Uptake and outcomes of sentinel lymph node mapping in women with endometrial cancer

Abstract

<h3>Objectives:</h3> The role of nodal evaluation for endometrial cancer (EmCa) remains controversial. Sentinel lymph node (SLN) mapping has been introduced as an alternative to lymph node dissection (LND) and may be associated with decreased morbidity. Little is known about the uptake and outcomes of SLN mapping. We examined trends in use and perioperative morbidity, mortality and complications for SLN mapping compared to LND for endometrial cancer. <h3>Methods:</h3> Women with EmCa who underwent a laparoscopic or robotic-assisted hysterectomy from 2012-2018 in the Premier Healthcare Database were examined. Performance of lymph node dissection was classified as SLN mapping, LND or no nodal evaluation based on procedural billing codes and CPT codes. Adjusted regression models were developed to examine the association between SLN mapping and perioperative morbidity, mortality and cost. <h3>Results:</h3> Among 45,381 patients, SLN mapping was performed in 7,768 (17.1%), LND in 23,214 (51.2%) and no lymphatic evaluation in 14,399 (31.7%). Performance of SLN mapping increased from 1.8% in 2012 to 35.3% in 2018 (19.6-fold increase), while the rate of LND decreased from 63.5% to 39.1% (1.6-fold decrease) (P<0.001) (Figure 1). Lymph node (LND or SLN mapping) evaluation increased from 65.2% in 2012 to 74.4% in 2018 (P<0.001). In a multivariable model, residence in the west, surgery at teaching hospitals, treatment at high-volume hospitals, BlackBlack race and use of robotic-assisted hysterectomy were associated with lymph node (LND or SLN mapping) evaluation (P<0.05 for all). Among women who underwent nodal evaluation, residence in the west, White race, and use of robotic-assisted hysterectomy were associated with performance of SLN mapping (P<0.05 for all). The overall complication rate was 5.9% in those who underwent SLN mapping compared to 7.3% in those that underwent LND (aRR=0.85; 95% CI 0.77-0.95). The median hospital cost in women who underwent SLN mapping ($10,479) and LND ($10,747) were substantially higher than in those who did not undergo nodal assessment ($9,149) (P<0.001). In an adjusted regression model, this difference in cost remained significant for SLN mapping ($805; 95% CI $689 to $922) and for those who underwent LND ($1,474; 95% CI $1,384 to $1,563). <h3>Conclusions:</h3> Performance of SLN mapping is increasing rapidly for women with endometrial cancer. Compared to LND, SLN mapping is associated with lower perioperative morbidity and lower cost.