Elsevier

The Lancet Oncology

Volume 8, Issue 9, September 2007, Pages 831-841
The Lancet Oncology

Review
Role of complete lymphadenectomy in endometrioid uterine cancer

https://doi.org/10.1016/S1470-2045(07)70275-9Get rights and content

Summary

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.

Introduction

Uterine corpus cancer is the most common gynaecological malignancy in developed countries.1 Most patients with endometrioid uterine cancer present at an early stage and have a good prognosis, but those with advanced disease have a significantly worse survival. Up to 20% of patients with endometrial cancer relapse and eventually die of their disease. In the USA, the annual number of deaths has increased, with about 3000 in the 1980s, 5000 in the 1990s, and 7000 in more recent years.1 In view of this increase, improvements are needed in the early diagnosis and treatment of this cancer. Previous studies suggest that age, stage, histology, tumour grade, myometrial invasion, and nodal involvement are important prognosticators.2, 3 One of the challenges in defining the optimum surgical treatment of endometrial cancer arises from inconsistencies in staging and, in particular, lymph-node assessment. This review focuses on comparing the benefits and risks of a complete (Figure 1, Figure 2) versus selective lymphadenectomy in patients with endometrioid corpus cancer.

Section snippets

Current practices around the world

In 1988, the staging of endometrial uterine cancer was changed from clinical to surgical staging, including pelvic and para-aortic lymphadenectomy on the basis of the International Federation of Gynaecologists and Obstetricians (FIGO) criteria.4 The role of comprehensive surgical staging, especially pelvic and para-aortic lymphadenectomy for all patients, remains controversial. Because of the lack of consistency in recommendations, the surgical treatment of endometrial cancer in academic and

Inaccuracies of preoperative and intraoperative assessment

Several investigators have advocated the use of preoperative or intraoperative pathological assessment of histological grade and depth of invasion, on the basis of gross inspection or frozen section, to identify patients at risk of nodal metastases who might benefit from a lymphadenectomy. However, most studies have shown that about 30% of tumours with preoperative grade 1 histology have a postoperative histological diagnosis indicating a higher risk for metastatic disease and, therefore, these

Prognostic relevance of positive lymph nodes

Surgical staging remains the most precise method for identifying nodal metastases. Standardised surgical staging provides prognostic information and helps formulate comparative assessments. Because lymph-node spread represents the most common site of extrauterine disease in endometrial cancer, identification of patients with nodal metastases is important for providing guidance on prognosis and adjuvant treatment. A review of 1109 patients with clinical stage I–II endometrial uterine cancer

Improved likelihood of finding a positive lymph node

Although complete lymphadenectomy is the standard of care in women with cervical and vulvar cancers, the role of a complete lymphadenectomy remains controversial in endometrioid uterine cancer. Because lymph-node metastasis is an important prognostic factor, adequate lymph-node dissection needs to be done to ensure a high probability of detecting a positive node. Previous studies have used arbitrary numbers to define such an adequate nodal dissection. Single institutional studies have claimed

Conclusion

Although complete lymph-node dissection should be used for most patients with endometrioid uterine cancer, those with low-risk disease might not benefit from lymphadenectomy. However, given the restrictions of preoperative and intraoperative pathological analyses, the role of lymphadenectomy in low-risk patients might still have merit. A complete lymphadenectomy provides prognostic information and directs the use of appropriate adjuvant treatment in node-positive patients. Additionally, it can

Search strategy and selection criteria

Published data were identified by a search of Pubmed, using the term “endometrial cancer” in combination with the terms “node metastases”, “adjuvant radiotherapy”, “intraoperative pathology”, “vascular space invasion”, and “myometrial depth”. Only studies published in English between 1966 and 2006 were included.

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