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Sentinel lymph node biopsy in high-grade endometrial cancer

Published:February 16, 2022DOI:https://doi.org/10.1016/j.ajog.2022.02.013
      We thank Levine and Fernandez for their interest in our study,
      • 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.
      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.
      Endometrial cancer (EC) is staged surgically to determine the most appropriate adjuvant treatment, as lymph node status is one of the most important prognostic factors for survival.
      • Amant F.
      • Mirza M.R.
      • Koskas M.
      • Creutzberg C.L.
      Cancer of the corpus uteri.
      Traditionally, full pelvic and para-aortic lymphadenectomies have been recommended as part of the staging for patients with high-grade EC. However, randomized controlled trials have demonstrated that lymphadenectomy has no direct therapeutic benefit and is associated with significant morbidity.
      • Kitchener H.
      • Swart A.M.
      • Qian Q.
      • Amos C.
      • Parmar M.K.
      ASTEC Study Group
      Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study.
      Our study aimed to determine whether SLN biopsy could replace full lymphadenectomy for surgical staging and assess the value of lymphadenectomy. We found that SLN biopsy accurately detects lymph node metastases in patients with high-grade EC (pooled detection rates of 91%, pooled sensitivity of 92%, and pooled negative predictive value of 97% per patient). These results were similar to those obtained in other cancer sites (vulva, breast, and skin), where SLN biopsy is a well-accepted standard of care, and suggested that SLN biopsy could replace full lymphadenectomy in patients with high-grade EC.
      In their discussion, Levine and Fernandez referenced several studies assessing preoperative use of 3-dimensional ultrasound as a predictive tool for myometrial invasion and cervical involvement in patients with low-grade EC. This approach has been proposed as a means of identifying patients at low risk of nodal involvement, in whom lymphadenectomy could be omitted. Although we agree that such an approach might be beneficial in patients with low-grade EC, its use may be limited in patients with high-grade EC, who are at a much higher risk of nodal metastases. We believe that imaging techniques are unlikely to ever replace surgical staging, which provides histologic confirmation of lymph node status.

      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
        • Amant F.
        • Mirza M.R.
        • Koskas M.
        • Creutzberg C.L.
        Cancer of the corpus uteri.
        Int J Gynaecol Obstet. 2018; 143: 37-50
        • Kitchener H.
        • Swart A.M.
        • Qian Q.
        • Amos C.
        • Parmar M.K.
        • ASTEC Study Group
        Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study.
        Lancet. 2009; 373: 125-136

      Linked Article

      • Determining the stage of endometrial cancer for its surgical treatment
        American Journal of Obstetrics & GynecologyVol. 226Issue 6
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          Marchocki et al1 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.
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