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Endometrial cancer with positive sentinel lymph nodes: pathologic characteristics of metastases as predictors of extent of lymphatic dissemination and prognosis
  1. Giorgia Dinoi1,2,
  2. Khaled Ghoniem2,
  3. Yajue Huang3,
  4. Valentina Zanfagnin2,
  5. Giuseppe Cucinella2,
  6. Carrie Langstraat2,
  7. Gretchen Glaser2,
  8. Amanika Kumar2,
  9. Amy Weaver4,
  10. Michaela McGree4,
  11. Francesco Fanfani1,5,
  12. Giovanni Scambia1,5 and
  13. Andrea Mariani2
    1. 1Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
    2. 2Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
    3. 3Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
    4. 4Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
    5. 5Università Cattolica del Sacro Cuore, Rome, Italy
    1. Correspondence to Dr Giorgia Dinoi, Department of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, 00168, Italy; giorgiadinoi{at}


    Objectives To assess predictors of extensive lymph node dissemination and non-vaginal recurrence in patients with endometrial cancer with positive sentinel lymph nodes (SLNs).

    Methods Patients with endometrial cancer who underwent primary surgery with SLN mapping and had at least one positive node between October 2013 and May 2019 were included. Positive SLNs were reviewed, and cases were classified according to the location of the metastasis (extracapsular vs intracapsular), and the size of the largest SLN metastasis (isolated tumor cells, micrometastasis, macrometastasis). Associations were assessed based on fitting logistic regression models and Cox proportional hazards models.

    Results A total of 103 patients met the inclusion criteria: including 36 (34.9%) with isolated tumor cells, 27 (26.2%) with micrometastasis, and 40 (38.8%) with macrometastasis. Notably, 71.4% of patients exhibiting extracapsular SLN metastases had multiple positive SLNs (p=0.008). Extracapsular invasion (adjusted odds ratio (aOR) 5.81, 95% CI 1.4 to 23.6) and age (aOR=1.8, 95% CI 1.1 to 3.0) emerged as independent predictors of multiple positive SLNs. Among the 38 patients who underwent a backup pelvic lymphadenectomy, 18 (47.4%) presented with positive pelvic non-SLNs, a phenomenon more prevalent in patients with macrometastasis (p=0.004).

    Independent predictors of non-vaginal recurrence included SLN macrometastasis (adjusted hazard ratio (aHR) 3.3, 95% CI 1.3 to 8.3), non-endometrioid histology (aHR=3.7, 95% CI 1.5 to 9.3), and cervical stromal invasion (aHR=5.5, 95% CI 2.0 to 14.9). Among the 34 patients with isolated tumor cells and endometrioid histology, 3 (9%) experienced a recurrence, all of whom had not received any adjuvant chemotherapy or external beam radiotherapy.

    Conclusion Patients with positive SLN macrometastasis are independently associated with extensive lymphatic dissemination and distant recurrences. The risk of multiple positive SLNs increases with the extracapsular location of the SLN metastasis and with age. Independent uterine pathologic predictors of non-vaginal recurrence are non-endometrioid histology and cervical stromal invasion.

    • SLN and Lympadenectomy
    • Neoplasm Micrometastasis
    • Uterine Cancer
    • Gynecology
    • Lymphatic Metastasis

    Data availability statement

    Data are available upon reasonable request.

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    Data availability statement

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    • X @KhaledGhoniemMD, @Cucinella_G

    • Contributors GD: guarantor; conceptualization, data curation, pathologic review, writing - original draft preparation; KG: conceptualization, data curation, methodology; YH: data curation, pathologic review; VZ: supervision, writing - review and editing. GC, CL, GG. AK: writing - review and editing; AW: data curation, formal analysis, methodology, writing - review and editing; MM: data curation, formal analysis, methodology; FF, GS: writing - review and editing; AM: conceptualization, supervision, writing - review and editing.

    • 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.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.