Multicenter study comparing oncologic outcomes after lymph node assessment via a sentinel lymph node algorithm versus comprehensive pelvic and paraaortic lymphadenectomy in patients with serous and clear cell endometrial carcinoma

Schlappe, Brooke A.; Weaver, Amy L.; McGree, Michaela E.; Ducie, J.A.; Eriksson, Ane Gerda Zahl; Dowdy, Sean C.; Cliby, William A.; Glaser, Gretchen; Abu‐Rustum, Nadeem R.; Mariani, Andrea; Leitao, Mario M.

doi:10.1016/j.ygyno.2019.11.002

Cited by 47 publications

(54 citation statements)

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“…The FIRES trial, enrolling stage I patients, yielded a high sensitivity of 97% and a negative predictive value of 99.6% by SLN mapping, and prevented more people from the morbidity of LND ( 38 ). Accumulating data indicated SLN was significantly associated with accurate detection of pelvic lymph nodes and was non-inferior to LND in para-aortic nodes assessment in high risk EC patients ( 7 , 18 , 21 – 23 , 32 , 41 ). The pathologic ultra-staging technique adopted by SLN mapping, defines positive lymph node as macro-metastasis (≥2 mm), micro-metastasis (≥0.2 mm), and isolated tumor cells (≤0.2 mm) ( 41 ).…”

Section: Discussionmentioning

confidence: 99%

“…Experience from a study with 1,135 low risk patients indicated that 3-year OS and PFS were similar in two groups (P>0.07) ( 15 ). A multicenter study in high risk patients showed HR for association of staging approach (SLN and LND) with progression and death was 3.12 (95% CI 1.02–9.57) and 0.69 (95% CI 0.24–1.95) respectively ( 32 ). Similarly, Multinu et al ( 18 ).…”

Section: Discussionmentioning

confidence: 99%

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Operative and Oncological Outcomes Comparing Sentinel Node Mapping and Systematic Lymphadenectomy in Endometrial Cancer Staging: Meta-Analysis With Trial Sequential Analysis

Huang

Zong

et al. 2021

Front. Oncol.

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ObjectiveTo evaluate the utility of sentinel lymph node mapping (SLN) in endometrial cancer (EC) patients in comparison with lymphadenectomy (LND).MethodsComprehensive search was performed in MEDLINE, EMBASE, CENTRAL, OVID, Web of science databases, and three clinical trials registration websites, from the database inception to September 2020. The primary outcomes covered operative outcomes, nodal assessment, and oncological outcomes. Software Revman 5.3 was used. Trial sequential analysis (TSA) and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) were performed.ResultsOverall, 5,820 EC patients from 15 studies were pooled in the meta-analysis: SLN group (N = 2,152, 37.0%), LND group (N = 3,668, 63.0%). In meta-analysis of blood loss, SLN offered advantage over LND in reducing operation bleeding (I2 = 74%, P<0.01). Z-curve of blood loss crossed trial sequential monitoring boundaries though did not reach TSA sample size. There was no difference between SLN and LND in intra-operative complications (I2 = 7%, P = 0.12). SLN was superior to LND in detecting positive pelvic nodes (P-LN) (I2 = 36%, P<0.001), even in high risk patients (I2 = 36%, P = 0.001). While no difference was observed in detection of positive para-aortic nodes (PA-LN) (I2 = 47%, P = 0.76), even in high risk patients (I2 = 62%, P = 0.34). Analysis showed no difference between two groups in the number of resected pelvic nodes (I2 = 99%, P = 0.26). SLN was not associated with a statistically significant overall survival (I2 = 79%, P = 0.94). There was no difference in progression-free survival between SLN and LND (I2 = 52%, P = 0.31). No difference was observed in recurrence. Based on the GRADE assessment, we considered the quality of current evidence to be moderate for P-LN biopsy, low for items like blood loss, PA-LN positive.ConclusionThe present meta-analysis underlines that SLN is capable of reducing blood loss during operation in regardless of surgical approach with firm evidence from TSA. SLN mapping is more targeted for less node dissection and more detection of positive lymph nodes even in high risk patients with conclusive evidence from TSA. Utility of SLN yields no survival detriment in EC patients.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Operative and Oncological Outcomes Comparing Sentinel Node Mapping and Systematic Lymphadenectomy in Endometrial Cancer Staging: Meta-Analysis With Trial Sequential Analysis

Huang

Zong

et al. 2021

Front. Oncol.

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“…As mentioned previously, diagnostic accuracy of the SLN has been proven in literature both prospectively and retrospectively [ 26 , 27 , 28 , 29 , 30 , 31 ]. The current review is the first to provide a systematic overview of the available literature on lower-extremity lymphedema and post-operative complications after SLN and LND in EC, with thorough quality assessment.…”

Section: Discussionmentioning

confidence: 99%

“…Diagnostic accuracy of SLN to detect metastatic nodes in high risk EC has been reported in literature with proven high sensitivity in a multi-center, prospective cohort study [ 26 ]. Also, in a number of retrospective studies, the progression free survival was comparable in similar cohorts independent of SLN or LND [ 27 , 28 , 29 , 30 , 31 ]. Recent years have seen a steep increase in the performance of the procedure.…”

Section: Introductionmentioning

confidence: 97%

Lymphedema and Post-Operative Complications after Sentinel Lymph Node Biopsy versus Lymphadenectomy in Endometrial Carcinomas—A Systematic Review and Meta-Analysis

Helgers

Winkens

Slangen

et al. 2020

JCM

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Background: Lymph node dissection (LND) is recommended as staging procedure in presumed low stage endometrial cancer. LND is associated with risk of lower-extremity lymphedema and post-operative complications. The sentinel lymph node (SLN) procedure has been shown to have high diagnostic accuracy, but its effects on complication risk has been little studied. This systematic review compares the risk of lower-extremity lymphedema and post-operative complications in SLN versus LND in patients with endometrial carcinoma. Methods: A systematic search was conducted in PubMed and Cochrane Library. Results: Seven retrospective and prospective studies (total n = 3046 patients) were included. Only three studies reported the odds ratio of lower-extremity lymphedema after SLN compared to LND, which was 0.05 (95% CI 0.01–0.37; p = 0.067), 0.07 (95% CI 0.00–1.21; p = 0.007) and 0.54 (95% CI 0.37–0.80; p = 0.002) in these studies. The pooled odds ratio of any post-operative complications after SLN versus LND was 0.52 (95% CI 0.36-0.73; I2 = 48%; p < 0.001). For severe post-operative complications the pooled odds ratio was 0.52 (95% CI 0.28–0.96; I2 = 0%; p = 0.04). Conclusions: There are strong indications that SLN results in a lower incidence of lower-extremity lymphedema and less often severe post-operative complications compared to LND. In spite of the paucity and heterogeneity of studies, direction of results was similar in all studies, supporting the aforementioned conclusion. These results support the increasing uptake of SLN procedures in endometrial cancer.

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“…With the development of sentinel lymph node (SLN) mapping in EC, it has been proposed that the evaluation of retroperitoneal lymph nodes in EC is merely diagnostic and not therapeutic [20,21], though no data from randomized controlled trials are available to support this conclusion.…”

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confidence: 99%

Comprehensive pelvic and paraaortic lymphadenectomy in patients with apparently early stage uterine serous carcinoma – an anachronism?

Emons

2020

J Gynecol Oncol

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Many patients with endometrial cancer (EC) which is apparently limited to the uterus have extrauterine disease [1]. In 1988, the International Federation of Gynecology and Obstetrics (FIGO) therefore introduced the concept of surgical staging for EC, including hysterectomy, bilateral salpingo-oophorectomy, pelvic washing, and pelvic plus paraaortic lymphadenectomy (LNE) [2]. Systematic retroperitoneal LNE was considered to be an essential staging tool to indicate adjuvant radio-and/or chemotherapy in case of nodal involvement [3,4]. In addition, comprehensive lymphadenectomy was regarded to be therapeutic by removing nodal micrometastases, which were not sterilized by radio-and/ or chemotherapy [3,4]. A number of retrospective analyses found a significantly improved overall survival after multisite pelvic lymph node sampling, which even remained after postoperative radiation therapy [5]. A review of the Surveillance, Epidemiology, and End Results (SEER) data of 4,178 women with serous endometrial cancer found that any LNE, as well as more extensive LNE were associated with improved 5-year overall survival (OS), even in patients with negative lymph nodes [6]. Consequently, comprehensive LNE was recommended for all patients with EC, even for those with well-differentiated endometrial cancers [3,4,7]. By the end of the first decade of the new century, 2 European randomized controlled trials were published that found no survival benefit by performing pelvic LNE in patients with early stage endometrial cancer [8,9], but a relevant increase in side effects, including lymphedema and lymphocysts [10]. An analysis of data from 27,000 EC patients (SEER) showed that disease specific 5-year survival of women with endometrioid EC, stage 1 was >98% (G1) or >96% (G2) respectively, no matter whether or not LNE had been performed [11]. In a retrospective analysis, the Mayo-Group observed that tumors with grade 1 or 2 histology ≤2 cm in diameter and ≤50% myometrial invasion had a lymph node metastasis rate of virtually zero [12]. These new data [8-12] and others led to the stepwise weakening of the recommendation of systematic LNE in patients with endometrioid EC, grade 1 or 2 and ≤50% myometrial invasion. It is either not recommended [13] or considered only as an option [14-16]. The analysis of Chan et al suggested that LNE was associated with an improved survival in stage I grade 3 and more advanced endometrioid EC [11]. Another land mark study retrospectively compared two cohorts of EC patients treated either with exclusive pelvic LNE

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Multicenter study comparing oncologic outcomes after lymph node assessment via a sentinel lymph node algorithm versus comprehensive pelvic and paraaortic lymphadenectomy in patients with serous and clear cell endometrial carcinoma

Cited by 47 publications

References 25 publications

Operative and Oncological Outcomes Comparing Sentinel Node Mapping and Systematic Lymphadenectomy in Endometrial Cancer Staging: Meta-Analysis With Trial Sequential Analysis

Operative and Oncological Outcomes Comparing Sentinel Node Mapping and Systematic Lymphadenectomy in Endometrial Cancer Staging: Meta-Analysis With Trial Sequential Analysis

Lymphedema and Post-Operative Complications after Sentinel Lymph Node Biopsy versus Lymphadenectomy in Endometrial Carcinomas—A Systematic Review and Meta-Analysis

Comprehensive pelvic and paraaortic lymphadenectomy in patients with apparently early stage uterine serous carcinoma – an anachronism?

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