Value of Sentinel Lymph Node (SLN) Mapping and Biopsy using Combined Intracervical Radiotracers and Blue Dye Injections for Endometrial Cancer

Risk factors associated with false negative rate of sentinel lymph node biopsy in endometrial cancer: a systematic review and meta-analysis

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.

A Model to Identify Candidates for Lymph Node Dissection Among Patients With High-Risk Endometrial Endometrioid Carcinoma According to Mayo Criteria

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.

ESGO/ESTRO/ESP Guidelines for the management of patients with endometrial carcinoma

A European consensus conference on endometrial carcinoma was held in 2014 to produce multidisciplinary 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 & 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. ESGO/ESTRO/ESP nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of endometrial carcinoma (27 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2014, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 191 independent international practitioners in cancer care delivery and patient representatives. The guidelines comprehensively cover endometrial carcinoma staging, definition of prognostic risk groups integrating molecular markers, pre- and intra-operative work-up, fertility preservation, management for early, advanced, metastatic, and recurrent disease and palliative treatment. Principles of radiotherapy and pathological evaluation are also defined.

Sentinel lymph node biopsy in endometrial cancer: state of the art

Endometrial cancer (EC) is the most common gynecological neoplasm in developed countries. In literature, there are discordant data regarding the therapeutic value of systematic lymphadenectomy whereas the importance of lymph node status for determining prognosis and the need for adjuvant treatment is undoubted. Given the low risk of lymph-node metastases in the apparent early-stage disease and the significant surgical and postoperative risks when performing a complete pelvic lymphadenectomy, the surgical approach in these patients is controversial, ranging from no nodal evaluation to comprehensive pelvic and aortic lymphadenectomy. The recent introduction of sentinel node mapping represents the mid-way between the execution and omission of node dissection in EC patients. Indeed, the sentinel node mapping has rapidly emerged as an alternative to complete lymphadenectomy to reduce morbidity. In the present review, we discuss the role of sentinel node mapping in the surgical management of EC evaluating all aspects of this procedure.

Should the left gastric artery lymph node be considered as the predictive lymph node for extra-gastric lymph node metastases?

Background

To validate the prognostic impacts of the left gastric artery lymph node (No. 7 LN) metastasis and investigate whether the No. 7 LN metastasis should be considered as the predictive LN for extra-gastric LN metastases.

Methods

Between January 2003 and December 2011, a total of 1,586 patients who underwent R0 gastrectomy were retrospected. Patients with LN metastases were divided into three groups: (I) patients with only peri-gastric LN metastases (peri-gastric group); (II) patients with peri-gastric and only No. 7 LN metastases (No. 7 group); and (III) patients with other extra-gastric LN metastases (extra-gastric group). Propensity score matching (PSM) was adopted to accurately evaluate prognoses of all patients after surgery.

Results

Of 1,586 patients, 235 (14.82%) were pathologically identified to present with the No. 7 LN metastases. Patients with the No. 7 LN metastases presented the significantly lower survival rate both before and after adjustment by pTNM stage, compared to those without the No. 7 LN metastases. Patients in the No. 7 group were identified to present the significant lower survival rate than those in the peri-gastric group, and to present the similar median overall survival (OS) to those in the extra-gastric group. In addition, patients with extra-gastric LN except No. 7 LN metastases failed to show any superiority of survival outcomes, compared with those with extra-gastric LN metastases including the No. 7 LN metastasis.

Conclusions

The No. 7 LN metastases had the crucial survival implications. Nevertheless, the No. 7 LN failed to be considered as the predictive LN for the extra-gastric LN metastases in gastric cancer (GC).

Graphene Oxide as a Multifunctional Platform for Intracellular Delivery, Imaging, and Cancer Sensing

Graphene oxide (GO), the most common derivative of graphene, is an exceptional nanomaterial that possesses multiple physical properties critical for biomedical applications. GO exhibits pH-dependent fluorescence emission in the visible/near-infrared, providing a possibility of molecular imaging and pH-sensing. It is also water soluble and has a substantial platform for functionalization, allowing for the delivery of multiple therapeutics. GO physical properties are modified to enhance cellular internalization, producing fluorescent nanoflakes with low (<15%) cytotoxicity at the imaging concentrations of 15 μg/mL. As a result, at lower flake sizes GO rapidly internalizes into HeLa cells with the following 70% fluorescence based clearance at 24 h, assessed by its characteristic emission in red/near-IR. pH-dependence of GO emission is utilized to provide the sensing of acidic extracellular environments of cancer cells. The results demonstrate diminishing green/red (550/630 nm) fluorescence intensity ratios for HeLa and MCF-7 cancer cells in comparison to HEK-293 healthy cells suggesting a potential use of GO as a non-invasive optical sensor for cancer microenvironments. The results of this work demonstrate the potential of GO as a novel multifunctional platform for therapeutic delivery, biological imaging and cancer sensing.