Tips and tricks to improve sentinel lymph node mapping with Indocyanin green in endometrial cancer

OBJECTIVE

To determine the validity of sentinel lymph node (SLN) biopsy with ICG in endometrial cancer and to evaluate the factors associated with poor mapping or false negative.

METHODS

We reviewed all patients who underwent primary surgery for endometrial carcinoma with SLN mapping using ICG followed by pelvic lymphadenectomy from February 2014 to December 2015. SLNs were ultrastaged on final pathology. Patients' demographics, surgical approach and histopathological factors were prospectively collected. Detection rate, sensitivity and negative predictive value (NPV) were calculated and univariate analysis was performed to evaluate factors associated with failed bilateral detection of SLNs.

RESULTS

A total of 119 patients were included. The overall and bilateral detection rates were 93% and 74%. Sensitivity and NPV were 100% in patients with bilateral detection; 95% and 99% respectively in cases with at least unilateral detection. Advanced FIGO stage (III or IV) was the only factor related to failed bilateral detection (p = 0.01). In 14 hemi-pelvis, the specimen labelled as SLN did not contain nodal tissue on final pathology (only lymphatic channels), which represented 37% of the "failed detection" cases. One false negative occurred in a patient with an ipsilateral clinically suspicious enlarged lymph node.

CONCLUSION

ICG is an excellent tracer for SLN mapping in endometrial cancer. Advanced FIGO stage correlated with failed bilateral detection (p = 0.01). Suspicious lymph nodes should be removed regardless of the mapping. Care should be taken to ensure that SLN specimen actually contains nodal tissue and not only swollen lymphatic channels, as this represents a significant cause of failed SLN mapping.

[Early-stage endometrial cancer: Sentinel node or lymphadenectomy?]

The endometrial cancers are mainly discovered at an early stage justifying a less aggressive treatment. The therapeutic choices are today based on preoperative classifications themselves based on histo-prognostic factors of the tumor and its extension measured in MRI: consequently, lymph node dissection in case of low and intermediate risk cancer is not systematically achieved. But a number of patients have lymph node involvement finally, probably justifying an adapted surgical and adjuvant treatment. The technique of sentinel node would compensate the weaknesses of preoperative prognostic evaluation. This new operative technique needs to be precised and evaluated: the topics subject to discussion are the technical implementation, the definition of its quality standards and the management of its histological results especially in cases of low volume lymph node metastasis.

[Application in France of the 2021 European recommendations on endometrial cancer]

The latest European recommendations of the European Societies of Gynecological Oncology (ESGO), Radiotherapy and Oncology (ESTRO) and Anatomopathology (ESP) concerning the management of patients with endometrial cancer were published in 2021. On behalf of the French Society of Gynecologic Oncology (SFOG) and the SFOG campus, we wish to summarize for the French-speaking readership the main measures with a more specific application for France. We also incorporate data from a Delphi survey conducted with a panel of French and French-speaking Swiss experts. The data presented in this article relate to histo-molecular characteristics, radiological data of endometrial cancer, and management of low-risk, intermediate-risk, intermediate-high-risk, and metastatic cancers. The aim of this review article is to show the application of the latest international recommendations to clinicians and pathologists for the implementation of these recommendations.

Can inter-observer consistency be achieved in the laparoscopic assessment of the peritoneal carcinomatosis index score in peritoneal metastasis? A pilot study

Objectives

The main prognostic factor for peritoneal metastasis (PM) is the complete resection of the disease during cytoreductive surgery. Accurate patient selection is therefore essential for determining eligibility for this type of surgery. The peritoneal carcinomatosis index (PCI) is a widely used tool for assessing the extent of carcinomatosis. This study aimed to evaluate the inter-observer reproducibility of PCI assessments via laparoscopy and identify factors influencing this reproducibility.

Methods

Between November 2020 and November 2022, 25 laparoscopic PCI assessment videos were reviewed by six surgeons from two centers. The total PCI score, regional PCI scores, and the number of visualized PCI areas were recorded. Inter-observer concordance was analyzed.

Results

The median PCI score was 12 out of 39 (range 0-39), and the median number of visualized PCI regions was 10 out of 13 (range 1-13). The intraclass correlation coefficient (ICC) for the total PCI score was 0.846 (95 % CI 0.738, 0.927). A history of abdominal surgery significantly impacted PCI assessment reproducibility (p=0.029).

Conclusions

This study found a high inter-observer concordance in laparoscopic PCI assessments. Previous abdominal surgery negatively affected reproducibility, highlighting a challenge in evaluating the PCI in these patients.

Management of Endometrial Cancer: French Society of Onco-Gynecology's Evaluation through a Delphi Survey

Our aim was to assess the opinion of a panel of experts and obtain a consensus on the management of endometrial cancer in France and French Switzerland. A Delphi survey was carried out among a panel of French and French-speaking Swiss experts. The first questionnaire included 65 questions divided into eight categories: characterization of experts, histo-molecular characteristics and radiological data of endometrial cancer, and management of low-risk, intermediate-risk, intermediate-high-risk, high-risk, and metastatic cancers. The experts were asked to reply on a 9-point scale, both on the validity and the clarity of each question. After the answers were analyzed, a second questionnaire was sent to the same experts. The study took place between December 2021 and March 2022. Further, 58 (57.4%) of the 101 experts responded in the first round, and 39 recommendations were obtained (60%). Six questions were voted redundant and 20 discordant. These questions were reformulated, and, at the end of the second round, 17 recommendations were validated (85%). In total, the study presents an analysis of 56 questions and related responses. Expert advice helps to clarify non-consensual issues, standardize the management of endometrial cancer, and optimize clinical practices.

Presentation of the ENDO-SFOG CAMPUS app: An easy therapeutic decision support app in endometrial cancer created by the French Society of Young Gynecological Oncologists (SFOG Campus)

OBJECTIVE

This study evaluates a new decision support tool-a computer/mobile application designed to align with the latest ESGO guidelines, French practices, and molecular biology data-to aid in decision-making for endometrial cancer management.

METHODS

An observational, multicenter, retrospective study was conducted. It compared management decisions from multidisciplinary tumor boards (MTBs) with those suggested by the application for patients with histologically confirmed endometrial cancer, irrespective of their FIGO stage. Each center included the last 20 cases discussed in multidisciplinary tumor boards between May to December 2022.

RESULTS

Thirteen centers participated: eight university hospitals (61.5 %), four cancer centers (30.8 %), and one private center (7.7 %). A total of 259 patients were included, with a mean age of 69 years (range 30-96 years). Most patients had endometrioid tumors (77.2 %), low-grade (62.6 %), FIGO stage IA (41.3 %), no lymphovascular invasion (77.9 %), and a non-specific molecular profile (50.6 %). The application's recommendations matched the MTB decisions 76.6 % of the time. Discrepancies arose mainly from the non-administration of brachytherapy (22.8 %), rare presentations or pathological discordance (22.8 %), and patients' deteriorated conditions precluding standard treatments (19.3 %).

CONCLUSION

The SFOG campus application demonstrates a high concordance with multidisciplinary tumor board decisions, indicating its potential as an efficient, and valuable tool for managing endometrial cancer.