The Sentinel Lymph Node Biopsy in High Risk Endometrial Carcinoma

Abstract

 Endometrial cancer is the most common cancer of the female genital system in developed countries, leading gynecological cancers and ranks seventh in cancer-related deaths. Endometrial cancer is classified into two different clinicopathological subtypes, type 1 and 2. The presence of type 2 cancer indicates a tumor behavior that is prone to metastasis in the early period, it tends to spread rapidly to peritoneal surfaces via the trans tubal route, and retroperitoneal lymph nodes via the lymphatic route. There are some studies reporting that the rate of nodal spread is up to 40% in type 2 cancer. Type 2 cancer is consisted of poorly differentiated tumor histologically and the prognosis is poor also. Two-thirds of patients with type 2 cancer have a disease that has spread beyond the uterus at the time of diagnosis. Tumors with the following characteristics are included in the group defined as high-risk endometrial cancer; Stage I, Grade 3 endometrioid histology, depth of myometrial invasion> 50%, independent of lymphovascular space invasion (LVSI). Stage I, Nonendometrioid histologies (serous, clear cell, undifferentiated type and carcinosarcoma) Stage II endometrial cancer (independent of histological type). Many international gynecological oncology guidelines (ESGO, NCCN), and guideline of Turkish Gynecological Oncology Association recommend a complete staging surgery including hysterectomy + bilateral salpingooferectomy (BSO) + omentectomy + pelvic and para-aortic lymphadenectomy for patients with highrisk endometrial cancer. However, systematic lymphadenectomy not only prolongs the operation time, but also may set stage for operative complications such as severe bleeding, and may cause increased morbidity in the post-operative period such as lymphocyst formation, lymphedema development. Accordingly, the concept of sentinel lymph node Mapping (SLNM) refers to an innovative and minimalist surgical approach that has been put forward to reduce both complications and morbidity. SLNM has been evaluated in many original studies on endometrial cancer in the last decade, its effectiveness has  been investigated in many meta-analysis, and it is now included in the above-mentioned international guidelines. However, in the review of literature, it is striking that SLNM is frequently studied on low and medium risk endometrial cancer. There are a limited number of studies conducted with the high risk  endometrial cancer. Since it is less common, the prognosis is poor and the number of cases suitable for SLNM is limited, high risk endometrial cancer has been the subject of few studies. If the latest version of the guideline of uterine cancers published on the website of the American National Comprehensive Cancer Data Network (NCCN) was reviewed, it concluded as ‘recent evidence indicates that SLN mapping may also be used in high risk histologies ie, serous carcinoma, clear cell carcinoma, carcinosarcoma’. In this review, the current literature on the subject has been reviewed and evaluated considering the results of highlighted studies.

Keywords

• endometrial cancer
• sentinel node
• high risk factors
• lymphatic mapping

Yüksek Riskli Endometrium Kanserinde Sentinel Lenf Nodu Biopsisinin Yeri

Abstract

Endometriyum kanseri, gelişmiş ülkelerde kadın genital sisteminin en sık görülen kanseri olup, jinekojik kanserlerin başını çekmekte ve kansere bağlı ölümlerde yedinci sırada yer almaktadır. Endometriyum kanseri, tip 1 ve 2 olmak üzere iki farklı klinikopatolojik alt tipe sınıflandırılarak incelenir. Tip 2 kanser varlığı, erken dönemde metastaz yapmaya yatkın bir tümör davranışına işaret eder, trans tubal yolla peritonal yüzeylere ve lenfatik yolla retroperitonal lenf nodlarına hızlıca yayılım eğilimi gösterir. Tip 2 kanserde, nodal yayılım oranının %40’a kadar çıktığını bildiren yayınlar mevcuttur. Bunlar histolojik olarak az diferansiye tümörler olup, prognozları da kötüdür. Tip 2 kanseri olan hastaların üçte ikisinde tanı anında uterus dışına yayılmış hastalığı vardır. Yüksek riskli endometriyum kanseri olarak tanımlanan grupta şu özelliklere sahip tümörler yer almaktadır; • Evre I, Grade 3 endometrioid histoloji, myometriyal invazyon derinliği >%50, lenfovaskuler alan invazyonundan (LVAI) bağımsız. • Evre I, Endometrioid dışı histolojiler (seröz, berrak hücreli, andiferansiye tip ve karsinosarkom) • Evre II endometriyum kanseri (histolojik tipten bağımsız). Bir çok yabancı jinekolojik onkoloji kılavuzunda (ESGO, NCCN) olduğu gibi, Türk Jinekolojik Onkoloji Derneğinin kılavuzu da; yüksek risk grubundaki endometriyal kanserli hastalara, histerektomi + bilateral salpingooferektomi (BSO) + omentektomi + pelvik ve para-aortik lenfadenektomi’yi kapsayan tam bir evreleme cerrahisi yapılması önerilmektedir. Ancak, sistematik lenfadenektomi operasyon süresini uzatmakla kalmaz, ciddi kanama gibi operatif komplikasyonlara zemin hazırlar ve post-operatif dönemde (lenfokist oluşumu, lenf ödem gelişimi gibi) morbidite artışına da neden olabilir. Bu bağlamda, sentinel lenf nodu biyopsisi (SLNB) kavramı, hem komplikasyonları hem de morbiditeyi azaltmak için ortaya atılmış yenilikçi ve minimalist bir cerrahi yaklaşımı ifade etmektedir. SLNB, son on yılda endometriyum kanserinde çok sayıdaki özgün çalışmada değerlendirilmiş, birçok meta-analizde etkinliği araştırılmış ve artık yukarıda bahsi geçen yabancı kılavuzlarda yer edinmiştir. bununla birlikte, literatür incelendiğinde, SLNB’nin sıklıkla düşük ve orta risk grubu üzerinde çalışıldığı göze çarpmaktadır. Yüksek risk grubu ile yapılmış sınırlı sayıda çalışma mevcuttur. Yüksek riskli hastalığın; daha az rastlanır olması, ileri evrede tanı aldığından prognozunun kötü seyretmesi ve SLNB için uygun vaka sayısının kısıtlı olması nedeniyle az sayıda çalışmaya konu olmuştur. Amerikan Ulusal Kapsamlı Kanser veri ağının (NCCN) internet sayfasında, Temmuz 2020’de yayınlanan uterin kanserler kılavuzunun son sürümü incelendiğinde (v2. 2020) ‘ Elimizdeki son kanıtlar, sentinel lenf nodu haritalamasının seröz karsinom, berrak hücreli karsinom ve karsinosarkom gibi yüksek riskli histolojilerde de kullanılabileceğini göstermektedir ‘ şeklinde güncel bir ifade yer almaktadır. Bu derlemede, konuyla ilgili güncel literatür gözden geçirilmiş ve önemli çalışmaların sonuçları dikkate alınarak değerlendirilmiştir.

Keywords

• endometrium kanseri
• sentinel lenf nodu
• yüksek risk faktörleri
• lenfatik haritalama

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