Elsevier

Gynecologic Oncology

Volume 133, Issue 3, June 2014, Pages 506-511
Gynecologic Oncology

Impact of sentinel lymph node biopsy on the therapeutic management of early-stage endometrial cancer: Results of a retrospective multicenter study

https://doi.org/10.1016/j.ygyno.2014.03.019Get rights and content

Highlights

  • Sentinel lymph node biopsy applied to low- and intermediate-risk patients enables to detect 3 times more metastatic lymph node.

  • Ultrastaging changed ESMO classification in half of the cases (10/22) and changed low- and intermediate-risk to high-risk group.

  • Ultrastaging could recuperate patients with undiagnosed micrometastasis by lymphadenectomy and permit the administration of an EBRT.

Abstract

Objective

The aim of this study is to assess the impact of sentinel lymph node (SLN) mapping and ultrastaging on the therapeutic management of early-stage endometrial cancer.

Methods

This retrospective multicenter study covered the period from January 2000 through December 2012 and included 304 women with presumed low- or intermediate-risk endometrial cancer. Node staging, histology results, and the effects of both on therapeutic management were assessed in two groups: those who underwent the SLN mapping and ultrastaging procedure and those treated in accordance with French guidelines.

Results

The SLN procedure detected metastatic lymph nodes in three times more women than lymphadenectomy did (16.2% versus 5.1%, p = 0.03). Specifically, it found 7 macrometastases (5.1%) and 15 micrometastases (11%); 11 of the latter (8.1%) were detected by serial sectioning and immunohistochemistry (IHC), that is, pathologic ultrastaging. The SLN biopsy false-negative rate was 0% (95% CI: 0–1.6%). This ultrastaging enabled us to modify the adjuvant therapy for half the patients. Women with micrometastases detected by the SLN procedure were treated with external beam radiotherapy (EBRT), while those whose SLN biopsies were negative received vaginal brachytherapy (VBT) or clinical follow-up. SLN biopsies had no impact on recurrence-free survival.

Conclusion

SLN mapping and ultrastaging improved staging and made it possible to adapt adjuvant therapy to risk of recurrence.

Introduction

Endometrial cancer is the most common gynecologic pelvic cancer in both the European Union and the United States. Prognosis is directly linked to histological type and grade and to surgical stage [1], [2], [3], and these factors guide the choice of adjuvant treatments. The prognostic relevance of assessing lymph node (LN) status by lymphadenectomy is, however, still a matter of debate. The recent recommendations for de-escalation of treatment in some patients [4] are based on results from two randomized trials and a meta-analysis, which have proved that pelvic lymphadenectomy has no effect on overall survival (OS) or relapse-free survival (RFS) but is associated with a higher incidence of early and late complications [5], [6], [7]. Nonetheless, 15% of the women whose cancer prognosis is considered good develop a recurrence, and its prognosis, in turn, is not well correlated with conventional histoprognostic factors [8].

Ballester et al. validated the feasibility, detection rates, and accuracy of the SLN mapping and ultrastaging procedure [8] as a possible alternative to pelvic lymphadenectomy in the early stages of endometrial cancer [9]. We report the results of a retrospective multicenter study to assess the impact of this procedure in choosing adjuvant treatment for women with early-stage endometrial cancer.

Section snippets

Patients

Our retrospective multicenter study is based on data from three participating French centers: Tenon Hospital in Paris, Reims University Hospital, and the Georges-François Leclerc Cancer Center in Dijon. Our data include all patients diagnosed with endometrial cancer at one of these hospitals between January 2000 and December 2012. Some of these women (n = 156) were included prospectively when they participated in the SENTI-ENDO protocol (a prospective, multicenter cohort study to assess the

Results

From January 2000 to December 2012, the three participating centers enrolled 494 women, 190 of whom were excluded because of: preoperative diagnosis of type 2 endometrial cancer (n = 87), MRI staging as FIGO stage I high-risk, II, III and IV or indeterminate (n = 92), and preoperative ESMO classification as undetermined (n = 11). This study therefore included 304 women (Fig. 1). The SLN procedure was followed by pelvic lymphadenectomy for 156 women (51.3%); 95 women had pelvic lymphadenectomy alone

Discussion

In this study, SLN mapping and ultrastaging applied to low- and intermediate-risk patients made it possible to detect metastatic LNs three times more often than complete pelvic lymphadenectomy (16.2% versus 5.1%, p = 0.03). Ultrastaging changed the ESMO classification in half of the cases.

The French INCa guidelines issued in 2010 called for therapy de-escalation for patients with a low risk of recurrence (no lymphadenectomy or adjuvant therapy) [4]. These recommendations are based on a Cochrane

Conflicts of interest

The authors declared no conflicts of interest.

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