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Gracia M, Alonso-Espías M, Zapardiel I. Impact of sentinel node use in lymphedema formation among gynecologic cancer patients. Curr Opin Oncol 2024; 36:406-411. [PMID: 39007239 DOI: 10.1097/cco.0000000000001059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
PURPOSE OF REVIEW The most common surgical procedure associated with lymphedema formation is the regional lymphadenectomy. One of the advantages of sentinel node biopsy is the reduction of the risk of lymphedema formation. The purpose of this review is to collect and analyze the most relevant and recent evidence of the use of sentinel node biopsy and its implication on the development of postoperative lymphedema in gynecological cancer. RECENT FINDINGS The current evidence of the use of sentinel node biopsy in cervical cancer to reduce lymphedema is heterogeneous and more data is needed to establish its role.Sentinel lymph node biopsy in endometrial cancer is a staging procedure with lower surgical complications, as well as lymphedema formation; while the results of prospective trials evaluating its impact on quality of life are still lacking.Sentinel lymph node biopsy in vulvar cancer minimizes the need for extensive dissection and reduces the incidence of complications associated with overharvesting of lymph nodes such as lymphedema without compromising oncological outcomes. SUMMARY The prevalence of lymphedema in gynecological cancer varies based on the surgical treatment or additional therapies applied. Over the past years, one of the most important surgical modifications to decrease lymphedema formation has been implementation of sentinel lymph node technique mainly in vulvar cancer patients.
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Affiliation(s)
- Myriam Gracia
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
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Bell S, Smith K, Kim H, Orellana T, Harinath L, Rush S, Olawaiye A, Lesnock J. Hysterectomy with sentinel lymph node dissection in the setting of preoperative endometrial intraepithelial neoplasia and an endometrial stripe ≥20 mm: a cost-effectiveness analysis . Int J Gynecol Cancer 2024:ijgc-2024-005658. [PMID: 39107049 DOI: 10.1136/ijgc-2024-005658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2024] Open
Abstract
OBJECTIVES Routine lymph node assessment in patients with endometrial intraepithelial neoplasia is institution and surgeon-dependent without clear guidelines. We sought to determine if routine sentinel lymph node (SLN) dissection at the time of laparoscopic hysterectomy for patients with a preoperative diagnosis of endometrial intraepithelial neoplasia and a preoperative ultrasound with endometrial stripe ≥20 mm is cost-effective. METHODS A decision model was created to perform two cost-effectiveness analyses: (1) hysterectomy with frozen section versus hysterectomy with SLN dissection in patients with a preoperative diagnosis of endometrial intraepithelial neoplasia and an endometrial stripe of 20 mm or greater, and (2) the same options in all patients with a preoperative diagnosis of endometrial intraepithelial neoplasia. Costs obtained from Centers for Medicare and Medicaid Services and event probabilities and quality of life utility values were obtained through literature review. RESULTS In the case of preoperative endometrial stripe ≥20 mm, hysterectomy with SLN dissection cost $2469 more than hysterectomy with frozen section and gained 0.010 quality adjusted life years, or $44,997/quality-adjusted life years gained. In one-way sensitivity analyses, SLN dissection remained the favored strategy at a willingness to pay threshold of $100,000/quality-adjusted life years unless chronic lower extremity lymphedema after full lymphadenectomy had a likelihood <13.1% (base case value 18.1%); otherwise, SLN dissection was favored with individual variation of all other parameters over plausible ranges. When considering all patients with endometrial intraepithelial neoplasia, hysterectomy with frozen section was favored, with results most sensitive to variation of lymphedema risk after full lymphadenectomy. CONCLUSION Hysterectomy with SLN dissection in patients with a preoperative endometrial stripe ≥20mm on ultrasound is cost-effective when compared with hysterectomy with frozen section.
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Affiliation(s)
- Sarah Bell
- Gynecologic Oncology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Kenneth Smith
- General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Haeyon Kim
- Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Taylor Orellana
- Gynecologic Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lakshmi Harinath
- Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shannon Rush
- Gynecologic Oncology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Alexander Olawaiye
- Gynecologic Oncology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
| | - Jamie Lesnock
- Gynecologic Oncology, Magee Womens Hospital of UPMC, Pittsburgh, Pennsylvania, USA
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Cucinella G, Di Donna MC, Casarin J, Schivardi G, Multinu F, Borsellino L, Buono N, Zaccaria G, Abbate A, Laganà AS, Chiantera V. Lower limb lymphedema after surgical staging for endometrial cancer: Current insights and future directions. Taiwan J Obstet Gynecol 2024; 63:500-505. [PMID: 39004476 DOI: 10.1016/j.tjog.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 07/16/2024] Open
Abstract
Lower extremity lymphedema (LEL) is a common complication following surgical staging of endometrial cancer. LEL is a chronic condition associated with significant impact on patient morbidity and quality of life (QoL). This review aimed to report the current evidence in the literature on secondary LEL after surgical staging for endometrial cancer, focusing on the incidence based on different approaches to lymph node staging, diagnosis, risk factors, and the impact on QoL. Due to the absence of a standardized agreement regarding the methodology for evaluating LEL, the documented frequency of occurrence fluctuates across different studies, ranging from 0% to 50%. Systematic pelvic lymphadenectomy appears to be the primary determinant associated with the emergence of LEL, whereas the implementation of sentinel lymph node biopsy has notably diminished the occurrence of this lymphatic complication after endometrial cancer staging. LEL is strongly associated with decreased QoL, lower limb function, and negative body image, and has a detrimental impact on cancer-related distress reported by survivors. Standardization of lymphedema assessment is needed, along with cross-cultural adaptation of subjective outcome measures for self-reported LEL. The advent of sentinel lymph node mapping represents the ideal approach for accurate nodal assessment with less short- and long-term morbidity. Further research is needed to definitively assess the prevalence and risk factors of LEL and to identify strategies to improve limb function and QoL in cancer survivors with this chronic condition.
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Affiliation(s)
- Giuseppe Cucinella
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, 90133 Palermo, Italy; Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy.
| | - Mariano Catello Di Donna
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, 90133 Palermo, Italy; Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | - Gabriella Schivardi
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
| | - Francesco Multinu
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, Milan, Italy
| | - Letizia Borsellino
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy
| | - Natalina Buono
- Ospedale San Leonardo, Castellammare di Stabia, ASL NA3 SUD, Naples, Italy
| | - Giulia Zaccaria
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy
| | - Antonino Abbate
- Unit of Gynecologic Oncology, ARNAS "Civico-Di Cristina-Benfratelli", 90127 Palermo, Italy
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy; Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, 90127 Palermo, Italy
| | - Vito Chiantera
- Gynecology Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy
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Shi XL, Chen S, Guo GD, Yang YL, Tong KM, Cao W, Huang LL, Zhang YR. Precise lymph node biopsy for endometrial cancer confined to the uterus: Analysis of 43 clinical cases. Taiwan J Obstet Gynecol 2024; 63:369-374. [PMID: 38802200 DOI: 10.1016/j.tjog.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2023] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE To explore a precise association between tumor location and lymph node (LN) biopsy algorithm in uterine confined endometrial cancer (EC). MATERIALS AND METHODS Patients with EC treated in the Department of Obstetrics and Gynecology, South Branch of Fujian Provincial Hospital were included in this observational retrospective study. Based on the procedure of treatment, patients were separated to stage I (2015.07-2019.09) and stage II (2019.09-2021.9). In each stage, patients were separated to high and low-risk group by the predicted results. Patients in the high-risk group received systematic lymphadenectomy in stage I and sentinel lymph node (SLN) dissection in stage II. The efficiency of lymph node metastasis (LNM) detection rates was compared between stage I and stage II cases. Precise lymph node biopsy algorithm was also constructed based on the outcomes of stage II. RESULTS Overall, 43 patients, 28 in stage I and 15 in stage II, were included in the study. No recurrence or death cases had been found within follow-up terms. Based on the difference in the detection efficiency of LNM (p > 0.05), there was no difference between two stages. Thus, systematic lymphadenectomy and SLN biopsy provided similar success rates. The location of tumor site was also important for deciding whether pelvic or para-aortic SLN should be sampled for LNM. CONCLUSIONS Precise SLN biopsy for EC confined to the uterus showed comparable LNM detection rate as systematic lymphadenectomy. EC location may be used to determine whether pelvic or para-aortic SLN sampling should be conducted for treatment.
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Affiliation(s)
- Xiao-Long Shi
- Provincial Clinical Medical College of Fujian Medical University, Fuzhou, Fujian Province, 350001, PR China; Department of Obstetrics and Gynecology, Fujian Provincial Hospital, Fuzhou, Fujian Province, 350001, PR China.
| | - Shuo Chen
- Provincial Clinical Medical College of Fujian Medical University, Fuzhou, Fujian Province, 350001, PR China; Department of Obstetrics and Gynecology, Fujian Provincial Hospital, Fuzhou, Fujian Province, 350001, PR China
| | - Guo-Dong Guo
- Provincial Clinical Medical College of Fujian Medical University, Fuzhou, Fujian Province, 350001, PR China; Department of Obstetrics and Gynecology, Fujian Provincial Hospital, Fuzhou, Fujian Province, 350001, PR China
| | - Yun-Ling Yang
- Provincial Clinical Medical College of Fujian Medical University, Fuzhou, Fujian Province, 350001, PR China; Department of Obstetrics and Gynecology, Fujian Provincial Hospital, Fuzhou, Fujian Province, 350001, PR China
| | - Kang-Mei Tong
- Provincial Clinical Medical College of Fujian Medical University, Fuzhou, Fujian Province, 350001, PR China; Department of Obstetrics and Gynecology, Fujian Provincial Hospital, Fuzhou, Fujian Province, 350001, PR China
| | - Wen Cao
- Provincial Clinical Medical College of Fujian Medical University, Fuzhou, Fujian Province, 350001, PR China; Department of Obstetrics and Gynecology, Fujian Provincial Hospital, Fuzhou, Fujian Province, 350001, PR China
| | - Lin-Lin Huang
- Provincial Clinical Medical College of Fujian Medical University, Fuzhou, Fujian Province, 350001, PR China; Department of Obstetrics and Gynecology, Fujian Provincial Hospital, Fuzhou, Fujian Province, 350001, PR China
| | - Yan-Ru Zhang
- Provincial Clinical Medical College of Fujian Medical University, Fuzhou, Fujian Province, 350001, PR China; Department of Obstetrics and Gynecology, Fujian Provincial Hospital, Fuzhou, Fujian Province, 350001, PR China
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Leone Roberti Maggiore U, Spanò Bascio L, Alboni C, Chiarello G, Savelli L, Bogani G, Martinelli F, Chiappa V, Ditto A, Raspagliesi F. Sentinel lymph node biopsy in endometrial cancer: When, how and in which patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107956. [PMID: 38286085 DOI: 10.1016/j.ejso.2024.107956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/27/2023] [Accepted: 01/08/2024] [Indexed: 01/31/2024]
Abstract
The role of nodal dissection in patients with endometrial cancer has been intensively studied in several studies. Historically, systematic pelvic and para-aortic lymphadenectomy represented the gold standard surgical treatment to assess potential nodal involvement and consequently define the appropriate stage of the tumor. Over the last years, sentinel node biopsy (SLNB) has been introduced as a more targeted alternative to lymph node dissection for lymph node staging and it has become popular among gynecologic oncologists. However, no level A evidence is still available, and several features of the SLNB technique have been matter of discussion among clinicians and a universally accepted methodology is still not currently available. This narrative review aims to summarize the body of knowledge on SLNB to offer the reader a complete picture about the evolution of this technique over the last decades.
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Affiliation(s)
| | - Ludovica Spanò Bascio
- Obstetrics and Gynecology, Policlinico Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Carlo Alboni
- Obstetrics and Gynecology, Policlinico Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Chiarello
- Department of Biomedical Sciences and Human Oncology, University of Bari, Italy
| | - Luca Savelli
- Obstetrics and Gynecology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Giorgio Bogani
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Fabio Martinelli
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Valentina Chiappa
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Antonino Ditto
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Francesco Raspagliesi
- Gynecologic Oncology Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
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Bjørnholt SM, Mogensen O, Bouchelouche K, Sponholtz SE, Parner ET, Hildebrandt MG, Loft A, Neumann G, Bjørn SF, Dahl K, Markauskas A, Frøding LP, Jensen PT. Identifying safe diagnostic algorithms for sentinel lymph node mapping in high-risk endometrial cancer: The SENTIREC-endo study. Gynecol Oncol 2024; 182:179-187. [PMID: 38335900 DOI: 10.1016/j.ygyno.2024.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/19/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION It is unclear if sentinel node (SLN) mapping can replace pelvic- (PLD) and paraaortic lymphadenectomy (PALD) for high-risk endometrial cancer (EC). A diagnostically safe surgical algorithm, taking failed mapping cases into account, is not defined. We aimed to investigate the diagnostic accuracy of SLN mapping algorithms in women with exclusively high-risk EC. METHODS We undertook a prospective national diagnostic cohort study of SLN mapping in women with high-risk EC from March 2017 to January 2023. The power calculation was based on the negative predictive value (NPV). Women underwent SLN mapping, PLD and PALD besides removal of suspicious and any FDG/PET-positive lymph nodes. Accuracy analyses were performed for five algorithms. RESULTS 170/216 included women underwent SLN mapping, PLD and PALD and were included in accuracy analyses. 42/170 (24.7%) had nodal metastasis. The algorithm SLN and PLD in case of failed mapping, demonstrated a sensitivity of 86% (95% CI 74-100) and an NPV of 96% (95% CI 91-100). The sensitivity increased to 93% (95% CI 83-100) and the NPV to 98% (95% CI 94-100) if PLD was combined with removal of any PET-positive lymph nodes. Equivalent results were obtained if PLD and PALD were performed in non-mapping cases; sensitivity 93% (95% CI 83-100) and NPV 98% (95% CI 95-100). CONCLUSION SLN-mapping is a safe staging procedure in women with high-risk EC if strictly adhering to a surgical algorithm including removal of any PET-positive lymph nodes independent of location and PLD or PLD and PALD in case of failed mapping.
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Affiliation(s)
- Sarah Marie Bjørnholt
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Institute of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard, 99 8200 Aarhus N, Denmark.
| | - Ole Mogensen
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Institute of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard, 99 8200 Aarhus N, Denmark
| | - Kirsten Bouchelouche
- Department of Clinical Medicine - Nuclear Medicine and PET, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Sara Elizabeth Sponholtz
- Department of Clinical Research, Faculty of Health Science, University of Southern Denmark, Denmark
| | - Erik Thorlund Parner
- Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus, Denmark
| | - Malene Grubbe Hildebrandt
- Department of Clinical Research, Faculty of Health Science, University of Southern Denmark, Denmark; Department of Nuclear Medicine, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Annika Loft
- Department of Clinical Physiology & Nuclear Medicine, Rigshospitalet, Blegdamsvej 9, 2100 København Ø, Denmark
| | - Gudrun Neumann
- Department of Gynaecology and Obstetrics, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Signe Frahm Bjørn
- Department of Gynaecology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 København Ø, Denmark
| | - Katja Dahl
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Algirdas Markauskas
- Department of Gynaecology and Obstetrics, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Ligita Paskeviciute Frøding
- Department of Gynaecology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 København Ø, Denmark
| | - Pernille Tine Jensen
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Institute of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard, 99 8200 Aarhus N, Denmark; Department of Clinical Research, Faculty of Health Science, University of Southern Denmark, Denmark
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Pino I, Gozzini E, Radice D, Boveri S, Iacobone AD, Vidal Urbinati AM, Multinu F, Gullo G, Cucinella G, Franchi D. Advancing Tailored Treatments: A Predictive Nomogram, Based on Ultrasound and Laboratory Data, for Assessing Nodal Involvement in Endometrial Cancer Patients. J Clin Med 2024; 13:496. [PMID: 38256630 PMCID: PMC10816430 DOI: 10.3390/jcm13020496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/12/2024] [Accepted: 01/13/2024] [Indexed: 01/24/2024] Open
Abstract
Assessing lymph node metastasis is crucial in determining the optimal therapeutic approach for endometrial cancer (EC). Considering the impact of lymphadenectomy, there is an urgent need for a cost-effective and easily applicable method to evaluate the risk of lymph node metastasis in cases of sentinel lymph node (SLN) biopsy failure. This retrospective monocentric study enrolled EC patients, who underwent surgical staging with nodal assessment. Data concerning demographic, clinicopathological, ultrasound, and surgical characteristics were collected from medical records. Ultrasound examinations were conducted in accordance with the IETA statement. We identified 425 patients, and, after applying exclusion criteria, the analysis included 313 women. Parameters incorporated into the nomogram were selected via univariate and multivariable analyses, including platelet count, myometrial infiltration, minimal tumor-free margin, and CA 125. The nomogram exhibited good accuracy in predicting lymph node involvement, with an AUC of 0.88. Using a cutoff of 10% likelihood of nodal involvement, the nomogram displayed a low false-negative rate of 0.04 (95% CI 0.00-0.19) in the training set. The adaptability of this straightforward model renders it suitable for implementation across diverse clinical settings, aiding gynecological oncologists in preoperative patient evaluations and facilitating the design of personalized treatments. However, external validation is mandatory for confirming diagnostic accuracy.
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Affiliation(s)
- Ida Pino
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (D.F.)
| | - Elisa Gozzini
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy;
| | - Davide Radice
- Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Sara Boveri
- Laboratory of Biostatistics and Data Management, Scientific Directorate, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy;
| | - Anna Daniela Iacobone
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (D.F.)
| | - Ailyn Mariela Vidal Urbinati
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (D.F.)
- Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy;
- Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy;
- Laboratory of Biostatistics and Data Management, Scientific Directorate, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy;
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy
| | - Francesco Multinu
- Department of Gynecologic Surgery, IRCCS European Institute of Oncology, 20141 Milan, Italy;
| | - Giuseppe Gullo
- Department of Obstetrics and Gynecology, Villa Sofia Cervello Hospital, University of Palermo, 90146 Palermo, Italy; (G.G.); (G.C.)
| | - Gaspare Cucinella
- Department of Obstetrics and Gynecology, Villa Sofia Cervello Hospital, University of Palermo, 90146 Palermo, Italy; (G.G.); (G.C.)
| | - Dorella Franchi
- Preventive Gynecology Unit, European Institute of Oncology IRCCS, 20141 Milan, Italy; (A.D.I.); (A.M.V.U.); (D.F.)
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Ueno Y, Yoshida E, Nojiri S, Kato T, Ohtsu T, Takeshita T, Suzuki S, Yoshida H, Kato K, Itoh M, Notomi T, Usui K, Sozu T, Terao Y, Kawaji H, Kato H. Use of clinical variables for preoperative prediction of lymph node metastasis in endometrial cancer. Jpn J Clin Oncol 2024; 54:38-46. [PMID: 37815156 PMCID: PMC10773201 DOI: 10.1093/jjco/hyad135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/19/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE Endometrial cancer is the most common gynaecological cancer, and most patients are identified during early disease stages. Noninvasive evaluation of lymph node metastasis likely will improve the quality of clinical treatment, for example, by omitting unnecessary lymphadenectomy. METHODS The study population comprised 611 patients with endometrial cancer who underwent lymphadenectomy at four types of institutions, comprising seven hospitals in total. We systematically assessed the association of 18 preoperative clinical variables with postoperative lymph node metastasis. We then constructed statistical models for preoperative lymph node metastasis prediction and assessed their performance with a previously proposed system, in which the score was determined by counting the number of high-risk variables among the four predefined ones. RESULTS Of the preoperative 18 variables evaluated, 10 were significantly associated with postoperative lymph node metastasis. A logistic regression model achieved an area under the curve of 0.85 in predicting lymph node metastasis; this value is significantly higher than that from the previous system (area under the curve, 0.74). When we set the false-negative rate to ~1%, the new predictive model increased the rate of true negatives to 21%, compared with 6.8% from the previous one. We also provide a spreadsheet-based tool for further evaluation of its ability to predict lymph node metastasis in endometrial cancer. CONCLUSIONS Our new lymph node metastasis prediction method, which was based solely on preoperative clinical variables, performed significantly better than the previous method. Although additional evaluation is necessary for its clinical use, our noninvasive system may help improve the clinical treatment of endometrial cancer, complementing minimally invasive sentinel lymph node biopsy.
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Affiliation(s)
- Yuta Ueno
- Department of Gynecology, Kanagawa Cancer Center, Yokohama, Japan
- Department of Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan
- Department of Obstetrics and Gynecology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Emiko Yoshida
- Department of Obstetrics and Gynecology, Juntendo University, Tokyo, Japan
- Medical Technology Innovation Center, Juntendo University, Tokyo, Japan
| | - Shuko Nojiri
- Clinical Research and Trial Center, Juntendo University, Tokyo, Japan
| | - Tomoyasu Kato
- Department of Gynecology, National Cancer Center, Tokyo, Japan
| | - Takashi Ohtsu
- Division of Advanced Cancer Therapeutics, Kanagawa Cancer Center Research Institute, Yokohama, Japan
- Center for Cancer Genome Medicine, Kanagawa Cancer Center, Yokohama, Japan
| | - Toshiyuki Takeshita
- Department of Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan
| | - Shunji Suzuki
- Department of Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Yoshida
- Department of Diagnostic Pathology, National Cancer Center, Tokyo, Japan
| | - Ken Kato
- Clinical Research Support Office, Biobank Translational Research Support Section, National Cancer Center Hospital, Tokyo, Japan
| | - Masayoshi Itoh
- Laboratory for Advanced Genomics Circuit, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Tsuguto Notomi
- Department of Obstetrics and Gynecology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Kengo Usui
- Medical Technology Innovation Center, Juntendo University, Tokyo, Japan
| | - Takashi Sozu
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Tokyo, Japan
| | - Yasuhisa Terao
- Department of Obstetrics and Gynecology, Juntendo University, Tokyo, Japan
| | - Hideya Kawaji
- Research Center for Genome and Medical Sciences, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Hisamori Kato
- Department of Gynecology, Kanagawa Cancer Center, Yokohama, Japan
- Kanagawa Health Service Association, Yokohama, Japan
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9
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Capasso I, Cucinella G, Volcheck G, McGree M, Fought AJ, Chuzhyk O, De Vitis LA, Schivardi G, Fumagalli D, Occhiali T, Fanfani F, Chiantera V, Scambia G, Reynolds E, Mariani A, Glaser G. Let go of the myth: safety of indocyanine green for sentinel lymph node mapping in endometrial cancer. Int J Gynecol Cancer 2024; 34:80-87. [PMID: 38088181 DOI: 10.1136/ijgc-2023-004918] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2024] Open
Abstract
OBJECTIVE Sentinel lymph node mapping by intracervical indocyanine green injection is the preferred method for surgical staging in endometrial cancer. Adverse reactions to indocyanine green are extremely rare, and information about the safety of this tracer in patients with a history of other allergies, asthma, or comorbidities is limited. We aim to evaluate the rate of adverse reactions to indocyanine green injected during sentinel lymph node mapping in patients with endometrial cancer and review the etiology of such reactions. METHODS All patients with endometrial cancer undergoing sentinel lymph node mapping with indocyanine green cervical stroma injection at the Mayo Clinic in Rochester, Minnesota between June 2014 and December 2018 were retrospectively evaluated. Any adverse reaction occurring intra-operatively or within 7 days after surgery was identified. A thorough chart review was performed by an allergy specialist physician for any patient with an allergic-type reaction. RESULTS We included 923 patients of which 565 (61.2%) had a history of allergy to antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), other medications, and/or environmental exposures. Of 490 patients who had previously received contrast media, 25 (5.1%) had a history of an adverse reaction. No immediate anaphylaxis or other allergic reactions were observed after indocyanine green injection. 10 (1.1%) patients developed a transient skin reaction within 7 days after surgery. None of these patients had a history of contrast media reaction. Based on timing and clinical/peri-operative history of affected patients, it was determined that skin reactions were likely induced by other newly prescribed medications or contact sensitivity, not administration of indocyanine green. CONCLUSION Indocyanine green injection for sentinel lymph node mapping in patients with endometrial cancer caused no immediate/delayed anaphylactic or other severe allergic reactions. This included patients with a history of other allergies, asthma, and comorbidities. The myth of iodine's relationship to allergic reactions must be refuted to allow indocyanine green use in patients with a history of contrast media or shellfish allergy.
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Affiliation(s)
- Ilaria Capasso
- Department of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Women, Children and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Lazio, Italy
| | - Giuseppe Cucinella
- Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Palermo, Sicilia, Italy
| | - Gerald Volcheck
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Michaela McGree
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Angela J Fought
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Olena Chuzhyk
- Department of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Diletta Fumagalli
- Department of Obstetrics and Gynecology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Lombardia, Italy
| | - Tommaso Occhiali
- Department of Obstetrics and Gynecology, Santa Maria della Misericordia University Hospital, Udine, Friuli-Venezia Giulia, Italy
| | - Francesco Fanfani
- Department of Women, Children and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Lazio, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Sicilia, Italy
| | - Giovanni Scambia
- Department of Women, Children and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Lazio, Italy
| | - Evelyn Reynolds
- Department of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea Mariani
- Department of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Department of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota, USA
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10
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Vieira-Serna S, Peralta J, Viveros-Carreño D, Rodriguez J, Feliciano-Alfonso JE, Pareja R. Sentinel lymph node assessment in patients with atypical endometrial hyperplasia: a systematic review and meta-analysis. Int J Gynecol Cancer 2024; 34:66-72. [PMID: 37973363 DOI: 10.1136/ijgc-2023-004936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE This systematic review and meta-analysis aimed to assess the rate of sentinel lymph node (SLN) metastases in patients with a pre-operative diagnosis of atypical hyperplasia/endometrial intra-epithelial neoplasia and endometrial cancer in hysterectomy specimens. METHODS A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and the protocol was registered in PROSPERO (CRD42023416769). MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scopus databases were searched from inception until April 2023. The inclusion criteria were patients with a pre-operative diagnosis of atypical hyperplasia/endometrial intra-epithelial neoplasia undergoing hysterectomy who did or did not undergo SLN assessment. RESULTS Four studies met the inclusion criteria. All studies were non-randomized studies with a total of 10 217 patients, 1044 in the SLN group and 9173 in the non-nodal assessment group. The unilateral and bilateral detection rate was 89% (I2=27.6%, 2 studies, 342 participants, 304 events) and 79% (I2=89.2%, 2 studies, 342 participants, 271 events), respectively. The rate of involved SLNs was 1.6% (I2=0%, 3 studies, 424 participants, 7 involved SLN) and 3.5% (I2=0%, 3 studies, 197 participants, 7 involved SLN) in patients with a pre-operative diagnosis of atypical hyperplasia/endometrial intra-epithelial neoplasia as the denominator and in those with endometrial cancer in the hysterectomy specimen, respectively. The cancer rate in the hysterectomy specimen was 45% (I2=72.8%, 3 studies, 503 participants, 224 events) and the most frequent endometrial cancer International Federation of Gynecology and Obstetrics 2009 stage was IA in 199 (89.2%) patients. The complication rate was similar between the groups. CONCLUSION The rate of SLN metastases in patients with pre-operative atypical hyperplasia/endometrial intra-epithelial neoplasia is less than 2%, suggesting that routine SLN evaluation may not be necessary in this population.
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Affiliation(s)
- Santiago Vieira-Serna
- Department of Gynecologic Oncology, Clínica Universitaria Colombia, Bogotá, Colombia
- Department of Obstetrics and Gynecology, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Jonathan Peralta
- Department of Gynecologic Oncology, Instituto Nacional de Cancerología, Bogotá, Colombia
| | - David Viveros-Carreño
- Department of Gynecologic Oncology, Clínica Universitaria Colombia, Bogotá, Colombia
- Department of Gynecologic Oncology, Instituto Nacional de Cancerología, Bogotá, Colombia
- Deparment of Gynecologic Oncology, Centro de Tratamiento e Investigación sobre Cáncer Luis Carlos Sarmiento Angulo - CTIC, Bogotá, Colombia
| | - Juliana Rodriguez
- Department of Gynecologic Oncology, Instituto Nacional de Cancerología, Bogotá, Colombia
- Department of Gynecology and Obstetrics, Section of Gynecologic Oncology, Fundación Santa Fe de Bogotá, Bogotá, Colombia
- Department of Obstetrics and Gynecology, Universidad Nacional de Colombia, Bogotá, Colombia
| | | | - Rene Pareja
- Department of Gynecologic Oncology, Instituto Nacional de Cancerología, Bogotá, Colombia
- Department of Gynecologic Oncology, Clinica ASTORGA, Medellín, Colombia
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11
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Pados G, Zouzoulas D, Tsolakidis D. Recent management of endometrial cancer: a narrative review of the literature. Front Med (Lausanne) 2024; 10:1244634. [PMID: 38235267 PMCID: PMC10792696 DOI: 10.3389/fmed.2023.1244634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 11/23/2023] [Indexed: 01/19/2024] Open
Abstract
Endometrial cancer is a common female gynecological neoplasia and its incidence rate has increased in the past years. Due to its predominant symptoms, most women will present uterine bleeding. It is usually diagnosed at an early stage and surgery has an important role in the treatment plan. The prognosis and quality of life of these patients can be quite favorable, if proper treatment is offered by surgeons. Traditionally, more invasive approaches and procedures were offered to these patients, but recent data suggest that more conservative and minimal invasive choices can be adopted in the treatment algorithm. Minimal invasive surgery, such as laparoscopy and robotic surgery, should be considered as an acceptable alternative, compared to laparotomy with less comorbidities and similar oncological and survival outcomes. Furthermore, sentinel lymph node biopsy has emerged in the surgical staging of endometrial cancer, in order to replace comprehensive lymphadenectomy. It is associated with less intra- and postoperative complications, while preliminary data show no difference in survival rates. However, sentinel lymph node biopsy should be offered within a strict algorithm, to avoid residual metastatic disease. The aim of this review is to analyze all the available data for the application of minimal invasive surgery in early endometrial cancer and especially the role of sentinel lymph node biopsy.
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Affiliation(s)
- George Pados
- Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, “Papageorgiou” Hospital, Thessaloniki, Greece
- Center for Endoscopic Surgery “Diavalkaniko” Hospital, Thessaloniki, Greece
| | - Dimitrios Zouzoulas
- Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, “Papageorgiou” Hospital, Thessaloniki, Greece
| | - Dimitrios Tsolakidis
- Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, “Papageorgiou” Hospital, Thessaloniki, Greece
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12
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Salman L, Cusimano MC, Marchocki Z, Ferguson SE. Sentinel lymph node mapping in endometrial cancer: Current evidence and practice. J Surg Oncol 2024; 129:117-119. [PMID: 38059317 DOI: 10.1002/jso.27550] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 11/15/2023] [Indexed: 12/08/2023]
Abstract
Surgical staging with total hysterectomy, bilateral salpingo-oophorectomy, and lymph node assessment is the standard of care for patients with clinical early-stage endometrial cancer. Traditionally, complete pelvic and para-aortic lymphadenectomy (LND) was performed to assess for nodal metastases; however, numerous prospective studies have demonstrated that sentinel lymph node biopsy has similar diagnostic accuracy, and is an acceptable alternative to complete LND. This has led to a paradigm shift in endometrial cancer staging.
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Affiliation(s)
- Lina Salman
- Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/Sinai Health Systems, Toronto, Ontario, Canada
| | - Maria C Cusimano
- Department of Gynecology, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
| | - Zibi Marchocki
- Department of Obstetrics and Gynaecology, University College Cork, Cork University Maternity Hospital, Cork, Ireland
| | - Sarah E Ferguson
- Department of Obstetrics & Gynecology, Division of Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
- Division of Gynecologic Oncology, Princess Margaret Cancer Centre/Sinai Health Systems, Toronto, Ontario, Canada
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13
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Buechi CA, Siegenthaler F, Sahli L, Papadia A, Saner FAM, Mohr S, Rau TT, Solass W, Imboden S, Mueller MD. Real-World Data Assessing the Impact of Lymphovascular Space Invasion on the Diagnostic Performance of Sentinel Lymph Node Mapping in Endometrial Cancer. Cancers (Basel) 2023; 16:67. [PMID: 38201495 PMCID: PMC10778553 DOI: 10.3390/cancers16010067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND SLN mapping has emerged as a standard of care in endometrial cancer due to its high sensitivity and significant reduction in morbidity. Although lymphovascular space invasion (LVSI) is a known risk factor for lymph node metastasis and recurrence, evidence on the reliability of SLN mapping in LVSI-positive patients is scarce. The aim of this study was to determine the impact of LVSI on the diagnostic performance of SLN mapping. METHODS This retrospective cohort study included patients with endometrial cancer who underwent primary surgical treatment at the Bern University Hospital, Switzerland, between 2012 and 2022. RESULTS LVSI was present in 22% of patients and was significantly associated with lymph node metastasis (p < 0.001) and recurrence (p < 0.001). In node-negative patients with only SLN mapping performed, LVSI was an independent predictor of recurrence during multivariable Cox regression analysis (p = 0.036). The negative predictive value of SLN mapping was 91.5% and was significantly lower in tumors with LVSI (75.0%) compared to LVSI-negative tumors (95.6%, p = 0.004). CONCLUSION The presence of LVSI was significantly associated with worse oncological outcomes. LVSI was an independent predictor of recurrence in node-negative patients with only SLN mapping performed. Furthermore, the negative predictive value of SLN mapping was significantly lower in LVSI-positive tumors.
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Affiliation(s)
- Carol A. Buechi
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, 3010 Bern, Switzerland; (C.A.B.)
| | - Franziska Siegenthaler
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, 3010 Bern, Switzerland; (C.A.B.)
| | - Laura Sahli
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, 3010 Bern, Switzerland; (C.A.B.)
| | - Andrea Papadia
- Department of Gynecology and Obstetrics, Ente Ospedaliero Cantonale of Lugano, 6900 Lugano, Switzerland
- Facoltà di Scienze Biomediche, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Flurina A. M. Saner
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, 3010 Bern, Switzerland; (C.A.B.)
| | - Stefan Mohr
- Department of Gynecology and Obstetrics, Bürgerspital Solothurn, 4500 Solothurn, Switzerland;
| | - Tilman T. Rau
- Institute of Pathology, Universitätsklinikum Düsseldorf, 40225 Düsseldorf, Germany
| | - Wiebke Solass
- Institute of Tissue Medicine and Pathology, University of Bern, 3008 Bern, Switzerland
| | - Sara Imboden
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, 3010 Bern, Switzerland; (C.A.B.)
| | - Michael D. Mueller
- Department of Obstetrics and Gynecology, Bern University Hospital and University of Bern, 3010 Bern, Switzerland; (C.A.B.)
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14
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Goncalves BT, Dos Reis R, Ribeiro R, Moretti-Marques R, Schamme FK, Oliveira GS, Tsunoda AT, Alvarenga-Bezerra V, Lopes A, Pastore CBP, Kumagai LY, Faloppa CC, Mantoan H, Badiglian-Filho L, De Brot L, Andrade CEMC, Baiocchi G. Does sentinel node mapping impact morbidity and quality of life in endometrial cancer? Int J Gynecol Cancer 2023; 33:1548-1556. [PMID: 37699707 DOI: 10.1136/ijgc-2023-004555] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
OBJECTIVES To evaluate the prevalence of post-operative complications and quality of life (QoL) related to sentinel lymph node (SLN) biopsy vs systematic lymphadenectomy in endometrial cancer. METHODS A prospective cohort included women with early-stage endometrial carcinoma who underwent lymph node staging, grouped as follows: SLN group (sentinel lymph node only) and SLN+LND group (sentinel lymph node biopsy with addition of systematic lymphadenectomy). The patients had at least 12 months of follow-up, and QoL was assessed by European Organization for Research and Treatment of Cervical Cancer Quality of Life Questionnaire 30 (EORTC-QLQ-C30) and EORTC-QLQ-Cx24. Lymphedema was also assessed by clinical evaluation and perimetry. RESULTS 152 patients were included: 113 (74.3%) in the SLN group and 39 (25.7%) in the SLN+LND group. Intra-operative surgical complications occurred in 2 (1.3%) cases, and all belonged to SLN+LND group. Patients undergoing SLN+LND had higher overall complication rates than those undergoing SLN alone (33.3% vs 14.2%; p=0.011), even after adjusting for confound factors (OR=3.45, 95% CI 1.40 to 8.47; p=0.007). The SLN+LND group had longer surgical time (p=0.001) and need for admission to the intensive care unit (p=0.001). Moreover, the incidence of lymphocele was found in eight cases in the SLN+LND group (0 vs 20.5%; p<0.001). There were no differences in lymphedema rate after clinical evaluation and perimetry. However, the lymphedema score was highest when lymphedema was reported by clinical examination at 6 months (30.1 vs 7.8; p<0.001) and at 12 months (36.3 vs 6.0; p<0.001). Regarding the overall assessment of QoL, there was no difference between groups at 12 months of follow-up. CONCLUSIONS There was a higher overall rate of complications for the group undergoing systematic lymphadenectomy, as well as higher rates of lymphocele and lymphedema according to the symptom score. No difference was found in overall QoL between SLN and SLN+LND groups.
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Affiliation(s)
| | - Ricardo Dos Reis
- Department of Gynecologic Oncology, Barretos Cancer Hospital, Barretos, Brazil
| | - Reitan Ribeiro
- Department of Gynecologic Oncology, Erasto Gaertner Hospital, Curitiba, Brazil
| | | | | | | | - Audrey Tieko Tsunoda
- Department of Gynecologic Oncology, Erasto Gaertner Hospital, Curitiba, Brazil
- HCor Oncology, Sao Paulo, Brazil
- PPGTS/Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | | | - Andre Lopes
- Department of Gynecologic Oncology, Sao Camilo Oncologia, Sao Paulo, Brazil
| | | | | | | | - Henrique Mantoan
- Department of Gynecologic Oncology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | | | - Louise De Brot
- Department of Anatomic Pathology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | | | - Glauco Baiocchi
- Department of Gynecologic Oncology, AC Camargo Cancer Center, Sao Paulo, Brazil
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15
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Terada S, Tanaka T, Murakami H, Tsuchihashi H, Toji A, Daimon A, Miyamoto S, Nishie R, Ueda S, Hashida S, Morita N, Maruoka H, Konishi H, Kogata Y, Taniguchi K, Komura K, Ohmichi M. Lymphatic Complications Following Sentinel Node Biopsy or Pelvic Lymphadenectomy for Endometrial Cancer. J Clin Med 2023; 12:4540. [PMID: 37445574 DOI: 10.3390/jcm12134540] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023] Open
Abstract
Sentinel node biopsy (SNB) is performed worldwide in patients with endometrial cancer (EC). The aim of this study was to evaluate and compare the occurrence rate of lymphatic complications between SNB and pelvic lymphadenectomy (LND) for EC. The medical records of women who underwent SNB or pelvic LND for EC between September 2012 and April 2022 were assessed. A total of 388 patients were enrolled in the current study. Among them, 201 patients underwent SNB and 187 patients underwent pelvic LND. The occurrence rates of lower-extremity lymphedema (LEL) and pelvic lymphocele (PL) were compared between the patients who underwent SNB and those who underwent pelvic LND. The SNB group had a significantly lower occurrence rate of lower-extremity LEL than the pelvic LND group (2.0% vs. 21.3%, p < 0.01). There were no patients who had PL in the SNB group; however, 4 (2.1%) patients in the pelvic LND group had PL. The occurrence rates of lower-extremity LEL and PL were significantly lower in patients who underwent SNB than those who underwent pelvic LND. SNB for EC has a lower risk of lymphatic complications compared to systemic LND.
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Affiliation(s)
- Shinichi Terada
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Tomohito Tanaka
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
- Translational Research Program, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Hikaru Murakami
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Hiromitsu Tsuchihashi
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Akihiko Toji
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Atsushi Daimon
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Shunsuke Miyamoto
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
- Translational Research Program, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Ruri Nishie
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Shoko Ueda
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Sousuke Hashida
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Natsuko Morita
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Hiroshi Maruoka
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Hiromi Konishi
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Yuhei Kogata
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Kohei Taniguchi
- Translational Research Program, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Kazumasa Komura
- Translational Research Program, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
| | - Masahide Ohmichi
- Department of Obstetrics and Gynecology, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka 569-0801, Japan
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16
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Martínez A, Chargari C, Kalbacher E, Gaillard AL, Leary A, Koskas M, Chopin N, Serre AA, Hardy-Bessard AC, Akladios C, Lecuru F. Recommandations pour la pratique clinique Nice/Saint-Paul-de-Vence 2022–2023 : prise en charge du cancer de l'endomètre localisé. Bull Cancer 2023; 110:6S20-6S33. [PMID: 37573036 DOI: 10.1016/s0007-4551(23)00331-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
Recommendations for clinical practice, Nice/Saint-Paul-de-Vence 2022-2023: Management of localized endometrial cancer Endometrial cancer is the most frequent gynecological cancers in industrialized countries and its incidence increases. The newmolecularclassification allows determination of the risk of recurrence and helps orienting therapeutic management. Surgery remains the cornerstone of treatment. Minimally invasive approach must be preferred for stages I and II. Surgery includes hysterectomy with bilateral adnexectomy, sentinel lymph node biopsy even in high risk diseases and omentectomy for non-endometrioid tumors (except in case of clear cells tumors). Fertility preservation can be proposed in low grade, stage I tumors without myometrial involvement. In stage III/IV disease, lymph node debulking without totallymphadenectomy is indicated. In case of peritoneal carcinomatosis, first-line cytoreductive surgery is recommended if complete resection can be achieved. Adjuvant therapy is not recommended in low risk tumors. In intermediate risk tumors, curietherapy is indicated. In tumors with high-intermediate risk, curietherapy and external radiotherapy are indicated according to prognostic factors (stage II, lymphovascular invasion); adjuvant chemotherapy can be considered on a case-by-case basis. In high risk tumors, chemotherapy and external radiotherapy are recommended using a concomitant or sequential approach.
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Affiliation(s)
- Alejandra Martínez
- Département de chirurgie oncologique, institut Claudius-Regaud, institut universitaire du cancer Toulouse Oncopole, France; Centre de recherche en cancérologie de Toulouse, UMR 1037 INSERM, France.
| | - Cyrus Chargari
- Département d'oncologie-radiothérapie, hôpital de la Pitié Salpêtrière, France
| | - Elsa Kalbacher
- Département d'oncologie médicale, hôpital de Besançon, France
| | | | - Alexandra Leary
- Département d'oncologie médicale, institut Gustave-Roussy, France
| | - Martin Koskas
- Département de gynécologie-obstétrique, hôpital Bichat, France
| | - Nicolás Chopin
- Département de gynécologie-obstétrique, centre Léon-Bérard, France
| | | | | | - Chérif Akladios
- Département de gynécologie-obstétrique, hôpitaux universitaires de Strasbourg, France
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17
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Bjørnholt SM, Sponholtz SE, Mogensen O, Bouchelouche K, Parner ET, Neumann G, Jochumsen KM, Hamid BH, Davidsen MB, Bjørn SF, Dahl K, Jensen PT. The SENTIREC-endo study - Risks and benefits of a national adoption of sentinel node mapping in low and intermediate risk endometrial cancer. Gynecol Oncol 2023; 171:121-128. [PMID: 36893488 DOI: 10.1016/j.ygyno.2023.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/20/2023] [Accepted: 02/24/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVE The SENTIREC-endo study aims to investigate risks and benefits of a national protocolled adoption of sentinel lymph node (SLN) mapping in women with early-stage low-grade endometrial cancer (EC) with low- (LR) and intermediate-risk (IR) of lymph node metastases. METHODS We performed a national multicenter prospective study of SLN-mapping in women with LR and IR EC from March 2017-February 2022. Postoperative complications were classified according to Clavien-Dindo. Lymphedema was assessed as a change score and as incidence of swelling and heaviness evaluated by validated patient-reported outcome measures at baseline and three months postoperatively. RESULTS 627 women were included in the analyses; 458 with LR- and 169 with IR EC. The SLN detection rate was 94.3% (591/627). The overall incidence of lymph node metastases was 9.3% (58/627); 4.4% (20/458) in the LR- and 22.5% (38/169) in the IR group. Ultrastaging identified 62% (36/58) of metastases. The incidence of postoperative complications was 8% (50/627) but only 0.3% (2/627) experienced an intraoperative complication associated with the SLN procedure. The lymphedema change score was below the threshold for clinical importance 4.5/100 CI: (2.9-6.0), and the incidence of swelling and heaviness was low; 5.2% and 5.8%, respectively. CONCLUSION SLN mapping in women with LR and IR EC carries a very low risk of early lymphedema and peri- and postoperative complications. The national change in clinical practice contributed to a more correct treatment allocation for both risk groups and thus supports further international implementation of the SLN technique in early stage, low grade EC.
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Affiliation(s)
- Sarah Marie Bjørnholt
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Denmark; Institute of Clinical Medicine, Faculty of Health, Aarhus University, Denmark.
| | | | - Ole Mogensen
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Denmark; Institute of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Kirsten Bouchelouche
- Department of Clinical Medicine - Nuclear Medicine and PET, Aarhus University Hospital, Denmark
| | | | - Gudrun Neumann
- Department of Gynecology and Obstetrics, Odense University Hospital, Denmark
| | | | | | | | - Signe Frahm Bjørn
- Department of Gynecology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Katja Dahl
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Denmark
| | - Pernille Tine Jensen
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Denmark; Institute of Clinical Medicine, Faculty of Health, Aarhus University, Denmark; Department of Clinical Research, Faculty of Health Science, University of Southern Denmark, Denmark
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18
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Raffone A, Fanfani F, Raimondo D, Rovero G, Renzulli F, Travaglino A, De Laurentiis U, Santoro A, Zannoni GF, Casadio P, Scambia G, Seracchioli R, Mollo A. Predictive factors of sentinel lymph node failed mapping in endometrial carcinoma patients: a systematic review and meta-analysis. Int J Gynecol Cancer 2023:ijgc-2022-004014. [PMID: 36914172 DOI: 10.1136/ijgc-2022-004014] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
OBJECTIVE In endometrial carcinoma patients, sentinel lymph node bilateral mapping fails in 20-25% of cases, with several factors affecting the likelihood of detection. However, pooled data about predictive factors of failure are lacking. The aim of this systematic review and meta-analysis was to assess the predictive factors of sentinel lymph node failed mapping in endometrial cancer patients undergoing sentinel lymph node biopsy. METHODS A systematic review and a meta-analysis was performed searching all studies assessing predictive factors of sentinel lymph node failed mapping in apparent uterine-confined endometrial cancer patients undergoing sentinel lymph node biopsy through the cervical injection of indocyanine green. The associations between sentinel lymph node failed mapping and predictive factors of failure were assessed, calculating the odds ratio (OR) with 95% confidence intervals. RESULTS Six studies with a total of 1345 patients were included. Compared with patients with sentinel lymph node bilateral successful mapping, patients with sentinel lymph node failed mapping showed: OR 1.39 (p=0.41) for body mass index >30 kg/m2; OR 1.72 (p=0.24) for menopausal status; OR 1.19 (p=0.74) for adenomyosis; OR 0.86 (p=0.55) for prior pelvic surgery; OR 2.38 (p=0.26) for prior cervical surgery; OR 0.96 (p=0.89) for prior Cesarean section; OR 1.39 (p=0.70) for lysis of adhesions during surgery before sentinel lymph node biopsy; OR 1.77 (p=0.02) for indocyanine green dose <3 mL; OR 1.28 (p=0.31) for deep myometrial invasion; OR 1.21 (p=0.42) for International Federation of Gynecology and Obstetrics (FIGO) grade 3; OR 1.89 (p=0.01) for FIGO stages III-IV; OR 1.62 (p=0.07) for non-endometrioid histotype; OR 1.29 (p=0.25) for lymph-vascular space invasion; OR 4.11 (p<0.0001) for enlarged lymph nodes; and OR 1.71 (p=0.022) for lymph node involvement. CONCLUSION Indocyanine green dose <3 mL, FIGO stage III-IV, enlarged lymph nodes, and lymph node involvement are predictive factors of sentinel lymph node failed mapping in endometrial cancer patients.
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Affiliation(s)
- Antonio Raffone
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Francesco Fanfani
- Department of Woman and Child Health and Public Health, Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,Department of Women and Child Health and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Diego Raimondo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Rovero
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Federica Renzulli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Antonio Travaglino
- Gynecopathology and Breast Pathology Unit, Department of Woman's Health Science, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Lazio, Italy.,Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Campania, Italy
| | - Umberto De Laurentiis
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Angela Santoro
- Gynecopathology and Breast Pathology Unit, Department of Woman's Health Science, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Lazio, Italy
| | - Gian Franco Zannoni
- Gynecopathology and Breast Pathology Unit, Department of Woman's Health Science, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Lazio, Italy
| | - Paolo Casadio
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giovanni Scambia
- Department of Woman and Child Health and Public Health, Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy.,Department of Women and Child Health and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Renato Seracchioli
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Antonio Mollo
- Gynecology and Obstetrics Unit, Department of Medicine, Surgery and Dentistry "Schola Medica Salernitana", University of Salerno, Baronissi, Campania, Italy
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Sbarra M, Lupinelli M, Brook OR, Venkatesan AM, Nougaret S. Imaging of Endometrial Cancer. Radiol Clin North Am 2023; 61:609-625. [PMID: 37169427 DOI: 10.1016/j.rcl.2023.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Endometrial cancer is the most common gynecologic cancer in the United States and Europe, with an increasing incidence rate in high-income countries. MR imaging is recommended for treatment planning because it provides critical information on the extent of myometrial and cervical invasion, extrauterine spread, and lymph node status, all of which are important in the selection of the most appropriate therapy. This article highlights the added value of imaging, focused on MR imaging, in the assessment of endometrial cancer and summarizes the role of MR imaging for endometrial cancer risk stratification and management.
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20
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Deluche E, Marti C, Jochum F, Bendifallah S, Azaïs H, Deidier J, Cockenpot V, Menoux I, Kissel M, Balaya V, Betrian S, Mathevet P, Chargari C, Gouy S, Genestie C, Uzan C, Devouassoux-Shisheboran M, Guyon F, Akladios C, Body N, Guani B. [Application in France of the 2021 European recommendations on endometrial cancer]. Bull Cancer 2023; 110:55-68. [PMID: 36462971 DOI: 10.1016/j.bulcan.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 12/02/2022]
Abstract
The latest European recommendations of the European Societies of Gynecological Oncology (ESGO), Radiotherapy and Oncology (ESTRO) and Anatomopathology (ESP) concerning the management of patients with endometrial cancer were published in 2021. On behalf of the French Society of Gynecologic Oncology (SFOG) and the SFOG campus, we wish to summarize for the French-speaking readership the main measures with a more specific application for France. We also incorporate data from a Delphi survey conducted with a panel of French and French-speaking Swiss experts. The data presented in this article relate to histo-molecular characteristics, radiological data of endometrial cancer, and management of low-risk, intermediate-risk, intermediate-high-risk, and metastatic cancers. The aim of this review article is to show the application of the latest international recommendations to clinicians and pathologists for the implementation of these recommendations.
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Affiliation(s)
- Elise Deluche
- Service d'Oncologie Médicale, 2, avenue Martin Luther King, Limoges, France.
| | - Carolin Marti
- Université de Lausanne, UNIL, Lausanne, Suisse; Service de gynécologie obstétrique, HFR, Fribourg, Suisse
| | - Floriane Jochum
- Université Paris-Saclay, département de Gynécologie, Institut Curie, Paris, France; Hopitaux Universitaires de Strasbourg, département de Gynécologie et d'Obstétrique, Strasbourg, France
| | | | - Henri Azaïs
- Hôpital Européen Georges Pompidou, Service de chirurgie oncologique gynécologique et mammaire, Paris, France
| | - Jonas Deidier
- Hôpital Universitaire Paris Ouest Site G Pompidou AP-HP, département de Radiologie, Paris, France
| | | | - Inès Menoux
- ICANS, département de Radiothérapie, Strasbourg, France
| | - Manon Kissel
- Département de Radiothérapie, institut Curie, Paris, France
| | - Vincent Balaya
- Hôpital Foch, département de Gynécologie, Suresnes, France
| | - Sarah Betrian
- IUCT Oncopole, département d'oncologie médicale, Toulouse, France
| | - Patrice Mathevet
- Université de Lausanne, UNIL, Lausanne, Suisse; CHUV, département de Gynécologie et d'Obstétrique, Lausanne, Suisse
| | - Cyrus Chargari
- Gustave Roussy, département de radio-oncologie, Paris, France
| | - Sebastien Gouy
- Gustave Roussy, département de gynécologie oncologie chirurgicale, Paris, France
| | | | - Catherine Uzan
- AP-HP, Hôpital de la Pitié Salpêtrière, département de gynécologie et d'obstétrique, Paris, France; Institut Universitaire de cancérologie, Sorbonne Université, Paris, France
| | | | - Frederic Guyon
- Institut Bergonié, département d'oncologie chirurgicale, Bordeaux, France
| | - Cherif Akladios
- Hopitaux Universitaires de Strasbourg, département de Gynécologie et d'Obstétrique, Strasbourg, France
| | - Noémie Body
- Institut de Cancérologie de l'Ouest (ICO), département d'Oncologie Chirurgicale, Angers, France
| | - Benedetta Guani
- Université de Lausanne, UNIL, Lausanne, Suisse; CHUV, département de Gynécologie et d'Obstétrique, Lausanne, Suisse; Université de Fribourg, UNIFR, Fribourg, Suisse
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21
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Matias-Guiu X, Selinger CI, Anderson L, Buza N, Ellenson LH, Fadare O, Ganesan R, Ip PPC, Palacios J, Parra-Herran C, Raspollini MR, Soslow RA, Werner HMJ, Lax SF, McCluggage WG. Data Set for the Reporting of Endometrial Cancer: Recommendations From the International Collaboration on Cancer Reporting (ICCR). Int J Gynecol Pathol 2022; 41:S90-S118. [PMID: 36305536 DOI: 10.1097/pgp.0000000000000901] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Endometrial cancer is one of the most common cancers among women. The International Collaboration on Cancer Reporting (ICCR) developed a standardized endometrial cancer data set in 2011, which provided detailed recommendations for the reporting of resection specimens of these neoplasms. A new data set has been developed, which incorporates the updated 2020 World Health Organization Classification of Female Genital Tumors, the Cancer Genome Atlas (TCGA) molecular classification of endometrial cancers, and other major advances in endometrial cancer reporting, all of which necessitated a major revision of the data set. This updated data set has been produced by a panel of expert pathologists and an expert clinician and has been subject to international open consultation. The data set includes core elements which are unanimously agreed upon as essential for cancer diagnosis, clinical management, staging, or prognosis and noncore elements which are clinically important, but not essential. Explanatory notes are provided for each element. Adoption of this updated data set will result in improvements in endometrial cancer patient care.
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22
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Collaborative centralization of gynaecological cancer care. Curr Opin Oncol 2022; 34:518-523. [PMID: 35900753 DOI: 10.1097/cco.0000000000000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To discuss the benefits of centralization of gynaecological cancer care on patients and the healthcare system and how to overcome its barriers. RECENT FINDINGS Evidence demonstrates that adherence to clinical practice management guidelines is more likely; the risk of adverse events is lower; survival is improved; in young women fertility preservation is higher; and cost effectiveness is higher; in systems that employ centralized care for women with gynaecological cancer. Barriers to the uptake of centralized models include knowledge, attitude as well as deficient systems and processes, including a lack of governance and leadership. Collaborative centralization refers to a model that sees both elements (centralization and treatment closer to home) utilized at the patient level that addresses some of the barriers of centralized gynaecological cancer care. SUMMARY Evidence supports centralized gynaecological cancer care, as it results in reduced risks of adverse events, improved survival and higher fertility rates at lower cost to funders. Collaborative centralization is a process that considers both the value of centralization and collaboration amongst healthcare professionals at primary, secondary and tertiary levels of healthcare to benefit patient outcomes.
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23
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Kim YN, Lee D, Cha J, Kang WJ, Lee YJ, Lee JY, Nam EJ, Kim S, Kim YT, Kim SW. Usefulness and potential pitfalls of pre-operative PET-CT in patients with endometrial cancer undergoing one- and two-step sentinel lymph node mapping: Do negative findings on PET-CT negativity really indicate node negativity? Gynecol Oncol 2022; 166:438-443. [PMID: 35907682 DOI: 10.1016/j.ygyno.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/08/2022] [Accepted: 07/17/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We investigated the utility of Positron emission tomography-Computed tomography (PET-CT) in the setting of two different sentinel lymph node (SLN) mapping techniques; the conventional cervical injection method (one-step) and the two-step method, which involves fundal injection followed by cervical injection. METHODS Patients with endometrial cancer undergoing FDG PET-CT followed by laparoscopic or robotic surgical staging with SLN mapping at the Yonsei Cancer Center between July 2014 and April 2021 were stratified into the PET-positive group (with suspected or likely lymph nodes metastasis) and PET-negative group. A chart review was performed for the number of harvested SLNs, patterns of SLN metastases, and recurrence. RESULTS Among 466 patients undergoing one-step (n = 276) and two-step (n = 190) SLN mapping, LN metastasis was identified in 21 of 434 PET-negative and 18 of 32 PET-positive patients. The sensitivity and specificity of PET-CT for diagnosing lymph node metastasis were 46.2% and 96.7%, respectively. Among PET-positive patients with LN metastasis, anatomical distribution was concordant in 14/18 patients (77.8%). Among PET-negative patients, four (2.3%) had metastatic para-aortic SLNs, including three (1.7%) with isolated para-aortic metastases; metastatic para-aortic SLNs were exclusively found in the two-step group. Among PET-positive patients, para-aortic SLN metastasis was identified in 35.7% of two-step and 16.7% of one-step group. Among the 21 PET false-negative patients, recurrence was seen in four patients (19%) after a median follow-up of 34 months (range: 7-70 months). CONCLUSIONS PET-CT served as a useful guide to clinicians with high anatomical concordance rate in patients with LN metastasis. However, despite high specificity, sensitivity was limited. SLN metastasis pattern, especially at the para-aortic level, indicates that the two-step SLN technique might be useful in PET-negative and PET-positive patients.
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Affiliation(s)
- Yoo-Na Kim
- Department of Obstetrics and Gynecology, Women's Cancer Center, Yonsei Cancer Center, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dahye Lee
- Department of Obstetrics and Gynecology, Women's Cancer Center, Yonsei Cancer Center, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jongtae Cha
- Department of Nuclear Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Jun Kang
- Department of Nuclear Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Jae Lee
- Department of Obstetrics and Gynecology, Women's Cancer Center, Yonsei Cancer Center, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Yun Lee
- Department of Obstetrics and Gynecology, Women's Cancer Center, Yonsei Cancer Center, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Ji Nam
- Department of Obstetrics and Gynecology, Women's Cancer Center, Yonsei Cancer Center, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sunghoon Kim
- Department of Obstetrics and Gynecology, Women's Cancer Center, Yonsei Cancer Center, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Tae Kim
- Department of Obstetrics and Gynecology, Women's Cancer Center, Yonsei Cancer Center, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Wun Kim
- Department of Obstetrics and Gynecology, Women's Cancer Center, Yonsei Cancer Center, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Molenaar L, Horstman-van de Loosdrecht MM, Krooshoop HJG, Wesselink RJH, Ten Haken B, Broeders IAMJ, Alic L. Excitation coil for sentinel lymph node harvesting: design, digital twin and prototype. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:4402-4406. [PMID: 36086020 DOI: 10.1109/embc48229.2022.9871415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
A recently developed prototype (Laparoscopic Differential Magnetometer, in short LapDiffMag) identifies magnetic tracer accumulated inside sentinel lymph nodes (SLNs) during clinical laparoscopic procedures. The LapDiffMag relies on excitation of superparamagnetic iron oxide nanoparticles (SPIONs) and subsequent laparoscopic detection based on a nonlinear detection principle. The prototype uses an excitation coil to generate a magnetic field needed to activate SPIONs. This study reports on the process of developing a new excitation coil by describing the design choices based upon clinical requirements, by modeling delivered magnetic field using digital twin, and by comparing the magnetic fields of modeled and manufactured prototype. Digital twin technology was used to produce relevant and reliable data to demonstrate the safety and effectiveness of the excitation coil. The magnetic field originating from manufactured prototype was validated at two different heights above the excitation coil and have shown a good concordance to the data generated by its digital twin. Clinical Relevance- Current standard-of-care for a variety of tumor types consists of minimally invasive radical resection of primary tumor and regional lymph nodes (LNs). The newly introduced excitation coil will (after full validation) enable minimally invasive harvesting of sentinel LNs by means of magnetic tracer detection.
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Wang T, Xu Y, Shao W, Wang C. Sentinel Lymph Node Mapping: Current Applications and Future Perspectives in Gynecology Malignant Tumors. Front Med (Lausanne) 2022; 9:922585. [PMID: 35847801 PMCID: PMC9276931 DOI: 10.3389/fmed.2022.922585] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/30/2022] [Indexed: 12/17/2022] Open
Abstract
The sentinel lymph nodes (SLNs) is a group of lymph nodes initially involved in the metastatic spread of cancer cells. SLN mapping refers to intraoperative localization and biopsy of SLNs with specific tracers to assess lymph node metastases. It is widely used in a variety of tumor surgeries for its high sensitivity and high negative predictive value. In the evaluation of the status of lymph node metastases in gynecological malignancies, it has received increasingly more attention due to its minor invasiveness, few complications, and high diagnosis rate. The National Comprehensive Cancer Network (NCCN) guidelines provide an excellent introduction to the indications and methods of SLN techniques in vulvar, cervical, and endometrial cancers, but they provide little explanation about some specific issues. In this review, we summarize different dyes and injection methods and discuss the indications of application and the clinical trials of SLN mapping in gynecological malignant tumors, aiming to provide a reference for the rational application of sentinel techniques in gynecology malignant tumors before relevant guidelines are updated.
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Wu C, Zhou X, Li J, Xiao R, Xin H, Dai L, Zhu Y, Bao W. Serum miRNA‑204‑5p as a potential non‑invasive biomarker for the diagnosis of endometrial cancer with sentinel lymph node mapping. Oncol Lett 2022; 24:248. [PMID: 35761942 PMCID: PMC9214711 DOI: 10.3892/ol.2022.13368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/24/2022] [Indexed: 11/06/2022] Open
Abstract
The lymph node status is one of the most critical prognostic factors used in determining adjuvant treatment in endometrial cancer (EC). Lymphadenectomy is associated significant surgical and postoperative risks. The use of sentinel lymph node mapping (SLNM) has emerged as an alternative method to complete lymphadenectomy in EC. However, there remains controversy surrounding the use of SLNM in high-risk disease and its false-negative rate (3%). The authors previously identified miR-204-5p as a tumor-suppressor miRNA associated with lymph node metastasis in EC tissues. The present study demonstrated that serum miR-204-5p in patients with EC has the potential for use as an early diagnostic biomarker combined with SLNM to assess the lymph node status prior to surgery. The present study also aimed to identify the optimal cut-off value of serum miR-204-5p. The relative expression levels of miR-204-5p were detected using reverse transcription-quantitative PCR in the serum of 52 patients with EC (total SLNM). A total of 20 patients diagnosed with ovarian cysts, 20 patients diagnosed with myoma, and 20 participants diagnosed with endometrial polyps or endometrial hyperplasia were included as the control group. miR-204-5p expression was also detected in lymph node tissues using in situ hybridization. The results revealed that serum miR-204-5p expression was downregulated in patients with EC compared with its expression in patients with benign ovarian cysts, myoma and endometrial hyperplasia/polyps (P<0.01). In accordance with the final pathological evaluation, patients with EC with a positive SLN status had a significantly lower level of miR-204-5p compared with those with a negative SLN status (P<0.01). The area under the ROC curve of miR-204-5p was 0.923, 95% CI (0.847-1.000), and the diagnostic value had a sensitivity of 87.2% and specificity of 80.0%, with an optimal cut-off value of 0.253. On the whole, it was demonstrated that a lower miR-204-5p expression is associated with lymph node metastasis in these SLN(+) EC tissues, indicating that the downregulation of serum miR-204-5p in patients with EC has potential for use as an early diagnostic biomarker combined with SLNM. In addition, with a cut-off value of 0.253, it appeared optimal for the prediction of lymph node metastasis in EC.
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Affiliation(s)
- Cailiang Wu
- Department of Obstetrics and Gynecology, Shanghai General Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai 200080, P.R. China
| | - Xuexin Zhou
- Department of Obstetrics and Gynecology, Shanghai General Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai 200080, P.R. China
| | - Jiayong Li
- Clinical Laboratory Medicine Center, Shanghai General Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai 200080, P.R. China
| | - Ruiying Xiao
- Department of Obstetrics and Gynecology, Shanghai General Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai 200080, P.R. China
| | - Haomin Xin
- Department of Obstetrics and Gynecology, Shanghai General Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai 200080, P.R. China
| | - Lei Dai
- Department of Obstetrics and Gynecology, Shanghai General Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai 200080, P.R. China
| | - Yaping Zhu
- Department of Obstetrics and Gynecology, Shanghai General Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai 200080, P.R. China
| | - Wei Bao
- Department of Obstetrics and Gynecology, Shanghai General Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai 200080, P.R. China
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Sentinel Lymph Node Biopsy in Surgical Staging for High-Risk Groups of Endometrial Carcinoma Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063716. [PMID: 35329403 PMCID: PMC8949341 DOI: 10.3390/ijerph19063716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/14/2022] [Accepted: 03/18/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND In endometrial carcinoma (EC) patients, sentinel lymph node (SLN) biopsy has shown the potential to reduce post-operative morbidity and long-term complications, and to improve the detection of low-volume metastasis through ultrastaging. However, while it has shown high sensitivity and feasibility in low-risk EC patient groups, its role in high-risk groups is still unclear. AIM To assess the role of SLN biopsy through the cervical injection of indocyanine green (ICG) in high-risk groups of early-stage EC patients. MATERIALS AND METHODS Seven electronic databases were searched from their inception to February 2021 for studies that allowed data extraction about detection rate and accuracy of SLN biopsy through the cervical injection of ICG in high-risk groups of early-stage EC patients. We calculated pooled sensitivity, false negative (FN) rate, detection rate of SLN per hemipelvis (DRh), detection rate of SLN per patients (DRp), and bilateral detection rate of SLN (DRb), with 95% confidence interval (CI). RESULTS Five observational cohort studies (three prospective and two retrospective) assessing 578 high risk EC patients were included. SLN biopsy sensitivity in detecting EC metastasis was 0.90 (95% CI: 0.03-0.95). FN rate was 2.8% (95% CI: 0.6-11.6%). DRh was 88.4% (95% CI: 86-90.5%), DRp was 96.6% (95% CI: 94.7-97.8%), and DRb was 80% (95% CI: 75.4-83.9). CONCLUSION SLN biopsy through ICG cervical injection may be routinely adopted instead of systematic pelvic and para-aortic lymphadenectomy in surgical staging for high-risk groups of early-stage EC patients, as well as in low-risk groups.
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van den Heerik ASVM, Horeweg N, Creutzberg CL, Nout RA. Vaginal brachytherapy management of stage I and II endometrial cancer. Int J Gynecol Cancer 2022; 32:304-310. [DOI: 10.1136/ijgc-2021-002493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/30/2021] [Indexed: 11/04/2022] Open
Abstract
Adjuvant radiotherapy is an important component of post-operative therapy for patients with early-stage endometrial cancer. In the past decades, many trials have been conducted to determine the optimal adjuvant treatment strategy, pelvic external beam radiotherapy or vaginal brachytherapy. As a result, vaginal brachytherapy became the treatment of choice for patients with early-stage endometrial cancer at high-intermediate risk, based on clinicopathological risk factors. Vaginal brachytherapy maximizes local control and has only mild side effects with limited impact on quality of life, in comparison with pelvic external beam radiotherapy. The most frequently used treatment schedule is the one which was used in the PORTEC-2 trial (21 Gy in three fractions specified at 5 mm depth) and, whenever available, image-guided brachytherapy should be used. However, the most convenient and effective treatment schedule remains to be established. More recently, the discovery and integration of four molecular classes in the risk assessment of endometrial cancer patients has created new opportunities to prevent over- and undertreatment. The 2021 endometrial cancer guideline of the European Society of Gynaecological Oncology (ESGO), European Society for Radiotherapy and Oncology (ESTRO), and the European Society of Pathology (ESP) now proposes an integrated risk stratification, in which both clinicopathologic and molecular factors are combined, to direct adjuvant therapy. This rationale is now investigated in multiple prospective trials. This review provides an overview of the rationale and currently recommended and new strategies for vaginal brachytherapy in patients with stage I and II endometrial cancer.
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Sentinel Lymph Node Mapping in High-Grade Endometrial Cancer. Curr Oncol 2022; 29:1123-1135. [PMID: 35200595 PMCID: PMC8870608 DOI: 10.3390/curroncol29020096] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 01/11/2023] Open
Abstract
Sentinel lymph node (SLN) mapping is becoming an acceptable alternative to full lymphadenectomy for evaluating lymphatic spread in clinical stage I endometrial cancer (EC). While the assessment of pelvic and para-aortic lymph nodes is part of the surgical staging of EC, there is a long-standing debate over the therapeutic value of full lymphadenectomy in this setting. Although lymphadenectomy offers critical information on lymphatic spread and prognosis, most patients will not derive oncologic benefit from this procedure as the majority of patients do not have lymph node involvement. SLN mapping offers prognostic information while simultaneously avoiding the morbidity associated with an extensive and often unnecessary lymphadenectomy. A key factor in the decision making when planning for EC surgery is the histologic subtype. Since the risk of lymphatic spread is less than 5% in low-grade EC, these patients might not benefit from lymph node assessment. Nonetheless, in high-grade EC, the risk for lymph node metastases is much higher (20–30%); therefore, it is crucial to determine the spread of disease both for determining prognosis and for tailoring the appropriate adjuvant treatment. Studies on the accuracy of SLN mapping in high-grade EC have shown a detection rate of over 90%. The available evidence supports adopting the SLN approach as an accurate method for surgical staging. However, there is a paucity of prospective data on the long-term oncologic outcome for patients undergoing SLN mapping in high-grade EC, and more trials are warranted to answer this question.
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Bogani G, Papadia A, Buda A, Casarin J, Di Donato V, Plotti F, Gasparri ML, Cimmino C, Pinelli C, Perrone AM, Barra F, Cromi A, Di Martino G, Palaia I, Ferrero S, Indini A, De Iaco P, Angioli R, Luvero D, Muzii L, Ghezzi F, Landoni F, Mueller MD, Benedetti Panici P, Raspagliesi F. Factors predicting morbidity in surgically-staged high-risk endometrial cancer patients. Eur J Obstet Gynecol Reprod Biol 2021; 266:169-174. [PMID: 34688098 DOI: 10.1016/j.ejogrb.2021.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/23/2021] [Accepted: 09/26/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To investigate factors predicting the risk of developing 90-day postoperative complications and lymphatic-specific morbidity in patients undergoing surgical staging for high-risk endometrial cancer. METHODS This is a multi-institutional retrospective cohort study. Patients affected by apparent early-stage high-risk endometrial cancer (endometrioid FIGO grade 3 with deep myometrial invasion and non-endometrioid endometrial cancer) undergoing surgical staging between 2007 and 2019. Complications were graded according to the Clavien-Dindo classification system. Martin criteria were applied to improve quality of complications reporting. RESULTS Charts of 279 patients were evaluated. Lymphadenectomy, sentinel node mapping (SNM), and SNM followed by back-up lymphadenectomy were performed in 83 (29.7%), 50 (17.9%), and 146 (52.4%) patients, respectively. The former group of patients included 13 patients who had lymphadenectomy after the failure of the SNM technique. Thirteen (4.6%) patients developed severe postoperative events (grade 3 or worse). At multivariate analysis, body mass index (OR: 1.08 (95%CI: 1.01, 1.17)) and open abdominal surgery (OR: 2.27 (95%CI: 1.02, 5.32)) were the two independent factors predictive of surgery-related morbidity. Seven severe lymphatic complications occurred. The adoption of laparoscopic approach (p < 0.001, log-rank test) and SNM (p = 0.038, log-rank test) correlated with a lower risk of developing surgery-related events. Independently, open abdominal surgery was associated with an increased risk of developing lymphatic morbidity (OR: 37.4 (95%CI: 4.38, 319.5); p = 0.001). CONCLUSION The adoption of the laparoscopic approach and SNM technique were associated with lower 90-day complication rates than open surgery in high-risk endometrial cancer undergoing staging surgery.
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Affiliation(s)
- Giorgio Bogani
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milano, Italy.
| | - Andrea Papadia
- Department of Obstetrics and Gynecology, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, University' of Italian Switzerland, Lugano, Switzerland
| | - Alessandro Buda
- Gynecology Oncology Surgical Unit, Department of Obstetrics and Gynecology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Varese, Italy
| | - Violante Di Donato
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Italy
| | - Francesco Plotti
- Department of Obstetrics and Gynecology, University Campus Biomedico of Rome, Rome, Italy
| | - Maria Luisa Gasparri
- Department of Obstetrics and Gynecology, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, University' of Italian Switzerland, Lugano, Switzerland
| | - Chiara Cimmino
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milano, Italy; Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Varese, Italy
| | - Ciro Pinelli
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Varese, Italy
| | - Anna Myriam Perrone
- Department of Obstetrics and Gynecology Sant'Orsola Malpighi University Hospital University of Bologna, 40138 Bologna, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Antonella Cromi
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Varese, Italy
| | - Giampaolo Di Martino
- Gynecology Oncology Surgical Unit, Department of Obstetrics and Gynecology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Innocenza Palaia
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Italy
| | - Alice Indini
- Unit of Medical Oncology, Department of Medicine and Surgery, University of Insubria, ASST dei Sette Laghi, Varese, Italy
| | - Pierandrea De Iaco
- Department of Obstetrics and Gynecology, University Campus Biomedico of Rome, Rome, Italy
| | - Roberto Angioli
- Department of Obstetrics and Gynecology, University Campus Biomedico of Rome, Rome, Italy
| | - Daniela Luvero
- Department of Obstetrics and Gynecology, University Campus Biomedico of Rome, Rome, Italy
| | - Ludovico Muzii
- Department of Gynecological, Obstetrical and Urological Sciences, "Sapienza" University of Rome, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, 'Filippo Del Ponte' Hospital, University of Insubria, Varese, Italy
| | - Fabio Landoni
- Gynecology Oncology Surgical Unit, Department of Obstetrics and Gynecology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Michael D Mueller
- Department of Obstetrics and Gynecology, University Hospital of Bern and University of Bern, Bern, Switzerland
| | | | - Francesco Raspagliesi
- Gynecological Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milano, Italy
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Ng ZY, Koh KML, Chin FHX, Aggarwal IM, Wong WL, Yeo YC, Lim YK. Sentinel Lymph-Node Mapping with Near-Infrared Indocyanine Green in Laparotomy for Early Endometrial Cancer. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Zheng Yuan Ng
- Department of Gynaecological Oncology, KK Women's and Children's Hospital, Singapore, Singapore
| | - Krystal Miao Lin Koh
- Division of Obstetrics and Gynaecology, and KK Women's and Children's Hospital, Singapore, Singapore
| | - Felicia Hui Xian Chin
- Department of Gynaecological Oncology, KK Women's and Children's Hospital, Singapore, Singapore
| | - Ieera Madan Aggarwal
- Department of Gynaecological Oncology, KK Women's and Children's Hospital, Singapore, Singapore
| | - Wai Loong Wong
- Department of Gynaecological Oncology, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yen Ching Yeo
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yong Kuei Lim
- Department of Gynaecological Oncology, KK Women's and Children's Hospital, Singapore, Singapore
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Zhai L, Zhang X, Cui M, Wang J. Sentinel Lymph Node Mapping in Endometrial Cancer: A Comprehensive Review. Front Oncol 2021; 11:701758. [PMID: 34268126 PMCID: PMC8276058 DOI: 10.3389/fonc.2021.701758] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/01/2021] [Indexed: 12/27/2022] Open
Abstract
Endometrial cancer (EC) is known as a common gynecological malignancy. The incidence rate is on the increase annually. Lymph node status plays a crucial role in evaluating the prognosis and selecting adjuvant therapy. Currently, the patients with high-risk (not comply with any of the following: (1) well-differentiated or moderately differentiated, pathological grade G1 or G2; (2) myometrial invasion< 1/2; (3) tumor diameter < 2 cm are commonly recommended for a systematic lymphadenectomy (LAD). However, conventional LAD shows high complication incidence and uncertain survival benefits. Sentinel lymph node (SLN) refers to the first lymph node that is passed by the lymphatic metastasis of the primary malignant tumor through the regional lymphatic drainage pathway and can indicate the involvement of lymph nodes across the drainage area. Mounting evidence has demonstrated a high detection rate (DR), sensitivity, and negative predictive value (NPV) in patients with early-stage lower risk EC using sentinel lymph node mapping (SLNM) with pathologic ultra-staging. Meanwhile, SLNM did not compromise the patient’s progression-free survival (PFS) and overall survival (OS) with low operative complications. However, the application of SLNM in early-stage high-risk EC patients remains controversial. As revealed by the recent studies, SLNM may also be feasible, effective, and safe in high-risk patients. This review aims at making a systematic description of the progress made in the application of SLNM in the treatment of EC and the relevant controversies, including the application of SLNM in high-risk patients.
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Affiliation(s)
- Lirong Zhai
- Department of Gynecology and Obstetrics, Peking University People's Hospital, Beijing, China
| | - Xiwen Zhang
- Department of Gynecology and Obstetrics, The Second Hospital of Jilin University, Changchun, China
| | - Manhua Cui
- Department of Gynecology and Obstetrics, The Second Hospital of Jilin University, Changchun, China
| | - Jianliu Wang
- Department of Gynecology and Obstetrics, Peking University People's Hospital, Beijing, China
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Loosdrecht MMVD, Molenaar L, Krooshoop EJG, Haken BT, Meijerink WJHJ, Alic L, Broeders IAMJ. Laparoscopic Probe for Sentinel Lymph Node Harvesting using Magnetic Nanoparticles. IEEE Trans Biomed Eng 2021; 69:286-293. [PMID: 34170819 DOI: 10.1109/tbme.2021.3092437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sentinel lymph node harvesting is an essential step in the surgical treatment of a growing number of malignancies. Various techniques are available to facilitate this purpose. The present study reports a new laparoscopic technique for lymph node harvesting using magnetic nanoparticles containing a superparamagnetic iron-oxide core and dextran coating. This study assesses the clinical relevance of the prototype and provides input for further technological development on the way to clinical implementation. METHODS A laparoscopic differential magnetometer prototype was built, utilizing a nonlinear detection principle (differential magnetometry) for magnetic identification of lymph nodes. The iron content sensitivity, depth & spatial sensitivity, and angular sensitivity were analyzed to investigate clinical options. RESULTS The minimum detectable amount of iron was 9.8 g at a distance of 1 mm. The detection depth was 5, 8, and 10 mm for samples containing 126, 252, and 504 g iron, respectively. The maximum lateral detection distance was 5, 7, and 8 mm for samples containing 126, 252, and 504 g iron, respectively. A sample containing 504 g iron was detectable at all angulations assessed (0, 30, 60 and 90). CONCLUSION The laparoscopic differential magnetometer demonstrates promising results for further investigation and development towards laparoscopic lymph node harvesting using magnetic nanoparticles. SIGNIFICANCE The laparoscopic differential magnetometer facilitates a novel method for sentinel lymph node harvesting, which helps to determine prognosis and treatment of cancer patients.
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Preoperative prediction of high-risk endometrial cancer by expert and non-expert transvaginal ultrasonography, magnetic resonance imaging, and endometrial histology. Eur J Obstet Gynecol Reprod Biol 2021; 263:181-191. [PMID: 34218206 DOI: 10.1016/j.ejogrb.2021.05.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/10/2021] [Accepted: 05/22/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To identify women with high-risk endometrial cancers using expert and non-expert transvaginal ultrasonography (TVS) and MRI. STUDY DESIGN Myometrial involvement was prospectively evaluated in patients with atypical hyperplasia or endometrial cancer on ultrasound by non-experts at first visit (non-expert-TVS: n = 266) and experts (expert-TVS: n = 188) at second visit. MRI (n = 175) was performed when high-risk cancer was suspected on non-expert-TVS. Preoperatively, high-risk cancer was defined as myometrial involvement ≥50 %, or preoperative unfavorable tumor histology (grade 3 endometrioid, non-endometrioid tumors, or tumor in cervical biopsies) obtained by endometrial sampling or hysteroscopic biopsies. Preoperative evaluations were compared with final histopathology obtained at surgery, high-risk cancer being defined as unfavorable tumor histology or patients with FIGO stage ≥1b. RESULTS Preoperative unfavorable tumor histology was seen in 64 women and correctly identified 63 of 128 high-risk cancers. Preoperative diagnosis of unfavorable tumor histology or myometrial involvement ≥50 %, i.e. judged high-risk, had an area under the curve (AUC), sensitivity, and specificity of 79.5 %, 93.8 %, 65.2 % on non-expert-TVS; 85.5 %, 84.4 %, 86.5 % on expert-TVS, and 85.4 %, 89.6 %, 81.2 % on MRI. AUC values were not significantly different between MRI and expert-TVS, but lower on non-expert-TVS (p < 0.02). However, sensitivity was highest on non-expert-TVS, where a low cutpoint for myometrial involvement was used (included potentially deep and difficult evaluations) in contrast to an exact cutpoint of myometrial involvement ≥50 % used on expert-TVS and MRI. The highest AUC, 88.6 %, was seen when MRI was performed in patients with myometrial involvement ≥50 %, determined on non-expert TVS. Sensitivity was reduced to 85.9 %, while specificity increased to 91.3 %. Thus, MRI was needed for risk classification in only 104 (39 %) patients. CONCLUSION Diagnostically, expert-TVS and MRI were comparable and superior to non-expert-TVS. However, non-expert-TVS classified all patients with unclear myometrial involvement ≥50 %, and thereby only misdiagnosed 6.2 % of high-risk cases. Non-expert-TVS combined with MRI when myometrial involvement was ≥50 % on non-expert-TVS was a simple and effective method comparable with expert imaging to identify low- and high-risk cancer and select patients for SLND. Addition of MRI to the diagnostic regimen was needed in only 39 % of our patients.
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Cibula D, Borčinová M, Marnitz S, Jarkovský J, Klát J, Pilka R, Torné A, Zapardiel I, Petiz A, Lay L, Sehnal B, Ponce J, Felsinger M, Arencibia-Sánchez O, Kaščák P, Zalewski K, Presl J, Palop-Moscardó A, Tingulstad S, Vergote I, Redecha M, Frühauf F, Köhler C, Kocián R. Lower-Limb Lymphedema after Sentinel Lymph Node Biopsy in Cervical Cancer Patients. Cancers (Basel) 2021; 13:cancers13102360. [PMID: 34068399 PMCID: PMC8153612 DOI: 10.3390/cancers13102360] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/07/2021] [Accepted: 05/11/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Lower-limb lymphedema (LLL) is a well-recognized adverse outcome of the surgical management of cervical cancer. Recently, sentinel lymph node (SLN) biopsy has emerged as an alternative procedure to systematic pelvic lymphadenectomy (PLND) aiming to decrease the risk of complications, especially LLL development. Our study represents the first prospective analysis of LLL incidence in cervical cancer patients after a uterine procedure with SLN biopsy, without systematic PLND. In an international multicenter trial SENTIX, the group of 150 patients was prospectively evaluated using both objective and subjective LLL assessments in 6 months intervals for 2 years. Contrary to the expectations, our results showed that SLN biopsy does not eliminate the risk of LLL development which occurred in a mild or moderate stage in about 26% of patients with a median interval to the onset of 9 months. Abstract Background: To prospectively assess LLL incidence among cervical cancer patients treated by uterine surgery complemented by SLN biopsy, without PLND. Methods: A prospective study in 150 patients with stage IA1–IB2 cervical cancer treated by uterine surgery with bilateral SLN biopsy. Objective LLL assessments, based on limb volume increase (LVI) between pre- and postoperative measurements, and subjective patient-perceived swelling were conducted in six-month periods over 24-months post-surgery. Results: The cumulative incidence of LLL at 24 months was 17.3% for mild LLL (LVI 10–19%), 9.2% for moderate LLL (LVI 20–39%), while only one patient (0.7%) developed severe LLL (LVI > 40%). The median interval to LLL onset was nine months. Transient edema resolving without intervention within six months was reported in an additional 22% of patients. Subjective LLL was reported by 10.7% of patients, though only a weak and partial correlation between subjective-report and objective-LVI was found. No risk factor directly related to LLL development was identified. Conclusions: The replacement of standard PLND by bilateral SLN biopsy in the surgical treatment of cervical cancer does not eliminate the risk of mild to moderate LLL, which develops irrespective of the number of SLN removed.
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Affiliation(s)
- David Cibula
- Gynecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital, 12000 Prague, Czech Republic; (M.B.); (F.F.); (R.K.)
- Correspondence: ; Tel.: +420-224-967-451
| | - Martina Borčinová
- Gynecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital, 12000 Prague, Czech Republic; (M.B.); (F.F.); (R.K.)
| | - Simone Marnitz
- Department of Special Operative and Oncologic Gynaecology, Asklepios-Clinic Hamburg, 22763 Hamburg, Germany; (S.M.); (C.K.)
| | - Jiří Jarkovský
- Data Analysis Department, Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic;
| | - Jaroslav Klát
- Department of Obstetrics and Gynecology, University Hospital Ostrava, 70800 Ostrava Poruba, Czech Republic;
| | - Radovan Pilka
- Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, Palacky University, University Hospital Olomouc, 77900 Olomouc, Czech Republic;
| | - Aureli Torné
- Unit of Gynecological Oncology, Institute Clinic of Gynaecology, Obstetrics, and Neonatology, Hospital Clinic-Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS), University of Barcelona, 08036 Barcelona, Spain;
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital, 28046 Madrid, Spain;
| | - Almerinda Petiz
- Serviço de Ginecologia, Instituto Portugues de Oncologia do Porto, 1099-023 Porto, Portugal;
| | - Laura Lay
- Department of Gynaecology, Institute of Oncology Angel H Roffo University of Bueno s Aires, Buenos Aires C1417 DTB, Argentina;
| | - Borek Sehnal
- Department of Obstetrics and Gynecology, First Faculty of Medicine, University Hospital Bulovka, Charles University, 18081 Prague, Czech Republic;
| | - Jordi Ponce
- Department of Gynecology, Biomedical Research Institute of Bellvitge (IDIBELL), University Hospital of Bellvitge, University of Barcelona, 08908 Barcelona, Spain;
| | - Michal Felsinger
- Department of Gynecology and Obstetrics, Faculty of Medicine, Masaryk University, 60177 Brno, Czech Republic;
| | - Octavio Arencibia-Sánchez
- Departments of Gynecologic Oncology, University Hospital of the Canary Islands, 35016 Las Palmas de Gran Canaria, Spain;
| | - Peter Kaščák
- Department of Obstetrics and Gynecology, Faculty Hospital Trencin, 911 71 Trencin, Slovakia;
| | - Kamil Zalewski
- Department of Gynecologic Oncology, Holycross Cancer Center, 25-734 Kielce, Poland;
| | - Jiri Presl
- Department of Obstetrics and Gynecology, Faculty of Medicine Pilsen, University Hospital in Pilsen and Charles University, 30460 Pilsen, Czech Republic;
| | - Alicia Palop-Moscardó
- Gynecology Department, Instituto Valenciano de Oncologia (IVO), 46009 Valencia, Spain;
| | - Solveig Tingulstad
- Department of Obstetrics and Gynecology, Trondheim University Hospital, 7030 Trondheim, Norway;
| | - Ignace Vergote
- Department of Gynecology and Obstetrics, Leuven Cancer Institute, University Hospital Leuven, 3000 Leuven, Belgium;
| | - Mikuláš Redecha
- Department of Gynaecology and Obstetrics, University Hospital, Comenius University, 814 99 Bratislava, Slovakia;
| | - Filip Frühauf
- Gynecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital, 12000 Prague, Czech Republic; (M.B.); (F.F.); (R.K.)
| | - Christhardt Köhler
- Department of Special Operative and Oncologic Gynaecology, Asklepios-Clinic Hamburg, 22763 Hamburg, Germany; (S.M.); (C.K.)
| | - Roman Kocián
- Gynecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital, 12000 Prague, Czech Republic; (M.B.); (F.F.); (R.K.)
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Niikura H, Toki A, Nagai T, Okamoto S, Shigeta S, Tokunaga H, Shimada M, Watanabe M, Yaegashi N. Prospective evaluation of sentinel node navigation surgery in Japanese patients with low-risk endometrial cancer-safety and occurrence of lymphedema. Jpn J Clin Oncol 2021; 51:584-589. [PMID: 33388755 DOI: 10.1093/jjco/hyaa252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/03/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The present study aimed to clarify the occurrence rate of lymphedema and prognosis in patients with endometrial cancer according to sentinel lymph node biopsy alone with intraoperative histopathological examination. METHODS The study included 45 consecutive patients with endometrial cancer treated at Tohoku University Hospital between October 2014 and August 2017. All patients had endometrial carcinoma with endometrioid histology Grade 1 or Grade 2 confirmed by biopsy and stage I on magnetic resonance imaging and/or computed tomography at their preoperative evaluation. Sentinel lymph node detection was performed by radioisotope and dye. Patients who were diagnosed intraoperatively as negative for sentinel lymph node metastasis did not undergo further systematic pelvic lymphadenectomy. The occurrence rate of lymphedema and prognosis was evaluated. RESULTS Bilateral sentinel lymph nodes were detected in 44 of 45 patients (97%). Forty-three patients underwent sentinel lymph node biopsy alone, and only two patients underwent systematic lymphadenectomy. Sentinel lymph node metastases were detected in one patient intraoperatively and two patients postoperatively as ITCs. No patients experienced recurrence. New symptomatic lower-extremity lymphedema was identified in one of 43 patients (2.3%) who underwent sentinel lymph node biopsy alone. CONCLUSION Sentinel lymph node biopsy alone with intraoperative histopathological diagnosis appears to be a safe and effective strategy to detect lymph node metastasis and to reduce the number of patients with lower-extremity lymphedema among patients with endometrial cancer.
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Affiliation(s)
- Hitoshi Niikura
- Department of Obstetrics and Gynecology, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Asami Toki
- Department of Obstetrics and Gynecology, Tohoku University School of Medicine, Sendai, Japan
| | - Tomoyuki Nagai
- Department of Obstetrics and Gynecology, Tohoku University School of Medicine, Sendai, Japan
| | - Satoshi Okamoto
- Department of Obstetrics and Gynecology, Tohoku University School of Medicine, Sendai, Japan
| | - Shogo Shigeta
- Department of Obstetrics and Gynecology, Tohoku University School of Medicine, Sendai, Japan
| | - Hideki Tokunaga
- Department of Obstetrics and Gynecology, Tohoku University School of Medicine, Sendai, Japan
| | - Muneaki Shimada
- Department of Obstetrics and Gynecology, Tohoku University School of Medicine, Sendai, Japan
| | - Mika Watanabe
- Department of Pathology, Tohoku University School of Medicine, Sendai, Japan
| | - Nobuo Yaegashi
- Department of Obstetrics and Gynecology, Tohoku University School of Medicine, Sendai, Japan
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Paucity of data evaluating patient centred outcomes following sentinel lymph node dissection in endometrial cancer: A systematic review. Gynecol Oncol Rep 2021; 36:100763. [PMID: 33869716 PMCID: PMC8042432 DOI: 10.1016/j.gore.2021.100763] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/10/2021] [Accepted: 03/22/2021] [Indexed: 12/24/2022] Open
Abstract
SLND has potentially favourable patient-centred outcomes over systematic LND. High-quality evidence comparing SLND with other methods of staging is lacking. SLND was associated with shorter operating times and lower estimated blood loss. Intraoperative and postoperative complications were not conclusively different.
Sentinel lymph node dissection (SLND) is presently used by the majority of gynaecologic oncologists for surgical staging of endometrial cancer. SLND assimilated into routine surgical practice because it increases precision of surgical staging and may reduce morbidity compared to a full, systematic LND. Previous research focussed on the accuracy of SLND. Patient centred outcomes have never been conclusively demonstrated. The objective of this systematic review was to evaluate patient centred outcomes of SLND for endometrial cancer patients. Literature published in the last five years (January 2015 to April 2020) was retrieved from PubMed, EMBASE, and Cochrane library, across five domains: (1) perioperative outcomes; (2) adjuvant treatment; (3) patient-reported outcomes (PROs); (4) lymphedema, and (5) cost. Covidence software ascertained a standardised and monitored review process. We identified 21 eligible studies. Included studies were highly heterogeneous, with widely varying outcome measures and reporting. SLND was associated with shorter operating times and lower estimated blood loss compared to systematic LND, but intra-operative and post-operative complications were not conclusively different. There was either no impact, or a trend towards less adjuvant treatment used in patients with SLND compared to systematic LND. SLND had lower prevalence rates of lymphedema compared to systematic LND, although this was shown only in three retrospective studies. Costs of surgical staging were lowest for no node sampling, followed by SLND, then LND. PROs were unable to be compared because of a lack of studies. The quality of evidence on patient-centred outcomes associated with SLND for surgical staging of endometrial cancer is poor, particularly in PROs, lymphedema and cost. The available studies were vulnerable to bias and confounding. Registration of Systematic Review: PROSPERO (CRD42020180339)
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Capozzi VA, Riemma G, Rosati A, Vargiu V, Granese R, Ercoli A, Cianci S. Surgical complications occurring during minimally invasive sentinel lymph node detection in endometrial cancer patients. A systematic review of the literature and metanalysis. Eur J Surg Oncol 2021; 47:2142-2149. [PMID: 33820674 DOI: 10.1016/j.ejso.2021.03.253] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/13/2021] [Accepted: 03/24/2021] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Endometrial cancer (EC) is the most common gynecological cancer. Sentinel lymph node (SLN) technique has been adopted worldwide and showed lower morbidity and superimposable survival outcomes than the systematic lymphadenectomy (LND). Although these encouraging results, no meta-analyzes were performed on surgical complications during SLN research among patients undergoing laparoscopic (L) versus robotic surgery (R). The present review aims to report surgical complications during laparoscopic versus robotic SLN technique. METHODS The Preferred Reporting Items for Systematic reviews and Meta-Analyzes (PRISMA) and the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines have been followed for the present meta-analysis. RESULTS Six studies, including 769 participants, were included. L-LND resulted in a significantly higher risk of operative complications relative to L-SLN (RR 2.10 [95% CI 1.37 to 3.21]). The risk of complications was comparable between R-SLN and L-SLN (RR 2.32 [95% CI 0.04-121.02]) and between R-LND and L-LND (RR 2.17 [95% CI 0.04-126.69]). According to the SUCRA analysis, L-SLN and R-SLN had the highest chances of being ranked first among proposed surgical procedures (SUCRA 48.9% and 28.4% respectively). CONCLUSIONS Our study reported a lower surgical complications rate in patients undergoing L-SLN technique compared to L-LND. A lower rate of surgical complications was also reported for the R-SLN technique compared to the R-LND. Both laparoscopic and robotic SLN surgical techniques were found to be safe surgical procedures.
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Affiliation(s)
- Vito Andrea Capozzi
- Department of Gynecology and Obstetrics, University of Parma, 43125, Parma, Italy.
| | - Gaetano Riemma
- Department of Women, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", 80138, Naples, Italy
| | - Andrea Rosati
- Dipartimento per le Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Department of Gynecology and Obstetrics, Roma, Italy
| | - Virginia Vargiu
- Dipartimento per le Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Department of Gynecology and Obstetrics, Roma, Italy
| | - Roberta Granese
- Dipartimento di Ginecologia Oncologica e Chirurgia Ginecologica Miniinvasiva, Università degli studi di Messina, Policlinico G. Martino, Messina, Italy
| | - Alfredo Ercoli
- Dipartimento di Ginecologia Oncologica e Chirurgia Ginecologica Miniinvasiva, Università degli studi di Messina, Policlinico G. Martino, Messina, Italy
| | - Stefano Cianci
- Dipartimento di Ginecologia Oncologica e Chirurgia Ginecologica Miniinvasiva, Università degli studi di Messina, Policlinico G. Martino, Messina, Italy
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Burg LC, Vermeulen RJ, Bekkers RLM, Wijn SRW, Rovers MM, Govers TM, Zusterzeel PLM. A cost-effectiveness analysis of three approaches for lymph node assessment in patients with low- and intermediate-risk endometrial cancer. Gynecol Oncol 2021; 161:251-260. [PMID: 33581847 DOI: 10.1016/j.ygyno.2021.01.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/25/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the cost-effectiveness of sentinel lymph node mapping compared to risk factor assessment and routine full lymph node dissection for the assessment of lymph nodes in patients with low- and intermediate-risk endometrioid endometrial cancer. METHODS A decision-analytic model was designed to compare three lymph node assessment strategies in terms of costs and effects: 1) sentinel lymph node mapping; 2) post-operative risk factor assessment (adjuvant therapy based on clinical and histological risk factors); 3) full lymph node dissection. Input data were derived from systematic literature searches and expert opinion. QALYs were used as measure of effectiveness. The model was built from a healthcare perspective and the impact of uncertainty was assessed with sensitivity analyses. RESULTS Base-case analysis showed that sentinel lymph node mapping was the most effective strategy for lymph node assessment in patients with low- and intermediate-risk endometrial cancer. Compared to risk factor assessment it was more costly, but the incremental cost effectiveness ratio stayed below a willingness-to-pay threshold of €20,000 with a maximum of €9637/QALY. Sentinel lymph node mapping was dominant compared to lymph node dissection since it was more effective and less costly. Sensitivity analyses showed that the outcome of the model was robust to changes in input values. With a willingness-to-pay threshold of €20,000 sentinel lymph node mapping remained cost-effective in at least 74.3% of the iterations. CONCLUSION Sentinel lymph node mapping is the most cost-effective strategy to guide the need for adjuvant therapy in patients with low and intermediate risk endometrioid endometrial cancer.
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Affiliation(s)
- Lara C Burg
- Radboud University Medical Center, Department of Obstetrics and Gynecology, Nijmegen, the Netherlands.
| | - Robin J Vermeulen
- Radboud University Medical Center, Department of Operating Rooms, Nijmegen, the Netherlands
| | - Ruud L M Bekkers
- Maastricht University, School for Oncology and Developmental Biology, Department of Obstetrics and Gynecology, Maastricht, the Netherlands
| | - Stan R W Wijn
- Radboud University Medical Center, Department of Operating Rooms, Nijmegen, the Netherlands
| | - Maroeska M Rovers
- Radboud University Medical Center, Department of Operating Rooms, Nijmegen, the Netherlands
| | - Tim M Govers
- Radboud University Medical Center, Department of Operating Rooms, Nijmegen, the Netherlands
| | - Petra L M Zusterzeel
- Radboud University Medical Center, Department of Obstetrics and Gynecology, Nijmegen, the Netherlands
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Gu Y, Cheng H, Zong L, Kong Y, Xiang Y. Operative and Oncological Outcomes Comparing Sentinel Node Mapping and Systematic Lymphadenectomy in Endometrial Cancer Staging: Meta-Analysis With Trial Sequential Analysis. Front Oncol 2021; 10:580128. [PMID: 33520696 PMCID: PMC7838488 DOI: 10.3389/fonc.2020.580128] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 11/26/2020] [Indexed: 12/20/2022] Open
Abstract
Objective To evaluate the utility of sentinel lymph node mapping (SLN) in endometrial cancer (EC) patients in comparison with lymphadenectomy (LND). Methods Comprehensive 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. Results Overall, 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. Conclusion The 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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Affiliation(s)
- Yu Gu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongyan Cheng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liju Zong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yujia Kong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Xiang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Gitas G, Freytag D, Allahqoli L, Baum S, Rody A, Maass N, Dinas K, Laganà AS, Moawad G, Sotiriadis A, Alkatout I. Lymphadenectomy in endometrial cancer - achieving more with less? MINIM INVASIV THER 2021; 31:531-539. [PMID: 33439061 DOI: 10.1080/13645706.2020.1868009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The lymph node status of patients with endometrial cancer is known to be a crucial determinant for the prognosis of the disease. It also provides the indication for further adjuvant treatment. The staging of endometrial cancer by surgery has been a controversial issue for more than 30 years. The significant complication rate after lymphadenectomy and the development of minimally invasive surgery have led to the use of sentinel lymph node (SLN) mapping. In the present review, we present the development of surgical staging procedures in patients with endometrial cancer and summarize the recently expanding body of published literature on the subject. SLN mapping is a safe and accurate technique, especially when indocyanine green is used as a tracer. SLN mapping appears to reduce complication rates as well as costs without affecting the oncologic outcome. Large prospective studies are needed to establish the effects of SLN mapping on the outcome of disease, especially in high-risk patients with endometrial cancer. Furthermore, the need for additional systematic lymphadenectomy prior to adjuvant radio-chemotherapy in patients diagnosed with isolated lymph node metastasis during SLN biopsy must be investigated further. This might pave the way for a new surgical approach in patients with endometrial cancer.
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Affiliation(s)
- Georgios Gitas
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Luebeck, Germany
| | - Damaris Freytag
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Kiel, Germany
| | - Leila Allahqoli
- Endometriosis Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Sascha Baum
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Luebeck, Germany
| | - Achim Rody
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Luebeck, Germany
| | - Nicolai Maass
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Kiel, Germany
| | - Konstantinos Dinas
- Second Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Gaby Moawad
- Department of Obstetrics and Gynecology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Alexandros Sotiriadis
- Second Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ibrahim Alkatout
- Department of Obstetrics and Gynecology, University Hospital of Schleswig Holstein, Kiel, Germany
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Helgers RJ, Winkens B, Slangen BF, Werner HM. Lymphedema and Post-Operative Complications after Sentinel Lymph Node Biopsy versus Lymphadenectomy in Endometrial Carcinomas-A Systematic Review and Meta-Analysis. J Clin Med 2020; 10:E120. [PMID: 33396373 PMCID: PMC7795280 DOI: 10.3390/jcm10010120] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/14/2020] [Accepted: 12/27/2020] [Indexed: 01/08/2023] Open
Abstract
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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Affiliation(s)
- Rianne J.A. Helgers
- Faculty of Health, Medicine and Life Sciences, Maastricht University, 6202 AZ Maastricht, The Netherlands;
| | - Bjorn Winkens
- Department of Methodology & Statistics, CAPHRI, Care and Public Health Research Institute, Maastricht University Medical Centre, 6202 AZ Maastricht, The Netherlands;
| | - Brigitte F.M. Slangen
- Department of Obstetrics and Gynecology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, 6202 AZ Maastricht, The Netherlands;
| | - Henrica M.J. Werner
- Department of Obstetrics and Gynecology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, 6202 AZ Maastricht, The Netherlands;
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Concin N, Matias-Guiu X, Vergote I, Cibula D, Mirza MR, Marnitz S, Ledermann J, Bosse T, Chargari C, Fagotti A, Fotopoulou C, Gonzalez Martin A, Lax S, Lorusso D, Marth C, Morice P, Nout RA, O'Donnell D, Querleu D, Raspollini MR, Sehouli J, Sturdza A, Taylor A, Westermann A, Wimberger P, Colombo N, Planchamp F, Creutzberg CL. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Int J Gynecol Cancer 2020; 31:12-39. [PMID: 33397713 DOI: 10.1136/ijgc-2020-002230] [Citation(s) in RCA: 846] [Impact Index Per Article: 211.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022] Open
Abstract
A European consensus conference on endometrial carcinoma was held in 2014 to produce multi-disciplinary evidence-based guidelines on selected questions. Given the large body of literature on the management of endometrial carcinoma published since 2014, the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy and Oncology (ESTRO), and the European Society of Pathology (ESP) jointly decided to update these evidence-based guidelines and to cover new topics in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.
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Affiliation(s)
- Nicole Concin
- Department of Gynecology and Obstetrics, Innsbruck Medical University, Innsbruck, Austria .,Evangelische Kliniken Essen-Mitte, Essen, Germany
| | - Xavier Matias-Guiu
- Department of Pathology, Hospital Universitari Arnau de Vilanova, University of Lleida, CIBERONC, Irblleida, Spain.,Department of Pathology, Hospital Universitari de Bellvitge, University of Barcelona, Idibell, Spain
| | - Ignace Vergote
- Department of Gynecology and Obstetrics, Gynecologic Oncology, Leuven Cancer Institute, Catholic University Leuven, Leuven, Belgium
| | - David Cibula
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital in Prague, Prague, Czech Republic
| | - Mansoor Raza Mirza
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Simone Marnitz
- Department of Radiation Oncology, Medical Faculty of the University of Cologne, Cologne, Germany
| | | | - Tjalling Bosse
- Department of Pathology, Leids Universitair Medisch Centrum, Leiden, Netherlands
| | - Cyrus Chargari
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Anna Fagotti
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Christina Fotopoulou
- Department of Gynaecologic Oncology, Imperial College London Faculty of Medicine, London, UK
| | | | - Sigurd Lax
- Department of Pathology, Hospital Graz II, Graz, Austria.,School of Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Domenica Lorusso
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Christian Marth
- Department of Obstetrics and Gynecology, Innsbruck Medical University, Innsbruck, Austria
| | - Philippe Morice
- Department of Surgery, Institut Gustave Roussy, Villejuif, France
| | - Remi A Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | | | - Denis Querleu
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy.,Department of Obstetrics and Gynecologic Oncology, University Hospital, Strasbourg, France
| | - Maria Rosaria Raspollini
- Histopathology and Molecular Diagnostics, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Jalid Sehouli
- Department of Gynecology with Center for Oncological Surgery, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | | | - Anneke Westermann
- Department of Medical Oncology, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, Netherlands
| | - Pauline Wimberger
- Department of Gynecology and Obstetrics, TU Dresden Medizinische Fakultat Carl Gustav Carus, Dresden, Germany
| | - Nicoletta Colombo
- Gynecologic Oncology Program, European Institute of Oncology, IRCCS, Milan and University of Milan-Bicocca, Milan, Italy
| | | | - Carien L Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, Netherlands
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Zorzato PC, Bosco M, Franchi MP, Mariani A, Cianci S, Garzon S, Uccella S. Sentinel lymph node for endometrial cancer treatment: review of the literature. Minerva Med 2020; 112:70-80. [PMID: 33198443 DOI: 10.23736/s0026-4806.20.07117-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Endometrial cancer is the most common gynecologic malignancy and in two thirds of patients it is apparently uterine confined at presentation. Lymph nodal status represents one of the main prognostic factors. Nodal evaluation with sentinel lymph node (SLN) mapping has gained more ground in clinical practice after the publication of different studies demonstrating the feasibility and accuracy of this technique. However, at the moment there are no RCTs available evaluating the long-term oncologic safety of SLN technique compared to LND. This review aims at summarizing the available evidence on oncologic outcomes between SLN mapping alone and LND. Differences in operative complications and long-term complications were also analyzed. EVIDENCE ACQUISITION The literature search was conducted in the PubMed database and it focused on comparative studies published from inception to September 2020 analyzing differences in oncological outcomes or complications between nodal evaluation with SLN technique alone and nodal evaluation with lymphadenectomy. Comparative studies with more than 10 cases, published in English, were included. EVIDENCE SYNTHESIS A total of 5 retrospective comparative studies have been identified reporting data on oncologic outcomes of patients who underwent SLN mapping alone vs. LND. Non significative difference has been reported in terms of overall survival and recurrence free survival between the two groups. Six studies evaluated differences in terms of complications between the two techniques. A total of 2302 patients were identified. Postoperative complications were detected in 9.6% and 7.7% of patients who underwent lymphadenectomy and SLN mapping respectively and no significant difference was noted (P=0.3). Looking at major postoperative complications the rate in the LND group was significantly higher than in the SLN group (3.6% vs. 1.5%, P=0.02). Two of these six studies reported data on lymphatic long-term complications. The prevalence of lymphedema ranged from 0% to 1.3% in the SLN group and from 10% to 18% in the LND group. The absolute difference reported (13.35%) was similar to the one found in literature. CONCLUSIONS SLN mapping in apparently uterine confined disease has been demonstrated to be a feasible and accurate technique for nodal evaluation and high-quality evidence support this. Moreover, SLN mapping resulted to be associated with less major postoperative and long-term complications when compared to LDN. Conversely, high-quality evidence is not available on long-term oncologic safety of this technique compared to the standard LND. Randomized trials are requested to provide reliable data on this aspect.
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Affiliation(s)
- Pier C Zorzato
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Universitaria Integrata (AOUI) Verona, Verona, Italy
| | - Mariachiara Bosco
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Universitaria Integrata (AOUI) Verona, Verona, Italy
| | - Massimo P Franchi
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Universitaria Integrata (AOUI) Verona, Verona, Italy
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Stefano Cianci
- Department of Woman, Child and General and Specialized Surgery, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Universitaria Integrata (AOUI) Verona, Verona, Italy
| | - Stefano Uccella
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Universitaria Integrata (AOUI) Verona, Verona, Italy -
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