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Robotic sentinel lymph node (SLN) mapping in endometrial cancer: SLN symmetry and implications of mapping failure
  1. Amanda J Stephens1,
  2. Jessica A Kennard1,
  3. Christine K Fitzsimmons1,
  4. Madhavi Manyam1,
  5. James E Kendrick1,
  6. Charanjeet Singh2,
  7. Nathalie D McKenzie1,
  8. Sarfraz Ahmad1 and
  9. Robert W Holloway1
  1. 1 Gynecologic Oncology, AdventHealth Cancer Institute, Orlando, Florida, USA
  2. 2 Pathology and Laboratory Medicine, AdventHealth Orlando, Orlando, Florida, USA
  1. Correspondence to Professor Sarfraz Ahmad, Gynecologic Oncology, Advent Health Cancer Institute, Orlando, Florida, USA; sarfraz.ahmad{at}


Purpose To establish the bilateral pelvic concordance rate of the sentinel lymph node (SLN) and determine the likelihood of lymph node metastasis in cases of mapping failure.

Methods A database analysis was performed on 414 patients with clinical stage I endometrial cancer who underwent SLN mapping followed by robotic hysterectomy and completion pelvic (n=414, 100%) and aortic (n=186, 44.9%) lymphadenectomy from March 2011 to August 2016. Stage, histology, SLN sites, and surgico-pathologic findings were analyzed. The bilateral concordance rate of SLN location, successful unilateral and bilateral mapping rates, false negative rate, and non-SLN metastasis associated with mapping failure were calculated.

Results Histologies included 354 (85.5%) endometrioid, 39 (9.4%) serous, 16 (3.9%) carcinosarcoma, 4 (1.0%) clear cell, and 1 (0.2%) undifferentiated. Final stages included 262 (63.3%) IA, 36 (8.7%) IB, 15 (3.6%) II, 6 (1.4%) IIIA, 68 (16.4%) IIIC1, and 27 (6.5%) IIIC2. Bilateral SLN mapping was successful in 355 (85.7%) patients, and 266 (74.9%) demonstrated mapping to the symmetrical lymphatic group contralaterally. The mapping failure rate was 13.5% (56/414) unilaterally and 0.7% (3/414) bilaterally. SLN locations were external iliac (69.1%), obturator (25.1%), internal iliac (2.2%), common iliac (1.9%), pre-sacral (0.9%), aortic (0.4%), parametrial (0.3%), and para-rectal (0.1%). Lymph node metastases were identified in 95 (22.9%) pelvic and 27 (6.5%) aortic nodes. 10 (16.9%) cases with mapping failure had lymph node metastasis on completion lymphadenectomy, similar to the proportion of SLNs with metastases (p=0.35). However, macro-metastases were more common in mapping failure completion lymphadenectomies than in the positive SLNs (80% vs 22.3%, p<0.001).

Conclusion The contralateral SLN location concordance rate was 75%. Most SLNs were along the medial external iliac or obturator locations. The rate of positive lymph nodes associated with SLN mapping failure was 16.9%, similar to the overall node-positive rate. The detection of pelvic node metastasis with SLN mapping failure was largely populated with macro-metastases and confirms the necessity of completion lymphadenectomy with mapping failure.

  • SLN and lympadenectomy
  • lymph nodes
  • sentinel lymph node
  • uterine cancer
  • surgical procedures, operative

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  • Editor's note This paper will feature in a special issue on sentinel lymph node mapping in 2020.

  • Twitter @NathalieMckenz3

  • Contributors AJS and RWH designed the study, and subsequently all the authors participated in the data collection, analyses, discussion on results and interpretation, and drafting the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.