Biopsy In Endometrial Cancer Research Articles

Impact of sentinel node use in lymphedema formation among gynecologic cancer patients.

The most common surgical procedure associated with lymphedema formation is the regional lymphadenectomy. One of the advantages of sentinel node biopsy is the reduction of the risk of lymphedema formation. The purpose of this review is to collect and analyze the most relevant and recent evidence of the use of sentinel node biopsy and its implication on the development of postoperative lymphedema in gynecological cancer. The current evidence of the use of sentinel node biopsy in cervical cancer to reduce lymphedema is heterogeneous and more data is needed to establish its role.Sentinel lymph node biopsy in endometrial cancer is a staging procedure with lower surgical complications, as well as lymphedema formation; while the results of prospective trials evaluating its impact on quality of life are still lacking.Sentinel lymph node biopsy in vulvar cancer minimizes the need for extensive dissection and reduces the incidence of complications associated with overharvesting of lymph nodes such as lymphedema without compromising oncological outcomes. The prevalence of lymphedema in gynecological cancer varies based on the surgical treatment or additional therapies applied. Over the past years, one of the most important surgical modifications to decrease lymphedema formation has been implementation of sentinel lymph node technique mainly in vulvar cancer patients.

Risk factors associated with false negative rate of sentinel lymph node biopsy in endometrial cancer: a systematic review and meta-analysis.

Currently, sentinel lymph node biopsy (SLNB) is increasingly used in endometrial cancer, but the rate of missed metastatic lymph nodes compared to systemic lymph node dissection has been a concern. We conducted a systematic review and meta-analysis to evaluate the false negative rate (FNR) of SLNB in patients with endometrial cancer and to explore the risk factors associated with this FNR. Three databases (PubMed, Embase, Web of Science) were searched from initial database build to January 2023 by two independent reviewers. Studies were included if they included 10 or more women diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I or higher endometrial cancer, the study technique used sentinel lymph node localization biopsy, and the reported outcome metrics included false negative and/or FNR. Two authors independently reviewed the abstracts and full articles. The FNR and factors associated with FNR were synthesized through random-effects meta-analyses and meta-regression. We identified 62 eligible studies. The overall FNR for the 62 articles was 4% (95% CL 3-5).There was no significant difference in the FNR in patients with high-risk endometrial cancer compared to patients with low-risk endometrial cancer. There was no difference in the FNR for whether frozen sections were used intraoperatively. The type of dye used intraoperatively (indocyanine green/blue dye) were not significantly associated with the false negative rate. Cervical injection reduced the FNR compared with alternative injection techniques. Indocyanine green reduced the FNR compared with alternative Tc-99m. Postoperative pathologic ultrastaging reduced the FNR. Alternative injection techniques (other than the cervix), Tc-99m dye tracer, and the absence of postoperative pathologic ultrastaging are risk factors for a high FNR in endometrial cancer patients who undergo SLNB; therefore, we should be vigilant for missed diagnosis of metastatic lymph nodes after SLNB in such populations. http://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023433637.

Oncologic Outcome of Robotic-Assisted and Laparoscopic Sentinel Node Biopsy in Endometrial Cancer.

Recently, sentinel lymph node biopsy (SLNB) has been introduced in the surgical staging of endometrial cancer as an alternative to systematic lymph node dissection (LND). However, the survival impact of SLNB is not yet well characterised. We performed a retrospective study of 419 patients with endometrial cancer treated with SLNB alone or with pelvic and para-aortic LND. For SLNB mapping, indocyanine green was used. Median follow-up was 66 months. After exclusions, 337 patients were eligible for analysis. Of them, 150 underwent SLNB and 187 LND. During the follow-up time, 27 (24.7%) of the 150 who underwent SLNB and 54 (28.9%) of the 187 who underwent LND were diagnosed with recurrent disease (p = 0.459). The estimated 5-year disease-free survival (DFS) rate was 76.7% and 72.2% for patients in the SLNB and LND group, respectively (p = 0.419). The 5-year overall survival (OS) rates were 80.7% and 77.0% in the SLNB and LND group, respectively (p = 0.895). Survival rates were similar in both groups independent of lymph node status. Multivariable analysis confirmed that the staging approach was not associated with oncological outcome. For patients without lymph node metastases, patient outcome was worsened by advanced tumour stage and non-endometrioid tumour histology. In the group of patients with confirmed lymph node metastases, advanced tumour stage and inadequate adjuvant treatment significantly reduced DFS and OS. Our data suggested that SLNB did not compromise the oncological outcome of patients with endometrial cancer compared to LND.

The fluorescence imaging for laparoscopic and laparotomic endometrial sentinel lymph node biopsy (FILLES) trial: Siriraj gynecologic sentinel node of endometrial cancer (SiGN-En) study.

The objective of this study is to establish the detection rate of sentinel lymph node (SLN) biopsies and to determine the sensitivity and false-negative rate of SLN biopsies compared with those of systematic pelvic and para-aortic lymphadenectomies in endometrial cancer. This prospective cohort study enrolled patients with endometrial cancer who were scheduled for surgical staging. Patients with a history of chemotherapy or radiotherapy, an abnormal liver function test, or an allergy to indocyanine green (ICG) were excluded. All patients underwent surgical staging with an ICG injection at the cervix. SLNs were identified by a near-infrared fluorescent camera. All SLNs were sent to a pathologist for ultrastaging. From November 2019 to June 2023, 142 patients underwent SLN mapping and surgical staging. SLNs were not detected bilaterally in 8 patients. The detection rate of the SLN biopsies in this study was 91.2%. Thus, the accuracy of the SLN biopsies was 97.6%. The sensitivity for finding metastatic SLNs was 84.2%, with a negative predictive value of 97.22%. A SLN biopsy in endometrial cancer has a high detection rate and high accuracy. However, surgical expertise and a learning curve are required.

Budget impact analysis of molecular subtype profiling in endometrial cancer

ObjectiveThis study evaluated the costs associated with four approaches to classifying endometrial cancer (EC), including histomorphological, histomorphological with ancillary immunohistochemical assays, histomolecular and selective molecular classification. MethodsDirect costs were determined per EC sample from the hospital's perspective. A budget impact analysis and sensitivity analysis were conducted to estimate the mean, minimum and maximum costs per sample and annual institutional costs in adjusted 2022 Canadian dollars. A provincial cost forecast was projected based on expected 2022 EC biopsies. ResultsIn 2018, our institution performed 190 EC biopsies. The mean cost per biopsy was $158 ($156–$212) for histomorphological classification, $384 ($360–$514) for histomorphological classification with immunohistochemistry and $1297 ($1265–1833) for histomolecular classification. Total annual institutional cost for histomorphological classification was $29,980 and $72,950 with immunohistochemistry. For histomolecular classification, the first year cost was $246,521, accounting for initial educational learning curve, and $233,461 thereafter, assuming a consistent number of biopsies per year. Targeted implementation of histomolecular classification among high-grade, p53 abnormal and/or MMR-deficient ECs (56% of cases) cost $169,688 in the first year and $162,418 annually thereafter. With a projected 3400 EC biopsies in Ontario in 2022, histomorphological classification would annually cost $537,078 and $1,305,677 with immunohistochemistry. Histomolecular classification would cost $4,410,203 in the first year and $4,176,737 annually once established. Selective molecular classification would lead to a cost of $3,044,178 in the first year and $2,913,443 thereafter. ConclusionsThe study highlights the need for informed decision-making when implementing molecular classification in clinical practice, given the substantial incremental healthcare costs associated with these approaches.

Hysteroscopic endometrial tumor localization and sentinel lymph node mapping. An upgrade of the hysteroscopic role in endometrial cancer patients

IntroductionGiven the growing interest in sentinel node mapping (SLN) biopsy in Endometrial Cancer (EC) patients, many efforts have been made to maximize the SLN bilateral detection rate. However, at present, no previous research assessed the potential correlation between primary EC location in the uterine cavity and SLN mapping. In this context, this study aims to investigate the possible role of intrauterine EC hysteroscopic localization in predicting SLN nodal placement. Materials and methodsEC patients surgically treated from January 2017 to December 2021 were retrospectively analyzed. All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and SLN mapping. During hysteroscopy, the location of the neoplastic lesion was described as follows: uterine fundus (comprising the most cranial portion of the uterine cavity up to the tubal ostium including the cornual areas), corpus uteri (from the tubal ostium to the inner uterine orifice), and diffuse (when the tumor invades more than 50% of the uterine cavity). ResultsThree hundred ninety patients met the inclusion criteria. The tumor pattern diffused to the whole uterine cavity was statistically associated with SLN uptake on common iliac lymph nodes (OR 2.4, 95%CI 1–5.8, p = 0.05). Patients'age is an independent factor associated with SLN failure (OR: 0.95, 95%CI 0.93–0.98, p < 0.001). ConclusionsThe study showed a statistically significant association between EC hysteroscopically spread throughout the whole uterine cavity and SLN uptake at the common iliac lymph nodes. Furthermore, patient age negatively affected the SLN detection rate.

Sentinel lymph node biopsy in endometrial cancer: The new norm - A multicentre, international experience

ObjectivesThe landscape of early-stage endometrial cancer treatment has changed dramatically over the last decade. The aim of this study is to provide a real-world view of the impact sentinel lymph node (SLN) biopsy has had on both clinical practice and patient outcomes. We describe detection and recurrence rates, as well as our experience in managing low volume lymph node disease. MethodsWe conducted an international, multicenter retrospective cohort study of 1012 patients with apparent early-stage endometrial cancer. Eligible patients underwent primary surgical staging and SLN biopsy in one of three large academic tertiary cancer centers in Canada or the Republic of Korea between 2015 and 2019. Demographic, surgical, clinicopathologic and recurrence data were collected through chart review. ResultsA total of 1012 patients were included. Overall SLN detection rate for all tracer types was 94.1% and recurrence rate was 5.3%. Higher FIGO stage (III vs. I/II) was associated with failed bilateral mapping (OR 2.27, 95%CI 1.14–4.52). We identified seven patients with micrometastases and 12 with isolated tumor cells, of which only one patient with micrometastases recurred at 17 months. Recurrence rates based on risk groups were 2.1%, 5.3%, 8.1%, and 9.9% for low, intermediate, high-intermediate, and high risk, respectively. ConclusionSLN biopsy is safe and feasible. Detection rates are high, regardless of which tracer type is used and recurrence rates are low, especially in low and intermediate risk disease. Patients with low volume metastases appear to have low risk of recurrence, but replication of our findings by large prospective studies are needed to elucidate their clinical importance.

Applications and Safety of Sentinel Lymph Node Biopsy in Endometrial Cancer.

Lymph node status is important in predicting the prognosis and guiding adjuvant treatment in endometrial cancer. However, previous studies showed that systematic lymphadenectomy conferred no therapeutic values in clinically early-stage endometrial cancer but might lead to substantial morbidity and impact on the quality of life of the patients. The sentinel lymph node is the first lymph node that tumor cells drain to, and sentinel lymph node biopsy has emerged as an acceptable alternative to full lymphadenectomy in both low-risk and high-risk endometrial cancer. Evidence has demonstrated a high detection rate, sensitivity and negative predictive value of sentinel lymph node biopsy. It can also reduce surgical morbidity and improve the detection of lymph node metastases compared with systematic lymphadenectomy. This review summarizes the current techniques of sentinel lymph node mapping, the applications and oncological outcomes of sentinel lymph node biopsy in low-risk and high-risk endometrial cancer, and the management of isolated tumor cells in sentinel lymph nodes. We also illustrate a revised sentinel lymph node biopsy algorithm and advocate to repeat the tracer injection and explore the presacral and paraaortic areas if sentinel lymph nodes are not found in the hemipelvis.

Sentinel Lymph Node Biopsy in Endometrial Cancer - A Systematic Review and Quality Assessment of Meta-Analyses.

To assess the quality of recent meta-analyses reviewing the diagnostic utility of sentinel node biopsy in endometrial cancer. With the MeSH terms endometrial neoplasms and sentinel lymph node biopsy, PubMed and Embase databases were searched on October 21, 2020, and again on November 10, 2021, with meta-analysis and publication date filters set to since 2015. The articles included were classified with the A Measurement Tool to Assess Systematic Reviews (AMSTAR 2) assessment tool. The database searches found 17, 7 of which, after the screening, were selected for full review by the author, finally extracting six meta-analyzes for quality analysis. The rating with the AMSTAR 2 assessment tool found that overall confidence in their results was critically low. This study found that the quality of recent meta-analyses on the utility of the staging of endometrial cancer with sentinel node biopsy, evaluated by the AMSTAR 2 assessment tool, is classified as critically low, and, therefore, these meta-analyses are not reliable in the summary of their studies.

Sentinel lymph node mapping versus sentinel lymph node mapping with systematic lymphadenectomy in endometrial cancer: an open-label, non-inferiority, randomized trial (ALICE trial)

BackgroundGrowing evidence suggest that sentinel lymph node (SLN) biopsy in endometrial cancer accurately detects lymph node metastasis. However, prospective randomized trials addressing the oncological outcomes of SLN biopsy in endometrial...

115 Surgical technique: indocyanine green and infrared fluorescence in sentinel lymph node mapping in endometrial cancer

Introduction: Endometrial cancer (EC) is the most common gynecological cancer in Europe and its incidence is increasing with aging population and obesity. Methods: We present a video describing the technical aspects of laparoscopic sentinel lymph node (SLN) biopsy using indocyanine green (ICG) and near-infrared fluorescence in FIGO stage IA endometrioid, low-grade EC, as part of the ongoing clinical trial at the author’s department regarding the use of SLN biopsy in EC. Results: A 72 year-old asymptomatic patient presented with a thickened endometrial lining on routine gynecological ultrasound and was diagnosed with endometrioid, low-grade EC on hysteroscopic endometrial biopsy.

Sentinel Lymph Node Biopsy in Endometrial Cancer: Dual Injection, Dual Tracer-A Multidisciplinary Exhaustive Approach to Nodal Staging.

Simple SummarySince clinical guidelines accepted the utilization of sentinel lymph node (SLN) in apparent uterine-confined endometrial cancer (EC), many centers have already used it as a standard staging surgery. The most widely accepted tracer is ICG alone, but several studies comment on the importance of surgeon experience in order not to lose sensitivity in the first 30-40 cases. This is a prospective, observational single-center trial designed to improve SLN detection rate specially during learning curve. The application of dual tracer (indocyanine green (ICG) and Technetium99 (Tc99) injected separately) helps us to reach a very good overall and bilateral SLN pelvic detection rate in early-stage endometrial cancer patients. Dual injection (cervical and fundal) improves para-aortic SLN detection rate.Introduction: Sentinel lymph node (SLN) has recently been introduced as a standard staging technique in endometrial cancer (EC). There are some issues regarding team experience and para-aortic detection. Objective: to report the accuracy of SLN detection in EC with a dual tracer (ICG and Tc99) and dual injection site (cervix and fundus) during the learning curve. Methods: A prospective, observational single-center trial including 48 patients diagnosed with early-stage EC. Dual intracervical tracer (Tc99 and ICG) was injected at different times. High-risk patients had a second fundus injection with both tracers. Results: the detection rates were as follows: 100% (48/48) overall for SLNs; 98% (47/48) overall for pelvic SLNs; 89.5% (43/48) for bilateral SLNs; and 2% (1/48) for isolated para-aortic SLNs. In high-risk patients, the para-aortic overall DR was 66.7% (22/33); 60.7% (17/28) with ICG and 51.5% (17/33) with Tc99 (p = 0.048)). Overall rate of lymph node involvement was 14.6% (7/48). Macroscopic pelvic metastasis was found in four patients (8.3%) and microscopic in one case (2%). No metastasis was found in any para-aortic SLNs. Half of the patients with positive pelvic SLNs had positive para-aortic nodes. In high-risk patients, when para-aortic SLNs mapped failed, 36.4% (4/11) had positive nodes in para-aortic lymphadenectomy. The sensitivity and negative predictive value (NPV) of SLN pelvic detection was 100%. Conclusions: Multidisciplinary exhaustive approach gives a suitable accuracy of SLN during learning curve. Dual injection (cervical and fundal) with dual tracer (ICG and Tc99) offers good overall detection rates and increases para-aortic SLN detection.

Comparison of Substance P Immunolocalization among Oral, Breast, Colorectal and Endometrial Carcinoma to Evaluate its Prognostic and Therapeutic Significance

Present study was conducted to evaluate the expression and immunolocalization of Substance P (SP) in different grades of Oral Squamous Cell Carcinoma (OSCC), Breast Cancer (BC), Colorectal Cancer (CRC) and Endometrial Cancer (EC). Patients and Methods: 40 OSCC, 22 BC, 30 CRC and 53 EC biopsies were immunohistochemically analyzed with SP antibody. 14 cases (35%) were well differentiated (WD), 14 cases (35%) moderately differentiated (MD) and 12 cases (30%) poorly differentiated (PD) OSCC. 2 cases (9%) were WD, 4 (18%) were MD and 16 (73%) were PD. There were 8 cases (27%) of PD, 14 (46%) MD and 8 cases (27%) of WD- CRC included in this study. In EC, there were 53 cases, 12 (22.69%) WD, 37 (67.8%) MD, 4 (75.4%) PD cases. Results: 65% of the OSCC, 55% of BC, all cases of CRC and EC were positive for SP. 8% of WD, 93% of MD, 100% PD were SP-positive in OSCC; 50% WD, 75% MD, 50% PD cases were SP-positive in BC; all cases of CRC and EC were SP-positive. Regarding the intensity of SP stain, SP expression was highest (+3) in PD-OSCC, PD-BC, all CRC and PD-EC and vice versa. Expression increased with an increasing grade of tumor in all except CRC. Conclusions: An association between grade of tumor and SP expression was observed in OSCC, BC and EC while no difference was observed in CRC. SP expression was in the increasing order from well to moderately differentiated cases in OSCC, BC and EC while it was reverse in CRC. We also suggest SP /NK-1R system as a potential therapeutic strategy to inhibit and manage OSCC, BC and EC. Key words: Breast carcinoma, Oral squamous cell carcinoma, Colorectal carcinoma, Substance P, neurokinin 1 receptor

TRP channel expression correlates with the epithelial\u2013mesenchymal transition and high-risk endometrial carcinoma

Transient receptor potential (TRP) channels excel in cellular sensing as they allow rapid ion influx across the plasma membrane in response to a variety of extracellular cues. Recently, a distinct TRP mRNA expression signature was observed in stromal cells (ESC) and epithelial cells (EEC) of the endometrium, a tissue in which cell phenotypic plasticity is essential for normal functioning. However, it is unknown whether TRP channel mRNA expression is subject to the phenotypic switching that occurs during epithelial to mesenchymal transition (EMT) and mesenchymal to epithelial transition (MET), and whether TRP channel mRNA expression is associated with aggressive phenotypes in endometrial cancer (EC). Here, we induced EMT and MET in vitro using in primary EEC and ESC, respectively, and analyzed expression and functionality of TRP channels using RT-qPCR and intracellular Ca2+ imaging. The outcome of these experiments showed a strong association between TRPV2 and TRPC1 mRNA expression and the mesenchymal phenotype, whereas TRPM4 mRNA expression correlated with the epithelial phenotype. In line herewith, increased TRPV2 and TRPC1 mRNA expression levels were observed in both primary and metastatic EC biopsies and in primary EC cells with a high EMT status, indicating an association with an aggressive tumor phenotype. Remarkably, TRPV2 mRNA expression in primary EC biopsies was associated with tumor invasiveness and cancer stage. In contrast, increased TRPM4 mRNA expression was observed in EC biopsies with a low EMT status and less aggressive tumor phenotypes. Taken together, this dataset proved for the first time that TRP channel mRNA expression is strongly linked to cellular phenotypes of the endometrium, and that phenotypic transitions caused by either experimental manipulation or malignancy could alter this expression in a predictable manner. These results implicate that TRP channels are viable biomarkers to identify high-risk EC, and potential targets for EC treatment.

Diagnostic Accuracy of Liquid Biopsy in Endometrial Cancer.

Simple SummaryThe number of endometrial cancer (EC) cases is constantly growing. However, the current diagnostic approach is still rather imprecise, leaving 1/3 of patients temporarily undiagnosed. Moreover, final diagnosis is made after the surgery. That mean the histology of tumor, which influences scope of resection, is uncertain during procedure. This results in over- and undertreatment of EC patients. Those diagnostic problems might be solved by liquid biopsy—a new, minimally invasive method to obtain tumor biomarkers. Therefore, this study aimed to evaluate the usefulness of information obtained from liquid biopsy components (tumor educated platelets and circulating tumor DNA) coupled with random forest algorithm and deep neural networks to diagnose EC patients and evaluate tumor histology preoperatively.Background: Liquid biopsy is a minimally invasive collection of a patient body fluid sample. In oncology, they offer several advantages compared to traditional tissue biopsies. However, the potential of this method in endometrial cancer (EC) remains poorly explored. We studied the utility of tumor educated platelets (TEPs) and circulating tumor DNA (ctDNA) for preoperative EC diagnosis, including histology determination. Methods: TEPs from 295 subjects (53 EC patients, 38 patients with benign gynecologic conditions, and 204 healthy women) were RNA-sequenced. DNA sequencing data were obtained for 519 primary tumor tissues and 16 plasma samples. Artificial intelligence was applied to sample classification. Results: Platelet-dedicated classifier yielded AUC of 97.5% in the test set when discriminating between healthy subjects and cancer patients. However, the discrimination between endometrial cancer and benign gynecologic conditions was more challenging, with AUC of 84.1%. ctDNA-dedicated classifier discriminated primary tumor tissue samples with AUC of 96% and ctDNA blood samples with AUC of 69.8%. Conclusions: Liquid biopsies show potential in EC diagnosis. Both TEPs and ctDNA profiles coupled with artificial intelligence constitute a source of useful information. Further work involving more cases is warranted.

Overall survival after surgical staging by lymph node dissection versus sentinel lymph node biopsy in endometrial cancer: a national cancer database study

ObjectiveSubstituting lymphadenectomy with sentinel lymph node biopsy for staging purposes in endometrial cancer has raised concerns about incomplete nodal resection and detrimental oncological outcomes. Therefore, this study aimed to investigate...

Utility of indocyanine green as a single tracer for sentinel node biopsy in endometrial cancer.

Our study aims to investigate the safety and effectiveness of sentinel lymph node biopsy using indocyanine green (ICG) for the surgical staging of early-stage endometrial cancer in comparison to technetium-99 m use. We conducted an observational retrospective study with patients diagnosed of endometrial cancer and FIGO stages I-II. All participants were injected technetium-99m the day prior to the surgery and underwent lymphoscintigraphy along with single-photon emission computed tomography. In addition, all patients were administered intraoperatively ICG injection to detect sentinel lymph node biopsy. The surgical staging was then completed according to the European Society for Medical Oncology preoperative risk category. Data obtained from the analysis of technetium-99m detection was compared to ICG detection. A total of 53 women with endometrial cancer were included in the study, 49 (92.5%) of them showed drainage preoperatively in the single-photon emission computed tomography and/or lymphoscintigraphy. The intraoperative bilateral detection rate for technetium-99 m was 26 (49.1%) patients compared to 40 (75.5%) patients with ICG (p= 0.013). We observed a 42.5% increase in the mean number of lymph nodes retrieved by ICG compared to technetium-99m (2.85 vs 2,0 nodes; p= 0.002). We intraoperatively identified 164 lymph nodes, 104 (63.4%) located in both obturator areas and external iliac vessels. The use of ICG for the performance of sentinel node biopsy in patients with endometrial cancer seems safe and could be superior to technetium-99 m, since it offers a higher bilateral detection rate and nodal retrieval, resulting in the possibility to perform safely less full staging lymphadenectomies.

The utilisation of sentinel lymph node biopsy for endometrial cancer in Australia and New Zealand.

The aim of this study was to identify to what extent the sentinel lymph node (SLN) technique is utilised by gynaecological oncologists in Australia and New Zealand, identifying the techniques used, any barriers to uptake, and management of isolated tumour cells (ITCs) and micrometastases. We conducted an online survey of all practising gynaecological oncologists in Australia and New Zealand. They were asked whether they utilised SLN biopsy and in what circumstances, how they managed non-mapping and how their multidisciplinary team managed small volume disease. Those who did not were asked to identify their concerns with the procedure, reasons for non-uptake and their alternate technique. We surveyed 63 gynaecological oncologists of whom 59 were practising, and 48 (81%) responded. Six members (11%) do not utilise SLN biopsy, and 42 (89%) do. Areas where clinicians differ in practice are those areas that are most controversial and include the use of SLN biopsy in complex atypical hyperplasia, the management of ITCs and micrometastases and procedures on unilateral or bilateral non-mapping. Those who do not utilise the technique cite concerns about the false-negative rate, equipment and training issues. The utilisation of SLN biopsy in endometrial cancer is well established in Australia and New Zealand, with similar practices and concerns to those of other international groups.

Lymphatic mapping and obesity with sentinel lymph node biopsy in endometrial cancer

<h3>Objectives:</h3> Sentinel lymph node biopsy (SLNB) has emerged as an acceptable alternative to complete pelvic and paraaortic lymph node dissection (PPALND) for patients with clinical stage I endometrial cancer. Several factors are associated with high risk of bilateral SLN detection failure. Our aim is to investigate the effect of obesity on bilateral SLN detection rates. <h3>Methods:</h3> Patients with either clinical stage I endometrial cancer or complex atypical hyperplasia were retrospectively reviewed from September 2016 through February 2020. All patients had undergone either a robot-assisted or laparoscopic hysterectomy with SLNB. Endometrioid, uterine papillary serous (UPSC), malignant mixed mesodermal tumor (MMMT), and clear cell (CC) histologies were included. Indocyanine green was injected into the cervix per our protocol. Patients with suboptimal lymph node mapping or nodes suspicious for metastasis underwent a side specific pelvic lymph node dissection (LND). In addition to SLNB, PPALND was performed for patients with UPSC, MMMT, and CC. Sentinel lymph nodes (SLN) were evaluated using ultra-staging protocols including serial sectioning and cytokeratin staining. The medical record was queried for successful bilateral or unilateral sentinel lymph node detection. Patient demographic data was then collected and analyzed with sentinel lymph node detection rate. <h3>Results:</h3> A total of 97 patients were reviewed and included: 92 had diagnosed endometrial cancer while 5 had complex atypical hyperplasia. Stage were as follows: 81 patients had stage I or II disease, and 8 patients had Stage III disease diagnosed at surgery. At least one SLN was detected 95.9% of cases, with an overall bilateral detection rate of 77.7%. In total, 53 patients classified as obese (25 Class I, 15 Class II and 13 Class III), 24 patients were overweight (BMI 25-29.9) and 20 patients had normal BMI. Unilateral and bilateral detection rates were not independently associated with obesity class. Bilateral SLN detection rates were 76% in normal BMI class and 67%, 83% and 73% for Class I, Class II and Class III obesity respectively; while at least one SLN was detected in 94% of normal BMI class and 92%, 96%, 100% and 92% in overweight weight class, Class I, II and II obesity respectively. <h3>Conclusions:</h3> Patient BMI is an important consideration for preoperative planning and success of bilateral sentinel lymph node mapping. Bilateral detection rates among obese patients are comparable to those of non-obese patients in our cohort. Despite previously reported correlation between BMI and successful bilateral mapping, our results do not demonstrate this relationship and obesity does not appear to be a contraindication to SLNB.

Update on Sentinel Lymph Node Biopsy in Surgical Staging of Endometrial Carcinoma.

Sentinel lymph node (SLN) biopsy has emerged as an alternative staging approach in women with assumed early-stage endometrial carcinoma. Through image-guided surgery and pathologic ultrastaging, the SLN approach is introducing “precision medicine” to the surgical management of gynecologic cancers, providing a comprehensive evaluation of high-yield lymph nodes. This approach improves the surgeons’ ability to detect small-volume metastatic disease while reducing intraoperative and postoperative morbidity associated with lymphadenectomy. Although the majority of clinicians in Europe and the USA have recognized the value of SLN biopsy in endometrial carcinoma and introduced this as part of clinical practice, there is ongoing debate regarding its role in very low-risk patients as well as in patients at high risk of nodal metastasis. The significance of low-volume metastasis is not fully understood, and there is no consensus in regard to how the presence of isolated tumor cells should guide adjuvant therapy. Standardized protocols for histopathologic evaluation of SLNs are lacking. In this review article we aim to provide a framework for the introduction of SLN biopsy in endometrial cancer, give an updated overview of the existing literature, as well as discuss potential controversies and unanswered questions regarding this approach and future directions.