Pelvic and para-aortic lymphadenectomy in patients with endometrioid adenocarcinoma of the endometrium.

BACKGROUND: The purpose is to determine the rate of lymph node metastases in women with endometrioid adenocarcinoma of the endometrium (EAE) undergoing systematic lymphadenectomy. METHODS: Patients (349) underwent a complete pelvic and para-aortic lymphadenectomy from caudal to the median circumflex to the level of the renal vessels. RESULTS: Grade 1 tumors accounted for 32.7% of the tumors and 31.0% of the positive nodes, grade 2 accounted for 47.3% of the tumors (37.9% of positive nodes), and grade 3 accounted for 20.1% of the tumors and 31.0% of the positive nodes (P>0.05). Positive nodes were found in 15.8% of grade 1 tumors, 13.3% of grade 2 tumors and 25.7% of grade 3 tumors (P>0.05). Isolated para-aortic involvement without pelvic nodal involvement occurred in 29% of patients with positive nodes. CONCLUSIONS: When complete lymphadenectomies are performed in EAE, positive lymph nodes (including isolated para-aortic lymph nodes) are common in all grades.     

Steroid receptors and clinical outcome in patients with adenocarcinoma of the endometrium

Progesterone receptor content was measured in tissue samples from 175 patients with endometrial adenocarcinoma by use of the dextran-charcoal method. The estradiol receptor content was determined in 138 of these samples. Ninety-two tumors (52.6%) tested positive for progesterone receptors (greater than 50 fmol/mg cytosol protein) and 111 (80.4%) tested positive for estradiol receptors (greater than 6 fmol/mg). Median follow-up was 27.3 months (range 1 to 152 months). Progesterone receptor status correlated significantly with grade, histology, adnexal spread, age, and recurrence rate in stage I cancer. There was no correlation between progesterone receptor status and clinical stage, myometrial invasion, peritoneal cytology, retroperitoneal lymph node involvement, or spread to the cervix. Estradiol receptor status correlated with adnexal spread and recurrence rate. Recurrence in patients with stage I disease was significantly more common if tumors were negative for progesterone receptor (16 of 43, 37.2%) than if they were positive (four of 57, 7%; p less than 0.001). Recurrence was also more common if tumors were negative for estradiol receptor (seven of 17, 41.2%) than if they were positive (eight of 63, 12.7%; p = 0.02). In recurrent or advanced disease, response to progestin was independent of estradiol receptor content, but tumors positive for progesterone receptors responded significantly more often than those lacking progesterone receptors. Overall survival was superior for patients with progesterone receptor-positive tumors (p = 0.001). Although survival in clinical stages I and II was also superior in patients with lesions positive for progesterone receptors (p = 0.13), there was no statistical difference in survival between patients with progesterone receptor-positive or -negative cancers and surgical stages I and II disease (p = 0.12). Estradiol receptor status had no apparent correlation with survival.     

Argyrophil cell adenocarcinoma of the endometrium.

Out of 11 endometrial adenocarcinomas examined with Grimelius staining, an argyrophil cell adenocarcinoma was found in a 64-year-old gravida 3, para 1 woman. Her chief complaint was irregular genital bleeding. Numerous polypoid tumor masses occupying the uterine cavity were revealed by surgery. The tumor was diagnosed at first as a well-differentiated endometrial adenocarcinoma with mucin production, by conventional pathology. Most of the tumor cells, however, were found to contain the argyrophil granules, especially in the apical portion of cytoplasm. This appears to be the first reported case of argyrophil cell adenocarcinoma of the endometrium.     

Papillary adenocarcinoma in the endometrium

Papillary adenocarcinoma should be regarded as a subtype of endometrial carcinoma with poor prognosis. Review of 22 cases indicates an older average age than is found with the usual endometrioid type, with frequent surgical upstaging, deep myometrial invasion, nodal and adnexal involvement, positive peritoneal washings, upper abdominal recurrence, and poor response to conventional treatment. These observations suggest a different natural history from that of the more common histologic subtypes of endometrial carcinoma. Management should include initial exploration of the entire abdominal cavity to determine the true extent of the disease, and treatment must include the upper abdomen.     

Secretory adenocarcinoma of the endometrium

Secretory adenocarcinomas of the endometrium are uncommon tumors distinct from clear cell carcinomas. We reviewed nine cases that included the original endometrial curettings and the specimens of uteri with both adnexa [total abdominal hysterectomy-bilateral salpingo-oophorectomy (TAH-BSO)]. The patients' ages ranged from 36 to 79 years (with an average of 55 years). Six women were postmenopausal, and most complained of vaginal bleeding. Two patients were nulliparous and the others had one to four children. Four patients were obese, of whom one was diabetic and hypertensive. Eight tumors were of grade I and one was grade II. The histologic pattern was comparable to that of secretory endometrium, days 17 to 22, and the glands were positive with periodic acid-Schiff (whether predigested or not); they were partly positive with alcian blue and negative with Best Carmine. The carcinoma in one case was positive for carcinoembryonic antigen; all cases were negative with alpha-fetoprotein. Six patients were staged as IA and three as IB. One 47-year-old patient had a concurrent endometrioid adenocarcinoma (grade II) of the right ovary with squamous, clear cell, and mucinous components. Three cases had no tumour penetration of the myometrium while in the others penetration varied from 5 to 70%. One patient received intracavitary radium prior to TAH-BSO and two had postoperative radiation. All patients are alive 11 to 113 months following surgery. Secretory adenocarcinoma of the endometrium should be separated from clear cell carcinoma, as it has the pattern of secretory endometrium day 17 to 22, is very well differentiated, and has a relatively good prognosis.     

Treatment of adenocarcinoma of the endometrium

The patients with adenocarcinoma of the endometrium treated from September 1961 to December 1968 are reviewed. Their 5-yr cure rate was 79%. Sixty-two patients with Stage I and II disease treated with preoperative radiation and extended hysterectomy, including pelvic lymphadenectomy and upper vaginectomy, showed a 90% 5-yr cure rate. They also had a high 24% major operative complication rate with a low 1.6% positive node rate. The efficacy of treating adenocarcinoma of the endometrium with radiation followed by radical pelvic surgery is discussed.     

Papillary serous adenocarcinoma of the endometrium

The clinical outcome of 15 women with papillary serous adenocarcinoma of the endometrium is presented. In 14 instances the diagnosis was made by uterine curettage. Eight cases (53.3%) were clinically understaged based on laparotomy findings. Intraoperative assessment for extrauterine spread of disease was infrequently performed. Recurrent disease developed in 12 patients (80.0%) with ten arising within the abdomen either alone or in conjunction with another site. Eleven patients (73.3%) have died of disease and two of the four alive have been treated for a recurrence. The need to determine appropriate adjuvant therapy for patients with this disease exists. A protocol for patient management is proposed.     

Steroid hormone receptors in adenocarcinoma of the endometrium

Estradiol cytosolic receptor levels were determined in tumor tissue of 73 patients with adenocarcinoma of the uterus. In 71% of the tumors, the estradiol receptor was >3 fmole/mg cytosol protein. An assay of 3 or more fmole/mg cytosol protein placed the tumor in the category of estrogen or progesterone positive. The levels of estrogen receptors were not related to the stage or histological grade of the tumor nor to the age of the patient. Progesterone cytosolic receptor levels were determined in 31 tumors. In 52% of the tumors the levels of progesterone receptor were >3 fmole/mg cytosol protein. No relationship could be demonstrated between the levels of progesterone receptor and the stage of the disease, the histological grade of the tumor, nor the age of the patient. Thirty-one cases were studied for the presence of both steroid hormone receptors and 52% of these tumors could be classified as both estrogen and progesterone receptor positive. Preoperative radiation appeared to interfere with the determination of the tumor's receptor status.     

Vaginal recurrence of adenocarcinoma of the endometrium

During a 28-year period, 949 patients were treated for adenocarcinoma of the endometrium at the University of Minnesota Hospitals. Eighty-one of these patients presented with vaginal recurrence. The incidence of vaginal recurrence for patients receiving primary therapy at this institution was 0.9%. Sixty-nine percent of patients presented with vaginal bleeding, but 22% were asymptomatic. Seventy-three percent of patients eventually died of disease. Seventy-five percent of recurrences occurred within 3 years of primary therapy, but much longer intervals were noted. In patients with isolated vaginal recurrences, the interval to recurrence directly correlated with survival (P < 0.0005). The poor outcome of these patients indicates a need for evaluation of adjuvant therapy.     

An alpha-fetoprotein-producing hepatoid adenocarcinoma of the endometrium

BACKGROUND: Hepatoid adenocarcinomas are tumors that arise outside the liver but resemble hepatic tissue and produce alpha-fetoprotein. These neoplasms have been described in many locations, including the lung, gastrointestinal tract, and urogenital tract, and have been associated with a poor prognosis. Two previously reported cases of hepatoid adenocarcinoma of the endometrium described aggressive tumors that were unresponsive to multiple forms of therapy. CASE: We report a case of an alpha-fetoprotein-producing hepatoid adenocarcinoma of the endometrium that was successfully treated with surgery and adjuvant chemotherapy. CONCLUSION: Eight years after therapy, the patient is alive with no evidence of disease, suggesting that cytoxan, adriamycin, and cis-platinum are active agents in this unusual entity.