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

Andrea Mariani, Sean Christopher Dowdy, William Arthur Cliby, Bobbie S. Gostout, Monica B. Jones, Timothy O. Wilson, Karl C. Podratz

Research output: Contribution to journalArticle

497 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)11-18
Number of pages8
JournalGynecologic Oncology
Volume109
Issue number1
DOIs
StatePublished - Apr 2008

Fingerprint

Endometrial Neoplasms
Inferior Mesenteric Artery
Lymph Node Excision
Neoplasm Metastasis
Lymph Nodes
Veins
Lymphatic Metastasis
Neoplasms
Guidelines
Kidney

Keywords

  • Endometrial neoplasms
  • Lymph node excision
  • Lymphatic metastasis
  • Outcomes assessment

ASJC Scopus subject areas

  • Obstetrics and Gynecology
  • Oncology

Cite this

Prospective assessment of lymphatic dissemination in endometrial cancer : A paradigm shift in surgical staging. / Mariani, Andrea; Dowdy, Sean Christopher; Cliby, William Arthur; Gostout, Bobbie S.; Jones, Monica B.; Wilson, Timothy O.; Podratz, Karl C.

In: Gynecologic Oncology, Vol. 109, No. 1, 04.2008, p. 11-18.

Research output: Contribution to journalArticle

Mariani, Andrea ; Dowdy, Sean Christopher ; Cliby, William Arthur ; Gostout, Bobbie S. ; Jones, Monica B. ; Wilson, Timothy O. ; Podratz, Karl C. / Prospective assessment of lymphatic dissemination in endometrial cancer : A paradigm shift in surgical staging. In: Gynecologic Oncology. 2008 ; Vol. 109, No. 1. pp. 11-18.
@article{6061e9bafd3f41dd8643df60a6eb4fa9,
title = "Prospective assessment of lymphatic dissemination in endometrial cancer: A paradigm shift in surgical staging",
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.",
keywords = "Endometrial neoplasms, Lymph node excision, Lymphatic metastasis, Outcomes assessment",
author = "Andrea Mariani and Dowdy, {Sean Christopher} and Cliby, {William Arthur} and Gostout, {Bobbie S.} and Jones, {Monica B.} and Wilson, {Timothy O.} and Podratz, {Karl C.}",
year = "2008",
month = "4",
doi = "10.1016/j.ygyno.2008.01.023",
language = "English (US)",
volume = "109",
pages = "11--18",
journal = "Gynecologic Oncology",
issn = "0090-8258",
publisher = "Academic Press Inc.",
number = "1",

}

TY - JOUR

T1 - Prospective assessment of lymphatic dissemination in endometrial cancer

T2 - A paradigm shift in surgical staging

AU - Mariani, Andrea

AU - Dowdy, Sean Christopher

AU - Cliby, William Arthur

AU - Gostout, Bobbie S.

AU - Jones, Monica B.

AU - Wilson, Timothy O.

AU - Podratz, Karl C.

PY - 2008/4

Y1 - 2008/4

N2 - 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.

AB - 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.

KW - Endometrial neoplasms

KW - Lymph node excision

KW - Lymphatic metastasis

KW - Outcomes assessment

UR - http://www.scopus.com/inward/record.url?scp=40949141349&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=40949141349&partnerID=8YFLogxK

U2 - 10.1016/j.ygyno.2008.01.023

DO - 10.1016/j.ygyno.2008.01.023

M3 - Article

C2 - 18304622

AN - SCOPUS:40949141349

VL - 109

SP - 11

EP - 18

JO - Gynecologic Oncology

JF - Gynecologic Oncology

SN - 0090-8258

IS - 1

ER -