Controversias en la técnica de detección del ganglio centinela en cáncer de endometrio / Controversy over sentinel lymph node detection in endometrial cancer

En la última década se ha introducido la biopsia selectiva del ganglio centinela en cáncer de endometrio de bajo riesgo, siendo opcional en el de riesgo intermedio y alto. Sin embargo, hasta hace un año no se existía consenso respecto al grupo de población indicado, el trazador de elección o el lugar de administración del trazador. En este trabajo, presentamos de forma multidisciplinar los aspectos más controvertidos sobre la técnica de detección del ganglio centinela en cáncer de endometrio, con mayor énfasis en las ventajas y desventajas de los tipos de trazadores disponibles: radiotrazadores, trazadores híbridos y verde de indocianina (AU)

In the last decade, the procedure of sentinel lymph node biopsy has been introduced in low-risk endometrial cancer, being optional in intermediate- and high-risk cancer. However, until the last year, there was no consensus regarding the group of patients to whom to apply it, the best tracer to use or the site of injection. In this paper, we present in a multidisciplinary view the most controversial issues about the sentinel lymph node procedure in endometrial cancer, emphasizing the pros and cons of the different tracers available: radiotracers, hybrid tracers and indocyanine green (AU)

Controversy over sentinel lymph node detection in endometrial cancer.

In the last decade, the procedure of sentinel lymph node biopsy has been introduced in low-risk endometrial cancer, being optional in intermediate- and high-risk cancer. However, until the last year, there was no consensus regarding the group of patients to whom to apply it, the best tracer to use or the site of injection. In this paper, we present in a multidisciplinary view the most controversial issues about the sentinel lymph node procedure in endometrial cancer, emphasizing the pros and cons of the different tracers available: radiotracers, hybrid tracers and indocyanine green.

Diagnostic performance of transvaginal ultrasound and magnetic resonance imaging for preoperative evaluation of low-grade endometrioid endometrial carcinoma: prospective comparative study.

OBJECTIVE: To compare the diagnostic performance of transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) in the prediction of deep myometrial invasion (DMI) and cervical stromal invasion (CSI) in patients with low-grade (Grade 1 or 2) endometrioid endometrial cancer (EEC). METHODS: This was a prospective study including all patients with low-grade EEC diagnosed between October 2013 and July 2018 at the Vall d'Hebron Hospital in Barcelona, Spain. Preoperative staging was performed using TVS and MRI, followed by surgical staging. Final histology was considered as the reference standard. Sensitivity, specificity, likelihood ratios and diagnostic accuracy were calculated for both imaging techniques in the prediction of DMI and CSI, and the agreement index was calculated for both techniques. The STARD 2015 guidelines were followed. RESULTS: A total of 131 patients with low-grade EEC were included consecutively. Sensitivity was higher for TVS than for MRI both for the prediction of DMI (69% (95% CI, 53-82%) vs 51% (95% CI, 36-66%), respectively) and CSI (43% (95% CI, 27-61%) vs 24% (95% CI, 12-41%), respectively). Specificity was similar for TVS and MRI in the prediction of DMI (87% (95% CI, 78-93%) vs 91% (95% CI, 82-96%)) and equal in the prediction of CSI (97% (95% CI, 91-99%) for both). The agreement index between TVS and MRI was 0.84 (95% CI, 0.76-0.90) for DMI and 0.92 (95% CI, 0.85-0.96) for CSI. CONCLUSIONS: The diagnostic performance of TVS is similar to that of MRI for the prediction of DMI and CSI in low-grade EEC, and TVS can play a role as a first-line imaging technique in the preoperative evaluation of low-grade EEC. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Vaginal fertility-sparing surgery and laparoscopic sentinel lymph node detection in early cervical cancer. Retrospective study with 15 years of follow-up.

OBJECTIVE: The aim of this study was to evaluate the oncological outcomes of vaginal fertility-sparing surgery plus laparoscopic sentinel lymph node biopsy in patients with early cervical cancer over a 15-years period. PATIENTS AND METHODS: From March 2005 to April 2018, 38 patients diagnosed with early stage cervical cancer underwent vaginal fertility-sparing surgery at the Hospital Clínic, Barcelona, Spain. Patients with FIGO stage IA1 with lymphovascular space invasion and stage IA2 underwent simple trachelectomy and patients with stage IB1 underwent radical vaginal trachelectomy. All cases underwent laparoscopic sentinel lymph node biopsy. In the first 19 cases, laparoscopic bilateral pelvic lymphadenectomy was completed immediately after sentinel lymph node biopsy. Clinical and oncological follow-up data were collected. RESULTS: The median age at diagnosis was 33.5 years (range 22-44). Simple trachelectomy was performed in seven cases (18.4%) and vaginal radical trachelectomy in 31 (81.6%). Nineteen patients were exclusively treated with laparoscopic sentinel lymph node biopsy and 19 with sentinel lymph node biopsy plus laparoscopic bilateral pelvic lymphadenectomy. There were no significant differences between the two lymph node assessment groups regarding histology and tumour size. The median follow-up was 73 months (range 1-160 months). There were 4 recurrences (3 patients with IB1 and 1 with IA2). Two occurred in the sentinel lymph node biopsy group and 2 in the sentinel lymph node biopsy plus laparoscopic bilateral pelvic lymphadenectomy group. All the recurrences were diagnosed in patients with adenocarcinoma and in 3 patients without lymphovascular space invasion. CONCLUSION: Vaginal fertility-sparing surgery combined with laparoscopic sentinel lymph node biopsy seems to be a safe oncological procedure in selected patients with early stage cervical cancer. Further studies are needed to clarify the role of sentinel lymph node biopsy in fertility- sparing surgery in cervical cancer. Adenocarcinoma histology seems to be an important risk factor for recurrence.

Comparison of robotic-assisted vs conventional laparoscopy for extraperitoneal paraaortic lymphadenectomy.

OBJECTIVE: To evaluate the perioperative outcomes of robotic-assisted extraperitoneal paraaortic lymphadenectomy for locally advanced cervical cancer and to compare to a previous series of patients from our institution undergoing the same procedure by conventional laparoscopy. METHODS: 17 patients with locally advanced cervical cancer (FIGO stages IB2, IIA2 and IIB-IVA) underwent pretherapeutic extraperitoneal paraaortic lymphadenectomy by robotic-assisted laparoscopy. Perioperative outcomes including age, BMI, FIGO stage, operating time, blood loss, complications and length of hospital stay were compared to a series of 83 patients from our institution undergoing the same procedure by conventional laparoscopy. RESULTS: The median values for operating time and hospital days for the robotic-assisted and conventional laparoscopy groups were 150 vs. 150 min and 2 vs 2 days, respectively. In the robotic group, blood loss was lower (90 vs 20 ml, p<0.05) and more aortic nodes were removed (14 vs 17 nodes, p<0.05). Docking time was 7 min (range 3-15). There were no intraoperative complications. There were no differences for postoperative complications (17.6% vs 8.4%). CONCLUSION: Robotic-assisted and conventional laparoscopy provide similar perioperative outcomes other than lower blood loss and higher number of aortic nodes removed (both without clinical impact) in robotic patients for the performance of extraperitoneal paraaortic lymphadenectomy in patients with locally advanced cervical cancer. We believe that robotic surgery is an additional tool to perform the same surgical procedure. HIGHLIGHTS: Robotic-assisted and conventional laparoscopic extraperitoneal paraaortic lymphadenectomy provide similar perioperative outcomes.

Location of aortic node metastases in locally advanced cervical cancer.

BACKGROUND: To assess the location of aortic node metastasis in patients with locally advanced cervical cancer undergoing extraperitoneal aortic lymphadenectomy to define the extent of the aortic lymphadenectomy. MATERIAL AND METHODS: Between August 2001 and December 2010, 100 consecutive patients with primary locally advanced cervical cancer underwent extraperitoneal laparoscopic aortic and common iliac lymphadenectomy. The location of aortic node metastases, inframesenteric or infrarenal was noted. RESULTS: The mean number±standard deviation (SD) of aortic nodes removed was 15.9 ± 7.8 (range 4-62). The mean number ± SD of inframesenteric (including common iliac) nodes removed was 8.8 ± 4.5 (range 2-41) and the mean number ± SD of infrarenal nodes removed was 7.8 ± 4.1 (range 2-21). Positive aortic nodes were observed in 16 patients, and in 5 (31.2%) of them the infrarenal nodes were the only nodes involved, with negative inframesenteric nodes. CONCLUSION: Inframesenteric aortic nodes are negative in the presence of positive infrarenal nodes in about one third of patients with locally advanced cervical cancer and aortic metastases.

Sentinel lymph node identification in a primary ductal carcinoma arising in the vulva.

Primary or metastatic breast-like carcinoma of the vulva is a rare event. Because of the similarity with breast ductal carcinoma, we think that the same principles used for treatment of orthotopic breast cancer can be applied, as well as the use of sentinel lymph node technique, which is widely accepted in the management of early-stage breast cancer. We report a 49-old-year postmenopausal woman who was referred to our institution after small biopsy of a 3.5- x 3-cm right vulvar tumor. Histopathologically, infiltration of the vulvar dermis by a ductal carcinoma of mammary gland type was reported. At operation, the sentinel node technique revealed two sentinel nodes in the right inguinal area. Although these nodes proved negative for malignancy, the patient underwent wide local excision of tumor and complete ipsilateral inguinofemoral lymphadenectomy. The remaining excised nodes were negative. Surgical specimen proved estrogen- and progesterone-positive receptors, the reason for which the patient received tamoxifen adjuvant therapy. This report represents the first case in the world literature of primary breast carcinoma arising in the vulva in which sentinel lymph node identification has been possible. Because of the rarity of this condition, the pathologic similarity of this tumor along with currently accepted guidelines for the management of breast cancer supports the possibility of local excision and sentinel lymph node identification as a possible alternative to inguinofemoral lymphadenectomy.

Modified approach for extraperitoneal laparoscopic staging for locally advanced cervical cancer.

Describe a modified approach to the technique for staging laparoscopic extraperitoneal aortic and common iliac lymph node dissection for locally advanced cervical cancer.Retrospective, nonrandomized clinical study. (Canadian Task Force classification II-2), setting in an acute-care, teaching hospital. Thirty-six patients with locally advanced cervical cancer underwent laparoscopic surgical staging via extraperitoneal approach with the conventional or the modified technique from August 2001 through September 2004. Clinical outcomes in 23 patients who were operated on with the conventional technique using index finger for first trocar entrance; 12 patients with the modified technique using direct trocar entrance, were compared. One patient was excluded due to peritoneal carcinomatosis. Technique, baseline characteristics, histopathologic variables and surgical outcome were measured. There were no significant differences in patients basal characteristics on comparative analysis between conventional and modified technique. With our proposed modified technique, we obtained a reduced surgical procedure duration and blood loss. The proposed modified surgical technique offers some advantages, is an easier approach because the parietal pelvic peritoneum is elastic and this helps to avoid its disruption at time of trocar insertion, size of incision is shorter, we achieved no CO2 leak through the trocar orifice, and wound suture is fast and simple.

Endometrial cancer in polyps: a clinical study of 27 cases.

PURPOSE OF INVESTIGATION: To review risk factors, clinical presentation, diagnostic methods, and histopathologic findings in 27 cases of endometrial cancer in polyps. METHODS: A descriptive, retrospective study of 204 consecutive patients with endometrial carcinoma who were diagnosed at our institution between June 1998 to June 2001. Endometrial cancer arising in polyps occurred in 27 patients (13.2%) and accounted for 1.8% of 1492 endometrial polyps diagnosed during this period. RESULTS: Patients had a mean age of 62 years. All except one woman were postmenopausal. Three breast cancer patients were currently given tamoxifen. Metrorrhagia was the presenting symptom in 74% of cases, although 22% of patients were asymptomatic at the time of diagnosis. Ultrasonography performed in 22 patients showed images compatible with an endometrial polyp in 50% of cases, myoma in 5%, and inconclusive findings in 45%. The median endometrial thickness was 11 mm (range 4-33 mm). Diagnosis was made by aspiration-biopsy in 13 patients and by hysteroscopic endometrial sampling in 13 (in one patient endometrial carcinoma was incidentally found in the surgical specimen). All patients were in FIGO Stage IA. Endometrioid carcinoma was found in 81.5% of cases. Retroperitoneal metastases were not found in 25 patients undergoing pelvic lymphadenectomy, nor neoplastic growth in the specimens of six polypeptomies performed during hysteroscopy. All patients are free of relapse after a mean follow-up of 30 months. CONCLUSIONS: Postmenopausal women with endometrial polyps diagnosed by ultrasonography should undergo directed biopsies under hysteroscopic vision. The present series confirms the good prognosis of endometrial cancer in polyps.