Optimized Sentinel Node Detection in Endometrial Cancer: Intraoperative Indocyanine Green Mapping with Postoperative Bread-Loaf Slicing Ultrastaging

Abstract Background:Accurate lymph node assessment is crucial in early-stage endometrial cancer staging, but traditional lymphadenectomy carries significant morbidity risks. This study evaluates whether indocyanine green (ICG)-based sentinel lymph node (SLN) mapping combined with bread-loaf slicing ultrastaging optimizes lymph node metastasis detection in uterine-confined endometrial cancer.Methods:We retrospectively analyzed patients with early-stage endometrial cancer who underwent surgery with SLN mapping at Kaohsiung Chang Gung Memorial Hospital from November 2021 to December 2024. SLN mapping was performed using either ICG fluorescence imaging or patent blue dye during minimally invasive and open surgical approaches. All retrieved lymph nodes underwent ultrastaging examination using the bread-loaf slicing method.Results:Among 131 patients, the overall SLN mapping success rate was 93.9%, with bilateral detection rate achieved 95.9%. ICG demonstrated superior bilateral mapping success compared to patent blue dye (79.2% vs. 27.3%, p < 0.001). While minimally invasive surgery showed higher mapping rates than open surgery (79.1% vs. 43.8%, p = 0.002), ICG effectively mitigated this difference by maintaining high detection rates even in open surgical cases. Bread-loaf slicing ultrastaging identified lymph node metastases in 4.0% of patients. Zero recurrence occurred in pathological stage I patients during follow-up.Conclusions:The combination of intraoperative ICG-based SLN mapping with bread-loaf slicing ultrastaging represents an optimal strategy for lymph node assessment in early-stage endometrial cancer, achieving superior detection rates while minimizing surgical morbidity and maintaining oncologic safety.