Oncological safety and perioperative morbidity in low-risk endometrial cancer with sentinel lymph-node dissection
Introduction
Endometrial cancer (EMCA) is the most common gynecologic-oncological disease, with a good 5-year overall survival rate of between 74% and 91% [1,2]. Due to the symptom of postmenopausal bleeding, in 75% of cases the diagnosis is made in early-stage disease [3]. The staging of the extent of disease is performed surgically; controversy is ongoing about the extent of lymph-node removal that is needed. In low-risk EMCA (FIGO Stage 1, endometrioid histology, Grades 1 and 2), the risk of lymph-node involvement is 4–17% [4]. Two prospective, randomized studies showed no improvement in overall and disease-free survival by adding a pelvic lymphadenectomy (LND) in Stage I disease [5,6]. For these reasons, systematic LND in this population is not mandatory [7,8]. However, in both studies mentioned, more patients of the “no LND group” had radiation therapy. Accordingly, a considerable number of patients had unnecessary adjuvant therapy, as the lymph-node status was not known.
Over the past few years, since the introduction of near-infrared optics and indocyanine green (ICG), the role of sentinel lymph node (SLN) removal is increasing; SLN dissection could offer a balance between the known morbidity of a complete lymph-node removal and the risk of missing lymph-node involvement due to not adding LND. Studies on lymph-node pathways and detection rates led to the inclusion of SLN removal in the National Comprehensive Cancer Network (NCCN) and British Gynecological Cancer Society (BGCS) guidelines [7,8]. However, oncological follow-up data on patients treated with SLN removal are scarce.
In this study, we analyzed intraoperative and postoperative data from patients diagnosed with low-risk EMCA and compared the oncologic outcome among the different surgical stagings performed: no LND; SLN mapping; and pelvic lymphadenectomy (PLND) +/-para-aortic lymphadenectomy (PALND).
Section snippets
Materials and methods
This retrospective comparative study compares three categories of low-risk endometrial cancer surgical treatments performed in two institutions: University Hospital of Bern/University of Bern (Switzerland) and Ospedale Santa Chiara di Trento (Italy). Three different lymph-node staging approaches were compared: (1) no LND; (2) SLN mapping; and (3) pelvic (PLND) and/or para-aortic lymphadenectomy (PALND).
For this study, only patients with FIGO Stage 1, endometrioid histology, Grade 1 or 2
Results
A total of 279 patients from the two institutions with a diagnosis of Stage 1 EMCA, including Grade 1 and 2, were included in the study. They were divided into groups according to the extent of LND: 103 (36.9%) had no LND, 118 (42.3%) had SLN removal, and 58 (20.8%) a pelvic ± para-aortic LND. Patient characteristics are presented in Table 1. Comparison of patient characteristics among the groups shows only a significant difference in BMI, with patients without LND having a BMI of 31.0,
Discussion
This study provides evidence that adding SLN removal to HE and bilateral salpingo-oophorectomy (BSO) in EMCA treatment rather than no LND does not lead to higher morbidity. Looking at the oncological safety, this data suggest that lymph node evaluation is needed to optimize the oncological outcome.
In Stage I, Grades 1 and 2 EMCA, the risk of lymph-node involvement is 6%. This is low. However, the impact of lymph-node involvement is important, since adjuvant treatment is then indicated, and the
Conclusion
In early-stage, endometrioid EMCA, Grades 1 and 2, SLN removal is a treatment option that offers a convincing balance between oncological safety and perioperative morbidity. Especially in LVSI-positive cases, lymph-node evaluation in any form is crucial.
Conflict of interest
All authors have no conflict of interest.
References (39)
- et al.
Carcinoma of the corpus uteri. FIGO 26th annual report on the results of treatment in gynecological cancer
Int J Gynaecol Obstet
(2006) - et al.
Endometrial cancer
Lancet
(2016) - et al.
Intraabdominal lymphatic mapping to direct selective pelvic and paraaortic lymphadenectomy in women with high- risk endometrial cancer: results of a pilot study
Gynecol Oncol
(1996) - et al.
Sentinel lymph node detection in patients with endometrial cancer
Gynecol Oncol
(2004) - et al.
A new approach to label sentinel nodes in endometrial cancer
Gynecol Oncol
(2007) - et al.
Sentinel node mapping with indocyanine green and endoscopic near-infrared fluorescence imaging in endometrial cancer. A pilot study and review of the literature
Gynecol Oncol
(2015) - et al.
A comparison of colorimetric versus fluorometric sentinel lymph node mapping during robotic surgery for endometrial cancer
Gynecol Oncol
(2014) - et al.
A study on uterine lymphatic anatomy for standardization of pelvic sentinel lymph node detection in endometrial cancer
Gynecol Oncol
(2017) - et al.
Real-time fluorescent sentinel lymph node mapping with indocyanine green in women with previous conization undergoing laparoscopic surgery for early invasive cervical cancer: comparison with Radiotracer ± Blue dye
J Minim Invasive Gynecol
(2018) - et al.
The importance of applying a sentinel lymph node mapping algorithm in endometrial cancer staging: beyond removal of blue nodes
Gynecol Oncol
(2012)
A comparison of sentinel lymph node biopsy to lymphadenectomy for endometrial cancer staging (FIRES trial): a multicentre, prospective, cohort study
Lancet Oncol
Sentinel lymph node biopsy in endometrial cancer—feasibility, safety and lymphatic complications
Gynecol Oncol
A prospective evaluation of the sentinel node mapping algorithm in endometrial cancer and correlation of its performance against endometrial cancer risk subtypes
Eur J Obstet Gynecol Reprod Biol
Patterns of recurrence and outcomes in surgically treated women with endometrial cancer according to ESMO-ESGO-ESTRO Consensus Conference risk groups: results from the FRANCOGYN study Group
Gynecol Oncol
Lymphovascular space invasion in uterine corpus cancer: what is its prognostic significance in the absence of lymph node metastases?
Gynecol Oncol
Imaging in endometrial cancer
Best Pract Res Clin Obstet Gynaecol
Cancer statistics
Ca - Cancer J Clin
Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study
Lancet
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Use of fluorescence imaging and indocyanine green during laparoscopic cholecystectomy: Results of an international Delphi survey
2022, Surgery (United States)Citation Excerpt :Indocyanine green (ICG) is a fluorophore that responds to near-infrared irradiation, absorbing light between the wavelengths of 790 and 805 nm and re-emitting it with an excitation wavelength of 835 nm.11 Since the initial use of ICG fluorescence imaging almost 50 years ago via the introduction of applied ophthalmic angiography,12 its use has expanded exponentially13 to include the identification of tumors and sentinel lymph nodes involving the breast,14–16 lungs,17,18 liver,19,20 colon,21,22 stomach,21–23 and pelvis24–28; the assessment of tissue perfusion in viscera19,22,29–31 and during plastic surgery32,33; identifying anastomotic leaks34–36; and assessing parathyroid gland vitality during thyroid and parathyroid resections.37,38 It was approximately 2 decades ago that intraoperative fluorescent imaging made its first foray into endoscopic surgery on the liver and biliary tree.39
Paucity of data evaluating patient centred outcomes following sentinel lymph node dissection in endometrial cancer: A systematic review
2021, Gynecologic Oncology ReportsCitation Excerpt :A comparison of postoperative complications reported in Geppert et al. (2018) was unable to be determined due to reporting of multiple risk groups. Of studies (n = 4) that compared SLND to no node dissection, two found that postoperative complications were higher in the SLND group (Imboden et al., 2019; Polan et al., 2019), while 2 reported higher complications in the group with no node dissection (Accorsi et al., 2020; Casarin et al., 2020). Five of the 13 studies reported on conversion rates, which ranged between 0.0% (Accorsi et al., 2020) and 43% (Geppert et al., 2018), with no consistent relationship between conversion rate and approach to lymph node sampling reported across the studies (Accorsi et al., 2020; Geppert et al., 2018; Casarin et al., 2020; Stewart et al., 2020).
- 1
contributed equal amounts of work to this study.