Abstract
ObjectiveTo evaluate the utility of sentinel lymph node mapping (SLN) in endometrial cancer (EC) patients in comparison with lymphadenectomy (LND).MethodsComprehensive search was performed in MEDLINE, EMBASE, CENTRAL, OVID, Web of science databases, and three clinical trials registration websites, from the database inception to September 2020. The primary outcomes covered operative outcomes, nodal assessment, and oncological outcomes. Software Revman 5.3 was used. Trial sequential analysis (TSA) and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) were performed.ResultsOverall, 5,820 EC patients from 15 studies were pooled in the meta-analysis: SLN group (N = 2,152, 37.0%), LND group (N = 3,668, 63.0%). In meta-analysis of blood loss, SLN offered advantage over LND in reducing operation bleeding (I2 = 74%, P<0.01). Z-curve of blood loss crossed trial sequential monitoring boundaries though did not reach TSA sample size. There was no difference between SLN and LND in intra-operative complications (I2 = 7%, P = 0.12). SLN was superior to LND in detecting positive pelvic nodes (P-LN) (I2 = 36%, P<0.001), even in high risk patients (I2 = 36%, P = 0.001). While no difference was observed in detection of positive para-aortic nodes (PA-LN) (I2 = 47%, P = 0.76), even in high risk patients (I2 = 62%, P = 0.34). Analysis showed no difference between two groups in the number of resected pelvic nodes (I2 = 99%, P = 0.26). SLN was not associated with a statistically significant overall survival (I2 = 79%, P = 0.94). There was no difference in progression-free survival between SLN and LND (I2 = 52%, P = 0.31). No difference was observed in recurrence. Based on the GRADE assessment, we considered the quality of current evidence to be moderate for P-LN biopsy, low for items like blood loss, PA-LN positive.ConclusionThe present meta-analysis underlines that SLN is capable of reducing blood loss during operation in regardless of surgical approach with firm evidence from TSA. SLN mapping is more targeted for less node dissection and more detection of positive lymph nodes even in high risk patients with conclusive evidence from TSA. Utility of SLN yields no survival detriment in EC patients.
Highlights
Endometrial cancer (EC) is the most common gynecological malignancy in developed countries, and an estimated 65,620 new cases in United States in 2020 [1]
sentinel lymph node mapping (SLN) was superior to LND in detecting positive pelvic nodes (P-LN) (I2 = 36%, P
Based on the GRADE assessment, we considered the quality of current evidence to be moderate for P-LN biopsy, low for items like blood loss, PA-LN positive
Summary
Endometrial cancer (EC) is the most common gynecological malignancy in developed countries, and an estimated 65,620 new cases in United States in 2020 [1]. The disease incidence has been climbing by 1.5 times over the last 10 years, and the death cases have increased by 58.4% according to latest statistics [1, 2]. Though 5-year overall survival (OS) has reached at 80%, it has not made any progress since 1985, estimated in the US Surveillance, Epidemiology, and End Results (SEER) database [3]. Surgical staging is the step of final diagnosis and first treatment in most EC patients, and the standard operation includes hysterectomy, bilateral salpingo-oophorectomy, and lymph node assessment, allowing prognostic stratification and potentially benefited patients identification [3]. Lymph node status is a definite prognostic factor, albeit clinical trials showed no survival benefit in patients with nodal examination versus those not [4, 5]. Traditional lymph node assessment contains systematic pelvic ± para-aortic lymphadenectomy (LND), and given low lymph nodal involvement rate, LND is prone to cause overtreatment and more surgery-related complications like lymphedema [6]
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