Aortic Lymphadenectomy Research Articles

Completion Surgery After Concomitant Chemoradiation in Locally Advanced Cervical Cancer: A Comprehensive Analysis of Pattern of Postoperative Complications

We provided a comprehensive analysis of rate, pattern, and severity of early and late postoperative complications in a very large, single-institution series of locally advanced cervical cancer (LACC) patients administered CT/RT plus radical surgery (RS). A total of 362 consecutive LACC (FIGO stage IB2-IVA) patients were submitted to RS after CT/RT at the Gynecologic Oncology Unit of the Catholic University (Rome/Campobasso). At 4 weeks after CT/RT, patients were evaluated for objective response and triaged to radical hysterectomy and pelvic ± aortic lymphadenectomy. Surgical morbidity was classified according to the Chassagne's grading system. Most cases underwent type III-IV radical hysterectomy (N = 313, 86.5 %); pelvic lymphadenectomy was performed in all patients, while 116 patients (32.1 %) were also submitted to aortic lymphadenectomy. A total of 93 patients (25.7 %) experienced any grade postoperative complications, and 60 (16.6 %) had ≥grade 2 complications; grade 3-4 complications occurred in 21 patients (5.8 %). Of all early postoperative complications (N = 100), 31 (31.0 %) were urinary, 9 (9.0 %) were gastrointestinal, and 45 (45.0 %) were vascular. Of all late complications (N = 31), 20 (64.5 %) were urinary, 7 (22.6 %) gastrointestinal, and 2 (6.4 %) were vascular. Multivariate analysis showed that not complete clinical response to treatment retained an independent, unfavorable association with risk of development of postoperative morbidity, while advanced stage, and aortic lymphadenectomy showed only a borderline value. Failure to achieve clinical complete response to treatment and, to a lesser extent, more advanced stage, and aortic lymphadenectomy, were associated with a higher risk of developing any grade as well as ≥grade 2 complications.

State of the art of surgery in advanced epithelial ovarian cancer

State of the art of surgery in advanced epithelial ovarian cancer

Detection of nodal metastases by 18F-FDG PET/CT in apparent early stage ovarian cancer: A prospective study

BackgroundThe rate of nodal metastases in ovarian cancer macroscopically confined to the pelvis is about 15%–20%. Systematic pelvic and aortic lymphadenectomy improves staging but it is associated with increased morbidity and costs. The purpose of this study was to evaluate the role of 18F-FDG PET/CT in the pre-operative nodal metastases detection in ovarian cancer grossly confined to the pelvis. MethodsFrom 2006 to 2012, 68 consecutive women with epithelial ovarian cancer confined to the pelvis underwent 18F-FDG PET/CT followed by surgery inclusive of systematic pelvic and aortic lymphadenectomy (SAPL). 18F-FDG PET/CT images were analyzed and correlated to histological examination. ResultsTwenty-six women underwent bilateral and 42 unilateral SAPL with 3165 nodes removed and analyzed. Median number of dissected nodes was 42 (range 16–91). Twelve women (17.6%) had nodal metastases. 18F-FDG PET/CT correctly identified 10 patients with nodal involvement. Sensitivity, specificity, accuracy, positive and negative-predictive value of 18F-FDG PET/CT in detecting nodal metastases were 83.3%, 98.2%, 95.6%, 90.9% and 96.5%, respectively, on overall patient-based, and 75.5%, 99.4%, 98.1%, 87.5% and 98.6%, respectively, on nodal lesion site-based analysis. Conclusion18F-FDG PET/CT is an accurate tool for the detection of nodal metastases. Metabolic imaging could be used to select women who could benefit from systematic lymphadenectomy. The high negative predictive value allows avoidance of SAPL in the vast majority of women, minimizing operative and post surgical complications. Further larger prospective investigation is required to confirm our data.

Quality of life in patients with endometrial cancer treated with or without systematic lymphadenectomy

ObjectiveTo compare the quality of life (QoL) of women affected by endometrial cancer treated with surgery with or without systematic lymphadenectomy. Study designConsecutive patients affected by stages I and II endometrial cancer and treated with surgery between 2008 and 2011 were selected. Eligible subjects were divided into two groups: Group A consisted of 36 patients who had hysterectomy plus bilateral salpingo-oophorectomy without lymphadenectomy; Group B consisted of 40 patients who had hysterectomy plus salpingo-oophorectomy plus pelvic and aortic lymphadenectomy. The EORTC Quality of Life Questionnaire-Cancer Module (QLQ-C30) and Quality of Life Questionnaire-Endometrial Cancer Module (QLQ-EN24) were administered to selected patients. All data were recorded and then analyzed using the scoring manual of the EORTC Quality of Life Group. ResultsAmong symptom scales, only lymphedema gave a statistically significant difference among two groups, with a score of 10.64±17.43 in Group A and 21.66±24.51 in Group B (p=0.0285). The p value obtained comparing the “Global Health Status” (items 29 and 30) in Group A and in Group B was not statistically significant. ConclusionLymphadenectomy did not influence negatively global health status, but lymphadenectomy maintained its importance in determining a patient's prognosis and in tailoring adjuvant therapies. We therefore support its practice as part of the surgical procedure in patients affected by high risk endometrial cancer.

Metastatic Calcaneal Lesion Associated with Uterine Carcinosarcoma

Metastatic lesions of uterine carcinosarcoma most commonly occur in the abdomen and lungs and less frequently in highly vascularized bone. We report a rare case of an 86-year-old female with uterine carcinosarcoma with metastasis to the left calcaneus. The patient had a history of uterine carcinosarcoma with hysterectomy and bilateral salpingo-oophorectomy, along with bilateral pelvic and aortic lymphadenectomy, with no adjuvant therapy. The initial pedal complaint was that of left foot pain. The initial radiographic findings were negative; however, magnetic resonance imaging scans revealed a substantial area of marrow edema in the calcaneus. An excisional biopsy was performed, and histopathologic analysis revealed adenocarcinoma with features consistent with the patient's previous uterine tumor specimen. The patient was given one treatment of chemotherapy and was discharged to a hospice, where she died of her disease 2 weeks later.

Comprehensive, therapeutic retroperitoneal pelvic and infrarenal aortic lymphadenectomy for advanced cervical carcinoma

This 49-year-old female with stage III cervical carcinoma presented with a PET/CT scan showing bilateral pelvic and common ileac adenopathy. A retroperitoneal approach to resect the nodes well above the highest documented PET positive region was employed in July 2011. The bilateral infrarenal, bulky inframesenteric and pelvic nodes were comprehensively removed, revealing bilaterally positive nodes in 5/36 pelvic nodes, 13/25 inframesenteric nodes, and 3/20 infrarenal nodes (these latter not detected on PET). Image-modulated radiation to 10cm above the renal vein, with concurrent cisplatin chemotherapy was undertaken, resulting in a disease-free status thus far.

Carcinosarcoma of the Uterus—A Single Institution Retrospective Analysis of the Management and Outcome and a Brief Review of Literature

Uterine carcinosarcomas are highly aggressive tumors of the uterus associated with a poor prognosis. Though initially classified as sarcomas, now these tumors are classified as carcinomas. The management approach of carcinosarcomas has also changed from those used for high grade sarcomas to that used for managing high grade endometrial carcinomas. The purpose of our study was to analyze the management and outcome of patients with uterine carcinosarcomas treated at our institution and also to attempt a brief review regarding the management of uterine carcinosarcomas. We did a retrospective analysis of all patients with a diagnosis of carcinosarcoma of the uterus treated at our Institution from January 2005 till December 2010. All Patients with a pathological diagnosis of carcinosacrcoma or malignant mixed mullerian tumours of the uterus were included. Data was obtained from the hospital electronic medical records and the hospital cancer registry. Data was analyzed using SPSS v.17. During this 6year period we had 20 patients with carcinosarcoma of the uterus. 75% of the patients belonged to Stage I and II. 95% of the patients underwent Hysterectomy with Bilateral salpingo oophorectomy and 60% had lymphadenectomy also along with hysterectomy.8 patients had disease recurrence . In patients who had gross extrauterine disease at the time of surgery , the survival was only 9months whereas in patients who had complete staging with disease confined to the uterus , the survival was 36months. Carcinosarcomas, accounts for more than 15% of the uterine cancer associated deaths. Surgery remains the cornerstone of management for these tumors and surgery with pelvic and para aortic lymphadenectomy and peritoneal and omental biopsies is required for the correct staging of the disease and may also provide a survival advantage. Radiation therapy has been shown to provide only better local control without any survival advantage. Further studies are needed to assess whether chemotherapy offers a definite survival benefit in uterine carcinosarcomas.

Should all endometrioid uterine cancer patients undergo systemic lymphadenectomy?

ObjectiveTo evaluate the potential benefits of systemic pelvic and para-aortic lymphadenectomy in endometrioid uterine cancer patients. MethodsWe conducted a retrospective study on 244 cases of endometrioid uterine cancer that involved surgery in the Center of Gynecologic Oncology, Peking University People's Hospital, Beijing, from January 2000 to May 2008. We conducted staging for each case to ensure accordance with FIGO 2009 surgical staging criteria. Clinical data, including histology, age at diagnosis, surgical procedure, adjuvant therapy, date of death or last follow-up, and date and sites of recurrence were collected for each patient. ResultsAmong 244 endometrioid uterine cancer patients, 207 cases (84.8%) underwent systemic pelvic lymphadenectomy. Among these cases, pelvic lymph nodes in 17 cases (8.2%) exhibited tumor metastasis. Systemic aortic lymphadenectomy was performed in 127 cases (52.0%) among 244 total patients. Five cases (3.9%) exhibited positive aortic lymph nodes, of which four exhibited positive pelvic lymph nodes. We investigated the impact of positive retroperitoneal lymph nodes on staging: 4 (4/161, 2.5%), 6 (6/29, 20.7%), 6 (6/35, 17.1%), 1 (1/8) and 1 (1/6) case changed to stage IIIc from stage Ia, Ib, II, IIIa, and IIIb, respectively. Tumor-free and overall survival did not differ between patients who underwent pelvic lymphadenectomy or not (P > 0.05). Tumor-free survival improved in stage Ib pelvic lymphadenectomy patients (P = 0.040); para-aortic lymphadenectomy did not improve patient survival in all stages (P > 0.05). ConclusionSystemic lymphadenectomy is not warranted in stage Ia endometrioid uterine cancer.

Defining the optimal lymphadenectomy cut-off value in epithelial ovarian cancer staging surgery utilizing a mathematical model of validation

ObjectiveSince 1985 International Federation of Gynecology and Obstetrics includes pelvic and aortic lymphadenectomy as part of the surgical staging in epithelial ovarian cancer (EOC). There is no consensus on the overall number of nodes needed in a systematic lymphadenectomy. The aim of this study is to calculate the optimal cut-off value using a mathematical modeling approach. MethodsData was collected retrospectively, from 1996 to 2000, of 120 consecutive Mayo Clinic patients with EOC and positive nodes. All patients was underwent pelvic and/or aortic lymphadnectomy during surgical staging.To mathematically predict the probability of a positive node in EOC patients we used a predictive mathematical model (PMM). The mathematical analysis consisted: creation of a new PMM according to our purposes, application of PMM to describe the experimental data in order to build the polynomial regression curves in each lymphatic area and determine the optimal point for each curve. ResultsThe mean number of lymph nodes and metastatic nodes removed were 35 and 7.8, respectively; the mean percentage of positive nodes was 28.3%. The optimal point of each fitting curves were: 7 nodes for unilateral aortic nodal sampling (at least 3 infrarenal or 5 inframesenteric) and 15 nodes for unilateral pelvic lymphadenectomy (at least 5 external iliac). ConclusionsWe can mathematically predict the probability to obtain a positive node in EOC surgical staging. Our results have shown the need to obtain at least 22 lymph nodes between pelvic and aortic lymphadenectomy.

Robotic-Assisted Transperitoneal Aortic Lymphadenectomy as Part of Staging Procedure for Gynaecological Malignancies: Single Institution Experience

Introduction. This study was designed to confirm the feasibility and safety of robotic-assisted transperitoneal aortic lymphadenectomy as part of staging procedure for gynecologic malignancies. Methods. Chart review of 51 patients who had undergone robotic staging with aortic lymphadenectomy for different gynaecologic malignancies was performed. Results. The primary diagnosis was as follows: 6 cases of endometrial cancer, 31 epithelial ovarian cancer, 9 nonepithelial ovarian cancer, 4 tubal cancer, and 1 cervical cancer. Median BMI was 23 kg/m2. Except for a single case of aortic lymphadenectomy only, both aortic and pelvic lymphadenectomies were performed at the time of the staging procedure. All the para-aortic lymphadenectomies were carried out to the level of the renal veinl but 6 cases were carried out to the level of the inferior mesenteric artery. Hysterectomy was performed in 24 patiens (47%). There was no conversion to LPT. The median console time was 285 (range 195–402) with a significant difference between patients who underwent hysterectomy and those who did not. The median estimated blood loss was 50 mL (range 20–200). The mean number of removed nodes was 29 ± 9.6. The mean number of pelvic nodes was 15 ± 7.6, whereas the mean number of para-aortic nodes was 14 ± 6.6. Conclusions. Robotic transperitoneal infrarenal aortic lymphadenectomy as part of staging procedure is feasible and can be safely performed. Additional trocars are needed when pelvic surgery is also performed.

Therapeutic and prognostic value of lymphadenectomy in gynecological oncology

Lymphadenectomy is an integral part of gynecological cancer surgery however there is still lack of standardization in the terminology used. In the current literature several types of surgical procedures for pelvic lymph nodes dissection are recognized. Complete pelvic lymphadenectomy is defined as the removal of all fatty lymphatic tissue from the predicted areas of high incidence of lymph nodes with possible metastatic involvement. Para-aortic lymphadenectomy is defined as the removal of all lymphatic tissue from the aortic region. The latter is divided into two levels: the lower--up to the inferior mesenteric artery and the upper--up to the left renal vein. Another classification divided pelvic and aortic lymphadenectomy into three classes. Class I is defined as the removal of the chosen lymph nodes, class II as the removal of lymph nodes located ventrally and laterally to the large retroperitoneal pelvic vessels, obturator nerves and laterally to the aorta and the inferior vena cava, whereas class III as the complete removal of lymphatic tissue surrounding the iliac vessels, obturator pits, dorsally to the obturator nerve and the presacral lymph tissue around the aorta and the inferior vena cava. In each gynecological cancer depending on the severity of the disease different procedures are applied concerning lymphadenectomy. In patients with advanced ovarian cancer systematic lymphadenectomy prolongs the survival rate. Omission of systematic lymphadenectomy can be considered only for patients with mucinous carcinoma G1 level. In the case of vulvar cancer removal of pelvic, iliac and obturator lymph nodes is inappropriate as it has not been proven to result in an increased survival rate. Inguinal lymphadenectomy in this cancer depends on the stage and location of the primary tumor--at an early stage vulvar cancer located laterally a superficial, unilateral inguinal lymphadenectomy can be performed, if the primary lesion is located centrally an inguinal lymphadenectomy should be performed on both sides. Deep inguinal lymphadenectomy should be performed only in cases where: primary tumor is located centrally in case of cancer in the early stages, in advanced stage and in patients with metastases in the superficial nodes. Sentinel lymph node biopsy is an alternative method that can be offered to patients with early-stage vulvar cancer located laterally. Lymphadenectomy in endometrial cancer is beneficial in stages I G3, II and III. In stages I G1 and G2 an increase in the survival time has not been shown. The cervical cancer stage IB-IIA removal of para-aortic lymph nodes (to the mesenteric artery) is indicated in patients with large tumors and suspected or known disease in the pelvic nodes. In patients in whom diagnostic imaging studies have not shown metastasis in para-aortic and pelvic lymph nodes or distant metastasis, para-aortic lymphadenectomy can be omitted. Further randomized studies are needed to elucidate the necessity and extent of lymphadenectomy in given gynecological cancers.

Lymph Node Assessment in Endometrial Cancer: Towards Personalized Medicine

Endometrial cancer (EC) is the most common malignancy of the female reproductive tract and is increasing in incidence. Lymphovascular invasion and lymph node (LN) status are strong predictive factors of recurrence. Therefore, the determination of the nodal status of patients is mandatory to optimally tailor adjuvant therapies and reduce local and distant recurrences. Imaging modalities do not yet allow accurate lymph node staging; thus pelvic and aortic lymphadenectomies remain standard staging procedures. The clinical data accumulated recently allow us to define low- and high-risk patients based on pre- or peroperative findings that will allow the clinician to stratify the patients for their need of lymphadenectomies. More recently, several groups have been introducing sentinel node mapping with promising results as an alternative to complete lymphadenectomy. Finally, the use of peroperative algorithm for risk determination could improve patient's staging with a reduction of lymphadenectomy-related morbidity.

A novel “intuitive” surgical technique for right robot-assisted retroperitoneal lymph node dissection for stage I testicular NSGCT

To describe a new technique for the right template RPLND able to offer a optimal exposure of surgical field, minimal bowel mobilization, and enabling a more "openlike dissection" technique. We used a variant of the aortic lymphadenectomy previously described by Magrina et al. for gynecologic malignancies. The patient is placed in a steep Trendelenburg, supine position and the robot column, at the patient's head. The trocar position is specular to that used for RALP and known for generating no collision between the robotic arms. The node dissection of the right template, including laterocaval and interaortocaval nodes, is carried out like in the "open" split-and-roll technique. The docking time was 15', the console time was 192', the blood loss was irrelevant (50 mL), and the number of retrieved nodes was 19. The exposure of the infrarenal vein region of the operatory field resulted optimal without extensive bowel mobilization. The dissection perfectly mimicked the open procedure. As the left RPLND template includes only para-aortic lymph nodes, the left full flank position seems adequate. On the contrary, it enables a less good exposure of the more extensive right RPLND template, requiring excellent robotic surgical skills to overpass related deadlocks. On the contrary, our technique allows adequate and safe performance of the robotic. It enables a good view of the retroperitoneal space reducing the need of bowel mobilization to obtain a good exposure of the operatory field. Moreover, the patient's supine position makes the procedure more similar to the open technique.

Congenital renal malrotation in ovarian cancer surgery: A case report

► We consider a case of laparoscopic aortic lymphadenectomy for an early ovarian cancer including a comprehensive surgical staging. ► The patient was found to have a congenital anatomic abnormality: a right renal malrotation with an accessory renal artery. ► We used a preoperative CT angiography study to diagnose such anatomical variations and to adequate the proper surgical technique.

Role of different approaches to the abdominal retroperitoneum for aortic lymphadenectomy in patients with gynecological cancers

BackgroundParaaortic lymphadenectomy (PALN) is a standard part of many interventions, but currently there are no established care protocols effective in preventing gastro-intestinal (GI) symptoms. The aim of our study was to retrospectively evaluate patients with gynecologic cancers submitted to PALN, in order to evaluate if different approaches to the retroperitoneum could influence the radicality of the procedure and the onset of GI complications. MethodsWe divided 121 patients with gynecologic tumors submitted to PALN into 3 groups according the used right, left or combined left–right approach to the retroperitoneum, comparing the groups according the main surgical-pathological parameters, such as the number of nodes removed and the incidence and severity of GI complications. ResultsThe mean number of nodes removed did not significantly differ between the groups, while the mean number of positive nodes was significantly higher in combined approach. 39.8% of our patients experienced GI side effects, but those submitted to the combined approach had a significantly higher incidence of GI symptoms. ConclusionsOur data demonstrate that the choice of the retroperitoneal approach could be the most important feature for the appearance of post-operative GI side effects, even if there is no significant difference on the radicality of PALN performed retroperitoneal approach.

Significance of lymphovascular space invasion in epithelial ovarian cancer

While the prognostic significance of lymphovascular space invasion (LVSI) is well established in endometrial and cervical cancer, its role in ovarian cancer is not fully understood. First, a training cohort was conducted to explore whether the presence and quantity of LVSI within the ovarian tumor correlated with nodal metastasis and survival (n = 127). Next, the results of the training cohort were applied to a different study population (validation cohort, n = 93). In both cohorts, histopathology slides of epithelial ovarian cancer cases that underwent primary cytoreductive surgery including pelvic and/or aortic lymphadenectomy were examined. In a post hoc analysis, the significance of LVSI was evaluated in apparent stage I cases (n = 53). In the training cohort, the majority of patients had advanced-stage disease (82.7%). LVSI was observed in 79.5% of cases, and nodal metastasis was the strongest variable associated with the presence of LVSI (odds ratio [OR]: 7.99, 95% confidence interval [CI]: 1.98–32.1, P = 0.003) in multivariate analysis. The presence of LVSI correlated with a worsened progression-free survival on multivariate analysis (hazard ratio [HR]: 2.06, 95% CI: 1.01–4.24, P = 0.048). The significance of the presence of LVSI was reproduced in the validation cohort (majority, early stage 61.3%). In apparent stage I cases, the presence of LVSI was associated with a high negative predictive value for nodal metastasis (100%, likelihood ratio, P = 0.034) and with worsened progression-free survival (HR: 5.16, 95% CI: 1.00–26.6, P = 0.028). The presence of LVSI is an independent predictive indicator of nodal metastasis and is associated with worse clinical outcome of patients with epithelial ovarian cancer.

Systematic lymphadenectomy in ovarian cancer at second-look surgery: a randomised clinical trial

Background:The role of systematic aortic and pelvic lymphadenectomy (SAPL) at second-look surgery in early stage or optimally debulked advanced ovarian cancer is unclear and never addressed by randomised studies.Methods:From January 1991 through May 2001, 308 patients with the International Federation of Gynaecology and Obstetrics stage IA–IV epithelial ovarian carcinoma were randomly assigned to undergo SAPL (n=158) or resection of bulky nodes only (n=150). Primary end point was overall survival (OS).Results:The median operating time, blood loss, percentage of patients requiring blood transfusions and hospital stay were higher in the SAPL than in the control arm (P<0.001). The median number of resected nodes and the percentage of women with nodal metastases were higher in the SAPL arm as well (44% vs 8%, P<0.001 and 24.2% vs 13.3%, P:0.02). After a median follow-up of 111 months, 171 events (i.e., recurrences or deaths) were observed, and 124 patients had died. Sites of first recurrences were similar in both arms. The adjusted risk for progression and death were not statistically different (hazard ratio (HR) for progression=1.18, 95% confidence interval (CI)=0.87–1.59; P=0.29; 5-year progression-free survival (PFS)=40.9% and 53.8% HR for death=1.04, 95% CI=0.733–1.49; P=0.81; 5-year OS=63.5% and 67.4%, in the SAPL and in the control arm, respectively).Conclusion:SAPL in second-look surgery for advanced ovarian cancer did not improve PFS and OS.

The Role of Lymphadenectomy in Node-Positive Epithelial Ovarian Cancer

To evaluate the therapeutic role of pelvic and aortic lymphadenectomy in patients with epithelial ovarian cancer (EOC) and positive nodes (stages IIIC and IV). Retrospective chart review. Data from all consecutive patients with EOC and positive retroperitoneal lymph nodes (stage IIIC and IV) in Mayo Clinic from 1996 to 2000 were included. To evaluate the impact of nodal metastases, the extent of lymphadenectomy was compared according to the number of nodes removed and positive nodes resected. Multivariable Cox regression and Kaplan-Meier survival curves were used for analysis. The median number of nodes removed was 31 (pelvic, 21.5, and aortic, 10), and the median number of positive nodes was 5. The 5-year overall survival was 44.8%. On multivariate analysis, only the extent of peritoneal metastases before surgery was a significant factor for survival (P = 0.001 for stage IIIC and P = 0.004 for stage IV). Analysis of 83 patients with advanced peritoneal disease more than 2 cm demonstrated before debulking, removal of more than 40 lymph nodes was a significant prognostic factor for overall survival (hazard ratio, 0.52; P = 0.032; 95% confidence interval, 0.29-0.35). In 29 patients with advanced peritoneal disease and no residual disease after debulking, removal of more than 10 positive was a factor for survival. There was a survival benefit in patients with EOC with advanced peritoneal disease more than 2 cm before debulking when more than 40 lymph nodes were removed. There was an additional survival benefit in those patients with no residual disease after debulking when more than 10 positive nodes were removed.

From the Tailoring of Adjuvant Treatment to the Tailoring of Pelvic and Aortic Lymphadenectomy in Stage I Endometrial Cancer

From the Tailoring of Adjuvant Treatment to the Tailoring of Pelvic and Aortic Lymphadenectomy in Stage I Endometrial Cancer

Prognostic Value of Lymph Node Ratio and Clinicopathologic Parameters in Patients Diagnosed With Stage IIIC Endometrial Cancer

To estimate the prognostic significance of lymph node ratio with respect to clinicopathologic characteristics in stage IIIC endometrial cancer patients. Using data from medical records and surgery notes, we identified all consecutive patients with stage IIIC endometrial cancer who received primary surgical treatment between 1993 and 2008. Lymph node ratio is the number of metastatic lymph nodes to the total number of removed lymph nodes. Survival analyses were performed using Kaplan-Meier and Cox proportional hazard methods. Two hundred sixteen patients with stage IIIC endometrial cancer were included in this multicenter study. Age, number of metastatic lymph nodes, lymph node ratio, grossly suspicious lymph nodes, histologic subtype, and cervical metastasis were associated with progression-free survival and overall survival, respectively. Patients with lymph node ratios 10% or less, more than 10-50%, and more than 50% had 5-year overall survival rates of 79.0%, 60.6%, and 35.8%, respectively (P<.001). In multivariable analysis, only lymph node ratio was associated with both progression-free survival and overall survival, respectively. Total number of removed lymph nodes and number of metastatic lymph nodes did not correlate with overall survival in the group with grossly suspicious lymph nodes, whereas lymph node ratio did. In the subgroup of 123 (56.9%) patients who had pelvic and aortic lymphadenectomies with a minimum of 10 lymph nodes removed, age and lymph node ratio were still associated with progression-free survival and overall survival, whereas total lymph nodes removed was not. Stratification based on lymph node ratio is useful when comprehensive lymphadenectomy is routinely performed and likely reflects metastatic nodal tumor burden. These data provide another prognostic variable in the heterogenic group of women with stage IIIC endometrial cancer. II.