At this meeting I was asked to talk about if the sentinel node mapping technique could be used for all endometrial cancer patients. I was supposed to have a critical perspective on the issue because there has been a lot of debate on it lately. Very hotshots within this area, at the latest congresses, have stood there together and advocated for using endometrial cancer, in all endometrial cancer patients and in all situations. So I was supposed to give a critical perspective on the issue.
To me, I must say that I’m quite happy for the sentinel node technique anyway. So I have implemented it in Denmark and am responsible for two large national studies on the subject in endometrial cancer patients. So I cannot say that I’m really critical but there are issues that we should be aware of. There are issues that are not yet resolved; there are issues that need more attention and there are certainly issues, especially in the high risk patients, that mean that today that the literature does not really support just a pure implementation of the sentinel node technique.
In our studies we still do a complete pelvic and paraaortic lymph node dissection in the study after the sentinel node technique and we are not sure yet whether the sensitivity and the false negative rate is acceptable in the high risk patients. On the other hand, for the low risk and the intermediate risk patients we are quite certain this actually works and we have implemented it as our standard treatment for these patients.
In the studies we are very keen to obtain data on their quality of life, their lymphedema and the complication rate related to the sentinel node technique and compare it to the data of the patient reported outcome measures that we get in the other studies where we remove all lymph nodes, pelvic and paraaortic. So these will be very interesting data.
Could you describe some of these issues?
The paraaortic lymph node basin is an important or difficult area. Say if we do preoperative scans, if we see lymph nodes in the paraaortic area or if we, for example, do find the sentinel nodes in the pelvic area should we go higher up? Do we need to go in the paraaortic area as well to look for paraaortic nodes there? There are concerns – do we miss residual disease in the paraaortic area if we find sentinel nodes in the pelvic area? Does it have a meaning? We don’t know. Do we have to make postoperative scans to identify and if we identify disease in the paraaortic area do we need to remove it? We still don’t know.
The other area is that we know that using or applying the sentinel node technique we will find more metastases. We will find single cells that are metastases and we will find micrometastases but how do we deal with these? We don’t know yet because, for example in breast cancer patients, they do not call micrometastases and single cell metastases as real metastases; they don’t give any adjuvant treatment for this. But endometrial cancer may be quite another disease, it may not behave as breast cancer. So in our studies we will give adjuvant treatment based on the micrometastases, even on single cell level. So this is really another area of concern that we don’t know – do we overtreat the patient by giving her adjuvant treatment just based on very low volume disease in the nodes. So these are just some of the areas that are still unresolved.
What is your take home message?
The take home message is that studies are now gathering up their evidence, at least about the endometrial adenocarcinoma grade 1, 2, that the sentinel node technique can be safely used and implemented in endometrial cancer patients. For the high risk patients, for the type 2 histology, there are still issues to resolve, at least in my opinion, that means that until we have more prospective data we should hesitate just a little to implement it just like that.
