Lymphadenectomy In Endometrial Cancer Research Articles

A selective anatomically based lymph node sampling can replace a side specific pelvic lymphadenectomy in endometrial cancer with failed sentinel node mapping

AimTo evaluate the locations of metastatic pelvic sentinel nodes (SLN) and the proportion of SLNs outside and within defined typical anatomical positions along the upper paracervical lymphatic pathway (UPP). Patients and methodsConsecutive women with endometrial cancer (EC) of all risk groups underwent pelvic SLN-detection using cervically injected indocyanine green (ICG). A strict anatomically based algorithm and definitions of SLNs was adhered to. The positions of ICG-defined SLNs were intraoperatively depicted on an anatomical chart. All SLNs were examined using ultrastaging and immunohistochemistry. The proximal third of the obturator fossa and the interiliac area were defined as typical positions. The parauterine lymphovascular tissue (PULT) was separately removed. The proportions of metastatic SLNs, overall and isolated, typically, and atypically positioned were analyzed per woman. ResultsA median of two (range 1–12) SLN metastases along the UPP including the PULT were found in 162 women. 41 of 162 women (25.3 %) had isolated metastases in the obturator fossa harboring 49.1 % of all SLN metastases. Three women (1,9 %) had isolated PULT metastases. SLN metastases outside typical positions were identified in 28/162 women (17.3 %); isolated metastases were seen in seven women (4.3 %), so 95.7 % of pelvic node positive women had at least one metastatic SLN located at a typical position. ConclusionA selective removal of lymph nodes at typical proximal obturator and interiliac positions and the PULT can replace a full side specific pelvic LND when SLN mapping is unsuccessful. The obturator fossa is the predominant location for metastatic disease.

Disease-Free and Overall Survival Implications of Pelvic Lymphadenectomy in Endometrial Cancer: A Retrospective Population-Based Single-Center Study

The role of pelvic lymphadenectomy in endometrial cancer remains unclear. In this study, we aimed to investigate the influence of lymphadenectomy on progression-free and overall survival among patients diagnosed with endometrial carcinoma. This retrospective single-center study included 1532 patients operated on in a Polish reference center for gynecologic oncology at Holy Cross Hospital, Kielce, between 2002 and 2020. A total of 1004 patients underwent systematic lymphadenectomy as a part of their surgical procedure. The median number of collected lymph nodes was seven. In total, 11.6% of patients were found to have lymph node invasion. The number of lymph nodes removed correlated with patient survival. In patients in whom the number of removed lymph nodes was above the median (>7), the risk of death was reduced (HR 0.68, p = 0.002). The risk of death correlated with the presence of lymph node metastasis (HR 4.12, p < 0.001). The risk of cancer progression was associated with the number of lymph nodes removed (HR 0.54, p = 0.006), and the risk of EC recurrence was greater in patients with lymph node metastasis (HR 1.94, p = 0.016). Our study provides additional evidence that systematic lymphadenectomy may influence the disease-free and overall survival of patients with endometrial cancer. The number of lymph nodes removed correlated with patient prognosis. Further studies are needed to evaluate the use of lymphadenectomy in endometrial cancer treatment.

Sentinel lymph biopsy versus full lymphadenectomy in endometrial cancer: SEER database analysis (1226)

Sentinel lymph biopsy versus full lymphadenectomy in endometrial cancer: SEER database analysis (1226)

Sentinel lymph node sampling versus full lymphadenectomy in endometrial cancer: a SEER database analysis

ObjectiveTo assess the long term outcomes and prognosis of sentinel lymph node sampling compared with full lymph node dissection in endometrial cancer patients.MethodsWe used the Surveillance, Epidemiology, and End Results...

Incidental damage of obturator nerve during laparoscopic pelvic lymphadenectomy in endometrial cancer – Demonstration of a successful repairing procedure

ObjectiveIn order to highlight the importance of intraoperative complications and their management, we demonstrate a video of an iatrogenic left obturator nerve lesion during a pelvic lymphadenectomy for endometrial cancer staging. The repair was promptly performed using an intracorporeal laparoscopic suture for an end-to-end tension-free nerve anastomosis. DesignStepwise demonstration of the technique with narrated video footage. SettingA 70-year-old woman with a stage IB grade I endometrial adenocarcinoma was submitted to a surgical laparoscopic staging with total hysterectomy(TH), bilateral adnexectomy(BA), and bilateral pelvic and lomboaortic lymphadenectomy. After an uneventful retroperitoneal lomboaortic lymphadenectomy, the left paravesical space was dissected until the obturator fossae and a left pelvic lymphadenectomy followed, during which the left obturator nerve was accidentally transected with LigaSure™. InterventionsA careful inspection revealed an almost complete transection (80%) of the nerve, with both proximal and distal cut ends identifiable and no fraying of the edges. The thickness of the non-sectioned nervous portion was less than 3 mm, but a tension-free reattachment of both edges seemed manageable. The edges were oriented towards each other and a single stitch suture was placed using a 5–0 prolene, providing an epineural end-to-end coaptation. To reinforce the suture, a Fibrin sealant Tissucol® was applied. The contralateral pelvic lymphadenectomy was then performed, followed by TH and BA. The pieces were removed through the vagina using an endobag. The patient was discharged on the second postoperative day. During the follow-up, there were no signs of diminished adductor function, and neither there was any other detectable residual neuropathy or neurologic deficit involving the left thigh. ConclusionIt is crucial to identify intraoperative complications and to develop abilities to manage them. This video proves that it is possible to repair a transected obturator nerve using laparoscopy, when performed by an experienced onco-gynecologist, with extremely good functional results.

Comparison of progression-free survival outcome of sentinel node biopsy without ultrastaging versus lymphadenectomy in endometrial cancer: a propensity-matched analysis.

We aimed to investigate the oncologic outcomes of patients with endometrial cancer who underwent sentinel lymph node (SLN) biopsy without ultrastaging compared with that of those who underwent lymphadenectomy (LND). Patients with endometrial cancer who underwent staging with SLN biopsy or LND during 2006 - 2021 were analyzed using propensity score matching (PSM). SLN metastasis was examined using hematoxylin and eosin staining, without ultrastaging. Progression-free survival (PFS) was compared between the two groups before and after PSM using age, histology, and stage as covariates. Clinical variables such as recurrence patterns and lymphatic complications, were assessed. After excluding 213 patients who underwent validation LND with SLN biopsy, 902 were identified. The demographics of the remaining patients differed according to histology, myometrial invasion depth, and stage. Lymph node metastasis was less frequent in the SLN group than in the LND group (9.4% vs. 3.8%, p=0.004). The recurrence rates within 2 years were lower in the SLN group. The SLN group exhibited significantly superior 2-year and overall PFS than the LND group. Among patients with uterus-confined disease, overall PFS was favorable for SLN biopsy. After matching, differences in PFS were no longer observed, although the lymphocele and lymphedema rates were significantly lower in the SLN group. In patients with endometrial cancer, SLN biopsy without ultrastaging did not compromise survival outcomes and was associated with significantly reduced lymphatic complication rates compared with LND. Therefore, SLN biopsy can be recommended for patients with endometrial cancer without definitive preoperative evidence of distant metastasis.

Serum miRNA-204-5p as a potential non-invasive biomarker for the diagnosis of endometrial cancer with sentinel lymph node mapping.

The lymph node status is one of the most critical prognostic factors used in determining adjuvant treatment in endometrial cancer (EC). Lymphadenectomy is associated significant surgical and postoperative risks. The use of sentinel lymph node mapping (SLNM) has emerged as an alternative method to complete lymphadenectomy in EC. However, there remains controversy surrounding the use of SLNM in high-risk disease and its false-negative rate (3%). The authors previously identified miR-204-5p as a tumor-suppressor miRNA associated with lymph node metastasis in EC tissues. The present study demonstrated that serum miR-204-5p in patients with EC has the potential for use as an early diagnostic biomarker combined with SLNM to assess the lymph node status prior to surgery. The present study also aimed to identify the optimal cut-off value of serum miR-204-5p. The relative expression levels of miR-204-5p were detected using reverse transcription-quantitative PCR in the serum of 52 patients with EC (total SLNM). A total of 20 patients diagnosed with ovarian cysts, 20 patients diagnosed with myoma, and 20 participants diagnosed with endometrial polyps or endometrial hyperplasia were included as the control group. miR-204-5p expression was also detected in lymph node tissues using in situ hybridization. The results revealed that serum miR-204-5p expression was downregulated in patients with EC compared with its expression in patients with benign ovarian cysts, myoma and endometrial hyperplasia/polyps (P<0.01). In accordance with the final pathological evaluation, patients with EC with a positive SLN status had a significantly lower level of miR-204-5p compared with those with a negative SLN status (P<0.01). The area under the ROC curve of miR-204-5p was 0.923, 95% CI (0.847-1.000), and the diagnostic value had a sensitivity of 87.2% and specificity of 80.0%, with an optimal cut-off value of 0.253. On the whole, it was demonstrated that a lower miR-204-5p expression is associated with lymph node metastasis in these SLN(+) EC tissues, indicating that the downregulation of serum miR-204-5p in patients with EC has potential for use as an early diagnostic biomarker combined with SLNM. In addition, with a cut-off value of 0.253, it appeared optimal for the prediction of lymph node metastasis in EC.

Systematic Lymphadenectomy and Oncological Outcomes of Women With Apparent Early-Stage Clear Cell Carcinoma of the Endometrium: A Multi-Institutional Cohort Study

ObjectiveThe survival value of systematic lymphadenectomy for endometrial cancer is ambiguous and controversial. The current study aimed to evaluate the long-term survival role of combined pelvic and para-aortic lymphadenectomy in patients with presumed early-stage clear cell carcinoma of the endometrium.MethodsPatients in three Chinese teaching hospitals who presented between 2012 and 2017 with apparent early-stage clear cell carcinoma of the endometrium and underwent surgical staging were selected. Patients who did and did not undergo systematic lymphadenectomy were identified and clinicopathological characteristics were compared. Disease-free survival and overall survival were evaluated following the generation of the Kaplan-Meier curves and the comparison using the log-rank test. A Cox proportional hazards model was employed to control for confounders.ResultsA total of 244 patients underwent systematic lymphadenectomy and 89 did not receive lymph node dissection. The demographic and baseline data were comparable between the two groups. The rate of disease-free survival at 5 years was 64.10% in patients who underwent systematic lymphadenectomy and 45.05% in patients who did not undergo lymphadenectomy. Patients who underwent systematic lymphadenectomy had better disease-free survival than those who did not receive lymphadenectomy (HR, 0.54. 95% CI, 0.38-0.76. P=0.000). The rate of 5-year overall survival was 68.87% in the lymphadenectomy group and 53.33% in patients who did not undergo systematic lymphadenectomy. Systematic lymphadenectomy was also associated with improved 5-year overall survival for women with presumed early-stage clear cell carcinoma of the endometrium (HR, 0.58. 95% CI, 0.39-0.85. P=0.005). After adjusting for confounders, systematic lymphadenectomy was still independently associated with improved disease-free survival and overall survival.ConclusionPatients with apparent early-stage clear cell carcinoma of the endometrium who underwent systematic lymphadenectomy had better long-term survival than those who did not undergo systematic lymphadenectomy.

The role of paraaortic lymphadenectomy along with sentinel mapping in clinically uterine confined intermediate-high risk endometrial cancer

This study aimed to find out whether sentinel algorithm can be sufficient in clinically uterine confined intermediate-high risk endometrial cancer. Detailed pathology characteristics and follow-up records of the 70 intermediate-high risk endometrial cancer patients were identified. Outcomes of patients who are performed sentinel algorithm and sentinel mapping followed by systematic pelvic and paraaortic lymph node dissection were compared. All patients who had obvious extrauterine disease in preoperative and intraoperative evaluation were excluded. Sentinel mapping is performed with methilene blue and cervical injection. 66 patients were identified (sentinel algorithm group, 25; Paraaortic lymph node dissection group, 45). Paraaortic lymph node dissection group had more high grade patients (p=0.02). The mean number of lymph nodes harvested was 11.3 and 36.9, respectively, in sentinel algorithm group and paraaortic lymph node dissection group(p&lt;0.001) and there was more lymph node metastasis in paraaortic lymph node dissection group (12% and 31,7%; p=0.07). 84% in the sentinel algorithm group and 92.7% in the paraaortic lymph node dissection group, respectively, received adjuvant therapy (p=0.02). Overall, four patients recurred within the first three year following surgery, two patients had systematic multiple metastasis and both of them died due to disease. There was no significant difference between the two groups in terms of overall survival (p = 0.252), disease specific survival (p = 0.10) and disease-free survival (p = 0.577). The mean follow-up period was calculated as 29.33 months. To date, there is no prospective study focused on whether sentinel lymphadenectomy in endometrial cancer is sufficient for management of moderate high-risk endometrial cancer and to establish the necessity of paraaortic lymphadenectomy in this patient group. Our study indicates that for clinically uterine confined intermediate-high risk endometrial cancer patients sentinel lymph node algorithm can be sufficient. Further studies are needed to confirm this finding.

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...

“Long-term outcome in endometrial cancer patients after robot-assisted laparoscopic surgery with sentinel lymph node mapping”

ObjectiveSentinel Lymph Node (SLN) mapping is increasingly used as an alternative to lymphadenectomy in endometrial cancer. There is, however, limited data regarding the clinical outcome and survival after SLN mapping. The aim of the study was to determine long-term outcome data in endometrial cancer patients undergoing robot-assisted laparoscopic surgery and SLN mapping.Study design: Retrospective cohort study of 108 patients with primary endometrial cancer who underwent robot-assisted laparoscopic surgery and sentinel lymph node mapping using the Memorial Sloan Kettering Cancer Center (MSKCC) algorithm with near-infrared fluorescence detection of indocyanine green for endometrial cancer, from November 20th 2012 to January 1st 2016 at St. Olav’s Hospital in Norway. The primary endpoint was recurrence-free survival. Secondary endpoints were overall survival and treatment complications. ResultsAmong 108 patients operated in accordance with the SLN algorithm, 17 (16%) had lymph node metastases. Adjuvant chemotherapy was administered on indication endometrial cancer to 36 (33%) of the patients. After a median follow up of 75 months (range 61–98), five (4.6%) patients had recurrence, and three patients had died from the disease. Four of the patients who had recurrence had lymph node metastasis at diagnosis. The 5-year recurrence-free survival was 95.4% (95% CI, 91.5 – 99.3). The 5-year disease-specific survival was 97.2% (95% CI, 94.1 – 100.3). The 5-year overall survival was 92.6% (95% CI, 87.7 – 97.5). Peripheral neuropathy after chemotherapy was the most common complication (9.3%), followed by lower limb lymphedema (2%) and postoperative hernia (2%). ConclusionThe present study demonstrated excellent oncologic outcome and low long-term treatment complication rate in patients treated according to the SLN algorithm more than five years after diagnosis.

Sentinel lymph node biopsy versus complete lymphadenectomy in high grade endometrial cancer: a systematic review and meta-analysis of performance characteristics

Objectives: Sentinel lymph node (SLN) biopsy is widely accepted as the standard of care for surgical staging in low grade endometrial cancer, but its value in high grade endometrial cancer remains unclear. The aim of this systematic review and meta-analysis was to evaluate the performance characteristics of SLN biopsy compared with pelvic lymphadenectomy in endometrial cancer patients with high-grade histology (PROSPERO ID: CRD42020160280). Methods: We systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, ClinicalTrials.gov, Ovid MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (January 1, 2000 to February 4, 2020) for prospective observational studies evaluating SLN biopsy in clinical stage I high grade endometrial cancer patients (grade 3 endometrioid, serous, clear cell, carcinosarcoma, mixed, undifferentiated/dedifferentiated, high grade not otherwise specified). Studies in which patients underwent cervical injection of indocyanine green for SLN detection, and at least a bilateral pelvic lymphadenectomy as a reference standard, were eligible for inclusion. If data was not reported specifically for patients with high grade histology, authors were contacted for aggregate data. We pooled detection rates and measures of diagnostic accuracy using a generalized linear mixed-effects model with a logit link, and assessed risk of bias using the QUADAS-II tool. Results: We identified 20 eligible studies, of which the authors for 8 provided data on 427 high grade patients specifically. The study-level median age was 66.9 years (range 44-82.8) and the study-level median BMI was 28.8 kg/m2 (range 18.9-45.2). The pooled detection rates were 91% per patient (95% CI 85-95; I2=62%) and 64% bilaterally (95% CI 53-73, I 2=72%). The overall node-positivity rate was 26% (95% CI 20-34; I 2=47%). Of 87 node positive patients, SLN biopsy correctly identified 80, yielding a pooled sensitivity of 92% per patient (95% CI 84-96; I2=0%) (Figure 1), false negative rate of 8% (95% CI 4-16; I2=0%), and negative predictive value of 97% (95% CI 95-99; I 2=0%). Conclusions: SLN biopsy accurately detects lymph node metastases in high grade endometrial cancer, with a false negative rate comparable to that observed in melanoma and breast cancer. Diagnostic accuracy would be even higher if a strict SLN algorithm was followed in all included studies. SLN biopsy can replace complete lymphadenectomy in patients with high grade endometrial cancer. Sentinel lymph node (SLN) biopsy is widely accepted as the standard of care for surgical staging in low grade endometrial cancer, but its value in high grade endometrial cancer remains unclear. The aim of this systematic review and meta-analysis was to evaluate the performance characteristics of SLN biopsy compared with pelvic lymphadenectomy in endometrial cancer patients with high-grade histology (PROSPERO ID: CRD42020160280). We systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, ClinicalTrials.gov, Ovid MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (January 1, 2000 to February 4, 2020) for prospective observational studies evaluating SLN biopsy in clinical stage I high grade endometrial cancer patients (grade 3 endometrioid, serous, clear cell, carcinosarcoma, mixed, undifferentiated/dedifferentiated, high grade not otherwise specified). Studies in which patients underwent cervical injection of indocyanine green for SLN detection, and at least a bilateral pelvic lymphadenectomy as a reference standard, were eligible for inclusion. If data was not reported specifically for patients with high grade histology, authors were contacted for aggregate data. We pooled detection rates and measures of diagnostic accuracy using a generalized linear mixed-effects model with a logit link, and assessed risk of bias using the QUADAS-II tool. We identified 20 eligible studies, of which the authors for 8 provided data on 427 high grade patients specifically. The study-level median age was 66.9 years (range 44-82.8) and the study-level median BMI was 28.8 kg/m2 (range 18.9-45.2). The pooled detection rates were 91% per patient (95% CI 85-95; I2=62%) and 64% bilaterally (95% CI 53-73, I 2=72%). The overall node-positivity rate was 26% (95% CI 20-34; I 2=47%). Of 87 node positive patients, SLN biopsy correctly identified 80, yielding a pooled sensitivity of 92% per patient (95% CI 84-96; I2=0%) (Figure 1), false negative rate of 8% (95% CI 4-16; I2=0%), and negative predictive value of 97% (95% CI 95-99; I 2=0%). SLN biopsy accurately detects lymph node metastases in high grade endometrial cancer, with a false negative rate comparable to that observed in melanoma and breast cancer. Diagnostic accuracy would be even higher if a strict SLN algorithm was followed in all included studies. SLN biopsy can replace complete lymphadenectomy in patients with high grade endometrial cancer.

Clinical study of the clinical characteristics and prognosis of 1219 cases of endometrial cancer with lymph node metastasis.

To analyze the clinical characteristics and prognosis of endometrial cancer patients with lymph node metastasis to provide a reference for lymphadenectomy in endometrial cancer. The data used in this study were extracted from a tertiary hospital in Guangxi, China based on the hospital information system. 1219 patients with endometrial malignancy who were treated in our hospital. The lymph node metastasis rate was 9.8%. The metastasis rate of the abdominal aorta + pelvic lymph nodes (56.7%) was significantly higher than that of the pelvic (24.2%) or para-aortic (19.2%) lymph nodes alone. The proportion of postmenopausal patients with lymph node metastasis was higher than that of premenopausal patients. The proportion of patients with lymph node metastasis with vaginal and uterus involvement, HPV detection, Thinprep Cytologic Testresults, CRP level <10 ug/mL, G3 tumor grade, postoperative pathology indicating cervical invasion, lymphovascular invasion, and muscular infiltration depth > 1/2 was higher than that of patients without lymph node metastasis. The proportion of endometrial cancer patients with lymph node metastasis with CA125 ≥ 35 U/ml was higher than that of those with CA125 < 35 U/ml. The lymph node-positive rate is related to tissue differentiation, lymphangitic infiltration, cervical invasion, muscle infiltration depth > 1/2, and CA125 level. The metastasis rate of pelvic and para-aortic lymph nodes is higher than that of pelvic lymph nodes or para-aortic lymph nodes alone. There was no statistically significant difference in the overall survival rate among the three groups.

Prospective Non-randomized Control Trial on Role of Systematic High Para-Aortic Lymphadenectomy in Endometrial Cancer: Indian Study

Endometrial cancer (EC) accounts for approximately 10% of all cancers in females and is the second most common gynecologic cancer. The primary goal of surgical staging in EC is to identify extrauterine disease. Pelvic and para-aortic lymph node dissection (PLND and PaLND) is the gold standard in the detection of lymph node metastases in EC. However, there is still no uniformity worldwide regarding the scope and extent of lymph node dissection in EC. The present prospective non-randomized study was conducted to establish the importance of systematic lymphadenectomy (LND), especially PaLND above the inferior mesenteric artery (IMA), and to identify the risk factors associated with lymph node metastasis. A total of 210 patients with EC were included. All patients underwent comprehensive surgical staging which included simultaneous PLND and PaLND. In addition for non-endometrioid, additional omental and peritoneal biopsies were also performed. PLND consisted of complete removal of common iliac, external iliac, internal iliac and obturator lymph nodes as per standard techniques. The extent of PaLND was up to the renal veins. Pelvic lymph nodes (PLN), para-aortic lymph nodes (PaLN) harvested below the IMA and PaLN dissected above the IMA were labeled separately and submitted for histopathological examination (HPE). Patient’s demographic factors, surgical outcomes and tumor histological findings were tabulated for analysis. Patients diagnosed with EC were most commonly in their seventh decade (59.5%). The mean time for LND was 35 min. In 66% of the cases with positive PLN, the PaLN was also positive. Twenty-nine (13.8%) patients had both PLN and PaLN involvement. In all cases of positive PaLN, the nodes between IMA and renal veins were the only positive nodes. In 15 (7.1%) patients, PaLN were the only positive nodes. The mean PaLN yield was 9.1. Predictors of PaLN positivity were pelvic node positivity, Grade III tumors and lymphovascular space invasion (LVSI). Major complications observed were wound infection, paralytic ileus and subacute intestinal obstruction. In oncology, a good loco-regional control has the greatest impact on survival. Systematic para-aortic lymphadenectomy done with good surgical technique results in minimal morbidity and mortality without any additional blood transfusion requirement. The trend toward greater use of complete surgical staging has been accompanied by a judicious use of adjuvant therapy. This has led to marked decrease in the use of pelvic radiation therapy and its complications and has a significant impact on the cost of treatment.

Lymphadenectomy issues in endometrial cancer.

ObjectivesThis review aims to introduce preoperative scoring systems to predict lymph node metastasis (LNM) and ongoing clinical trials to investigate the therapeutic role of lymphadenectomy for endometrial cancer.MethodsWe summarized previous reports on the preoperative prediction models for LNM and evaluated their validity to omit lymphadenectomy in our recent cohorts. Next, we compared characteristics of two ongoing lymphadenectomy trials (JCOG1412, ECLAT) to examine the survival benefit of lymphadenectomy in endometrial cancer, and described the details of JCOG1412.ResultsLymphadenectomy has been omitted for 64 endometrial cancer patients who met low-risk criteria to omit lymphadenectomy using our scoring system (LNM score) and no lymphatic failure has been observed. Other two models also produced comparable results. Two randomized phase III trials to evaluate survival benefit of lymphadenectomy are ongoing for endometrial cancer. JCOG1412 compares pelvic lymphadenectomy alone with pelvic and para-aortic lymphadenectomy to evaluate the therapeutic role of para-aortic lymphadenectomy for patients at risk of LNM. For quality assurance of lymphadenectomy, we defined several regulations, including lower limit of the number of resected nodes, and submission of photos of dissected area to evaluate thoroughness of lymphadenectomy in the protocol. The latest monitoring report showed that the quality of lymphadenectomy has been well-controlled in JCOG1412.ConclusionOur strategy seems reasonable to omit lymphadenectomy and could be generalized in clinical practice. JCOG1412 is a high-quality lymphadenectomy trial in terms of the quality of surgical procedures, which would draw the bona-fide conclusions regarding the therapeutic role of lymphadenectomy for endometrial cancer.

Application of thrombin gel matrix for the prevention of lymphocele in patients with endometrial cancer: A prospective randomized trial

ObjectiveTo evaluate a thrombin gel matrix (TGM), Floseal, for the prevention of lymphocele in patients with endometrial cancer who underwent pelvic lymphadenectomy. MethodsA total of 79 consecutive patients with endometrial cancer were randomly allocated to one of two groups: the TGM group and control group. After completion of the lymphadenectomy, 5 mL of Floseal was applied to the bilateral pelvic sidewalls, especially the femoral canal, obturator, and common iliac vessels areas. Computed tomography scans were obtained for lymphocele evaluation 2 months after the surgery. ResultsThree patients from the TGM group, and four patients from the control group were lost during follow-up, and data from 36 participants from each group were analyzed. As the primary outcome, lymphocele developed in 12 patients in both groups (33 %). There was no significant difference between the groups in terms of lymphocele and symptomatic lymphocele development. Lymphocele localization was also not different between the two groups, but the diameter of the lymphoceles detected in the TGM group was significantly greater (p = 0.021). The mean drainage days was significantly shorter in the TGM group (p = 0.015). The amount of drainage was also less in the TGM group, but the difference was not statistically significant. ConclusionThrombin gel matrix applied to the pelvic sidewalls does not reduce the incidence of symptomatic or asymptomatic lymphoceles after pelvic lymphadenectomy in endometrial cancer. However, it can reduce the amount of drainage and the number of drainage days so it can help to shorten hospitalization.

Impact of Sentinel Node Mapping in Decreasing the Risk of Lymphocele in Endometrial Cancer.

Due to the growing evidence of sentinel lymph node (SLN) mapping in endometrial cancer (EC), our aim was to evaluate the impact of SLN mapping and other clinical-pathological variables in the risk of developing lymphocele. We retrospectively analyzed a series of patients with ECs who underwent lymph node staging with SLN mapping with or without systematic pelvic ± para-aortic lymphadenectomy from November 2012 to January 2020. The lymphocele diagnosis was performed by computed tomography or magnetic resonance imaging. Of 348 patients included, 178 underwent SLN mapping only and 170 underwent SLN mapping and systematic lymphadenectomy (46.5% pelvic only; 53.5% pelvic and para-aortic). Seventy-three (21%) patients had open surgery and 275 (79%) had a minimally invasive approach. After a median follow-up of 25.4 months, the overall prevalence of lymphocele was 8.6% (n = 30), with 29 cases in a pelvic location. Lymphocele was found in 3.4% (n = 6/178) of patients submitted to SLN mapping only, compared with 14.1% (n = 24/170) among those who underwent SLN with lymphadenectomy (p = 0.009). Among those patients with lymphocele, seven (23.3%) were symptomatic and five (16.6%) required drainage. All symptomatic cases occurred in lymphoceles larger than 4cm (p = 0.001). Neither resected lymph node count nor the type of systematic lymphadenectomy were related to the presence of lymphocele. Systematic lymphadenectomy was the only factor that emerged as a risk factor for the presence of lymphocele in multivariate analysis (odds ratio 3.68, 95% confidence interval 1.39-9.79; p = 0.009). Our data suggest that SLN mapping independently decreases the risk of lymphocele formation compared with full lymphadenectomy in EC.

Lymphadenectomy in endometrial cancer—achieving more with less?

Lymphadenectomy in endometrial cancer—achieving more with less?

Case Series for Same-Day Discharge for Minimally Invasive Robotic Surgery for Endometrial Cancer

Study Objective Goal of this study is to present a cases series endorsing same-day discharge after minimally invasive robotic surgery for endometrial cancer and to determine factors that affect the length of hospital stay. Design Retrospective study is comprised of all cases (N = 50) by a single gynecologic oncologist (July 1, 2017 to January 30, 2019) that involved a robotic total hysterectomy (RTH) with bilateral salpingo-oophorectomy (BSO) and total pelvic lymphadenectomy for endometrial cancer. Categorical and continuous variables were analyzed using the Chi-square test and unpaired t-test respectively. Bivariate correlation analysis was utilized to determine risk factor influence on length of stay. Setting This study was conducted in El Paso, TX, a borderland city primarily comprised of a Hispanic population. Patients or Participants 50 patients who underwent robotic total hysterectomy with bilateral salpingo-oophorectomy and total pelvic lymphadenectomy for surgical treatment of endometrial cancer. Interventions N/A. Measurements and Main Results Total of 50 women with a median age of 62 years-old underwent RTH/BSO and surgical staging, and 62% (31) of patients were successfully discharged the same day ( 2 hrs.), or increased surgical complexity (para-aortic lymphadenectomy and/or omentectomy). Conclusion Same-day discharge is feasible following minimally invasive robotic surgery for endometrial cancer, despite older age, multiple comorbidities, later surgery time of day, and higher surgical stage.

Role of lymphadenectomy in endometrial cancer with nonbulky lymph node metastasis: Comparison of comprehensive surgical staging and sentinel lymph node algorithm

ObjectivesTo compare survival and progression outcomes between 2 nodal assessment approaches in patients with nonbulky stage IIIC endometrial cancer (EC). MethodsPatients with stage IIIC EC treated at 2 institutions were retrospectively identified. At 1 institution, a historical series (2004–2008) was treated with systematic pelvic and para-aortic lymphadenectomy (LND cohort). At the other institution, more contemporary patients (2006–2013) were treated using a sentinel lymph node algorithm (SLN cohort). Outcomes (hazard ratios [HRs]) within the first 5 years after surgery were compared between cohorts using Cox models adjusted for type of adjuvant therapy. ResultsThe study included 104 patients (48 LND, 56 SLN). The use of chemoradiotherapy was similar in the 2 cohorts (46% LND vs 50% SLN), but the use of chemotherapy alone (19% vs 36%) or radiotherapy alone (15% vs 2%) differed. Although there was evidence of higher risk of cause-specific death (HR, 2.10; 95% CI, 0.79–5.58; P = 0.14) and lower risk of para-aortic progression (HR, 0.27; 95% CI, 0.05–1.42; P = 0.12) for the LND group, the associations did not meet statistical significance. The risk of progression was not significantly different between the groups (HR, 1.27; 95% CI, 0.60–2.67; P =0 .53). In parsimonious multivariable models, high-risk tumor characteristics and nonendometrioid type were independently associated with lower cause-specific survival and progression-free survival. ConclusionsIn EC patients with nonbulky positive lymph nodes, use of the SLN algorithm with limited nodal dissection does not compromise survival compared with LND. Aggressive pathologic features of the primary tumor are the strongest determinants of prognosis.