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Hill BL, Goon K, Fresia J, Sheeder J, Wolsky RJ, Alldredge J. Does Lymph Node Dissection Impact Adjuvant Treatment or Survival Outcomes in High-Risk Endometrial Cancers? Cureus 2022; 14:e24710. [PMID: 35663703 PMCID: PMC9162804 DOI: 10.7759/cureus.24710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives Lymphadenectomy does not improve overall survival outcomes in patients with low-risk endometrial cancers. Sentinel node mapping has a high detection rate and accuracy; however, its prognostic implications have not been well explored. We evaluated the overall survival and therapies received by patients undergoing varied lymph node dissection approaches for high-risk endometrial cancers. Methods Retrospective review of grade 3 endometrioid and high-grade non-endometrioid cancers at one institution over ten years. Patients who received neoadjuvant therapy and/or debulking of only grossly abnormal lymph nodes were excluded. Data was abstracted from electronic medical records. Chi-squared tests and survival analyses were used to compare groups. Results One hundred and fifty-three patients with grade 3 endometrioid, serous, clear cell, carcinosarcoma, or mixed high-grade on final pathology were identified; 16 had no lymph node dissection, 26 had sentinel lymph nodes, and 111 had complete lymph node dissection. Patients with open surgery were more likely to have complete nodes than sentinel nodes when compared to a minimally invasive approach (p<0.001). Sentinel nodal dissection significantly impacted the utilization of, or modality choice, in adjuvant therapy (p=0.051). Recurrence-free survival and cancer-specific overall survival were not significantly different across the three nodal-assessment groups. Conclusions Sentinel lymph node dissection in high-risk endometrial cancers led to no significant differences in recurrence-free survival or cancer-specific overall survival. While limited by sample size and its retrospective nature, results from this single-institution study are hypothesis-generating and prompt consideration of non-inferiority trials. Performing the least invasive surgery possibly can lead to fewer complications while maintaining overall survival outcomes.
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Affiliation(s)
- Breana L Hill
- Obstetrics and Gynecology, University of Colorado Hospital School of Medicine, Aurora, USA
| | - Kelsey Goon
- Obstetrics and Gynecology, University of Colorado Hospital School of Medicine, Aurora, USA
| | - Joellen Fresia
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, USA
| | - Jeanelle Sheeder
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, USA
| | - Rebecca J Wolsky
- Pathology, University of Colorado Hospital School of Medicine, Aurora, USA
| | - Jill Alldredge
- Obstetrics and Gynecology/Gynecologic Oncology, University of Colorado Hospital School of Medicine, Aurora, USA
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Helgers RJ, Winkens B, Slangen BF, Werner HM. Lymphedema and Post-Operative Complications after Sentinel Lymph Node Biopsy versus Lymphadenectomy in Endometrial Carcinomas-A Systematic Review and Meta-Analysis. J Clin Med 2020; 10:E120. [PMID: 33396373 PMCID: PMC7795280 DOI: 10.3390/jcm10010120] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/14/2020] [Accepted: 12/27/2020] [Indexed: 01/08/2023] Open
Abstract
Background: Lymph node dissection (LND) is recommended as staging procedure in presumed low stage endometrial cancer. LND is associated with risk of lower-extremity lymphedema and post-operative complications. The sentinel lymph node (SLN) procedure has been shown to have high diagnostic accuracy, but its effects on complication risk has been little studied. This systematic review compares the risk of lower-extremity lymphedema and post-operative complications in SLN versus LND in patients with endometrial carcinoma. Methods: A systematic search was conducted in PubMed and Cochrane Library. Results: Seven retrospective and prospective studies (total n = 3046 patients) were included. Only three studies reported the odds ratio of lower-extremity lymphedema after SLN compared to LND, which was 0.05 (95% CI 0.01-0.37; p = 0.067), 0.07 (95% CI 0.00-1.21; p = 0.007) and 0.54 (95% CI 0.37-0.80; p = 0.002) in these studies. The pooled odds ratio of any post-operative complications after SLN versus LND was 0.52 (95% CI 0.36-0.73; I2 = 48%; p < 0.001). For severe post-operative complications the pooled odds ratio was 0.52 (95% CI 0.28-0.96; I2 = 0%; p = 0.04). Conclusions: There are strong indications that SLN results in a lower incidence of lower-extremity lymphedema and less often severe post-operative complications compared to LND. In spite of the paucity and heterogeneity of studies, direction of results was similar in all studies, supporting the aforementioned conclusion. These results support the increasing uptake of SLN procedures in endometrial cancer.
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Affiliation(s)
- Rianne J.A. Helgers
- Faculty of Health, Medicine and Life Sciences, Maastricht University, 6202 AZ Maastricht, The Netherlands;
| | - Bjorn Winkens
- Department of Methodology & Statistics, CAPHRI, Care and Public Health Research Institute, Maastricht University Medical Centre, 6202 AZ Maastricht, The Netherlands;
| | - Brigitte F.M. Slangen
- Department of Obstetrics and Gynecology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, 6202 AZ Maastricht, The Netherlands;
| | - Henrica M.J. Werner
- Department of Obstetrics and Gynecology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre, 6202 AZ Maastricht, The Netherlands;
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Diagnostic Accuracy and Clinical Impact of Sentinel Lymph Node Sampling in Endometrial Cancer at High Risk of Recurrence: A Meta-Analysis. J Clin Med 2020; 9:jcm9123874. [PMID: 33260511 PMCID: PMC7761304 DOI: 10.3390/jcm9123874] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/20/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose. To assess the value of sentinel lymph node (SLN) sampling in high risk endometrial cancer according to the ESMO-ESGO-ESTRO classification. Methods. We performed a comprehensive search on PubMed for clinical trials evaluating SLN sampling in patients with high risk endometrial cancer: stage I endometrioid, grade 3, with at least 50% myometrial invasion, regardless of lymphovascular space invasion status; or stage II; or node-negative stage III endometrioid, no residual disease; or non-endometrioid (serous or clear cell or undifferentiated carcinoma, or carcinosarcoma). All patients underwent SLN sampling followed by pelvic with or without para-aortic lymphadenectomy. Results. We included 17 original studies concerning 1322 women. Mean detection rates were 89% for unilateral and 68% for bilateral. Pooled sensitivity was 88.5% (95%CI: 81.2–93.2%), negative predictive value was 96.0% (95%CI: 93.1–97.7%), and false negative rate was 11.5% (95%CI: 6.8; 18.8%). We noted heterogeneity in SLN techniques between studies, concerning the tracer and its detection, the injection site, the number of injections, and the surgical approach. Finally, we found a correlation between the number of patients included and the SLN sampling performances. Discussion. This meta-analysis estimated the SLN sampling performances in high risk endometrial cancer patients. Data from the literature show the feasibility, the safety, the limits, and the impact on surgical de-escalation of this technique. In conclusion, our study supports the hypothesis that SLN sampling could be a valuable technique to diagnose lymph node involvement for patients with high risk endometrial cancer in replacement of conventional lymphadenectomy. Consequently, randomized clinical trials are necessary to confirm this hypothesis.
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Factors predicting recurrence in patients with stage IA endometrioid endometrial cancer: what is the importance of LVSI? Arch Gynecol Obstet 2019; 301:737-744. [PMID: 31883046 DOI: 10.1007/s00404-019-05418-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of this study is to define the clinical and pathological prognostic factors for recurrence and to evaluate the recurrence patterns and adjuvant therapies used in this group of patients with stage IA endometrioid type endometrial cancer (FIGO 2009-International Federation of Gynecology and Obstetrics). METHODS Among the patients with epithelial endometrial cancer operated between January 1993 and May 2013 in a single institution, 720 patients with stage IA endometrioid endometrial cancer were included. Patients with a tumor type of serous, clear cell, mucinous, undifferentiated, and mixed type and with a tumor containing sarcomatous component and the patients with a secondary primer cancer were excluded from the study. RESULTS Lympho-vascular space invasion (LVSI) was present in 60 (8.3%) patients. Pelvic and para-aortic lymphadenectomy was performed in 266 (36.9%) patients. Median follow-up time was 48 months (range 3-240). Recurrence occurred in 23 (3.4%) patients and 6 (0.9%) died of disease. The median time-to recurrence (TTR) was 24 months (range 4-52 months) in the patients with recurrence. LVSI was associated with recurrence in the univariate analysis. Five-year disease-free survival (DFS) decreased from 96.8 to 80.1% in the presence of LVSI (p < 0.001). This association could not be shown in patients who had had lymphadenectomy (p = 0.136). Extra-pelvic recurrence occurred in 6.7% and 1% of the patients with and without LVSI, respectively, (p = 0.001). Any independent prognostic factor could not be detected in the multivariate analysis. CONCLUSIONS Only LVSI and tumor grade were associated with DFS and disease-specific survival (DSS), respectively, in the 686 patients with stage IA endometrial cancer in the univariate analysis, since these associations could not be shown in multivariate analysis.
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Walentowicz-Sadlecka M, Dziobek K, Grabiec M, Sadlecki P, Walentowicz P, Mak P, Szymankiewicz M, Kwinta P, Dutsch-Wicherek M. The analysis of human leukocyte antigen-G level in patients with endometrial cancer by Western blot technique. Am J Reprod Immunol 2018; 81:e13070. [DOI: 10.1111/aji.13070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/27/2018] [Accepted: 11/06/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Małgorzata Walentowicz-Sadlecka
- Department of Obstetrics and Gynecology, L. Rydygier Collegium Medicum in Bydgoszcz; Nicolaus Copernicus University; Bydgoszcz Poland
| | - Konrad Dziobek
- Center of Oncology; M. Sklodowska-Curie Memorial Institute, Krakow Branch; Kraków Poland
| | - Marek Grabiec
- Department of Obstetrics and Gynecology, L. Rydygier Collegium Medicum in Bydgoszcz; Nicolaus Copernicus University; Bydgoszcz Poland
| | - Pawel Sadlecki
- Department of Obstetrics and Gynecology, L. Rydygier Collegium Medicum in Bydgoszcz; Nicolaus Copernicus University; Bydgoszcz Poland
| | - Pawel Walentowicz
- Department of Obstetrics and Gynecology, L. Rydygier Collegium Medicum in Bydgoszcz; Nicolaus Copernicus University; Bydgoszcz Poland
| | - Paweł Mak
- Department of Analytical Biochemistry, Faculty of Biochemistry, Biophysics and Biotechnology; Jagiellonian University; Krakow Poland
| | - Maria Szymankiewicz
- Department of Obstetrics and Gynecology, L. Rydygier Collegium Medicum in Bydgoszcz; Nicolaus Copernicus University; Bydgoszcz Poland
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Lymph Node Metastasis in Patients With Endometrioid Endometrial Cancer: Overtreatment Is the Main Issue. Int J Gynecol Cancer 2018; 27:748-753. [PMID: 28301338 DOI: 10.1097/igc.0000000000000937] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the effectiveness of histological grade, depth of myometrial invasion, and tumor size to identify lymph node metastasis (LNM) in patients with endometrioid endometrial cancer (EC). METHODS A retrospective computerized database search was performed to identify patients who underwent comprehensive surgical staging for EC between January 1993 and December 2015. The inclusion criterion was endometrioid type EC limited to the uterine corpus. The associations between LNM and surgicopathological factors were evaluated by univariate and multivariate analyses. RESULTS In total, 368 patients were included. Fifty-five patients (14.9%) had LNM. Median tumor sizes were 4.5 cm (range, 0.7-13 cm) and 3.5 cm (range, 0.4-33.5 cm) in patients with and without LNM, respectively (P = 0.005). No LMN was detected in patients without myometrial invasion, whereas nodal spread was observed in 7.7% of patients with superficial myometrial invasion and in 22.6% of patients with deep myometrial invasion (P < 0.0001). Lymph node metastasis tended to be more frequent in patients with grade 3 disease compared with those with grade 1 or 2 disease (P = 0.131). CONCLUSIONS The risk of lymph node involvement was 30%, even in patients with the highest-risk uterine factors, that is, those who had tumors of greater than 2 cm, deep myometrial invasion, and grade 3 disease, indicating that 70% of these patients underwent unnecessary lymphatic dissection. A precise balance must be achieved between the desire to prevent unnecessary lymphadenectomy and the ability to diagnose LNM.
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Lee HJ, Hong CM, Song BI, Kim HW, Kang S, Jeong SY, Lee SW, Lee J, Ahn BC. Preoperative risk stratification using 18F-FDG PET/CT in women with endometrial cancer. Nuklearmedizin 2017; 50:204-13. [DOI: 10.3413/nukmed-0375-10-12] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Accepted: 06/07/2011] [Indexed: 12/13/2022]
Abstract
SummaryThe aim of this study is to evaluate the usefulness of 18F-FDG PET/CT for preoperative stratification of high-risk and low-risk carcinomas in patients with endometrial cancer. Patients, methods: 60 women (mean age 53.8 ± 9.9 years) with endometrial cancer, who underwent 18F-FDG PET/CT for preoperative staging work-up, followed by primary cytoreductive surgery, were enrolled in this study. Maximum and mean standardized uptake values (SUVmax, SUVmean) of endometrial tumors were measured, and compared with the various clinicopathologic findings obtained after surgery. Tumour aggressiveness was classified as high-risk and low-risk carcinomas. Patients with stage I or II, endometrioid adenocarcinoma, histologic grade 1 or 2, invasion of less than half of the myometrium, maximum tumor size less than 2.0 cm, and absence of cervical invasion and lymphovascular space involvement (LVSI) were classified as the lowrisk carcinoma group. The remaining patients were classified as the high-risk carcinoma group. Results: In univariate analysis, SUVmax of the primary endometrial tumor was significantly higher in patients who were in a postmenopausal state (p = 0.047), large (> 2 cm) primary tumor (p <0.001), nonendometrioid subtype (p = 0.024), invasion of more than half of the myometrium (p = 0.020), or LVSI (p = 0.004). SUVmax differed significantly according to FIGO stage (p = 0.013) and histologic grade (p <0.001). In multivariate analysis, FIGO stage, histologic grade, LVSI, and maximum tumor size demonstrated a significant association with SUVmax (p <0.001; r = 0.843, r2 = 0.711). SUVmean showed similar results. Forty-one (68.3%) patients were diagnosed postoperatively as high-risk and 19 patients (31.7%) as low-risk carcinoma. Patients with high-risk carcinoma (12.1 ± 6.1) showed significantly higher SUVmax than patients with low-risk carcinoma (5.8 ± 2.8, p <0.001). The optimal SUVmax cut-off value of 8.7, determined by ROC analysis, revealed 75.6% sensitivity, 89.5% specificity, and 81.7% accuracy for risk stratification. Conclusion: High-risk endometrial cancer might be differentiated by means of higher SUVmax from low-risk endometrial cancer. 18F-FDG FDG PET/CT can be applied preoperatively for stratification of risk in patients with endometrial cancer.
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Nitschmann CC, Multinu F, Bakkum-Gamez JN, Langstraat CL, Occhino JA, Weaver AL, Cliby WA, Mariani A, Dowdy SC. Vaginal vs. robotic hysterectomy for patients with endometrial cancer: A comparison of outcomes and cost of care. Gynecol Oncol 2017; 145:555-561. [PMID: 28392125 DOI: 10.1016/j.ygyno.2017.03.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/03/2017] [Accepted: 03/05/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare outcomes and cost for patients with endometrial cancer undergoing vaginal hysterectomy (VH) or robotic hysterectomy (RH), with or without lymphadenectomy (LND). METHODS Patients undergoing planned VH (and laparoscopic LND) or RH (and robotic LND) between January 2007 and November 2012 were reviewed. Patients with stage IV disease, synchronous cancer, synchronous surgery, or treated with palliative intent were excluded. Patients were objectively triaged to LND per institutional protocol based on frozen section. Outcomes were compared between VH and RH groups matched 1:1 on propensity scores. RESULTS VH was planned in 153 patients; 60 (39%) had concurrent LND while 93 (61%) were low risk and did not require LND. RH was planned in 398 patients; 225 (56%) required concurrent LND and 173 (44%) did not. Among 50 PS-matched pairs without LND, there was no significant difference in complications, length of stay, readmission, or progression free survival. However, median operative time was 1.3h longer and median 30-day cost $3150 higher for RH compared to VH (both p<0.001). Among patients requiring LND, 42 PS-matched pairs were identified. Median operative time was not different when pelvic and para-aortic LND was performed, and 12min longer in the VH group for pelvic LND alone (p=0.03). Median 30-day cost was $921 higher for RH compared to VH when LND was required (p=0.08). CONCLUSION Utilization of vaginal hysterectomy for endometrial cancer results in similar surgical and oncologic outcomes and lower costs compared to RH and should be considered for appropriate patients with a low risk of requiring LND.
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Affiliation(s)
- C C Nitschmann
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - F Multinu
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - J N Bakkum-Gamez
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - C L Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - J A Occhino
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - A L Weaver
- Department of Health Science Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - W A Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - A Mariani
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - S C Dowdy
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States.
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Lindqvist E, Wedin M, Fredrikson M, Kjølhede P. Lymphedema after treatment for endometrial cancer − A review of prevalence and risk factors. Eur J Obstet Gynecol Reprod Biol 2017; 211:112-121. [DOI: 10.1016/j.ejogrb.2017.02.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 01/19/2017] [Accepted: 02/17/2017] [Indexed: 11/16/2022]
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Rižner TL. Discovery of biomarkers for endometrial cancer: current status and prospects. Expert Rev Mol Diagn 2016; 16:1315-1336. [DOI: 10.1080/14737159.2016.1258302] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Mo Z, Liu J, Zhang Q, Chen Z, Mei J, Liu L, Yang S, Li H, Zhou L, You Z. Expression of PD-1, PD-L1 and PD-L2 is associated with differentiation status and histological type of endometrial cancer. Oncol Lett 2016; 12:944-950. [PMID: 27446374 PMCID: PMC4950473 DOI: 10.3892/ol.2016.4744] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 05/26/2016] [Indexed: 02/05/2023] Open
Abstract
Endometrial cancer (EC) is the most frequent gynecological malignancy and a major cause of morbidity and mortality for women worldwide. Programmed cell death protein 1 (PD-1) and its ligands programmed death ligand 1 (PD-L1) and programmed death ligand 2 (PD-L2) have been well studied in lung cancer, melanoma and renal-cell cancer. However, few studies have been performed in EC. The purpose of the present study was to assess the expression of PD-1, PD-L1 and PD-L2 in 35 human normal endometrial tissue samples and 75 human EC tissue samples using immunohistochemical staining. It was found that 61.3% of ECs were positive for PD-1 staining, which was almost exclusively found in the tumor-infiltrating immune cells. By contrast, PD-1 was not expressed in the tumor cells or normal endometrial tissues. It was also found that 14.3% of normal endometria and 17.3% of EC tissues were positive for PD-L1 expression, while 20.0% of normal endometrium and 37.3% of EC tissues were positive for PD-L2 expression; however, there was no statistically significant difference between the normal endometrium and EC tissues. PD-1 expression in the tumor-infiltrating immune cells was more frequently found in the moderately and poorly-differentiated ECs and non-endometrioid (type II) ECs than in the well-differentiated ECs and endometrioid (type I) ECs. Similarly, PD-L1 and PD-L2 expression in the tumor-infiltrating immune cells was more frequently found in the moderately and poorly-differentiated ECs and type II ECs than in the type I ECs. The present findings indicate a possible better outcome for future treatment with anti-PD-1 or anti-PD-L1 antibody-based therapies against these subgroups of endometrial cancers with frequent expression of the PD-1/PD-L1/PD-L2 axis.
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Affiliation(s)
- Zhongfu Mo
- Department of Obstetrics and Gynecology, Shijiazhuang Maternal and Child Health Care Hospital, Shijiazhuang, Hebei 050000, P.R. China
- Department of Structural and Cellular Biology, Tulane University, New Orleans, LA 70112, USA
| | - Jing Liu
- Department of Obstetrics and Gynecology, Shijiazhuang Maternal and Child Health Care Hospital, Shijiazhuang, Hebei 050000, P.R. China
- Department of Structural and Cellular Biology, Tulane University, New Orleans, LA 70112, USA
| | - Qiuyang Zhang
- Department of Structural and Cellular Biology, Tulane University, New Orleans, LA 70112, USA
| | - Zhiquan Chen
- Department of Structural and Cellular Biology, Tulane University, New Orleans, LA 70112, USA
- Department of Thoracic Surgery, Affiliated Hospital of North China University of Science and Technology, Tangshan, Hebei 063000, P.R. China
| | - Jiandong Mei
- Department of Structural and Cellular Biology, Tulane University, New Orleans, LA 70112, USA
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
- Western China Collaborative Innovation Center for Early Diagnosis and Multidisciplinary Therapy of Lung Cancer, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Lunxu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
- Western China Collaborative Innovation Center for Early Diagnosis and Multidisciplinary Therapy of Lung Cancer, Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Shijie Yang
- Department of Structural and Cellular Biology, Tulane University, New Orleans, LA 70112, USA
- Department of Urology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050011, P.R. China
| | - Huina Li
- Department of Pathology, Shijiazhuang Maternal and Child Health Care Hospital, Shijiazhuang, Hebei 050000, P.R. China
| | - Lifei Zhou
- Department of Obstetrics and Gynecology, Shijiazhuang Maternal and Child Health Care Hospital, Shijiazhuang, Hebei 050000, P.R. China
| | - Zongbing You
- Department of Structural and Cellular Biology, Tulane University, New Orleans, LA 70112, USA
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Wu Y, Zhu H, Sun J, Wang X. Accuracy of frozen section in management and prediction of lymph node metastasis in endometrial carcinoma. Gynecol Minim Invasive Ther 2015. [DOI: 10.1016/j.gmit.2015.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Kokcu A, Kurtoglu E, Celik H, Kefeli M, Tosun M, Onal M. Is Surgical Staging Necessary for Patients with Low-risk Endometrial Cancer? A Retrospective Clinical Analysis. Asian Pac J Cancer Prev 2015. [PMID: 26225674 DOI: 10.7314/apjcp.2015.16.13.5331] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The aim of this study was to compare the tumor-free and overall survival rates between patients with low-risk endometrial cancer who underwent surgical staging and those who did not undergo surgical staging. MATERIALS AND METHODS Data, including demographic characteristics, grade of the tumor, myometrial invasion, cervical involvement, peritoneal washing, lymph node involvement, lymphovascular space invasion, postoperative complication, adjuvant treatment, cancer recurrence, and tumor-free and overall survival rates, for patients with low-risk endometrioid endometrial cancer who were treated surgically with and without pelvic and paraaortic lymph node dissection (LND) were analyzed retrospectively. The patients diagnosed with endometrioid endometrial cancer including the following criteria were considered low-risk: 1) a grade 1 (G1) or grade 2 (G2) endometrioid histology; 2) myometrial invasion of <50% upon magnetic resonance imaging (MRI); 3) no stromal glandular or stromal invasion upon MRI; and 4) no evidence of intra-abdominal metastasis. Then the patients at low-risk were divided into two groups; group 1 (n=117): patients treated surgically with pelvic and paraaortic LND and group 2 (n=170): patients treated surgically without pelvic and paraaortic LND. RESULTS There was no statistical significance when the groups were compared in terms of lymphovascular space invasion, cervical involvement, positive cytology, and recurrence, whereas the administration of an adjuvant therapy was higher in group 2 (p<0.005). The number of patients with positive pelvic nodes and the number of metastatic pelvic nodes were significantly higher in the group with positive LVI than in the group without LVI (p<0.005). No statistically significant differences were detected between the groups in terms of tumor-free survival (p=0.981) and overall survival (p=0.166). CONCLUSIONS Total hysterectomy with bilateral salpingo-oophorectomy and stage-adapted postoperative adjuvant therapy without pelvic and/or paraaortic lymphadenectomy may be safe and efficient treatments for low-risk endometrial cancer.
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Affiliation(s)
- Arif Kokcu
- Department of Obstetrics and Gynecology, Ondokuz Mayis University, Samsun, Turkey E-mail :
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Bae HS, Lim MC, Lee JS, Lee Y, Nam BH, Seo SS, Kang S, Chung SH, Kim JY, Park SY. Postoperative Lower Extremity Edema in Patients with Primary Endometrial Cancer. Ann Surg Oncol 2015; 23:186-95. [DOI: 10.1245/s10434-015-4613-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Indexed: 11/18/2022]
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Lymphedema after surgery for endometrial cancer: prevalence, risk factors, and quality of life. Obstet Gynecol 2014; 124:307-315. [PMID: 25004343 DOI: 10.1097/aog.0000000000000372] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate lower extremity lymphedema prevalence in patients surgically treated for endometrial cancer, identify predictors of lymphedema, and evaluate the effects of lymphedema on quality of life. METHODS One thousand forty-eight consecutive patients who were operated on between 1999 and 2008 at the Mayo Clinic were mailed a survey, which included our validated 13-item lymphedema screening questionnaire and two validated quality-of-life measures. Logistic regression models were fit to identify factors associated with prevalent lymphedema; a multivariable model was obtained using stepwise and backward variable selection methods. The relationship between lymphedema and obesity with each quality-of-life score was evaluated separate multivariable linear models. RESULTS There were 591 responders (56%) after exclusions. Our questionnaire revealed a previous self-reported lymphedema diagnosis in 103 (17%) patients and identified undiagnosed lymphedema in 175 (30%) (overall prevalence 47.0%, median 6.2 years follow-up). Lymphedema prevalence in patients treated with hysterectomy alone compared with lymphadenectomy was 36.1% and 52.3%, respectively (attributable risk 23%). Lymphedema risk was not associated with the number of nodes removed or the extent of lymphadenectomy after adjusting for other factors. On multivariable analysis, higher body mass index, congestive heart failure, performance of lymphadenectomy, and radiation therapy were associated with prevalent lymphedema. Multiple quality-of-life scores were worse in women with lymphedema. CONCLUSION The attributable risk of developing lower extremity lymphedema was 23% for patients with endometrial cancer who underwent lymphadenectomy compared with hysterectomy alone with an overall prevalence of 47%. Lymphedema was associated with reductions in multiple quality-of-life domains. LEVEL OF EVIDENCE II.
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Turan T, Ureyen I, Karalök A, Taşçı T, Ilgın H, Keskin L, Kose MF, Tulunay G. What is the importance of omental metastasis in patients with endometrial cancer? J Turk Ger Gynecol Assoc 2014; 15:164-72. [PMID: 25317045 DOI: 10.5152/jtgga.2014.13109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 07/25/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To identify surgico-pathologic factors, survival, and the factors determining survival in patients with omental metastasis from endometrial cancer. MATERIAL AND METHODS Patients with endometrial cancer operated on between 1993-2012 in our hospital and who had omental metastases were included. Patients with either uterine sarcoma or synchronous tumors were excluded. RESULTS Omentectomy was performed in 811 patients with endometrial cancer, and omental metastasis was found in 48 (5.9%) patients. Tumor type was endometrioid cancer in 26 patients. Omental metastasis was macroscopic and microscopic in 60% and 40% of the patients, respectively. Total omentectomy increased the chance of detection of the microscopic metastases. Among the patients with omental metastasis, 68.8% had positive peritoneal cytology, 66.7% had adnexal involvement, 60.5% had metastases in the lymph nodes, 47.9% had cervical involvement, and 29.2% had serosal involvement; 43.8% of these patients had intra-abdominal spread beyond the omentum, adnexa, and peritoneal cytology. Two-year disease-free survival (DFS) was 28.2%, and 2-y overall survival (OS) was 40%. The depth of myometrial invasion, grade, cytology, and status of pelvic lymph nodes affected 2-y DFS, while cervical invasion and cytology affected 2-y OS. CONCLUSION Omental metastasis in endometrial cancer means poor prognosis, and two-thirds of these patients are lost at the end of the second year. Although total omentectomy increases the chance of the detection of micrometastases, its effect on survival is controversial. New treatment modalities are necessary in this patient group.
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Affiliation(s)
- Taner Turan
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Işın Ureyen
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Alper Karalök
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Tolga Taşçı
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Hilal Ilgın
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Levent Keskin
- Department of Gynecology and Obstetrics, Ankara Atatürk Education and Research Hospital, Ankara, Turkey
| | - M Faruk Kose
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Gökhan Tulunay
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women's Health Teaching and Research Hospital, Ankara, Turkey
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Bell JG, Patterson DM, Klima J, Harvison M, Rath K, Reid G. Outcomes of patients with low-risk endometrial cancer surgically staged without lymphadenectomy based on intra-operative evaluation. Gynecol Oncol 2014; 134:505-9. [PMID: 25003655 DOI: 10.1016/j.ygyno.2014.06.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 06/26/2014] [Accepted: 06/28/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate clinical outcomes in patients with stage I endometrial cancer undergoing surgical management without lymphadenectomy based on intra-operative assessment for low-risk disease. METHODS Between 2000 and 2009, a total of 179 patients were surgically staged without lymphadenectomy for low-risk stage I endometrial cancer. Low-risk cancer was defined by intra-operative criteria based on both gross and frozen tissue microscopic evaluation: 1) G1 or G2 endometrioid histology; 2) myoinvasion <50%; 3) no cervical disease, and 4) no intra-abdominal metastasis. Records were reviewed for postoperative complications, pathological diagnoses, adjuvant radiation treatment, cancer recurrence, and mortality. RESULTS Morbidity, cancer recurrence, and disease-specific mortality were low. Postoperative complications occurred in 5 patients (2.8%). Nine patients (5.0%) were offered adjuvant radiation for higher risk disease diagnosed on final pathology. Radiation morbidity was minimal: grade 1 vaginal toxicity in 2 patients. Three patients (1.7%) experienced recurrent cancer with mean time to recurrence of 43.7 months. Five year overall survival was 95.8%. The five year probability of disease-specific death was 1.1%. CONCLUSION In an institution with reliable capability of pathological frozen tissue diagnosis, omission of lymph node dissection is a reasonable option in the surgical management of those patients with low-risk disease diagnosed by intra-operative factors.
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Affiliation(s)
- Jeffrey G Bell
- Riverside Methodist Hospital, 3535 Olentangy River Road, Columbus, OH 43214, United States.
| | - Diana M Patterson
- Riverside Methodist Hospital, 3535 Olentangy River Road, Columbus, OH 43214, United States
| | - Jennifer Klima
- OhioHealth Reseach Institute, 3545 Olentangy River Road, Columbus, OH 43214, United States
| | - Michelle Harvison
- Riverside Methodist Hospital, 3535 Olentangy River Road, Columbus, OH 43214, United States
| | - Kellie Rath
- Riverside Methodist Hospital, 3535 Olentangy River Road, Columbus, OH 43214, United States
| | - Gary Reid
- Riverside Methodist Hospital, 3535 Olentangy River Road, Columbus, OH 43214, United States
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Walentowicz-Sadlecka M, Malkowski B, Walentowicz P, Sadlecki P, Marszalek A, Pietrzak T, Grabiec M. The preoperative maximum standardized uptake value measured by 18F-FDG PET/CT as an independent prognostic factor of overall survival in endometrial cancer patients. BIOMED RESEARCH INTERNATIONAL 2014; 2014:234813. [PMID: 24719847 PMCID: PMC3956283 DOI: 10.1155/2014/234813] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 11/06/2013] [Accepted: 11/06/2013] [Indexed: 01/07/2023]
Abstract
PURPOSE The aim of this study was to determine if the preoperative maximum standardized uptake value (SUVmax) measured by 18F-FDG PET/CT in the primary tumor has prognostic value in the group of patients with endometrial cancer. PATIENTS, MATERIALS, AND METHODS A total of one hundred one consecutive endometrial cancer patients, age range 40-82 years (mean 62 years) and FIGO I-IV stage, who underwent 18-FDG-PET/CT within two weeks prior radical surgery, were enrolled to the study. The maximum SUV was measured and compared with the clinicopathologic features of surgical specimens. The relationship between SUVmax and overall survival was analyzed. RESULTS The mean preoperative SUVmax was 14.34; range (3.90-33.80) and was significantly lower for FIGO I than for higher stages (P = 0.0012), as well as for grade 1 than for grade 2 and 3 (P = 0.018), deep myometrial invasion (P = 0.0016) and for high risk group (P = 0.0004). The analysis of survival ROC curve revealed SUVmax cut-off value of 17.7 to predict high risk of recurrence. Endometrial cancer patients with SUVmax higher than 17.7 characterized by lower overall survival. CONCLUSION The preoperative SUVmax measured by 18F-FDG PET/CT is considered as an important indicator reflecting tumor aggressiveness which may predict poor prognosis. High value of SUVmax would be useful for making noninvasive diagnoses and deciding the appropriate therapeutic strategy for patients with endometrial cancer.
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Affiliation(s)
- Malgorzata Walentowicz-Sadlecka
- Department of Obstetrics and Gynecology, The Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University of Torun, Ujejskiego 75, 85-168 Bydgoszcz, Poland
| | - Bogdan Malkowski
- Department of Nuclear Medicine, Lukaszczyk Oncology Center of Bydgoszcz, Poland
| | - Pawel Walentowicz
- Department of Obstetrics and Gynecology, The Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University of Torun, Ujejskiego 75, 85-168 Bydgoszcz, Poland
| | - Pawel Sadlecki
- Department of Obstetrics and Gynecology, The Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University of Torun, Ujejskiego 75, 85-168 Bydgoszcz, Poland
| | - Andrzej Marszalek
- Department of Clinical Pathology, The Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University of Torun, Poland
| | - Tomasz Pietrzak
- Department of Nuclear Medicine, Lukaszczyk Oncology Center of Bydgoszcz, Poland
| | - Marek Grabiec
- Department of Obstetrics and Gynecology, The Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University of Torun, Ujejskiego 75, 85-168 Bydgoszcz, Poland
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Robova H, Rob L, Halaska MJ, Pluta M, Skapa P. Current status of sentinel lymph node mapping in the management of endometrial cancer. Expert Rev Anticancer Ther 2014; 13:55-61. [DOI: 10.1586/era.12.157] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Methodological considerations in the analysis of the therapeutic significance of lymphadenectomy in endometrial cancer. Taiwan J Obstet Gynecol 2013; 52:8-13. [DOI: 10.1016/j.tjog.2013.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2012] [Indexed: 12/18/2022] Open
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Turan T, Oguz E, Unlubilgin E, Tulunay G, Boran N, Demir OF, Kose MF. Accuracy of frozen-section examination for myometrial invasion and grade in endometrial cancer. Eur J Obstet Gynecol Reprod Biol 2013; 167:90-5. [DOI: 10.1016/j.ejogrb.2012.11.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 08/14/2012] [Accepted: 11/21/2012] [Indexed: 11/29/2022]
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The role of para-aortic lymphadenectomy in the surgical staging of women with intermediate and high-risk endometrial adenocarcinomas. Int J Surg Oncol 2013; 2013:858916. [PMID: 23533741 PMCID: PMC3600173 DOI: 10.1155/2013/858916] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 01/30/2013] [Accepted: 01/31/2013] [Indexed: 11/17/2022] Open
Abstract
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.
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Todo Y, Sakuragi N. Systematic lymphadenectomy in endometrial cancer. J Obstet Gynaecol Res 2012; 39:471-7. [DOI: 10.1111/j.1447-0756.2012.02062.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 09/18/2012] [Indexed: 12/22/2022]
Affiliation(s)
- Yukiharu Todo
- Division of Gynecologic Oncology; National Hospital Organization, Hokkaido Cancer Center; Sapporo; Japan
| | - Noriaki Sakuragi
- Department of Obstetrics and Gynecology; Hokkaido University School of Medicine; Sapporo; Japan
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Less Gastrointestinal Toxicity After Adjuvant Radiotherapy on a Small Pelvic Field Compared to a Standard Pelvic Field in Patients With Endometrial Carcinoma. Int J Gynecol Cancer 2012; 22:1177-86. [DOI: 10.1097/igc.0b013e31826302dd] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ObjectiveRadiotherapy is associated with short-term and long-term morbidity. This study compared toxicity rates among patients with endometrial carcinoma (EC) treated with adjuvant external beam radiation therapy (EBRT) on a small pelvic field (SmPF) in comparison with a standard pelvic field (StPF) or an extended field (EF).MethodsPatients with EC preoperatively diagnosed with high-grade histological disease (grade 3 endometrioid, papillary serous, clear cell, and mixed tumor type) or cervical involvement were treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy in the University Medical Center Groningen between 1999 and 2008. Patients who received adjuvant EBRT were included in this study. External beam radiation therapy on SmPF (includes only the central pelvis and proximal vagina) was applied in case of negative lymph nodes after adequate lymphadenectomy (≥10 lymph nodes removed at the bilateral obturator and external iliac nodal stations). In case of positive pelvic lymph nodes or inadequate lymphadenectomy, EBRT on StPF was given. External beam radiation therapy on EF was applied in case of common iliac and/or para-aortic lymph node metastases.Retrospectively, using the Common Terminology Criteria for Adverse Events v3.0, acute toxicity was scored during radiotherapy, whereas late toxicity was scored, from 3 months onward after treatment.ResultsToxicity could be evaluated in 75 patients treated with SmPF (n = 33), StPF (n = 28), and EF EBRT (n = 14). Most patients with late adverse events had also reported toxicity during radiotherapy (71%). The most common late adverse events were gastrointestinal tract related, more frequently present in the StPF group (60.7%) compared to SmPF (33.3%; P = 0.032). In particular, nausea and anorexia were more frequent in the StPF group (32.1%) compared to the SmPF group (3.0%; P = 0.004), as well as ileus (14.3% vs 0%, P = 0.039, respectively).ConclusionsTreatment with adjuvant EBRT on SmPF results in less gastrointestinal late adverse events compared to treatment with EBRT on StPF in patients with surgically staged EC.
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[Arguments against sentinel node procedure in endometrial cancer]. ACTA ACUST UNITED AC 2012; 40:264-6. [PMID: 22483716 DOI: 10.1016/j.gyobfe.2012.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Interobserver agreement for endometrial cancer characteristics evaluated on biopsy material. Obstet Gynecol Int 2012; 2012:414086. [PMID: 22496699 PMCID: PMC3306930 DOI: 10.1155/2012/414086] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 10/17/2011] [Indexed: 11/17/2022] Open
Abstract
A shift toward a disease-based therapy designed according to patterns of failure and likelihood of nodal involvement predicted by pathologic determinants has recently led to considering a selective approach to lymphadenectomy for endometrial cancer. Therefore, it became critical to examine reproducibility of diagnosing the key determinants of risk, on preoperative endometrial tissue samples as well as the concordance between preoperative and postresection specimens. Six gynaecologic pathologists assessed 105 consecutive endometrial biopsies originally reported as positive for endometrial cancer for cell type (endometrioid versus nonendometrioid), tumor grade (FIGO 3-tiered and 2-tiered), nuclear grade, and risk category (low risk defined as endometrioid histology, grade 1 + 2 and nuclear grade <3). Interrater agreement levels were substantial for identification of nonendometrioid histology (κ = 0.63; SE = 0.025), high tumor grade (κ = 0.64; SE = 0.025), and risk category (κ = 0.66; SE = 0.025). The overall agreement was fair for nuclear grade (κ = 0.21; SE = 0.025). There is agreement amongst pathologists in identifying high-risk pathologic determinants on endometrial cancer biopsies, and these highly correlate with postresection specimens. This is ascertainment prerequisite adaptation of the paradigm shift in surgical staging of patients with endometrial cancer.
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Felix AS, Stone RA, Chivukula M, Bowser R, Parwani AV, Linkov F, Edwards RP, Weissfeld JL. Survival outcomes in endometrial cancer patients are associated with CXCL12 and estrogen receptor expression. Int J Cancer 2012; 131:E114-21. [PMID: 22025313 DOI: 10.1002/ijc.27317] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 10/11/2011] [Indexed: 01/18/2023]
Abstract
CXCL12 is a chemotactic cytokine that has pro-metastatic functions in several malignancies through interactions with its receptor, CXCR4. CXCL12 is an estrogen-regulated gene, and notably, estrogen is a major risk factor for endometrial cancer (EC) development. As few studies examine concurrent CXCL12, CXCR4, and estrogen receptor (ER) expression in EC patients, we examined this pathway in 199 EC patients with data from the University of Pittsburgh Medical Center Cancer Registry. Immunohistochemistry (IHC) was used to detect CXCR4, CXCL12 and ER protein expression. As CXCR4 expression was positive in all cases, this investigation focused on associations between CXCL12 and ER expression, clinicopathologic factors and survival outcomes using chi-square tests, Kaplan-Meier graphs, and log-rank tests. CXCL12 expression was negative in 63 cases (32%) and positive in 136 cases (68%). Negative CXCL12 expression was borderline significantly associated with metastasis (χ(2) p = 0.07). ER expression was negative in 75 cases (38%) and positive in 124 cases (62%). Positive ER expression was significantly associated with low grade and early stage tumors (χ(2) p < 0.001). CXCL12 and ER were not significantly associated (χ(2) p = 0.11). Positive CXCL12 expression was associated with longer overall survival (OS) (log-rank p = 0.006) and longer recurrence-free survival (RFS) (log-rank p = 0.01) in ER negative patients, but not in ER positive patients. We identified a unique molecular signature associated with better OS and RFS in EC patients. In addition to pathological characteristics of the tumor, expression of CXCL12 and ER may be clinically useful for assigning adjuvant treatment to EC cases.
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Affiliation(s)
- Ashley S Felix
- Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD 20852-7234, USA.
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Abstract
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.
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Bats AS, Bensaïd C, Huchon C, Scarabin C, Nos C, Lécuru F. [Current indications of lymphadenectomy in endometrial cancer]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2010; 38:754-759. [PMID: 21111657 DOI: 10.1016/j.gyobfe.2010.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Accepted: 07/08/2010] [Indexed: 05/30/2023]
Abstract
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.
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Affiliation(s)
- A-S Bats
- Service de chirurgie gynécologique et cancérologique, hôpital européen Georges-Pompidou, AP-HP, 20 rue Leblanc, Paris, France.
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Han SS, Lee SH, Kim DH, Kim JW, Park NH, Kang SB, Song YS. Evaluation of preoperative criteria used to predict lymph node metastasis in endometrial cancer. Acta Obstet Gynecol Scand 2010; 89:168-74. [PMID: 19916890 DOI: 10.3109/00016340903370114] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate whether we could accurately predict lymph node (LN) metastasis with preoperative tests in endometrial cancer. Design. Retrospective study. SETTING Seoul National University Hospital, South Korea. Population. Three hundred patients with endometrial cancer who underwent surgical staging including lymphadenectomy between January 1999 and July 2007. METHODS We reviewed the medical records of 300 patients with endometrial cancer. The preoperative factors used to predict LN metastasis were as follows: old age (> or = 55 years), serum CA-125 level [level > or = 20 U/mL (if age < 50 years), level > or = 28 U/mL (if age > or = 50 years)], non-endometrioid histologic type and Grade 3, metastatic LN assessed by pelvic MRI or CT, and deep myometrial invasion assessed by pelvic MRI only. Logistic regression analysis was used to determine the significant predictive factors. MAIN OUTCOME MEASURES Sensitivity/specificity and false positive/negative rates. RESULTS Thirty patients had LN metastasis. Although LN evaluation by pelvic MRI or CT and high CA-125 level were the significant independent predictors for LN metastasis, the sensitivity/specificity and false positive/negative rates for LN metastasis by these two combined preoperative tests were 86.7%/71.4% and 68.7%/2.7%, respectively. However, the sensitivity/specificity and false positive/negative rates for LN metastasis by six combined preoperative tests were 100%/28.9% and 84.6%/0%, respectively. CONCLUSIONS The six combined preoperative tests are useful in selecting patients without LN metastasis in endometrial cancer. Lymphadenectomy could be avoided in about 29% of patients with endometrial cancer who have no LN metastasis by using six combined preoperative tests.
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Affiliation(s)
- Seung-Su Han
- Department of Obstetrics and Gynecology, Chung-Ang University College of Medicine, Seoul, Korea
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Systemic lymphadenectomy cannot be recommended for low-risk corpus cancer. Obstet Gynecol Int 2010; 2010:490219. [PMID: 20168975 PMCID: PMC2820258 DOI: 10.1155/2010/490219] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Accepted: 01/09/2010] [Indexed: 11/18/2022] Open
Abstract
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.
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Tsujikawa T, Yoshida Y, Kudo T, Kiyono Y, Kurokawa T, Kobayashi M, Tsuchida T, Fujibayashi Y, Kotsuji F, Okazawa H. Functional Images Reflect Aggressiveness of Endometrial Carcinoma: Estrogen Receptor Expression Combined with 18F-FDG PET. J Nucl Med 2009; 50:1598-604. [DOI: 10.2967/jnumed.108.060145] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Wang X, Zhang H, Di W, Li W. Clinical factors affecting the diagnostic accuracy of assessing dilation and curettage vs frozen section specimens for histologic grade and depth of myometrial invasion in endometrial carcinoma. Am J Obstet Gynecol 2009; 201:194.e1-194.e10. [PMID: 19564019 DOI: 10.1016/j.ajog.2009.05.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2008] [Revised: 01/04/2009] [Accepted: 05/06/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We sought to investigate clinical factors affecting accuracy of dilation and curettage (D&C) and frozen section diagnosis of endometrial cancer. STUDY DESIGN Clinical parameters affecting concordance of D&C or frozen section compared with final hysterectomy pathology were analyzed in 218 patients with endometrial cancer. RESULTS The overall concordance of grade between D&C and final hysterectomy findings was 35.2% (62/176). The following factors increased accuracy of D&C: depth of uterus cavity > or = 9 cm (P = .043), deep (> 50%) myometrial invasion (P = .03), P53 positivity (P = .023), grade 2 (P = .01), and grade 3 (P = .048). When comparing frozen section with final hysterectomy findings, the concordance was 69% (58/84) in tumor grade and 87% (67/77) in myometrial invasion. Postmenopausal bleeding (P = .004) and less resistance index of endometrial lesion blood flow (P = .005) increased efficacy of grade diagnosis by frozen section. CONCLUSION Discordance with hysterectomy assessment was most common for women with D&C or frozen section diagnoses of low-grade superficial cancers.
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Affiliation(s)
- Xipeng Wang
- Department of Obstetrics and Gynecology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Lee JH, Jung US, Kyung MS, Hoh JK, Choi JS. Laparoscopic Systemic Retroperitoneal Lymphadenectomy for Women with Low-Risk Early Endometrial Cancer. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n7p581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Introduction: There is no consensus on the extent of lymphadenectomy and the appropriate patients for lymphadenectomy in low-risk patients with endometrial cancer. This study aimed to evaluate the feasibility and effectiveness of laparoscopic lymphadenectomy for low-risk patients with endometrial cancer.
Materials and Methods: From January 2004 to May 2008, we reviewed the medical records of 28 patients with low-risk, endometrial cancer; endometrioid type, grade 1 or 2, and with a depth of myometrial invasion of less than one-half of the myometrium. All patients underwent laparoscopically-assisted staging surgery.
Results: The median age and body mass index were 56 years (range, 28 to 75) and 25.5 kg/m2 (range, 21.3 to 37.2). The median operating time, estimated blood loss, and length of hospital stay were 142 minutes (range, 110 to 410), 215 mL (range, 100 to 700), and 7 days (range, 3 to 19), respectively. No conversion to laparotomy was noted. The median number of harvested lymph nodes was 21 (range, 10 to 48) pelvic nodes and 12 (range, 4 to 21) para-aortic nodes. One (3.6%) patient presented pelvic lymph node metastasis and 2 (7.1%) presented isolated para-aortic lymph node metastasis. The complication rate was 14.3%. No recurrence in the vaginal vault, distant metastasis, port site metastasis was noted up to the last follow-up.
Conclusion: Systemic pelvic and para-aortic lymphadenectomy should be considered in all low-risk patients with endometrial cancer until it is concluded to be clinically insignificant through large-scale prospective research in the future. However, it will be difficult to explain statistical differences in survival rates according to lymphadenectomy, because the increase of the survival rate resulting from lymphadenectomy will fall within the margin of statistical error.
Key words: Endometrial cancer, Laparoscopy, Lymphadenectomy
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Affiliation(s)
- Jung Hun Lee
- Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Un Suk Jung
- Konyang University College of Medicine, Daejeon, Korea
| | - Min Sun Kyung
- Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - Joong Sub Choi
- Sungkyunkwan University School of Medicine, Seoul, Korea
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Frederick PJ, Straughn JM. The role of comprehensive surgical staging in patients with endometrial cancer. Cancer Control 2009; 16:23-9. [PMID: 19078926 DOI: 10.1177/107327480901600104] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The cornerstone of the management of patients with endometrial cancer is hysterectomy. Since 1988, the role of lymphadenectomy for patients with endometrial cancer has been debated. Patients who undergo pelvic and para-aortic lymphadenectomy are more likely to be accurately staged and are less likely to receive adjuvant radiation therapy. METHODS The authors perform a narrative review of the recent literature. Overall survival, utilization of radiation therapy, impact on quality of life, and alternative approaches to surgical staging are discussed. RESULTS Although a survival benefit from comprehensive surgical staging has not been clearly demonstrated in patients diagnosed with endometrial cancer, surgical staging allows one to determine the need for adjuvant therapy. Preoperative and intraoperative assessment of lymph node metastasis and tumor grade lacks accuracy. Unstaged patients are more likely to receive postoperative radiation therapy. CONCLUSIONS Comprehensive surgical staging with lymphadenectomy allows patients to be classified accurately into risk categories. Risk status can be definitively determined only with final pathology. Surgically staged patients are more likely to receive appropriate adjuvant therapy or observation when warranted.
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Affiliation(s)
- Peter J Frederick
- University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Birmingham, AL 35249-7333, USA.
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Issues surrounding lymphadenectomy in the management of endometrial cancer. J Surg Oncol 2008; 99:232-41. [DOI: 10.1002/jso.21200] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Limits of lymphoscintigraphy for sentinel node biopsy in women with endometrial cancer. Gynecol Oncol 2008; 112:348-52. [PMID: 19081610 DOI: 10.1016/j.ygyno.2008.11.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Revised: 10/27/2008] [Accepted: 11/04/2008] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Lymph node status in endometrial cancer is a major prognostic factor. Sentinel lymph node (SLN) biopsy using radiocolloid and blue dye labeling has emerged as an alternative to systematic lymphadenectomy. This technique requires a preoperative lymphoscintigraphy. The aim of this study was to evaluate the limits of day-before preoperative lymphoscintigraphy to SLN biopsy. METHODS Between July 2002 and March 2007, 38 patients with endometrial cancer underwent laparoscopic SLN procedure using radiocolloid and blue dye. Those with early-stage I endometrial cancer (35 patients) underwent a SLN procedure followed by systematic pelvic lymphadenectomy and a hysterectomy with bilateral salpingo-oophorectomy while those with presumed stage IIB on MR imaging (3 patients) underwent a radical hysterectomy. Omentectomy and paraaortic lymphadenectomy were also performed for women with clear cell or serous papillary carcinoma (5 patients). The SLN identification rates and false-negative rates were studied. RESULTS The detection rate of lymphoscintigraphy was 84.5% (32/38), with 1.9 nodes per patient. Eight of 17 patients (47%) with unilateral sentinel lymph node on lymphoscintigraphy had bilateral SLNs at surgery and three of 15 patients (20%) with bilateral SLN on lymphoscintigraphy had unilateral SLN at surgery. The correlation was poor (kappa=0.266). When categorized in <2 and > or =2 sentinel nodes, the correlation between lymphoscintigraphic and surgical SLN mapping was moderate (kappa=0.33). CONCLUSION Our results demonstrated the low correlation between day-before lymphoscintigraphy and surgical SLN mapping raising issues of its usefulness and cost-effectiveness in routine practice.
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Berretta R, Merisio C, Piantelli G, Rolla M, Giordano G, Melpignano M, Nardelli GB. Preoperative transvaginal ultrasonography and intraoperative gross examination for assessing myometrial invasion by endometrial cancer. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2008; 27:349-355. [PMID: 18314512 DOI: 10.7863/jum.2008.27.3.349] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Endometrial cancer is the most common gynecologic malignancy. The cornerstone of treatment remains surgery according to International Federation of Gynecology and Obstetrics staging. The aim of this study was to evaluate the concordance between myometrial infiltration detected by ultrasonography and gross examination with respect to definitive histologic examination and to select a population in which lymphadenectomy could be excluded. We also evaluated the concordance for the degree of tumor differentiation between diagnostic biopsy and final histologic results. METHODS Our study included 75 patients with International Federation of Gynecology and Obstetrics stage I endometrial cancer. We evaluated preoperative and definitive grading and myometrial infiltration detected by ultrasonography and gross examination. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the procedures under study were determined with the Bayes theorem. To determine the predictive value of preoperative transvaginal ultrasonography and intraoperative gross examination for myometrial invasion, we used a multiple logistic regression model with a statistical software package. RESULTS Our study showed 60% concordance between biopsy and histologic results. In 80% of the cases with discordant results, the tumor was undergraded. Ultrasonography had diagnostic accuracy of 73%, whereas gross examination correctly determined myometrial invasion in 82.6% of the patients, with sensitivity of 62% and specificity of 79%. CONCLUSIONS Preoperative transvaginal ultrasonography and macroscopic gross examination appear to be simple, fast, and reliable methods to predict in myometrial invasion in patients with a low risk for lymph node metastasis, for which lymphadenectomy can reasonably be avoided.
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Affiliation(s)
- Roberto Berretta
- Department of Obstetrics and Gynecology, University of Parma, Via A. Gramsci 14, 43100 Parma, Italy.
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