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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] [What about the content of this article? (0)] [Affiliation(s)] [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 In recent years, systematic lymphadenectomy has been replaced by sentinel lymph node (SLN) biopsy and ultrastaging, allowing for the detection of macrometastases, micrometastases, and isolated tumor cells (ITCs).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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De Vitis LA, Fumagalli D, Schivardi G, Capasso I, Grcevich L, Multinu F, Cucinella G, Occhiali T, Betella I, Guillot BE, Pappalettera G, Shahi M, Fought AJ, McGree M, Reynolds E, Colombo N, Zanagnolo V, Aletti G, Langstraat C, Mariani A, Glaser G. Incidence of sentinel lymph node metastases in apparent early-stage endometrial cancer: a multicenter observational study. Int J Gynecol Cancer 2024:ijgc-2023-005173. [PMID: 38514100 DOI: 10.1136/ijgc-2023-005173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024] Open
Abstract
OBJECTIVE Ultrastaging is accurate in detecting nodal metastases, but increases costs and may not be necessary in certain low-risk subgroups. In this study we examined the risk of nodal involvement detected by sentinel lymph node (SLN) biopsy in a large population of apparent early-stage endometrial cancer and stratified by histopathologic characteristics. Furthermore, we aimed to identify a subgroup in which ultrastaging may be omitted. METHODS We retrospectively included patients who underwent SLN (with bilateral mapping and no empty nodal packets on final pathology) ± systematic lymphadenectomy for apparent early-stage endometrial cancer at two referral cancer centers. Lymph node status was determined by SLN only, regardless of non-SLN findings. The incidence of macrometastasis, micrometastasis, and isolated tumor cells (ITC) was measured in the overall population and after stratification by histotype (endometrioid vs serous), myometrial invasion (none, <50%, ≥50%), and grade (G1, G2, G3). RESULTS Bilateral SLN mapping was accomplished in 1570 patients: 1359 endometrioid and 211 non-endometrioid, of which 117 were serous. The incidence of macrometastasis, micrometastasis, and ITC was 3.8%, 3.4%, and 4.8%, respectively. In patients with endometrioid histology (n=1359) there were 2.9% macrometastases, 3.2% micrometastases, and 5.3% ITC. No macro/micrometastases and only one ITC were found in a subset of 274 patients with low-grade (G1-G2) endometrioid endometrial cancer without myometrial invasion (all <1%). The incidence of micro/macrometastasis was higher, 2.8%, in 708 patients with low-grade endometrioid endometrial cancer invading <50% of the myometrium. In patients with serous histology (n=117), the incidence of macrometastases, micrometastasis, and ITC was 11.1%, 6.0%, and 1.7%, respectively. For serous carcinoma without myometrial invasion (n=36), two patients had micrometastases for an incidence of 5.6%. CONCLUSIONS Ultrastaging may be safely omitted in patients with low-grade endometrioid endometrial cancer without myometrial invasion. No other subgroups with a risk of nodal metastasis of less than 1% have been identified.
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Affiliation(s)
- Luigi Antonio De Vitis
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Diletta Fumagalli
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Obstetrics and Gynecology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Gabriella Schivardi
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Ilaria Capasso
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Leah Grcevich
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Francesco Multinu
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giuseppe Cucinella
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Tommaso Occhiali
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Clinic of Obstetrics and Gynecology, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Ilaria Betella
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Benedetto E Guillot
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Giulia Pappalettera
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Maryam Shahi
- Department of Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Angela J Fought
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Michaela McGree
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Evelyn Reynolds
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicoletta Colombo
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Faculty of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Vanna Zanagnolo
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giovanni Aletti
- Department of Gynecology, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Carrie Langstraat
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea Mariani
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
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