detection rate. Adding lymphadenectomy to SLN mapping does not reduce the risk of relapse.

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“…We recently reported that the SLN approach compared with full lymphadenectomy does not compromise the prognosis of high-intermediate and high-risk patients21 and in the present study we confirmed the ability of OSNA to detect positive SLNs in high–intermediate and high-risk patients. SLN biopsy has been defined as a highly sensitive technique for identifying nodal metastases with a minimally invasive approach 22. The risk of metastatic non-SLNs in patients with successful mapping is reported to be ≤1%,14–23 and the systematic use of the Memorial-Sloan Kettering algorithm reduces its risk by the introduction of side-specific lymphadenectomy in cases of negative side-specific mapping 24.…”

Section: Discussionmentioning

confidence: 99%

Intra-operative assessment of sentinel lymph node status by one-step nucleic acid amplification assay (OSNA) in early endometrial cancer: a prospective study

Monterossi

Buca

Dinoi

et al. 2019

Int J Gynecol Cancer

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BackgroundSentinel node mapping has been proposed to reduce surgical side effects, maintaining the accuracy in nodal status assessment for endometrial cancer.ObjectiveTo investigate the role of one-step nucleic acid amplification assay (OSNA) analysis, in the intra-operative tailoring of full nodal dissection, and to analyze the correlation between the type of sentinel node metastasis and the risk of non-sentinel node metastasis.MethodsSurgical and pathological data were collected from 141 consecutive, clinical stage I patients with endometrial cancer undergoing surgical staging. Patients were excluded if they had previous pelvic or abdominal radiotherapy, chemotherapy, abdominal cancer, pelvic or abdominal lymphadenectomy, or contraindications to indocyanine green. All sentinel nodes were analyzed by OSNA, and full lymphadenectomy was performed in positive cases. Statistical analysis was performed using Χ2 and Fisher's exact test to determine whether any of these characteristics could accurately predict the non-sentinel nodes status in positive sentinel node patients.ResultsA total of 141 patients were included in the analysis. Bilateral sentinel nodes were identified in 104 (73.8%) patients, with a median number of 2 (range 2–6) sentinel nodes per patient. In the remaining 37 patients (26.2%), a unilateral sentinel node was obtained, with a median of 1 (range 1–3) sentinel node per patient. Thirty-three (12.0%) positive nodes were found in 24 (17.0%) patients: micro-metastases and macro-metastases were detected in 22 and 2 patients, respectively. At final pathology, all patients with positive non-sentinel nodes had macro-metastases in the sentinel node, whereas in micro-metastatic sentinel nodes no other positive nodes were found at full lymphadenectomy (p<0.001).ConclusionsOur results showed a correlation between the type of metastasis in the sentinel lymph node (SLN) and the incidence of positive non-SLNs. These data suggest a potential role of OSNA analysis in the surgical tailoring of patients with early endometrial cancer, with the goal of definitive risk stratification and a better individualization of adjuvant therapy.

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Lymph node evaluation in high-risk early stage endometrial cancer: A multi-institutional retrospective analysis comparing the sentinel lymph node (SLN) algorithm and SLN with selective lymphadenectomy

Cited by 43 publications

References 29 publications

A Prospective Study of Sentinel Lymph Node Mapping for Endometrial Cancer: Is It Effective in High-Risk Subtypes?

A Prospective Study of Sentinel Lymph Node Mapping for Endometrial Cancer: Is It Effective in High-Risk Subtypes?

Sentinel lymph node mapping in endometrial cancer: performance of hysteroscopic injection of tracers

Intra-operative assessment of sentinel lymph node status by one-step nucleic acid amplification assay (OSNA) in early endometrial cancer: a prospective study

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