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Fumagalli D, De Vitis LA, Caruso G, Occhiali T, Palmieri E, Guillot BE, Pappalettera G, Langstraat CL, Glaser GE, Reynolds EA, Fruscio R, Landoni F, Mariani A, Grassi T. Low-Volume Metastases in Apparent Early-Stage Endometrial Cancer: Prevalence, Clinical Significance, and Future Perspectives. Cancers (Basel) 2024; 16:1338. [PMID: 38611016 PMCID: PMC11011093 DOI: 10.3390/cancers16071338] [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: 02/27/2024] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Endometrial cancer (EC) is the most diagnosed gynecologic malignancy, and its incidence and mortality are increasing. The prognosis is highly dependent on the disease spread. Surgical staging includes retroperitoneal evaluation to detect potential lymph node metastases. In recent years, systematic lymphadenectomy has been replaced by sentinel lymph node (SLN) biopsy and ultrastaging, allowing for the detection of macrometastases, micrometastases, and isolated tumor cells (ITCs). Micrometastases and ITCs have been grouped as low-volume metastases (LVM). The reported prevalence of LVM in studies enrolling more than one thousand patients with apparent early-stage EC ranges from 1.9% to 10.2%. Different rates of LVM are observed when patients are stratified according to disease characteristics and their risk of recurrence. Patients with EC at low risk for recurrence have low rates of LVM, while intermediate- and high-risk patients have a higher likelihood of being diagnosed with nodal metastases, including LVM. Macro- and micrometastases increase the risk of recurrence and cause upstaging, while the clinical significance of ITCs is still uncertain. A recent meta-analysis found that patients with LVM have a higher relative risk of recurrence [1.34 (95% CI: 1.07-1.67)], regardless of adjuvant treatment. In a retrospective study on patients with low-risk EC and no adjuvant treatment, those with ITCs had worse recurrence-free survival compared to node-negative patients (85.1%; CI 95% 73.8-98.2 versus 90.2%; CI 95% 84.9-95.8). However, a difference was no longer observed after the exclusion of cases with lymphovascular space invasion. There is no consensus on adjuvant treatment in ITC patients at otherwise low risk, and their recurrence rate is low. Multi-institutional, prospective studies are warranted to evaluate the clinical significance of ITCs in low-risk patients. Further stratification of patients, considering histopathological and molecular features of the disease, may clarify the role of LVM and especially ITCs in specific contexts.
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Affiliation(s)
- Diletta Fumagalli
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (R.F.); (F.L.)
| | - Luigi A. De Vitis
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy
| | - Giuseppe Caruso
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy
| | - Tommaso Occhiali
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Clinic of Obstetrics and Gynecology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy
| | - Emilia Palmieri
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Gynecologic Oncology Unit, Department of Women, Children and Public Health Sciences, , Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00136 Roma, Italy
| | - Benedetto E. Guillot
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy
| | - Giulia Pappalettera
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
- Department of Gynecology, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy
| | - Carrie L. Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
| | - Gretchen E. Glaser
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
| | - Evelyn A. Reynolds
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
| | - Robert Fruscio
- Department of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (R.F.); (F.L.)
- Division of Gynecologic Surgery, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy
| | - Fabio Landoni
- Department of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (R.F.); (F.L.)
- Division of Gynecologic Surgery, IRCCS Fondazione San Gerardo dei Tintori, 20900 Monza, Italy
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN 55905, USA; (D.F.); (L.A.D.V.); (G.C.); (T.O.); (E.P.); (B.E.G.); (G.P.); (C.L.L.); (G.E.G.); (E.A.R.); (A.M.)
| | - Tommaso Grassi
- Department of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy; (R.F.); (F.L.)
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Matsuo K, Chen L, Neuman MK, Klar M, Carlson JW, Roman LD, Wright JD. Lymph Node Isolated Tumor Cells in Patients With Endometrial Cancer. JAMA Netw Open 2024; 7:e240988. [PMID: 38497964 PMCID: PMC10949095 DOI: 10.1001/jamanetworkopen.2024.0988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/12/2024] [Indexed: 03/19/2024] Open
Abstract
Importance Isolated tumor cells (ITCs) are the histopathological finding of small clusters of cancer cells no greater than 0.2 mm in diameter in the regional lymph nodes. For endometrial cancer, the prognostic significance of ITCs is uncertain. Objective To assess clinico-pathological characteristics and oncologic outcomes associated with ITCs in endometrial cancer. Design, Setting, and Participants This retrospective cohort study using the National Cancer Database included patients with endometrial cancer who had primary hysterectomy and nodal evaluation from 2018 to 2020. Patients with microscopic and macroscopic nodal metastases and distant metastases were excluded. Data were analyzed from June to September 2023. Exposure Regional nodal status with ITCs (N0[i+] classification) or no nodal metastasis (N0 classification). Main Outcomes and Measures (1) Clinical and tumor characteristics associated with ITCs, assessed with multivariable binary logistic regression model, and (2) overall survival (OS) associated with ITCs, evaluated by nonproportional hazard analysis with restricted mean survival time at 36 months. Results A total of 56 527 patients were included, with a median (IQR) age of 64 (57-70) years. The majority had T1a lesion (37 836 [66.9%]) and grade 1 or 2 endometrioid tumors (40 589 [71.8%]). ITCs were seen in 1462 cases (2.6%). In a multivariable analysis, ITCs were associated with higher T classification, larger tumor size, lymphovascular space invasion (LVSI), and malignant peritoneal cytology. Of those tumor factors, LVSI had the largest association with ITCs (7.9% vs 1.4%; adjusted odds ratio [aOR], 4.37; 95% CI, 3.87-4.93), followed by T1b classification (5.3% vs 1.3%; aOR, 2.62; 95% CI, 2.30-2.99). At the cohort level, 24-month OS rates were 94.3% (95% CI, 92.4%-95.7%) for the ITC group and 96.1% (95% CI, 95.9%-96.3%) for the node-negative group, and the between-group difference in expected mean OS time at 36 months was 0.35 (SE, 0.19) months, but it was not statistically significant (P = .06). There was a statistically significant difference in OS when the low-risk group (stage IA, grade 1-2 endometrioid tumors with no LVSI) was assessed per nodal status and adjuvant therapy use (P < .001): (1) among the cases treated with surgical therapy alone, 24-month OS rates were 95.9% (95% CI, 89.5%-98.5%) for the ITC group and 98.8% (95% CI, 98.6%-99.0%) for the node-negative group, and the between-group mean OS time difference at 36 months was 0.61 (SE, 0.43) months (P = .16); and (2) among the cases with ITCs, adjuvant therapy (radiotherapy alone, systemic chemotherapy alone, or both) was associated with improved survival compared with no adjuvant therapy (24-month OS rates, 100% vs 95.9%; between-group mean OS time difference at 36 months, 0.95 [SE, 0.43] months; P = .03). Conclusions and Relevance In this cohort study of patients with surgically staged endometrial cancer, the results of exploratory analysis suggested that presence of ITCs in the regional lymph node may be associated with OS in the low-risk group. While adjuvant therapy was associated with improved OS in the low-risk group with ITCs, careful interpretation is necessary given the favorable outcomes regardless of adjuvant therapy use. This hypothesis-generating observation in patients with low-risk endometrial cancer warrants further investigation, especially with prospective setting.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles
| | - Ling Chen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Monica K. Neuman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Joseph W. Carlson
- Department of Pathology, University of Southern California, Los Angeles
| | - Lynda D. Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles
| | - Jason D. Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
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Matsuo K, Vallejo A, Rau AR, Ciccone MA, Roman LD, Klar M. Cancer Stage-Shifting with Sentinel Lymph Node Biopsy in Low-Grade Endometrial Cancer. Ann Surg Oncol 2023; 30:3191-3193. [PMID: 36882568 DOI: 10.1245/s10434-023-13310-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 02/20/2023] [Indexed: 03/09/2023]
Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA. .,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
| | - Andrew Vallejo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Alesandra R Rau
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Marcia A Ciccone
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Applications and Safety of Sentinel Lymph Node Biopsy in Endometrial Cancer. J Clin Med 2022; 11:jcm11216462. [DOI: 10.3390/jcm11216462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/27/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022] Open
Abstract
Lymph node status is important in predicting the prognosis and guiding adjuvant treatment in endometrial cancer. However, previous studies showed that systematic lymphadenectomy conferred no therapeutic values in clinically early-stage endometrial cancer but might lead to substantial morbidity and impact on the quality of life of the patients. The sentinel lymph node is the first lymph node that tumor cells drain to, and sentinel lymph node biopsy has emerged as an acceptable alternative to full lymphadenectomy in both low-risk and high-risk endometrial cancer. Evidence has demonstrated a high detection rate, sensitivity and negative predictive value of sentinel lymph node biopsy. It can also reduce surgical morbidity and improve the detection of lymph node metastases compared with systematic lymphadenectomy. This review summarizes the current techniques of sentinel lymph node mapping, the applications and oncological outcomes of sentinel lymph node biopsy in low-risk and high-risk endometrial cancer, and the management of isolated tumor cells in sentinel lymph nodes. We also illustrate a revised sentinel lymph node biopsy algorithm and advocate to repeat the tracer injection and explore the presacral and paraaortic areas if sentinel lymph nodes are not found in the hemipelvis.
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