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Chauvet P, Jacobs A, Jaillet L, Comptour A, Pereira B, Canis M, Bourdel N. Indocyanine green in gynecologic surgery: Where do we stand? A literature review and meta-analysis. J Gynecol Obstet Hum Reprod 2024; 53:102819. [PMID: 38950735 DOI: 10.1016/j.jogoh.2024.102819] [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: 04/30/2024] [Accepted: 06/28/2024] [Indexed: 07/03/2024]
Abstract
The main objective of this study was to review and perform a meta-analysis of current literature on the use of indocyanine green for sentinel lymph node detection in pelvic gynecologic cancer. We included all studies focusing on indications and procedures associated with the use of ICG in gynecologic surgery and available on the Medline and Pubmed database. For the meta-analysis, random effect models were used for estimation of the 95 % detection rate and 95 % confidence interval, and stratified analyses by cancer type, concentration and localization of injection were performed. A total of 147 articles were included, of which 91 were studied in a meta-analysis. Results concerning detection rate by indocyanine green injection site were found to be 95.1 % and 97.3 % respectively for intracervical injection in 2 or 4 quadrants, and 77.0 % and 94.8 % for hysteroscopic and intradermal injection respectively. Results concerning detection rate by cancer type were 95.8 %, 95.2 %, 94.7 % and 95.7 % respectively for cervical, endometrial, vulvar and endometrial/cervical cancers. Finally, the results concerning detection rate by indocyanine green concentration were 91.2 %, 95.7 %, 96.7 % and 97.7 % for concentrations of <1.25 mg/ml, 1.25 mg/ml, 2.5 mg/ml and 5 mg/ml respectively. In conclusion, indocyanine green is shown to allow highlighting of sentinel lymph nodes with good reliability with an overall indocyanine green detection rate of 95.5 %. Our literature review revealed that indocyanine green feasibility has also been demonstrated in several surgical contexts, notably for reconstructive surgery and detection of endometriosis.
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Affiliation(s)
- Pauline Chauvet
- CHU Clermont-Ferrand, Department of Gynecologic surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63000 Clermont, Ferrand, France; Université Clermont Auvergne, EnCoV, Institut Pascal, UMR 6602 CNRS, SIGMA Clermont, F-63000 Clermont, Ferrand, France; INSERM, CIC 1405 CRECHE Unit, CHU Clermont-Ferrand, Department of Gynecological Surgery, 63000 Clermont, Ferrand, France.
| | - Aurélie Jacobs
- CHU Clermont-Ferrand, Department of Gynecologic surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63000 Clermont, Ferrand, France; INSERM, CIC 1405 CRECHE Unit, CHU Clermont-Ferrand, Department of Gynecological Surgery, 63000 Clermont, Ferrand, France
| | - Lucie Jaillet
- CHU Clermont-Ferrand, Department of Gynecologic surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63000 Clermont, Ferrand, France; Université Clermont Auvergne, EnCoV, Institut Pascal, UMR 6602 CNRS, SIGMA Clermont, F-63000 Clermont, Ferrand, France
| | - Aurélie Comptour
- CHU Clermont-Ferrand, Department of Gynecologic surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63000 Clermont, Ferrand, France; INSERM, CIC 1405 CRECHE Unit, CHU Clermont-Ferrand, Department of Gynecological Surgery, 63000 Clermont, Ferrand, France
| | - Bruno Pereira
- CHU Clermont-Ferrand, Biostatistics Unit, 7 Place Henri Dunant, 63000 Clermont, Ferrand, France
| | - Michel Canis
- CHU Clermont-Ferrand, Department of Gynecologic surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63000 Clermont, Ferrand, France; Université Clermont Auvergne, EnCoV, Institut Pascal, UMR 6602 CNRS, SIGMA Clermont, F-63000 Clermont, Ferrand, France; INSERM, CIC 1405 CRECHE Unit, CHU Clermont-Ferrand, Department of Gynecological Surgery, 63000 Clermont, Ferrand, France
| | - Nicolas Bourdel
- CHU Clermont-Ferrand, Department of Gynecologic surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63000 Clermont, Ferrand, France; Université Clermont Auvergne, EnCoV, Institut Pascal, UMR 6602 CNRS, SIGMA Clermont, F-63000 Clermont, Ferrand, France; INSERM, CIC 1405 CRECHE Unit, CHU Clermont-Ferrand, Department of Gynecological Surgery, 63000 Clermont, Ferrand, France
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2
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Fan MS, Qiu KX, Wang DY, Wang H, Zhang WW, Yan L. Risk factors associated with false negative rate of sentinel lymph node biopsy in endometrial cancer: a systematic review and meta-analysis. Front Oncol 2024; 14:1391267. [PMID: 38634055 PMCID: PMC11021692 DOI: 10.3389/fonc.2024.1391267] [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: 02/25/2024] [Accepted: 03/19/2024] [Indexed: 04/19/2024] Open
Abstract
Objective Currently, sentinel lymph node biopsy (SLNB) is increasingly used in endometrial cancer, but the rate of missed metastatic lymph nodes compared to systemic lymph node dissection has been a concern. We conducted a systematic review and meta-analysis to evaluate the false negative rate (FNR) of SLNB in patients with endometrial cancer and to explore the risk factors associated with this FNR. Data sources Three databases (PubMed, Embase, Web of Science) were searched from initial database build to January 2023 by two independent reviewers. Research eligibility criteria Studies were included if they included 10 or more women diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I or higher endometrial cancer, the study technique used sentinel lymph node localization biopsy, and the reported outcome metrics included false negative and/or FNR. Study appraisal and synthesis methods Two authors independently reviewed the abstracts and full articles. The FNR and factors associated with FNR were synthesized through random-effects meta-analyses and meta-regression. The results We identified 62 eligible studies. The overall FNR for the 62 articles was 4% (95% CL 3-5).There was no significant difference in the FNR in patients with high-risk endometrial cancer compared to patients with low-risk endometrial cancer. There was no difference in the FNR for whether frozen sections were used intraoperatively. The type of dye used intraoperatively (indocyanine green/blue dye) were not significantly associated with the false negative rate. Cervical injection reduced the FNR compared with alternative injection techniques. Indocyanine green reduced the FNR compared with alternative Tc-99m. Postoperative pathologic ultrastaging reduced the FNR. Conclusions Alternative injection techniques (other than the cervix), Tc-99m dye tracer, and the absence of postoperative pathologic ultrastaging are risk factors for a high FNR in endometrial cancer patients who undergo SLNB; therefore, we should be vigilant for missed diagnosis of metastatic lymph nodes after SLNB in such populations. Systematic review registration http://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023433637.
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Affiliation(s)
- Meng-si Fan
- Department of Gynecology, Shandong Provincial Qianfoshan Hospital, Shandong Second Medical University, Key Laboratory of Laparoscopic Technology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Ke-xin Qiu
- Department of Gynecology, Shandong Provincial Qianfoshan Hospital, Shandong Second Medical University, Key Laboratory of Laparoscopic Technology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Dong-yue Wang
- School of Clinical Medicine, Shandong First Medical University, Jinan, China
| | - Hao Wang
- School of Clinical Medicine, Shandong First Medical University, Jinan, China
| | - Wei-wei Zhang
- Department of Gynecology, Tengzhou Maternal and Child Health Hospital, Tengzhou, Shandong, China
| | - Li Yan
- Department of Gynecology, Shandong Provincial Qianfoshan Hospital, Shandong Second Medical University, Key Laboratory of Laparoscopic Technology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
- Department of Gynecology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
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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: 3.0] [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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4
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How JA, Frumovitz M, Stewart KI, Soliman PT. Lymphatic Mapping and Sentinel Node Biopsy in High-Grade Uterine Cancers. Curr Oncol Rep 2022; 24:1521-1529. [PMID: 35781863 DOI: 10.1007/s11912-022-01294-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Sentinel lymph node (SLN) mapping has been adopted as an acceptable method of lymph node evaluation in the surgical staging for low-grade endometrial cancer. In this review, we analyze the literature on the utility of SLN mapping in high-grade endometrial cancer. RECENT FINDINGS SLN mapping in high-grade endometrial cancer demonstrates similar high detection rates and diagnostic accuracy as seen in low-grade endometrial cancers. However, obtaining sufficient operator experience (at least 30 cases) and following SLN mapping algorithm continues to be essential to preserving diagnostic accuracy. Although limited in retrospective study design and short-term follow-up, current studies have not demonstrated inferior survival outcomes of SLN mapping compared to traditional lymphadenectomy. SLN mapping is an acceptable and accurate method of lymph node evaluation in high-grade endometrial cancer. Future prospective studies are needed to evaluate long-term oncologic outcomes between SLN mapping and systematic lymphadenectomy in this patient population.
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Affiliation(s)
- Jeffrey A How
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1362, Houston, TX, 77030, USA
| | - Michael Frumovitz
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1362, Houston, TX, 77030, USA
| | - Katherine I Stewart
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Pamela T Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1362, Houston, TX, 77030, USA.
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5
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Otsuka I. Therapeutic Benefit of Systematic Lymphadenectomy in Node-Negative Uterine-Confined Endometrioid Endometrial Carcinoma: Omission of Adjuvant Therapy. Cancers (Basel) 2022; 14:cancers14184516. [PMID: 36139675 PMCID: PMC9497184 DOI: 10.3390/cancers14184516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/02/2022] [Accepted: 09/14/2022] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Endometrial cancer is the most common gynecological tract malignancy in developed countries. Extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors. Abstract Endometrial cancer is the most common gynecological tract malignancy in developed countries, and its incidence has been increasing globally with rising obesity rates and longer life expectancy. In endometrial cancer, extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors. In this review, I discuss the characteristics of lymph node metastasis, the methods of lymph node assessment, and the therapeutic benefits of systematic lymphadenectomy in patients with intermediate- and high-risk endometrioid endometrial carcinoma.
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Affiliation(s)
- Isao Otsuka
- Department of Obstetrics and Gynecology, Kameda Medical Center, Kamogawa 296-8602, Chiba, Japan
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6
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Kalampokas E, Giannis G, Kalampokas T, Papathanasiou AA, Mitsopoulou D, Tsironi E, Triantafyllidou O, Gurumurthy M, Parkin DE, Cairns M, Vlahos NF. Current Approaches to the Management of Patients with Endometrial Cancer. Cancers (Basel) 2022; 14:4500. [PMID: 36139659 PMCID: PMC9497194 DOI: 10.3390/cancers14184500] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/06/2022] [Accepted: 09/13/2022] [Indexed: 02/07/2023] Open
Abstract
The incidence of endometrial cancer (EC) is rising and healthcare professionals need to be informed about the latest data on the constant developments in the field of its management. With particular interest in the classification and management of EC, we surveyed current literature, national and international data, and guidelines, as well as the latest studies to present the most recent data regarding the management of EC. It became evident that despite the consensus on low-risk EC, there are still controversies surrounding the management of high-risk EC, especially regarding the role of sentinel lymph node biopsy (SLNB). Our aim is to present the old and new perspectives in the management of EC, the different available surgical routes, the possible desire for fertility preservation, the role of adjuvant therapies and the focus on the advantages and the limitations of the implementation of SLNB in therapeutic strategies. It became evident throughout our search and based on literature data that minimally invasive surgery (MIS) leads to satisfying outcomes, thus becoming gradually the preferred route of surgery, while SLNB could provide essential information and guidance about the overall management needed in cases of both low-risk and high-risk EC.
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Affiliation(s)
- Emmanouil Kalampokas
- Unit of Gynecologic Oncology, Second Department of Obstetrics and Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Georgios Giannis
- Medical School, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Theodoros Kalampokas
- Unit of Obstetrics and Gynecology, Second Department of Obstetrics and Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | | | - Dimitra Mitsopoulou
- Medical School, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Evangelia Tsironi
- Medical School, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Olga Triantafyllidou
- Unit of Obstetrics and Gynecology, Second Department of Obstetrics and Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | | | - David E. Parkin
- Honorary Consultant Gynaecologist Oncologist, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK
| | - Mary Cairns
- Department of Gynaecological Oncology, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK
| | - Nikolaos F. Vlahos
- Unit of Obstetrics and Gynecology, Second Department of Obstetrics and Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, 115 28 Athens, Greece
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7
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Burg LC, Verheijen S, Bekkers RLM, IntHout J, Holloway RW, Taskin S, Ferguson SE, Xue Y, Ditto A, Baiocchi G, Papadia A, Bogani G, Buda A, Kruitwagen RFPM, Zusterzeel PLM. The added value of SLN mapping with indocyanine green in low- and intermediate-risk endometrial cancer management: a systematic review and meta-analysis. J Gynecol Oncol 2022; 33:e66. [PMID: 35882605 PMCID: PMC9428296 DOI: 10.3802/jgo.2022.33.e66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/09/2022] [Accepted: 06/12/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The aim of this study was to assess the SLN detection rate in presumed early stage, low- and intermediate-risk endometrial cancers, the incidence of SLN metastases, and the negative predictive value of SLN mapping performed with indocyanine green (ICG). METHODS A systematic review with meta-analyses was conducted. Study inclusion criteria were A) low- and intermediate-risk endometrial cancer, B) the use of ICG per cervical injection; C) a minimum of twenty included patients per study. To assess the negative predictive value of SLN mapping, D) a subsequent lymphadenectomy was an additional inclusion criterion. RESULTS Fourteen studies were selected, involving 2,117 patients. The overall and bilateral SLN detection rates were 95.6% (95% confidence interval [CI]=92.4%-97.9%) and 76.5% (95% CI=68.1%-84.0%), respectively. The incidence of SLN metastases was 9.6% (95% CI=5.1%-15.2%) in patients with grade 1-2 endometrial cancer and 11.8% (95% CI=8.1%-16.1%) in patients with grade 1-3 endometrial cancer. The negative predictive value of SLN mapping was 100% (95% CI=98.8%-100%) in studies that included grade 1-2 endometrial cancer and 99.2% (95% CI=97.9%-99.9%) in studies that also included grade 3. CONCLUSION SLN mapping with ICG is feasible with a high detection rate and negative predictive value in low- and intermediate-risk endometrial cancers. Given the incidence of SLN metastases is approximately 10% in those patients, SLN mapping may lead to stage shifting with potential therapeutic consequences. Given the high negative predictive value with SLN mapping, routine lymphadenectomy should be omitted in low- and intermediate-risk endometrial cancer.
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Affiliation(s)
- Lara C Burg
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Shenna Verheijen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ruud L M Bekkers
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.,Department of Obstetrics and Gynaecology, Catharina Hospital, Eindhoven, The Netherlands
| | - Joanna IntHout
- Department for Health Evidence, Section Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert W Holloway
- Gynecologic Oncology Program, AdventHealth Cancer Institute, Orlando, FL, USA
| | - Salih Taskin
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Sarah E Ferguson
- Division of Gynecologic Oncology, Princess Margaret Cancer Center, Toronto, Canada.,Department of Obstetrics and Gynecology, University of Toronto, Toronto, Canada
| | - Yu Xue
- Department of Gynecologic Oncology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Antonino Ditto
- Department of Gynecological Oncology, Fondazione IRCCS, Istituto dei Tumori, Milano, Italy
| | - Glauco Baiocchi
- Department of Gynecologic Oncology, AC Camargo Cancer Center, Sao Paulo, SP, Brazil
| | - Andrea Papadia
- Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Giorgio Bogani
- Department of Maternal and Child Health and Urologynecological Sciences, Sapienza University, Rome, Italy
| | - Alessandro Buda
- Obstetrics and Gynecology Department, Ospedale San Gerardo di Monza, University of Milano Bicocca, Monza, Italy.,Ospedale Michele e Pietro Ferrero, Verduno (cuneo), Italy
| | - Roy F P M Kruitwagen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Obstetrics and Gynaecology, Maastricht University Medical Center, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Petra L M Zusterzeel
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
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8
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Lu W, Chen X, Ni J, Li Z, Su T, Li S, Wan X. A Model to Identify Candidates for Lymph Node Dissection Among Patients With High-Risk Endometrial Endometrioid Carcinoma According to Mayo Criteria. Front Oncol 2022; 12:895834. [PMID: 35795035 PMCID: PMC9251056 DOI: 10.3389/fonc.2022.895834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/17/2022] [Indexed: 12/24/2022] Open
Abstract
Background The Mayo criteria are the most widely accepted algorithm for predicting the risk of lymph node metastasis in endometrial endometrioid carcinoma (EEC). However, the clinical value of these criteria in high-risk patients is limited and inconclusive. Methods A total of 240 patients with EEC meeting the Mayo high-risk criteria between January 1, 2015, and December 31, 2018 were included in our study. We retrospectively collected the laboratory reports, basic clinical information, clinicopathological and immunohistochemistry (IHC) findings, and the sequences of molecular pathological markers of these patients. A nomogram for predicting the likelihood of positive lymph node status was established based on these parameters. Results Among the 240 patients, 17 were diagnosed with lymph node metastasis. The univariable analyses identified myometrial invasion >50%, aberrant p53 expression, microsatellite instable (MSI), and cancer antigen 125 (CA125) ≥35 U/ml as potential risk factors for lymph node metastasis. The multivariable analyses showed that aberrant p53 expression, MSI, and CA125 ≥35 U/ml were independent predictors of lymph node metastasis. The area under the curve (AUC) for the nomogram was 0.870, as compared to 0.665 for the Mayo criteria. Conclusions Our novel prediction model effectively identifies patients at high risk for lymphatic metastasis. This model is a promising strategy for personalized surgery in patients with high risk according to the Mayo criteria.
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Affiliation(s)
- Wen Lu
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tong Ji University, Shanghai, China
| | - Xiaoyue Chen
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tong Ji University, Shanghai, China
| | - Jingyi Ni
- Department of Clinical Research Center, Shanghai First Maternity and Infant Hospital, School of Medicine, Tong Ji University, Shanghai, China
| | - Zhen Li
- Department of Clinical Research Center, Shanghai First Maternity and Infant Hospital, School of Medicine, Tong Ji University, Shanghai, China
| | - Tao Su
- Department of Gynecology, The International Peace Maternity & Child Health Hospital of China Welfare Institute, Shanghai Jiaotong University, Shanghai, China
| | - Shuangdi Li
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tong Ji University, Shanghai, China
- *Correspondence: Shuangdi Li, ; Xiaoping Wan,
| | - Xiaoping Wan
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tong Ji University, Shanghai, China
- *Correspondence: Shuangdi Li, ; Xiaoping Wan,
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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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10
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Diagnostic accuracy of sentinel node biopsy in non-endometrioid, high-grade and/or deep myoinvasive endometrial cancer: A Turkish gynecologic oncology group study (TRSGO-SLN-006). Gynecol Oncol 2022; 164:492-497. [PMID: 35033380 DOI: 10.1016/j.ygyno.2022.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/16/2021] [Accepted: 01/03/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION This study aimed to evaluate the diagnostic accuracy of the sentinel lymph node (SLN) mapping algorithm in high-risk endometrial cancer patients. METHODS Two hundred forty-four patients with non-endometrioid histology, grade 3 endometrioid tumors and/or tumors with deep myometrial invasion were enrolled in this retrospective, multicentric study. After removal of SLNs, all patients underwent pelvic ± paraaortic lymphadenectomy. Operations were performed via laparotomy, laparoscopy or robotic surgery. Indocyanine green (ICG) and methylene blue (MB) were used as tracers. SLN detection rate, sensitivity, negative predictive value (NPV) and false-negative rate (FNR) were calculated. RESULTS Surgeries were performed via laparotomy in 132 (54.1%) patients and 152 (62.3%) underwent both bilateral pelvic and paraaortic lymphadenectomy. At least 1 SLN was detected in 222 (91%) patients. Fifty-five (22.5%) patients had lymphatic metastasis and 45 patients had at least 1 metastatic SLN. Lymphatic metastases were detected by side-specific lymphadenectomy in 8 patients and 2 patients had isolated paraaortic metastasis. Overall sensitivity, NPV and FNR of SLN biopsy were 81.8%, 95% and 18.2%, respectively. By applying SLN algorithm steps, sensitivity and NPV improved to 96.4% and 98.9%, respectively. For grade 3 tumors, sensitivity, NPV and FNR of the SLN algorithm were 97.1%, 98.9% and 2.9%. CONCLUSION SLN algorithm had high diagnostic accuracy in high-risk endometrial cancer. All pelvic metastases were detected by the SLN algorithm and the isolated paraaortic metastasis rate was ignorable. But long-term survival studies are necessary before this approach becomes standard of care.
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11
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Sánchez-Izquierdo N, Vidal-Sicart S, Campos F, Torné A, Angeles MA, Migliorelli F, Munmany M, Saco A, Diaz-Feijoo B, Glickman A, Ordi J, Perissinotti A, del Pino M, Paredes P. Detection of the sentinel lymph node with hybrid tracer (ICG-[ 99mTc]Tc-albumin nanocolloid) in intermediate- and high-risk endometrial cancer: a feasibility study. EJNMMI Res 2021; 11:123. [PMID: 34905122 PMCID: PMC8671586 DOI: 10.1186/s13550-021-00863-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/17/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Indocyanine green (ICG) is frequently used for the detection of the sentinel lymph node (SLN) in gynecology, but it carries the loss of the presurgical SLN mapping provided by [99mTc]-based colloids. Hybrid tracers such as ICG-[99mTc]Tc-albumin nanocolloid combine the benefits of both components. The aim of this study was to evaluate the feasibility and applicability of this hybrid tracer injected by transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR) approach in the detection of SLNs in patients with intermediate- and high-risk EC. METHODS Fifty-two patients with intermediate- and high-risk EC underwent SLN biopsy after injection of a hybrid tracer using the TUMIR approach, followed by pelvic and paraaortic lymphadenectomy. SLNs were detected preoperatively by lymphoscintigraphic study and intraoperatively by gamma probe and near-infrared (NIR) optical laparoscopic camera. RESULTS Preoperative lymphatic drainage was obtained in 69% and intraoperative detection in 71.4% of patients. A total of 146 SLNs (4.17 SLNs/patient) were biopsied. Pelvic bilateral detection was observed in 57% of the women and paraaortic drainage in 34% of the patients. The radioactive component allowed the detection of SLN in 97.1% of the patients, while the fluorescent component detected 80%. In more than 17% of the patients with intraoperative detection, SLNs were detected only by the radioactive signal. Lymph node metastasis was identified in 14.3% of patients submitted to SLNB. The sensitivity and negative predictive value for metastatic involvement were 100%. CONCLUSION TUMIR injection of a hybrid tracer in patients with intermediate- and high-risk EC combines the benefits of the radiotracer and the fluorescence methods with a single tracer. The method increases the paraaortic detection rate and allows a potential increase in SLN detection. Notwithstanding, based on our findings, the radioactive component of the hybrid tracer cannot be obviated.
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Affiliation(s)
- Nuria Sánchez-Izquierdo
- Department of Nuclear Medicine, Hospital Clínic of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Sergi Vidal-Sicart
- Department of Nuclear Medicine, Hospital Clínic of Barcelona, Villarroel 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Francisco Campos
- Department of Nuclear Medicine, Hospital Clínic of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Aureli Torné
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Martina Aida Angeles
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Barcelona, Spain
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Federico Migliorelli
- Department of Gynecology and Obstetrics, Centre Hospitalier Intercommunal des Vallées de l’Ariège, Saint-Jean-de-Verges, France
| | - Meritxell Munmany
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Adela Saco
- Department of Pathology, Hospital Clínic of Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Berta Diaz-Feijoo
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Ariel Glickman
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Jaume Ordi
- Department of Pathology, Hospital Clínic of Barcelona, Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic-Universitat de Barcelona, 08036 Barcelona, Spain
| | - Andrés Perissinotti
- Department of Nuclear Medicine, Hospital Clínic of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Marta del Pino
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Pilar Paredes
- Department of Nuclear Medicine, Hospital Clínic of Barcelona, Villarroel 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
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12
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Sentinel lymph node biopsy in high-grade endometrial cancer: a systematic review and meta-analysis of performance characteristics. Am J Obstet Gynecol 2021; 225:367.e1-367.e39. [PMID: 34058168 DOI: 10.1016/j.ajog.2021.05.034] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE A sentinel lymph node biopsy is widely accepted as the standard of care for surgical staging in low-grade endometrial cancer, but its value in high-grade endometrial cancer remains controversial. The aim of this systematic review and meta-analysis was to evaluate the performance characteristics of sentinel lymph node biopsy in patients with endometrial cancer with high-grade histology (registered in the International Prospective Register of Systematic Reviews with identifying number CRD42020160280). DATA SOURCES We systematically searched the MEDLINE, Epub Ahead of Print, MEDLINE In-Process & Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Embase databases all through the OvidSP platform. The search was performed between January 1, 2000, and January 26, 2021. ClinicalTrials.gov was searched to identify ongoing registered clinical trials. STUDY ELIGIBILITY CRITERIA We included prospective cohort studies in which sentinel lymph node biopsy were evaluated in clinical stage I patients with high-grade endometrial cancer (grade 3 endometrioid, serous, clear cell, carcinosarcoma, mixed, undifferentiated or dedifferentiated, and high-grade not otherwise specified) with a cervical injection of indocyanine green for sentinel lymph node detection and at least a bilateral pelvic lymphadenectomy as a reference standard. If the data were not reported specifically for patients with high-grade histology, the authors were contacted for aggregate data. METHODS We pooled the detection rates and measures of diagnostic accuracy using a generalized linear mixed-effects model with a logit and assessed the risk of bias using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. RESULTS We identified 16 eligible studies of which the authors for 9 of the studies provided data on 429 patients with high-grade endometrial cancer specifically. The study-level median age was 66 years (range, 44-82.5 years) and the study-level median body mass index was 28.6 kg/m2 (range, 19.4-43.7 kg/m2). The pooled detection rates were 91% per patient (95% confidence interval, 85%-95%; I2=59%) and 64% bilaterally (95% confidence interval, 53%-73%; I2=69%). The overall node positivity rate was 26% (95% confidence interval, 19%-34%; I2=44%). Of the 87 patients with positive node results, a sentinel lymph node biopsy correctly identified 80, yielding a pooled sensitivity of 92% per patient (95% confidence interval, 84%-96%; I2=0%), a false negative rate of 8% (95% confidence interval, 4%-16%; I2=0%), and a negative predictive value of 97% (95% confidence interval, 95%-99%; I2=0%). CONCLUSION Sentinel lymph node biopsy accurately detect lymph node metastases in patients with high-grade endometrial cancer with a false negative rate comparable with that observed in low-grade endometrial cancer, melanoma, vulvar cancer, and breast cancer. These findings suggest that sentinel lymph node biopsy can replace complete lymphadenectomies as the standard of care for surgical staging in patients with high-grade endometrial cancer.
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13
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Xue Y, Shan WW, Wang Q, Wang C, Luo XZ, Chen XJ. Efficacy of sentinel lymph node mapping in endometrial cancer with low- or high-intermediate risk. J Surg Oncol 2021; 125:256-263. [PMID: 34569625 DOI: 10.1002/jso.26694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/19/2021] [Accepted: 09/17/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES This study was aimed to evaluate the efficacy of sentinel lymph node (SLN) mapping using indocyanine green (ICG) in Chinese women with endometrial cancer (EC). METHODS Consecutive EC patients undergoing SLN mapping at Obstetrics and Gynecology Hospital of Fudan University were retrospectively reviewed. Overall and bilateral SLN detection rates and SLN locations were presented. Sensitivity, negative predictive value (NPV), and agreement rate were calculated and were compared between patients with low-intermediate (LIR) or high-intermediate risk (HIR). RESULTS There were 454 patients screened, with SLN mapping with ICG performed in 428 patients and systematic lymphadenectomy performed in 159 patients. Overall and bilateral SLN detection rates were 96.50% and 82.71%, respectively. The sensitivity of SLN mapping was 80.00%, and the NPV was 97.76%. SLNs were most commonly located in obturator and external iliac regions. Efficacy of SLN mapping was higher in LIR patients than in HIR patients, with sensitivities of 100.00% and 75.00% (p > 0.05), NPVs of 100.00% and 90.00% (p = 0.002), and agreement rates of 100.00% and 92.31% (p = 0.007), respectively. CONCLUSION SLN mapping with ICG had acceptable diagnostic efficacy in Chinese women with EC, but may cause more missed diagnoses in patients with HIR due to relatively low NPV and agreement rate.
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Affiliation(s)
- Yu Xue
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Wei-Wei Shan
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Qian Wang
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Chao Wang
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xue-Zhen Luo
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xiao-Jun Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
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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: 21] [Impact Index Per Article: 5.3] [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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15
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Nagar H, Wietek N, Goodall RJ, Hughes W, Schmidt-Hansen M, Morrison J. Sentinel node biopsy for diagnosis of lymph node involvement in endometrial cancer. Cochrane Database Syst Rev 2021; 6:CD013021. [PMID: 34106467 PMCID: PMC8189170 DOI: 10.1002/14651858.cd013021.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Pelvic lymphadenectomy provides prognostic information for those diagnosed with endometrial (womb) cancer and provides information that may influence decisions regarding adjuvant treatment. However, studies have not shown a therapeutic benefit, and lymphadenectomy causes significant morbidity. The technique of sentinel lymph node biopsy (SLNB), allows the first draining node from a cancer to be identified and examined histologically for involvement with cancer cells. SLNB is commonly used in other cancers, including breast and vulval cancer. Different tracers, including colloid labelled with radioactive technetium-99, blue dyes, e.g. patent or methylene blue, and near infra-red fluorescent dyes, e.g. indocyanine green (ICG), have been used singly or in combination for detection of sentinel lymph nodes (SLN). OBJECTIVES To assess the diagnostic accuracy of sentinel lymph node biopsy (SLNB) in the identification of pelvic lymph node involvement in women with endometrial cancer, presumed to be at an early stage prior to surgery, including consideration of the detection rate. SEARCH METHODS We searched MEDLINE (1946 to July 2019), Embase (1974 to July 2019) and the relevant Cochrane trial registers. SELECTION CRITERIA We included studies that evaluated the diagnostic accuracy of tracers for SLN assessment (involving the identification of a SLN plus histological examination) against a reference standard of histological examination of removed pelvic +/- para-aortic lymph nodes following systematic pelvic +/- para-aortic lymphadenectomy (PLND/PPALND) in women with endometrial cancer, where there were sufficient data for the construction of two-by-two tables. DATA COLLECTION AND ANALYSIS Two review authors (a combination of HN, JM, NW, RG, and WH) independently screened titles and abstracts for relevance, classified studies for inclusion/exclusion and extracted data. We assessed the methodological quality of studies using the QUADAS-2 tool. We calculated the detection rate as the arithmetic mean of the total number of SLNs detected out of the total number of women included in the included studies with the woman as the unit of analysis, used univariate meta-analytical methods to estimate pooled sensitivity estimates, and summarised the results using GRADE. MAIN RESULTS The search revealed 6259 unique records after removal of duplicates. After screening 232 studies in full text, we found 73 potentially includable records (for 52 studies), although we were only able to extract 2x2 table data for 33 studies, including 2237 women (46 records) for inclusion in the review, despite writing to trial authors for additional information. We found 11 studies that analysed results for blue dye alone, four studies for technetium-99m alone, 12 studies that used a combination of blue dye and technetium-99m, nine studies that used indocyanine green (ICG) and near infra-red immunofluorescence, and one study that used a combination of ICG and technetium-99m. Overall, the methodological reporting in most of the studies was poor, which resulted in a very large proportion of 'unclear risk of bias' ratings. Overall, the mean SLN detection rate was 86.9% (95% CI 82.9% to 90.8%; 2237 women; 33 studies; moderate-certainty evidence). In studies that reported bilateral detection the mean rate was 65.4% (95% CI 57.8% to 73.0%) . When considered according to which tracer was used, the SLN detection rate ranged from 77.8% (95% CI 70.0% to 85.6%) for blue dye alone (559 women; 11 studies; low-certainty evidence) to 100% for ICG and technetium-99m (32 women; 1 study; very low-certainty evidence). The rates of positive lymph nodes ranged from 5.2% to 34.4% with a mean of 20.1% (95% CI 17.7% to 22.3%). The pooled sensitivity of SLNB was 91.8% (95% CI 86.5% to 95.1%; total 2237 women, of whom 409 had SLN involvement; moderate-certainty evidence). The sensitivity for of SLNB for the different tracers were: blue dye alone 95.2% (95% CI 77.2% to 99.2%; 559 women; 11 studies; low-certainty evidence); Technetium-99m alone 90.5% (95% CI 67.7% to 97.7%; 257 women; 4 studies; low-certainty evidence); technetium-99m and blue dye 91.9% (95% CI 74.4% to 97.8%; 548 women; 12 studies; low-certainty evidence); ICG alone 92.5% (95% CI 81.8% to 97.1%; 953 women; 9 studies; moderate-certainty evidence); ICG and blue dye 90.5% (95% CI 63.2.6% to 98.1%; 215 women; 2 studies; low-certainty evidence); and ICG and technetium-99m 100% (95% CI 63% to 100%; 32 women; 1 study; very low-certainty evidence). Meta-regression analyses found that the sensitivities did not differ between the different tracers used, between studies with a majority of women with FIGO stage 1A versus 1B or above; between studies assessing the pelvic lymph node basin alone versus the pelvic and para-aortic lymph node basin; or between studies that used subserosal alone versus subserosal and cervical injection. It should be noted that a false-positive result cannot occur, as the histological examination of the SLN is unchanged by the results from any additional nodes removed at systematic lymphadenectomy. AUTHORS' CONCLUSIONS The diagnostic test accuracy for SLNB using either ICG alone or a combination of a dye (blue or ICG) and technetium-99m is probably good, with high sensitivity, where a SLN could be detected. Detection rates with ICG or a combination of dye (ICG or blue) and technetium-99m may be higher. The value of a SLNB approach in a treatment pathway, over adjuvant treatment decisions based on uterine factors and molecular profiling, requires examination in a high-quality intervention study.
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Affiliation(s)
- Hans Nagar
- Belfast Health and Social Care Trust, Belfast City Hospital and the Royal Maternity Hospital, Belfast, UK
| | - Nina Wietek
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Richard J Goodall
- Department of Surgery and Cancer , Imperial College London, London, UK
| | - Will Hughes
- Department of Plastic Surgery, Addenbrookes Hospital, Cambridge, UK
| | - Mia Schmidt-Hansen
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, GRACE Centre, Musgrove Park Hospital, Taunton, UK
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16
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Angeles MA, Migliorelli F, Vidal-Sicart S, Saco A, Ordi J, Ros C, Fusté P, Munmany M, Escura S, Carreras N, Sánchez-Izquierdo N, Pahisa J, Torné A, Paredes P, Del Pino M. Paraaortic sentinel lymph node detection in intermediate and high-risk endometrial cancer by transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR). J Gynecol Oncol 2021; 32:e52. [PMID: 33908710 PMCID: PMC8192237 DOI: 10.3802/jgo.2021.32.e52] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/21/2021] [Accepted: 02/20/2021] [Indexed: 12/11/2022] Open
Abstract
Objective We aimed to evaluate the accuracy of sentinel lymph node (SLN) mapping with transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR) to detect lymph node (LN) metastases, in patients with intermediate and high-risk endometrial cancer (EC), focusing on its performance to detect paraaortic involvement. Methods Prospective study including women with preoperative intermediate or high-risk EC, according to ESMO-ESGO-ESTRO consensus, who underwent SLN mapping using the TUMIR approach. SLNs were preoperatively localized by planar and single photon emission computed tomography/computed tomography images, and intraoperatively by gamma-probe. Immediately after SLN excision, all women underwent systematic pelvic and paraaortic lymphadenectomy by laparoscopy. Results The study included 102 patients. The intraoperative SLN detection rate was 79.4% (81/102). Pelvic and paraaortic drainage was observed in 92.6% (75/81) and 45.7% (37/81) women, respectively, being exclusively paraaortic in 7.4% (6/81). After systematic lymphadenectomy, LN metastases were identified in 19.6% (20/102) patients, with 45.0% (9/20) showing paraaortic involvement, which was exclusive in 15.0% (3/20). The overall sensitivity and negative predictive value (NPV) of SLNs by the TUMIR approach to detect lymphatic involvement were 87.5% and 97.0%, respectively; and 83.3% and 96.9%, for paraaortic metastases. After applying the MSKCC SLN mapping algorithm, the sensitivity and NPV were 93.8% and 98.5%, respectively. Conclusion The TUMIR method provides valuable information of endometrial drainage in patients at higher risk of paraaortic LN involvement. The TUMIR approach showed a detection rate of paraaortic SLNs greater than 45% and a high sensitivity and NPV for paraaortic metastases in women with intermediate and high-risk EC.
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Affiliation(s)
- Martina Aida Angeles
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Spain.,Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse - Oncopole, Toulouse, France
| | - Federico Migliorelli
- Department of Gynecology and Obstetrics, Centre Hospitalier Intercommunal des Vallées de l'Ariège, St. Jean de Verges, France
| | - Sergi Vidal-Sicart
- Department of Nuclear Medicine, Hospital Clínic of Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Adela Saco
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Faculty of Medicine, University of Barcelona, Barcelona, Spain.,Department of Anatomo-pathology, Hospital Clínic of Barcelona, Spain
| | - Jaume Ordi
- Faculty of Medicine, University of Barcelona, Barcelona, Spain.,Department of Anatomo-pathology, Hospital Clínic of Barcelona, Spain.,Institut de Salut Global de Barcelona (ISGlobal), Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Cristina Ros
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Spain.,Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Pere Fusté
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Spain.,Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Meritxell Munmany
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Spain
| | - Sílvia Escura
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Spain
| | - Núria Carreras
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Spain
| | | | - Jaume Pahisa
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Aureli Torné
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Pilar Paredes
- Department of Nuclear Medicine, Hospital Clínic of Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Faculty of Medicine, University of Barcelona, Barcelona, Spain.
| | - Marta Del Pino
- Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic of Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Faculty of Medicine, University of Barcelona, Barcelona, Spain
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Ji Q, Wang X, Jiang J, Chen L. Sentinel lymph node mapping in high-risk endometrial cancer: a systematic review and meta-analysis. Gland Surg 2020; 9:2091-2105. [PMID: 33447560 PMCID: PMC7804562 DOI: 10.21037/gs-20-807] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/16/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND In the staging of endometrial cancer (EC), the role of sentinel lymph node (SLN) mapping for high-risk EC is still unclear. METHODS Two authors independently reviewed abstracts and full-text articles for inclusion and assessed study quality. English studies published in PubMed, Embase, and Cochrane Library before 20th SEP, 2019 were retrieved to perform a systematic evaluation and meta-analysis which evaluate the detection rate and diagnostic accuracy of SLN mapping in high-risk EC. Statistical analysis was conducted using stata14.0 software. RESULTS A total of 12 studies were included, including 758 high-risk EC patients. The detection rate of SLN mapping was 84.8% (95% CI, 79.9-89.6%). The pooled bilateral detection rate was 67.0% (95% CI, 56.8-77.3%). The pooled para-aortic detection rate was 8.4% (95% CI, 1.8-14.9%). The pooled sensitivity was 87% (95% CI, 79-92%), and the pooled specificity was 98% (95% CI, 96-99%). Pooled negative predictive value (NPV) was 97.7% (95% CI, 96.4-99.1%), AUC =0.99 (95% CI, 0.97-0.099). CONCLUSIONS SLN mapping still has a high detection rate and diagnostic accuracy in high-risk EC. SLN mapping is a reliable alternative to systematic lymph node dissection, but its prognostic effect on high-risk EC is yet to be further studied and verified by large sample studies.
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Affiliation(s)
- Qiang Ji
- Gynecological Oncology Ward, Dalian Maternal and Child Health Hospital Affiliated to Dalian Medical University, Dalian, China
| | - Xiuying Wang
- Gynecological Oncology Ward, Dalian Maternal and Child Health Hospital Affiliated to Dalian Medical University, Dalian, China
| | - Jiyong Jiang
- Gynecological Oncology Ward, Dalian Maternal and Child Health Hospital Affiliated to Dalian Medical University, Dalian, China
| | - Liyan Chen
- Gynecological Oncology Ward, Dalian Maternal and Child Health Hospital Affiliated to Dalian Medical University, Dalian, China
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Diagnostic Accuracy and Clinical Impact of Sentinel Lymph Node Sampling in Endometrial Cancer at High Risk of Recurrence: A Meta-Analysis. J Clin Med 2020; 9:jcm9123874. [PMID: 33260511 PMCID: PMC7761304 DOI: 10.3390/jcm9123874] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/20/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose. To assess the value of sentinel lymph node (SLN) sampling in high risk endometrial cancer according to the ESMO-ESGO-ESTRO classification. Methods. We performed a comprehensive search on PubMed for clinical trials evaluating SLN sampling in patients with high risk endometrial cancer: stage I endometrioid, grade 3, with at least 50% myometrial invasion, regardless of lymphovascular space invasion status; or stage II; or node-negative stage III endometrioid, no residual disease; or non-endometrioid (serous or clear cell or undifferentiated carcinoma, or carcinosarcoma). All patients underwent SLN sampling followed by pelvic with or without para-aortic lymphadenectomy. Results. We included 17 original studies concerning 1322 women. Mean detection rates were 89% for unilateral and 68% for bilateral. Pooled sensitivity was 88.5% (95%CI: 81.2–93.2%), negative predictive value was 96.0% (95%CI: 93.1–97.7%), and false negative rate was 11.5% (95%CI: 6.8; 18.8%). We noted heterogeneity in SLN techniques between studies, concerning the tracer and its detection, the injection site, the number of injections, and the surgical approach. Finally, we found a correlation between the number of patients included and the SLN sampling performances. Discussion. This meta-analysis estimated the SLN sampling performances in high risk endometrial cancer patients. Data from the literature show the feasibility, the safety, the limits, and the impact on surgical de-escalation of this technique. In conclusion, our study supports the hypothesis that SLN sampling could be a valuable technique to diagnose lymph node involvement for patients with high risk endometrial cancer in replacement of conventional lymphadenectomy. Consequently, randomized clinical trials are necessary to confirm this hypothesis.
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Patterns of use and outcomes of sentinel lymph node mapping for patients with high-grade endometrial cancer. Gynecol Oncol 2020; 159:732-736. [PMID: 33004215 DOI: 10.1016/j.ygyno.2020.09.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 09/13/2020] [Indexed: 11/22/2022]
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