Lymph node assessment at the time of hysterectomy has limited clinical utility for patients with pre-cancerous endometrial lesions

Sullivan, Mackenzie W.; Philp, Lauren; Kanbergs, Alexa; Safdar, Nida; Oliva, Esther; Bregar, Amy; Carmen, Marcela G. del; Eisenhauer, Eric L.; Goodman, Annekathryn; Muto, Michael G.; Sisodia, Rachel; Growdon, Whitfield B.

doi:10.1016/j.ygyno.2021.07.004

Cited by 16 publications

(11 citation statements)

References 13 publications

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“…Although lymph node evaluation remains a cornerstone in the surgical management of endometrial cancer, there remain no clear consensus guidelines regarding lymph node evaluation in patients with endometrial intraepithelial neoplasia. Several studies have demonstrated that routine SLN dissection in all patients with endometrial intraepithelial neoplasia has limited benefit and is not cost effective 20–22. Given the low grade and early stage disease in this cohort, routine SLN dissection in all patients would have resulted in overtreatment in up to 98% of patients, supporting the argument against routine SLN mapping in all patients with endometrial intraepithelial neoplasia.…”

Section: Discussionmentioning

confidence: 75%

“…In this cohort, we also observed misdiagnosis on frozen section of 40% (2 of 5) of cases of invasive stage IB carcinoma, leading to reoperation of one patient and missed opportunities for staging. Previous studies have demonstrated that, even in large academic centers with specialized pathologists, errors in frozen section at the time of surgery for endometrial intraepithelial neoplasia can lead to underdiagnosis of malignancy by up to 75% 20. Further, many patients undergoing hysterectomy for endometrial intraepithelial neoplasia may be having surgery in centers where frozen section is either unavailable or less reliable.…”

Section: Discussionmentioning

confidence: 99%

“…As a result, some surgeons perform SLN dissection in all patients with a preoperative diagnosis of endometrial intraepithelial neoplasia at the time of surgery, prior to hysterectomy. However, given the low rates of invasive cancer in patients with preoperative diagnoses of endometrial intraepithelial neoplasia, routine SLN dissection appears to have limited benefit, and also be a more costly staging method, than hysterectomy with frozen section 20 21. These data have raised the question of preoperative stratification to inform the use of a more selective SLN algorithm.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Endometrial stripe thickness: a preoperative marker to identify patients with endometrial intraepithelial neoplasia who may benefit from sentinel lymph node mapping and biopsy

Abt

Macharia

Hacker

et al. 2022

Int J Gynecol Cancer

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ObjectivesThe goal of our study was to identify preoperative factors in patients with endometrial intraepithelial neoplasia that are associated with concurrent endometrial cancer to select patients who may benefit from sentinel lymph node (SLN) assessment at the time of hysterectomy.MethodsRetrospective single institution cohort study of patients with a preoperative diagnosis of endometrial intraepithelial neoplasia who underwent hysterectomy with or without staging from January 2010 to July 2020. Modified Poisson regression was used to calculate risk ratios (RR) and 95% confidence intervals (CI).ResultsOf 378 patients with a preoperative diagnosis of endometrial intraepithelial neoplasia, 275 (73%) had endometrial intraepithelial neoplasia and 103 (27%) had invasive cancer on final pathology. Age (p=0.003), race (p=0.02), and hypertension (p=0.02) were significantly associated with concurrent endometrial cancer. The median preoperative endometrial stripe was significantly greater in the endometrial cancer group (14 mm (range 10–19)) than in the endometrial intraepithelial neoplasia group (11 mm (range 8–16); p=0.002). A preoperative endometrial stripe ≥20 mm was associated with double the risk of endometrial cancer on final pathology (crude RR 2.0, 95% CI 1.3 to 2.9) and preoperative endometrial stripe ≥15 mm was 2.5 times more likely to be associated with high risk Mayo criteria on final pathology (crude RR 2.5, 95% CI 1.2 to 5.2). Of those with concurrent endometrial cancer, 5% were stage IB, 29% had tumors >2 cm, and 1% had grade 3 histology. Only 3% of all patients underwent lymph node evaluation.ConclusionsIn a large cohort of patients with a preoperative diagnosis of endometrial intraepithelial neoplasia, less than a third had invasive cancer and even fewer had pathologic features considered high risk for nodal metastasis, arguing against the use of routine SLN dissection in these patients. Endometrial stripe ≥15 mm may be a useful preoperative marker to identify patients at higher risk for concurrent endometrial cancer and may be an important criterion for use of selective SLN dissection in carefully selected patients with endometrial intraepithelial neoplasia.

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Section: Discussionmentioning

confidence: 75%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Endometrial stripe thickness: a preoperative marker to identify patients with endometrial intraepithelial neoplasia who may benefit from sentinel lymph node mapping and biopsy

Abt

Macharia

Hacker

et al. 2022

Int J Gynecol Cancer

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“…In this regard, preoperative diagnosis of adenocarcinoma is crucial in establishing the correct diagnostic and therapeutic course. Several studies have demonstrated that routine sentinel lymph node biopsy (SLNB) in all patients with AEH has limited benefit and is not cost-effective [ 28 , 29 , 30 ] given the high prevalence of low-grade and early-stage disease in this category. For AEH and early-stage low-grade EC, a comprehensive surgical staging with lymph node assessment via lymphadenectomy or SLNB would result in overtreatment [ 31 ].…”

Section: Discussionmentioning

confidence: 99%

Clinical, Sonographic, and Hysteroscopic Features of Endometrial Carcinoma Diagnosed after Hysterectomy in Patients with a Preoperative Diagnosis of Atypical Hyperplasia: A Single-Center Retrospective Study

et al. 2022

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Background: atypical endometrial hyperplasia (AEH) is a precancerous condition implying a high risk of concurrent endometrial cancer (EC), which might be occult and only diagnosed at postoperative histopathological examination after hysterectomy. Our study aimed to investigate potential differences in preoperative clinical, sonographic, and hysteroscopic characteristics in patients with AEH and postoperative diagnosis of EC. Methods: a retrospective single-center study was carried out on a case series of 80 women with AEH undergoing diagnostic workup, including ultrasonography and hysteroscopy, with subsequent hysterectomy. Women with AEH confirmed at the histopathological examination were compared with patients with a postoperative diagnosis of EC. Results: in our population, EC was diagnosed in 53 women, whereas the preoperative diagnosis of AEH was confirmed in 27 cases. At ultrasonography, women with occult EC showed greater endometrial thickness (20.3 mm vs. 10.3 mm, p 0.001) and size of the endocavitary lesion (maximum diameter 25.2 mm vs. 10.6 mm, p 0.001), and a higher prevalence of irregular endometrial-myometrial junction (40.5% vs. 6.7%, p 0.022) and endouterine vascularization at color Doppler (64.2% vs. 34.6%, p 0.017). At hysteroscopy, patients with occult EC showed a higher prevalence of necrosis (44.2% vs. 4.2%, p 0.001) and atypical vessels (70.6% vs. 33.3%, p 0.003), whereas true AEH mainly presented as a protruding intracavitary lesion (77.8% vs. 50.9%, p 0.029). In EC, subjective assessment by the operator was more frequently indicative of cancer (80.0% vs. 12.5%). No difference was found for clinical variables. Conclusions: occult EC in AEH may exhibit some differences in ultrasonographic and hysteroscopic patterns of presentation compared with real AEH, which could prompt a more significant suspect for the possible presence of concurrent EC at preoperative diagnostic workup.

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“…Glassman et al estimated that 200 patients with EIN following endometrial biopsy would need to undergo sentinel lymph node dissection to identify one nodal involvement 33. Sullivan et al examined 141 patients with pre-cancerous lesions and found that only 5% met the “Mayo criteria” on final hysterectomy pathology and therefore concluded that patients with EIN are at low risk and that universal nodal assessment is of limited value 34. Touhami et al tried to determine the risk of endometrial cancer and lymph node involvement in patients with a preoperative diagnosis of “atypical hyperplasia – only” vs “atypical hyperplasia – cannot rule out carcinoma.” They found that the risk of lymph node metastasis in patients with a preoperative diagnosis of “atypical hyperplasia – only” was null, and therefore concluded that lymph node assessment can be omitted in those patients.…”

Section: Discussionmentioning

confidence: 99%

Incidence of endometrial carcinoma in patients with endometrial intraepithelial neoplasia versus atypical endometrial polyp

Cohen

Tsur

Tako

et al. 2022

Int J Gynecol Cancer

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ObjectiveOur study’s primary aim was to compare the incidence of endometrial carcinoma in patients with a presurgical diagnosis of endometrial intraepithelial neoplasia confined to the endometrium (EIN-E) versus endometrial intraepithelial neoplasia confined to a polyp (EIN-P). Our secondary aim was to examine the difference in pathological features, prognostic risk groups and sentinel lymph node involvement between the two groups.MethodsWe conducted a retrospective cohort study between January 2014 and December 2020 in a tertiary university-affiliated medical center. The study considered the characteristics of women who underwent hysterectomy with sentinel lymph node dissection for endometrial intraepithelial neoplasia (EIN). We compared EIN-E diagnosed by endometrial sampling via dilatation curettage or hysteroscopic curettage vs EIN-P. A multivariate logistic regression analysis was used to assess risk factors for endometrial cancer.ResultsEighty-eight women were included in the study, of those, 50 were women with EIN-P (EIN-P group) and 38 were women with EIN following an endometrial biopsy (EIN-E group).The median age was 57.5 years (range; 52–68) in the EIN-P group as compared with 63 years (range; 53–71) in the EIN-E group (p=0.47). Eighty-nine percent of the women in the EIN-E group presented with abnormal uterine bleeding whereas 46% of the women in the EIN-P group were asymptomatic (p=0.001). Pathology results following hysterectomy revealed concurrent endometrial carcinoma in 26% of women in the EIN-P group compared with 47% of women in the EIN-E group (p=0.038). Multivariate analysis showed that endometrial cancer was significantly less common in the EIN-P group (overall response (OR)=0.3 95% confidence interval (CI)=0.1–0.9, p=0.03). Eighty-four percent of cancers were grade one in the EIN-P group compared with 50% in the EIN-E group (p=0.048).ConclusionsConcurrent endometrial cancer is less frequent with EIN-P than with EIN-E. The high incidence of endometrial carcinoma in both groups supports the current advice to perform hysterectomy for post-menopausal women. Our data does not support performing sentinel lymph node dissection for EIN-P that was completely resected. The benefit of sentinel lymph node dissection for women with pre-operative EIN-E is yet to be determined.

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Lymph node assessment at the time of hysterectomy has limited clinical utility for patients with pre-cancerous endometrial lesions

Cited by 16 publications

References 13 publications

Endometrial stripe thickness: a preoperative marker to identify patients with endometrial intraepithelial neoplasia who may benefit from sentinel lymph node mapping and biopsy

Endometrial stripe thickness: a preoperative marker to identify patients with endometrial intraepithelial neoplasia who may benefit from sentinel lymph node mapping and biopsy

Clinical, Sonographic, and Hysteroscopic Features of Endometrial Carcinoma Diagnosed after Hysterectomy in Patients with a Preoperative Diagnosis of Atypical Hyperplasia: A Single-Center Retrospective Study

Incidence of endometrial carcinoma in patients with endometrial intraepithelial neoplasia versus atypical endometrial polyp

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