Comprehensive pelvic and paraaortic lymphadenectomy in patients with apparently early stage uterine serous carcinoma – an anachronism?

Abstract

Many patients with endometrial cancer (EC) which is apparently limited to the uterus have extrauterine disease [1]. In 1988, the International Federation of Gynecology and Obstetrics (FIGO) therefore introduced the concept of surgical staging for EC, including hysterectomy, bilateral salpingo-oophorectomy, pelvic washing, and pelvic plus paraaortic lymphadenectomy (LNE) [2]. Systematic retroperitoneal LNE was considered to be an essential staging tool to indicate adjuvant radio-and/or chemotherapy in case of nodal involvement [3,4]. In addition, comprehensive lymphadenectomy was regarded to be therapeutic by removing nodal micrometastases, which were not sterilized by radio-and/ or chemotherapy [3,4]. A number of retrospective analyses found a significantly improved overall survival after multisite pelvic lymph node sampling, which even remained after postoperative radiation therapy [5]. A review of the Surveillance, Epidemiology, and End Results (SEER) data of 4,178 women with serous endometrial cancer found that any LNE, as well as more extensive LNE were associated with improved 5-year overall survival (OS), even in patients with negative lymph nodes [6]. Consequently, comprehensive LNE was recommended for all patients with EC, even for those with well-differentiated endometrial cancers [3,4,7]. By the end of the first decade of the new century, 2 European randomized controlled trials were published that found no survival benefit by performing pelvic LNE in patients with early stage endometrial cancer [8,9], but a relevant increase in side effects, including lymphedema and lymphocysts [10]. An analysis of data from 27,000 EC patients (SEER) showed that disease specific 5-year survival of women with endometrioid EC, stage 1 was >98% (G1) or >96% (G2) respectively, no matter whether or not LNE had been performed [11]. In a retrospective analysis, the Mayo-Group observed that tumors with grade 1 or 2 histology ≤2 cm in diameter and ≤50% myometrial invasion had a lymph node metastasis rate of virtually zero [12]. These new data [8-12] and others led to the stepwise weakening of the recommendation of systematic LNE in patients with endometrioid EC, grade 1 or 2 and ≤50% myometrial invasion. It is either not recommended [13] or considered only as an option [14-16]. The analysis of Chan et al suggested that LNE was associated with an improved survival in stage I grade 3 and more advanced endometrioid EC [11]. Another land mark study retrospectively compared two cohorts of EC patients treated either with exclusive pelvic LNE

Lymphadenectomy issues in endometrial cancer

“…Quality assurance of procedures is one of the most critical issues in the surgical trial to investigate its therapeutic role, because low quality of the procedures might draw incorrect conclusions even from prospective studies. In ECLAT, all participating surgeons must show their qualification and to document the correct extent of systematic lymphadenectomy for the purpose of quality assurance of lymphadenectomy [ 22 ]. To assure the quality of lymphadenectomy in our JCOG1412, we defined 3 regulations [ 8 ].…”