Detection of micrometastases in the sentinel lymph nodes of patients with endometrial cancer

OBJECTIVE: We investigated the utility of sentinel lymph node (SLN) mapping for the detection of endometrial carcinoma micrometastases. We reevaluated the accuracy of our SLN detection procedure, this time combining step-serial section with cytokeratin immunostaining. PATIENTS AND METHODS: Between March 2002 and March 2005, consecutive patients undergoing laparotomy (total abdominal hysterectomy, bilateral salpingo-oophorectomy, total pelvic lymphadenectomy and para-aortic lymphadenectomy to the level of renal veins) with SLN biopsy for endometrial cancer at Tohoku University Hospital were enrolled in this study. Excluded were patients in whom lymph node metastases were detected by routine histological examination or those without detectable SLNs. All surgically removed lymph nodes, including SLNs, were examined histopathologically by immunohistochemistry staining with an anti-cytokeratin antibody (AE1/AE3) combined with step-serial sectioning at 200-500 microm intervals. RESULTS: Four of seventy-four SLNs (5%) obtained from 20 patients had micrometastases or isolated tumor cells (ITC). In contrast, only 4 of the 1350 non-SLNs obtained from 20 patients (0.3%) had detectable micrometastases. The micrometastases were detected in the external iliac basin (two cases) and in the para-aortic area (two cases). The isolated tumor cell was detected in the external iliac basin (one case). CONCLUSION: SLNs detected by our method had micrometastases more frequently than did non-SLNs. Easy detection of micrometastases by immunostaining is only possible with step-serial sectioning of the SLNs.     

Sentinel lymph node mapping for endometrial cancer improves the detection of metastatic disease to regional lymph nodes

Objective

To compare the incidence of metastatic cancer cells in sentinel lymph nodes (SLN) vs. non-sentinel nodes in patients who had lymphatic mapping for endometrial cancer and to determine the contribution of metastases detected on ultrastaging to the overall nodal metastasis rate.

Methods

All patients who underwent lymphatic mapping for endometrial cancer were reviewed. Cervical injection of blue dye was used in all cases. Sentinel nodes were examined by routine hematoxylin and eosin (H&E), and if negative, by standardized institutional pathology protocol that included additional sections and immunohistochemistry (IHC).

Results

Between 09/2005 and 03/2010, 266 patients with endometrial cancer underwent lymphatic mapping. Sentinel node identification was successful in 223 (84%) cases. Positive nodes were diagnosed in 32/266 (12%) patients. Of those, 8/266 patients (3%) had the metastasis detected only by additional section or IHC as part of SLN ultrastaging. Excluding the 8 cases with positive SLN on ultrastaging only, 24/801 (2.99%) SLN and 30/2698 (1.11%) non-SLN were positive for metastatic disease (p = 0.0003).

Conclusion

Using a cervical injection for mapping, metastatic cells from endometrial cancer are three times as likely to be detected in SLN than in the non-sentinel nodes. This finding strongly supports the concept of lymphatic mapping in endometrial cancer to fine tune the nodal dissection topography. By adding SLN mapping to our current surgical staging procedures we may increase the likelihood of detecting metastatic cancer cells in regional lymph nodes. An additional benefit of incorporating pathologic ultrastaging of SLN is the detection of micrometastasis, which may be the only evidence of extrauterine spread.     

The significance of surgical staging in intermediate-risk endometrial cancer

Objective

The objective was to evaluate rates of nodal disease in endometrial cancer within risk groups based on uterine factors, and to estimate the rate of potential undertreatment and impact on survival if nodal status was unknown.

Methods

This was a population-based retrospective cohort study of endometrioid-type endometrial cancer in British Columbia from 2005 to 2009. All women with a preoperative grade 2/3 cancer underwent hysterectomy, bilateral salpingo-oophorectomy (HBSO) and lymphadenectomy, and those with intermediate- or high-risk disease based on uterine factors after HBSO alone underwent secondary lymphadenectomy. We compared rates of node-positivity and potential undertreatment in each group if nodal status had been unknown (chi-square test), and estimated the survival benefit from lymphadenectomy.

Results

There were 222 women who underwent primary or secondary lymphadenectomy. Median age was 65 (range 38-86) and median number of lymph nodes was 10 (range 2-39). Of the 66 women with intermediate-risk disease (grade 1 or 2 tumor, deep myometrial invasion), 6 had nodal disease (9.1%) and received adjuvant chemotherapy. They remain disease-free after 24 months (range 8-55). They would not have qualified for chemotherapy based on uterine factors alone, and would have been undertreated compared to other risk groups (chi-square p = 0.071). A 1% survival benefit was estimated from lymphadenectomy.

Conclusion

Women with a grade 1 or 2 tumor and deep myometrial invasion have a 9% risk of nodal disease. Lymphadenectomy is significant for this subgroup as they would have been undertreated based on uterine risk factors alone, although the survival benefit is limited.     

The importance of applying a sentinel lymph node mapping algorithm in endometrial cancer staging: beyond removal of blue nodes

Objective

To determine the false-negative rate of a surgical sentinel lymph node (SLN) mapping algorithm that incorporates more than just removing SLNs in detecting metastatic endometrial cancer.

Methods

A prospective database of all patients who underwent lymphatic mapping for endometrial cancer was reviewed. Cervical injection of blue dye was used in all cases. The surgical algorithm is as follows: 1) peritoneal and serosal evaluation and washings; 2) retroperitoneal evaluation including excision of all mapped SLNs and suspicious nodes regardless of mapping; and 3) if there is no mapping on a hemi-pelvis, a side-specific pelvic, common iliac, and interiliac lymph node dissection (LND) is performed. Paraaortic LND is performed at the attendings' discretion. The algorithm was retrospectively applied.

Results

From 9/2005 to 4/2011, 498 patients received a blue dye cervical injection for SLN mapping. At least one LN was removed in 95% of cases (474/498); at least one SLN was identified in 81% (401/498). SLN correctly diagnosed 40/47 patients with nodal metastases who had at least one SLN mapped, resulting in a 15% false-negative rate. After applying the algorithm, the false-negative rate dropped to 2%. Only one patient, whose LN spread would not have been caught by the algorithm, had an isolated positive right paraaortic LN with a negative ipsilateral SLN and pelvic LND.

Conclusions

Satisfactory SLN mapping in endometrial cancer requires adherence to a surgical SLN algorithm and goes beyond just the removal of blue SLNs. Removal of any suspicious node along with side-specific lymphadenectomy for failed mapping are an integral part of this algorithm. Further validation of the false-negative rate of this algorithm is necessary.     

The role of omental biopsy in endometrial cancer staging

Omental biopsy is not part of FIGO staging for endometrial cancer. The few studies that have looked into this matter have had conflicting results. This is the largest study in terms of the number of cases studying the incidence of omental involvement in endometrioid and non-endometrioid endometrial cancer. A retrospective study assessing 248 cases of endometrial cancer with omental biopsy at the time of primary surgical treatment for endometrial cancer at the Gynaecological Oncology Centre, Norfolk and Norwich University Hospital between January 2004 and May 2008. Demographic, clinico-pathologic and surveillance data were collected from hospital records, operative notes and histopathology results. The histology included tumour type, stage, grade and omental biopsy. All histological types were included in the study. Two hundred and forty eight patients had an omental biopsy at the time of primary surgical treatment for endometrial cancer during the study period. Of them, 187 cases were stage I, 27 stage II, 27 stage III and seven stage IV. According to histological type, 202 (81.4%) had endometrioid, 20 (8.0%) serous papillary, 20 (8.0%) malignant mixed Mullerian tumour (MMMT), three (1.2%) clear cell and three (1.2%) sarcoma. Overall, six cases (2.4%) had omental involvement, 4/202 (1.98%) with endometrioid type, 1/20 (5.0%) with serous papillary type and 1/20 (5.0%) MMMT. Eighty four percent of omental metastases (five cases) were macroscopic and noted at operation .The overall risk of omental metastases is 2.4% and in the absence of gross lesions the risk is around 0.4%. Most omental metastases can be diagnosed by careful inspection and palpation of the omentum. The possibility of missing microscopic disease is low. Based on these figures and possible increase in morbidity and operative time, omental biopsy cannot be justified as a standard procedure in endometrial cancer staging.     

Evaluation of sentinel lymph nodes in vulvar,endometrial and cervical cancers

Sentinel lymph node (SLN) biopsies are a sensitive tool in evaluating lymph nodes for multiple cancers, and in some diseases they decrease morbidity in both the short- and long-term. SLN detection in gynecologic malignancies has been studied extensively over the past decade. We review the current literature on SLN dissection in vulvar, endometrial and cervical cancers. Large, well-designed trials in each of the three types of cancer have demonstrated high sensitivity and low false-negative rates when SLN biopsy is performed in the correct patients and with an appropriate technical approach. In all of these cases the addition of ultra-staging to conventional pathology yields increased detection of micrometastatic disease. Biopsy of the sentinel nodes is feasible and safe in early vulvar malignancies, with multiple studies describing low recurrence rates in those women who have with negative SLNs. There does not appear to be a survival benefit to lymphadenectomy over SLN biopsy and quality of life is improved in women undergoing SLN biopsy. Optimal treatment strategies for women with positive nodal biopsies, particularly in cases with micrometastatic disease, remain unclear. Multiple large studies investigating the utility of SLN biopsy in endometrial malignancy have found that sentinel nodal status is a reliable predictor of metastases in women with low-risk disease. Prospective studies are ongoing and suggest sentinel nodal detection may soon become widely accepted as an alternative standard of care for select cases of endometrial cancer. In cervical cancer, SLN biopsy is accurate for diagnosing metastatic disease in early stage tumors (≤ 2 cm diameter or stage ≤ IB2) where the risk of metastasis is low. It is unknown if women who undergo SLN biopsy alone will have different survival outcomes than women who undergo complete lymphadenectomy in these cases. In a specific population of women with vulvar cancer, SLN dissection is an effective and safe alternative to complete dissection. It can be offered as an alternative management strategy in these women. In women who do undergo SLN biopsy, it is associated with improved quality of life. Promising evidence supporting the utility of SLN dissection in endometrial and cervical cancer continues to emerge, and it may soon become a reasonable option for select patients. However, continued research and refinement of appropriate patient selection and long-term follow-up are necessary.     

Participation of the general gynecologist in surgical staging of endometrial cancer: analysis of cost and perioperative outcomes

OBJECTIVE: To compare the cost and perioperative outcomes of endometrial cancer staging when the procedure is performed by a gynecologic oncologist alone or when a general gynecologist participates in the procedure. METHODS: A retrospective analysis was performed on a series of women with clinical stage I endometrial cancer treated at a single institution between 1/98 and 12/00. The patients were grouped according to the participation of a general gynecologist in their surgery. The 48 patients in Group 1 underwent surgery with a general gynecologist who consulted a gynecologic oncologist intraoperatively. Group 2 included 77 patients whose procedure was performed completely by a gynecologic oncologist. The two groups were compared with the chi-square, Fisher's exact, and Wilcoxon rank sum tests. Cost analysis included total hospital costs (room, pharmacy, and ancillary services) and total surgical costs (anesthesia, operating room, procedure, and perioperative physician evaluation costs). RESULTS: The groups did not differ in age, type of surgeries performed, distribution of surgical stage, proportion of patients undergoing lymph node sampling (LNS), and length of follow-up. When LNS was performed, Group 2 had a significantly shorter median operative time (170 vs. 180 min; P=0.05) and shorter total time in the operating room (204 vs. 224 min; P=0.02). This group had a lower procedure cost when considered both in terms of payor's cost ($1,414 vs. $2,134; P<0.0001) and physician charge ($7,106 vs. $11,116; P<0.0001). Perioperative physician evaluation was reduced by almost half ($685 vs. $424; P<0.0001) in Group 2. Group 2 had a savings in total surgical cost by payor's cost ($9,142 vs. 10,294; P=0.005) or physician's charge ($14,546 vs. $19,276; P<0.0001), and in combined hospital and surgical cost by payor's cost ($15,664 vs. $17,346; P=0.004) or physician charge ($21,311 vs. $26,328; P<0.0001). Total hospital costs, however, did not differ between groups. CONCLUSION: Operative time and costs increase when general gynecologists participate in the surgical procedure of patients with clinical stage I endometrial cancer. Although perioperative outcomes are similar, the involvement of two surgeons increases the length of the procedure as well as the cost of operating room time and physician reimbursement. The efficient use of limited health care resources must be considered as we plan the surgical approach to endometrial cancer.     

子宫内膜癌腹膜后淋巴结转移相关因素分析

目的:探讨预测子宫内膜癌腹膜后淋巴结转移的指标,以期为确定子宫内膜癌手术范围提供参考。方法:回顾分析1997年1月至2006年12月初治为手术治疗的641例子宫内膜癌患者的临床与病理资料,单因素分析用χ2检验和Fish确切概率法,多因素分析用Logistic回归模型。结果:经多因素分析显示,病理分级G3、深肌层浸润、附件转移对预测子宫内膜癌盆腔淋巴结(pelvic lymph node,PLN)转移具有统计学意义;盆腔淋巴结转移与腹主动脉旁淋巴结(para-aortic lymph node,PALN)转移显著相关。结论:病理分级G3、深肌层浸润、附件转移是子宫内膜癌盆腔淋巴结转移的重要预测因素;盆腔淋巴结转移对预测腹主动脉旁淋巴结转移具有重要意义。病理分级G3、深肌层浸润、附件转移的子宫内膜癌患者应行盆腔淋巴结清扫术,并根据术中患者的盆腔淋巴结状况决定是否行腹主动脉旁淋巴结清扫术。     

Comparison between 155 cases of robotic vs. 150 cases of open surgical staging for endometrial cancer

Objective

To compare the outcomes of 155 cases of endometrial cancer who had robot-assisted surgical staging to 150 open cases.

Methods

Retrospective chart review of cases of endometrial cancer that underwent staging two different ways by two surgeons at an academic institution.

Results

Mean age was 62.4 years in the robotic arm and 65 (P = 0.04) in the open arm. Mean body mass index was 34.5 Kg/m² in the robotic arm and 33 Kg/m² in the open arm (P = 0.2). Pelvic and para-aortic lymph node dissection were performed in 94.8% and 67.7% of the robotic cases versus 95.3% and 74% of the open cases, respectively. Mean operative time was 127 min in the robotic arm, and 141 min in the open arm (P = 0.0001). Mean lymph node count was 20.3 in the robotic arm, and 20 in the open arm (P = 0.567). Mean estimated blood loss was 119 ml in the robotic arm and 185 in the open arm (P = 0.015). Mean hospital stay was 1.5 days in the robotic arm, and 4 days in the open arm (P = 0.0001). The incidence of postoperative ileus (0.6% vs. 10.7%, P = 0.0001), infections (5.2% vs. 24%, P = 0.0001), anemia/transfusion (1.3% vs. 7.7%, P = 0.005), and cardiopulmonary complications (3.2% vs.14.7%, P = 0.003) was significantly lower in the robotic arm vs. the open arm. There was one death in the robotic arm attributed to pre-existing cardiac condition.

Conclusion

Robotic-assisted staging reaps the benefits of minimally invasive surgery without compromising the adequacy of the procedure. Dedication to the technique shortens the operative time.     

Tracer injection sites and combinations for sentinel lymph node detection in patients with endometrial cancer

Objective

The aim of the present study was to clarify the most effective combination of injected tracer types and injection sites in order to detect sentinel lymph nodes (SLNs) in early endometrial cancer.

Patients and methods

The study included 100 consecutive patients with endometrial cancer treated at Tohoku University Hospital between June 2001 and December 2012. The procedure for SLN identification entailed either radioisotope (RI) injection into the endometrium during hysteroscopy (55 cases) or direct RI injection into the uterine cervix (45 cases). A combination of blue dye injected into the uterine cervix or uterine body intraoperatively in addition to preoperative RI injection occurred in 69 of 100 cases. All detected SLNs were recorded according to the individual tracer and the resultant staging from this method was compared to the final pathology of lymph node metastases including para-aortic nodes.

Results

SLN detection rate was highest (96%) by cervical RI injection; however, no SLNs were detected in para-aortic area. Para-aortic SLNs were detected only by hysteroscopic RI injection (56%). All cases with pelvic lymph node metastases were detected by pelvic SLN biopsy. Isolated positive para-aortic lymph nodes were detected in 3 patients. Bilateral SLN detection rate was high (96%; 26 of 27 cases) by cervical RI injection combined with dye.

Conclusion

RI injection into the uterine cervix is highly sensitive in detection of SLN metastasis in early stage endometrial cancer. It is a useful and safe modality when combined with blue dye injection into the uterine body.     

Regional variation in surgical assessment of lymph nodes for staging among women with early-stage epithelial ovarian cancer

Objective

To investigate geographical and socioeconomic variations in performance of lymph node dissection for the evaluation of patients with early-stage epithelial ovarian cancer.

Methods

A population-based, retrospective cohort study was conducted using data from the National Cancer Institute's SEER Program for 15 geographic registries and county-level measures. Women with early-stage epithelial ovarian cancer registered between 2000 and 2008 with known lymph node assessment status were studied. A multiple logistic regression analysis was used to evaluate the differences in the likelihood of lymph node assessment according to geographic SEER region.

Results

After adjusting for tumor characteristics, demographics, and area-based socioeconomic measures, a significant relationship between SEER region and lymph node dissection remained. Compared to the region with the highest proportion of lymph node dissection, there is a significantly lower probability of surgical assessment of lymph nodes in 8 of the remaining 14 geographical regions.

Conclusions

The variation in ovarian cancer surgical care by region reported in this study has implications for access and outcomes for patients with early-stage disease. Study findings merit further investigation and should be characterized to permit targeted interventions aimed at reducing the observed disparities.     

Sentinel lymph node mapping with pathologic ultrastaging: A valuable tool for assessing nodal metastasis in low-grade endometrial cancer with superficial myoinvasion

Objective

To report the incidence of nodal metastases in patients presenting with presumed low-grade endometrioid adenocarcinomas using a sentinel lymph node (SLN) mapping protocol including pathologic ultrastaging.

Methods

All patients from 9/2005 to 12/2011 who underwent endometrial cancer staging surgery with attempted SLN mapping for preoperative grade 1 (G1) or grade 2 (G2) tumors with < 50% invasion on final pathology, were included. All lymph nodes were examined with hematoxylin and eosin (H&E). Negative SLNs were further examined using an ultrastaging protocol to detect micrometastases and isolated tumor cells.

Results

Of 425 patients, lymph node metastasis was found in 25 patients (5.9%) on final pathology—13 cases on routine H&E, 12 cases after ultrastaging. Patients whose tumors had a DMI < 50% were more likely to have positive SLNs on routine H&E (p < 0.005) or after ultrastaging (p = 0.01) compared to those without myoinvasion.

Conclusions

Applying a standardized SLN mapping algorithm with ultrastaging allows for the detection of nodal disease in a presumably low-risk group of patients who in some practices may not undergo any nodal evaluation. Ultrastaging of SLNs can likely be eliminated in endometrioid adenocarcinoma with no myoinvasion. The long-term clinical significance of ultrastage-detected nodal disease requires further investigation as recurrences were noted in some of these cases.     

Evaluation of the sensitivity, specificity, positive and negative predictive values of preoperative magnetic resonance imaging for staging endometrial cancer. A prospective study of 100 cases at the Dorset Cancer Centre

OBJECTIVES: The objectives were to evaluate the sensitivity and specificity of preoperative magnetic resonance imaging (MRI) in predicting myometrial invasion and disease stage in cases of endometrial carcinoma. STUDY DESIGN: Prospective analytic study in 100 sequential cases of endometrial carcinoma referred to the Dorset Cancer Centre between January 1999 and July 2004. The study included 100 women with histologically proven endometrial malignancy, the mean age of the studied population being 68.6 years +/-2S.D. The preoperative MRI findings were compared with final surgical and histological staging; the latter was taken as the gold standard. The main outcome measures were the sensitivity and specificity of preoperative MRI for staging endometrial cancer. RESULTS: A total of 100 consecutive cases of endometrial cancer were analysed, of which 62 cases were classified as stage Ia/Ib (early disease) by histology. MRI accurately predicted the degree of invasion in 54 cases and overestimated in 8, giving a sensitivity of 87% and specificity of 90%. In stage Ic disease the sensitivity and specificity of MRI were 56 and 86%, respectively. However, MRI showed significantly reduced sensitivity for predicting stage II endometrial cancer at 19% but was found to be both sensitive and specific for predicting advanced endometrial cancer (stages III and IV); the sensitivity and specificity were 100 and 99%, respectively. CONCLUSIONS: The accuracy of MRI scanning in predicting early and advanced endometrial disease is very good, but there is reduced accuracy with stage Ic and stage II disease. MRI is a valuable imaging modality in the preoperative assessment of cases of endometrial cancer.     

Laparoscopic-assisted vaginal hysterectomy with laparoscopic pelvic and paraaortic staging for early endometrial cancer

While abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymphadenectomy is still considered the gold standard for the surgical treatment of endometrial cancer, the laparoscopic-assisted vaginal hysterectomy (LAVH) plus laparoscopic lymphadenectomy has been performed in FIGO stage I endometrial cancer in selected centers for about a decade. Clinical studies have shown that the frequency of intra- and postoperative complications, the pelvic and paraaortic lymph node yield, and—more importantly—the overall survival, are similar both with the laparoscopic-assisted vaginal approach and the abdominal approach in stage I disease. Blood loss and duration of hospital stay may even be reduced with the LAVH. In summary, provided there is compliance with established oncologic guidelines, LAVH with pelvic and paraaortic lymphadenectomy can probably be performed in patients with endometrial cancer FIGO stage I without safety loss.     

Short- and long-term morbidity and outcomes after robotic surgery for comprehensive endometrial cancer staging

Objective

Although intra-operative and immediate postoperative complications of robotic surgery are relatively low, little is known about long-term morbidity. We set out to assess both short- and long-term morbidities after robotic surgery for endometrial cancer staging.

Methods

All patients who underwent robotic staging for EMCA between 2006 and 2009 from two institutions were identified. Patient charts were retrospectively reviewed for surgical complications and postoperative morbidities.

Results

Five hundred three patients were identified. No differences in complication rates were found between 2006-2007 and 2008-2009, even though the median BMI increased from 29.9 (range 19-52) to 32 (range 17-70) (p = 0.03). 6.4% of cases were converted to laparotomy. Median length of stay was one day (range 1-46). No cystotomies, two enterotomies, one ureteric injury, and five vessel injuries occurred (1.6% intra-operative complications). Thirty-eight (7.6%) patients developed major postoperative complications, 11 (2.2%) had wound infections, and 15 (3%) required a transfusion in the 30-day peri-operative period. The total venous thromboembolism (VTE) rate for robotic cases was 1.7%. Partial cuff dehiscence managed conservatively occurred in 5 (1%) and complete dehiscence requiring closure in 7 (1.4%) patients; Sixty-three (13.4%) patients who had robotic staging developed lymphedema, with 40 (8%) requiring physical therapy.

Conclusions

This study provides one of the largest cohorts of patients with robotic-assisted hysterectomy and lymphadenectomy (in 92.6%) with an assessment of morbidity. Our data demonstrates that robotic surgical staging can be safely performed with a low risk of short-term complications and lymphedema is the most frequent long-term morbidity.     

Assessing the efficacy of targeting the phosphatidylinositol 3-kinase/AKT/mTOR signaling pathway in endometrial cancer

Objective

Alterations in the PI3K pathway are prevalent in endometrial cancer due to PIK3CA mutation and loss of PTEN. We investigated the anti-tumor activity of the PI3K inhibitor NVP BKM-120 (BKM) as a single agent and in combination with standard cytotoxic chemotherapy in a human primary endometrial xenograft model.

Methods

NOD/SCID mice bearing xenografts of primary human tumors with and without PIK3CA gene mutations were divided into two and four arm cohorts with equivalent tumor volumes. BKM was administered alone and in combination with paclitaxel and carboplatin (P/C) and endometrial xenograft tumor volumes were assessed. Tumors from the BKM, P/C, P/C + BKM and vehicle treated mice were processed for determination of PI3K/AKT/mTOR pathway activation.

Results

In both single agent experiments, BKM resulted in significant tumor growth suppression starting at days 5–10 compared to the linear growth observed in vehicle treated tumors (p < 0.04 in all experiments). Tumor resurgence manifested between days 14 and 25 (p < 0.03). When BKM was combined with P/C, this resistance pattern failed to develop in three separate xenograft lines (p < 0.05). Synergistic tumor growth suppression (p < 0.05) of only one xenograft tumor with no detected PIK3CA mutation was observed. Acute treatment with BKM led to a decrease in pAKT levels.

Conclusion

Independent of PIK3CA gene mutation, BKM mediated inhibition of the PI3K/AKT/mTOR pathway in endometrial tumors precludes tumor growth in a primary xenograft model. While a pattern of resistance emerges, this effect appears to be mitigated by the addition of conventional cytotoxic chemotherapy.     

A validation study of the new revised FIGO staging system to estimate prognosis for patients with stage IIIC endometrial cancer

Objective

The aim of this study was to validate the role of the new FIGO staging system for estimating prognosis for patients with stage IIIC endometrial cancer.

Methods

A total of 93 cases with stage IIIC were entered in this study and classified into three groups: one group of patients who underwent pelvic lymphadenectomy (PLX) and para-aortic lymphadenectomy (PALX) and who were for positive for pelvic node metastasis (PLNM) and negative for para-aortic node metastasis (PANM) (Group 1), one group of patients who underwent PLX alone and were positive for PLNM (Group 2) and one group of patients who underwent PLX and PALX and were positive for PANM (Group 3). Information on clinicopathologic findings and treatments was obtained from medical charts. Cox regression analysis was used to select prognostic factors.

Results

The 5-years survival rates were 89.3% in Group 1, 46.5% in Group 2 and 59.9% in Group 3. The overall survival rate in Group 1 was significantly better than that in Group 2 (p = 0.0001) and Group 3 (p = 0.0016). No significant difference in overall survival was found between Group 2 and Group 3. Age, number of metastatic lymph nodes, type of lymphadenectomy and type of adjuvant therapy were significantly and independently related to overall survival. Only when patients received PALX, PANM was a prognostic risk factor.

Conclusion

Sub-classification of stage IIIC would be functional for estimating prognosis in the revised FIGO staging system. Systematic lymphadenectomy including PALX has therapeutic significance for patients with stage IIIC endometrial cancer. Prognosis of patients with stage IIIC endometrial cancer would depend much more on application of lymphadenectomy including PALX than nodal status.     

An unusual case of recurrent endometrial cancer presented with isolated cervical lymph node metastasis

Endometrial cancer (EC) is the most common malignancy of the female genital tract. Lymph node involvement is one of the major prognostic factors. Therefore, pelvic and paraaortic lymph nodes dissection is a part of the surgical management of these patients. Isolated peripheral lymph node metastasis has not been previously reported as a finding of recurrence in EC. We report a 67-year-old woman with recurrent EC presented with an isolated cervical lymph node metastasis (ICLM). Following the combination chemotherapy of doxorubicin, cisplatin and cyclophosphamide, her cervical lymph node was completely regressed. To our knowledge, this is the first case of recurrent EC presented with ICLM. We suggest that for women with EC who had isolated peripheral lymphadenopathies, peripheral lymph node metastasis should be considered as the finding of recurrence in patient with EC.