Oncological safety and perioperative morbidity in low-risk endometrial cancer with sentinel lymph-node dissection

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Abstract

Background

and Purpose: In endometrial cancer, staging is performed surgically. Controversy about the required extent of lymph node removal is ongoing. In low-risk endometrial cancer (FIGO Stage 1, endometrioid histology, Grades 1 and 2), the risk of lymph-node involvement is 4–17%. Since the introduction of near-infrared optics and the use of indocyanine green, the role of sentinel lymph node removal is increasing and could offer an appropriate balance between the morbidity of a complete lymph-node dissection and the risk of missing lymph-node involvement.

Methods

In this retrospective comparative study on low-risk endometrial cancer, the extent of surgical lymph-node assessment (no lymphadenectomy vs removal vs lymphadenectomy) in two European institutions was compared and analyzed on the basis of perioperative data and oncological outcome.

Results

The study included 279 patients from: 103 (36.9%) had no lymphadenectomy, 118 (42.3%) underwent SLN removal and 58 (20.8%) underwent pelvic and/or para-aortic lymphadenectomy. There were significant differences among the groups in blood loss (p = 0.000), operation time (p = 0.000), and severity of postoperative complications (p = 0.063). In comparing only sentinel lymph-node removal vs no lymphadenectomy, there were no significant differences. No significant difference was seen between the extent of lymphadenectomy removal and the risk of recurrence. Age and Lymphovascular space invasion positivity were significant risk factors for recurrence (p = 0.004 and p = 0.019).

Conclusions

In early-stage, endometrial cancer, Grade 1 and 2, sentinel lymph node removal offers a convincing balance between oncological safety and perioperative morbidity. Especially in LVSI-positive cases, lymph-node evaluation in any form is crucial.

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.

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