Abstract
Sentinel lymph node (SLN) mapping is becoming an acceptable alternative to full lymphadenectomy for evaluating lymphatic spread in clinical stage I endometrial cancer (EC). While the assessment of pelvic and para-aortic lymph nodes is part of the surgical staging of EC, there is a long-standing debate over the therapeutic value of full lymphadenectomy in this setting. Although lymphadenectomy offers critical information on lymphatic spread and prognosis, most patients will not derive oncologic benefit from this procedure as the majority of patients do not have lymph node involvement. SLN mapping offers prognostic information while simultaneously avoiding the morbidity associated with an extensive and often unnecessary lymphadenectomy. A key factor in the decision making when planning for EC surgery is the histologic subtype. Since the risk of lymphatic spread is less than 5% in low-grade EC, these patients might not benefit from lymph node assessment. Nonetheless, in high-grade EC, the risk for lymph node metastases is much higher (20–30%); therefore, it is crucial to determine the spread of disease both for determining prognosis and for tailoring the appropriate adjuvant treatment. Studies on the accuracy of SLN mapping in high-grade EC have shown a detection rate of over 90%. The available evidence supports adopting the SLN approach as an accurate method for surgical staging. However, there is a paucity of prospective data on the long-term oncologic outcome for patients undergoing SLN mapping in high-grade EC, and more trials are warranted to answer this question.
Highlights
Sentinel lymph node (SLN) mapping is a minimally invasive approach developed to identify occult metastases in normal-appearing lymph nodes, while avoiding complete pelvic lymph node dissection [1]
SLN mapping is associated with reduced surgical morbidity and postoperative lymphedema compared to complete lymphadenectomy [3], but has similar, if not improved, diagnostic accuracy for nodal metastases [2]
This led to several prospective trials that aimed to evaluate the sensitivity of SLN mapping compared to complete lymphadenectomy as the reference standard [22,23,25,26,63]
Summary
Sentinel lymph node (SLN) mapping is a minimally invasive approach developed to identify occult metastases in normal-appearing lymph nodes, while avoiding complete pelvic lymph node dissection [1]. The rates of lymphedema were far lower in patients undergoing SLN biopsy compared to lymphadenectomy (1.9% vs 25%) These findings have led to the practice of omitting regional lymph node dissection in vulvar cancer when SLNs are negative. The rate of groin recurrence was high at 22% for those who received radiotherapy only for macrometastases, compared to 6.9% in those who had complete inguinofemoral lymph node dissection These findings highlight the need to evaluate SLN mapping for each cancer type and identify the patients with suitable clinicopathologic tumor characteristics for which the SLN technique can be performed with high accuracy and safety. Many pivotal prospective studies evaluating SLN technique in EC included patients with different histologic subtypes and predominantly low-grade EC [22,23]. We will discuss the role of SLN mapping in EC, focusing on patients with high-grade histology [27]
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