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Determining the stage of endometrial cancer for its surgical treatment

Published:February 16, 2022DOI:https://doi.org/10.1016/j.ajog.2022.02.014
      To the Editors:
      Marchocki et al
      • Marchocki Z.
      • Cusimano M.C.
      • Clarfield L.
      • et al.
      Sentinel lymph node biopsy in high-grade endometrial cancer: a systematic review and meta-analysis of performance characteristics.
      addressed an important topic regarding sentinel lymph node (SLN) mapping for high-grade endometrial cancer (EC) cases to determine the value of pelvic lymphadenectomy with hysterectomy in its treatment. Although the article stated that SLN biopsy was considered as the “standard of care” for the participating centers included in the study, other methodologies for determining the staging of EC using different imaging techniques should be strongly considered as a best practice. This is especially true, given the well-recognized confusion and difficulties using such SLN mapping, with its use of different dyes (colorimetric and radioactive) and dye injection sites and the possible need for surgeon certification for its performance, as is stated in the article. The 100% accuracy of using preoperative 3-dimensional transvaginal sonography for this has been documented multiple times from different authors,
      • Alcázar J.L.
      • Galván R.
      • Albela S.
      • et al.
      Assessing myometrial infiltration by endometrial cancer: uterine virtual navigation with three-dimensional US.
      • Jantarasaengaram S.
      • Praditphol N.
      • Tansathit T.
      • Vipupinyo C.
      • Vairojanavong K.
      Three-dimensional ultrasound with volume contrast imaging for preoperative assessment of myometrial invasion and cervical involvement in women with endometrial cancer.
      • Fernandez C.M.
      • Levine E.M.
      • Dini M.
      • Bannon K.
      • Butler S.
      • Locher S.
      Predictive value of three-dimensional transvaginal sonography for staging of endometrial carcinoma.
      and this should not be ignored. The use of SLN mapping to optimally select those cases of EC benefiting from pelvic lymphadenectomy in high-stage or low-stage EC cases is certainly worthwhile. However, comparing the practical ease, associated cost, and overall generalizability of these diagnostic techniques
      • Green R.W.
      • Epstein E.
      Dynamic contrast-enhanced ultrasound improves diagnostic performance in endometrial cancer staging.
      must be considered before any “standard of care” is recognized. Moreover, the reproducibility and consistency of performing SLN mapping, the availability and accuracy of the frozen section,
      • Stephan J.M.
      • Hansen J.
      • Samuelson M.
      • et al.
      Intra-operative frozen section results reliably predict final pathology in endometrial cancer.
      and the preoperative prediction of the staging of EC are important to consider. Evidence obtained from meta-analyses along with practicality should dictate standard medical practice, in terms of the optimal method to use in preparation for the surgical treatment of EC, whether to expect to perform a pelvic lymphadenectomy. The benefit of lymphadenectomy performance for stage IB has been suggested, with its greater risk of lymph node metastasis, if it is known at the time of surgery.
      • Ghanem A.I.
      • Khan N.T.
      • Mahan M.
      • Ibrahim A.
      • Buekers T.
      • Elshaikh M.A.
      The impact of lymphadenectomy on survival endpoints in women with early stage uterine endometrioid carcinoma: a matched analysis.

      References

        • Marchocki Z.
        • Cusimano M.C.
        • Clarfield L.
        • et al.
        Sentinel lymph node biopsy in high-grade endometrial cancer: a systematic review and meta-analysis of performance characteristics.
        Am J Obstet Gynecol. 2021; 225: 367.e1-367.e39
        • Alcázar J.L.
        • Galván R.
        • Albela S.
        • et al.
        Assessing myometrial infiltration by endometrial cancer: uterine virtual navigation with three-dimensional US.
        Radiology. 2009; 250: 776-783
        • Jantarasaengaram S.
        • Praditphol N.
        • Tansathit T.
        • Vipupinyo C.
        • Vairojanavong K.
        Three-dimensional ultrasound with volume contrast imaging for preoperative assessment of myometrial invasion and cervical involvement in women with endometrial cancer.
        Ultrasound Obstet Gynecol. 2014; 43: 569-574
        • Fernandez C.M.
        • Levine E.M.
        • Dini M.
        • Bannon K.
        • Butler S.
        • Locher S.
        Predictive value of three-dimensional transvaginal sonography for staging of endometrial carcinoma.
        J Diagn Med Sonogr. 2018; 34: 496-500
        • Green R.W.
        • Epstein E.
        Dynamic contrast-enhanced ultrasound improves diagnostic performance in endometrial cancer staging.
        Ultrasound Obstet Gynecol. 2020; 56: 96-105
        • Stephan J.M.
        • Hansen J.
        • Samuelson M.
        • et al.
        Intra-operative frozen section results reliably predict final pathology in endometrial cancer.
        Gynecol Oncol. 2014; 133: 499-505
        • Ghanem A.I.
        • Khan N.T.
        • Mahan M.
        • Ibrahim A.
        • Buekers T.
        • Elshaikh M.A.
        The impact of lymphadenectomy on survival endpoints in women with early stage uterine endometrioid carcinoma: a matched analysis.
        Eur J Obstet Gynecol Reprod Biol. 2017; 210: 225-230

      Linked Article

      • Sentinel lymph node biopsy in high-grade endometrial cancer
        American Journal of Obstetrics & GynecologyVol. 226Issue 6
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          We thank Levine and Fernandez for their interest in our study,1 and we agree that the implementation of sentinel lymph node (SLN) biopsy into clinical practice may be associated with an additional certification requirement and learning curve. However, we do not view this process as a barrier but rather as a form of quality assurance required for all new surgical techniques to ensure patient safety.
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