Pernille Bjerre Trent

A cost-effectiveness analysis of sentinel lymph node biopsy compared with lymphadenectomy in intermediate- and high- risk endometrial carcinoma

Sentinel lymph node biopsy (SLN) is increasingly used for surgical staging of endometrial carcinoma. To estimate the effect and cost-effectiveness of the implementation of an SLN algorithm for surgical staging in patients with intermediate- and high-risk endometrial carcinoma compared with lymphadenectomy. We performed a model-based, cost-effectiveness analysis using primary data from a tertiary referral hospital that included 829 patients with endometrial carcinoma undergoing surgical staging. We quantified the health and economic outcomes from two time periods, before and after implementation of the SLN algorithm by robotic surgery. Costs were measured directly from the hospital's financial department, while long-term health outcomes were estimated using self-reported lymphedema and health-related quality-of-life among survivors. Sensitivity analyses were conducted to evaluate uncertainty. We projected that the SLN implementation period, predominately reflecting use of robotic SLN, simultaneously improved health outcomes (0.08 incremental quality-adjusted life-years) and lowered costs (US$1051) compared with the prior period involving robotic or open lymphadenectomy. SLN remained more beneficial and less costly across key sensitivity analyses-namely, varying the cost of the robotic platform, surgical equipment, number of yearly robotic procedures, percentage of robotic procedures versus percentage of laparotomies, length of stay, and lymphedema development. After 1000 simulations of the model, SLN implementation provided greater health benefits for lower costs (ie, cost saving) in 89% of simulations. Implementation of an SLN algorithm in the staging of intermediate- and high-risk endometrial carcinoma improved health outcomes for lower costs compared with lymphadenectomy. Cost-effectiveness could further improve by continuing to increase the proportion of robotic procedures.

The detection rate of metastatic lymph nodes comparing sentinel lymph node biopsy and lymphadenectomy for staging of intermediate- and high-risk endometrial carcinoma

The primary aim of this study was to compare the detection rates of nodal metastases between lymphadenectomy (LND) and sentinel lymph node (SLN) in intermediate- and high-risk patients with assumed uterine-confined disease. This was a single-center observational study of patients from a tertiary referral center (2006-2023). Intermediate risk was defined as endometrioid adenocarcinoma grade 1/2 with ≥50% myoinvasion or grade 3 with <50% myoinvasion. High risk was defined as endometrioid adenocarcinoma grade 3 with ≥50% myoinvasion, non-endometrioid histologies regardless of myoinvasion or cervical involvement of any histology, and myoinvasion. All SLNs underwent pathologic ultra-staging. Nodal metastases were defined as the presence of macro- or micro-metastases. The comparison of metastatic lymph node rates by nodal assessment method was performed using the χ A total of 996 patients were included (333 in the intermediate-risk group and 663 in the high-risk group). In the intermediate-risk group 192/333 (58%) patients underwent LND and 141/333 (42%) underwent SLN. Nodal metastases were detected in 11% and 9% of the LND and SLN cohorts (p = .46). Increasing proportions of staged patients were observed after SLN implementation (57% vs 78%) (p < .001). In the high-risk group, 412/663 (62%) patients underwent LND, and 251/663 (38%) underwent SLN. Nodal metastases were detected in 19% and 14% of the LND and SLN cohorts, respectively (p = .11). The majority of isolated tumor cells were observed in endometrioid histologies compared to non-endometrioid histologies (71% vs 29%, p = .01). Increasing proportions of staged patients were observed after SLN implementation (82% vs 88%) (p = .02). In the multivariable analysis, no association was observed between the nodal assessment method and the detection rates of nodal metastases in either risk group. In this predominantly high-risk population, the implementation of an SLN algorithm did not compromise the detection of nodal metastases. As more patients are comprehensively staged after SLN implementation, we expect more accurate surgical staging and adjuvant therapy allocation in this specific patient group in the future.

Effect of substantial lymphovascular space invasion on location of first disease recurrence in surgical stage I endometrioid endometrial adenocarcinoma

Lymphovascular invasion can predict nodal spread and recurrence in endometrioid endometrial cancer; however, the impact of lymphovascular invasion quantification on local versus distant recurrence in surgically staged patients has not yet been established. This multicenter, retrospective cohort study included surgically staged patients with International Federation of Obstetrics and Gynecology 2009 stage I node-negative endometrioid endometrial cancer. Patients were treated between January 2012 and December 2019 at 2 tertiary cancer centers. Staging included a total hysterectomy and lymph node assessment. The extent of lymphovascular invasion was defined using the World Health Organization criteria as focal (50%) myoinvasion and grade 3 histology were more frequently observed in patients with substantial myoinvasion. Overall, 323 patients (20.8%) received adjuvant therapy. The 5-year cumulative incidence failure rates for any recurrence were 6.0% for no, 19.5% for focal, and 19.0% for substantial invasion. Compared to no lymphovascular invasion, substantial invasion was associated with an increased risk of distant recurrence (adjusted HR 2.29, 95% CI 1.17 to 4.46). In patients with surgical stage I endometrioid endometrial cancer, the focal and substantial lymphovascular invasion was associated with a 3-fold increased risk of cumulative incidence failure versus no lymphovascular invasion. Patients with substantial invasion had more deeply invasive and grade 3 tumors and appeared to experience more distant than local recurrences. These findings challenge the International Federation of Obstetrics and Gynecology 2023 staging classification that combines no lymphovascular invasion and focal lymphovascular invasion into a single risk category.