ObjectivesLaparoscopy is commonly used for endometrial cancer treatment, and sentinel lymph node (SLN) mapping has become the standard procedure for nodal assessment. Despite the standardization of the technique, there is no definitive data regarding its failure rate. The objective of this study is to identify factors associated with unsuccessful SLN mapping in endometrial cancer patients undergoing laparoscopic SLN mapping after intracervical indocyanine green (ICG) injection.MethodsWe retrospectively evaluated a consecutive series of endometrial cancer patients who underwent laparoscopic SLN mapping with intracervical ICG injection, in four oncological referral centers from January 2016 to July 2019. Inclusion criteria were biopsy-proven endometrial cancer, total laparoscopic approach, and intracervical ICG injection. Exclusion criteria were evidence of lymph node involvement or extrauterine disease at pre-operative imaging, synchronous invasive cancer, the use of tracers different from ICG, and the use of neoadjuvant treatment. Bilateral and failed bilateral SLN mapping groups were compared for clinical and pathological features. In patients with an unsuccessful procedure, side-specific lymphadenectomy was performed. Logistic regression was used to identify predictors of failure.ResultsA total of 376 patients were included in the study. The overall bilateral and unilateral SLN detection rates were 96.3%, 76.3%, and 20.0% respectively. The failed bilateral mapping detection rate was 23.7%. The median number of sentinel nodes removed was 2.2 (range, 0–5). After multivariate analysis, lymph vascular space involvement [OR 2.4 (1.04–1.12), P=0.003], non-endometrioid histology [OR 3.0 (1.43–6.29), P=0.004], and intraoperative finding of enlarged lymph node [OR 2.3 (1.01–5.31), P=0.045] were identified as independent predictors of failure of SLN mapping.ConclusionLymph vascular space involvement, non-endometrioid histology, and intra-operative finding of enlarged lymph nodes were identified as independent risk factors for unsuccessful mapping in patients undergoing laparoscopic SLN mapping.

Aortic lymph node metastases are a relative common finding in locally advanced cervical cancer. Minimally invasive surgery is the preferred approach to perform para-aortic lymph nodal staging to reduce complications, hospital stay, and the time to primary treatment. This meta-analysis (CRD42022335095) aimed to compare the surgical outcomes of the two most advanced approaches for the aortic staging procedure: conventional laparoscopy (CL) versus robotic-assisted laparoscopy (RAL). The meta-analysis was conducted according to the PRISMA guideline. The search string included the following keywords: “Laparoscopy” (MeSH Unique ID: D010535), “Robotic Surgical Procedures” (MeSH Unique ID: D065287), “Lymph Node Excision” (MeSH Unique ID: D008197) and “Aorta” (MeSH Unique ID: D001011), and “Uterine Cervical Neoplasms” (MeSH Unique ID: D002583). A total of 1324 patients were included in the analysis. Overall, 1200 patients were included in the CL group and 124 patients in the RAL group. Estimated blood loss was significantly higher in CL compared with RAL (p = 0.02), whereas hospital stay was longer in RAL compared with CL (p = 0.02). We did not find significant difference for all the other parameters, including operative time, intra- and postoperative complication rate, and number of lymph nodes excised. Based on our data analysis, both CL and RAL are valid options for para-aortic staging lymphadenectomy in locally advanced cervical cancer.

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ObjectivesSurvival of patients with cervical cancer is strongly associated with the local extent of the primary disease. The aim of the study was to develop an integrated diagnostic algorithm, including ultrasonography (USG), magnetic resonance imaging (MRI), and examination under anesthesia, to define the local extent of disease in patients with newly diagnosed cervical cancer.MethodsPatients with biopsy proven cervical cancer who underwent primary surgery from January 2013 to December 2018 in four participating centers were recruited. Patients who underwent USG, MRI, and examination under anesthesia prior to surgery were included in the study. Those for whom complete data were not available were excluded. Data regarding tumor size, parametrial invasion, and vaginal involvement obtained by USG, MRI, and examination under anesthesia were retrieved and compared with final histology. Specificity and sensitivity of the three methods were calculated for each parameter and the methods were compared with each other. An integrated pre-surgical algorithm was constructed considering the accuracy of each diagnostic method for each parameter.ResultsA total of 79 consecutive patients were included in the study. Median age was 53 years (range 28–87) and median body mass index was 24.6 kg/m2 (range 16–43). Fifty-five (69.6%) patients had squamous carcinoma, 18 (22.8%) patients had adenocarcinoma, and six (7.6%) patients had other histological subtypes. A statistically significant difference among the three methods was found for detecting tumor size (p=0.002 for tumors >2 cm and p=0.006 for tumors >4 cm) and vaginal involvement (p=0.01). There was no difference in detection of parametrial invasion between USG, MRI, and examination under anesthesia (p=0.26). Furthermore, regarding tumor size assessment, USG was found to be the significantly better method (p<0.01 for tumors >2 cm and p=0.02 for tumors >4 cm). Examination under anesthesia was the most accurate method for detection of vaginal involvement (p=0.01). Examination under anesthesia and MRI had higher accuracy than USG for identification of parametrial invasion. Application of the algorithm provided the correct definition of local extent of disease in 77.2% of patients (p=0.04). USG was the most accurate method to determine tumor size, while examination under anesthesia was found to be more accurate in prediction of vaginal involvement.ConclusionOur integrated diagnostic algorithm allows a higher accuracy in defining the local extent of disease and may be used as a tool to determine the therapeutic approach in women with cervical cancer.

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