Surgical staging of uterine cancer: an analysis of perioperative morbidity

Recent management of endometrial cancer: a narrative review of the literature

Endometrial cancer is a common female gynecological neoplasia and its incidence rate has increased in the past years. Due to its predominant symptoms, most women will present uterine bleeding. It is usually diagnosed at an early stage and surgery has an important role in the treatment plan. The prognosis and quality of life of these patients can be quite favorable, if proper treatment is offered by surgeons. Traditionally, more invasive approaches and procedures were offered to these patients, but recent data suggest that more conservative and minimal invasive choices can be adopted in the treatment algorithm. Minimal invasive surgery, such as laparoscopy and robotic surgery, should be considered as an acceptable alternative, compared to laparotomy with less comorbidities and similar oncological and survival outcomes. Furthermore, sentinel lymph node biopsy has emerged in the surgical staging of endometrial cancer, in order to replace comprehensive lymphadenectomy. It is associated with less intra- and postoperative complications, while preliminary data show no difference in survival rates. However, sentinel lymph node biopsy should be offered within a strict algorithm, to avoid residual metastatic disease. The aim of this review is to analyze all the available data for the application of minimal invasive surgery in early endometrial cancer and especially the role of sentinel lymph node biopsy.

Predictive factors of preoperative sentinel lymph node detection in intermediate and high-risk endometrial cancer

BACKGROUND

In endometrial cancer (EC), sentinel lymph node (SLN) mapping has emerged as an alternative to systematic lymphadenectomy. Little is known about factors that might influence SLN preoperative detection. The aim of our study was to evaluate the clinical and technical variables that may influence on the success of SLN detection in preoperative lymphatic mapping in patients with intermediate and high-risk EC when performing transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR).

METHODS

Between March 2006 and March 2017, we prospectively enrolled patients with histologically confirmed EC with intermediate or high-risk of lymphatic involvement. All women underwent SLN detection by using TUMIR approach. After radiotracer injection, pelvic and abdominal planar and SPECT/CT images were acquired to obtain a preoperative lymphoscintigraphic mapping. Pattern of drainage was registered and analyzed to identify the factors directly involved in drainage. Sonographer learning curves to perform TUMIR approach were created following Cumulative Sum and Wright methods. Univariate and multivariate analyses were performed using logistic regression.

RESULTS

During study period, 123 patients were included. SLN preoperative detection rate was 70.7%. Age under 75 years at diagnosis (P<0.01), radiotracer injection above 4 mL -high-volume- (P<0.01), and tumoral size below 2 cm (P=0.04) were associated with higher SLN preoperative detection rate. Twenty-five procedures were necessary to attain an adequate performance in TUMIR approach.

CONCLUSIONS

The higher SLN preoperative detection rate in women with intermediate and high-risk endometrial cancer after TUMIR approach was related with younger age, smaller tumors and high-volume injection of radiotracer. Sonographers are required to perform 25 procedures before acquiring an expertise in radiotracer injection.

Improving locoregional outcome in high-intermediate-risk and high-risk stage I endometrial cancer with surgical staging followed by brachytherapy

Purpose

This study aims to assess the locoregional efficacy of postoperative vaginal brachytherapy (VBT) alone in patients undergoing surgical staging for early-stage high-intermediate-risk (HIR) and high-risk (HR) endometrial cancer.

Materials and Methods

One hundred and four patients with early-stage HIR and HR endometrial cancer who underwent surgical staging were treated with adjuvant VBT alone. The patients with stage Ib, grade I–III, stage Ia, grade III, lower uterine segment involvement, and lymphovascular invasion (LVI) were included to study.

Results

The 5- and 10-year overall survival (OS) rates were 87% and 76%, respectively. The 5- and 10-year DFS rates were 86% and 86%, respectively. Among the patients, 92% had endometrioid adenocarcinoma, 2% had undifferentiated carcinoma, 2% had serous papillary carcinoma, and 4% had clear-cell carcinoma. Of the patients, 63% had stage Ib disease, while 37% had stage Ia disease. None of the patients had vaginal or pelvic lymph node recurrence, whereas two had para-aortic lymph node metastasis, one had surgical scar recurrence, one had para-aortic lymph node and brain metastasis, and one had lung metastasis. The presence of lymphatic invasion was found to be a statistically significant prognostic factor for increased distant metastasis rates (p = 0.020). Lymphatic invasion was also regarded as an independent prognostic factor for metastasis-free survival (p = 0.044).

Conclusion

Our study results suggest that postoperative VBT alone is an effective and safe treatment modality with low complication in patients undergoing surgical staging for HIR and HR endometrial cancer.

Predictors for the Recurrence of Clinically Uterine-Confined Endometrial Cancer and the Role of Cytokeratin Immunohistochemistry Stain in the Era of Sentinel Lymph Node Mapping

Simple Summary

Sentinel lymph node (SLN) mapping in women with endometrial cancer is gradually gaining popularity worldwide. The objectives of this retrospective study were to elucidate the predictors for cancer recurrence in the era of SLN mapping, and to compare the clinical outcomes between SLN mapping and traditional lymphadenectomy, as well as to investigate the role of cytokeratin immunohistochemistry stain in detecting lymph node metastases. Para-aortic lymph node metastasis was found to be the sole predictor for cancer recurrence. Cytokeratin immunohistochemistry stain detects more lymph node metastases. In addition, both SLN mapping and traditional lymphadenectomy have similar probabilities of cancer recurrence.

Abstract

Background: The primary objective of this study was to elucidate the predictors for cancer recurrence in women with clinically uterine-confined endometrial cancer in the era of sentinel lymph node (SLN) mapping. Methods: All consecutive women with clinically determined uterine-confined endometrial cancer who had lymph node assessment by either SLN mapping or traditional pelvic lymphadenectomy were reviewed. Results: Women in the SLN mapping group had lower total dissected pelvic nodes, lower incidence of para-aortic lymph node dissection, less intraoperative blood loss and lower complication rates, but a longer operation time compared to the traditional lymphadenectomy group. Para-aortic lymph node metastasis (hazard ratio = 7.60, p = 0.03) was the sole independent predictor for recurrence-free survival. In addition, the utilization of cytokeratin immunohistochemistry stain detected more lymph node metastases (adjusted odds ratio = 3.04, p = 0.03). Recurrence-free survival did not differ between SLN mapping and traditional lymphadenectomy groups (p = 0.24). Conclusions: Para-aortic lymph node metastasis is an important predictor of cancer recurrence. Women with negative hematoxylin and eosin stain should undergo cytokeratin immunohistochemistry stain to increase the detection rate of positive lymph node metastasis. Besides, the probabilities of recurrence seem to be similar between SLN mapping and traditional lymphadenectomy groups in women with clinically uterine-confined endometrial cancer.

Role of Pelvic Lymphadenectomy in Intermediate-Risk Endometrial Cancer and Predictors of Nodal Positivity in Indian Patients

One of the most intense controversies in endometrial cancer revolves around the need for lymphadenectomy at the time staging. The study carried out to analyze the role of staging with pelvic lymphadenectomy in intermediate-risk stage I endometrial cancer-stage IA grade III and stage IB grades I and II. Review analysis of all the patients with stage I carcinoma endometrium intermediate risk treated at our institution between January 2006 and December 2014. All demographic data, tumor factors, adjuvant treatment, follow-up, and recurrence were recorded. Sixty-five were in intermediate-risk group, of which 21 were in low intermediate- and 44 in high intermediate-risk group, with 4 patients with positive pelvic node in each group. In patients with low intermediate-risk stage IA, grade III tumors, the nodal involvement was substantial even when the myometrial invasion was less than 50%. All grade 1 tumors did not have pelvic nodal metastasis. Overall percentage of pelvic nodal metastasis in our review of intermediate-risk carcinoma endometrium was 12%, with 19% in stage IA, grade III tumors, and 9% with stage IB, grade I and II tumors. A systematic lymphadenectomy should be done in patients with endometrial cancer who are at intermediate to high risk of lymph node metastases. The grade III histology is more likely to predict for nodal metastasis more than depth of myometrial invasion. It is recommended to stratify patients into risk groups to formulate guidelines for therapeutic lymphadenectomy.

Long term complications following pelvic and para-aortic lymphadenectomy for endometrial cancer, incidence and potential risk factors: a single institution experience

OBJECTIVE

To determine the incidence of long term lymphadenectomy complications in primary surgery for endometrial cancer and to elucidate risk factors for these complications.

METHODS

A retrospective chart review was carried out for all patients with endometrial cancer managed at Parma University Hospital Unit of Gynecology and Obstetrics between 2010 and 2016. Inclusion criteria were surgical procedure including hysterectomy and lymphadenectomy (pelvic or pelvic and aortic). We identified patients with postoperative lymphocele and lower extremity lymphedema. Logistic regression analysis was used to identify predictive factors for postoperative complications.

RESULTS

Of the 249 patients tested, 198 underwent pelvic lymphadenectomy (79.5%), and 51 (20.5%) of those underwent both pelvic and para-aortic lymphadenectomy. Among the 249 patients, 92 (36.9 %) developed lymphedema while 43 (17.3%) developed lymphocele. Multivariate analysis showed that addition of para-artic lymphadenectomy was an independent predictor for both lymphedema (odds ratio (OR) 2.764, 95% confidence interval (CI) 1.023 to 7.470) and lymphocele (OR 5.066, 95% CI 1.605 to 15.989). Moreover, postoperative adjuvant radiotherapy (OR 2.733, 95% CI 1.149 to 6.505) and identification of any positive lymph node (OR 19.391, 95% CI 1.486 to 253.0) were significantly correlated with lymphedema, while removal of circumflex iliac nodes (OR 8.596, 95% CI 1.144 to 65.591) was associated with lymphoceles occurrence.

CONCLUSION

Although sentinel lymph node navigation is a promising option, lymphadenectomy represents the primary treatment in many patients with endometrial cancer. However, comprehensive nodal dissection remains associated with a high rate of long term complications, such as lymphedema and lymphocele. Avoiding risk factors that are related to the development of these postoperative complications is often difficult and, therefore, the strategy to assess lymph nodal status in these women must be tailored to obtain the maximum results in terms of oncological and functional outcome.

A practical guide for the use of indocyanine green and methylene blue in fluorescence-guided abdominal surgery

Near-infrared (NIR) fluorescence imaging is gaining clinical acceptance over the last years and has been used for detection of lymph nodes, several tumor types, vital structures and tissue perfusion. This review focuses on NIR fluorescence imaging with indocyanine green and methylene blue for different clinical applications in abdominal surgery with an emphasis on oncology, based on a systematic literature search. Furthermore, practical information on doses, injection times, and intraoperative use are provided.

Trends in Sentinel Lymph Node Mapping and Adjuvant Therapy in Endometrial Carcinoma

We analyzed 54,039 women with uterine cancer in the National Cancer Database from 2013 to 2014 including 38,453 (71.2%) who underwent lymphadenectomy, 1929 (3.6%) who underwent sentinel lymph node (SLN) mapping, and 13,657 (25.3%) who did not undergo nodal assessment. SLN mapping increased from 2.8% in 2013 to 4.3% in 2014 (P < 0.001). Patients treated in 2014 and those at community centers were more likely to undergo SLN biopsy, while women with advanced-stage disease, sarcomas, and grade 3 tumors were less likely to undergo SLN mapping (P < 0.05). There was no association between use of SLN biopsy and use of radiation (aRR = 0.92; 95% CI, 0.82-1.05).

Low-Volume Lymph Node Metastases in Endometrial Carcinoma

Objective

The aim of this study was to determine the histopathologic characteristics of patients with endometrial carcinoma with low-volume metastases (micrometastases and isolated tumor cells) compared with macrometastases.

Methods

We performed a retrospective review of patients with endometrial carcinoma.

Results

Among 350 robotic-assisted hysterectomies for endometrial cancer, 187 (53%) underwent attempted sentinel lymph node (SLN) biopsy. At least 1 SLN was detected in 185, a 99% overall detection rate; 108 (58%) also had non-SLNs removed. Among 91 patients with SLNs and non-SLNs from the ipsilateral hemipelvis, both were negative in 74 (81%) and positive in 7 (8%), and 10 (11%) had a positive SLN with negative non-SLNs. Among 17 patients with SLNs and non-SLNs from the contralateral hemipelvis, both were negative in 12 (71%), both were positive in 3 (18%), and 2 patients (12%) had negative SLNs with contralateral positive non-SLNs. Among 79 patients with only a SLN dissection, 4 (5%) were positive; among 69 patients with only a non-SLN dissection, 14 (20%) had positive lymph nodes. Among 24 patients with metastatic SLNs, 9 (38%) had isolated tumor cells, 3 (13%) had micrometastases, and 12 (50%) had macrometastases. Among the 40 total patients with metastatic lymph nodes, low-volume metastases represented the largest metastatic deposit in one third of patients, all of which had SLN dissection. All 12 with low-volume metastases had endometrioid histology compared with less than half (46%) of those with macrometastases (P < 0.01). Grade 1 carcinoma was present in 7 (58%) of the patients with low-volume metastases compared with 4 (14%) of those with macrometastases (P < 0.01) Furthermore, significantly more patients with low-volume metastases versus macrometastases had less than 50% myometrial invasion (67% vs 4%, P < 0.001).

Conclusions

Low-volume disease was present in one third of patients with nodal metastases, the largest metastatic deposit only in patients who had SLN dissection; these patients were significantly more likely to have grade 1 endometrioid carcinoma with less than 50% myometrial invasion, traditional “low-risk” features.

Feasibility of a reduced field-of-view diffusion-weighted (rFOV) sequence in assessment of myometrial invasion in patients with clinical FIGO stage I endometrial cancer

PURPOSE

To compare the clinical usefulness of reduced field-of-view diffusion-weighted imaging (rFOV) with other imaging techniques in determining the depth of myometrial invasion (DMI) in endometrial cancer.

MATERIALS AND METHODS

In this prospective study we reviewed 3T magnetic resonance images of 51 patients with clinical Stage I endometrial cancer who underwent total abdominal hysterectomy with bilateral salphingoopherectomy within 3 days after imaging. rFOV with apparent diffusion coefficient reconstruction was obtained in three standard planes followed by sagittal T2 -weighted (T2 WI) images and 3D dynamic T1 -weighted and contrast-enhanced imaging (DCE MRI). Two radiologists with expertise in imaging gynecologic cancers evaluated images independently. The DMI was recorded on imaging and correlated with surgical pathology results. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for DMI were calculated (<50% vs. >50%).

RESULTS

Compared with sagittal T2 WI + DCE MRI, rFOV imaging yielded greater specificity (82.2% vs. 90.0%, positive predictive value (42.8% vs. 60.0%), and accuracy (84.0% vs. 92%) for DMI determined by reader 1 and greater the sensitivity (83.3% vs. 100%) for DMI determined by reader 2. The error of measurement of DMI as a continuous variable in millimeters did not differ significantly between the rFOV and pathology results (P < 0.21). However, there was a statistically significant difference for the DMI measured on the dynamic sequence. The DMI on DCE was greater than that seen on pathology at P = 0.02.

CONCLUSION

rFOV can be used to assess DMI in clinical Stage I endometrial cancer.

The Added Value of SPECT/CT in Sentinel Lymph Nodes Mapping for Endometrial Carcinoma

OBJECTIVES

This study was designed to evaluate the detection rate (DR) and sensitivity of sentinel lymph node (SLN) mapping in patients with endometrial cancer using TC99m colloid and blue dye and to evaluate the contribution of preoperative planar lymphoscintigraphy (PLSG) and SPECT/CT.

METHODS

A retrospective analysis of patients who underwent SLN mapping as part of their primary surgery for endometrial cancer. Patients underwent preoperative PLSG and later with additional SPECT/CT. Intraoperative detection was performed using TC99m colloid and blue dye by cervical injections. SLNs were sent separately for pathologic evaluation with ultrastaging.

RESULTS

Fifty-three patients were included in this study. Successful preoperative mapping was achieved in 31 of 37 patients (84 %) who underwent SPECT/CT compared with only 30 of 45 patients (67 %) who underwent PLSG. SPECT/CT localizations of SLNs were anatomically accurate in 91 % of cases. Intraoperative DR of at least one SLN was 77 %, whilst the bilateral DR was 49 %. DR was significantly better using combined blue dye and TC99m colloid injections compared with blue dye alone: 81 versus 57 % for unilateral and 54 versus 28 % for bilateral mapping (P = 0.01, 0.009, respectively). Six cases of nodal metastasis were diagnosed: four by positive SLNs, and two cases were diagnosed using side-specific full dissection according to the SLN algorithm when SLN detection failed. There were no cases of false-negative results.

CONCLUSIONS

SLN detection using cervical injections of TC99m colloid and blue dye is feasible and sensitive for patients with endometrial cancer. SPECT/CT aids to accurate locating of the SLN.

Staging for endometrial cancer: The controversy around lymphadenectomy - Can this be resolved?

Endometrial cancer remains the most common malignancy of the female genital tract. Lymph node metastasis is one of the most important prognostic factors, and stratification into pelvic lymph node invasion (stage IIIC1) and para-aortic lymph node invasion (stage IIIC2) improved the predictive value of the 2009 International Federation of Gynecology and Obstetrics (FIGO) classification. Radiological examination methods such as magnetic resonance imaging and positron emission tomography-computed tomography do not have good-enough sensitivity to avoid lymphadenectomy for the assessment of lymph node invasion. Prediction scores are becoming increasingly valuable to exclude lymph node metastasis in low-risk groups, and biomarkers could help to identify patients with high-risk lymph node metastatic probability. The therapeutic role of lymph node dissection remains a matter of debate. Several end points can be considered to evaluate the opportunity of lymphadenectomy in endometrial cancer. First, we compare survival according to the realization, the extent, and the numbers of nodes removed during lymphadenectomy. Second, we assess the opportunity of lymphadenectomy in order to tailor adjuvant treatment modalities. Third, we analyze the surgical complication rate after pelvic lymphadenectomy.

Recent progress in the treatment and prevention of cancer-related lymphedema

This article provides an overview of the recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema. Lymphedema incidence by tumor site is evaluated. Measurement techniques and trends in patient education and treatment are also summarized to include current trends in therapeutic and surgical treatment options as well as longer-term management. Finally, an overview of the policies related to insurance coverage and reimbursement will give the clinician an overview of important trends in the diagnosis, treatment, and management of cancer-related lymphedema.

A comparison of colorimetric versus fluorometric sentinel lymph node mapping during robotic surgery for endometrial cancer

OBJECTIVE

The study objective was to compare the ability to detect sentinel lymph nodes (SLNs) in women with endometrial cancer (EC) or complex atypical hyperplasia (CAH) using fluorometric imaging with indocyanine green (ICG) versus colorimetric imaging with isosulfan blue (ISB).

METHODS

Women underwent SLN mapping, with either ISB or ICG, during robotic-assisted total laparoscopic hysterectomy (RA-TLH) from September 2012 to March 2014. SLNs were submitted for permanent pathologic analysis. Completion lymphadenectomy and ultrastaging were performed according to institutional protocols.

RESULTS

RA-TLH and SLN mapping was performed in 71 women; 64 had EC (64) and 7 had CAH. Age, body mass index (BMI), stage and tumor characteristics were similar in the ICG versus the ISB cohorts. Overall, SLNs were identified bilaterally (62.0%), unilaterally (21.1%), or neither (16.9%), and in 103 of 142 hemi-pelvises (72.5%). The mean number of SLNs retrieved per hemipelvis was 2.23(SD 1.7). SLNs were identified in the hypogastric (76.8%), external iliac (14.2%), common iliac (4.5%) and paraaortic (4.5%) regions. ICG mapped bilaterally in 78.9% of women compared with 42.4% of those injected with ISB (p=0.02). Five women (7%) had positive lymph nodes, all identified by the SLN protocol (false negative rate: 0%). On multivariate analysis, BMI was negatively correlated with bilateral mapping success (p=0.02). When stratified by dye type, the association with BMI was only significant for ISB (p=0.03).

CONCLUSIONS

Fluorescence imaging with ICG may be superior to colorimetric imaging with ISB in women undergoing SLN mapping for endometrial cancer. SLN mapping success is negatively associated with increasing patient BMI only when ISB is used.

Factors affecting sonographic preoperative local staging of endometrial cancer

OBJECTIVES

To identify major factors in the under- and overestimation of cervical and myometrial invasion by endometrial cancer at preoperative staging by ultrasound.

METHODS

This prospective study involved all patients with histologically confirmed endometrial cancer referred consecutively for surgical staging between January 2009 and December 2011. All patients underwent transvaginal ultrasound examination, obtaining metric and perfusion data, and the results were compared with final histology: myometrial invasion was defined at histology in the final pathology report as being either < or ≥ 50%, while cervical stromal invasion was reported as being either present or absent, and sonographic over-/underestimation was determined relative to these.

RESULTS

Enrolled prospectively into the study were 210 patients. The proportion of cases with sonographic underestimation, relative to final histology, of myometrial invasion (i.e. false-negative estimation of no or superficial invasion < 50%) and of cervical invasion (i.e. false-negative finding of absence of stromal invasion) was comparable: 8.6% (n = 18) and 10.5% (n = 22), respectively. Myometrial invasion was overestimated by ultrasound (i.e. false-positive estimation of deep invasion ≥ 50%) in 15.7% (n = 33) of cases, and cervical invasion was overestimated (i.e. false-positive finding of presence of stromal invasion) in 4.8% (n = 10) of cases. These outcomes correspond to positive and negative predictive values of 67.6% (95% CI, 57.7-76.6) and 83.3% (95% CI, 74.9-89.8), respectively, for the subjective assessment of myometrial invasion, and 60.0% (95% CI, 38.2-79.2) and 88.1% (95% CI, 82.5-92.4), respectively, for that of cervical stromal invasion. The staging error in subjective assessment was not related to body mass index (BMI), to the position of the uterus in the pelvis or to image quality. Cervical and myometrial invasion were more often underestimated in well-differentiated endometrial cancers that were smaller in size, with thick minimum tumor-free myometrium and lower perfusion, and more often overestimated in moderately and poorly differentiated cancers that were larger in size, with thin minimum tumor-free myometrium and richer perfusion.

CONCLUSION

The accuracy of subjective assessment of myometrial and cervical invasion by ultrasound was significantly influenced by tumor size, density of tumor vascularization, tumor vessel architecture and histological grading, while it was not significantly affected by BMI, uterine position and image quality.

Lymphocele Prevention After Pelvic Laparoscopic Lymphadenectomy by a Collagen Patch Coated With Human Coagulation Factors: A Matched Case-Control Study

Objective

Lymphoceles are among the most common postoperative complications of pelvic lymphadenectomy (PL), with a reported incidence of 1% to 50%. Symptoms are pelvic pain, leg edema, gastrointestinal obstruction, obstructive uropathy, and deep vein thrombosis, and severe complications such as sepsis and lymphatic fistula formation. After laparoscopic PL, we tested the prevention of lymphoceles using collagen patch coated with the human coagulation factors (TachoSil, Nycomed International Management GmbH, Zurich, Switzerland) on 55 patients with endometrial cancer stages IB to II who had undergone laparoscopy.

Materials and Methods

The authors divided the patients into 2 laparoscopy groups: PL plus TachoSil (group 1: 26 patients) and PL without TachoSil in a control group (group 2: 29 patients), as historical cohort of patients who underwent PL between 2010 and 2012. We collected surgical parameters, and the patients underwent ultrasound examination on postoperative days 7, 14, and 28. The main outcome measures were the development of symptomatic or asymptomatic lymphoceles, the need for further surgical intervention, as adverse effect of surgery, and the drainage volume and duration.

Results

The same number of lymph nodes in both groups was removed; group 1 showed a lower drainage volume. Lymphoceles developed in 5 patients in group 1 and in 15 patients in group 2; of these, only 2 patients were symptomatic in group 1 and 5 patients were symptomatic in group 2, without statistical difference and no percutaneous drainage request.

Conclusions

In this preliminary investigation, the intraoperative laparoscopy application of TachoSil seems to reduce the rate of postoperative lymphoceles after PL, providing a useful additional treatment option for reducing drainage volume and preventing lymphocele development after PL.

The role of para-aortic lymphadenectomy in the surgical staging of women with intermediate and high-risk endometrial adenocarcinomas

Objectives. To characterize clinical outcomes in patients with intermediate or high-risk endometrial carcinoma who underwent surgical staging with or without para-aortic lymphadenectomy. Methods. This is a retrospective cohort study of patients with intermediate or high-risk endometrial adenocarcinoma who underwent surgical staging with (PPALN group) or without (PLN) para-aortic lymphadenectomy. Data were collected, Kaplan-Meier curves were generated, and univariate and multivariate analyses performed to compare differences in adjuvant therapy, disease recurrence, disease-free survival (DFS), and overall survival (OS). Results. 118 patients were included in the PPALN group and 139 in the PLN group. Patients in the PPALN group were more likely to receive adjuvant vaginal brachytherapy (25.4% versus 11.5%, OR = 2.5, P = 0.03) and less likely to receive adjuvant multimodal combination therapy (17.81% versus 28.8%, OR = 0.28, P = 0.002). DFS was improved in the PLN group as compared to PPALN (80% versus 62%, P = 0.02). OS was equivalent (P = 0.93). Patients in the PPALN group who had less than 10 para-aortic nodes removed were twice as likely to recur than patients who had 10 or more para-aortic nodes or patients in the PLN group (HR 2.08, CI 1.20–3.60, P = 0.009). Conclusions. Patients in the PLN group were more likely to receive multimodal adjuvant therapy and had better DFS than the PPALN group. Pelvic lymphadenectomy followed by adjuvant radiation and chemotherapy may represent an effective treatment option for patients with intermediate or high-risk disease. If systematic para-aortic lymphadenectomy is performed and less than 10 para-aortic lymph nodes are obtained, multimodality adjuvant therapy should be considered to improve DFS.

Endometrial cancer

Despite the questions and barriers, the incorporation of molecular therapy into treatment regimens in endometrial cancer is an exciting area of investigation with the potential to improve outcomes. Outside of the development of a reliable screening test for endometrial cancer, converting the disease to a chronic state and improving progression-free survival is our best hope to reverse the concerning trend of decreasing 5-year survival for this disease.

Prospective assessment of survival, morbidity, and cost associated with lymphadenectomy in low-risk endometrial cancer

OBJECTIVE

Since 1999, patients with low risk endometrial cancer (EC) as defined by the Mayo criteria have preferably not undergone lymphadenectomy (LND) at our institution. Here we prospectively assess survival, sites of recurrence, morbidity, and cost in this low risk cohort.

METHODS

Cause-specific survival (CSS) was estimated using the Kaplan-Meier method and compared using the log-rank test. Complications were graded per the Accordion Classification. Thirty-day cost analyses were expressed in 2010 Medicare dollars.

RESULTS

Among 1393 consecutive surgically managed cases, 385 (27.6%) met inclusion criteria, accounting for 34.1% of type I EC. There were 80 LND and 305 non-LND cases. Complications in the first 30 days were significantly more common in the LND cohort (37.5% vs. 19.3%; P<0.001). The prevalence of lymph node metastasis was 0.3% (1/385). Over a median follow-up of 5.4 years only 5 of 31 deaths were due to disease. The 5-year CSS in LND and non-LND cases was 97.3% and 99.0%, respectively (P=0.32). None of the 11 total recurrences occurred in the pelvic or para-aortic nodal areas. Median 30-day cost of care was $15,678 for LND cases compared to $11,028 for non-LND cases (P<0.001). The estimated cost per up-staged low-risk case was $327,866 to $439,990, adding an additional $1,418,189 if all 305 non-LND cases had undergone LND.

CONCLUSION

Lymphadenectomy dramatically increases morbidity and cost of care without discernible benefits in low-risk EC as defined by the Mayo criteria. In these low-risk patients, hysterectomy with salpingo-oophorectomy alone is appropriate surgical management and should be standard of care.

The role of lymphadenectomy in surgical staging of endometrial cancer

Surgical staging, including lymph node sampling, for endometrial cancer was adopted by the International Federation of Gynecology and Obstetrics (FIGO) in 1988 based on reports demonstrating diagnostic and therapeutic advantages. This review focuses on the incidence of lymph node metastasis, risk factors for lymph node involvement, the effect of lymph node metastasis on prognosis, the therapeutic effect and diagnostic usefulness of lymphadenectomy, risks of lymph node dissection, and future directions in surgical staging of endometrial cancer. Surgical staging identifies most patients with extrauterine disease as well as uterine risk factors for recurrence, thereby allowing for a more informed approach to postoperative adjuvant therapy. Lymphadenectomy as a part of surgical staging is not required in patients assessed intraoperatively to be at low risk for lymph node metastasis (<2 cm grade 1 tumors with superficial myometrial invasion), however, a systematic lymph node dissection should be performed in most other patients with endometrial cancer. In the future, molecular markers may be useful to predict preoperatively tumor aggressiveness and lymph node metastasis. It is hoped that an approach of surgical staging with selective lymph node dissection will improve survival and spare patients additional surgical complications or unnecessary postoperative exposure to radiation and/or chemotherapy.

[Current position of the sentinel lymph node procedure in endometrial cancer]

Lymph node status is a major prognostic element in endometrial cancer and affects the choice of adjuvant therapy. The sentinel lymph node (SLN) procedure is proposed as an alternative to lymphadenectomy. This review aims to assess its feasibility. To this end, 19 studies have been analysed. It appears that double detection (colorimetric and isotopic) is better than single detection, independent of injection site. Hysteroscopic injection is technically more difficult, yet can be done near the tumoral lesion. The cervical site does not accurately reflect the lymphatic drainage of the uterine body but is easier to access. SLN detection rate is notably identical between these two injections sites. Lomboaortic detection rate is lower for cervical injections than for endometrial ones. The myometrial site is also difficult to access (intraoperatively), due to same limitations as the hysteroscopic route, and can be deceiving (insufficient detection rate and high false-negative rate). The SLN allows for ultrastadification (micrometastases and isolated tumoral cells) with the development of new pathological techniques (serial sections and immunohistochemistry). Data on SLN in endometrial cancer is very heterogeneous in terms of methodology and populations studied. Despite being well-known, the SLN procedure in endometrial cancer remains in its feasibility stage. Its place in therapeutic strategies needs to be further explored and its potential benefit remains to be confirmed.

Lymphedema beyond breast cancer: a systematic review and meta-analysis of cancer-related secondary lymphedema

BACKGROUND

Secondary lymphedema is a debilitating, chronic, progressive condition that commonly occurs after the treatment of breast cancer. The purpose of the current study was to perform a systematic review and meta-analysis of the oncology-related literature excluding breast cancer to derive estimates of lymphedema incidence and to identify potential risk factors among various malignancies.

METHODS

The authors systematically reviewed 3 major medical indices (MEDLINE, Cochrane Library databases, and Scopus) to identify studies (1972-2008) that included a prospective assessment of lymphedema after cancer treatment. Studies were categorized according to malignancy, and data included treatment, complications, lymphedema measurement criteria, lymphedema incidence, and follow-up interval. A quality assessment of individual studies was performed using established criteria for systematic reviews. Bayesian meta-analytic techniques were applied to derive summary estimates when sufficient data were available.

RESULTS

A total of 47 studies (7779 cancer survivors) met inclusion criteria: melanoma (n = 15), gynecologic malignancies (n = 22), genitourinary cancers (n = 8), head/neck cancers (n = 1), and sarcomas (n = 1). The overall incidence of lymphedema was 15.5% and varied by malignancy (P < .001): melanoma, 16% (upper extremity, 5%; lower extremity, 28%); gynecologic, 20%; genitourinary, 10%; head/neck, 4%; and sarcoma, 30%. Increased lymphedema risk was also noted for patients undergoing pelvic dissections (22%) and radiation therapy (31%). Objective measurement methods and longer follow-up were both associated with increased lymphedema incidence.

CONCLUSIONS

Lymphedema is a common condition affecting cancer survivors with various malignancies. The incidence of lymphedema is related to the type and extent of treatment, anatomic location, heterogeneity of assessment methods, and length of follow-up.

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

Introduction:

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.

Methods:

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.

Results:

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%).

Conclusions:

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.

[Current indications of lymphadenectomy in endometrial cancer]

Endometrial cancer is a tumor associated with a good prognosis as it is often diagnosed at an early stage. Up to 20 % of patients with stage I disease have a nodal involvement. Knowledge of nodal status provides important prognostic information. As preoperative assessment yields a poor value, prognostic lymphadenectomy appears to be indicated. However, therapeutic benefit of pelvic and para-aortic lymphadenectomy remains controversial. Recent randomized trials did not find any impact on survival for patients with low risk of nodal involvement. Thus, lymphadenectomy should no more be systematically performed in this low risk group. Nevertheless, pelvic and para-aortic lymphadenectomy seems to have a benefit in the high risk group, as isolated involved para-aortic nodes have been described.

Clinical value of immunohistochemically detected lymphatic and vascular invasions in clinically staged endometrioid endometrial cancer

BACKGROUND

A novel technique to differentiate lymphatic from vascular invasion and to assess the clinicopathological significance in patients with early endometrial cancer.

METHODS

Dual immunohistochemical techniques against pancytokeratin epithelial cell marker (PCK), D6 lymphatic endothelial marker, and CD31 nonspecific endothelial marker were deployed for differentiation. Seventy-seven patients were included with a median follow-up of 161 months. Tumors with positive evidence of lymphovascular space invasion on PCK-CD31 immunohistochemistry and absence of lymphatic space invasion on PCK-D6 were regarded as cases with vascular space invasion only.

RESULTS

Significant association between depth of myometrial invasion, recurrence rate, and hematoxylin and eosin that detected lymphovascular space invasion were noted (P < 0.0001 and P = 0.009, respectively). The 5-year recurrence-free survival was 45% for the group with hematoxylin and eosin evidence of lymphovascular space invasion compared with 89% for the group without (P = 0.0014). Pancytokeratin epithelial cell marker-D6 dual immunostaining detected lymphatic space invasion in 22 (29%) patients. There was significant association between lymphatic space invasion and depth of myometrial invasion (P = 0.046). Lymphatic space invasion detected on immunohistochemistry was present in 8 (72%) of 11 patients with recurrent disease. Of the remaining 49 patients with no evidence of recurrent disease, only 11 (22%) had presented with lymphatic space invasion. Positive association between tumor recurrence rate and lymphatic space invasion was noted (P = 0.003). The 5-year recurrence-free survival was 53% for the group with lymphatic invasion compared with 93% for the group without. This difference was similarly shown to be of significance (P = 0.0009). There were no apparent association between immunohistochemically detected lymphovascular or vascular space invasion and any clinicopathological factor.

CONCLUSIONS

Lymphatic space invasion detected by using dual immunostaining is of significant value in identifying high-risk patients.

Lymphatic mapping in endometrial cancer: a literature review of current techniques and results

The objective of this study was to review available literature pertaining to lymphatic mapping in endometrial cancer. We reviewed all published series of lymphatic mapping in endometrial cancer available through a PubMed search. Techniques used for identification of sentinel lymph nodes fell into three main categories in relation to the site of injection: 1) uterine subserosal, 2) cervical, and 3) endometrial via hysteroscopy. High detection rates may be achieved in all three categories. The use of both radiolabeled technetium and blue dye has been reported. A combination of cervical and uterine corpus injections appears feasible and less technically demanding than hysteroscopic injections. Immunohistochemistry staining of sentinel nodes coupled with step-serial section may improve the detection of micrometastasis in sentinel nodes. Meaningful sensitivity and false-negative rates cannot be calculated from current series due to their small numbers. The role of lymphatic mapping in endometrial carcinoma and the optimal injection site remains to be determined. A combination of cervical and uterine fundal injections may result in acceptable detection rates. Large-scale validation trials requiring complete pelvic and para-aortic lymphadenectomy are needed to evaluate its role in future clinical practice.

Is common iliac lymph node dissection necessary in early stage cervical carcinoma?

OBJECTIVES

Nodal metastasis is one of the most important prognostic factors in early stage cervical carcinoma and has an immense impact on the subsequent management. Thus, searching for nodal metastasis by pelvic lymphadenectomy is an integral part in the surgical management of cervical carcinoma. Complete nodal clearance of lymphatic tissue up to 2 cm above the bifurcation of common iliac vessels is therefore performed as a routine in our unit. The aim of this study is to investigate the incidence and pattern of pelvic lymph node metastases in patients with early stage cervical carcinoma to determine the role of common iliac node dissection in the surgery.

METHODS

We retrospectively reviewed 174 operation and histopathology reports of patients who underwent pelvic lymphadenectomy because of stage IA2 to IIA cervical carcinoma. Lymph nodes collected below and above the bifurcation of common iliac vessels were labeled as pelvic nodes and common iliac nodes, respectively. The incidence and distribution of nodal metastases were analyzed.

RESULTS

Complete and selective pelvic lymphadenectomy was performed in 163 and 11 patients, respectively. Nodal metastasis was documented in 35 (20.1%) patients. Pelvic and common iliac nodes were involved in 34 and 8 cases, respectively. All except one patient with common iliac node metastases were also found to have pelvic node metastasis.

CONCLUSIONS

In early stage cervical carcinoma, isolated common iliac lymph node metastasis is rare, especially in cases without associated high risk factors. Less extensive pelvic lymphadenectomy may be considered in these patients in order to reduce operation morbidity and time.

Imaging of endometrial adenocarcinoma

Endometrial cancer is the most common gynaecological malignancy and the incidence rising. Prognosis depends on age of patient, histological grade, depth of myometrial invasion and cervical invasion and lymph node metastases. Myometrial invasion and accurate cervical involvement cannot be predicted clinically. Pre-treatment knowledge of these criteria is advantageous in order to plan treatment. The clinical challenge is to effectively select patients at risk of relapse for more radical treatment whilst avoiding over treating low risk cases. This is important as endometrial cancer predominately occurs in postmenopausal women with co-morbidities. Modern imaging provides important tools in the accurate pre-treatment assessment of endometrial cancer and may optimize treatment planning. However, there is little consensus to date on imaging in the routine preoperative assessment of endometrial carcinoma and practice varies amongst many gynaecologists. Transvaginal ultrasound is often the initial imaging examination for women with uterine bleeding. However, once the diagnosis of endometrial cancer has been made, contrast-enhanced magnetic resonance imaging (MRI) provides the best assessment of the disease. The results of contrast-enhanced MRI may identify patients who need more aggressive therapy and referral to a cancer centre. In this article we review the role of imaging in the diagnosis and staging/preoperative assessment of endometrial carcinoma.

Risk factors for early and late postoperative complications of patients with endometrial cancer

OBJECTIVE

We have routinely performed staging with pelvic and/or paraaortic lymphadenectomy in patients with endometrial cancer having moderate to high risk for lymph node metastasis. The aim of this study was to investigate the risk factors for the occurrence of early and late postoperative complications in patients managed primarily by surgery in our institution.

STUDY DESIGN

Two-hundred and fifty-nine consecutive cases of endometrial cancer were enrolled in the study. Past history, body mass index, type of surgery, intraoperative findings, and follow-up information were collected from patient charts. Of these, 200, 127, and 30 patients underwent systematic pelvic lymphadenectomy, systematic paraaortic lymphadenectomy, and radical hysterectomy, respectively. The median numbers of dissected pelvic and paraaortic lymph nodes were 32 and 14, respectively.

RESULTS

None of the complications resulted in death. Of the study population, 36 early complications and 34 late complications occurred. Overall 65 patients (25.1%) had at least one complication. Multivariate analysis revealed that a longer operative time and paraaortic lymphadenectomy were independent predictors for the occurrence of early and late postoperative complications, respectively.

CONCLUSIONS

Since the therapeutic value of lymphadenectomy is still under evaluation, the indications for systematic pelvic and paraaortic lymphadenectomy should be carefully considered.

Sentinel Node Mapping With Isosulfan Blue Dye in Endometrial Cancer

OBJECTIVE

To determine the feasibility of sentinel node mapping in endometrial cancer using hysteroscopic injection of isosulfan blue dye.

METHODS

Sixteen patients with endometrial cancer were enrolled in this pilot study. Hysteroscopy was performed at laparotomy to locate the tumour. Isosulfan blue dye was injected into the endomyometrium around the tumour by hysteroscopy, into the serosa overlying the tumour, or both. Blue lymph nodes were removed as sentinel nodes. Pelvic lymphadenectomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy were then performed.

RESULTS

Dye uptake into lymphatics occurred in 13 of the 16 cases (81%). Blue lymph nodes were identified in five cases with serosal injection alone (56%) and in two cases with combined serosal and hysteroscopic injection (50%). No blue lymph nodes were identified with hysteroscopic injection alone. The overall sentinel node identification rate was 44%, and the negative predictive value was 86%.

CONCLUSION

Although the concept of sentinel node mapping in endometrial cancer is appealing, the technique of hysteroscopic injection of isosulfan blue dye alone had minimal success in this study. Alternative methods should be explored.

Hysterectomy for gynaecological cancer: a follow-up study of subjective and objective outcome

AIMS

To evaluate morbidity and subjective outcome associated with hysterectomy either with or without pelvic or pelvic and para-aortic lymphadenectomy for gynaecological cancer.

METHODS

Ninety-nine patients who underwent hysterectomy with lymphadenectomy (n = 38) or simple hysterectomy (n = 61) for ovarian, endometrial and cervical cancer in Turku University Hospital, Turku, Finland, were followed-up prospectively to determine the incidence of complications during a 1-year period after operation. Subjective outcomes were assessed using two questionnaires, 6 weeks and 1 year after operation. Hospital records of the patients were reviewed up to 6 years after operation.

RESULTS

During their hospital stay 58% of patients in the hysterectomy with lymphadenectomy group and 56% in the simple hysterectomy group experienced some type of complication. Serious complications occurred in four patients (10.5%) in the former group and in two patients (3.3%) in the latter group. In the study population overall, the incidence of subjective complaints increased from 18% of respondents 6 weeks after operation to 55% 1 year after operation. Most patients (95 and 92%, respectively) remained satisfied with the operation at both times of evaluation.

CONCLUSIONS

More than half of the patients experienced morbidity related to surgical treatment for gynaecological cancer. The incidence of complications and subjective complaints were unaffected by the type of operation.

Clinical utility of magnetic resonance imaging and the preoperative identification of low risk endometrial cancer

BACKGROUND

Magnetic resonance imaging (MRI) is reported to offer the best imaging of local disease in endometrial cancer. We audited MRI scans to identify their clinical utility, particularly in the preoperative identification of 'low risk' endometrial cancer (grade one or two endometrioid tumours confined to the inner half of the myometrium).

AIM

To correlate histological and MRI findings and to establish our ability to preoperatively identify women with 'low risk' tumours.

STUDY DESIGN

A retrospective audit of MRI scans in women with a new diagnosis of endometrial cancer from July 1998 to November 2002. Radiology and pathology reports and surgical staging data were extracted. Independently a team of radiologists reviewed MRI films and the findings were compared to pathology.

RESULTS

Thirty-nine patients were included. Only 10% of original reports contained all the clinically relevant information. On review, the sensitivity for the detection of myometrial invasion was 90%, specificity 71%, positive predictive value (PPV) 93% and negative predictive value (NPV) 63%. For the detection of deep invasion, sensitivity was 56%, specificity 77%, PPV 64% and NPV 71%. All women with grade one or two tumours having no invasion or grade one having superficial invasion detected on MRI had pathological 'low risk' disease.

CONCLUSIONS

Magnetic resonance imaging scans as reported offered limited clinical benefit. Attention needs to be given to MRI sequencing and reporting protocols. If the review results can be confirmed by prospective studies, MRI offers significant clinical utility in the identification of low risk patients and their surgical treatment planning.

Frozen section examination of pelvic lymph nodes in endometrial and cervical cancer: accuracy in patients submitted to neoadjuvant treatments

OBJECTIVE

The aim of the study was to analyze the accuracy, the positive and negative predictive values, the specificity, and the sensitivity of the pelvic node frozen section examination in endometrial (EC) and cervical cancer (CC) patients. An accurate evaluation of the results of the frozen section examination in patients submitted to neoadjuvant treatments (chemotherapy and radiochemotherapy), and a comparison between specialist and general pathologist results were performed.

METHODS

A total of 186 consecutive patients with endometrial [52 cases (27.9%)] and cervical [134 cases (72.1%)] cancer underwent surgery at our Department between January 2000 and September 2003. All patients underwent a systematic pelvic lymphadenectomy. While all definitive diagnosis were primarily performed or secondarily revised by the specialist pathologist, the frozen section examination was performed in 65 (35%) cases by the specialist pathologist and in 121 (65%) cases by a general pathologist.

RESULTS

Two thousand seven hundred eighteen out of a total of 6710 pelvic lymph nodes, which underwent a definitive histological analysis, were also analyzed at intraoperative frozen section examination. In our series, we observed 10 false negative and five false positive cases. Six out of the 10 (60%) false negative cases and two out of the five (40%) false positive were found in the neoadjuvant treated cervical cancer patients. In this subgroup, five out the six (83.3%) false negative and the two false positive diagnoses were made by the general pathologist, while the specialist pathologist registered only one false negative diagnosis.

CONCLUSION

Intraoperative examination of pelvic lymph nodes during surgery for endometrial and cervical cancer can be considered a safe procedure in the presence of an expert gynecologic oncological team, and can be safely performed in patients submitted to neoadjuvant treatments.

Influence of omental biopsy on adjuvant treatment field in clinical Stage I endometrial carcinoma

In this study to assess the role of omental biopsy in the diagnosis of extrapelvic disease, data from 100 consecutive women with clinical Stage I endometrial cancer undergoing primary surgical treatment in our institution were analysed: 80 women had an omental biopsy, 20 did not, and six had adenocarcinoma in the omentum. No obvious morbidity attributable to this rapid and easily performed surgical procedure was recorded. We conclude that visual inspection and palpation of the omentum at the time of abdominal surgery for endometrial carcinoma is worthwhile and advisable. In addition, adopting a protocol of histological assessment upstaged a further two cases of this series. These data suggest that this technique might influence the prescription of adjuvant pelvic radiation in approximately one in 10 women currently considered for such therapy, as disease can be easily documented as having extended beyond the conventional radiotherapy field.

Is there a place for a less extensive radical surgery in locally advanced cervical cancer patients?

OBJECTIVE

The aim of this study was to assess the association among the pathological status of different lymph node groups and parametrium in a single institutional population of 103 locally advanced cervical cancer (LACC) cases who underwent surgery after a neoadjuvant approach. A series of 29 early cervical cancer patients was also included in the analysis.

METHODS

Eighty-two LACC patients with documented clinical response to neoadjuvant treatment and 29 early stage cases underwent radical surgery. The operative technique consisted of a type II-V radical hysterectomy and systematic pelvic lymphadenectomy (median number of lymph nodes removed 46; range 5-140). Sixty-four cases were submitted to para-aortic lymphadenectomy up to the level of the inferior mesenteric artery (median number of lymph nodes removed 13; range 1-37).

RESULTS

Two subgroups of lymph nodes were defined: lower pelvic lymph nodes (LPN), including obturator and external iliac nodes, and upper pelvic nodes (UPN) including common iliac, presacral, and internal iliac nodes. Metastatic UPN involvement showed a strict association with LPN involvement: in LACC cases, 6 of 7 (86%) positive UPN cases had tumor disease at the LPN level. The single positive UPN case with negative LPN was intraoperatively identified by palpation and frozen section. Similarly, in early cervical cancer patients, 100% of positive UPN cases showed metastatic involvement at the LPN level. Sixty-three of 70 (90%) LACC patients with negative histological parametrium had negative LPN. Among 12 cases with metastatic involvement of parametrium, 5 cases (41.7%) had positive LPN. In early stage cervical cancer, 23 of 27 (85%) cases with negative parametrium showed no lymph nodal involvement. Intraoperative palpation of the parametrium could identify all cases with parametrial involvement not predicted by LPN status.

CONCLUSIONS

These data offer the basis for tailoring the extent of radical surgery in LACC patients, through the selection of those lymph node stations likely to provide reliable information on the pathological status of UPN and parametrium.

Lymphadenectomy in high risk endometrial carcinoma stage I and II: no more morbidity and no need for external pelvic radiation

The objectives of this retrospective study were to analyze the morbidity of surgical staging and to evaluate the omission of external radiotherapy in high-risk patients with stage I and II endometrial carcinoma when the lymph nodes were negative. From 1988 to 1996, 63 of 117 patients underwent a pelvic and periaortic lymphadenectomy. The decision to perform lymphadenectomy was influenced by patient general health. Patients with lymphadenectomy had a better physical status (P < 0.0001). Lymphadenectomy increased mean operative time (P < 0.0001) and blood loss (P < 0.01), but there was no increase in postoperative complications. At a median follow-up of 54 months, there was one cuff recurrence in 56 patients. Nineteen high-risk patients without external pelvic radiation had the same disease-free survival rate as 37 low-risk patients (P = 0.1). In the group without lymphadenectomy, the disease-free survival for 18 high-risk patients and 32 low-risk patients was similar (P = 0.21). Surgical staging in properly selected patients does not increase postoperative complications and brachytherapy without external radiotherapy is associated with excellent disease-free survival when the lymph nodes are negative.

Preoperative radiotherapy and surgery for endometrial carcinoma: prognostic significance of the sterilization of the specimen

INTRODUCTION

We report a retrospective study on the analysis of the operative specimen after preoperative radiotherapy for FIGO (1971) stage I or II endometrial carcinoma.

METHODS AND MATERIALS

From 1976 to 1996, 221 patients were treated with external radiotherapy (XRT) and/or low-dose-rate brachytherapy (BT) followed by surgery (S). Patients with cervical involvement (89 patients) or with high-grade tumors (49 patients) received XRT and BT. Patients stage FIGO Ia (89 patients) or with low-grade tumors (57 patients) received BT alone. Surgery was performed 5 to 6 weeks after irradiation.

RESULTS

The mean follow-up is 78 months (12-216). The 5-year survival was 90% for FIGO Ia, 80% for FIGO Ib, and 84% for FIGO II (p = 0.51). According to the differentiation, 5-year survival was 87% for grade 1, 84% for grade 2, 84% for grade 3 (p = 0.10). Grade 3 complications were registered in 2% (no grade 4). The tumors were sterilized in 37 patients (17%), sterilized but with dystrophic glands in 34 patients (16%), only modified and altered in 21 patients (9.5%), with viable cells in 56 patients (26%). After preoperative radiotherapy, 37/148 specimens were sterilized (25%), 14/74 after brachytherapy and surgery (19%), 23/74 after external radiotherapy-brachytherapy and surgery (31%). According to the response of the specimen, 5-year survival was 87% when the tumor was sterilized, 96% when altered glands were present, 85% when modified, and 76% if residual tumor with viable cells was identified (p = 0.043).

CONCLUSION

Preoperative radiotherapy followed by surgery is a safe and effective treatment of FIGO stage I or II endometrial carcinomas. BT with two uterine tubes seems to be of interest in the contribution of the treatment of the uterus to sterilize the specimen. The analysis of this new prognostic factor remains important to select a population with worst prognosis.

Paraaortic lymph node biopsy: a twenty-year study

OBJECTIVES

Paraaortic lymph node biopsy is a controversial but proved technique to determine the extent of spread of cancers from the uterine cervix or endometrium. This article explores the following questions. Does the presence of positive paraaortic lymph nodes result in modification of the patient's therapy? Does the evidence gained from a paraaortic lymph note biopsy improve patient survival?

STUDY DESIGN

Five hundred sixty-eight patients had paraaortic lymph node sampling in conjunction with another operative procedure between 1976 and 1995. Five hundred seven (89.3%) of these patients had either endometrial or cervical cancer.

RESULTS

Paraaortic lymph node biopsies led to a survival rate of 9.1% for cervical carcinoma and 46.6% for endometrial carcinoma and were associated with acceptable morbidity.

CONCLUSIONS

We believe that paraaortic lymph node biopsies should be part of the routine evaluation of patients with gynecologic cancers. The knowledge gained by this procedure along with appropriately administered radiation therapy can save lives.

Stage I corpus cancer: is teletherapy necessary?

OBJECTIVE

Our aim was to evaluate the perioperative morbidity after hysterectomy and lymphadenectomy as primary treatment of endometrial cancer and to analyze the recurrence and survival of patients classified as having surgical stage I disease who did not receive adjunctive teletherapy.

STUDY DESIGN

Over a 10-year interval 444 patients underwent extensive surgical staging for corpus cancer. Perioperative events were recorded prospectively. Outcome events were updated after the last year of study.

RESULTS

After patients with high-risk histologic types of cancer were excluded, 396 patients were evaluable. The risk of extrauterine disease, detected in 21.8% of patients, increased with increasing lack of tumor differentiation. The associated surgical morbidity, including blood loss (mean 336 ml), surgical site infection (3.5%), thromboembolic events (1.5%), and urinary injury (0.6%), and deaths (0.6%) did not differ from those in reports of women undergoing lesser operative procedures. Late complications, including lymphocyst (1.2%), leg edema (1.8%), and hernia (2.9%), were infrequent. Recurrence and survival analysis indicated a calculated 5-year survival of 97% of all patients with surgical stage I disease. There was a significant survival difference related to grade and stage for women in whom disease was confined to the uterus. Overall survival in patients with stage IA (100%) was significantly different (p < 0.0001) from that of patients with stage IB (97%) and stage IC (93%). All recurrences included a distal component.

CONCLUSION

Extensive surgical staging including lymphadenectomy can be performed safely. Our results suggest that the risk of pelvic recurrence is not increased and the risk of survival is not compromised in those women not receiving adjunctive teletherapy.