Lower-Limb Drainage Mapping for Lymphedema Risk Reduction After Pelvic Lymphadenectomy for Endometrial Cancer

Abstract

Objectives. Pelvic lymphadenectomy is associated with a significant risk of lower-limb lymphedema. In this proof-of-concept study, we evaluated the feasibility of identifying the lower-limb drainage nodes (LLDNs) during pelvic lymphadenectomy for endometrial cancer. Secondary objectives were to map lower-limb drainage and to assess the diagnostic value of our mapping technique. Methods. This prospective study included patients with endometrial cancer requiring pelvic lymphadenectomy, without neoadjuvant radiotherapy or chemotherapy and without history of lower-limb surgery. A radiopharmaceutical was injected into both feet on the day before surgery. LLDNs were identified using preoperative lymphoscintigraphy and intraoperative isotopic probe detection, then removed before complete pelvic lymphadenectomy. LLDNs and pelvic lymphadenectomy specimens underwent separate histological analysis. Results.Of the 12 patients with early-stage endometrial cancer, 10 underwent preoperative lymphoscintigraphy, which consistently identified inguinal, femoral, and pelvic LLDNs (detection rate: 100%). The intraoperative detection rate was 83% (10/12). Median number of hot nodes per patient was 5 nodes (range: 3-7) on the right and 3 nodes (range: 2-6) on the left. Of 107 LLDNs, 106 were in the external iliac area, including 38 in the lateral group and 45 in the intermediate and medial groups. None of the patients had node metastases at any site. No early complications related to the technique occurred. Conclusion.Our mapping technique appears feasible, safe, and associated with a high LLDN identification rate. LLDN mapping may allow the preservation of LLDNs, thereby decreasing the risk of lower-limb lymphedema and improving quality of life. The Oncologist 2013;18:174 -179 Implications for Practice: Pelvic lymphadenectomy is associated with substantial postoperative morbidity related to the removal of pelvic lower-limb drainage nodes, which are not identified during the procedure. The sentinel node biopsy technique has been developed to decrease lymphadenectomy-related morbidity. In some gynecological cancers, however, routine pelvic lymphadenectomy remains required. Our proof-of-concept study was designed to evaluate the feasibility of identifying the lower-limb drainage nodes (LLDNs) during pelvic lymphadenectomy for endometrial cancer. Our results hold promise for preserving the lymphatic drainage pathways of the lower limbs. Sparing the LLDNs may decrease the risk of lower-limb lymphedema, which is associated with both a decrease in quality of life and additional healthcare costs.

Uptake and outcomes of sentinel lymph node mapping in women undergoing minimally invasive surgery for endometrial cancer

“…20 Although lymph node evaluation may provide prognostic information, lymphadenectomy is associated with increased operative time and significant shortand long-term morbidity, which dampens enthusiasm for the performance of the procedure in all woman with endometrial cancer. 1,[21][22][23][24][25][26] As an alternative to universal lymphadenectomy, criteria have been created to stratify patients into higher and lower risk cohorts. One such system, developed by the Mayo Clinic, identifies a 'low-risk' population with a <1% risk of nodal metastases or recurrences in whom lymphadenectomy could safely be omitted.…”

“…One study noted that women with disease of high intermediate risk who underwent lymphadenectomy were less likely to receive adjuvant whole‐pelvic radiotherapy than women who did not have nodal evaluation 20 . Although lymph node evaluation may provide prognostic information, lymphadenectomy is associated with increased operative time and significant short‐ and long‐term morbidity, which dampens enthusiasm for the performance of the procedure in all woman with endometrial cancer 1,21–26 . As an alternative to universal lymphadenectomy, criteria have been created to stratify patients into higher and lower risk cohorts.…”

Uptake and Outcomes of Sentinel Lymph Node Mapping in Women With Atypical Endometrial Hyperplasia

“…Although lymph node evaluation may provide prognostic information in women ultimately found to have endometrial cancer, lymphadenectomy is associated with significant morbidity dampening enthusiasm for performance in all women with complex atypical endometrial hyperplasia as the procedure is unnecessary in a significant number of women and associated with significant shortterm and long-term morbidity. [27][28][29][30][31][32] To limit the potential morbidity of lymph node assessment in women with complex atypical endometrial hyperplasia, identification of women with endometrial cancer intraoperatively via frozen section or gross assessment at the bedside has been proposed as an alternate strategy to universal nodal dissection. 33 Theoretically, nodal sampling could be performed in just women with an invasive cancer or targeted to women with cancer and pathologic factors that increase the risk of nodal metastases.…”

“…Although lymph node evaluation may provide prognostic information in women ultimately found to have endometrial cancer, lymphadenectomy is associated with significant morbidity dampening enthusiasm for performance in all women with complex atypical endometrial hyperplasia as the procedure is unnecessary in a significant number of women and associated with significant short-term and long-term morbidity. 27–32…”