Sentinel node biopsy shortens operative time by 13% and may play a role in reducing recovery time and length of hospital stay, reported David L. Tait, MD, of the Levine Cancer Institute, Charlotte, N.C., and colleagues.
In an effort to compare the immediate perioperative outcomes for narcotic usage and use of hospital resources for patients having sentinel node dissection, Dr. Tait and his colleagues conducted a retrospective study of 241 consecutive cases of minimally invasive surgery performed between Jan. 1, 2018, and Aug. 31, 2019, on endometrial cancer patients.
A total of 156 (65%) patients received nodal dissection, including 93 (60%) who received sentinel node biopsy and 63 (40%) who underwent a full lymphadenectomy in accordance with pathological criteria established at the time of surgery. The authors noted no differences between the sentinel group and the lymphadenectomy group in terms of age, body mass index, estimated blood loss, use of a preoperative enhanced recovery after surgery (ERAS) program, tobacco use, or ethanol use. They also found no difference in primary outcome of intravenous narcotics dispensed in surgery, recovery, or total dose.
Sentinel node biopsy offers several advantages
Dr. Tate and colleagues noted that a significantly shorter surgery time, by 27 minutes, on average, was not unexpected with the sentinel node biopsy technique. With lymphadenectomy, surgical procedure and recovery times were longer (214.2 minutes vs. 185.2 minutes and 157.6 minutes vs. 125.2 minutes, respectively) than sentinel biopsy, a difference the researchers could not explain given the similar use of narcotics between the two procedures. Lymphadenectomy also resulted in longer hospital stay than sentinel biopsy (23.5 hours vs. 15.5 hours), with same-day discharge significantly less frequent (16% vs. 50%).
The differences in operative time, recovery time, and hospital stay “are important with respect to improving the efficiency of the operating room, which has become even more important in the era of the COVID-19 pandemic,” the authors noted. They also found noteworthy that recovery and hospital stay are longer after full lymphadenectomy even though there was no difference in overall narcotic administration. Although this suggests surgeon and staff bias, other factors that were not accounted for in the study include distance from hospital, social situation, and functional status.
Change in practice patterns over time and the introduction of a universal ERAS program during the study period were noted as possible limitations. It was also noted that the study did not collect data on functional status or long-term outcome of patients.
The authors did note that using the sentinel node technique was advantageous because it was performed on all patients regardless of risk factors for extra uterine spread since the injection must be performed before hysterectomy. What makes this so beneficial is the potential it offers for detecting nodal metastasis in low-risk patients who may not have otherwise qualified for dissection, said Dr. Tait and colleagues.
In a separate interview, Justin Chura, MD, director of gynecologic oncology and robotic surgery at the Cancer Treatment Centers of America in Philadelphia, observed that “sentinel lymph node [SLN] mapping has been around since the late 1970s. It is most validated in melanoma and breast cancers but has also seen application for gynecological cancers including vulva, cervix, and endometrium. More than 5 years ago, the Society of Gynecologic Oncology issued a clinical practice statement regarding the role of sentinel lymph node mapping for endometrial cancer. An SLN algorithm has been part of [National Comprehensive Cancer Network] guidelines for a similar time frame. The technique faced a lot of skepticism and criticism in the breast cancer literature until randomized studies demonstrated that full axillary adenopathy did not confer a survival benefit. For endometrial cancer, it is unlikely that we will have as robust data, so we often look to retrospective studies such as the one presented by Tait et al.
“The study utilized a data set that was originally collected to assess the impact of an ERAS protocol. So, it is important to note that the data set was not collected with the intent of evaluating SLN mapping versus full lymphadenectomy. This explains why pathological data regarding lymph node yield and final surgicopathologic staging are absent,” he said.
Adoption of sentinel node biopsy is gaining popularity
“Overall, SLN mapping is safe (from a surgical standpoint) and may decrease perioperative morbidity,” Dr. Chura said. “The adoption of SLN mapping also appears to be increasing. Some gyn oncologists (including myself) are even performing SLN mapping on patients with endometrial intraepithelial neoplasia given the risk of malignancy being identified on final pathology.
“The current study provides more of a glimpse into the practice patterns of the authors’ institution where ‘full lymphadenectomy was very dependent upon the surgeon (P < .001)’ than it demonstrates one technique is better than the other. The ultimate question is how we define ‘better?’ Survival? Less morbidity? Improved accuracy of nodal metastasis? Shorter length of stay?” Dr. Chura said.Dr. Tait and colleagues as well as Dr. Chura had no conflicts of interest and no relevant financial disclosures.
SOURCE: Tate DL et al. J Minim Invasive Gynecol. 2020 Dec 19. doi: 10.1016/jmig.2020.12.019.