الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
E
ndometrial carcinoma (EC) is the sixth most common gynaecological malignancy and the fourteenth leading cause of cancer-related deaths worldwide.
382 000 new cases of endometrial cancer were estimated to be diagnosed with this malignancy in 2018. High-income countries have a greater incidence of endometrial cancer (11.1 per 100,000 females) in comparison to low-resource countries (3.3 per 100,000 females). This might be due to high rates of obesity and physical inactivity, the two major risk factors in high-income countries, and to ageing of the population.
The European Society for Medical Oncology (ESMO) has identified specific prognostic factors (i.e., age, FIGO stage, histological type, depth of myometrial invasion, lymphovascular space invasion, and lymph node metastases) on which clinicians based the multidisciplinary therapeutic approach (surgery, radiotherapy and chemotherapy)
In December 2020, the World Health Organization recommended the integration of molecular features in pathology reporting where available. The last few years have seen an eruption of peer-reviewed journal reviews, point-of-care resources (UpToDate and Medscape), and societal guidelines (National Comprehensive Cancer Network and European Society of Gynaecological Oncology [ESGO]/European Society for Radiotherapy and Oncology [ESTRO]/ European Society of Pathology [ESP]) that describe how EC classification is changing to incorporate molecular subtypes, which can inform prognosis and management.
The cornerstone of treatment is surgery. It includes hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy; with or without para-aortic lymphadenectomy for patients at risk for recurrence. Surgical staging with lymphadenectomy have a prognostic benefit and helps to tailor adjuvant treatment.
Traditionally, laparotomy was the approach to surgical staging for gynecological malignancies. In the last decades, the introduction of minimally invasive approach, laparoscopic and robotic surgeries, offered new options for surgical treatment, as an alternative to open surgery.
The minimally invasive approach has the advantages of faster recovery, shorter hospital stays, and fewer perioperative complications, such as blood loss, venous thromboembolism, and infections, compared to the open surgery approach. Quality of life had improved in the first 6 months after minimal invasive surgeries (MIS) in all subscales related to patients dealing with cancer, as shown in randomised studies.
Port site metastasis may be related to understaging of microscopic EC localization and not to laparoscopy per se. Safe deflation through the trocars has been suggested by some authors to reduce the risk of port-site metastasis.
There is no clear correlation between the uterine manipulator and recurrence. Sealing the tubes is suggested by some authors as well as minimizing the movements of the uterine manipulator during the intervention to overcome this risk. Intrauterine manipulators (IUM) have no adverse impact on lymphovascular space invasion (LVSI) status and peritoneal cytology nor on overall survival rates and disease free survival (DFS).
Predictors of intraoperative conversion from MIS to open surgery including uterine weight and adhesiolysis should be considered, along with age, race and tobacco use during preoperative risk stratification.
Sentinel lymph node (SLN) technique was firstly established in the treatment of solid cancers, such as melanoma and breast cancer. It was first described in endometrial cancer in 1996. A consensus among international endometrial cancer experts recently defined the SLN as “the most proximal node irrespective of the nodal station in which the node is found”.
Lymphadenectomy is required for accurate staging and is considered a staging procedure. Its potential therapeutic benefits are mainly contribution to accurate indication for adjuvant therapy.
In low-risk endometrial cancer patients (endometrioid type, grade 1 or 2, myometrial invasion <50%, no intraoperative macroscopic spread), disease-free survival (DFS) and overall survival (OS) are not affected by lymphadenectomy.
Sentinel lymph node mapping (SLNM) tracers include fluorescent dyes, blue dyes, radioactive dyes and carbon nanoparticles. These dyes can be used alone or in combination. Fluorescent dye indocyanine green (ICG) is a safe and effective agent for SLNM. It has emerged as the most recommended tracer for intraoperative detection of SLN in endometrial cancer owing to its higher sensitivity and specificity compared with conventional tracers (blue dye and radiotracer).
The SLNs were 38% of cases external iliac, 25% obturator, 14% inframesenteric para-aortic, 10% internal iliac, 8% common iliac, 3% presacral, 1% infrarenal para-aortic, and 1% parametrial. Additionally, it is found that 7.9% of SLNs were detected in areas not routinely harvested during a standard lymph node dissection, such as the internal iliac vein, parametrial, and presacral areas.
Three different sites of injection have been described for the SLN mapping: (1) uterine subserosal, (2) cervical, and (3) via hysteroscopy. The cervical injection is the preferred method.
Ultrastaging is combining serial sectioning and immunohistochemical analysis. Sentinel lymph node mapping is a useful method to detect lymph node metastasis when ultra-staging is performed. However, ultra-staging may be difficult to perform during surgery. In addition, all the metastatic lymph nodes may not be mapped.
The aim of the study is to assess the intraoperative and early postoperative complications of laparoscopic hysterectomy in patients with endometrial carcinoma as a primary outcome and to assess the feasibility and the diagnostic reliability of sentinel lymph node biopsy as a secondary outcome.
After ethical committee approval and written consents from the patients, this one arm clinical trial study was performed on a single group of a total of 20 patients with endometrial carcinoma. They underwent laparoscopic total hysterectomy, sentinel lymph node biopsy and complete pelvic lymphadenectomy at Ain Shams University Maternity Hospital in the period from February 2020 till March 2022 with inclusion and exclusion criteria.
Majority of the studied cases had TLH and vaginal vault closure through vagina. Vessel sealing laparoscopic device used was bipolar and ligasure. Median of operation duration was 3 hours. Mean of blood loss was 467.5 mL. Two cases needed conversion to open surgery after beginning with laparoscopy. Visceral injury and need to parenteral iron were the most frequent complications. One case of ICU admission. One case of blue dye intravasation with bluish discoloration of the tissues. Single case of vesicovaginal fistula. Hemoglobin and hematocrit significantly decreased postoperatively. Total leucocytic count significantly increased postoperatively. Tumor size area median was 83.0 mm2. Eighty percent of the cases had endometrioid adenocarcinoma. The most common stage was IA, grade was grade II and tumor location was fundal. Myometrial invasion with more than 50% was seen in 56.3%. Lymphovascular invasion was seen in 18.8%. Sentinel lymph nodes were identified in 75.0% of the studied cases. Median (1st−3rd IQ) of number of sentinel LNs in one study case was 3 lymph nodes. They were present bilaterally in majority of the cases. Most common location was medial to external iliac artery. Median of duration between dye injection to node dissection was 20 minutes.
We concluded that laparoscopic sentinel lymph node detection is a feasible and safe method in patients with endometrial cancer. The identification of the node from other tissue is aided by using blue dye which stains the lymph node.
Laparoscopic lymphatic mapping is a potentially valuable intraoperative tool for assuring removal of the sentinel node, defining the extent of the pelvic regional lymph node dissection.