Challenges to Intraoperative Evaluation of Endometrial Cancer

Abstract

Background and Objectives: Intraoperative evaluation of the uterus has been reported to predict risk of lymph node spread in endometrial cancer. Four criteria have been prospectively validated by the Mayo Clinic; histopathology, grade, tumor size, and depth of myometrial invasion. The objective of this study is to assess the accuracy of intraoperative evaluation in a university-affiliated teaching setting. Methods: This study was a retrospective chart review of 105 cases of endometrial cancer who underwent roboticassisted staging from January 2016 through December 2017. Results: Seventy-five cases were included. The mean age was 65 y and mean body mass index was 33 kg/m 2. Fifty-eight patients (80.6%) had no change between intraoperative and postoperative grade. This yielded a 19.4% discordance rate with a significant disagreement (P ϭ .003, Cohen's ϭ 0.705). Fifty-eight patients (82.9%) had no change in depth of invasion. This yielded a 17.1% discordance rate with a significant disagreement (P ϭ .0498, Cohen's kappa of 0.69 [95% confidence interval, 0.53-0.85]). Average tumor diameter was 3.4 cm. Seven patients (11.7%) were upsized from the low-risk (Յ2 cm) to the high-risk category (Ͼ2 cm). This led to an 11.7% discordance rate, with a significant disagreement (P ϭ .008, Cohen's kappa of 0.69 [95% confidence interval, 0.48-0.89]). In 15 of 75 cases (20%), intraoperative evaluation of the size of the tumor was not possible and deferred to the final pathology report. Conclusion: We conclude the Mayo Clinic Criteria cannot be universally adopted until all four criteria can be validated through a prospective study that includes institutions that have variable resources.

Accuracy of MRI in predicting deep myometrial invasion in endometrial cancer and the influence of leiomyoma, adenomyosis and the microcystic elongated and fragmented tumour pattern

“…Diagnostic concordance between frozen sections and permanent sections have been reported between 67-98% whereas agreement rates between gross visual inspection and final histology are reported between 68-87% demonstrating less reliability with higher tumour grades. 23,25,26 Though frozen sections appear to show higher accuracy rates, evaluation is not without its limitations given confounding factors such as deep adenomyosis with or without associated tumour, leading to overestimation. 27 Intraoperative frozen section evaluation of nodes is another method considered in an attempt to tailor nodal dissection at the time of surgery.…”

“…in 2012 24 demonstrated MRI DMI accuracy, sensitivity and specificity rates of 84%, 69% and 88%; and that of frozen sections of 94%, 73% and 100% respectively in the same group. Diagnostic concordance between frozen sections and permanent sections have been reported between 67–98% whereas agreement rates between gross visual inspection and final histology are reported between 68–87% demonstrating less reliability with higher tumour grades 23,25,26 . Though frozen sections appear to show higher accuracy rates, evaluation is not without its limitations given confounding factors such as deep adenomyosis with or without associated tumour, leading to overestimation 27 …”

Sentinel Lymph Node Sampling in Robot-Assisted Staging of Endometrial Cancer

“…We recently published our experience with risk-based LND, 24 in which we found a significant discrepancy between intraoperative evaluation and the final pathology report prohibiting the use of this method at our institution 24 . The purpose of the present study was, therefore, to assess the map rate, sensitivity, and negative predictive value of SLN sampling in robot-assisted endometrial cancer staging using cervical injection of ICG in a university-affiliated teaching setting.…”

A Modern Approach to Endometrial Carcinoma: Will Molecular Classification Improve Precision Medicine in the Future?

“…Treatment decisions and patient guidance have been tailored to the latter risk groups. However, comparison of treatment recommendations may be difficult since the international scientific community has used different risk classifications in the past and has not yet been able to implement a standardized classification system [ 6 , 7 , 8 , 9 , 10 ] ( Figure 1 ).…”

“…These preoperative uncertainties lead to either undertreatment with subsequent second surgery or the risk of overtreatment. Maximum tumor size and myometrial infiltration can be determined using intraoperative frozen sections, which are not available everywhere [ 9 , 11 ]. Of course, if future treatment also depends on increasingly complex analyses like molecular classification, there is a need for centralization of the diagnostic procedure and even the gynecological cancer treatment.…”