Prospective assessment of lymphatic dissemination in endometrial cancer: A paradigm shift in surgical staging

• Published in: Gynecologic oncology Vol. 109; no. 1; pp. 11 - 18
• Main Authors: Mariani, Andrea, Dowdy, Sean C, Cliby, William A, Gostout, Bobbie S, Jones, Monica B, Wilson, Timothy O, Podratz, Karl C
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.04.2008
• Subjects: Adult; Aged; Aged, 80 and over; Aorta; Endometrial neoplasms; Endometrial Neoplasms - pathology; Endometrial Neoplasms - surgery; Female; Hematology, Oncology and Palliative Medicine; Humans; Hysterectomy; Laparoscopy; Lymph Node Excision; Lymph Nodes - pathology; Lymph Nodes - surgery; Lymphatic Metastasis; Mesenteric Artery, Inferior; Middle Aged; Neoplasm Staging; Obstetrics and Gynecology; Outcomes assessment; Prospective Studies; myometrial invasion; PTD; Gynecological Oncology Group trial 99; FIGO; GOG-99; Lymph node excision; Postoperative Radiation Therapy for Endometrial Carcinoma; inferior mesenteric artery; Lymphatic metastasis; International Federation of Gynecology and Obstetrics; IMA; MI; PORTEC; primary tumor diameter; Endometrial neoplasms; Outcomes assessment
• ISSN: 0090-8258; 1095-6859
• DOI: 10.1016/j.ygyno.2008.01.023

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) ≤ 50% and primary tumor diameter (PTD) ≤ 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 ≤ 50% and PTD ≤ 2 cm.