Is an indocyanine green (ICG) cervix injection to guide pelvic sentinel lymph node dissection covered for a patient with complex atypical endometrial hyperplasia?

ICG Sentinel Lymph Node Mapping for Complex Atypical Hyperplasia: Coverage Determination

This procedure should NOT be covered for complex atypical hyperplasia alone, as the standard of care is hysterectomy without routine lymph node assessment for this pre-malignant condition. 1, 2

Clinical Context and Standard Treatment

The patient has complex atypical hyperplasia (CAH), which is a pre-malignant condition, not cancer. 2 While CAH carries a 40-50% risk of concurrent undetected endometrial cancer, the diagnosis remains hyperplasia until proven otherwise. 2

The standard treatment for CAH is simple hysterectomy with bilateral salpingo-oophorectomy—lymph node assessment is NOT part of standard staging for hyperplasia. 1, 2

Guideline-Based Lymph Node Assessment Criteria

According to European Society for Medical Oncology (ESMO) guidelines, lymphadenectomy recommendations are stratified by confirmed cancer stage and risk factors: 1

For Low-Risk Endometrial Cancer (G1/2 with <50% myometrial invasion):

• Lymphadenectomy "can be considered for staging" but is optional 1
• Sentinel lymph node dissection (SLND) is listed as an option 1

For Complex Atypical Hyperplasia:

• No mention of routine lymph node assessment in any guideline 1, 2
• Standard treatment is hysterectomy alone 2

When ICG Mapping Would Be Appropriate

ICG cervical injection for sentinel lymph node mapping would only be medically necessary if: 1

1. Final surgical pathology confirms endometrial cancer (not just hyperplasia) 1
2. Intraoperative frozen section reveals cancer with risk factors (grade 3, deep myometrial invasion, or non-endometrioid histology) 1, 3
3. Preoperative imaging suggests invasive disease beyond hyperplasia 2

Evidence Supporting ICG Use in Confirmed Cancer

When cancer IS confirmed, ICG mapping demonstrates superior performance: 4, 3, 5

• Overall detection rate of 100% with bilateral mapping in 97.6% of cases 3
• Zero false-negative rate for identifying stage IIIC disease 3
• Superior to isosulfan blue dye, particularly in patients with BMI >30 4, 5
• Reduces unnecessary systematic lymphadenectomies 3

Critical Coverage Determination

The procedure is being requested BEFORE surgical pathology confirms cancer. This represents:

• Premature staging for a pre-malignant condition 1
• Not aligned with any published guideline for CAH management 2
• Potential overtreatment without confirmed malignancy 1

Common Pitfall Being Avoided

The 40-50% concurrent cancer risk does NOT justify routine lymph node assessment in all CAH cases, as: 2, 6

• Most patients will have hyperplasia only on final pathology 6
• If cancer is found, it is typically low-grade and early-stage 6
• Lymph node metastases in low-grade, early-stage disease are rare 1

Recommended Approach

The appropriate surgical plan is: 1, 2

1. Proceed with hysterectomy and bilateral salpingo-oophorectomy 2
2. Send uterus for intraoperative frozen section if available 3
3. Only perform ICG mapping and lymph node assessment IF frozen section confirms cancer with intermediate or high-risk features 1, 3
4. If frozen section unavailable, await final pathology and stage surgically only if cancer is confirmed with risk factors 1

This staged approach avoids unnecessary lymph node dissection in the majority of CAH patients who will not have cancer or will have low-risk disease not requiring nodal assessment. 1, 3