Sentinel Lymph Node in Aged Endometrial Cancer Patients “The SAGE Study”: A Multicenter Experience

Abstract

ObjectiveThe incidence of endometrial cancer is increasing in elderly people. Considering that aging progressively affects lymphatic draining function, we aimed to define its impact on IGC uptake during SLN mapping.MethodsA multicenter retrospective cohort of endometrial cancer patients with apparently early-stage endometrial cancer undergoing complete surgical staging with SLN dissection was identified in four referral cancer centers from May 2015 to March 2021. Patients were classified in Group 1 (<65 years old) and Group 2 (≥65 years old). The primary endpoint was the assessment of the overall, bilateral, and unsuccessful SLN mapping in the two groups. Secondary outcomes were the evaluation of SLN anatomical distribution and the identification of predictors for mapping failure applying a logistic regression.ResultsA total of 844 patients were enrolled in the study (499 in Group 1 and 395 in Group 2). The overall detection rate, the successful bilateral mapping, and the mapping failure rate of the SLN were 93.8% vs. 87.6% (p = 0.002), 77.1% vs. 66.8% (p = 0.001), and 22.9% vs. 33.2% (p = 0.001), respectively, in Group 1 vs. Group 2. The advanced age affects the anatomical distribution of the SLN leading to a stepwise reduction of “unexpected” mapping sites (left hemipelvis: p < 0.001; right hemipelvis: p = 0.058). At multivariate analysis age ≥ 65 (OR: 1.495, 95% CI: 1.095–2.042, p = 0.011), BMI (OR: 1.023, 95% CI: 1.000–1.046, p = 0.047), non-endometrioid histotype (OR: 1.619, 95% CI: 1.067–2.458, p = 0.024), and LVSI (OR: 1.407, 95% CI: 1.010–1.961, p = 0.044) represent independent predictors of unsuccessful mapping. Applying binomial logistic regression analysis, there was a 1.280-fold increase in the risk of failed mapping for every 10-year-old increase in age (OR: 1.280, 95% CI: 1.108–1.479, p = 0.001). A higher rate of surgical under-staging (0.9% vs. 3.3%, p = 0.012) and adjuvant undertreatment (p = 0.018) was reported in Group 2.ConclusionsOld age represents a risk factor for SLN mapping failure both intrinsically and in relation to the greater incidence of other independent risk factors such as LVSI, non-endometrioid histotype, and BMI. Surgeons should target the usual uptake along UPP during the SLN dissection in this subgroup of patients to minimize mapping failure and the consequent risk of surgical under-staging and adjuvant undertreatment.

Surgical and oncological outcomes of sentinel lymph node sampling in elderly patients with intermediate to high-risk endometrial carcinoma

“…Tortorella et al (2019) reported that age was a predictive factor for unsuccessful mapping in univariable analysis with an OR of 1.41 per 10 year increase in age 34. Age was also shown as an independent risk factor for SLN mapping failure by Cianci et al35 In our study sentinel mapping was successful in 93.2%, with metastatic disease detected in 23% of patients undergoing SLN only. Staging information obtained by SLN sampling in the SLN group might have been translated into a higher rate of adjuvant radiation in this group.…”

Sentinel Node Biopsy for Endometrial Cancer by Retroperitoneal Transvaginal Natural Orifice Transluminal Endoscopic Surgery: A Preliminary Study

“…Compared to conventional laparoscopy, SLNB by retroperitoneal vNOTES allows inspection of the pelvic retroperitoneal space in a more logical sequence, starting from the cervix and following the lymphatic paths, with a potential improvement in the identification of SLNs. This could be especially important for old or obese patients, for whom there is a greater risk of SLN mapping failure ( 36 , 37 ).…”

Nodal Assessment in Endometrial Atypical Hyperplasia

“…In selected patients, sentinel nodal staging could correctly refer the patient to adjuvant therapy with minimal intraoperative morbidity. Furthermore, despite the long-term oncological outcomes of the SLN, research is still lacking [20]; on the other hand, the removal of the single SNL has proved to be a safe technique with complication rates comparable to simple hysterectomy in expert hands [21][22][23].…”