Survival Analysis of Endometrial Cancer Patients With Positive Lymph Nodes

The da Vinci robotic surgery system for the management of endometrial cancer: a single-center experience

The aim of this study was to report our single-center experience of the da Vinci robotic surgery system in the management of endometrial cancer (EC) patients during 2019-2023. We descriptively summarized the preoperative, intraoperative, and postoperative outcomes. Moreover, we conducted subgroup analyses based on obesity (BMI ≥ 30 kg/m2) and the intraoperative use of indocyanine green dye (ICG). Overall, 100 patients were analyzed. Eighty-five patients (85%) were obese. The mean operative time and estimated blood loss (EBL) were 240.84 ± 70.08 min (range: 110-720) and 104.2 ± 80.3 ml (range: 20-500), respectively. The mean number of retrieved pelvic LNs was 3.01 ± 3.06 (range: 0-15). The use of ICG was employed in 58 (58%). Only a single patient (1%) underwent conversion to laparotomy. Besides, only three (3%) patients experienced vaginal laceration intraoperatively, respectively. The mean hospital stay was 1.34 ± 0.69 days (range: 1-5). No patient experienced postoperative complications. Most tumors had endometrioid histology (82%), grade-1 tumor (49%), and stage-1A disease (67%). At 3-year follow-up, only two patients (2%) developed recurrence. Patients who received the ICG had significantly lower operative time (225.86 vs. 261.52 min, p = 0.011), estimated blood loss (90 vs. 123.81 ml, p = 0.037), and hospital stay (1.12 vs. 1.64 days, p < 0.001) compared with patients who did not receive it. However, there was no significant difference between both groups regarding the number of retrieved pelvic LNs. Obesity had no significant impact on the rates of intraoperative complications, postoperative complications, and 3-year recurrence incidence. In conclusion, robotic surgery was technically feasible and safe. The use of ICG was statistically linked to favorable outcomes, in terms of decreased operative time, EBL, and hospital stay. Obesity did not impact the perioperative surgical outcomes.

Uterine Neoplasms, Version 1.2023, NCCN Clinical Practice Guidelines in Oncology

Adenocarcinoma of the endometrium (also known as endometrial cancer, or more broadly as uterine cancer or carcinoma of the uterine corpus) is the most common malignancy of the female genital tract in the United States. It is estimated that 65,950 new uterine cancer cases will have occurred in 2022, with 12,550 deaths resulting from the disease. Endometrial carcinoma includes pure endometrioid cancer and carcinomas with high-risk endometrial histology (including uterine serous carcinoma, clear cell carcinoma, carcinosarcoma [also known as malignant mixed Müllerian tumor], and undifferentiated/dedifferentiated carcinoma). Stromal or mesenchymal sarcomas are uncommon subtypes accounting for approximately 3% of all uterine cancers. This selection from the NCCN Guidelines for Uterine Neoplasms focuses on the diagnosis, staging, and management of pure endometrioid carcinoma. The complete version of the NCCN Guidelines for Uterine Neoplasms is available online at NCCN.org.

Therapeutic Benefit of Systematic Lymphadenectomy in Node-Negative Uterine-Confined Endometrioid Endometrial Carcinoma: Omission of Adjuvant Therapy

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.

Long-term survival of a patient with stage IIIC2 grade 3 endometrioid endometrial carcinoma treated with surgery alone

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The therapeutic benefit of lymphadenectomy in endometrial carcinoma is controversial.

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Long-term survival was achieved in a stage IIIC2 patient treated with surgery alone.

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Pelvic and para-aortic lymphadenectomy may have a therapeutic benefit.

Background

The therapeutic benefit of lymphadenectomy in endometrial carcinoma is controversial.

Case

A 70-year-old woman with grade 3 endometrioid endometrial carcinoma with deep myometrial invasion underwent surgical staging comprising total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal cytology, and pelvic and para-aortic lymphadenectomy. Pathological examination revealed micro-metastases in the para-aortic node, pelvic node, and left ovary. Peritoneal cytology was negative, and abnormal p53 expression was not detected. The patient was diagnosed with stage IIIC2 endometrial carcinoma. Adjuvant chemotherapy was advised, but the patient refused chemotherapy and was followed up regularly thereafter. The patient survived without any evidence of disease 67 months after surgery.

Conclusion

Pelvic and para-aortic lymphadenectomy may have a therapeutic benefit in a patient with high-grade endometrioid carcinoma, but without p53 abnormality.

Tumor diameter as a predictor of lymph node involvement in endometrioid type endometrial adenocarcinomas

AIM

To analyze the risk factors of lymph node involvement in pure endometrioid type endometrial cancer and assess factors that necessitate lymphadenectomy.

METHODS

Patients who had been operated on due to endometrial cancer and whose final pathology was reported as pure endometrioid carcinoma between January 2014 and January 2020 were assessed. Hysterectomy, bilateral salpingo-oophorectomy, and systematic lymphadenectomy were performed in all patients. All specimens were reported by expert gynecopathologists.

RESULTS

The lymph node positivity rate was 14.4%. When the study population was classified according to the Mayo risk criteria; lymph node involvement in the low-risk and high-risk groups was 9.1% and 14.8%, respectively and there was no statistically difference (p > 0.05). The median of tumor size and the rate of deep myometrial invasion, lymphovascular space invasion, adnexal involvement, FIGO grade 3 tumor were found significantly higher in the positive lymph node group in univariate analysis. In the receiver operating characteristic curve analysis, the cut-off value of the tumor diameter was determined as 47.5 mm (sensitivity 85%, specificity 62%). Every 10 mm increase in tumor diameter increased the risk of lymph node involvement 10 times.

CONCLUSION

This study defined that the tumor diameter is an independent predictor for lymphatic dissemination. In the future, it could be shown that even with new modeling based on tumor diameter, lymphadenectomy or adjuvant radiotherapy requirements would be reevaluated.

Stage IIIC endometrial cancer review: Current controversies in adjuvant therapy

Stage IIIC is the most common stage of locally advanced sub-stage of endometrial cancer, nevertheless, the optimal management for these patients remains controversial. Adjuvant chemotherapy alone more effectively suppressed distant metastases but resulted in a higher rate of pelvic failure, while adjuvant radiation more effectively controlled pelvic recurrences but was associated with more frequent distant metastases. Two recent randomized trials, PORTEC3 and GOG 258, each have attempted to integrate multimodal therapy. However, heterogeneous cohorts analyzed together, including high risk stage I, stage III and stage IV, limit our ability to make conclusions specific to stage IIIC disease. Here, we review clinical evidence pertaining to management and outcomes with stage IIIC uterine carcinoma with brief discussion on evolving approaches. The studies reviewed demonstrate for stage IIIC disease radiation improves local control but does not confer an overall survival benefit and chemotherapy can improve overall survival. The data seem to suggest that aside from the possibility of defining subgroups that may confer an overall survival benefit from combined modality therapy, the future to improving survival lies in the exploration of better therapeutic regimens that will result from tailored biomarker-based therapy.

A Lymph Node Count-Based AJCC Staging System Facilitates a More Accurate Prediction of the Prognosis of Patients With Endometrial Cancer

Purpose

Both the International Federation of Gynecology and Obstetrics (FIGO) and the American Joint Committee on Cancer (AJCC) staging system for endometrial cancer (EC) defined the N category by the location of metastatic lymph nodes (LNs) rather than the metastatic LN count. We aimed to compare the accuracy of the AJCC staging system and the LN count-based staging system.

Patients and Methods

EC patients were selected from the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2016. Patients' characteristics were collected, including age, race, marital status, histological type, grade, therapeutic measures, the number of metastatic LNs, the number of dissected LNs, vital status, and survival in months. Overall survival (OS) was analyzed by the Kaplan-Meier (KM) method and the concordance index (C-index) was used to compare the prognostic value of the AJCC staging system and the LN count-based staging system.

Results

We identified 4,276 EC cases from the SEER database, including 2,693 patients with stage IIIC1 and 1,583 patients with stage IIIC2. Multivariate analyses showed that independent prognostic factors for patients with stage IIIC1 included age, race, marital status, grade, histology, chemotherapy, and radiotherapy. Independent prognostic factors for patients with stage IIIC2 included age, marital status, grade, histology, chemotherapy, and radiotherapy. The C-index of the AJCC staging system and the LN count-based staging system were 0.483 and 0.617, respectively. At least six LNs should be dissected to ensure the accuracy of the LN count-based staging system.

Conclusion

A modified AJCC staging system based on the count of metastatic LNs might be superior to the current AJCC staging system, which still had room for improvement and further refinements were required. For accurate staging, we recommended that at least six LNs should be examined in the modified AJCC staging system.

Role of adjuvant therapy in stage IIIC2 endometrial cancer

OBJECTIVE

The role of the different types of adjuvant treatments in endometrial cancer with para-aortic node metastases is unclear. The aim of this study was to report oncologic outcomes after adjuvant therapy in patients with stage IIIC2 endometrial cancer.

METHODS

This retrospective single-institution study assessed patients with stage IIIC2 endometrial cancer who underwent primary surgery from January 1984 to December 2014. All patients had hysterectomy (±salpingo-oophorectomy) plus lymphadenectomy (para-aortic nodes, ±pelvic nodes). We included all patients with stage III endometrial cancer and documented para-aortic lymph node metastases (International Federation of Obstetrics and Gynecologists stage IIIC2). We excluded patients who did not provide consent, who had synchronous cancer, or who underwent neoadjuvant chemotherapy. Follow-up was restricted to the first 5 years post-operatively. Cox proportional hazards models, with age as the time scale, was used to evaluate associations of risk factors with disease-free survival and overall survival.

RESULTS

Among 105 patients with documented adjuvant therapy, external beam radiotherapy was administered to 25 patients (24%), chemotherapy to 24 (23%), and a combination (chemotherapy and external beam radiotherapy) to 56 (53%) patients. Most patients receiving chemotherapy and external beam radiotherapy (80%) had chemotherapy first. The majority of relapses had a distant component (31/46, 67%) and only one patient had an isolated para-aortic recurrence. Non-endometrioid subtypes had poorer disease-free survival (HR 2.57; 95% CI 1.38 to 4.78) and poorer overall survival (HR 2.00; 95% CI 1.09 to 3.65) compared with endometrioid. Among patients with endometrioid histology (n=60), chemotherapy and external beam radiotherapy improved disease-free survival (HR 0.22; 95% CI 0.07 to 0.71) and overall survival (HR 0.28; 95% CI 0.09 to 0.89) compared with chemotherapy or external beam radiotherapy alone. Combination therapy did not improve prognosis for patients with non-endometrioid histology (n=45).

CONCLUSIONS

In our cohort of patients with stage IIIC2 endometrioid endometrial cancer, those receiving chemotherapy and external beam radiotherapy had improved survival compared with patients receiving chemotherapy or external beam radiotherapy alone. However, the prognosis of patients with non-endometrioid endometrial cancer remained poor, regardless of the adjuvant therapy administered. Distant recurrences were the most common sites of failure.

Impact of adjuvant radiotherapy on the survival of women with optimally resected stage III endometrial cancer in the era of modern radiotherapy: a retrospective study

Background

The optimal adjuvant treatment for stage III endometrial cancer in the era of modern radiotherapy remains undefined. We investigated the benefit of adjuvant radiotherapy for women who underwent optimal resection for stage III endometrial cancer in the era of modern radiotherapy.

Methods

We retrospectively reviewed patients with endometrial cancer who were treated between 2010 and 2018. Adjuvant treatment included radiotherapy by modern radiotherapy techniques (intensity-modulated or volumetric modulated arc radiotherapy), chemotherapy, or both. Recurrence-free survival (RFS) and overall survival (OS) were calculated using the Kaplan-Meier method and analyzed via multivariate Cox proportional hazards models.

Results

One hundred sixty-one patients were initially included (52, 9, and 100 with stages IIIA, IIIB, and IIIC cancer, respectively); 154 patients (96%) received adjuvant therapy. Such adjuvant treatment was associated with improved RFS (p = 0.014) and OS (p = 0.044) over surgery alone. Adjuvant radiotherapy by modern radiotherapy techniques led to low incidence of acute (25%) and chronic (7%) grade ≥ 2 gastrointestinal toxicity. On univariate analysis, non-endometrioid histology and grade 3 status were associated with higher risks of tumor recurrence and death, whereas adjuvant radiotherapy alone or in combination chemotherapy reduced their risks. On multivariate analysis, non-endometrioid histology was associated with increased recurrence (hazard ratio [HR], 2.95; p = 0.009), whereas adjuvant radiotherapy alone or with chemotherapy was associated with lower recurrence (HR, 0.62; p = 0.042). Patients > 60 years of age (p = 0.038) as well as those with endometrioid histology (p = 0.045), lymphovascular space invasion (p = 0.031), and ≥ 2 positive lymph nodes (p = 0.044) benefited most from adjuvant radiotherapy.

Conclusions

Modern adjuvant radiotherapy (intensity-modulated or volumetric modulated arc radiotherapy) alone or with chemotherapy should be considered for women with optimally resected stage III endometrial cancer.

Trial registration

ClinicalTrials.gov, NCT04251676. Registered 24 January 2020. Retrospectively registered.

Learning curve for sentinel lymph node mapping in gynecologic malignancies

BACKGROUND AND OBJECTIVES

Only a few studies have reported the learning curve for sentinel lymph node (SLN) detection in gynecologic malignancies. We investigated the learning curve for SLN detection during robot-assisted laparoscopic surgery for endometrial and cervical carcinomas.

METHODS

This retrospective analysis included patients with stage IA to IIA1 cervical cancer or stage I to III endometrial cancer who underwent SLN mapping using indocyanine green during robot-assisted laparoscopic surgery performed by a single surgeon. Learning curves were analyzed in consecutive cases using SLN detection rates and the cumulative sum (CUSUM) method.

RESULTS

SLN mapping was achieved in 81.25% (65/80), 77.50% (62/80), and 66.25% (53/80) of the cases involving the right, left, and simultaneous bilateral pelvic areas, respectively. Learning curve analysis based on the cumulative detection rate showed initial fluctuations followed by stabilization; the time required for proficiency was discordant among the LN regions. However, the CUSUM method showed proficient mapping of the right, left, and bilateral SLNs after 27 to 28 cases.

CONCLUSION

At least 27 cases were required for SLN mapping proficiency in gynecologic cancer; the learning period could influence the surgical quality. Further studies are warranted to confirm the impact of this learning curve on disease outcomes.

A multi-institutional analysis of sequential versus 'sandwich' adjuvant chemotherapy and radiotherapy for stage IIIC endometrial carcinoma

Objective

To analyze the outcomes of sequential or sandwich chemotherapy (ChT) and radiotherapy (RT) in patients with node-positive endometrial cancer (EC).

Methods

Data from 4 centers were collected retrospectively for 179 patients with stage IIIC EC treated with postoperative RT and ChT (paclitaxel and carboplatin). Patients were either treated with 6 cycles of ChT followed by RT (sequential arm; 96 patients) or with 3 cycles of ChT, RT, and an additional 3 cycles of ChT (sandwich arm; 83 patients). Prognostic factors affecting overall survival (OS) and progression-free survival (PFS) were analyzed.

Results

The 5-year OS and PFS rates were 64% and 59%, respectively, with a median follow-up of 41 months (range, 5–167 months). The 5-year OS rates were significantly higher in the sandwich than sequential arms (74% vs. 56%; p=0.03) and the difference for 5-year PFS rates was nearly significant (65% vs. 54%; p=0.05). In univariate analysis, treatment strategy, age, International Federation of Gynecology and Obstetrics (FIGO) stage, pathology, rate of myometrial invasion, and grade were prognostic factors for OS and PFS. In multivariate analysis, non-endometrioid histology, advanced FIGO stage, and adjuvant sequential ChT and RT were negative predictors for OS, whereas only non-endometrioid histology was a prognostic factor for PFS.

Conclusion

Postoperative adjuvant ChT and RT for stage IIIC EC patients, either given sequentially or sandwiched, offers excellent clinical efficacy and acceptably low toxicity. Our data support the superiority of the sandwich regimen compared to the sequential strategy in stage IIIC EC patients for OS.

SATEN III—Splitting Adjuvant Treatment of stage III ENdometrial cancers: an international, multicenter study

Introduction

The purposes of this study were to compare adjuvant treatment modalities and to determine prognostic factors in stage III endometrioid endometrial cancer (EC).

Methods

SATEN III was a retrospective study involving 13 centers from 10 countries. Patients who had been operated on between 1998 and 2018 and diagnosed with stage III endometrioid EC were analyzed.

Results

A total of 990 women were identified; 317 with stage IIIA, 18 with stage IIIB, and 655 with stage IIIC diseases. The median follow-up was 42 months. The 5-year disease-free survival (DFS) of patients with stage III EC by adjuvant treatment modality was 68.5% for radiotherapy (RT), 54.6% for chemotherapy (CT), and 69.4% for chemoradiation (CRT) (p=0.11). The 5-year overall survival (OS) for those patients was 75.6% for RT, 75% for CT, and 80.7% for CRT (p=0.48). For patients with stage IIIA disease treated by RT versus CT versus CRT, the 5-year OS rates were 75.6%, 75.0%, and 80.7%, respectively (p=0.48). Negative peritoneal cytology (HR: 0.45, 95% CI: 0.23 to 0.86; p=0.02) and performance of lymphadenectomy (HR: 0.33, 95% CI: 0.16 to 0.77, p=0.001) were independent predictors for improved OS for stage IIIA EC. For women with stage IIIC EC treated by RT, CT, and CRT, the 5-year OS rates were 78.9%, 67.0%, and 69.8%, respectively (p=0.08). Independent prognostic factors for better OS for stage IIIC disease were age <60 (HR: 0.50, 95%CI: 0.36 to 0.69, p<0.001), grade 1 or 2 disease (HR: 0.59, 95% CI: 0.37 to 0.94, p=0.014; and HR: 0.65, 95%CI: 0.46 to 0.91, p=0.014, respectively), absence of cervical stromal involvement (HR: 063, 95% CI: 0.46 to 0.86, p=0.004) and performance of para-aortic lymphadenectomy (HR: 0.52, 95% CI: 0.35 to 0.72, p<0.001).

Discussion

Although not statistically significant, CRT seemed to be a better adjuvant treatment option for stage IIIA endometrioid EC. Systematic lymphadenectomy seemed to improve survival outcomes in stage III endometrioid EC.

Treatment outcomes of endometrial cancer patients with paraaortic lymph node metastasis: a multi-institutional analysis

Objective

To analyze the prognostic factors and treatment outcomes in endometrial cancer patients with paraaortic lymph node metastasis.

Methods

Data from four centers were collected retrospectively for 92 patients with endometrial cancer treated with combined radiotherapy and chemotherapy or adjuvant radiotherapy alone postoperatively, delivered by either the sandwich or sequential method. Prognostic factors affecting overall survival and progression-free survival were analyzed.

Results

The 5-year overall survival and progression-free survival rates were 35 % and 33 %, respectively, after a median follow-up time of 33 months. The 5-year overall survival and progression-free survival rates were significantly higher in patients receiving radiotherapy and chemotherapy postoperatively compared with patients treated with adjuvant radiotherapy alone (P < 0.001 and P < 0.001, respectively). In a subgroup analysis of patients treated with adjuvant combined chemotherapy and radiotherapy, the 5-year overall survival and progression-free survival rates were significantly higher in patients receiving chemotherapy and radiotherapy via the sandwich method compared with patients treated with sequential chemotherapy and radiotherapy (P = 0.02 and P = 0.03, respectively). In the univariate analysis, in addition to treatment strategy, pathology, depth of myometrial invasion, and tumor grade were significant prognostic factors for both overall survival and progression-free survival. In the multivariate analysis, grade III disease, myometrial invasion greater than or equal to 50%, and adjuvant radiotherapy alone were negative predictors for both overall survival and progression-free survival.

Conclusion

We demonstrated that adjuvant combined treatment including radiotherapyand chemotherapy significantly increases overall survival and progression-free survival rates compared with postoperative pelvic and paraaortic radiotherapy.

Current Status of Magnetic Resonance Imaging in Patients with Malignant Uterine Neoplasms: A Review

In this study, we summarize the clinical role of magnetic resonance imaging (MRI) in the diagnosis of patients with malignant uterine neoplasms, including leiomyosarcoma, endometrial stromal sarcoma, adenosarcoma, uterine carcinosarcoma, and endometrial cancer, with emphasis on the challenges and disadvantages. MRI plays an essential role in patients with uterine malignancy, for the purpose of tumor detection, primary staging, and treatment planning. MRI has advanced in scope beyond the visualization of the many aspects of anatomical structures, including diffusion-weighted imaging, dynamic contrast enhancement-MRI, and magnetic resonance spectroscopy. Emerging technologies coupled with the use of artificial intelligence in MRI are expected to lead to progressive improvement in case management of malignant uterine neoplasms.

Chemotherapy Reduces Para-aortic Node Recurrences in Endometrial Cancer With Positive Pelvic and Unknown Para-aortic Nodes

Objective

The objective of this study was to evaluate how the administration of different adjuvant therapies influences the risk for developing recurrences in the para-aortic area in endometrial cancer (EC) with positive pelvic and unknown para-aortic nodes.

Methods

We retrospectively evaluated the data of 58 patients with EC affected by stage IIIC1 who had undergone pelvic but not para-aortic lymphadenectomy from January 1, 1990 to December 31, 2011. Survival outcomes within the first 5 years after surgery were assessed using the Kaplan-Meier model.

Results

Chemotherapy plus radiotherapy, chemotherapy only, and external radiotherapy only were administered in 12 (23%), 18 (34%), and 23 (43%) patients, respectively. Five (9%) patients, who were selected to forego adjuvant therapy due to poor performance status, were excluded from the analysis. Disease-free and overall survivals assessed at 5 years were 54%, and 61%, respectively. All para-aortic recurrences were observed among the patients with endometrioid EC, whereas no cases of para-aortic recurrences were found in patients with nonendometrioid histology (5/36 (14%) vs 0/17 (0%); P = 0.16); the latter were more likely to develop distant (hematogenous, peritoneal, and distant lymphatic) recurrences (P = 0.09). Type of adjuvant therapy was the only factor influencing para-aortic failure: chemotherapy (± radiotherapy) reduced the rate of para-aortic node recurrence in comparison with pelvic radiotherapy as a sole modality (P = 0.01). However, adjuvant therapy did not influence the 5-year survival outcomes (P > 0.05).

Conclusions

In the absence of local treatment (ie, para-aortic lymphadenectomy and radiotherapy), the administration of chemotherapy seems effective in reducing recurrences in the para-aortic area among patients with stage IIIC1 endometrioid EC.

Prognosis for Endometrial Cancer Patients Treated With Systematic Pelvic and Para-Aortic Lymphadenectomy Followed by Platinum-Based Chemotherapy

Objective

The purpose of this study was to analyze the prognosis for endometrial cancer patients treated with systematic pelvic and para-aortic lymphadenectomy (PLA and PALA) followed by platinum-based chemotherapy.

Materials and Methods

From 1994 to 2004, in the Cancer Institute Hospital, 502 patients who were surgically treated with systematic PLA and PALA were enrolled in this study. Their prognosis and clinicopathological features were retrospectively reviewed.

Results

One hundred ninety-one (38.0%) patients received adjuvant platinum-based chemotherapy. Lymph node (LN) metastasis was observed in 80 (15.9%) patients, pelvic-only LN metastasis in 27 (5.4%), para-aortic-only LN metastasis in 15 (3.0%), and both pelvic and para-aortic LN metastasis in 38 (7.6%). The median number of metastatic LNs was 2 (range, 1–57), 1 (range, 1–4), and 6 (range, 2–50) in patients with pelvic-only, para-aortic-only, and both pelvic and para-aortic LN metastasis, respectively (P< 0.001). Only 2.6% (2/76) of patients with no myometrial invasion had LN metastasis, and no less than 8.9% (22/247) of patients with myometrial invasion (limited to the inner half) had LN metastasis. Five-year overall survival (OS) for LN metastasis–negative and –positive patients was 96.7% and 76% (P< 0.001), respectively. Five-year OS for patients with metastasis in 1 or 2 LNs was 84.8% and was significantly higher than that for patients with metastasis in 3 or more LNs (57.8%;P= 0.011). In patients with LN metastasis, 5-year OS of endometrioid adenocarcinoma and non–endometrioid adenocarcinoma cell types was 90.2% and 56.7% (P= 0.0016), respectively.

Conclusions

Under the settings of thorough PLA and PALA followed by intensive platinum-based chemotherapy for endometrial cancer, metastasis in 1 or 2 LNs seems to have little effect on survival, although para-aortic LNs are involved. This therapeutic strategy could not improve the prognosis of patients with metastasis in 3 or more LNs or patients with non–endometrioid adenocarcinoma cell types along with LN involvement.

Factors predicting nodal metastasis in endometrial cancer

PURPOSE

Evaluation of lymph node (LN) metastases in endometrial carcinoma (EC) is an important prognostic factor and a required element of cancer staging. The purpose of this study is to analyze what factors might predict the likelihood of nodal involvement in EC.

METHODS

A retrospective search of our institutional database for hysterectomies with associated LN dissection in women with EC revealed 207 cases between 2005 and 2012. Cases with primary EC, irrespective of histologic subtype, including carcinosarcomas were included in the study, but pure sarcomas were excluded. We evaluated various factors including tumor size (TS; ≤2.0 cm and >2.0 cm), depth of myometrial invasion (DMI; absent, ≤50 %, >50 %), positive pelvic cytology (PPC), cervical stromal invasion (CSI), and lymph-vascular invasion (LVI), to determine which factors correlated with the presence of LN metastasis.

RESULTS

Of the 207 (age = 62.29 ± 10.9, mean ± SD) cases of EC with LN dissection in our study group, 34 (16.42 %) had positive LNs. On univariate analysis, we found that TS (p = 0.04), tumor grade (Grade I and II versus grade III, p < 0.0001), DMI (p < 0.0001), CSI (p < 0.0001), LVI (p < 0.0001), and PPC (p = 0.001) showed statistically significant correlation with LN metastasis. However, on multivariate analysis, only DMI (p = 0.002) and LVI (p = 0.004) independently showed statistically significant correlation with LN metastasis. In addition, 18 (8.7 %) grade I and II (well/moderately differentiated) tumors with TS ≤2.0 cm and <50 % DMI showed no LN metastasis, LVI, CSI, or PPC.

CONCLUSION

We concluded that DMI and LVI were independent factors predictive of LN metastasis.