Elsevier

Gynecologic Oncology

Volume 104, Issue 1, January 2007, Pages 222-231
Gynecologic Oncology

Review
Endometrial cancer—Revisiting the importance of pelvic and para aortic lymph nodes

https://doi.org/10.1016/j.ygyno.2006.10.013Get rights and content

Abstract

In 1998, FIGO (International Federation of Gynecologists and Obstetricians) required a change from clinical to surgical staging in early endometrial cancer. This staging requirement raised numerous controversies around the importance of determining nodal status and its impact on outcomes. A diversity of opinions exists as to the actual benefits and toxicities associated with surgical staging which includes lymph node sampling, ranging from those whose opinion is that staging is required for all patients even when the a priori risk of nodal involvement is extremely low through to those who consider that staging is unnecessary in any patient.

While knowledge of the presence or absence of extra uterine sites of disease may change treatment approaches and direct different treatment interventions in some patients, the impact of those changes on survival is much less clear.

This paper examines recommendations for surgical staging in various subgroups of patients with clinically early endometrial cancer and the impact on survival and toxicity of the various approaches and the subsequent use of adjuvant irradiation and/or chemotherapy.

Section snippets

Unstaged “high-risk” disease and routine adjuvant pelvic irradiation

The apparent “high-risk” group [3], [17] constitutes 25% of the early population; extra uterine disease is predicted in 25% of them (i.e., 6 patients of 100 presenting). Half of those with extra uterine disease will have extra nodal sites of disease including those with cytology positive only [31]. If the high-risk group are not staged (Fig. 1), routine adjuvant external beam pelvic irradiation is usual practice. Two relevant randomized studies provide an understanding of outcomes; the first by

Staging only the high risk

The relatively negative consequences of following algorithm 1 (Fig. 1) have led many [33], [34] to consider an alternate treatment algorithm (Fig. 3). In this algorithm, only patients having “high-risk” clinical stage I disease by virtue of grade and myometrial depth would have surgical staging. Of the 25 patients surgically staged, 17 would have no evidence of extra uterine disease although a few would have stage IIB disease. Many would argue that the 17 can be spared “unnecessary” irradiation

“High-risk” summary

Surgical staging may be justified in the clinically high-risk patients since 11 patients in 100 would be spared unnecessary pelvic irradiation and 5 in 100 will have extra pelvic uterine disease detected for which different treatments may be recommended. It would appear at the present time that patients with grade III outer half disease whose nodal status is unknown may benefit from pelvic irradiation (possibly external beam plus vault brachytherapy) if not subjected to a further staging

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