Sentinel lymph node biopsy in high-grade endometrial cancer: a systematic review and meta-analysis of performance characteristics.

Abstract

OBJECTIVE\nSentinel lymph node biopsy (SLNB) is widely accepted as the standard of care for surgical staging in low-grade endometrial cancer (EC), but its value in high-grade EC remains controversial. The aim of this systematic review and meta-analysis was to evaluate the performance characteristics of SLNB in EC patients with high-grade histology (PROSPERO CRD42020160280).\n\n\nDATA SOURCES\nWe systematically searched Medline, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Embase, all through the OvidSP platform. The search was performed between January 1, 2000, and January 26, 2021. ClinicalTrials.gov was searched to identify the ongoing registered clinical trials.\n\n\nSTUDY ELIGIBILITY CRITERIA\nWe included prospective cohort studies evaluating SLNB in clinical stage I high-grade EC patients (grade 3 endometrioid, serous, clear cell, carcinosarcoma, mixed, undifferentiated/dedifferentiated, high-grade not otherwise specified) with a cervical injection of indocyanine green for SLN detection, and at least a bilateral pelvic lymphadenectomy as a reference standard. If data was not reported specifically for patients with high-grade histology, authors were contacted for aggregate data.\n\n\nSTUDY APPRAISAL AND SYNTHESIS METHODS\nWe pooled detection rates and measures of diagnostic accuracy using a generalized linear mixed-effects model with a logit, and assessed the risk of bias using the Quality Assessment of Diagnostic Accuracy Studies-2 tool (QUADAS-2).\n\n\nRESULTS\nWe identified 16 eligible studies, of which the authors for 9 provided data on 429 high-grade patients specifically. The study-level median age was 66 years (range 44-82.5) and the study-level median BMI was 28.6 kg/m2 (range 19.4-43.7). The pooled detection rates were 91% per patient (95% CI 85-95; I2=59%) and 64% bilaterally (95% CI 53-73, I2=69%). The overall node-positivity rate was 26% (95% CI 19-34; I2=44%). Of 87 node positive patients, SLNB correctly identified 80, yielding a pooled sensitivity of 92% per patient (95% CI 84-96; I2=0%), false negative rate of 8% (95% CI 4-16; I2=0%), and negative predictive value of 97% (95% CI 95-99; I2=0%).\n\n\nCONCLUSIONS\nSLNB accurately detects lymph node metastases in high-grade EC, with a false negative rate comparable to that observed in low-grade EC, melanoma, vulvar cancer, and breast cancer. These findings suggest that SLNB can replace complete lymphadenectomy as a standard of care for surgical staging in patients with high-grade EC.