Blakely Morgan, Liu Yuxin, Rahaman Jamal, Prasad-Hayes Monica, Tismenetsky Mikhail, Wang Xiaofei, Nair Navya, Dresser Karen A, Nagarsheth Nimesh, Kalir Tamara
Department of Pathology (M.B.) Division of Gynecologic Pathology (Y.L., T.K.) Gynecologic Oncology (J.R., M.P.-H., N.N., N.N.), Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York Department of Pathology, Englewood Hospital and Medical Center, Englewood, New Jersey (M.T.) Department of Pathology, University of Massachusetts Medical School, Worcester, Massachusetts (X.W., K.A.D.).
Int J Gynecol Pathol. 2019 Jan;38(1):52-58. doi: 10.1097/PGP.0000000000000463.
For endometrial cancer (EC), most surgeons rely on intraoperative frozen section (IFS) to determine the risk of nodal metastasis and necessity of lymphadenectomy. IFS remains a weak link in this practice due to its susceptibility to diagnostic errors. As a less invasive alternative, sentinel lymph node (SLN) mapping and ultra-staging have gradually gained acceptance for EC. We aimed to establish the SLN success rate, negative predictive value, and whether SLNs provide useful information for cases misdiagnosed on IFS. From 2013 to 2017, 100 patients (63 low-risk and 37 high-risk EC) underwent hysterectomy, bilateral salpingo-oophorectomy, and SLN. Among them, 56 had additional pelvic lymphadenectomy. A total of 337 SLNs were obtained in 86 cases: 55 bilaterally and 31 unilaterally. The remaining 14 cases failed because of patient obesity or leiomyoma. Pathology ultra-staging detected 2 positive SLNs from 2 patients (1 with isolated tumor cells, 1 with micrometastases). One of 773 nonsentinel pelvic nodes was positive on the contralateral hemi-pelvis in a patient who was mapped unilaterally, resulting in negative predictive value of 100%. During IFS, tumor grade and/or depth of myometrial invasion was misdiagnosed in 22 cases (22%). These errors would have resulted in under-staging in 10 high-risk patients or over-staging in 4 low-risk patients. SLNs were mapped in these misestimated patients, with one revealing metastases. SLN provides invaluable information on nodal status while detecting occult metastases in cases misdiagnosed on IFS. Our findings justify the incorporation of SLN in initial surgery for EC as an offset to IFS diagnostic errors, minimizing their negative impact on patient care.
对于子宫内膜癌（EC），大多数外科医生依靠术中冰冻切片（IFS）来确定淋巴结转移风险和淋巴结清扫的必要性。由于IFS易出现诊断错误，它在这种实践中仍然是一个薄弱环节。作为一种侵入性较小的替代方法，前哨淋巴结（SLN）定位和超分期已逐渐被子宫内膜癌所接受。我们旨在确定SLN成功率、阴性预测值，以及SLN是否能为IFS误诊的病例提供有用信息。2013年至2017年，100例患者（63例低风险和37例高风险EC）接受了子宫切除术、双侧输卵管卵巢切除术和SLN定位。其中，56例患者还接受了盆腔淋巴结清扫术。86例患者共获取了337个SLN：55例双侧获取，31例单侧获取。其余14例因患者肥胖或子宫肌瘤而失败。病理超分期检测到2例患者的2个SLN阳性（1例为孤立肿瘤细胞，1例为微转移）。1例单侧定位的患者对侧半盆腔的773个非前哨盆腔淋巴结中有1个阳性，阴性预测值为100%。在IFS过程中，22例（22%）患者的肿瘤分级和/或肌层浸润深度被误诊。这些错误会导致10例高风险患者分期过低或4例低风险患者分期过高。对这些估计错误的患者进行了SLN定位，其中1例发现有转移。SLN在检测IFS误诊病例中的隐匿转移时，能提供关于淋巴结状态的宝贵信息。我们的研究结果证明，将SLN纳入EC的初始手术中可弥补IFS诊断错误，将其对患者治疗的负面影响降至最低。
