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Faria SL, Ferrigno R. Câncer do Endométrio: Tratamento Adjuvante Pélvico apenas com Radioterapia Externa após Cirurgia sem Linfadenectomia. REVISTA BRASILEIRA DE CANCEROLOGIA 2022. [DOI: 10.32635/2176-9745.rbc.1999v45n3.2778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A incidência mediana de câncer endometrial no Brasil é de 6 casos novos/cem mil mulheres/ ano. A radioterapia tem sido usada como tratamento adjuvante pré ou pós cirurgia, com ou sem braquiterapia. Há consenso de que os casos estadiados como II e III pela FIGO recebam irradiação pélvica, com ou sem braquiterapia. Entretanto, 75% dos casos são estádios I. Por isso há subgrupos prognósticos que dependem da profundidade de invasão do miométrio e do grau histológico do tumor. Tumores em estádio I com invasão profunda do miométrio e/ou alto grau têm também sido tratados com irradiação. A adição de braquiterapia vaginal após a radioterapia externa resulta em melhor controle de falha pélvica? Esta é uma pergunta não resolvida. Desde 1990 temos feito apenas radioterapia externa nos casos de câncer do endométrio que têm indicação de irradiação adjuvante, sem braquiterapia. A cirurgia básica destes casos têm sido histerectomia abdominal total + salpingo-ooforectomia bilateral sem dissecção de rotina dos linfonodos pélvicos. Foram revistas retrospectivamente 61 destes casos tratados no nosso serviço, com 4 campos pélvicos. Cobalto, dose total entre 45Gy-50,4Gy em 25 a 28 frações. Seguimento mediano de 33 meses mostrou um único caso de falha em vagina, 6/61 casos de pacientes que morreram e apenas um caso de complicação intestinal moderada. Estes resultados se assemelham com outros da literatura que não usam a braquiterapia de rotina após a irradiação externa na pelve.
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Otsuka I. Therapeutic Benefit of Systematic Lymphadenectomy in Node-Negative Uterine-Confined Endometrioid Endometrial Carcinoma: Omission of Adjuvant Therapy. Cancers (Basel) 2022; 14:cancers14184516. [PMID: 36139675 PMCID: PMC9497184 DOI: 10.3390/cancers14184516] [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] [Received: 08/15/2022] [Revised: 09/02/2022] [Accepted: 09/14/2022] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Endometrial cancer is the most common gynecological tract malignancy in developed countries. Extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors. Abstract Endometrial cancer is the most common gynecological tract malignancy in developed countries, and its incidence has been increasing globally with rising obesity rates and longer life expectancy. In endometrial cancer, extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors. In this review, I discuss the characteristics of lymph node metastasis, the methods of lymph node assessment, and the therapeutic benefits of systematic lymphadenectomy in patients with intermediate- and high-risk endometrioid endometrial carcinoma.
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Affiliation(s)
- Isao Otsuka
- Department of Obstetrics and Gynecology, Kameda Medical Center, Kamogawa 296-8602, Chiba, Japan
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Abakay CD, Arslan S, Kurt M, Cetintas S. Improving locoregional outcome in high-intermediate-risk and high-risk stage I endometrial cancer with surgical staging followed by brachytherapy. Radiat Oncol J 2022; 40:103-110. [PMID: 35796113 PMCID: PMC9262699 DOI: 10.3857/roj.2021.00864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/26/2022] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Candan Demiroz Abakay
- Department of Radiation Oncology, Faculty of Medicine, Uludag University, Bursa, Turkey
- Correspondence: Candan Demiroz Abakay Department of Radiation Oncology, Faculty of Medicine, Uludag University, Nilufer/Bursa 16059, Turkey. Tel: +90-5336663507 E-mail:
| | - Sonay Arslan
- Department of Radiation Oncology, Manisa City Hospital, Manisa, Turkey
| | - Meral Kurt
- Department of Radiation Oncology, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Sibel Cetintas
- Department of Radiation Oncology, Faculty of Medicine, Uludag University, Bursa, Turkey
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Open Surgery including Lymphadenectomy without Adjuvant Therapy for Uterine-Confined Intermediate- and High-Risk Endometrioid Endometrial Carcinoma. Curr Oncol 2022; 29:3728-3737. [PMID: 35621688 PMCID: PMC9139559 DOI: 10.3390/curroncol29050298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/02/2022] [Accepted: 05/18/2022] [Indexed: 11/17/2022] Open
Abstract
Minimally invasive surgery may not be an appropriate surgical approach in intermediate- and high-risk endometrial carcinoma, even though adjuvant therapy is given. The objective of this study was to evaluate the results of open surgery including lymphadenectomy without adjuvant therapy in patients with uterine-confined intermediate- and high-risk endometrioid endometrial carcinoma. Two hundred fifty-six patients with uterine-confined endometrioid endometrial carcinoma were treated with open surgery, including pelvic with or without para-aortic lymphadenectomy. Of the 81 patients with uterine-confined intermediate- or high-risk disease, 77 were treated with systematic lymphadenectomy without adjuvant therapy. Seven patients developed recurrence, comprising 5.5% (3/55) and 18.2% (4/22) of the intermediate- and high-risk patients, respectively. The time to recurrence was 1–66 months. The sites of recurrence were the vaginal apex (n = 2), lung (n = 2), vaginal sidewall (n = 1), pelvic lymph nodes (n = 1), and para-aortic to supraclavicular nodes (n = 1). Of these, five patients were alive without disease after salvage treatment, but two understaged high-risk patients died of disease. The five-year disease-specific survival rates of intermediate- and high-risk patients were 100% and 90%, respectively. The present study indicated that patients with uterine-confined intermediate- and high-risk endometrioid endometrial carcinoma had excellent survival when treated with open surgery, including lymphadenectomy alone. The safety of omitting adjuvant therapy should be evaluated in prospective randomized trials comparing open surgery with minimally invasive surgery.
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A modified technique to perform para-aortic lymphadenectomy up to the renal vein. Taiwan J Obstet Gynecol 2021; 59:541-545. [PMID: 32653126 DOI: 10.1016/j.tjog.2020.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To investigate the safety and feasibility of our modified technique to perform lymph node excision up to the renal vein in cases of gynecological cancer. MATERIALS AND METHODS 87 patients with endometrial or ovarian neoplasms underwent laparoscopic para-aortic lymphadenectomy (LPAL) up to the left renal vein were enrolled prospectively. During surgery, the surgeon was positioned to the right side of the patient and an additional trocar was introduced into the upper right abdomen. The laparoscopic video screen was placed to the side of the patient's head. Three-fan retractor forceps were used to hold up the duodenum and small bowel. The rest of the procedure was the same as conventional LPAL. RESULTS The median operating time for LPAL was 72 min (range: 40-115 min) and the median estimated blood loss was 45 ml (range: 15-1000 mL). There were two cases of intra-operative vascular injury. The median number of retrieved para-aortic lymph nodes (PALNs) was 18 (range: 10-37). Of the 87 patients, 11 patients had positive PALNs. None of the cases required laparotomy. CONCLUSION Our findings demonstrate that our modified LPAL technique is feasible, reproducible, can achieve good exposure and reduces surgical difficulty.
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Fu K, Li Y, Song J, Cai W, Wu W, Ye X, Xu J. Identification of a MicroRNA Signature Associated With Lymph Node Metastasis in Endometrial Endometrioid Cancer. Front Genet 2021; 12:650102. [PMID: 33936173 PMCID: PMC8082502 DOI: 10.3389/fgene.2021.650102] [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] [Received: 01/06/2021] [Accepted: 03/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background Lymph node metastasis (LNM) is an important prognostic factor in endometrial cancer. Anomalous microRNAs (miRNAs) are associated with cell functions and are becoming a powerful tool to characterize malignant transformation and metastasis. The aim of this study was to construct a miRNA signature to predict LNM in endometrial endometrioid carcinoma (EEC). Method Candidate target miRNAs related to LNM in EEC were screened by three methods including differentially expressed miRNAs (DEmiRs), weighted gene co-expression network analysis (WGCNA), and decision tree algorithms. Samples were randomly divided into the training and validation cohorts. A miRNA signature was built using a logistic regression model and was evaluated by the area under the curve (AUC) of receiver operating characteristic curve (ROC) and decision curve analysis (DCA). We also conducted pathway enrichment analysis and miRNA-gene regulatory network to look for potential genes and pathways engaged in LNM progression. Survival analysis was performed, and the miRNAs were tested whether they expressed differently in another independent GEO database. Result Thirty-one candidate miRNAs were screened and a final 15-miRNA signature was constructed by logistic regression. The model showed good calibration in the training and validation cohorts, with AUC of 0.824 (95% CI, 0.739-0.912) and 0.821 (95% CI, 0.691-0.925), respectively. The DCA demonstrated the miRNA signature was clinically useful. Hub miRNAs in signature seemed to contribute to EEC progression via mitotic cell cycle, cellular protein modification process, and molecular function. MiR-34c was statistically significant in survival that a higher expression of miR-34c indicated a higher survival time. MiR-34c-3p, miR-34c-5p, and miR-34b-5p were expressed differentially in GSE75968. Conclusion The miRNA signature could work as a noninvasive method to detect LNM in EEC with a high prediction accuracy. In addition, miR-34c cluster may be a key biomarker referring LNM in endometrial cancer.
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Affiliation(s)
- Kaiyou Fu
- School of Medicine, Zhejiang University, Hangzhou, China.,Women's hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yanrui Li
- School of Control Science and Engineering, Zhejiang University, Hangzhou, China
| | - Jianyuan Song
- Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wangyu Cai
- Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Wu
- Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaohang Ye
- School of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Xu
- Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Prospective Non-randomized Control Trial on Role of Systematic High Para-Aortic Lymphadenectomy in Endometrial Cancer: Indian Study. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2021. [DOI: 10.1007/s40944-020-00482-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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8
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Huang CY, Liao KW, Chou CH, Shrestha S, Yang CD, Chiew MY, Huang HT, Hong HC, Huang SH, Chang TH, Huang HD. Pilot Study to Establish a Novel Five-Gene Biomarker Panel for Predicting Lymph Node Metastasis in Patients With Early Stage Endometrial Cancer. Front Oncol 2020; 9:1508. [PMID: 32039004 PMCID: PMC6985442 DOI: 10.3389/fonc.2019.01508] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/16/2019] [Indexed: 12/27/2022] Open
Abstract
Introduction: In the United States and Europe, endometrial endometrioid carcinoma (EEC) is the most prevalent gynecologic malignancy. Lymph node metastasis (LNM) is the key determinant of the prognosis and treatment of EEC. A biomarker that predicts LNM in patients with EEC would be beneficial, enabling individualized treatment. Current preoperative assessment of LNM in EEC is not sufficiently accurate to predict LNM and prevent overtreatment. This pilot study established a biomarker signature for the prediction of LNM in early stage EEC. Methods: We performed RNA sequencing in 24 clinically early stage (T1) EEC tumors (lymph nodes positive and negative in 6 and 18, respectively) from Cathay General Hospital and analyzed the RNA sequencing data of 289 patients with EEC from The Cancer Genome Atlas (lymph node positive and negative in 33 and 256, respectively). We analyzed clinical data including tumor grade, depth of tumor invasion, and age to construct a sequencing-based prediction model using machine learning. For validation, we used another independent cohort of early stage EEC samples (n = 72) and performed quantitative real-time polymerase chain reaction (qRT-PCR). Finally, a PCR-based prediction model and risk score formula were established. Results: Eight genes (ASRGL1, ESR1, EYA2, MSX1, RHEX, SCGB2A1, SOX17, and STX18) plus one clinical parameter (depth of myometrial invasion) were identified for use in a sequencing-based prediction model. After qRT-PCR validation, five genes (ASRGL1, RHEX, SCGB2A1, SOX17, and STX18) were identified as predictive biomarkers. Receiver operating characteristic curve analysis revealed that these five genes can predict LNM. Combined use of these five genes resulted in higher diagnostic accuracy than use of any single gene, with an area under the curve of 0.898, sensitivity of 88.9%, and specificity of 84.1%. The accuracy, negative, and positive predictive values were 84.7, 98.1, and 44.4%, respectively. Conclusion: We developed a five-gene biomarker panel associated with LNM in early stage EEC. These five genes may represent novel targets for further mechanistic study. Our results, after corroboration by a prospective study, may have useful clinical implications and prevent unnecessary elective lymph node dissection while not adversely affecting the outcome of treatment for early stage EEC.
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Affiliation(s)
- Chia-Yen Huang
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan.,Department of Obstetrics and Gynecology, Gynecologic Cancer Center, Cathay General Hospital, Taipei, Taiwan.,School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Kuang-Wen Liao
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan.,Institute of Molecular Medicine and Bioengineering, National Chiao Tung University, Hsinchu, Taiwan
| | - Chih-Hung Chou
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan.,Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), National Chiao Tung University, Hsinchu, Taiwan.,Institute of Bioinformatics and Systems Biology, National Chiao Tung University, Hsinchu, Taiwan
| | - Sirjana Shrestha
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Chi-Dung Yang
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan.,School of Life and Health Sciences, Chinese University of Hong Kong, Shenzhen, China.,Warshel Institute for Computational Biology, Chinese University of Hong Kong, Shenzhen, China
| | - Men-Yee Chiew
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Hsin-Tzu Huang
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Hsiao-Chin Hong
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan.,Institute of Bioinformatics and Systems Biology, National Chiao Tung University, Hsinchu, Taiwan.,School of Life and Health Sciences, Chinese University of Hong Kong, Shenzhen, China.,Warshel Institute for Computational Biology, Chinese University of Hong Kong, Shenzhen, China
| | - Shih-Hung Huang
- Department of Pathology, Cathay General Hospital, Taipei, Taiwan
| | - Tzu-Hao Chang
- International Center for Health Information Technology, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Hsien-Da Huang
- School of Life and Health Sciences, Chinese University of Hong Kong, Shenzhen, China.,Warshel Institute for Computational Biology, Chinese University of Hong Kong, Shenzhen, China
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9
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Salinas EA, Miller MD, Newtson AM, Sharma D, McDonald ME, Keeney ME, Smith BJ, Bender DP, Goodheart MJ, Thiel KW, Devor EJ, Leslie KK, Gonzalez Bosquet J. A Prediction Model for Preoperative Risk Assessment in Endometrial Cancer Utilizing Clinical and Molecular Variables. Int J Mol Sci 2019; 20:ijms20051205. [PMID: 30857319 PMCID: PMC6429416 DOI: 10.3390/ijms20051205] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 02/27/2019] [Accepted: 03/06/2019] [Indexed: 01/27/2023] Open
Abstract
The utility of comprehensive surgical staging in patients with low risk disease has been questioned. Thus, a reliable means of determining risk would be quite useful. The aim of our study was to create the best performing prediction model to classify endometrioid endometrial cancer (EEC) patients into low or high risk using a combination of molecular and clinical-pathological variables. We then validated these models with publicly available datasets. Analyses between low and high risk EEC were performed using clinical and pathological data, gene and miRNA expression data, gene copy number variation and somatic mutation data. Variables were selected to be included in the prediction model of risk using cross-validation analysis; prediction models were then constructed using these variables. Model performance was assessed by area under the curve (AUC). Prediction models were validated using appropriate datasets in The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases. A prediction model with only clinical variables performed at 88%. Integrating clinical and molecular data improved prediction performance up to 97%. The best prediction models included clinical, miRNA expression and/or somatic mutation data, and stratified pre-operative risk in EEC patients. Integrating molecular and clinical data improved the performance of prediction models to over 95%, resulting in potentially useful clinical tests.
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Affiliation(s)
| | - Marina D Miller
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
| | - Andreea M Newtson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
| | - Deepti Sharma
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY 52242, USA.
| | - Megan E McDonald
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
| | - Matthew E Keeney
- Winfield Pathology Consultants, Central DuPage Hospital, Winfield, IL 60190, USA.
| | - Brian J Smith
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA 52242, USA.
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
| | - David P Bender
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
| | - Michael J Goodheart
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
| | - Kristina W Thiel
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
| | - Eric J Devor
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
| | - Kimberly K Leslie
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
| | - Jesus Gonzalez Bosquet
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
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Identifiable Risk Factors for Lymph Node Metastases in Grade 1 Endometrial Carcinoma. Int J Gynecol Cancer 2017; 27:1694-1700. [DOI: 10.1097/igc.0000000000001070] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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11
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Topfedaisi Ozkan N, Meydanlı MM, Sarı ME, Demirkiran F, Kahramanoglu I, Bese T, Arvas M, Şahin H, Haberal A, Celik H, Coban G, Oge T, Yalcin OT, Akbayır Ö, Erdem B, Numanoğlu C, Özgül N, Boyraz G, Salman MC, Yüce K, Dede M, Yenen MC, Taşkın S, Altın D, Ortaç UF, Aydın Ayık H, Şimşek T, Güngör T, Güngördük K, Sancı M, Ayhan A. Factors associated with survival after relapse in patients with low-risk endometrial cancer treated with surgery alone. J Gynecol Oncol 2017; 28:e65. [PMID: 28657226 PMCID: PMC5540724 DOI: 10.3802/jgo.2017.28.e65] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 05/11/2017] [Accepted: 05/18/2017] [Indexed: 11/30/2022] Open
Abstract
Objective To determine factors influencing overall survival following recurrence (OSFR) in women with low-risk endometrial cancer (EC) treated with surgery alone. Methods A multicenter, retrospective department database review was performed to identify patients with recurrent “low-risk EC” (patients having less than 50% myometrial invasion [MMI] with grade 1 or 2 endometrioid EC) at 10 gynecologic oncology centers in Turkey. Demographic, clinicopathological, and survival data were collected. Results We identified 67 patients who developed recurrence of their EC after initially being diagnosed and treated for low-risk EC. For the entire study cohort, the median time to recurrence (TTR) was 23 months (95% confidence interval [CI]=11.5–34.5; standard error [SE]=5.8) and the median OSFR was 59 months (95% CI=12.7–105.2; SE=23.5). We observed 32 (47.8%) isolated vaginal recurrences, 6 (9%) nodal failures, 19 (28.4%) peritoneal failures, and 10 (14.9%) hematogenous disseminations. Overall, 45 relapses (67.2%) were loco-regional whereas 22 (32.8%) were extrapelvic. According to the Gynecologic Oncology Group (GOG) Trial-99, 7 (10.4%) out of 67 women with recurrent low-risk EC were qualified as high-intermediate risk (HIR). The 5-year OSFR rate was significantly higher for patients with TTR ≥36 months compared to those with TTR <36 months (74.3% compared to 33%, p=0.001). On multivariate analysis for OSFR, TTR <36 months (hazard ratio [HR]=8.46; 95% CI=1.65–43.36; p=0.010) and presence of HIR criteria (HR=4.62; 95% CI=1.69–12.58; p=0.003) were significant predictors. Conclusion Low-risk EC patients recurring earlier than 36 months and those carrying HIR criteria seem more likely to succumb to their tumors after recurrence.
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Affiliation(s)
- Nazli Topfedaisi Ozkan
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Mehmet Mutlu Meydanlı
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Mustafa Erkan Sarı
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey.
| | - Fuat Demirkiran
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ilker Kahramanoglu
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Tugan Bese
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Macit Arvas
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Hanifi Şahin
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Ali Haberal
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Husnu Celik
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Gonca Coban
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Tufan Oge
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Osmangazi University, Eskisehir, Turkey
| | - Omer Tarik Yalcin
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Osmangazi University, Eskisehir, Turkey
| | - Özgür Akbayır
- Department of Gynecologic Oncology, Kanuni Sultan Suleyman Teaching and Research Hospital, Istanbul, Turkey
| | - Baki Erdem
- Department of Gynecologic Oncology, Kanuni Sultan Suleyman Teaching and Research Hospital, Istanbul, Turkey
| | - Ceyhun Numanoğlu
- Department of Gynecologic Oncology, Kanuni Sultan Suleyman Teaching and Research Hospital, Istanbul, Turkey
| | - Nejat Özgül
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Gökhan Boyraz
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mehmet Coşkun Salman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kunter Yüce
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Murat Dede
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Gulhane Training and Researh Hospital, Ankara, Turkey
| | - Mufit Cemal Yenen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Gulhane Training and Researh Hospital, Ankara, Turkey
| | - Salih Taşkın
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Ankara University, Ankara, Turkey
| | - Duygu Altın
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Ankara University, Ankara, Turkey
| | - Uğur Fırat Ortaç
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, School of Medicine, Ankara University, Ankara, Turkey
| | - Hülya Aydın Ayık
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Tayup Şimşek
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Tayfun Güngör
- Department of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Faculty of Medicine, University of Health Sciences, Ankara, Turkey
| | - Kemal Güngördük
- Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Faculty of Medicine, University of Health Sciences, Izmir, Turkey
| | - Muzaffer Sancı
- Department of Gynecologic Oncology, Tepecik Education and Research Hospital, Faculty of Medicine, University of Health Sciences, Izmir, Turkey
| | - Ali Ayhan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Ankara, Turkey
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Padak A, Kasap B, Yetimalar H, Kılıç Sakarya D, Yiğit S. Deep obturator lymph node dissection in gynaecological cancer patients: Is it feasible and useful? J OBSTET GYNAECOL 2016; 36:812-816. [PMID: 27159250 DOI: 10.3109/01443615.2016.1157147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Our aim was to investigate the feasibility and outcomes of deep obturator lymph node (DOLN) dissection in gynaecological cancer patients. A prospective study included 62 patients with a diagnosis of ovarian, endometrial or cervical cancer who underwent surgery. In the study group, 36 patients underwent obturator lymph node dissection above and under the obturator nerve, while 26 control group patients underwent routine obturator lymph node dissection above the obturator nerve. Groups were compared with respect to dissected lymph node count, intraoperative characteristics and early postoperative complications. Total lymph node count in the DOLN dissected group was greater than that in the control group, and the difference was statistically significant. No statistically significant difference was found between the groups, regarding postoperative complications and intraoperative characteristics. The total number of lymph nodes dissected by using DOLN dissection increased without an increase in intra- and postoperative complications in gynaecological cancer patients.
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Affiliation(s)
- Ahmet Padak
- a Department of Obstetrics and Gynecology , Şanlıurfa Maternity Hospital , Urfa , Turkey
| | - Burcu Kasap
- b Department of Obstetrics and Gynecology , School of Medicine, Mugla Sitki Kocman University , Mugla , Turkey
| | - Hakan Yetimalar
- c Department of Obstetrics and Gynecology Clinic III , Izmir Ataturk Training and Research Hospital , Izmir , Turkey , and
| | - Derya Kılıç Sakarya
- c Department of Obstetrics and Gynecology Clinic III , Izmir Ataturk Training and Research Hospital , Izmir , Turkey , and
| | - Seyran Yiğit
- d Department of Pathology , Izmir Ataturk Training and Research Hospital , Izmir , Turkey
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13
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Bhosale P, Ma J, Iyer R, Ramalingam P, Wei W, Soliman P, Frumovitz M, Kundra V. 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. J Magn Reson Imaging 2016; 43:316-24. [PMID: 26185031 PMCID: PMC4715803 DOI: 10.1002/jmri.25001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 06/25/2015] [Indexed: 01/23/2023] Open
Abstract
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.
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Affiliation(s)
- Priya Bhosale
- Department of Diagnostic Radiology, the University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Jingfei Ma
- Department of Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Revathy Iyer
- Department of Diagnostic Radiology, the University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Preetha Ramalingam
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Wei Wei
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030
| | - Pamela Soliman
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Michael Frumovitz
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Vikas Kundra
- Department of Diagnostic Radiology, the University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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14
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Bou Zgheib N, Marchion DC, Bush SH, Judson PL, Wenham RM, Apte SM, Lancaster JM, Gonzalez-Bosquet J. Molecular determinants for lymph node metastasis in clinically early-stage endometrial cancer. Oncol Lett 2015; 11:323-329. [PMID: 26870211 DOI: 10.3892/ol.2015.3883] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 07/16/2015] [Indexed: 11/06/2022] Open
Abstract
Patients with occult lymph node metastasis in endometrioid-type endometrial cancer (EC) are prone to the development of recurrences and have worse outcomes compared with patients without lymph node metastasis. In the current study, the aim was to identify molecular parameters associated with lymph node metastasis in EC clinically early-stage disease. A univariate analysis of differentially expressed genes, proteins and clinicopathological parameters (including myometrial invasion and tumor grade) was performed, comparing EC patients with and without lymph node metastasis (n=262 patients from The Cancer Genome Atlas). Significant parameters were introduced in a multivariate model and a gene expression pathway analysis. Lymph node metastasis was associated with expression of 268 unique genes (P<0.001), 19 unique proteins (P<0.05), tumor grade and myometrial invasion in univariate analysis. Multivariate analysis demonstrated 10 genes independently associated with lymph node metastasis and 4 independently associated proteins. Myometrial invasion was the only independent clinicopathological parameter associated with lymph node status. The enrichment pathway analysis demonstrated that expression of epidermal growth factor receptor, Bcl2 antagonist of cell death and phosphatase and tensin homolog pathways were significantly involved in lymph node metastasis (P≤0.001). A gene expression signature to predict lymph node status in EC was created for future validation. Few studies have focused on the association between EC's molecular characteristics and nodal metastasis. Defining molecular risk factors for EC lymphatic nodal metastasis may help to individualize treatment and improve patient outcomes.
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Affiliation(s)
- Nadim Bou Zgheib
- Department of Women's Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Douglas C Marchion
- Department of Women's Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Stephen H Bush
- Department of Women's Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Patricia L Judson
- Department of Women's Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; Department of Oncologic Sciences, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Robert M Wenham
- Department of Women's Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; Department of Oncologic Sciences, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Sachin M Apte
- Department of Women's Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; Department of Oncologic Sciences, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Johnathan M Lancaster
- Department of Women's Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; Chemical Biology and Molecular Medicine Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; Department of Oncologic Sciences, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Jesus Gonzalez-Bosquet
- Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Iowa Hospital and Clinics, Iowa, IA 52242, USA
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Sethasathien P, Charoenkwan K, Siriaunkgul S. Accuracy of Intraoperative Gross Examination of Myometrial Invasion in Stage I-II Endometrial Cancer. Asian Pac J Cancer Prev 2014; 15:7061-4. [DOI: 10.7314/apjcp.2014.15.17.7061] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Latif NA, Haggerty A, Jean S, Lin L, Ko E. Adjuvant therapy in early-stage endometrial cancer: a systematic review of the evidence, guidelines, and clinical practice in the U.S. Oncologist 2014; 19:645-53. [PMID: 24821823 PMCID: PMC4041674 DOI: 10.1634/theoncologist.2013-0475] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 03/15/2014] [Indexed: 11/17/2022] Open
Abstract
Endometrial cancer is the most common gynecologic malignancy in the U.S., with an increasing incidence likely secondary to the obesity epidemic. Surgery is usually the primary treatment for early stage endometrial cancer, followed by adjuvant therapy in selected cases. This includes radiation therapy [RT] with or without chemotherapy, based on stratification of patients into categories dependent on their future recurrence risk. Several prospective trials (PORTEC-1, GOG#99, and PORTEC-2) have shown that the use of adjuvant RT in the intermediate risk (IR) and the high-intermediate risk (HIR) groups decreases locoregional recurrence (LRR) but has no effect on overall survival. The ad hoc analyses from these studies have shown that an even larger LRR risk reduction was seen within the HIR group compared with the IR group. Vaginal brachytherapy is as good as external beam radiotherapy in controlling vaginal relapse where the majority of recurrence occur, and with less toxicity. In the high-risk group, multimodality therapy (chemotherapy and RT) may play a significant role. Although adjuvant RT has been evaluated in many cost-effectiveness studies, high-quality data in this area are still lacking. The uptake of the above prospective trial results in the U.S. has not been promising. Factors that are driving current practices and defining quality-of-care measures for patients with early-stage disease are what future studies need to address.
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Affiliation(s)
- Nawar A Latif
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, and Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashley Haggerty
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, and Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephanie Jean
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, and Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lilie Lin
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, and Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Ko
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, and Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Pelikan HMP, Trum JW, Bakers FCH, Beets-Tan RGH, Smits LJM, Kruitwagen RFPM. Diagnostic accuracy of preoperative tests for lymph node status in endometrial cancer: a systematic review. Cancer Imaging 2013; 13:314-22. [PMID: 23876490 PMCID: PMC3719052 DOI: 10.1102/1470-7330.2013.0032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Approximately 72% of endometrial cancers are FIGO stage I at diagnosis and about 10% have lymph node metastases. An ideal diagnostic test for nodal disease would be able to prevent both overtreatment (i.e. unnecessary lymphadenectomy) and undertreatment (i.e. withholding lymphadenectomy or adjuvant postoperative treatment to patients with lymph node metastases). Objectives: In this review we compare the accuracy of preoperative tests (computed tomography, magnetic resonance imaging, positron emission tomography-computed tomography, CA-125 serum levels, and ultrasonography) for the detection of lymph node metastases in endometrial cancers with the final histopathologic diagnosis after complete pelvic and para-aortic lymphadenectomy as the gold standard. Method: A systematic search in MEDLINE (using PubMed), Embase and The Cochrane Library was performed up to 23 July 2012. Results: We found one article that met our inclusion criteria for computed tomography, none for magnetic resonance imaging, 2 for positron emission tomography/computed tomography), 2 for CA-125 and none for ultrasonography. Conclusions: Due to the lack of high-quality articles on a preoperative test for lymph node status in endometrial cancer, no proper comparison between these modalities can be made.
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Affiliation(s)
- H M P Pelikan
- Department of Obstetrics and Gynaecology, Bronovo Hospital, Bronovolaan 5, 2597 AX Den Haag, The Netherlands.
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18
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Contemporary clinical management of endometrial cancer. Obstet Gynecol Int 2013; 2013:583891. [PMID: 23864861 PMCID: PMC3707260 DOI: 10.1155/2013/583891] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 05/28/2013] [Indexed: 12/15/2022] Open
Abstract
Although the contemporary management of endometrial cancer is straightforward in many ways, novel data has emerged over the past decade that has altered the clinical standards of care while generating new controversies that will require further investigation. Fortunately most cases are diagnosed at early stages, but high-risk histologies and poorly differentiated tumors have high metastatic potential with a significantly worse prognosis. Initial management typically requires surgery, but the role and extent of lymphadenectomy are debated especially with well-differentiated tumors. With the changes in surgical staging, prognosis correlates more closely with stage, and the importance of cytology has been questioned and is under evaluation. The roles of radiation in intermediate-risk patients and chemotherapy in high-risk patients are emerging. The therapeutic index of brachytherapy needs to be considered, and the best sequencing of combined modalities needs to balance efficacy and toxicities. Additionally novel targeted therapies show promise, and further studies are needed to determine the appropriate use of these new agents. Management of endometrial cancer will continue to evolve as clinical trials continue to answer unsolved clinical questions.
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19
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AlHilli MM, Mariani A. The role of para-aortic lymphadenectomy in endometrial cancer. Int J Clin Oncol 2013; 18:193-9. [PMID: 23412768 DOI: 10.1007/s10147-013-0528-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Indexed: 10/27/2022]
Abstract
Endometrial cancer (EC) is the most common malignancy of the female reproductive tract and the fourth most common cancer overall. Approximately 20 % of patients with EC harbor disease outside the uterus, and 10 % of patients initially diagnosed with cancer confined to the uterus are found to have lymph node metastases. Para-aortic lymph node involvement occurs in approximately 7-8 % of EC patients overall and in about 50 % of patients with positive pelvic nodes. Metastases to the para-aortic lymph nodes are associated with poor prognosis. Factors associated with para-aortic lymph node dissemination include advanced stage, high histological grade, deep myometrial invasion, cervical involvement, lymphovascular space involvement, and the presence of pelvic lymph node metastases. Approximately 77 % of patients with para-aortic nodal involvement are found to have metastases above the level of the inferior mesenteric artery. Systematic pelvic and para-aortic lymphadenectomy with dissection optimally carried out to the renal vessels is important in high-risk patients in order to identify nodes present at distant sites, particularly above the inferior mesenteric artery (IMA). While the definitive management of EC varies widely across the gynecological oncology community, there is a consensus that patients at risk for lymphatic metastases (high and intermediate risk) who are targeted with systematic lymphadenectomy may have an improved prognosis. Well-designed prospective studies evaluating the therapeutic role of systematic lymphadenectomy in EC are needed. Herein, we describe the role of para-aortic lymphadenectomy in the surgical staging of EC emphasizing its prerequisites, extent, and diagnostic and potential therapeutic advantages.
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Affiliation(s)
- Mariam M AlHilli
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Eisenberg Lobby 71, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA
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Designing the next lymphadenectomy trial: what should we learn for our prior experiences. Gynecol Oncol 2012; 126:1-2. [PMID: 22713367 DOI: 10.1016/j.ygyno.2012.05.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 04/19/2012] [Indexed: 11/22/2022]
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Lajer H, Elnegaard S, Christensen RD, Ortoft G, Schledermann DE, Mogensen O. Survival after stage IA endometrial cancer; can follow-up be altered? A prospective nationwide Danish survey. Acta Obstet Gynecol Scand 2012; 91:976-82. [PMID: 22548255 DOI: 10.1111/j.1600-0412.2012.01438.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To present Danish national survival data on women with early stage endometrial cancer and use these data to discuss the relevance of postoperative follow-up. DESIGN Prospective study. SETTING Danish Endometrial Cancer Study (DEMCA). POPULATION Five hundred and seventy-one FIGO stage IA (1988 classification) endometrial cancer patients prospectively included between 1986 and 1999. All patients had total abdominal hysterectomy and bilateral salpingo-oophorectomy without adjuvant therapy. METHODS The patient and the disease characteristics were drawn from the DEMCA database with cross-references to the national death registry and the national pathology database. Statistical methods included Kaplan-Meier, log-rank and Cox regression analysis. MAIN OUTCOME MEASURES Survival rates in relation to histopathology. RESULTS The five year overall survival rate was 88.9% and five year disease-specific survival was 97.3%. Patients with low- (91.8%) and high-risk histopathology (8.2%) were compared. The age-adjusted overall and disease-specific survival differed significantly between women with low- and high-risk histopathology (p = 0.039 and p = 0.004, respectively). The disease-specific survival adjusted for age between patients with well-differentiated endometrioid tumors differed from those with moderately differentiated tumors (p = 0.008, hazard ratio = 3.75, 95% confidence interval 1.41-10.00). Recurrence data were available on 464 patients. Twenty-three (3.9%) experienced recurrence. Of these recurrences, 15 of 23 (65%) were vaginal. Death from recurrence was observed in nine of 23 (39%) patients, and five of these nine had vaginal recurrences. CONCLUSIONS Women with FIGO stage IA endometrial cancer have a very high disease-specific five year survival. Survival was related to histopathology. Follow-up at a highly specialized tertiary care center for patients with an extremely good prognosis may be questioned.
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Affiliation(s)
- Henrik Lajer
- Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
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22
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Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 2, 2007. The role of radiotherapy (both pelvic external beam radiotherapy (EBRT) and vaginal intracavity brachytherapy (VBT)) in stage I endometrial cancer following hysterectomy remains controversial. OBJECTIVES To assess the efficacy of adjuvant radiotherapy following surgery for stage I endometrial cancer. SEARCH METHODS We searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Specialised Register to end-2005 for the original review, and extended the search to January 2012 for the update. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared post-operative adjuvant radiotherapy (either EBRTor VBT, or both) versus no radiotherapy or VBT in women with stage I endometrial cancer. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials and extracted data to a specifically designed data collection form. The primary outcome was overall survival. Secondary outcomes were endometrial cancer-related deaths, locoregional recurrence and distant recurrence. Meta-analyses were performed using Cochrane Review Manager Software 5.1. MAIN RESULTS We included eight trials. Seven trials (3628 women) compared EBRT with no EBRT (or VBT), and one trial (645 women) compared VBTwith no additional treatment. We considered six of the eight trials to be of a high quality. Time-to-event data were not available for all trials and all outcomes.EBRT (with or without VBT) compared with no EBRT (or VBT alone) for stage I endometrial carcinoma significantly reduced locoregional recurrence (time-to-event data: five trials, 2965 women; Hazard Ratio (HR) 0.36, 95% Confidence Interval (CI) 0.25 to 0.52; and dichotomous data: seven trials, 3628 women; Risk Ratio (RR) 0.33, 95% CI 0.23 to 0.47). This reduced risk of locoregional recurrence did not translate into improved overall survival (time-to-event data: five trials, 2,965 women; HR 0.99, 95% CI 0.82 to1.20; and dichotomous data: seven trials, 3628 women; RR 0.98, 95% CI 0.83 to 1.15) or improved endometrial cancer-related survival (time-to-event data: five trials, 2965 women; HR 0.96, 95% CI 0.72 to 1.28; and dichotomous data: seven trials, 3628 women; RR 1.02, 95% CI 0.81 to 1.29) or improved distant recurrence rates (dichotomous data: seven trials, 3628 women; RR 1.04, 95% CI 0.80 to 1.35).EBRT did not improve survival outcomes in either the intermediate-risk or high-risk subgroups, although high-risk data were limited, and a benefit of EBRT for high-risk women could not be excluded. One trial (PORTEC-2) compared EBRT with VBT in the high-intermediate risk group and reported that VBT was effective in ensuring vaginal control with a non-significant difference in loco-regional relapse rate compared to EBRT (5.1% versus 2.1%; HR 2.08, 95% CI 0.71 to 6.09; P = 0.17). In the subgroup of low-risk patients (IA/B and grade 1/2), EBRT increased the risk of endometrial carcinoma-related deaths (including treatment-related deaths) (two trials, 517 women; RR 2.64, 95% CI 1.05 to 6.66) but there was a lack of data on overall survival. We considered the evidence for the low-risk subgroup to be of a low quality.EBRT was associated with significantly increased severe acute toxicity (two trials, 1328 patients, RR 4.68, 95% CI 1.35 to 16.16), increased severe late toxicity (six trials, 3501 women; RR 2.58, 95% CI 1.61 to 4.11) and significant reductions in quality of life scores and rectal and bladder function more than 10 years after randomisation (one trial, 351 women) compared with no EBRT.One trial of VBT versus no additional treatment in women with low-risk lesions reported a non-significant reduction in locoregional recurrence in the VBT group compared with the no additional treatment group (RR 0.39, (95% CI 0.14 to 1.09). There were no significant differences in survival outcomes in this trial. AUTHORS' CONCLUSIONS EBRT reduces the risk of locoregional recurrence but has no significant impact on cancer-related deaths or overall survival. It is associated with significant morbidity and a reduction in quality of life. There is no demonstrable survival advantage from adjuvant EBRT for high-risk stage I endometrial cancer, however, the meta-analyses of this subgroup were underpowered and also included high-intermediate risk women, therefore we cannot exclude a small benefit in the high-risk subgroup. EBRT may have an adverse effect on endometrial cancer survival when used to treat uncomplicated low-risk (IA/B grade 1/2) endometrial cancer. For the intermediate to high-intermediate risk group, VBT alone appears to be adequate in ensuring vaginal control compared to EBRT. Further research is needed to guide practice for lesions that are truly high risk. In addition, the definitions of risk should be standardised.
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Affiliation(s)
- Anthony Kong
- Department of Oncology, Oxford University Hospitals NHS Trust and Oxford University, Oxford, UK.
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Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 2, 2007. The role of radiotherapy (both pelvic external beam radiotherapy (EBRT) and vaginal intracavity brachytherapy (VBT)) in stage I endometrial cancer following hysterectomy remains controversial. OBJECTIVES To assess the efficacy of adjuvant radiotherapy following surgery for stage I endometrial cancer. SEARCH METHODS We searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Specialised Register to end-2005 for the original review, and extended the search to January 2012 for the update. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared post-operative adjuvant radiotherapy (either EBRT or VBT, or both) versus no radiotherapy or VBT in women with stage I endometrial cancer. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials and extracted data to a specifically designed data collection form. The primary outcome was overall survival. Secondary outcomes were endometrial cancer-related deaths, locoregional recurrence and distant recurrence. Meta-analyses were performed using Cochrane Review Manager Software 5.1. MAIN RESULTS We included eight trials. Seven trials (3628 women) compared EBRT with no EBRT (or VBT), and one trial (645 women) compared VBT with no additional treatment. We considered six of the eight trials to be of a high quality. Time-to-event data were not available for all trials and all outcomes.EBRT (with or without VBT) compared with no EBRT (or VBT alone) for stage I endometrial carcinoma significantly reduced locoregional recurrence (time-to-event data: five trials, 2965 women; Hazard Ratio (HR) 0.36, 95% Confidence Interval (CI) 0.25 to 0.52; and dichotomous data: seven trials, 3628 women; Risk Ratio (RR) 0.33, 95% CI 0.23 to 0.47). This reduced risk of locoregional recurrence did not translate into improved overall survival (time-to-event data: five trials, 2,965 women; HR 0.99, 95% CI 0.82 to 1.20; and dichotomous data: seven trials, 3628 women; RR 0.98, 95% CI 0.83 to 1.15) or improved endometrial cancer-related survival (time-to-event data: five trials, 2965 women; HR 0.96, 95% CI 0.72 to 1.28; and dichotomous data: seven trials, 3628 women; RR 1.02, 95% CI 0.81 to 1.29) or improved distant recurrence rates (dichotomous data: seven trials, 3628 women; RR 1.04, 95% CI 0.80 to1.35).EBRT did not improve survival outcomes in either the intermediate-risk or high-risk subgroups, although high-risk data were limited, and a benefit of EBRT for high-risk women could not be excluded. In the subgroup of low-risk patients (IA/B and grade 1/2), EBRT increased the risk of endometrial carcinoma-related deaths (including treatment-related deaths) (two trials, 517 women; RR 2.64, 95% CI 1.05 to 6.66) but there was a lack of data on overall survival. We considered the evidence for the low-risk subgroup to be of a low quality.EBRT was associated with significantly increased severe acute toxicity (two trials, 1328 patients, RR 4.68, 95% CI 1.35 to 16.16), increased severe late toxicity (six trials, 3501 women; RR 2.58, 95% CI 1.61 to 4.11) and significant reductions in quality of life scores and rectal and bladder function more than 10 years after randomisation (one trial, 351 women) compared with no EBRT.One trial of VBT versus no additional treatment in women with low-risk lesions reported a non-significant reduction in locoregional recurrence in the VBT group compared with the no additional treatment group (RR 0.39, (95% CI 0.14 to 1.09). There were no significant differences in survival outcomes in this trial. AUTHORS' CONCLUSIONS EBRT reduces the risk of locoregional recurrence but has no significant impact on cancer-related deaths or overall survival. It is associated with significant morbidity and a reduction in quality of life, and bladder and rectal function. EBRT may have an adverse effect on endometrial cancer survival when used to treat uncomplicated low-risk (IA/B grade 1/2) endometrial cancer. There is no demonstrable survival advantage from adjuvant EBRT for high-risk stage I endometrial cancer, however, the meta-analyses of this subgroup were underpowered and also included high-intermediate risk women. Further research is likely to have an important impact on our confidence in the estimates of effects and may change the estimates. Therefore, whilst there appears to be no survival benefit in the routine use of EBRT in women with stage I endometrial cancer, we cannot exclude a benefit in high-risk women. VBT is potentially useful in intermediate-risk and high-risk subgroups but evidence from further RCTs is needed. In addition, the definitions of risk should be standardised.
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Affiliation(s)
- Anthony Kong
- Department of Oncology, Oxford University Hospitals NHS Trust and Oxford University, Oxford, UK.
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McMeekin DS. What should lymphadenectomy offer in early-stage endometrial cancer: lots of variables, little control. Am J Obstet Gynecol 2011; 205:509-10. [PMID: 22114937 DOI: 10.1016/j.ajog.2011.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 09/06/2011] [Indexed: 11/18/2022]
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Endometrial cancer: prognostic significance of risk classification based on pre-intraoperative findings. Arch Gynecol Obstet 2011; 285:521-7. [PMID: 21779772 DOI: 10.1007/s00404-011-2004-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2010] [Accepted: 07/08/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE The aim of this study was to determine whether a pre-intraoperative prognostic classification of endometrial cancer (EC) patients may accurately predict prognosis. METHODS Prognostic factors achievable before and during surgery (histotype, grade, myoinvasion, cervical spread, abdominal spread) were utilized to classify patients in low-risk (endometrial adenocarcinoma, grade 1-2, myoinvasion <50%, no evidence of abdominal spread), and in intermediate/high risk (serous papillary and clear cell, grade 3, myoinvasion >50%, cervical invasion, abdominal spread). Risk classification obtained pre-intraoperatively was compared with the classification obtained from definitive surgical-pathological assessment in 130 consecutive patients with EC treated with surgery. RESULTS Pre-intraoperative risk assessment correctly identified risk classification in 125 (96%) patients; sensitivity, specificity, PPV and NPV were 98%, 94%, 94%, and 98%, respectively. Median follow-up was 38 months (range 6-93), and 14 (10%) patients relapsed (median time 14 months, range 3-60). Relative risk of relapse was higher in intermediate/high-risk patients with both classifications (pre-intraoperative RR 3.37, CI 0.99-11.5; surgical-pathological RR 4.56, CI 1.2-17.3). As regards survival 11 patients have died, 6 due to endometrial cancer and 5 due to intercurrent disease. Five-years DFS according to pre-intraoperative assessment was 89% and 71% for low-risk and intermediate high-risk patients (p = 0.028), respectively; according to definitive assessment was 91% and 70% for low-risk and intermediate/high-risk patients (p = 0.009), respectively. CONCLUSION This classification, giving an accurate risk and prognostic estimate with parameters routinely utilized in clinical practice, may help the surgeon when undertaking the decision to perform limited or extended surgical staging according to tumor and patient characteristics.
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Kwon JS, Mazgani M, Miller DM, Ehlen T, Heywood M, McAlpine JN, Finlayson SJ, Plante M, Stuart GC, Carey MS. The significance of surgical staging in intermediate-risk endometrial cancer. Gynecol Oncol 2011; 122:50-4. [DOI: 10.1016/j.ygyno.2011.02.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 02/24/2011] [Accepted: 02/25/2011] [Indexed: 10/18/2022]
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Boyle JM, Diavolitsis VM, Small W. The role of radiation therapy in uterine-confined endometrial carcinoma. Pract Radiat Oncol 2011; 1:196-203. [DOI: 10.1016/j.prro.2011.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Revised: 02/19/2011] [Accepted: 02/22/2011] [Indexed: 11/30/2022]
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Loubeyre P, Undurraga M, Bodmer A, Petignat P. Non-invasive modalities for predicting lymph node spread in early stage endometrial cancer? Surg Oncol 2011; 20:e102-8. [DOI: 10.1016/j.suronc.2011.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Accepted: 01/19/2011] [Indexed: 11/25/2022]
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Lymphadenectomy as a prognostic marker in uterine non-endometrioid carcinoma. Arch Gynecol Obstet 2011; 285:207-14. [DOI: 10.1007/s00404-011-1914-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 04/19/2011] [Indexed: 01/09/2023]
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Is lymphadenectomy a prognostic marker in endometrioid adenocarcinoma of the human endometrium? BMC Cancer 2010; 10:224. [PMID: 20492712 PMCID: PMC2891635 DOI: 10.1186/1471-2407-10-224] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2009] [Accepted: 05/21/2010] [Indexed: 11/12/2022] Open
Abstract
Background During surgery for endometrial cancer, a pelvic lymphadenectomy with or without para-aortic lymphadenectomy is performed at least in patients with risk factors (stage I, grading 2 and/or histological subtypes with higher risk of lymphatic spread), and is hence recommended by the International Federation of Obstetrics and Gynecology (FIGO). Although lymph node metastases are important prognostic parameters, it has been contentious whether a pelvic lymph node dissection itself has a prognostic impact in the treatment of endometrial cancer, especially in endometrioid adenocarcinoma. Therefore, this study evaluated whether lymphadenectomy has a prognostic impact in patients with endometrioid adenocarcinoma. Methods The benefits of lymphadenectomy were examined in 214 patients with a histological diagnosis of endometrial adenocarcinoma. Tumour characteristics were analysed with respect to the surgical and pathological stage. Results Of the 214 patients with endometrial adenocarcinoma, 171 (79.9%) were classified as FIGO stage I, 15 (7.0%) FIGO stage II, 21 (9.8%) FIGO stage III and 7 (3.3%) FIGO stage IV. One hundred and thirty four (62.6%) of the patients had a histological grade 1 tumour, while 56 (26.2%) and 24 (11.2%) had a histological grade 2 or grade 3 tumour, respectively. Lymphadenectomy was performed in 151 (70.6%) patients. Only 11 (5.1%) patients showed metastatic disease in the lymph nodes. The performance of a lymphadenectomy resulted in significantly increased cause-specific and overall survival, while progression-free survival was not affected by this operative procedure. Conclusions The performance of an operative lymphadenectomy resulted in better survival of patients with endometrioid adenocarcinoma. This increase was significant for cause-specific and overall survival, while there was a tendency only towards increased progression-free survival. Therefore, even in endometrioid adenocarcinoma, a pelvic and/or para-aortic lymphadenectomy should be performed.
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Seamon LG, Cohn DE, Richardson DL, Hurt JD, Nickerson EC, Fowler JM. Robotic Pelvic and Aortic Lymphadenectomy for Endometrial Cancer: The Console Surgeon's Perspectives on Surgical Technique and Directing the Assistant. J Minim Invasive Gynecol 2010; 17:180-5. [DOI: 10.1016/j.jmig.2009.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Revised: 11/02/2009] [Accepted: 11/04/2009] [Indexed: 11/17/2022]
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[Is there an interest in para-aortic lymphadenectomy in operable endometrial cancer?]. Bull Cancer 2009; 97:199-209. [PMID: 19812008 DOI: 10.1684/bdc.2009.0956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The indication and extent of lymph node dissection in the surgical management of endometrial cancer remains controversial especially concerning the para-aortic lymph nodes. The therapeutic benefit of the lymph node dissection is criticized mainly for low-risk patients for extra-uterine spread. Surgically staging patients is the best method to predict node involvement and it allows an optimal decision for adjuvant therapy to be taken. The different prognostic factors for para-aortic lymph nodes metastasis are histological grade and size of the tumour, myometrial wall invasion and lymphovascular dissemination, as well as positive pelvic lymph nodes. However, these elements are not correctly evaluated before and during the surgery. Positive para-aortic lymph nodes can be found without a lymphatic spread to the pelvic area. Even though the prevalence of para-aortic node involvement is weak, it seems legitimate to propose in selected cases of important lymph node involvement, it's complete dissection if a pelvic lymphadenectomy is indicated and if it is surgically possible.
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Are Uterine Risk Factors More Important Than Nodal Status in Predicting Survival in Endometrial Cancer? Obstet Gynecol 2009; 114:736-743. [DOI: 10.1097/aog.0b013e3181b96ec6] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Many reports suggest the significance of pelvic lymph-node (PLN) adenectomy in patients with endometrial cancer. However, among these, there is controversy regarding not only what type of patients should have lymphadenectomy performed, but also what extent lymphadenectomy should be performed. RECENT FINDINGS It has been reported that PLN adenectomy has therapeutic significance in stage I grade 3 and more advanced endometrioid uterine cancer. However, the effects of para-aortic lymph-node adenectomy on its prognostic benefit have not been discussed. SUMMARY Patients with low-risk disease might not benefit from PLN adenectomy. However, PLN adenectomy might still have merit in low-risk patients, as there are inaccuracies of preoperative and intraoperative assessments. A complete lymphadenectomy is safe with minimum complications. At this point, hysterectomy and bilateral salpingo-oophorectomy with complete PLN adenectomy as the standard surgical procedure for endometrial cancer is thought to be reasonable. At present, the addition of p-aortic lymph-node adenectomy is regarded as an investigated protocol for endometrial cancer. However, p-aortic lymph-node adenectomy may have a therapeutic role for stage IIIC patients. Prospective randomized controlled trial composed of intermediate/high-risk patients should be conducted to clearly demonstrate prognostic improvement by p-aortic lymph-node adenectomy itself.
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Abstract
Endometrial cancer is the most common gynecologic malignancy in the United States. The majority of women are diagnosed with early-stage disease. Surgical therapy of early-stage endometrial cancer includes full staging, including pelvic and para-aortic lymphadenectomy. While most women with early-stage endometrial cancer can anticipate cure with surgery alone, a significant minority of women with deeply invasive or high-grade tumors will experience local, regional, or distant recurrences of their disease. Therefore, adjuvant therapies have been proposed for these women. While radiotherapy is effective at reducing the risk of local and regional tumor recurrence, studies have demonstrated no improvement on survival. The role of systemic adjuvant chemotherapies in this high-risk, early-stage patient population is currently the focus of several randomized trials. In addition, for women with early-stage tumors with atypical histology, such as papillary serous and clear cell malignancies, the role of adjuvant therapy remains uncertain. Optimizing management of women with early-stage disease requires a careful assessment of the risk of recurrent disease, the potential benefit of various adjuvant strategies, and the risk associated with adjuvant therapy. New molecular markers may be helpful in the future to refine our ability to identify high-risk, early-stage patients.
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Affiliation(s)
- Karen H Lu
- Department of Gynecologic Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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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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Endometrial cancer and lymph node surgery: the spins continue — A case for reason. Gynecol Oncol 2008; 111:3-6. [DOI: 10.1016/j.ygyno.2008.07.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Accepted: 07/02/2008] [Indexed: 11/22/2022]
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Kuoppala T, Mäenpää J, Tomas E, Puistola U, Salmi T, Grenman S, Lehtovirta P, Fors M, Luukkaala T, Sipilä P. Surgically staged high-risk endometrial cancer: Randomized study of adjuvant radiotherapy alone vs. sequential chemo-radiotherapy. Gynecol Oncol 2008; 110:190-5. [DOI: 10.1016/j.ygyno.2008.03.020] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2008] [Revised: 03/14/2008] [Accepted: 03/29/2008] [Indexed: 10/22/2022]
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Kohler MF, Creasman WT. Controversies surrounding lymphadenectomy and postoperative radiotherapy in the treatment of carcinoma of the endometrium. Future Oncol 2008; 4:379-87. [DOI: 10.2217/14796694.4.3.379] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Hysterectomy and bilateral salpingo-oophorectomy have long been acknowledged to be the centerpiece of therapy for carcinoma of the endometrium. However, 30 years ago, realization of the metastatic potential of this disease, particularly to regional lymph nodes, led many clinicians to include lymphadenectomy in the surgical management of uterine cancer. Retrospective studies have since demonstrated that lymphadenectomy is associated with an acceptably low level of surgical morbidity. The incorporation of lymphadenectomy into the surgical management of uterine cancer has accompanied a dramatic reduction in the use of peri-operative radiotherapy. Though not confirmed by prospective data, retrospective series have associated complete lymphadenectomy with an improvement in survival, even in node-negative patients. Contributing to a reduction in the use of postoperative radiation in endometrial cancer have been several randomized trials demonstrating a reduction in locoregional recurrence, but at the cost of significant radiation-induced toxicity and no improvement in overall survival.
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Affiliation(s)
- Matthew F Kohler
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Medical University of South Carolina, Charleston, SC 29425, USA
| | - William T Creasman
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Medical University of South Carolina, Charleston, SC 29425, USA
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Thomas GM, Aalders JG. “Rational risk based nodal staging in endometrial cancer”. Gynecol Oncol 2008. [DOI: 10.1016/j.ygyno.2007.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Orr JW, Naumann WR, Escobar P. “Attitude is a little thing that makes a big difference” Winston Churchill. Gynecol Oncol 2008; 109:147-51; author reply 151-3. [DOI: 10.1016/j.ygyno.2007.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Accepted: 12/14/2007] [Indexed: 10/22/2022]
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Prospective assessment of lymphatic dissemination in endometrial cancer: a paradigm shift in surgical staging. Gynecol Oncol 2008; 109:11-8. [PMID: 18304622 DOI: 10.1016/j.ygyno.2008.01.023] [Citation(s) in RCA: 564] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 01/16/2008] [Accepted: 01/17/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To prospectively assess pelvic and para-aortic lymph node metastases in endometrial cancer with lymphatic dissemination, emphasizing the examination of para-aortic metastases relative to the inferior mesenteric artery (IMA). METHODS Over 36 months, 422 consecutive patients were managed by predefined surgical guidelines differentiating low-risk patients from patients at risk for dissemination requiring systematic lymphadenectomy. Low risk was defined as grade 1 or 2 endometrioid type with myometrial invasion (MI) < or = 50% and primary tumor diameter (PTD) < or = 2 cm. Pelvic and para-aortic lymph nodes were submitted separately, with nodes identified from all 8 pelvic and 4 para-aortic node-bearing basins. Surgical quality assessments examined median node counts (primary surrogate for quality) and nodes harvested above and below the IMA and excised gonadal veins (secondary surrogates). RESULTS Lymphadenectomy was not required in 27% of patients (all low risk) and in 33% (n=112) of endometrioid cases. However, 22 patients (20%) of this latter cohort had lymphadenectomy and all lymph nodes were negative. Sixty-three (22%) of 281 patients undergoing lymphadenectomy had lymph node metastases: both pelvic and para-aortic in 51%, only pelvic in 33%, and isolated to the para-aortic area in 16%. Therefore, 67% of patients with lymphatic dissemination had para-aortic lymph node metastases. Furthermore, 77% of patients with para-aortic node involvement had metastases above the IMA, whereas nodes in the ipsilateral para-aortic area below the IMA and ipsilateral common iliac basin were declared negative in 60% and 71%, respectively. Gonadal veins were excised in 25 patients with para-aortic node metastases; 7 patients (28%) had documented metastatic involvement of gonadal veins or surrounding soft tissue. CONCLUSIONS The high rate of lymphatic metastasis above the IMA indicates the need for systematic pelvic and para-aortic lymphadenectomy (vs sampling) up to the renal vessels. The latter should include consideration of excision of the gonadal veins. Conversely, lymphadenectomy does not benefit patients with grade 1 and 2 endometrioid lesions with MI < or = 50% and PTD < or = 2 cm.
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Lachance JA, Stukenborg GJ, Schneider BF, Rice LW, Jazaeri AA. A cost-effective analysis of adjuvant therapies for the treatment of stage I endometrial adenocarcinoma. Gynecol Oncol 2008; 108:77-83. [DOI: 10.1016/j.ygyno.2007.08.072] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Revised: 08/20/2007] [Accepted: 08/20/2007] [Indexed: 10/22/2022]
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Bakkum-Gamez JN, Gonzalez-Bosquet J, Laack NN, Mariani A, Dowdy SC. Current issues in the management of endometrial cancer. Mayo Clin Proc 2008; 83:97-112. [PMID: 18174012 DOI: 10.4065/83.1.97] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Endometrial cancer (EC) remains the most common gynecologic malignancy in the United States. It is expected to become more common as the prevalence of obesity, one of the most common risk factors for EC, increases worldwide. The 2 main histologic subcategories of EC, endometrioid and nonendometrioid EC, show unique molecular aberrations and are responsible for markedly disparate clinical behaviors. The primary treatment of EC is surgery, ie, hysterectomy, removal of the adnexa, and pelvic and para-aortic lymphadenectomy, either via laparotomy or endoscopic techniques. Adjuvant therapy is necessary for patients at high risk of recurrence and consists of vaginal brachytherapy, teletherapy, systemic chemotherapy, or some combination thereof. Multi-institutional trials are in progress in this country and in Europe to better define optimal adjuvant treatment for subsets of patients, as well as the role of surgical staging in reducing both overuse and underuse of radiation therapy. Hormonal therapy is an option for some young women with EC who wish to preserve fertility. This review summarizes the diagnosis and management of EC and discusses current controversies and upcoming investigations pertaining to EC staging and adjuvant treatment.
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Affiliation(s)
- Jamie N Bakkum-Gamez
- Division of Gynecologic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Abstract
Although surgical pathological staging is the standard of care for uterine carcinoma, the benefits of a complete lymphadenectomy remain controversial. Evidence suggests that this procedure provides prognostic information and directs the use of appropriate adjuvant treatment in patients who are node-positive. Furthermore, it eliminates the need for adjuvant treatment in low-risk patients with negative nodes and no extrauterine spread of disease. Although the complications associated with this procedure raise the question as to whether all low-risk patients need a complete lymphadenectomy, the limitations of preoperative and intraoperative pathological analyses mean that lymphadenectomy in low-risk patients might still have merit. Future advances are warranted to enhance preoperative radiological and intraoperative pathological assessment to establish the risk of nodal disease. In this review, we assess the evidence on the prognostic and therapeutic benefits of a complete versus selective lymphadenectomy. Moreover, we discuss the complications associated with lymphadenectomy and identify subsets of low-risk patients who might not need to undergo this procedure.
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Affiliation(s)
- John K Chan
- University of California, San Francisco Comprehensive Cancer Center, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco School of Medicine, San Francisco, CA, USA.
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Tangjitgamol S, Manusirivithaya S, Lertbutsayanukul C. Adjuvant therapy for early-stage endometrial cancer: a review. Int J Gynecol Cancer 2007; 17:949-56. [PMID: 17309664 DOI: 10.1111/j.1525-1438.2007.00860.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Most patients with endometrial cancer (EMC) present their symptoms early in their course, leading to an overall favorable outcome. However, some patients who are in early-stage diseases may carry some risk features that would hamper their prognoses. For these early-stage diseases with high risk of recurrences, radiation therapy certainly plays a major role as an adjuvant treatment. Despite an excellent local diseases control by radiation, systemic failures are still encountered. To improve the prognoses, other types of adjuvant therapy have been attempted. In this review, various options of adjuvant treatment for this early-stage EMC including radiation therapy, chemotherapy, and hormonal therapy are discussed.
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Affiliation(s)
- S Tangjitgamol
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology, Bangkok Metropolitan Administration Medical College and Vajira Hospital, Bangkok, Thailand.
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Kwon JS, Carey MS, Goldie SJ, Kim JJ. Cost-effectiveness analysis of treatment strategies for Stage I and II endometrial cancer. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2007; 29:131-139. [PMID: 17346483 DOI: 10.1016/s1701-2163(16)32387-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Practice patterns vary across Canada with respect to indications for surgical staging and adjuvant radiotherapy in early endometrial cancer. We evaluated the cost-effectiveness of two common strategies for managing early endometrial cancer as part of an Ontario population-based study. METHODS A decision-analytic model (DATA 4.5) was developed for Stage I and II endometrioid-type cancer using empiric data from Ontario. On the basis of preoperative biopsy grade, one of two surgical procedures was selected: (1) hysterectomy and bilateral salpingo-oophorectomy (HBSO) or (2) surgical staging (HBSO and pelvic +/- para-aortic lymphadenectomy). Adjuvant radiotherapy (RT) was administered according to final grade and stage. After HBSO, pelvic RT was indicated for Grades 1 and 2 if Stage IC, IIA with > 50% myometrial invasion (MI), or IIB, and for Grade 3 if Stage IB, IC, IIA, or IIB. After staging, pelvic RT was indicated for Grades 1 and 2 if Stage IIB, and for Grade 3 if Stage IC, IIA with > 50% MI, or IIB. Main outcome measures were quality-adjusted life-years (QALY) and incremental cost-effectiveness ratios (ICER). Sensitivity analyses were used to evaluate uncertainty around various parameters. RESULTS The most cost-effective (dominant) strategies were determined for each preoperative grade. For Grade 1, HBSO strongly dominated surgical staging. For Grade 2, neither strategy was dominant; surgical staging had an ICER of $5216 per QALY. For Grade 3, surgical staging strongly dominated HBSO. These results were stable over a wide range of estimates for costs and utilities (i.e., patient preferences for a particular health state). CONCLUSION The most cost-effective treatment strategies for early endometrial cancer in Ontario differ according to preoperative grade.
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Affiliation(s)
- Janice S Kwon
- Department of Obstetrics and Gynecology, University of Western Ontario, London ON
| | - Mark S Carey
- Department of Obstetrics and Gynecology, University of Western Ontario, London ON
| | - Sue J Goldie
- Department of Health Policy and Management, Harvard School of Public Health, Boston MA
| | - Jane J Kim
- Department of Health Policy and Management, Harvard School of Public Health, Boston MA
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Yaegashi N, Ito K, Niikura H. Lymphadenectomy for endometrial cancer: is paraaortic lymphadenectomy necessary? Int J Clin Oncol 2007; 12:176-80. [PMID: 17566839 DOI: 10.1007/s10147-006-0621-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Indexed: 11/28/2022]
Abstract
Total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) have been performed as a standard surgical treatment for endometrial cancer. Many studies have reported on issues such as whether retroperitoneal lymphadenectomy should also be performed with TAH+BSO, to what extent lymphadenectomy should be performed when TAH+BSO is performed, and in what type of patients should lymphadenectomy be performed. These issues have been actively discussed, but there has not been any consensus. In this review article, the benefits of retroperitoneal lymphadenectomy in the initial surgical treatment for endometrial cancer will be discussed in terms of patients with pelvic lymphadenectomy and those with paraaortic (PA) lymphadenectomy. From the previous data, the establishment of TAH+BSO plus pelvic lymphadenectomy as the standard surgical treatment for endometrial cancer is thought to be reasonable. In this situation, is there benefit in performing PA lymphadenectomy? A discussion will be provided by separating the diagnostic significance from the therapeutic significance of this treatment. At present, there are no established treatments for PA-lymph node-positive patients that can be recommended more than the adjuvant therapies that are already performed at various institutions. A scientific basis that clearly indicates the therapeutic effect of PA lymphadenectomy does not exist at the present time. Despite performing thorough PA lymphadenectomy, the route of progression to extrauterine sites cannot be completely controlled. The standard surgical procedure for endometrial cancer is TAH+BSO+pelvic lymphadenectomy, which is considered necessary and sufficient. At present, the addition of PA lymphadenectomy for endometrial cancer can be regarded as only an investigated protocol.
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Affiliation(s)
- Nobuo Yaegashi
- Department of Obstetrics and Gynecology, Tohoku University, Graduate School of Medicine, Sendai, 980-8574, Japan.
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Cohn DE, Huh WK, Fowler JM, Straughn JM. Cost-Effectiveness Analysis of Strategies for the Surgical Management of Grade 1 Endometrial Adenocarcinoma. Obstet Gynecol 2007; 109:1388-95. [PMID: 17540812 DOI: 10.1097/01.aog.0000262897.21628.06] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate the costs and outcomes of various strategies used for the management of grade 1 endometrial cancer. METHODS A cost-effectiveness analysis compared three strategies for the management of grade 1 endometrial cancer: 1) surgical staging in all patients (including hysterectomy and lymphadenectomy); 2) frozen section following hysterectomy with surgical staging based on the results of tumor grade and depth of myometrial invasion; and 3) hysterectomy without surgical staging (no staging). Surgical probabilities and recurrence rates were estimated from published data. Actual payer costs of surgery, radiation therapy, and chemotherapy were estimated for each strategy. Cost-effectiveness ratios were estimated for each strategy. Sensitivity analyses evaluated the costs of radiation and survival estimates used in the model. RESULTS For the estimated 10,000 women diagnosed annually with grade 1 endometrial cancer in the United States, the annual cost of surgical staging is $240.4 million, compared with $252.4 million for frozen section and $255.8 million for no staging. Five-year disease-free survival for surgical staging is 87.9%, compared with 87.3% for frozen section and 86.7% for no staging. This translates into a lower cost-effectiveness ratio for surgical staging ($27,337) compared with frozen section ($28,913) or no staging ($29,513). Surgical staging yielded 64 additional disease-free patients per 10,000 patients compared with frozen section and 126 additional disease-free patients compared with no staging. Use of adjuvant radiation therapy was the lowest in the surgical staging strategy (13%). CONCLUSION Surgical staging of all patients with grade 1 endometrial cancer is the most cost-effective strategy and decreases the use of radiation therapy without negatively impacting survival.
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Affiliation(s)
- David E Cohn
- Division of Gynecologic Oncology, Ohio State University College of Medicine, Columbus, Ohio, USA.
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