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

Abstract

ObjectiveTo evaluate the role of sentinel lymph node biopsy (SLNB) to avoid staging lymphadenectomies by detecting nodal metastasis in intermediate- and high-risk endometrial cancer (EC).MethodsA single institutional retrospective study was performed including all patients with intermediate- and high-risk EC who underwent surgical nodal staging between January 2012 and December 2019. Patients with disseminated disease detected on imaging techniques or at the time of surgery were excluded. Patients were evaluable if they underwent nodal staging with SLNB and pelvic (PLD) and paraaortic (PALD) lymph node dissection. We analyzed the accuracy of the sentinel lymph node technique. Only patients with at least one sentinel lymph node (SLN) detected were included in the sensitivity and negative predictive value (NPV) analyses. The tracers used were technetium 99m, blue dye, and indocyanine green.ResultsEighty-eight patients presented intermediate- and high-risk EC (51 patients and 37 patients respectively) and underwent SLNB with consecutive PLD and PALD. The median (range) number of sentinel nodes retrieved was 2.9 (0–11). The global detection rate of SLN was 96.6% with a bilateral detection of 80.7% when considering all tracers used. However, when combination of indocyanine green and technetium was used the bilateral detection rate was 90.3%. Nodal metastases were detected in 17 (19.3%) cases, 8 (47%) of them corresponded to low volume metastasis (LVM), 7 (87.5%) of them diagnosed at ultrastaging pathologic exam. Finally, we obtained a sensitivity of 90%, a NPV of 97.5%, and a false negative rate (FNR) of 10% in the intermediate-risk EC compared to sensitivity of 85.7%, NPV of 96.6%, and FNR of 14.3% in the high-risk EC group. The only patient with isolated paraaortic nodal metastasis was found at the high-risk group, 1.1%.ConclusionsAccording to our results, full lymphadenectomy could be avoided by performing SLNB in patients with intermediate-risk EC because the only false negative case detected was at the beginning of ICG learning curve. For high-risk EC patients we did not find enough evidence to support the systematic avoidance of staging full lymph node dissection. Nevertheless, SLNB should be performed in all cases of EC as it improves LVM diagnosis substantially.

Comparison of oncological outcomes between sentinel lymph node biopsy and complete lymphadenectomy for endometrial cancer

“…This finding is higher than that reported in the FIRES trial 8 . However, Pineda et al 27 reported an FNR of 10% for intermediate‐risk EC and 14.3% for high‐risk EC, which is a higher rate than our findings. The main difference in our study is that not all patients underwent complete lymphadenectomy after SLN biopsy because the main objective of our study was to compare oncological outcomes between the two groups.…”

Impact of severe obesity in the management of patients with high-risk endometrial cancer: A FRANCOGYN study

“…Pineda et al recently studied whether systematic lymphadenectomy could be avoided by performing a single SLN biopsy. They found an overall sensitivity of 85% and a false negative rate of 15% in their population of patients with high-risk endometrial cancer (all stages) (22). On another note, the success of SLN biopsy does not appear to be influenced by BMI (23,24), and a Canadian study showed that obese women who underwent SLN biopsy without complete lymphadenectomy presented fewer operative adverse events and that their survival was not impacted (25).…”

Personalized Sentinel Node Mapping in Endometrial Cancer by the Indocyanine Green Implementation as Single Tracer: A Case Control Study

“…In fact, the percentage of women with positive nodes missed does not differ according to the tracer used. What has been shown is that at the initial stages of ICG, using a learning curve, a higher number of SLNs are identified, which decreases with the surgeon’s experience, being reduced to the minimum over years of experience of our center, with the use of IC, currently being more precise [ 36 ]. Our median SLN node number seen intraoperatively with ICG was 2 (2–3) compared to 3 (2–4) using the double-tracer technique ( p = 0.006).…”