Editorial
Management of the sentinel lymph node in endometrial cancer: Is the role of Nuclear Medicine specialists still needed?
Manejo del ganglio centinela en el cáncer de endometrio, ¿sigue siendo necesario el papel del médico nuclear?
Pilar Paredesa,b,c,
, Berta Díaz-Feijoob,c,d
Corresponding author
pparedes@clinic.cat
Corresponding author at: Servicio de Medicina Nuclear, Hospital Clínic Barcelona, C/Villarroel 170, 08036 Barcelona, Spain.
Corresponding author at: Servicio de Medicina Nuclear, Hospital Clínic Barcelona, C/Villarroel 170, 08036 Barcelona, Spain.
a Servicio de Medicina Nuclear, CDI, Hospital Clínic Barcelona, Barcelona, Spain
b Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
c Facultat de Medicina – Universitat de Barcelona, Barcelona, Spain
d Unidad de Ginecología Oncológica, Institut Clínic de Ginecologia, Obstetríciai Neonatologia, Hospital Clínic Barcelona, Barcelona, Spain
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "273" "paginaFinal" => "274" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Pilar Paredes, Berta Díaz-Feijoo" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Pilar" "apellidos" => "Paredes" "email" => array:1 [ 0 => "pparedes@clinic.cat" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Berta" "apellidos" => "Díaz-Feijoo" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, CDI, Hospital Clínic Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Facultat de Medicina – Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Ginecología Oncológica, Institut Clínic de Ginecologia, Obstetríciai Neonatologia, Hospital Clínic Barcelona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Servicio de Medicina Nuclear, Hospital Clínic Barcelona, C/Villarroel 170, 08036 Barcelona, Spain." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo del ganglio centinela en el cáncer de endometrio, ¿sigue siendo necesario el papel del médico nuclear?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Endometrial cancer is the sixth most frequent neoplasm in women worldwide and the second gynecological neoplasia following cervical cancer<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. Endometrial cancer is divided into groups of risk based on the histopathological characteristics of the tumor. These characteristics include the histological type, tumoral grade, myometrial infiltration and lymphovascular invasion and make up 4 prognostic groups: low, intermediate, intermediate-high and high risk<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. The European Society of Gynaecological Oncology (ESGO), the European Society of Radiotherapy and Oncology (ESTRO) and the European Society of Pathology (ESP) recently published guidelines for determining the groups of risk in endometrial cancer<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>, integrating both molecular diagnostics and clinic-pathological variables, and representing a revolutionary change in the management of these patients.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the last decade the concept of selection sentinel lymph node biopsy (SLNB) has been introduced for tumors of low risk, being optional in case of high or intermediate risk. Given its high sensitivity and the possibility of performing ultrastaging, this technique allows the detection of low volume lymph node metastases<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>: micrometastasis and isolated tumor cells. The first have been associated with a greater risk of recurrence<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5,6</span></a>, being susceptible to adjuvant treatment and are included in the 8th edition of the American Joint Committee on Cancer<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The management of endometrial cancer requires a multidisciplinary team including gynecologists, oncologists, medical oncologists and radiotherapy oncologists, pathologists, radiologists and specialists in Nuclear Medicine. The recent ESGO/ESTRO/ESP guidelines include the recommendations of the three societies for the diagnosis, molecular classification, treatment and follow-up of patients with endometrial cancer.</p><p id="par0020" class="elsevierStylePara elsevierViewall">This consensus recommends adding the detection of the sentinel lymph node in tumors of low/intermediate risk to identify patients with lymph node dissemination/infiltration and advise against this procedure in tumors without myometrial infiltration. Likewise, these guidelines accept the possibility of performing SLNB in tumors of intermediate-high risk as an alternative to pelvic and aortic lymph node dissection. Surprisingly, the only method recommended is cervical injection of indocyanine green (ICG).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Since the introduction of SLNB in breast cancer, the tracers most commonly used for detection of the sentinel lymph node in gynecological tumors are radiotracers which provide a lymphatic map prior to surgery and have shown an elevated detection of lymph node involvement and the identification of unexpected drainage even in patients with high risk tumors<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–12</span></a>. Cervical injection of the radiotracer in tumors of high risk, whether alone<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> or combined with dyes<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> has shown a detection rate of 88–91%<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–11</span></a>, being 80% with myometrial injection<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>. The SENTI-ENDO study<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>, which included low, intermediate and high risk tumors demonstrated that lymphoscintigraphy increased not only the global detection rate, achieving 86%, but also the identification of aberrant drainages, especially in the paraaortic territory. In this localization, the lymphatic map provided by the lymphoscintigraphy prior to surgery allows identification of 9.5% of sentinel lymph nodes after cervical injection<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>, rising to 46% when myometrial injection is performed<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>, being greater than that achieved with ICG.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Several tracers have been used in endometrial cancer including the use of vital stains such as methylene blue of isosulfan blue, the previously mentioned radiotracers or ICG. In a systematic review of the literature comparing the diagnostic accuracy of these tracers<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>, blue stains showed a lower rate of detection, achieving a global detection of 71% and bilaterality of 40%. ICG presented the maximum detection rate at 95%, with elevated bilaterality of drainage of 66%, while the radiotracers used alone or combined with blue stains achieved a similar global detection rate (93%) and greater bilaterality (71%). The introduction of ICG has replaced the use of blue stains and has shown to be an easy to use intraoperative tool due to its elevated drainage capacity, greater intraoperative visualization compared to the blue stains and better identification of lymph node structures in fatty tissue. However, similar to radiotracers, specific equipment is necessary for the use of ICG, requiring a near-infrared fluorescence camera and lymphatic migration is very rapid. In addition, up to 8% of the sentinel lymph nodes detected with ICG are empty lymph node packets, which are lymph nodes intraoperatively considered as sentinel lymph nodes but in the definitive histopathological analysis lymph node structure is not detected<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. Radiotracers, which require the collaboration of different specialties, provide a preoperative lymphatic map which is useful to guide the surgical team and is more specific than the drainage of ICG since the tracer remains retained in the sentinel lymph node and can be detected after several hours. This map indicates the presence of drainage in unexpected territories and the presence of sentinel lymph nodes in the paraaortic territory which remain unnoticed with ICG.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Hybrid tracers (ICG-[<span class="elsevierStyleSup">99m</span>Tc]Tc-albumin nanocolloid) have been developed in the last decade and combine the advantages of both components – the facility of intraoperative visual detection of ICG and the specificity and the lymphatic map of the radiotracers. These tracers have been used in gynecological tumors<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> such as cancer of the vulva<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> and cancer of the cervix<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>, demonstrating an elevated rate of detection and sensitivity for the detection of metastasis in both cases. These tracers reinforce the multidisciplinary management of gynecological tumors and open a new stage in oncologic gynecology.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Similar to the European recommendations<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a> which include the use of radiotracers alone or combined with stains for the detection of the sentinel lymph node in cancer of the vulva and cervical cancer, we consider that for endometrial cancer the guidelines should include the use of radiotracers combined with ICG, whether sequentially or through hybrid tracers. For this it is necessary for the guidelines and consensus to consider the participation of all the specialists involved in the management of endometrial cancer, including Nuclear Medicine specialists.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Paredes P and Díaz-Feijoo B. Manejo del ganglio centinela en el cáncer de endometrio, ¿sigue siendo necesario el papel del médico nuclear? Rev Esp Med Nucl Imagen Mol. 2021. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.remn.2021.06.004">https://doi.org/10.1016/j.remn.2021.06.004</span></p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Corpus uteri. global cancer observatory: cancer today" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Ferlay" 1 => "M. Ervik" 2 => "F. Lam" 3 => "M. Colombet" 4 => "L. Mery" 5 => "M. 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