| Endometrial cancer is a common malignant tumor.At present,with the influence of different factors such as environmental pollution and people’s dietary habits,the number of endometrial cancer incidence and deaths continues to increase,and the trend is younger.Worldwide,there were 319,500 new cases and 76,000 deaths in 2015.By2018,there were 380,000 new cases and 89,000 deaths worldwide.The incidence of endometrial cancer in my country shows significant regional differences,and there are large differences between rural and urban areas in terms of new and dead patients.Compared with rural areas,the new cases of endometrial cancer in urban areas are larger,but the mortality rate of clinical patients is lower.Sentinel lymph node(SLN)mapping is a more recent and accurate method for assessing lymph node status in endometrial cancer.This technique minimizes the risk of neurovascular injury,lymphocyst formation,and lymphedema during systemic lymphadenectomy.As a newly developed technique for assessing the status of lymphatic metastasis in endometrial cancer,SLN mapping shows good clinical significance and application value.However,the diagnostic performance of SLN mapping for low-risk and highrisk endometrial cancer patients needs further in-depth evaluation to improve patient benefit and provide important judgment indicators for guiding the diagnosis and treatment of endometrial cancer.Chapter 1 Analysis of risk factors for lymph node metastasis in patients with endometrial cancerObjective It is very important to assess the risk of lymph node metastasis in patients with endometrial cancer.First,For patients who underwent total hysterectomy for benign diseases and were diagnosed as endometrial cancer in routine postoperative pathological examination,accurate assessment of the risk factors for lymph node metastasis can provide an important reference for further postoperative treatment.The second is to evaluate the lymph node metastasis status of patients before and during surgery,which can help doctors identify high-risk patients,so as to formulate more accurate and individualized diagnosis and treatment plans,and further improve the quality of life of patients.This chapter first explores the related factors of lymph node metastasis in patients diagnosed with endometrial cancer through postoperative detection,and provides more reference for clinical diagnosis and treatment of patients.Methods A retrospective analysis of 131 patients with endometrial cancer who were treated in Shanghai First Maternity and Infant Health Hospital in July 2016 and July 2018 and confirmed by endometrial biopsy.The patients were 3576 years old and their body mass index(BMI)was 18.537.8kg/m2.Record the patient’s clinical baseline data,including age,pregnancy history,clinical symptoms,comorbidities,menopausal status,etc.;record the patient’s postoperative pathological data,including lymph node metastasis,pathological type,tumor diameter,muscle layer Infiltration depth,cervical interstitial infiltration,lymphovascular space infiltration,histological grade,peritoneal lavage cytology,etc.The indicators with statistical difference were included in binary logistic analysis,and the predictive value of ROC curve analysis for lymph node metastasis.Results(1)There was no difference in age,BMI index and peritoneal lavage cytology in lymph node metastasis of endometrial cancer patients(P>0.05);There were differences in lymph node metastasis in patients with pathological grade,histological subtype,tumor size,lymphovascular space immersion,cervical stromal infiltration,myometrial infiltration depth and serum CA125 level(P<0.05).(2)Cervical stromal invasion,lymphovascular space immersion,non-endometrioid adenocarcinoma,depth of myometrial invasion ≥1/2,poorly differentiated,tumor diameter ≥20mm,CA125 >35U/ml,were included in the regression analysis and showed that: non-endometrioid Adenocarcinoma,depth of myometrial invasion ≥1/2,poorly differentiated and CA125 > 35U/ml were independent risk factors for lymph node metastasis.(3)The predictors are the depth of myometrial invasion,CA 125,histological grade and pathological type.According to the expression of the joint equation,it can be obtained that Y=﹣6.720+1.271*histological grade+1.186*CA 125+1.519*depth of myometrial invasion+ 1.571* pathological type.From the ROC curve,it can be seen that the specificity of the combined predictor is 81.0%,the sensitivity is 90.5%,and the maximum AUC is 0.879.It can be seen that the depth of muscle invasion,CA125 level,histological grade and pathological type are in a certain degree.Prediction of lymph node metastasis in endometrial cancer.Conclusions Well-differentiated,myometrial invasion depth ≥ 1/2,CA125level>35U/ml,and non-endometrioid adenocarcinoma are high risk factors for lymph node metastasis in patients with endometrial cancer.Risk stratification of patients,and then develop individualized plans to improve the prognosis of patients and improve the quality of life of patients.Chapter 2 Cervical injection of indocyanine green sentinel lymph node mapping for the determination of lymph node metastasis in high-risk endometrial cancerObjective This chapter intends to analyze the low-risk and high-risk types of endometrial cancer respectively,so as to correctly evaluate the diagnostic accuracy of SLN mapping by cervical injection of indocyanine green in endometrial cancer surgery.The value of lymph node metastasis determination has important clinical significance.Methods A total of 131 patients with endometrial cancer who were treated in Shanghai First Maternity and Infant Health Hospital in July 2016 and July 2018 and were confirmed by endometrial biopsy were selected.All enrolled patients underwent laparoscopic total hysterectomy and bilateral salpingo-oophorectomy,and pelvic lymph node dissection after sentinel lymph node mapping.For endometrial clear cell carcinoma,serous carcinoma,undifferentiated carcinoma and Patients with carcinosarcoma underwent concurrent abdominal aortic lymphadenectomy(to the level of the inferior mesenteric artery)and omentectomy.Indocyanine green was injected into the cervix during the operation to detect the development of sentinel lymph nodes.All SLNs underwent "hyperstaged" sections.According to the location,number,and pathological examination results of SLN,the sensitivity,specificity and negative predictive value of sentinel lymph node mapping for cervical injection of indocyanine green in detecting lymph node metastasis in high-risk endometrial cancer were calculated.Results(1)After SLN detection,all patients underwent pelvic lymphadenectomy.Para-aortic lymphadenectomy and omentectomy were performed in all 25 patients with high-risk histology.Radical hysterectomy,bilateral salpingooophorectomy(HBSO)and pelvic lymphadenectomy were performed for 2 of 4patients with stage II endometrial cancer.The remaining 2 patients had high-risk histologic endometrial cancer and underwent additional para-aortic lymphadenectomy.No serious adverse events occurred in all patients.(2)Among the 131 patients with endometrial cancer,122 cases were successfully detected with SLN,accounting for 93.1%,41 cases of SLN were detected unilaterally,the detection rate was 31.3%,and 81 cases of SLN were detected bilaterally,the detection rate was 61.8%;Abdominal aortic SLN imaging in 2 cases,accounting for1.5%.The mean visualization time was(17.8 ± 3.15)minutes.A total of 291 SLNs were detected in 122 patients.The sentinel lymph nodes were distributed in the following locations according to frequency: 155 cases of external iliac,accounting for53.3%,76 cases of obturator,accounting for 26.1%,47 cases of internal iliac,accounting for 16.2%,9 cases of common iliac,accounting for 3.0%,the main There were 4 cases next to the arteries,accounting for 1.3%.(3)Eight of the 131 patients(6.1%)were lymph node positive,all of which occurred in 122 patients with at least one SLN successfully located.A total of 4 positive sentinel lymph nodes were found in the above-mentioned patients.Of these 4 patients,3(75%)SLN was the only positive lymph node,while in the fourth patient,paraaortic lymph node metastasis was found in systematic lymph node resection specimens.In the remaining 4 patients,lymph node metastasis was found only in systematic lymph node resection samples,but not in SLN.(4)According to histology,patients with endometrial cancer were divided into high-risk group and low-risk group.106 patients had low-risk endometrial cancer(endometrioid adenocarcinoma,grade 12),and 25 patients had high-risk histology(endometrioid adenocarcinoma G3,serous adenocarcinoma,clear cell carcinoma and carcinomatous sarcoma).Among 106 low-risk patients,3(2.8%)had metastasis in pelvic SLN,and all non SLN were negative in final histology.Among 25 patients with high-risk endometrial cancer,one patient(4%)found lymph node metastasis in pelvic SLN.In the final pathological report,lymph node metastasis was also found in the paraaortic area other than sentinel lymph nodes.The final pathological report of the other 4 patients(16%)found lymph node metastasis,but the SLN test was negative,of which 3 cases had metastatic lymph nodes in the paraaortic region and 1 case in the left extrailiac region.The rate of lymph node metastasis in high-risk group was 20%(5/25),which was higher than 2.8%(3/106)in low-risk group(P<0.05);There were differences in mean age,BMI index,SLN detection rate,SLN development time and the number of SLNs between high-risk group and low-risk group(P>0.05).(5)In 122 patients who successfully located at least one SLN,the sensitivity and specificity data are shown in Table 5.The overall sensitivity of sentinel lymph node technology in identifying lymph node metastatic diseases was 50%(95% CI 17.482.5),the negative predictive value was 96.6%(95% CI 90.298.8),and the false negative rate was 50%.In the low-risk group,the sensitivity was 100%(95% CI 31.0100),the negative predictive value was 100%(95% CI 95.1100),and the false negative rate was0%;In the high-risk group,the sensitivity was 20%(95% CI 17.482.5),the negative predictive value was 83.3%(95% CI 17.482.5),and the false negative rate was 80%.Conclusion Cervical indocyanine green SLN assay has low sensitivity and high false-negative rate in identifying lymph node metastases in endometrial cancer with high-risk histology.The strategy of SLNs in these patients may increase the risk of missed diagnosis of isolated para-aortic lymph node metastases and appears to be unacceptable in clinical practice.The conclusions of this study still need to be verified by multi-center,large-sample prospective studies in the future. |
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