Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study

Major clinical research advances in gynecologic cancer in 2010

This review summarizes 11 major clinical research advances in gynecologic oncology in 2010. For ovarian cancer, bevacizumab as a leading molecular targeted agent, pegylated liposomal doxorubicin in recurrent disease, the role of neoadjuvant chemotherapy in an advanced setting, an effective screening method, and ARID1A mutations as a clue to the origin of clear cell carcinoma are mentioned. For cervical cancer, confirmation of the efficacy and the introduction of a self collection method of the human papillomavirus (HPV) test, and the association between the HPV vaccine and miscarriage are examined. For endometrial cancer, the superiority of laparoscopy in staging operation, the role of vaginal brachytherapy in an adjuvant setting, and the effect of para-aortic lymph node dissection are reviewed. In addition, the trend of geriatric oncology and chemotherapy in carcinosarcomas is also assessed.

Lower uterine segment involvement is associated with poor outcomes in early-stage endometrioid endometrial carcinoma

BACKGROUND

The clinicopathologic significance of lower uterine segment involvement (LUSI) in endometrial cancer patients remains unclear. Although LUSI has been reported to be a prognostic indicator, literature is limited.

METHODS

We studied 481 surgically staged endometrioid endometrial cancers with disease confined to the uterus (FIGO 1988 stage I or II). Primary outcomes were overall survival (OS) and disease-free survival (DFS). The relationships between LUSI and OS and DFS were assessed using the Kaplan-Meier method and Cox proportional hazard models. The t test or Fisher exact test was used for evaluating relationships between variables of interest.

RESULTS

LUSI was present in 223 cases (46.4%), and was associated with both decreased disease free survival (P = 0.02) and overall survival (P = 0.01) in univariate analysis. Multivariate analysis confirmed the association between LUSI and increased risk for recurrence [hazard ratio (HR) 2.27; 95% confidence interval (95% CI) 1.09-4.7; P = 0.03] and increased mortality (HR 1.76; 95% CI 1.12-2.78; P = 0.01).

CONCLUSIONS

LUSI in patients with early-stage endometrioid endometrial cancer is associated with decreased survival.

Management of lymph nodes in endometrioid uterine cancer

PURPOSE OF REVIEW

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.

RECENT FINDINGS

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.

SUMMARY

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.

DICER1 expression and outcomes in endometrioid endometrial adenocarcinoma

BACKGROUND

The objective of this study was to determine whether lower expression levels of DICER1 are associated with disease recurrence in patients with endometrioid endometrial cancer. The authors also explored DNA methylation and haploinsufficiency as potential mechanisms related to altered DICER1 expression in these tumors.

METHODS

DICER1 expression was assessed by quantitative polymerase chain reaction in a selected cohort of endometrioid endometrial tumors (N = 169). Loss of heterozygosity analyses were conducted using 2 single nucleotide polymorphisms, and combined bisulfate restriction analysis was used to assess methylation in the 5'-untranslated region of DICER1 in representative tumors. The correlations between DICER1 expression and clinicopathologic variables, including overall survival (OS) and disease-free survival (DFS), were assessed using nonparametric rank-sum tests and Cox proportional hazard models as appropriate. Survival distributions were described using the Kaplan-Meier method. A nested case-control analysis was conducted to confirm the association between transcript levels and disease recurrence.

RESULTS

Lower DICER1 expression (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.05-1.75; P = .02) and advanced disease stage (HR, 2.79; 95%CI, 1.59-4.90; P < .001) were associated with worse DFS. Three variables were associated significantly with reduced OS: age (HR, 1.04; 95%CI, 1.02-1.06; P < .0001), advanced disease stage (HR, 6.41; 95%CI, 3.57-11.52; P < .0001), and high tumor grade (HR, 2.96; 95%CI, 1.46-5.99; P = .003). Nested case-control analyses confirmed that there were lower DICER1 transcript levels in patients who had recurrent disease (P = .01). Deletion of DICER1 sequences was an infrequent event (5% of analyzed patients), and no methylation was observed in the 5' DICER1 regulatory region.

CONCLUSIONS

Lower DICER1 transcript levels were correlated with disease recurrence and worse DFS survival in patients with endometrioid endometrial cancer. The factors that influence DICER1 transcript levels in primary endometrial cancers remain unknown.

Does postoperative radiotherapy provide any survival advantage over observation in stage IC endometrial cancer after comprehensive surgical staging?

OBJECTIVE

To compare postoperative radiotherapy and observation for survival and recurrence rates in stage IC endometrial carcinoma patients who underwent comprehensive surgical staging.

STUDY DESIGN

Fifty-seven stage IC endometrial cancer patients who underwent surgical staging were included in this study. Twenty cases (35%) received postoperative radiotherapy and 37 (65%) were observed without additional therapy. The two groups were compared for survival and recurrence rates.

RESULTS

Mean follow-up times for the radiotherapy and observation groups were 52.05 and 38.71 months, respectively. Five-year disease-free survival rates for the radiotherapy and observation groups were 91% and 63%, respectively, and 5-year overall survival rates for the radiotherapy and observation groups were 90.0% and 80.8%, respectively. Both the disease-free and overall survival rates were similar between the two groups (p > 0.05). One (5%) of the 20 patients in the radiotherapy group, and four (10.8%) of the 37 patients in the observation group had recurrences and there was no statistical difference for the recurrence rates (p > 0.05). Disease grade had no prognostic significance in terms of survival after surgical staging.

CONCLUSIONS

Comprehensive surgical staging might minimize the unfavorable role of deep myometrial invasion and grade. After surgical staging, postoperative observation without radiotherapy may be an appropriate approach in stage IC, all grades, endometrial carcinoma.

[Role of laparoscopy in the treatment of early endometrial cancer]

Endometrial cancer is the most frequent malignant tumor of the female genital tract. Traditionally, surgical treatment is performed via laparotomy, but laparoscopy has recently gained wider acceptance. Data regarding survival and recurrence are comparable in case of laparotomy or laparoscopy. Surgical morbidity and postoperative recovery time are significantly lower by laparoscopy. In case of early endometrial cancer laparoscopy is an invaluable alternative method of choice but it has to be performed by skilled laparoscopic surgeons. Authors review the current literature regarding the role of laparoscopy in the treatment of early stage endometrial cancer.

Imaging of endometrial and cervical cancer

In this article we review the ever increasing role of imaging in endometrial and cervical cancer. Magnetic resonance imaging (MRI) has emerged as the most widely used technique in the management of women with gynaecological cancer. In endometrial cancer, MRI is reliable in identifying myometrial and cervical invasion and extra-uterine disease, thereby informing preoperative surgical planning. In cervical cancer, MRI plays a crucial role in distinguishing early from advanced disease, thereby stratifying patients for surgery and chemoradiation. MRI is also valuable in assessing proximal extension of cervical tumours in young women with early stage disease for feasibility of fertility preserving surgery. In both cancers, imaging is used for diagnosing nodal metastases, detection of recurrence, and dealing with complications of both the disease and treatment.

Asian society of gynecologic oncology workshop 2010

This workshop was held on July 31-August 1, 2010 and was organized to promote the academic environment and to enhance the communication among Asian countries prior to the 2nd biennial meeting of Australian Society of Gynaecologic Oncologists (ASGO), which will be held on November 3-5, 2011. We summarized the whole contents presented at the workshop. Regarding cervical cancer screening in Asia, particularly in low resource settings, and an update on human papillomavirus (HPV) vaccination was described for prevention and radical surgery overview, fertility sparing and less radical surgery, nerve sparing radical surgery and primary chemoradiotherapy in locally advanced cervical cancer, were discussed for management. As to surgical techniques, nerve sparing radical hysterectomy, optimal staging in early ovarian cancer, laparoscopic radical hysterectomy, one-port surgery and robotic surgery were introduced. After three topics of endometrial cancer, laparoscopic surgery versus open surgery, role of lymphadenectomy and fertility sparing treatment, there was a special additional time for clinical trials in Asia. Finally, chemotherapy including neo-adjuvant chemotherapy, optimal surgical management, and the basis of targeted therapy in ovarian cancer were presented.

Current status in the management of uterine corpus cancer in Korea

Uterine corpus cancer has increased in prevalence in Korean women over the last decade. Recently, elegant studies have been reported from many institutes. To improve treatment strategies, a review of our own data is warranted. This work will discuss the risks and prognostic factors for uterine corpus cancer, and the radiologic evaluation, prediction of lymph node metastasis, systematic lymphadenectomy, minimally invasive surgery, ovarian-saving surgery, fertility-sparing treatment, and adjuvant treatment in women with uterine cancer.

Laparoscopic surgery for endometrial cancer: a phenomenological study

AIM

This paper is a report of a study of women's perspectives on the experience of laparoscopic surgery for endometrial cancer.

BACKGROUND

Laparoscopic surgery is increasingly used to treat early endometrial cancer. It is associated with low levels of morbidity and is considered safe as cancer surgery, but research on quality of life and women's experiences is limited.

METHOD

Heideggerian hermeneutic phenomenology was used to explore the experiences of 14 women who had undergone the procedure in two English cancer centres between February 2008 and July 2009. In-depth interviews were taped, transcribed and analysed using Colaizzi's framework.

FINDINGS

A phenomenological description was produced from five identified themes: having cancer, transfer of responsibility to the surgeon, information and support, independence, and normality. The experience of laparoscopic surgery was overshadowed by the presence of cancer. Fear and lack of knowledge played an important role in entrusting the surgeon with the responsibility for decision-making. Individual, unmet information needs focused on the practicalities of treatment and being in an unfamiliar situation and environment. Loss of control and vulnerability were associated with illness and surgery, but early postoperative mobility and reduced pain, facilitated rapid return to independence and maintained a sense of normality.

CONCLUSION

Healthcare professionals should deliver care in early endometrial cancer in a way that recognizes the significance of the cancer diagnosis, the role of the surgeon in decision-making and the need for practical information. Women with endometrial cancer should have access to treatments that reduce dependency and maintain normality.

To Stage or Not to Stage? That is the Question: (With Apologies to Shakespeare)

The International Federation of Gynecology and Obstetrics staging rules for endometrial cancer require pelvic and para-aortic node dissection to define the extent of disease. Retrospective studies have reported improved survival in women who underwent lymphadenectomy compared with those who did not. This association may not be causally related because of bias. Recently reported prospective randomized trials of pelvic lymphadenectomy have failed to demonstrate a survival benefit. Critics of these trials remain skeptical because of perceived limitations in design, particularly the inclusion of non-high-risk women and the lack of full para-aortic lymphadenectomy. Until new trial evidence is produced to the contrary, routine lymphadenectomy cannot be recommended for endometrial cancer.

Does the use of the 2009 FIGO classification of endometrial cancer impact on indications of the sentinel node biopsy?

Background

Lymphadenectomy is debated in early stages endometrial cancer. Moreover, a new FIGO classification of endometrial cancer, merging stages IA and IB has been recently published. Therefore, the aims of the present study was to evaluate the relevance of the sentinel node (SN) procedure in women with endometrial cancer and to discuss whether the use of the 2009 FIGO classification could modify the indications for SN procedure.

Methods

Eighty-five patients with endometrial cancer underwent the SN procedure followed by pelvic lymphadenectomy. SNs were detected with a dual or single labelling method in 74 and 11 cases, respectively. All SNs were analysed by both H&E staining and immunohistochemistry. Presumed stage before surgery was assessed for all patients based on MR imaging features using the 1988 FIGO classification and the 2009 FIGO classification.

Results

An SN was detected in 88.2% of cases (75/85 women). Among the fourteen patients with lymph node metastases one-half were detected by serial sectioning and immunohistochemical analysis. There were no false negative case. Using the 1988 FIGO classification and the 2009 FIGO classification, the correlation between preoperative MRI staging and final histology was moderate with Kappa = 0.24 and Kappa = 0.45, respectively. None of the patients with grade 1 endometrioid carcinoma on biopsy and IA 2009 FIGO stage on MR imaging exhibited positive SN. In patients with grade 2-3 endometrioid carcinoma and stage IA on MR imaging, the rate of positive SN reached 16.6% with an incidence of micrometastases of 50%.

Conclusions

The present study suggests that sentinel node biopsy is an adequate technique to evaluate lymph node status. The use of the 2009 FIGO classification increases the accuracy of MR imaging to stage patients with early stages of endometrial cancer and contributes to clarify the indication of SN biopsy according to tumour grade and histological type.

PET/CT in Gynecologic Cancer: Present Applications and Future Prospects-A Clinician's Perspective

This article briefly reviews the epidemiology, diagnosis, and treatment of the common gynecologic malignancies, with an emphasis on the shortcomings of current clinical practice. The persistent need to achieve early diagnosis, adjust proper treatment, enhance surveillance, and improve the outcome of these patients has led to the development of new diagnostic modalities. Novel tools such as 18F-fluorodeoxyglucose PET/CT should aim at enhancing the clinician's ability to make critical decisions in treating difficult scenarios.

Lymph nodes: is total number or station number a better predictor of lymph node metastasis in endometrial cancer?

OBJECTIVE

Gynecologic oncologists have sought to define adequate lymphadenectomy. The purpose of this study is to determine the probability of detecting lymph node metastasis by lymph node count compared to number of nodal stations sampled.

METHODS

This is a clinicopathologic review of surgically staged endometrial carcinoma patients from 2000 to 2008. Information was extracted from patients' medical records. Student t-test, Wilcoxon rank sum test, Chi-square and Fisher exact tests were used. Elimination logistic regression was performed to identify independent significant predictors of lymph node metastasis. p<.05 was considered significant for all tests.

RESULTS

The study population consisted of 352 patients with a mean age of 65. Forty patients (11.36%) had lymph node metastasis. Number of nodes sampled was not associated with lymph node status on univariate analyses. Patients with lymph node metastases detected was increased when 8 or more nodal stations were sampled compared to less than 8 (19.4% vs. 9.8%, p=.04). More significance was seen when 9 or more stations were sampled (32% vs. 9.8%, p=.004). Multivariate logistic regression analysis, controlling for age, grade, depth of myometrial invasion, number of nodes sampled, and number of nodal stations sampled, found only grade (p=.002), depth of myometrial invasion (p<.0003), and sampling of 9 or more nodal stations (p=.03) to be independent predictors of node status.

CONCLUSIONS

Lymph node count did not accurately predict risk of lymph node metastasis. Number of nodal stations sampled was a more precise predictor of lymph node metastases.

Risk factors for postoperative lower-extremity lymphedema in endometrial cancer survivors who had treatment including lymphadenectomy

OBJECTIVE

The aim of this study was to determine the incidence rate of lower-extremity lymphedema after systematic lymphadenectomy in patients with uterine corpus malignancies and to elucidate risk factors for this type of lymphedema.

METHODS

A retrospective chart review was carried out for all patients with uterine corpus malignant tumor managed at Hokkaido Cancer Center between 1991 and 2007. Patients who did not undergo lymphadenectomy as a treatment or died of cancer/intercurrent disease were excluded from this study. All living patients included in this study had hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy and their medical records were reviewed. We identified patients with postoperative lower-extremity lymphedema (POLEL). Logistic regression analysis was used to select the risk factors for POLEL.

RESULTS

Of 286 patients evaluated, 103 (37.8%) had POLEL. Multivariate analysis confirmed that adjuvant radiation therapy (OR=5.2, 95% CI=2.1-12.7), resection of more than 31 lymph nodes (OR=2.6, 95% CI=1.4-4.9), and removal of circumflex iliac nodes to the distal external iliac nodes (CINDEIN) (OR=6.1, 95% CI=1.3-28.2) were independent risk factors for POLEL.

CONCLUSION

Adjuvant radiation therapy should be avoided in patients who undergo systematic lymphadenectomy if an alternative postoperative strategy is possible. Although reducing the number of resected lymph nodes is not appropriate from a therapeutical point of view, elimination of CINDEIN dissection may be helpful in reducing the incidence of POLEL. The clinical significance of CINDEIN dissection needs to be investigated by a randomized controlled trial.

Controversies in surgical staging of endometrial cancer

Endometrial cancer is the most common gynaecological malignancy and its incidence is increasing. In 1998, international federation of gynaecologists and obstetricians (FIGO) required a change from clinical to surgical staging in endometrial cancer, introducing pelvic and paraaortic lymphadenectomy. This staging requirement raised controversies around the importance of determining nodal status and impact of lymphadenectomy on outcomes. There is agreement about the prognostic value of lymphadenectomy, but its extent, therapeutic value, and benefits in terms of survival are still matter of debate, especially in early stages. Accurate preoperative risk stratification can guide to the appropriate type of surgery by selecting patients who benefit of lymphadenectomy. However, available preoperative and intraoperative investigations are not highly accurate methods to detect lymph nodes and a complete surgical staging remains the most precise method to evaluate extrauterine spread of the disease. Laparotomy has always been considered the standard approach for endometrial cancer surgical staging. Traditional and robotic-assisted laparoscopic techniques seem to provide equivalent results in terms of disease-free survival and overall survival compared to laparotomy. These minimally invasive approaches demonstrated additional benefits as shorter hospital stay, less use of pain killers, lower rate of complications and improved quality of life.

Controversies in the management of endometrial carcinoma

Endometrial carcinoma is the most common type of female genital tract malignancy. Although endometrial carcinoma is a low grade curable malignancy, the condition of the disease can range from excellent prognosis with high curability to aggressive disease with poor outcome. During the last 10 years many researches have provided some new valuable data of optimal treatments for endometrial carcinoma. Progression in diagnostic imaging, radiation delivery systems, and systemic therapies potentially can improve outcomes while minimizing morbidity. Firstly, total hysterectomy and bilateral salphingo-oophorectomy is the primary operative procedure. Pelvic lymhadenectomy is performed in most centers on therapeutic and prognostic grounds and to individualize adjuvant treatment. Women with endometrial carcinoma can be readily segregated intraoperatively into “low-risk” and “high-risk” groups to better identify those women who will most likely benefit from thorough lymphadenectomy. Secondly, adjuvant therapies have been proposed for women with endometrial carcinoma postoperatively. Postoperative irradiation is used to reduce pelvic and vaginal recurrences in high risk cases. Chemotherapy is emerging as an important treatment modality in advanced endometrial carcinoma. Meanwhile the availability of new hormonal and biological agents presents new opportunities for therapy.

[Endometrial cancer: survey of surgical practice in france in 2008]

OBJECTIVES

Endometrial cancer is the most common gynecologic malignancy. We aimed to assess the management of this disease among French surgeons as regards to the French guidelines.

MATERIALS AND METHODS

Six hundred questionnaires were given to surgeons during two national French Meetings in 2008. They focused on the surgeon (age, gender, center of work, number of treated cancers individually and in the center) and on the disease (initial work-up, surgical management). Three case reports related to endometrial cancer were proposed to assess the conformity of the French guidelines (two case reports about endometrioid carcinomas stages IB and II and one about serous papillary adenocarcinoma).

RESULTS

Nineteen percent of surgeons (n=114) answered the questionnaire. The French Guidelines were respected in less than 60 % in the answers of the three case reports (only 13.3 % of the answers were conformed in all the three cases). The surgeons who respected the recommendations took care of more than five treated patients per year (92.9 % versus 57.8 %, P=0.01), they were younger (41 year versus 49 years, P=0.01), and the post-graduation delay was shorter (9.1 versus 20.5 years, P=0.002). The center where the surgeon worked was not a determinant factor for treatment. The surgical procedures were mostly transverse laparotomy in 35.4 %. Peritoneal cytology and lymphadenectomy were provided in 69.9 % and 74.7 % of cases, respectively.

CONCLUSION

Despite the limits of our study based on volunteer answers of surgeons to a questionnaire, our results highlight the efforts of learned societies and medical authorities should be used to standardize the treatment of cancer. A reflection should be conducted on the basis of initial training and throughout a professional career to provide patients optimal care of their pathology.

Is lymphadenectomy a prognostic marker in endometrioid adenocarcinoma of the human endometrium?

Background

During surgery for endometrial cancer, a pelvic lymphadenectomy with or without para-aortic lymphadenectomy is performed at least in patients with risk factors (stage I, grading 2 and/or histological subtypes with higher risk of lymphatic spread), and is hence recommended by the International Federation of Obstetrics and Gynecology (FIGO). Although lymph node metastases are important prognostic parameters, it has been contentious whether a pelvic lymph node dissection itself has a prognostic impact in the treatment of endometrial cancer, especially in endometrioid adenocarcinoma. Therefore, this study evaluated whether lymphadenectomy has a prognostic impact in patients with endometrioid adenocarcinoma.

Methods

The benefits of lymphadenectomy were examined in 214 patients with a histological diagnosis of endometrial adenocarcinoma. Tumour characteristics were analysed with respect to the surgical and pathological stage.

Results

Of the 214 patients with endometrial adenocarcinoma, 171 (79.9%) were classified as FIGO stage I, 15 (7.0%) FIGO stage II, 21 (9.8%) FIGO stage III and 7 (3.3%) FIGO stage IV. One hundred and thirty four (62.6%) of the patients had a histological grade 1 tumour, while 56 (26.2%) and 24 (11.2%) had a histological grade 2 or grade 3 tumour, respectively. Lymphadenectomy was performed in 151 (70.6%) patients. Only 11 (5.1%) patients showed metastatic disease in the lymph nodes. The performance of a lymphadenectomy resulted in significantly increased cause-specific and overall survival, while progression-free survival was not affected by this operative procedure.

Conclusions

The performance of an operative lymphadenectomy resulted in better survival of patients with endometrioid adenocarcinoma. This increase was significant for cause-specific and overall survival, while there was a tendency only towards increased progression-free survival. Therefore, even in endometrioid adenocarcinoma, a pelvic and/or para-aortic lymphadenectomy should be performed.

The role of pelvic and/or para-aortic lymphadenectomy in surgical management of apparently early carcinosarcoma of uterus

AIMS

To determine the incidence of lymph node (LN) metastasis in patients with apparently early carcinosarcoma of the uterus, to analyze the clinicopathologic factors associated with LN metastasis, and to evaluate the role of pelvic and/or para-aortic lymphadenectomy in treatment of such conditions.

METHODS

We retrospectively analyzed 41 patients with carcinosarcoma intraoperatively confined to the uterus who underwent complete staging procedures including pelvic and/or para-aortic lymphadenectomy.

RESULTS

After surgery, two patients (4.9%) were upstaged to stage IIIA because of positive peritoneal washing cytology, and 13 (31.7%) were upstaged to stage IIIC as a result of LN metastasis. Five patients had pelvic, three had paraaortic, and five had both pelvic and para-aortic LN metastases. The mean number of metastatic LNs was 3.7 (range 1-15). On multivariate analysis, myometrial invasion >1/2 [odds ratio (OR) 8.50; 95% confidence interval (CI) 1.57-45.92; P = 0.013] and lymphovascular space invasion (LVSI) (OR 8.50; 95% CI 1.57-45.92; P = 0.013) were significantly predictive of LN metastasis. After a median follow-up interval of 32 months (range 3-179 months), the 2-year disease-free survival (DFS) and overall survival (OS) rates were 73% and 84%, respectively, and the 5-year DFS and OS rates were 73% and 69%, respectively. Patients with LVSI or LN metastasis had significantly poorer DFS and OS.

CONCLUSIONS

Pelvic and para-aortic lymphadenectomy should be performed in patients with apparently early carcinosarcoma of the uterus, especially in those with myometrial invasion >1/2 or LVSI.

Endometrial carcinoma: controversies in histopathological assessment of grade and tumour cell type

Histopathological assessment of tumour grade and cell type is central to the management of endometrial carcinoma, guiding the extent of surgery and the use of adjuvant radiation therapy and chemotherapy. Endometrioid carcinomas are usually low grade but high-grade examples are encountered, and they have a significantly worse prognosis, similar to that of high-grade subtypes such as serous and clear cell carcinoma. This article reviews the various grading systems that have been proposed for use with endometrioid endometrial carcinoma, and discusses the recent progress in cell type assignment, including the use of immunohistochemistry as a diagnostic adjunct.

Uterine papillary serous carcinoma: epidemiology, pathogenesis and management

PURPOSE OF REVIEW

Uterine papillary serous carcinoma (UPSC) is a rare but aggressive subtype of endometrial cancer. Although it represents only 10% of all endometrial cancer cases, UPSC accounts for up to 40% of all endometrial cancer-related recurrences and subsequent deaths. The present article reviews the literature concerning the epidemiology, molecular pathogenesis and recent updates on management of UPSC.

RECENT FINDINGS

Women most often present with postmenopausal vaginal bleeding but may also be diagnosed by vaginal cytology. In women diagnosed with metastatic disease, ascites, omental implants or a pelvic mass may be present. Pelvic and extrapelvic recurrences occur frequently, with extrapelvic relapses being observed most commonly. Although few prospective trials exist, several retrospective series have demonstrated that optimal cytoreduction and adjuvant platinum/taxane-based chemotherapy with or without radiotherapy appears to improve survival. In addition, another approach to UPSC management may lie in targeted therapy.

SUMMARY

Women diagnosed with UPSC should undergo comprehensive surgical staging and an attempt at optimal cytoreduction. Platinum/taxane-based adjuvant chemotherapy should be considered in the treatment of both early and advanced-stage patients. Careful long-term surveillance is indicated as many of these women will recur. Prospective studies are needed to define the optimal treatment regimens and to study the role of targeted therapies in UPSC.

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

BACKGROUND

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.

METHODS

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.

FINDINGS

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.

INTERPRETATION

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.

FUNDING

Japanese Foundation for Multidisciplinary Treatment of Cancer, and the Japan Society for the Promotion of Science.

Magnetic resonance lymphography in gynaecological malignancies

Following the submission of this article to Cancer Imaging, unfortunately the European manufacturer of ferumoxtran-10 (Guerbet) has withdrawn the product pending further phase III studies. This is secondary to the view of the Committee for Medicinal Products for Human Use that the phase III data did not provide adequate statistical demonstration of the product's efficacy.

Magnetic resonance lymphography holds much promise for the non-invasive evaluation of lymph nodes. The technique utilizes ultrasmall superparamagnetic particles of iron oxide and has been shown to be highly sensitive and specific in the diagnosis of malignant lymph nodes. This article reviews the technique and the performance of magnetic resonance lymphography in studies to date; alternative newer methods of nodal assessment such as fluorodeoxyglucose-positron emission tomography/computed tomography and diffusion-weighted magnetic resonance imaging are also discussed, with emphasis on gynaecological malignancies.

Vaginal brachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate risk (PORTEC-2): an open-label, non-inferiority, randomised trial

BACKGROUND

After surgery for intermediate-risk endometrial carcinoma, the vagina is the most frequent site of recurrence. This study established whether vaginal brachytherapy (VBT) is as effective as pelvic external beam radiotherapy (EBRT) in prevention of vaginal recurrence, with fewer adverse effects and improved quality of life.

METHODS

In this open-label, non-inferiority, randomised trial undertaken in 19 Dutch radiation oncology centres, 427 patients with stage I or IIA endometrial carcinoma with features of high-intermediate risk were randomly assigned by a computer-generated, biased coin minimisation procedure to pelvic EBRT (46 Gy in 23 fractions; n=214) or VBT (21 Gy high-dose rate in three fractions, or 30 Gy low-dose rate; n=213). All investigators were masked to the assignment of treatment group. The primary endpoint was vaginal recurrence. The predefined non-inferiority margin was an absolute difference of 6% in vaginal recurrence. Analysis was by intention to treat, with competing risk methods. The study is registered, number ISRCTN16228756.

FINDINGS

At median follow-up of 45 months (range 18-78), three vaginal recurrences had been diagnosed after VBT and four after EBRT. Estimated 5-year rates of vaginal recurrence were 1.8% (95% CI 0.6-5.9) for VBT and 1.6% (0.5-4.9) for EBRT (hazard ratio [HR] 0.78, 95% CI 0.17-3.49; p=0.74). 5-year rates of locoregional relapse (vaginal or pelvic recurrence, or both) were 5.1% (2.8-9.6) for VBT and 2.1% (0.8-5.8) for EBRT (HR 2.08, 0.71-6.09; p=0.17). 1.5% (0.5-4.5) versus 0.5% (0.1-3.4) of patients presented with isolated pelvic recurrence (HR 3.10, 0.32-29.9; p=0.30), and rates of distant metastases were similar (8.3% [5.1-13.4] vs 5.7% [3.3-9.9]; HR 1.32, 0.63-2.74; p=0.46). We recorded no differences in overall (84.8% [95% CI 79.3-90.3] vs 79.6% [71.2-88.0]; HR 1.17, 0.69-1.98; p=0.57) or disease-free survival (82.7% [76.9-88.6] vs 78.1% [69.7-86.5]; HR 1.09, 0.66-1.78; p=0.74). Rates of acute grade 1-2 gastrointestinal toxicity were significantly lower in the VBT group than in the EBRT group at completion of radiotherapy (12.6% [27/215] vs 53.8% [112/208]).

INTERPRETATION

VBT is effective in ensuring vaginal control, with fewer gastrointestinal toxic effects than with EBRT. VBT should be the adjuvant treatment of choice for patients with endometrial carcinoma of high-intermediate risk.

FUNDING

Dutch Cancer Society.

Systemic lymphadenectomy cannot be recommended for low-risk corpus cancer

Objective. The objective of this study is to ascertain whether omission of lymphadenectomy could be possible when uterine corpus cancer is considered low-risk based on intraoperative pathologic indicators. Patient and Methods. Between 1998 and 2007, a total of 83 patients with low risk corpus cancer (endometrioid type, grade 1 or 2, myometrial invasion <==50%, and no intraoperative evidence of macroscopic extrauterine spread, including pelvic and paraaortic lymph node swelling and adnexal metastasis) underwent the total abdominal hysterectomy and bilateral salpingo-oophorectomy without lymphadenectomy. A retrospective review of the medical records was performed, and the disease-free survival (DFS), overall survival (OS), peri- and postoperative morbidities and complications were evaluated. Results. The 5-year DFS rates and the 5-year OS rates were 97.6% and 98.8%, respectively. No patient presented postoperative leg lymphedema and deep venous thrombosis. Conclusion. Omission of lymphadenectomy did not worsen the DFS or OS. The present findings suggest that systemic lymphadenectomy could be omitted in low-risk endometrial carcinoma.

Lymph node dissection in the surgical management of atypical endometrial hyperplasia

OBJECTIVE

The aim of this study was to evaluate the effect of lymph node dissection in patients with atypical endometrial hyperplasia.

STUDY DESIGN

Patients undergoing surgical management of atypical endometrial hyperplasia during the study period were retrospectively identified. Clinical and pathologic information was analyzed.

RESULTS

Eighty-eight patients comprised our cohort. Median age was 54 years (range, 37-85 years). Sixty-seven patients had lymph node dissection at the time of surgery for atypical endometrial hyperplasia, whereas 21 did not. Twenty-five of 88 (28.4%) had endometrial carcinoma on final uterine pathology. Stages were as follows: 4 IA, 15 IB, 3 IC, 2 IIB, and 1 IIIC. Surgical outcomes were not statistically significant between staged and unstaged groups. Information from lymph node dissection influenced management decisions in 7 of the 25 (28%) cancer patients.

CONCLUSION

Lymph node dissection did not adversely affect surgical outcomes in patients with atypical endometrial hyperplasia. Because many of these patients have concurrent endometrial cancer, we recommend consideration of lymph node dissection in atypical endometrial hyperplasia patients undergoing definitive surgical treatment.

[Are there still contra-indications to laparoscopic treatment of endometrial carcinoma?]

Laparoscopic treatment is becoming a standard of care for early endometrial carcinoma. However, not all patients are suitable for this approach. A review of the current literature provides some arguments to differentiate absolute contra-indications from relative ones, for which, whenever possible, some options are suggested.

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.

Lymphadenectomy for the management of endometrial cancer

BACKGROUND

Endometrial carcinoma is the most common gynaecological cancer in western Europe and North America. Lymph node metastases can be found in approximately 10% of women who clinically have cancer confined to the womb prior to surgery and removal of all pelvic and para-aortic lymph nodes (lymphadenectomy) is widely advocated. Pelvic and para-aortic lymphadenectomy is part of the FIGO staging system for endometrial cancer. This recommendation is based on non-randomised controlled trials (RCTs) data that suggested improvement in survival following pelvic and para-aortic lymphadenectomy. However, treatment of pelvic lymph nodes may not confer a direct therapeutic benefit, other than allocating women to poorer prognosis groups. Furthermore, a systematic review and meta-analysis of RCTs of routine adjuvant radiotherapy to treat possible lymph node metastases in women with early-stage endometrial cancer, did not find a survival advantage. Surgical removal of pelvic and para-aortic lymph nodes has serious potential short and long-term sequelae and most women will not have positive lymph nodes. It is therefore important to establish the clinical value of a treatment with known morbidity.

OBJECTIVES

To evaluate the effectiveness and safety of lymphadenectomy for the management of endometrial cancer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2009. Cochrane Gynaecological Cancer Review Group Trials Register, MEDLINE (1966 to June 2009), Embase (1966 to June 2009). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

RCTs and quasi-RCTs that compared lymphadenectomy with no lymphadenectomy, in adult women diagnosed with endometrial cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Hazard ratios (HRs) for overall and progression-free survival and risk ratios (RRs) comparing adverse events in women who received lymphadenectomy or no lymphadenectomy were pooled in random effects meta-analyses.

MAIN RESULTS

Two RCTs met the inclusion criteria; they randomised 1945 women, and reported HRs for survival, adjusted for prognostic factors, based on 1851 women.Meta-analysis indicated no significant difference in overall and recurrence-free survival between women who received lymphadenectomy and those who received no lymphadenectomy (pooled HR = 1.07, 95% CI: 0.81 to 1.43 and HR = 1.23, 95% CI: 0.96 to 1.58 for overall and recurrence-free survival respectively).We found no statistically significant difference in risk of direct surgical morbidity between women who received lymphadenectomy and those who received no lymphadenectomy. However, women who received lymphadenectomy had a significantly higher risk of surgically related systemic morbidity and lymphoedema/lymphocyst formation than those who had no lymphadenectomy (RR = 3.72, 95% CI: 1.04 to 13.27 and RR = 8.39, 95% CI: 4.06, 17.33 for risk of surgically related systemic morbidity and lymphoedema/lymphocyst formation respectively).

AUTHORS' CONCLUSIONS

We found no evidence that lymphadenectomy decreases the risk of death or disease recurrence compared with no lymphadenectomy in women with presumed stage I disease. The evidence on serious adverse events suggests that women who receive lymphadenectomy are more likely to experience surgically related systemic morbidity or lymphoedema/lymphocyst formation.

The role of sentinel node biopsy in gynecological cancer: a review

PURPOSE OF REVIEW

In early-stage vulvar, cervical and endometrial cancer, lymph node status is the most important prognostic factor. Surgical treatment is aimed at removing the primary tumor and adequately staging the regional lymph nodes. As morbidity of regional lymphadenectomy is high, sentinel node biopsy is a technique with potential for adequate staging with less treatment-related morbidity. This manuscript reviews its current role in vulvar, cervical and endometrial cancer.

RECENT FINDINGS

In early-stage vulvar cancer, level 3 evidence indicates that it appears to be safe to omit inguinofemoral lymphadenectomy in case of a negative sentinel node. However, false-negative results with fatal consequences do occur and are often attributable to procedural failures. For early-stage cervical cancer, level 3 evidence points to an acceptable false-negative rate of a negative sentinel node; clinical utility and safety remain to be established. The optimal technique of the sentinel node biopsy in endometrial cancer is currently unclear.

SUMMARY

In early-stage vulvar cancer, data suggest that sentinel node biopsy could be offered as a treatment option instead of routine inguinofemoral lymphadenectomy. However, more (long-term follow-up) data are needed to further appreciate real clinical benefits. It is emphasized that the procedure should be performed by a skilled multidisciplinary team, centralized in oncology centers and preferably within the protection of clinical trials. For cervical cancer, data are promising, but routine application cannot be recommended due to lack of data on clinical utility and safety. For endometrial cancer, studies on the sentinel node biopsy are still in feasibility stage.