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FIGO stage IIIC endometrial cancer identification among patients with complex atypical hyperplasia, grade 1 and 2 endometrioid endometrial cancer: laparoscopic indocyanine green sentinel lymph node mapping versus frozen section of the uterus, why get around the problem?

  • Andrea Papadia
  • Maria Luisa Gasparri
  • Franziska Siegenthaler
  • Sara Imboden
  • Stefan Mohr
  • Michael D. Mueller
Original Article – Clinical Oncology

Abstract

Purpose

To compare two surgical strategies used to identify lymph node metastases in patients with preoperative diagnosis of complex atypical hyperplasia (CAH), grade 1 and 2 endometrial cancer (EC).

Methods

Data on patients with preoperative diagnosis of CAH, grade 1 and 2 EC undergoing laparoscopic indocyanine green (ICG) sentinel lymph node (SLN) mapping followed by frozen section of the uterus were collected. When risk factors were identified at frozen section, patients were subjected to a systematic lymphadenectomy. False negative (FN) rates, negative predictive values (NPV), positive predictive values (PPV) and correlation with stage IIIC EC were calculated for the systematic lymphadenectomy based on frozen section of the uterus and for the SLN mapping.

Results

Six (9.5%) out of 63 patients had lymph nodal metastases. Based on frozen section of the uterus, 22 (34.9%) and 15 (22.2%) patients underwent a pelvic and a pelvic and paraaortic lymphadenectomy, respectively. Five patients with stage IIIC disease were identified with a FN rate of 16.7% and a NPV and PPV of 97.6 and 27.3%, respectively. Overall and bilateral detection rates of ICG SLN mapping were 100 and 97.6%, respectively; no FN were recorded. The identification of patients with stage IIIC disease with ICG SLN mapping showed a NPV and PPV of 100%. Correlation between indication to lymphadenectomy and stage IIIC disease was poor (κ = 0.244) when based on frozen section of the uterus and excellent (κ = 1) when based on SLN mapping.

Conclusions

ICG SLN mapping reduces the number of unnecessary systematic lymphadenectomies and the risk of underdiagnosing patients with metastatic lymph nodes.

Keywords

Endometrial cancer Sentinel lymph node mapping Indocyanine green Laparoscopy Frozen section Surgical staging 

Notes

Compliance with ethical standards

Conflict of interest

All of the authors declare no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

  1. Abu-Rustum NR (2013) The increasing credibility of sentinel lymph node mapping in endometrial cancer. Ann Surg Oncol 20:353–354CrossRefPubMedGoogle Scholar
  2. Buda A, Di Martino G, Vecchione F, Bussi B, Dell’Anna T, Palazzi S et al (2015) Optimizing strategies for sentinel lymph node mapping in early-stage cervical and endometrial cancer: comparison of real-time fluorescence with indocyanine green and methylene blue. Int J Gynecol Cancer 25:1513–1518CrossRefPubMedGoogle Scholar
  3. Buda A, Bussi B, Di Martino G, Di Lorenzo P, Palazzi S, Grassi T et al (2016a) Sentinel lymph node mapping with near-infrared fluorescent imaging using indocyanine green: a new tool for laparoscopic platform in patients with endometrial and cervical cancer. J Minim Invasive Gynecol 23:265–269CrossRefPubMedGoogle Scholar
  4. Buda A, Papadia A, Zapardiel I, Vizza E, Ghezzi F, De Ponti E et al (2016b) From conventional radiotracer Tc-99(m) with blue dye to indocyanine green fluorescence: a comparison of methods towards optimization of sentinel lymph node mapping in early stage cervical cancer for a laparoscopic approach. Ann Surg Oncol 23:2959–2965CrossRefPubMedGoogle Scholar
  5. Colombo N, Creutzberg C, Amant F, Bosse T, González-Martín A, Ledermann J, ESMO-ESGO-ESTRO endometrial consensus conference working group et al (2016) ESMO-ESGO-ESTRO consensus conference on endometrial cancer: diagnosis, treatment and follow-up. Ann Oncol 27:16–41CrossRefPubMedGoogle Scholar
  6. Creasman WT, Morrow CP, Bundy BN, Homesley HD, Graham JE, Heller PB (1987) Surgical pathologic spread patterns of endometrial cancer. Gynecol Oncol Group Study Cancer 60:2035–2041Google Scholar
  7. Ditto A, Martinelli F, Bogani G, Papadia A, Lorusso D, Raspagliesi F (2015) Sentinel node mapping using hysteroscopic injection of indocyanine green and laparoscopic near-infrared fluorescence imaging in endometrial cancer staging. J Minim Invasive Gynecol 22:132–133CrossRefPubMedGoogle Scholar
  8. Dowdy SC, Borah BJ, Bakkum-Gamez JN, Weaver AL, McGree ME, Haas LR et al (2012) Prospective assessment of survival, morbidity, and cost associated with lymphadenectomy in low-risk endometrial cancer. Gynecol Oncol 127:5–10CrossRefPubMedGoogle Scholar
  9. Gubbala PK, Laios A, Wang Z, Dhar S, Pathiraja PJ, Haldar K et al (2016) Routine intraoperative frozen section examination to minimize bimodal treatment in early-stage cervical cancer. Int J Gynecol Cancer 26:1148–1153CrossRefPubMedGoogle Scholar
  10. Imboden S, Papadia A, Nauwerk M, McKinnon B, Kollmann Z, Mohr S et al (2015) A comparison of radiocolloid and indocyanine green fluorescence imaging, sentinel lymph node mapping in patients with cervical cancer undergoing laparoscopic surgery. Ann Surg Oncol 22:4198–4203CrossRefPubMedPubMedCentralGoogle Scholar
  11. Jewell EL, Huang JJ, Abu-Rustum NR, Gardner GJ, Brown CL, Sonoda Y et al (2014) Detection of sentinel lymph nodes in minimally invasive surgery using indocyanine green and near-infrared fluorescence imaging for uterine and cervical malignancies. Gynecol Oncol 133:274–277CrossRefPubMedGoogle Scholar
  12. Kitchener HC (2011) Sentinel-node biopsy in endometrial cancer: a win–win scenario? Lancet Oncol 12:413–414CrossRefPubMedGoogle Scholar
  13. Kumar S, Medeiros F, Dowdy SC, Keeney GL, Bakkum-Gamez JN, Podratz KC et al (2012) A prospective assessment of the reliability of frozen section to direct intraoperative decision making in endometrial cancer. Gynecol Oncol 127:525–531CrossRefPubMedGoogle Scholar
  14. Laufer J, Scasso S, Papadia A, Sosa C, Cirillo F, Raspagliesi F (2013) Association between tumor diameter and lymphovascular space invasion among women with early-stage endometrial cancer. Int J Gynaecol Obstet 123:142–145CrossRefPubMedGoogle Scholar
  15. Mariani A, Webb MJ, Keeney GL, Haddock MG, Calori G, Podratz KC (2000) Low-risk corpus cancer: is lymphadenectomy or radiotherapy necessary? Am J Obstet Gynecol 182:1506–1519CrossRefPubMedGoogle Scholar
  16. Morotti M, Menada MV, Moioli M, Sala P, Maffeo I, Abete L et al (2012) Frozen section pathology at time of hysterectomy accurately predicts endometrial cancer in patients with preoperative diagnosis of atypical endometrial hyperplasia. Gynecol Oncol 125:536–540CrossRefPubMedGoogle Scholar
  17. Naumann RW, Higgins RV, Hall JB (1999) The use of adjuvant radiation therapy by members of the society of gynecologic oncologists. Gynecol Oncol 75:4–9CrossRefPubMedGoogle Scholar
  18. NCCN clinical practice guidelines in oncology (2015) Uterine neoplasms. Version 2.2015. http://www.nccn.org/professionals/physician_gls/pdf/uterine.pdf
  19. Papadia A, Azioni G, Brusacà B, Fulcheri E, Nishida K, Menoni S et al (2009) Frozen section underestimates the need for surgical staging in endometrial cancer patients. Int J Gynecol Cancer 19:1570–1573CrossRefPubMedGoogle Scholar
  20. Papadia A, Imboden S, Siegenthaler F, Gasparri ML, Mohr S, Lanz S et al (2016a) Laparoscopic indocyanine green sentinel lymph node mapping in endometrial cancer. Ann Surg Oncol 23:2206–2211CrossRefPubMedPubMedCentralGoogle Scholar
  21. Papadia A, Imboden S, Gasparri ML, Siegenthaler F, Fink A, Mueller MD (2016b) Endometrial and cervical cancer patients with multiple sentinel lymph nodes at laparoscopic ICG mapping: how many are enough? J Cancer Res Clin Oncol 142:1831–1836CrossRefPubMedGoogle Scholar
  22. Rossi EC, Jackson A, Ivanova A, Boggess JF (2013) Detection of sentinel nodes for endometrial cancer with robotic assisted fluorescence imaging: cervical versus hysteroscopic injection. Int J Gynecol Cancer 23:1704–1711CrossRefPubMedGoogle Scholar
  23. Ruscito I, Gasparri ML, Braicu EI, Bellati F, Raio L, Sehouli J et al (2016) Sentinel node mapping in cervical and endometrial cancer: indocyanine green versus other conventional dyes-a meta-analysis. Ann Surg Oncol 23:3749–3756CrossRefPubMedGoogle Scholar
  24. Sala P, Morotti M, Menada MV, Cannavino E, Maffeo I, Abete L et al (2014) Intraoperative frozen section risk assessment accurately tailors the surgical staging in patients affected by early-stage endometrial cancer: the application of 2 different risk algorithms. Int J Gynecol Cancer 24:1021–1026CrossRefPubMedGoogle Scholar
  25. Simpkins F, Papadia A, Kunos C, Michener C, Frasure H, AbuShahin F et al (2013) Patterns of recurrence in stage I endometrioid endometrial adenocarcinoma with lymphovascular space invasion. Int J Gynecol Cancer 23:98–104CrossRefPubMedGoogle Scholar
  26. Sinno AK, Peijnenburg E, Fader AN, Temkin SM, Stone R, Levinson K et al (2016) Reducing overtreatment: a comparison of lymph node assessment strategies for endometrial cancer. Gynecol Oncol (Epub ahead of print), PMID:27568279Google Scholar
  27. Tanner EJ, Sinno AK, Stone RL, Levinson KL, Long KC, Fader AN (2015) Factors associated with successful bilateral sentinel lymph node mapping in endometrial cancer. Gynecol Oncol 138:542–547CrossRefPubMedGoogle Scholar
  28. Todo Y, Choi HJ, Kang S, Kim JW, Nam JH, Watari H et al (2013) Clinical significance of tumor volume in endometrial cancer: a Japan-Korea cooperative study. Gynecol Oncol 131:294–298CrossRefPubMedGoogle Scholar
  29. Trimble CL, Kauderer J, Zaino R, Silverberg S, Lim PC, Burke JJ 2nd et al (2006) Concurrent endometrial carcinoma in women with a biopsy diagnosis of atypical endometrial hyperplasia: a gynecologic oncology group study. Cancer 106:812–819CrossRefPubMedGoogle Scholar
  30. Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS et al (2009) Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: gynecologic oncology group study LAP2. J Clin Oncol 27:5331–5336CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  1. 1.Department of Obstetrics and Gynecology, University Hospital of BerneUniversity of BerneBernSwitzerland
  2. 2.Department of Gynecology and Obstetrics“Sapienza” University of RomeRomeItaly

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