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Sentinel node biopsy for diagnosis of lymph node involvement in endometrial cancer

Can tests to identify the main draining lymph nodes in women with endometrial cancer accurately diagnose if the cancer has spread to the lymph nodes?

Women who have endometrial cancer (cancer arising from the lining of the womb) may have cancer cells spread to lymph nodes in the pelvis and/or the para-aortic area (main blood vessel in the upper abdominal cavity) and need additional radiotherapy treatment, with or without chemotherapy, following initial hysterectomy. Previous studies looked at the effect of removing as many of the pelvic lymph nodes as possible (lymphadenectomy), but did not show a benefit to survival. However, lymphadenectomy often causes problems with lymphoedema (swelling of the legs) and lymphocysts (collections of lymph fluid). Sentinel lymph node (SLN) biopsy (SLNB) involves identifying the first SLN draining the tumour, using a dye or radioactive tracer, or both. The SLNs are removed and examined under a microscope to check for cancer cells. Additional treatment decisions may change depending on these findings.

Why is this review important?

Several studies used dyes or traceable agents to identify SLNs in women with womb cancer. It is not clear whether all of these agents are sufficiently accurate to predict which women have cancerous spread to lymph nodes and whether it is better to inject dye to the cervix or the muscle of the womb. This review summarises the evidence and produces overall estimates of the relative accuracies of the available tests.

How was the review conducted?

We included studies that tested the accuracy of tracer agent/s to identify SLN against the standard method of removing all pelvic nodes, with or without para-aortic lymph nodes. We restricted the studies to those that examined the SLNs by taking multiple slices of the node and staining for cancer cells using antibody markers (immunohistochemistry (IHC)) before examining them under a microscope (ultrastaging).

What are the findings?

We included 33 studies (2237 women) that evaluated any techniques used to identify the SLN draining from the womb.

Read the results of this Cochrane Review here:

Comparing standard and extended lymph node removal in people with cancer of the head of the pancreas and the periampullary region

Review question

We attempted to find out whether more extensive surgical removal of lymph nodes had a positive effect on survival, recurrence, and eventual complications, and how their removal may affect the person’s quality of life.

Background

Pancreatic and periampullary adenocarcinomas reflect the most common and aggressive among pancreatic cancers. Most common symptoms include pain, jaundice (yellowing of the skin and whites of the eyes), and weight loss. Unfortunately, these symptoms often do not present during early stages of the disease, thereby delaying diagnosis. This delay means that only about 15% to 25% of people with pancreatic cancer are eligible for potentially curative therapy. Partial pancreaticoduodenectomy (PD) is the treatment of choice. This includes the removal of the head of the pancreas (a large gland that produces insulin and secretions that aid digestion), the duodenum (first part of the small intestine), the gallbladder (an organ that stores bile, which aids digestion), the far end of the bile duct (carries bile from the liver or gallbladder to the duodenum), lymph nodes close to the affected area (structures that act as filters to prevent foreign particles from entering the bloodstream), and sometimes, the far end of the stomach.

However, controversy remains as to whether it is potentially beneficial to remove more lymph nodes. In general, about 5% of people die from pancreatic surgery, and 18% to 52% face complications. These include delayed emptying of the stomach after eating, development of a pancreatic fistula (an abnormal connection between the pancreas and the abdominal cavity or other organs), the collection of pus in the abdomen, and excessive bleeding from the stomach, intestine, or abdominal cavity.

Study characteristics

We included seven randomised controlled trials (type of study in which participants are randomly assigned to the treatment groups), published before 10 September 2020, with a total of 843 adult participants who had undergone PD with either standard or extended lymph node removal. There were differences in sample size, treatments, and quality of the research between the studies.

Key results

We found little or no difference in overall survival between the two groups. It was likely that the operating time was longer, there was more blood loss, and more lymph nodes were removed in the group that underwent extended lymph node resection. However, there was little or no difference in the rate of negative resection margins (i.e. no detectable tumour cells at the cutting surface of the specimen) between the two groups.

We conclude that at present, a more extensive removal of lymph nodes does not improve survival in people with pancreatic and periampullary adenocarcinomas.

Quality of the evidence

Overall, we found low-quality evidence. The studies used different treatment regimens and different definitions of standard and extended lymph node resection; lack of blinding of the surgeons and other caregivers introduced a risk of performance bias for all outcomes; the use of chemotherapy and other co-interventions was different between studies, and between groups in individual studies. Therefore, we have limited confidence in the estimate of the effect, and the true effect may be substantially different from what we found.