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Sentinel lymph node mapping in endometrial cancer: performance of hysteroscopic injection of tracers
  1. Fabio Martinelli,
  2. Antonino Ditto,
  3. Giorgio Bogani,
  4. Umberto Leone Roberti Maggiore,
  5. Mauro Signorelli,
  6. Valentina Chiappa and
  7. Francesco Raspagliesi
  1. Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
  1. Correspondence to Dr Fabio Martinelli, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; Fabio.Martinelli{at}istitutotumori.mi.it

Abstract

Objective To report on the performance of hysteroscopic injection of tracers (indocyanine green (ICG) and technetium-99m (Tc-99m)) for sentinel lymph node (SLN) mapping in endometrial cancer.

Methods Single-center retrospective evaluation of consecutive patients who underwent SLN mapping following hysteroscopic peritumoral injection of tracer. Detection rate (overall/bilateral/aortic) diagnostic accuracy, and oncologic outcomes were evaluated.

Results A total of 221 procedures met the inclusion criteria. Mean patient age was 60 (range 28–84) years and mean body mass index was 26.9 (range 15–47) kg/m2 . In 164 cases (70.9%) mapping was performed laparoscopically. The overall detection rate of the technique was 94.1% (208/221 patients). Bilateral pelvic mapping was found in 62.5% of cases with at least one SLN detected and was more frequent using ICG than with Tc-99m (73.8% vs 53.3%; p<0.001). In 47.6% of cases SLNs mapped in both pelvic and aortic nodes, and in five cases (2.4%) only in the aortic area. In eight patients (3.8%) SLNs were found in aberrant (parametrial/presacral) areas. Mean number of detected SLNs was 3.7 (range 1–8). In 51.9% of cases at least one node other than SLNs was removed. Twenty-six patients (12.5%) had nodal involvement: 12 (46.2%) macrometastases, six (23.1%) micrometastases, and eight (30.7%) isolated tumor cells. In 12 cases (46.8%) the aortic area was involved. Overall, 6/221 (2.7%) patients had isolated para-aortic nodes. Three false-negative results were found, all in the Tc-99m group. All had isolated aortic metastases. Overall sensitivity was 88.5% (95% CI 71.7 to 100.0) and overall negative predictive value was 96.5% (95% CI 86.8 to 100.0). There were 10 (4.8%) recurrences: five abdominal/distant, four vaginal, and one nodal (in the aortic area following a unilateral mapping plus side-specific pelvic lymphadenectomy). Most recurrences (9/10 cases) were patients in whom a completion lymphadenectomy was performed. No deaths were reported after a mean follow-up of 47.7 months.

Conclusions Hysteroscopic injection of tracers for SLN mapping in endometrial cancer is as accurate as cervical injection with a higher detection rate in the aortic area. ICG improves the bilateral detection rate. Adding lymphadenectomy to SLN mapping does not reduce the risk of relapse.

  • endometrial neoplasms
  • sentinel lymph node
  • hysteroscopes
  • surgery
  • SLN and lympadenectomy
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Footnotes

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

  • Twitter @Fabio Martinelli@DrFMartinelli

  • Contributors FM, AD, FR: conception and design of the work. FM, AD, GB, ULRM, MS, VC: data acquisition. FM: data analysis and interpretation. FM, FR: drafting and revising the paper. FM, FR: final approval of the paper.

  • 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 All data relevant to the study are included in the article or uploaded as supplementary information.

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