Immediate intraoperative sentinel lymph node analysis by frozen section is predictive of lymph node metastasis in endometrial cancer

  • M. Renz
  • N. Marjon
  • K. Devereaux
  • S. Raghavan
  • A. K. Folkins
  • A. KaramEmail author
Original Article


Sentinel lymph nodes sampling (SLN) in endometrial cancer is being evaluated as a means to gather prognostic information about lymphatic metastasis while avoiding the morbidity associated with complete lymphadenectomy. SLN ultrastaging has been advocated to identify low-volume metastases, but its value remains uncertain. This study aims to evaluate a pathological protocol for the immediate intraoperative SLN work-up using H&E staining alone. In this retrospective single-center study, patients received standardized cervical injection of indocyanine green, SLN mapping followed by pelvic lymphadenectomy with or without para-aortic lymphadenectomy. SLNs were entirely frozen, multiple H&E stained sections prepared and evaluated intraoperatively. No immunohistochemistry was performed. SLN results were compared with the complete lymphadenectomy specimen. Over 3.5 years, 90 patients were identified who underwent SLN mapping and subsequent complete pelvic lymphadenectomy. At least one SLN was detected in 79 (88%) patients. The median number of SLNs removed was 2.0. Para-aortic SLNs were detected in 7%. Final pathology showed 67% Type I tumors, 76% locally confined. The mean number of lymph nodes removed during complete lymphadenectomy was 21. In this series, only 6 patients had lymph node metastases. 5/6 were identified by the described SLN approach resulting in 83.3% sensitivity and a negative predictive value of 98.7%. Our approach permits immediate intraoperative results and helps guide the primary surgery. The immediate SLN work-up using frozen sections showed both high accuracy and negative predictive value. The comparably lower sensitivity may be related to the low number of patients with positive lymph nodes (7.6%).


Sentinel lymph nodes Endometrial cancer Immediate and exhaustive intraoperative analysis without ultrastaging 


Compliance with ethical standards

Conflict of interest

The authors declare that they have 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 was obtained from all individual participants included in the study.

Supplementary material

11701_2019_928_MOESM1_ESM.pdf (18 kb)
Supplementary material 1 (PDF 18 KB)
11701_2019_928_MOESM2_ESM.pdf (18 kb)
Supplementary material 2 (PDF 18 KB)


  1. 1.
    Mikuta JJ (1993) International Federation of Gynecology and Obstetrics staging of endometrial cancer 1988. Cancer 71(4 Suppl):1460–1463CrossRefGoogle Scholar
  2. 2.
    Kilgore LC et al (1995) Adenocarcinoma of the endometrium: survival comparisons of patients with and without pelvic node sampling. Gynecol Oncol 56(1):29–33CrossRefGoogle Scholar
  3. 3.
    Trimble EL, Kosary C, Park RC (1998) Lymph node sampling and survival in endometrial cancer. Gynecol Oncol 71(3):340–343CrossRefGoogle Scholar
  4. 4.
    Chan JK et al (2006) Therapeutic role of lymph node resection in endometrioid corpus cancer: a study of 12,333 patients. Cancer 107(8):1823–1830CrossRefGoogle Scholar
  5. 5.
    Benedetti Panici P et al (2008) Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial. J Natl Cancer Inst 100(23):1707–1716CrossRefGoogle Scholar
  6. 6.
    group As et al (2009) Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study. Lancet 373(9658):125–136CrossRefGoogle Scholar
  7. 7.
    Mariani A et al (2008) Prospective assessment of lymphatic dissemination in endometrial cancer: a paradigm shift in surgical staging. Gynecol Oncol 109(1):11–18CrossRefGoogle Scholar
  8. 8.
    Case AS et al (2006) A prospective blinded evaluation of the accuracy of frozen section for the surgical management of endometrial cancer. Obstet Gynecol 108(6):1375–1379CrossRefGoogle Scholar
  9. 9.
    Kumar S et al (2011) The role of frozen section in surgical staging of low risk endometrial cancer. PLoS One 6(9):e21912CrossRefGoogle Scholar
  10. 10.
    Abu-Rustum NR et al (2009) Sentinel lymph node mapping for grade 1 endometrial cancer: is it the answer to the surgical staging dilemma? Gynecol Oncol 113(2):163–169CrossRefGoogle Scholar
  11. 11.
    Holloway RW et al (2017) Sentinel lymph node mapping and staging in endometrial cancer: a Society of Gynecologic Oncology literature review with consensus recommendations. Gynecol Oncol 146(2):405–415CrossRefGoogle Scholar
  12. 12.
    Tanner E et al (2017) Use of a novel sentinel lymph node mapping algorithm reduces the need for pelvic lymphadenectomy in low-grade endometrial cancer. Gynecol Oncol 147(3):535–540CrossRefGoogle Scholar
  13. 13.
    Cabanas RM (1977) An approach for the treatment of penile carcinoma. Cancer 39(2):456–466CrossRefGoogle Scholar
  14. 14.
    Krag DN et al (2010) Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol 11(10):927–933CrossRefGoogle Scholar
  15. 15.
    Giuliano AE et al (2011) Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA 305(6):569–575CrossRefGoogle Scholar
  16. 16.
    Levenback CF et al (2012) Lymphatic mapping and sentinel lymph node biopsy in women with squamous cell carcinoma of the vulva: a gynecologic oncology group study. J Clin Oncol 30(31):3786–3791CrossRefGoogle Scholar
  17. 17.
    Oonk MH et al (2010) Size of sentinel-node metastasis and chances of non-sentinel-node involvement and survival in early stage vulvar cancer: results from GROINSS-V, a multicentre observational study. Lancet Oncol 11(7):646–652CrossRefGoogle Scholar
  18. 18.
    Stehman FB et al (1992) Groin dissection versus groin radiation in carcinoma of the vulva: a Gynecologic Oncology Group study. Int J Radiat Oncol Biol Phys 24(2):389–396CrossRefGoogle Scholar
  19. 19.
    Network NCC, NCCN clinical practice guidelines in oncology (NCCN Guidelines) Uterine Neoplasms., 2017. version 1.2017Google Scholar
  20. 20.
    Kim CH, Soslow RA, Park KJ, Barber EL, Khoury-Collado F, Barlin JN, Sonoda Y, Hensley ML, Barakat RR, Abu-Rustum NR (2013) Pathologic ultrastaging improves micrometastasis detection in sentinel lymph nodes during endometrial cancer staging. Int J Gynecol Cancer 23(5):964–970CrossRefGoogle Scholar
  21. 21.
    Holloway RW et al (2016) Sentinel lymph node mapping with staging lymphadenectomy for patients with endometrial cancer increases the detection of metastasis. Gynecol Oncol 141(2):206–210CrossRefGoogle Scholar
  22. 22.
    Desai PH et al (2014) Accuracy of robotic sentinel lymph node detection (RSLND) for patients with endometrial cancer (EC). Gynecol Oncol 135(2):196–200CrossRefGoogle Scholar
  23. 23.
    Touhami O et al (2015) Predictors of non-sentinel lymph node (non-SLN) metastasis in patients with sentinel lymph node (SLN) metastasis in endometrial cancer. Gynecol Oncol 138(1):41–45CrossRefGoogle Scholar
  24. 24.
    Ballester M et al (2013) Sentinel node biopsy upstages patients with presumed low- and intermediate-risk endometrial cancer: results of a multicenter study. Ann Surg Oncol 20(2):407–412CrossRefGoogle Scholar
  25. 25.
    Khoury-Collado F et al (2011) Sentinel lymph node mapping for endometrial cancer improves the detection of metastatic disease to regional lymph nodes. Gynecol Oncol 122(2):251–254CrossRefGoogle Scholar
  26. 26.
    Rossi EC et al (2017) A comparison of sentinel lymph node biopsy to lymphadenectomy for endometrial cancer staging (FIRES trial): a multicentre, prospective, cohort study. Lancet Oncol 18(3):384–392CrossRefGoogle Scholar
  27. 27.
    Holloway RW et al (2017) A prospective cohort study comparing colorimetric and fluorescent imaging for sentinel lymph node mapping in endometrial cancer. Ann Surg Oncol 24(7):1972–1979CrossRefGoogle Scholar
  28. 28.
    Ballester M et al (2011) Detection rate and diagnostic accuracy of sentinel-node biopsy in early stage endometrial cancer: a prospective multicentre study (SENTI-ENDO). Lancet Oncol 12(5):469–476CrossRefGoogle Scholar
  29. 29.
    Raimond E et al (2014) Impact of sentinel lymph node biopsy on the therapeutic management of early-stage endometrial cancer: results of a retrospective multicenter study. Gynecol Oncol 133(3):506–511CrossRefGoogle Scholar
  30. 30.
    National Comprehensive Cancer Network. Breast Cancer (Version 2.2017). Accessed Sept 2017
  31. 31.
    Surgical Procedures Manual (2005) Gynecology oncology group. Statistical & Data Center Group, Buffalo (NY), p 9–11Google Scholar
  32. 32.
    Ballester M et al (2012) Comparison of diagnostic accuracy of frozen section with imprint cytology for intraoperative examination of sentinel lymph node in early-stage endometrial cancer: results of Senti-Endo study. Ann Surg Oncol 19(11):3515–3521CrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Ltd., part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Gynecologic Oncology, Department of Obstetrics and GynecologyStanford University School of MedicineStanfordUSA
  2. 2.Department of PathologyStanford University School of MedicineStanfordUSA

Personalised recommendations