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ABSTRACT
Introduction
Endometroid intraepithelial neoplasia (EIN) is a premalignant lesion to endometrial cancer. Increasing number of gynecologic oncologists are performing sentinel lymph node (SLN) evaluation during hysterectomy for EIN to ensure complete staging if there is cancer on the final specimen. However, there are no clear guidelines and the benefits and risks to performing SLN evaluation for EIN patients are unclear.
Areas Covered
This narrative review examines the advantages and disadvantages of SLN evaluation for EIN patients and provides an algorithm to assist clinicians in selectively applying the procedure for maximal patient benefit. Relevant articles up to March 2024 were obtained from a PubMed search on SLN use with endometrial pathology.
Expert Opinion
Sentinel lymph node evaluation for patients with EIN is safe, feasible and particularly important for the approximately 10% of patients with high-risk endometrial carcinoma on final pathology. However, as most diagnosed carcinomas are low-risk, SLN evaluation would have limited oncologic benefit. While SLN assessment may overtreat most patients with EIN, a significant minority of patients will be improperly staged. We propose an algorithm highlighting the importance of maximal preoperative endometrial sampling and stratifying patients via risk factors to selectively identify those who would benefit most from SLN evaluation.
Plain Language Summary
Endometroid intraepithelial neoplasia (EIN) is a premalignant lesion to endometrial cancer, the most common gynecologic cancer in the United States. The definitive treatment for EIN is hysterectomy. An increasing number of gynecologic oncologists are performing sentinel lymph node (SLN) assessment during surgery for EIN since 30-40% of patients with EIN will have underlying carcinoma. For those patients, lymph node evaluation is important for cancer staging, especially if high-risk or advanced stage disease is found on the pathologic specimen. The SLN procedure cannot be performed post-hysterectomy, so an improperly staged patient may require a second operation for lymphadenectomy; this has a greater chance of morbidity compared to a SLN biopsy. However, a SLN evaluation still confers perioperative risk and comes at an additional monetary cost, especially when most patients diagnosed with endometrial cancer after EIN will ultimately have low-risk, stage IA disease. We propose an algorithm for clinicians to help determine which patients with EIN would best benefit from the SLN procedure; this includes maximizing preoperative endometrial sampling and considering selective criterion with risk factors for concurrent endometrial carcinoma including age, endometrial thickness, obesity, and molecular classification.
Disclaimer
As a service to authors and researchers we are providing this version of an accepted manuscript (AM). Copyediting, typesetting, and review of the resulting proofs will be undertaken on this manuscript before final publication of the Version of Record (VoR). During production and pre-press, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal relate to these versions also.Article Highlights
30-40% of patients with EIN will have underlying endometrial carcinoma and up to 10% of these cancers will be high-risk.
The use of SLN during hysterectomy for EIN has been increasing over the past decade.
Benefits of SLN dissection for patients with EIN include proper staging for those with underlying carcinoma and a lower risk of lymphedema compared to full lymphadenectomy.
Disadvantages of SLN dissection for patients with EIN include the additional risk of the dissection, cost and overtreatment for those without underlying carcinoma.
Risk factors for underlying carcinoma in patients with EIN include advanced age, obesity, diabetes mellitus, endometrial stripe thickness >15mm.
New guidelines are needed to define which patients have a higher risk for underlying carcinoma and therefore would benefit from a SLN dissection.
Abbreviations
| EIN | = | Endometroid intraepithelial neoplasia |
| ACOG | = | American College of Obstetricians and Gynecologists |
| SGO | = | Society of Gynecologic Oncology |
| NCCN | = | National Comprehensive Cancer Network |
| SLN | = | Sentinel lymph node |
| ICG | = | indocyanine green |
| CAH | = | complex atypical hyperplasia |
| GOG | = | Gynecologic Oncology Group |
| BMI | = | body mass index |
| DM | = | diabetes mellitus |
| EEC | = | endometrial echo complex |
| EMB | = | endometrial biopsy |
| D&C | = | dilation and curettage |
| SEER | = | Surveillance, Epidemiology, and End Results |
| MMRd | = | mismatch repair protein deficient |
| aOR | = | adjusted odds ratio |
| CI | = | confidence interval |
Declaration of Interests
K. Matsuo receives academic support from the Ensign Endowment for Gynecologic Cancer Research, an institutional endowment at the University of Southern California. X.M. Guo has received educational payments from Intuitive Surgical for a robotics training course. The remaining authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.
Table 1. Risk of pelvic and paraaortic nodal involvement
Table 2 Complications associated with sentinel and systematic lymph node assessment [Citation13,Citation20,Citation43,Citation44,Citation52]
Table 3. Risk factors for EIN with concurrent underlying carcinoma. CI=Confidence Interval; EEC=endometrial echo complex; TVUS=transvaginal ultrasound; BMI=body mass index.
EIN=endometrial epithelial neoplasia; SLN=sentinel lymph node.