Lymphadenectomy In Endometrial Cancer Research Articles

The role of lymphadenectomy in endometrial cancer: Was the ASTEC trial doomed by design and are we destined to repeat that mistake?

The role of lymphadenectomy in endometrial cancer: Was the ASTEC trial doomed by design and are we destined to repeat that mistake?

Interobserver Agreement for Endometrial Cancer Characteristics Evaluated on Biopsy Material

A shift toward a disease-based therapy designed according to patterns of failure and likelihood of nodal involvement predicted by pathologic determinants has recently led to considering a selective approach to lymphadenectomy for endometrial cancer. Therefore, it became critical to examine reproducibility of diagnosing the key determinants of risk, on preoperative endometrial tissue samples as well as the concordance between preoperative and postresection specimens. Six gynaecologic pathologists assessed 105 consecutive endometrial biopsies originally reported as positive for endometrial cancer for cell type (endometrioid versus nonendometrioid), tumor grade (FIGO 3-tiered and 2-tiered), nuclear grade, and risk category (low risk defined as endometrioid histology, grade 1 + 2 and nuclear grade <3). Interrater agreement levels were substantial for identification of nonendometrioid histology (κ = 0.63; SE = 0.025), high tumor grade (κ = 0.64; SE = 0.025), and risk category (κ = 0.66; SE = 0.025). The overall agreement was fair for nuclear grade (κ = 0.21; SE = 0.025). There is agreement amongst pathologists in identifying high-risk pathologic determinants on endometrial cancer biopsies, and these highly correlate with postresection specimens. This is ascertainment prerequisite adaptation of the paradigm shift in surgical staging of patients with endometrial cancer.

Role of Lymphadenectomy in Endometrial Cancer

Endometrial cancer is the most frequent gynaecological carcinoma with an increasing incidence. However, this tumour is usually identified in its early stages due to its symptomatology appearing fairly soon. This fact allows for a diagnosis in early stages in most patients, thus providing a good prognosis with an overall survival rate at 5 years higher than 95%. The classical management has been hysterectomy with bilateral salpingo-oophorectomy and pelvic-aortic lymphadenectomy, but we know that many patients in early stages may be treated with only hysterectomy plus salpingooophorectomy. The role of lymphadenectomy in the surgical treatment of these patients is a controversial issue. Assessment of regional nodes varies from elective omission to sampling (selective assessment) to systematic pelvic and para-aortic lymphadenectomy. In order to prevent under or overtreatment, some authors also propose pelvic lymphadenectomy and, in case of it being positive proceed to an aortic lymphadenectomy. At present this technical procedure seems to be useful only in high-risk patients since low-risk patients would not obtain real benefits. Taking into account that in endometrial cancer the drainage is through the pelvic and para-aortic lymph nodes, lymphadenectomy should include all the nodal regions mentioned. Lymphadenectomy allows for a selection of high-risk patients candidates for adjuvant therapy. Keywords: Endometrial cancer, lymphadenectomy, survival, node, gynaecological carcinoma, tumour, hysterectomy, salpingo-oophorectomy, para-aortic lymphadenectomy, para-aortic lymph nodes

Risk Factors for Node Affectation and Recurrence in Endometrial Cancer

Endometrial cancer is the most common gynecologic malignancy in western countries. In United States, 42000 estimated new cases were diagnosed in 2009, approximately 7780 women died from this cancer last year. This malignancy has a five year survival rate around 80%, thanks to its early diagnosis. The surgical management of endometrial cancer includes hysterectomy as main surgical procedure. The role of lymphadenectomy, pelvic and para aortic is still controversial. The authors discuss in this article the risk factors for lymph node metastases and recurrence for endometrial cancer by reviewing the international literature. Conclusions: Lymphadenectomy is a crucial surgical procedure for an adequate staging of endometrial cancer. It is necessary a to evaluate the prognostic factors of this disease in order to properly select the most adequate adjuvant therapy. Since last trials on lymphadenectomy in endometrial cancer have not been convincing, further studies are warranted.

A Prospective Evaluation of Lymphatic Dissemination in Endometrial Cancer

This study aimed to assess para-aortic metastases relative to the inferior mesenteric artery (IMA). In addition, the clinicopathologic features of these patients are discussed. Between 2007 and 2009, a total of 78 consecutive patients who had open systematic pelvic and para-aortic lymphadenectomy surgery for endometrial cancer extending to the renal vessels and who were treated at the gynecologic oncology department were included in this prospective study. The para-aortic lymph nodes (PALNs) removed from these patients were classified as supramesenteric (between the renal vein and the IMA) or inframesenteric (between the IMA and the presacral). Patients' clinical data, pathologic tumor characteristics, and operative and early postoperative data were recorded after surgery. Descriptive statistics were calculated using the SPSS 17.0 package program. Of these 78 patients, 18 (21.3%) had metastatic nodal involvement. From a total of 12 patients with PALN metastasis, 7 had only supramesenteric and 1 had only inframesenteric nodal involvement, whereas 4 had both supramesenteric and inframesenteric metastases. Of the 5 patients in the inframesenteric±supramesenteric group, none had a grade 1 tumor. On the other hand, of the 7 patients with only supramesenteric metastasis, 57.1% (n=4) had a grade 1 tumor and 42.8% (n=3) had less than half of myometrial invasion. In the case of well-defined risk factors in which a lymphadenectomy is indicated according to current guidelines from the International Federation of Gynecology and Obstetrics, a PALN dissection should be extended up to the renal vessels. We also conclude that tumor grade, histologic type, and myometrial invasion cannot be used as markers to decide on supramesenteric lymphadenectomy in endometrial cancer.

The Role of Lymphadenectomy in Endometrial Cancer

The role of lymphadenectomy in the management of endometrial cancer is rapidly evolving. Although retrospective reports have suggested that lymphadenectomy is associated with a therapeutic benefit, recent prospective trials have questioned the therapeutic effect of lymphadenectomy. Lymphadenectomy remains the gold standard for detecting metastatic disease to the regional nodes. In this review, we discuss the controversies surrounding lymphadenectomy for endometrial cancer.

The role of lymphadenectomy in endometrial cancer: Was the ASTEC trial doomed by design and are we destined to repeat that mistake?

The role of lymphadenectomy in endometrial cancer: Was the ASTEC trial doomed by design and are we destined to repeat that mistake?

Initial failure site according to primary treatment with or without para-aortic lymphadenectomy in endometrial cancer

ObjectiveThe objective of this study was to compare the initial failure sites in patients with endometrial cancer who underwent surgical treatment including pelvic lymphadenectomy with or without para-aortic lymphadenectomy. MethodsA retrospective chart review was carried out for 657 endometrial cancer patients with no residual disease after initial treatments including lymphadenectomy at two tertiary centers between 1987 and 2004. Surgical treatment at one institute included pelvic lymphadenectomy (PLX) without para-aortic lymphadenectomy (PALX), while surgical treatment including PLX+PALX was routinely performed at the other institute. We identified patients with recurrence and evaluated initial failure sites. Rates of recurrence in the respective sites were compared according to the type of lymphadenectomy. ResultsOf the 657 patients, 103 (15.7%) suffered recurrence. There was no significant difference between the rate of intrapelvic recurrence in the PLX alone group and that in the PLX+PALX group (4.7% vs. 2.9%, p=0.22). The rate of extrapelvic recurrence in the PLX alone group was significantly higher than that in the PLX+PALX group (16.1% vs. 6.2%, p<0.0001), and the rate of para-aortic node (PAN) recurrence in the PLX alone group was also significantly higher than that in the PLX+PALX group (5.1% vs. 0.6%, p=0.0004). In the analysis of patients who received adjuvant chemotherapy, the rate of PAN recurrence in the PLX alone group was significantly higher than that in the PLX+PALX group (9.5% vs. 1.3%, p=0.0036). ConclusionPAN recurrence was a failure pattern peculiar to the PLX alone group. Adjuvant chemotherapy might not be able to replace surgical removal as a treatment for metastatic lymph nodes.

A Retrospective Analysis of Postoperative Complications With or Without Para-aortic Lymphadenectomy in Endometrial Cancer

Although para-aortic lymphadenectomy (PALX) has not been accepted as a standard treatment for patients with endometrial cancer, it is possible that systematic lymphadenectomy including PALX has therapeutic significance for patients with intermediate-/high-risk endometrial cancer. On the other hand, a consensus regarding the safety of PALX has not been reached. The aim of this study was to compare the incidence rates of postoperative complications after pelvic lymphadenectomy (PLX) with or without PALX in patients with uterine corpus cancer. A retrospective chart review was carried out for all patients with endometrial cancer treated at 2 tertiary centers between 1998 and 2004. Surgery at one institute included both PLX and PALX, whereas PLX alone was routinely performed at the other institute. A total of 142 patients underwent PLX + PALX and 138 patients underwent PLX alone. We evaluated postoperative complications including intraoperative injury, ileus, lymphedema, lymphocyst, and thrombosis. There was no fatal accident associated with surgery. Lymphedema was the most frequent complication. Comparing the PLX + PALX group and the PLX group, there were no significant differences in the rate of cases of lymphedema (23.2% vs 28.3%), lymphocyst (9.2% vs 9.4%), and thrombosis (4.9% vs 2.2%). The rate of cases of mild/moderate ileus in the PLX + PALX group was significantly higher than that in the PLX group (10.5% vs 2.9%; P = 0.011). However, no significant difference in the rates of cases of severe ileus was found between the 2 groups (1.4% vs 0.7%). There were also no significant differences between the 2 groups in the rates of intraoperative organ injury (2.8% vs 2.2%) and secondary operation for postoperative complications (4.9% vs 4.3%). Para-aortic lymphadenectomy can be performed with an acceptable morbidity under the conditions in which it is performed by experienced surgeons, and measures to prevent complications are properly taken.

Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis

Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis

Management of lymph nodes in endometrioid uterine cancer

Hysterectomy with bilateral salpingo-oophorectomy is the standard surgery for endometrial cancer. However, the indication and extent of surgical lymph node staging continues to be controversial if the carcinoma is confined to the uterus, even in the eyes of the experts. The survival benefit of this invasive staging technique has not been clearly demonstrated in this setting. We have focused our review on lymph node disease in patients with early endometrial cancer. We report on the important issues surrounding lymphadenectomy in endometrial cancer and the results of a recent large randomized trial that do not indicate a benefit of surgical staging. Other issues, including complications and the benefits of combining laparoscopy with lymphadenectomy, will also be discussed. Pelvic and para-aortic lymphadenectomies are not appropriate for low-risk patients with endometrioid uterine cancer. The risk-benefit balance for these patients seems rather in favor of not performing surgical staging. On the contrary, high-risk patients would seem to benefit from complete pelvic and para-aortic lymph node staging with adjuvant treatments tailored to the results of lymphadenectomy.

Lymphadenectomy in Endometrial Cancer: Which Is the Right Question?

Lymphadenectomy in Endometrial Cancer: Which Is the Right Question?

Glomus Tumor of the Ovary: A Case Report

A 55-year-old woman underwent a total hysterectomy, bilateral salpingo-oophorectomy, partial omentectomy, and lymphadenectomy for endometrial cancer. Histologically, the cancer was endometrioid adenocarcinoma grade 1, which invaded the myometrium. There was no macroscopically detectable mass in the ovaries. However, histological examination revealed a small tumor, 1 mm in size, in the medulla of the right ovary. The ovarian tumor was composed of uniform epithelioid cells that grew in nests. Vessels of various sizes were observed within the tumor, and they were surrounded by tumor cells. Immunohistochemically, the ovarian tumor was positive for smooth muscle actin and vimentin but negative for desmin and CD34. Based on these findings, the authors made the diagnosis of ovarian glomus tumor. Although an ovarian glomus tumor is extremely rare, the authors believe that it should be included in the differential diagnosis of ovarian mesenchymal tumors and sex cord tumors.

Lymphadenectomy in endometrial cancer: when, not if

The lack of consensus for primary surgical treatment of endometrial cancer, the most common gynaecological cancer, is deplorable. Whether lymphadenectomy should be done together with hysterectomy has been debated at length and passionately. Resolution of this problem has been confounded by several issues, such as selection of patients, the perceived goals of lymphadenectomy, and clinicians' failure to recognise the known routes of lymphatic spread from the uterus. 1 Bakkum-Gamez JN Gonzalez-Bosquet J Laack NN Mariani A Dowdy SC Current issues in the management of endometrial cancer. Mayo Clin Proc. 2008; 83: 97-112 Summary Full Text Full Text PDF PubMed Scopus (115) Google Scholar In practice, lymphadenectomy varies from complete omission, to various iterations of lymph-node sampling, to systematic lymphadenectomy. Furthermore, the extent of lymphadenectomy ranges from pelvic-node dissection alone to dissection of the para-aortic area, which can include the aortic bifurcation to the inferior mesenteric artery and up to the renal vessels. Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysisCombined pelvic and para-aortic lymphadenectomy is recommended as treatment for patients with endometrial carcinoma of intermediate or high risk of recurrence. If a prospective randomised or comparative cohort study is planned to validate the therapeutic effect of lymphadenectomy, it should include both pelvic and para-aortic lymphadenectomy in patients of intermediate or high risk of recurrence. Full-Text PDF

Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis

In response to findings that pelvic lymphadenectomy does not have any therapeutic benefit for endometrial cancer, we aimed to establish whether complete, systematic lymphadenectomy, including the para-aortic lymph nodes, should be part of surgical therapy for patients at intermediate and high risk of recurrence. We selected 671 patients with endometrial carcinoma who had been treated with complete, systematic pelvic lymphadenectomy (n=325 patients) or combined pelvic and para-aortic lymphadenectomy (n=346) at two tertiary centres in Japan (January, 1986-June, 2004). Patients at intermediate or high risk of recurrence were offered adjuvant radiotherapy or chemotherapy. The primary outcome measure was overall survival. Overall survival was significantly longer in the pelvic and para-aortic lymphadenectomy group than in the pelvic lymphadenectomy group (HR 0.53, 95% CI 0.38-0.76; p=0.0005). This association was also recorded in 407 patients at intermediate or high risk (p=0.0009), but overall survival was not related to lymphadenectomy type in low-risk patients. Multivariate analysis of prognostic factors showed that in patients with intermediate or high risk of recurrence, pelvic and para-aortic lymphadenectomy reduced the risk of death compared with pelvic lymphadenectomy (0.44, 0.30-0.64; p<0.0001). Analysis of 328 patients with intermediate or high risk who were treated with adjuvant radiotherapy or chemotherapy showed that patient survival improved with pelvic and para-aortic lymphadenectomy (0.48, 0.29-0.83; p=0.0049) and with adjuvant chemotherapy (0.59, 0.37-1.00; p=0.0465) independently of one another. Combined pelvic and para-aortic lymphadenectomy is recommended as treatment for patients with endometrial carcinoma of intermediate or high risk of recurrence. If a prospective randomised or comparative cohort study is planned to validate the therapeutic effect of lymphadenectomy, it should include both pelvic and para-aortic lymphadenectomy in patients of intermediate or high risk of recurrence. Japanese Foundation for Multidisciplinary Treatment of Cancer, and the Japan Society for the Promotion of Science.

Systematic pelvic and aortic lymphadenectomy in intermediate and high-risk endometrial cancer: Lymph-node mapping and identification of predictive factors for lymph-node status

Objective To systematically assess the metastatic pattern of intermediate- and high-risk endometrial cancer in pelvic and para-aortic lymph-nodes and to evaluate risk factors for lymph-node metastases. Study Design Between 01/2005 and 01/2009 62 consecutive patients with intermediate- and high-risk endometrial cancer who underwent a systematic surgical staging including pelvic and para-aortic lymphadenectomy were enrolled into this study. Patients’ characteristics, histological findings, lymph-node localization and involvement, surgical morbidity and relapse data were analyzed. Univariate analysis was performed to define risk factors for lymph-node metastasis. Results Of the 13 patients (21%) with positive lymph-nodes (N1), 8 (61.5%) had both pelvic and para-aortic lymph-nodes affected, 2 (15.4%) only para-aortic and 3 (23%) only pelvic lymph-node metastases. Overall, 54% of the N1-patients had positive lymph-nodes above the inferior mesenteric artery (IMA) to the level of the renal veins. Univariate analysis revealed lymph vascular space invasion ( p-value: <0.001), vascular-space-invasion ( p-value: <0.001) and incomplete tumor resection ( p-value: 0.008) as significant risk factors for N1-status. Overall and progression-free survival was not significantly different between N1- and N0-patients. Conclusions Since the proportion of N1-endometrial cancer patients with positive para-aortic lymph-nodes is, at 76%, considerably high, and more than half of them have affected lymph-nodes above the IMA-level, lymphadenectomy for endometrial cancer should be extended up to the renal veins, when indicated. The therapeutic impact of systematic lymphadenectomy on overall and progression-free survival has still to be evaluated in future prospective randomized studies.

Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis

Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis

Massive chylous ascites following robotic-assisted surgical staging in patient with endometrial carcinoma

Chylous ascites is an infrequent postoperative complication of retroperitoneal surgery caused by unrecognized disruption of major retroperitoneal lymphatics and is associated with serious mechanical, nutritional, and immunologic consequences due to the constant loss of protein and lymphocytes. Recently, the robotic‐assisted approach to surgical staging for gynecologic malignancy is increased, which allows for enabling the performance of complex procedures. As our experience, in patients with robotic‐assisted lymphadenectomy for endometrial cancer, chylous ascites can be also developed despite the meticulous dissection. In our opinion, it is recommended to remove large amount of ascites through paracentesis as much as possible at a time and we should be observed at least 8 weeks before surgical intervention while maintaining nutritional supports.

Benefit of Lymphadenectomy in Endometrial Cancer

Benefit of Lymphadenectomy in Endometrial Cancer

Efficacy of Systematic Pelvic Lymphadenectomy in Endometrial Cancer (MRC ASTEC Trial)

Efficacy of Systematic Pelvic Lymphadenectomy in Endometrial Cancer (MRC ASTEC Trial)