Abstract
There is a continuous debate about the extent and prognostic value of retroperitoneal lymphadenectomy in endometrial cancer. Systematic pelvic and para-aortic lymphadenectomy in endometrial cancer provides a more accurate assessment of neoplastic spread and may help in better individualization of patients for adjuvant therapy. To evaluate the risk and pattern of retroperitoneal lymph nodes metastasis in patients with endometrial cancers having intermediate and high risk factors for nodal metastasis and recurrence. We conducted a prospective nonrandomized study of 62 cases of high risk endometrial cancers examined and treated at our regional cancer institute between the years 2008 and 2012. The inclusion criteria: The intermediate risk; all patients having grade 3 or undifferentiated adenocarcinomas with less than half MI and the grade 1, 2 tumors having more than half MI with tumor size >2 cm. The high risk group; all the patients having grade 3 or undifferentiated adenocarcinomas with more than half MI, the grade 1, 2 tumors with lymph vascular space invasion (LVSI) or cervical stromal invasion as depicted by pre-operative MRI. The type 2 histology uterine papillary serous, clear cell and squamous cell carcinomas. The patients staging was carried out according to the classification established by the FIGO for endometrial cancer in 2009. The Chi-square test was used to analyze the correlation between tumor grade, myometrial invasion, size of the lesion and lymph nodes metastasis and Fisher’s correction done whenever the frequency distribution was less than five. The patients mean age was 58.3 (range 31 to 76 years). A total of 118 endometrial cancer patients were treated during the study period. The 56 (47.5 %) patients belonged to low risk and 62 (52.5 %) patients belonged to high risk endometrial cancers. The 52 of 62 cases were eligible for the analysis. The 10 patients’ were excluded from further analysis as the post operative specimens final histopathologic examinations in nine cases revealed carcinosarcoma uterus and one case with yolk sac tumor of endometrium. The total 17(32.7 %) of 52 cases had retroperitoneal nodes metastasis; nine of 17 (52.9 %) in this group had both pelvic and para-aortic lymph nodal metastasis and one of 17 (5.9 %) had isolated para-aortic lymph nodal metastasis. The high grade tumors (grade 3) revealed 41.4 % pelvic and 20.7 % para-aortic lymph nodes metastasis and there was statistically significant higher nodal metastasis in both pelvic and para-aortic lymph nodes with increasing depth of myometrial invasion (P = 0.0119 and P = 0.0001) and increasing size of the lesion. (P = 0.04 and P = 0.0501). The intermediate and high risk endometrial cancer is associated with greater degree of lymph node metastasis. A complete surgical staging which involves extrafascial hysterectomy or a type 3 radical hysterectomy when there is a cervical involvement, along with bilateral salphingo-oophorectomy, pelvic, para-aortic lymphadenectomy and an omentectomy when indicated as in the present study, is a valuable modality of treatment in intermediate and high risk cases of endometrial cancers for determining the prognosis and appropriate categorization of these women for adjuvant therapy. It is also possible to achieve a complete surgical staging in these groups of women with acceptable morbidity when performed by a trained gynaecologic oncologist.
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References
Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008 v 2.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 10 [Accessed on 12/01/13]
May K, Bryant A, Dickinson HO, Kehoe S, Morrison J (2010) Lymphadenectomy for the management of endometrial cancer. Cochrane Database Syst Rev, Issue 1. Art. No.: CD007585. doi:10.1002/14651858.CD007585.pub2
Chang SJ, Kim WY, Yoon JH, Yoo SC, Chang KH, Ryu HS (2008) Para-aortic lymphadenectomy improves survival in patients with intermediate to high-risk endometrial carcinoma. Acta Obstet Gynecol Scand 87:1361–1369. doi:10.1080/00016340802503054
Todo Y, Kato H, Kaneuchi M, Watari H, Takeda M, Sakuragi N (2010) Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis. Lancet 375(9721):1165–72. doi:10.1016/S0140-6736(09)62002-X, Epub 2010 Feb 24
Mariani A, Dowdy S, Podratz K (2009) The role of pelvic and para-aortic lymph node dissection in the surgical treatment of endometrial cancer: a view from the USA. Obstet Gynaecol 11:199–204. doi:10.1576/toag.11.3.199.27505
Mariani A, Webb MJ, Galli L, Podratz KC (2000) Potential therapeutic role of para-aortic lymphadenectomy in node-positive endometrial cancer. Gynecol Oncol 76(3):348–56
Neubauer NL, Lurain JR (2011) The role of lymphadenectomy in surgical staging of endometrial cancer. Int J Surg Oncol 2011:814649
Rathod PS, Reddihalli PV, Krishnappa S, Devi UK, Bafna UD (2014) A retrospective clinicopathological study of 131 cases with endometrial cancers- is it possible to define the Role of Retroperitoneal Lymphadenectomy in Low Resourace Settings?. http://www.indianjcancer.com/aheadofprint.asp. Indian J Cancer
Silverberg SG, Mutter GL, Kurman RJ, Kubik-Huch RA, Nogales F, Tavassoli FA (2003) Tumors of the uterine corpus: epithelial tumors and related lesions. In: Tavassoli FA, Stratton MR (eds) WHO classification of tumors: pathology and genetics of tumors of the breast and female genital organs. IARC Press, Lyon, pp 221–232
Querleu D, Planchamp F, Narducci F, Morice P, Joly F et al (2011 Jul) Clinical practice guidelines for the management of patients with endometrial cancer in France: recommendations of the Institut National du Cancer and the Société Française d’Oncologie Gynécologique. Int J Gynecol Cancer 21(5):945–50. doi:10.1097/IGC.0b013e31821bd473
Berek and Hacker’s Gynecologic Oncology, 5e. Chapter 10: Uterine Cancers; Uterine sarcomas. pp 429–30
DeVita, Hellman, and Rosenberg’s cancer: principles & practice of oncology, 9e. Chapter 102: Cancers of the Uterine Body; Uterine Sarcomas. pp 1356–7
Prat J (2009) FIGO staging for uterine sarcomas. Int J Gynaecol Obstet 104(3):177–8. doi:10.1016/j.ijgo.2008.12.008, Epub 2009 Jan 9
FIGO Committee on Gynaecologic Oncology (2009) Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynecol Obst 105:103–104
Rosner B (2000) Fundamentals of biostatististics, 5th edn, Duxbury
Reddy V (2002) Statistics for mental health care research. NIMHANS publication, India
Kitchener H, Swart AM, Qian Q et al (2009) Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomized study. Lancet 373(9658):125–136
Panici PB, Basile S, Maneschi F et al (2008) Systematic pelvic lymphadenectomy vs no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial. J Natl Cancer Inst 100(23):1707–1716
Mariani A, Dowdy SC, Cliby WA et al (2008) Prospective assessment of lymphatic dissemination in endometrial cancer: a paradigm shift in surgical staging. Gynecol Oncol 109:11–18
Yokoyama Y, Maruyama H, Sato S, Saito Y (1997) Indispensability of pelvic and para aortic lymphadenectomy in endometrial cancers. Gynecol Oncol 64:411–17
Nomura H, Aoki D, Suzuki N, Susumu N, Suzuki A, Tamada Y et al (2006) Analysis of clinicopathologic factors predicting para aortic lymph node metastasis in endometrial cancer. Int J Gynecol Cancer 16:799–804
Mariani A, Dowdy SC, Cliby WA, Haddock MG, Keeney GL, Lesnick TG et al (2006) Efficacy of systematic lymphadenectomy and adjuvant radiotherapy in node-positive endometrial cancer patients. Gynecol Oncol 10:200–208
Morrow CP, Bundy BN, Kurman RJ, Creasman WT, Heller P, Homesley HD et al (1991) Relationship between surgical-pathologic riskfactors and outcome in clinical stage I and II carcinoma of theendometrium: a Gynecologic Oncology Group study. Gynecol Oncol 40:55–65
Schink JC, Lurain JR, Wallemark CB, Chmiel JS (1987) Tumor size in endometrial cancer: a prognostic factor for lymph node metastasis. Obstet Gynecol 70(2):216–219
Mariani A, Webb MJ, Keeney GL, Lesnick TG, Podratz KC (2002) Surgical stage I endometrial cancer: predictors of distant failure and death. Gynecol Oncol 87(3):274–280
Disaia PJ, Creasman WT, Boronow RC, Blessing JA (1985) Risk factors and recurrent patterns in stage I endometrial cancer. Am J Obstet Gynecol 151(8):1009–1015
Niikura H, Okamura C, Utsunomiya H et al (2004) Sentinel lymph node detection in patients with endometrial cancer. Gynecol Oncol 92:669–74
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Rathod, P.S., Shakuntala, P.N., Pallavi, V.R. et al. The Risk and Pattern of Pelvic and Para Aortic Lymph Nodal Metastasis in Patients with Intermediate and High Risk Endometrial Cancer. Indian J Surg Oncol 5, 109–114 (2014). https://doi.org/10.1007/s13193-014-0303-x
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DOI: https://doi.org/10.1007/s13193-014-0303-x