The choice between sentinel lymph node biopsy (SLN mapping) and systematic lymphadenectomy (LNE) in endometrial carcinoma depends on several factors, including the FIGO stage, histology, molecular markers (p53, POLE, L1CAM), and lymphovascular invasion (LVSI).
Indication-Dependent Choice of SLN vs. LNE
| Criterion | Sentinel Lymph Node Biopsy (SLN Mapping) | Systematic LNE |
|---|
| FIGO I, G1-G2, no LVSI | Recommended as standard | Not recommended |
| FIGO I, G3 or ≥50% myometrial infiltration | Possible if detected bilaterally | Consideration if SLN is not detected on both sides |
| FIGO II (cervical stromal infiltration) | Possible in low-/intermediate-risk | Recommended in high-risk or unclear SLN detection |
| FIGO III-IV (lymph node metastases, distant metastases) | Not recommended | Mandatory |
| Serous, clear cell carcinoma, carcinosarcoma, p53 abnormal | Possible, but complete LNE preferred | Recommended |
| POLE-mutated carcinoma | Sufficient due to low metastasis rate | Not recommended |
| L1CAM expression >10% | Possible if no LVSI | Recommended |
| LVSI (lymphovascular invasion) | Possible with focal LVSI | Extensive LVSI → LNE recommended |
| Macroscopic enlarged lymph nodes (bulky nodes) | Not recommended | Mandatory |
| Unilateral SLN detection (no SLN found on one side) | Systematic LNE for the undetected side | Recommended |
Interpretation of Molecular Markers for Lymphadenectomy
| Molecular Marker | Significance | Recommended Strategy |
|---|
| POLE mutation | Low metastasis rate, favorable prognosis | SLN sufficient, no LNE necessary |
| p53 abnormal tumors | High metastasis rate, aggressive course | SLN possible, but systematic LNE preferred |
| L1CAM >10% | Increased risk of distant metastases | SLN possible, LNE recommended for high-risk patients |
| LVSI focal | Lower risk of nodal metastasis | SLN possible |
| LVSI extensive | High likelihood of pelvic and para-aortic metastasis | Systematic LNE recommended |
Comparison of Guideline Recommendations for SLN vs. LNE
| Guideline | Recommendation for SLN | Recommendation for Systematic LNE |
|---|
| German S3 Guideline (2024) | SLN as preferred method for low-/intermediate-risk | LNE recommended for high-risk patients or visible lymph nodes |
| ESGO/ESTRO/ESP (2021) | SLN as standard for FIGO I-II, optional for type II carcinomas | Recommended for high-risk tumors (serous, clear cell, p53 abnormal) |
| NCCN (2025) | SLN as primary staging procedure, also in high-risk tumors under certain conditions | Systematic LNE recommended for macroscopic metastases or unclear SLN results |
Differences Between SLN and LNE
| Argument for SLN | Argument for Systematic LNE |
|---|
| Reduces postoperative morbidity (lymphedema, intraoperative complications) | Higher sensitivity for high-risk tumors |
| High sensitivity for micrometastases (≥97%) | Increased detection rate in high-risk types like serous or clear cell tumors |
| SLN offers improved detection of micrometastases through ultrastaging | SEPAL study shows improved survival through systematic LNE in high-risk patients |
| Recommended in low-/intermediate-risk patients | Recommended for macroscopic lymph node metastases or extensive LVSI |
- SLN mapping is the preferred strategy for most low- and intermediate-risk patients.
- Systematic LNE remains standard for high-risk tumors, especially serous or clear cell carcinomas and p53 abnormal tumors.
- If SLN is not detected bilaterally, additional LNE is required.
- The choice between SLN and LNE should be made individually based on histological and molecular risk factors.
Reference:
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