Pericervical injection of 99mTc-Nanocolloid IS superior to peritumoral injection for sentinel lymph node detection in SPECT/CT Dr. Martin Weiss Department for womens health Tübingen

Actual german recommendations for endometrial cancer therapy pT1a and G1/G2 No LNE If macrosopically cN(-) ≥ pT1b or G3 Systematic pelvic and para-aortic LNE http://www.ago-online.de/de/infothek-fuer-aerzte/leitlinienempfehlungen/uterus/ Latest access: 18.01.2017

Benefit of pelvic and paraaortic LNE in case of endometrial cancer FIGO I Systematic lymphadenectomy Increased Morbidity ASTEC study group, Kitchener H et al. (2009): - “Pelvic lymphadenectomy cannot be recommended as routine procedure” Benedetti-Panici et al. (2009) - „Systematic LNE did not improve disease-free or overall survival” May et al. (2010) - No benefit of systematic LNE Todo et al. (2010) - OS significantly longer in intermediate and high risk carcinomas - No increase of OS in low risk carcinomas Compromise between systematic LNE and Non-LNE

Benefit of pelvic and paraaortic LNE in case of endometrial cancer FIGO I Ballester et al. (2011, Senti-ENDO) - „SLN biopsy upstaged 10% of patients with low-risk” Lurain et al. (1991) LN metastasis  5Y disease free survival drops from 90% to 54% Most important prognostic factor LN metastasis in FIGO Ia: 5%  Need for adequate staging! but.. Compromise between systematic LNE and Non-LNE

Tübingen treatment algorithm for endometrial cancer AE bilateral Maximal tumor resection pelvic LNE paraaortic LNE Maximal tumor resection / Exenteration Laparoscopic Hysterectomy Abdominal Hyster-ectomy + Extrafascial hysterectomy pelvic SLNE pelvic (S) LNE paraaortic LNE pelvic (S) LNE paraaortic LNE

Different approaches of sentinel lymphnode labeling Established methods Experimental methods Pericervical injection Hysteroscopic peritumoral injection Fundal peritumoral injection Transvaginal ultrasound–guided myometrial radiotracer injection Transcervical subepithelial injection into the isthmocervical region of the myometrium Brucker et al. 2014 Torné et al. 2013

Sentinel Lymph Node Detection of Endometrial Cancer in SPECT/CT: Tübingen trial design Patients randomised Pericervical Tc-injection 3-, 6-, 9-, 12-o‘clock Peritumoral Tc-injection 4 sites (hysteroscopy) Pre-operative SPECT/CT image acquisition at > 3 h p.i. Sentinel lymph node identification by handheld γ-probe surgery Histopathological examination

Sentinel Lymph Node Detection of Endometrial Cancer in SPECT/CT: Tübingen trial results Sahbai S, Taran FA, [..], Wallwiener D, [..] Brucker SY et al. 2016

Pericervical injection of 99mTc-Nanocolloid for sentinel lymph node detection in SPECT/CT Peritumoral injection Enhanced SLN detection Enhanced detecion of bilateral pelvic SLN Enhanced detection of macro-metastases Low invasiveness Better detection of paraaortic SLN More invasive, general anasthesia SLN detection in pT1a endometrial cancer Accurate staging and prognosis assessment. Pericervical injection of 99mTc-Nanocolloid and SPECT/CT Simplified and the less invasive injection procedure. Higher sentinel lymphnode detection rate. Improved accuracy of sentinel lymphnode mapping.

Modern Gyneco(onco)logy Minimisation of surgical trauma Maximum of oncological safety Optimized staging and therapy Reliable prognostic parameters Individualised and best fitting therapy concepts

Acknowledgements Herr Prof. Dr. Diethelm Wallwiener Frau Prof. Dr. Sara Brucker Herr Prof. Dr. Andrei Taran martin.weiss@med.uni-tuebingen.de