The incidence of isolated para-aortic nodal metastasis in completely staged endometrial cancer patients

Objective

To describe and review the incidence of para-aortic (PA) nodal metastasis in completely staged endometrial cancer patients who are negative for pelvic nodal metastasis.

Methods

Using an institutionally maintained database, we identified all patients with endometrial cancer from 2002 to 2006 who had both pelvic and aortic nodal dissections and determined the rate of isolated para-aortic nodal metastasis in non-malignant (i.e. negative) pelvic nodes.

Results

201 endometrial cancer patients were surgically treated at our institution from 2002 to 2006. 171 patients had both pelvic and PA nodes removed during surgery, and specimens examined by a pathologist. Only 2 (1.2%) had PA nodes that tested positive for malignance (i.e. positive PA nodes) with pelvic nodes that tested negative for malignance (i.e. negative pelvic nodes). The final International Federation of Gynecology and Obstetrics (FIGO) grade for the endometrial tumor cells in the two patients was “G1” with endometrioid adenocarcinoma and “G3” with endometrioid adenocarcinoma and mucinous differentiation, respectively.

Conclusion

Based on the very low incidence of patients inflicted with endometrial cancer that have positive para-aortic lymph nodes (PALNs) with negative pelvic nodes found both in our literature review (1.5%) and in our own study (1.2%), the addition of PA lymphadenectomy in all patients was found to have minimal diagnostic and therapeutic value. At the present, the role of complete PA lymphadenectomy in all patients with endometrial cancer should be re-examined. Individualized algorithms should be developed based on risk factors and status of pelvic nodes.     

Sentinel node identification and intraoperative lymphatic mapping. First results of a pilot study in patients with endometrial cancer

INTRODUCTION: To minimize the surgical morbidity after lymphadenectomy, sentinel node biopsy (SLNB) has become fundamental in the management of different malignancies. We decided to evaluate sentinel lymph node (SNL) biopsies also in patients with endometrial cancer undergoing hysterectomy with lymphadenectomy. METHODS: In the setting of a prospective study we developed a technique for sentinel node biopsy of ten patients with histologically confirmed endometrial cancer. Prior to surgery 99m Tc Nanocol was injected in the peritumoral region by hysteroscopy. Six hours later lymphoscintigraphy was performed to identify the draining lymph nodes. During surgery we first detected the sentinel lymph node by a hand-held gamma tracer and then removed it. Surgery was completed by the standard therapy of total hysterectomy, bilateral salpingo-oophorectomy and pelvic and/or para-aortic lymphadenectomy. RESULTS: Scintigraphic identification was possible in eight out of ten patients. Intraoperative identification of sentinel lymph nodes was possible in seven out of eight patients. In five patients we found the sentinel lymph nodes in the pelvic region while the other two patients had bilateral sentinel nodes in the pelvic and para-aortic region. Histologically confirmed microscopic tumor metastases of the SLNs and para-aortic lymph nodes were only found in one case. The sentinel lymph nodes from the other six patients were free of tumor and accurately reflected the pathological status. CONCLUSION: The identification of sentinel lymph nodes in endometrial cancer is a practical and safe method. In order to improve this technique as a standard procedure for staging of endometrial cancer further studies with a larger number of patients have to be done.     

Para-aortic node biopsy in cervical and endometrial cancers: does it affect survival?

Two hundred ten patients with endometrial and cervical carcinoma had para-aortic node biopsies. Nineteen of the 210 patients (9.0%) had positive para-aortic nodes. These 19 patients received pelvic irradiation, and 18 patients received para-aortic irradiation. The incidence of para-aortic nodal involvement in cervical carcinoma was directly related to the stage of the disease. Eleven of the 12 patients with cervical carcinoma and positive para-aortic nodes received both pelvic and para-aortic irradiation. Three of these patients are alive without disease, resulting in a survival rate of 25%. These patients are surviving for 16, 30, and 41 months. The incidence of positive para-aortic nodes in endometrial adenocarcinoma was related to the uterine length and the histologic grade. The survival rate for patients with endometrial adenocarcinoma and positive para-aortic nodes in this study was 57.1%. Four patients have survived for 1, 30, 60, and 71 months. There were no surgical deaths or radiation therapy complications directly attributable to para-aortic biopsy or irradiation.     

FIGO stage IIIC endometrial carcinoma with metastases confined to pelvic lymph nodes: analysis of treatment outcomes, prognostic variables, and failure patterns following adjuvant radiation therapy.

OBJECTIVES: This study was undertaken to evaluate the prognostic significance of isolated positive pelvic lymph nodes on survival and to analyze other prognostic variables, overall survival, and failure patterns in surgically staged endometrial carcinoma patients with positive pelvic lymph nodes and negative para-aortic lymph nodes following radiation therapy (RT). METHODS: Between January 1, 1987, and December 31, 1997, 782 women underwent primary treatment for uterine cancer at Indiana University Medical Center. Through a review of the medical records, we identified 58 patients with pathologic stage IIIA, 27 patients with pathologic stage IIIB, and 77 patients with pathologic stage IIIC endometrial carcinoma. Patients with pathologically positive or unsampled para-aortic lymph nodes and patients who received preoperative radiation therapy were excluded, leaving a study group of 17 patients with nodal metastases confined to pelvic lymph nodes. Thirteen patients received adjuvant pelvic RT using AP-PA or four-field technique. A median dose of 5040 cGy was delivered. Four patients received whole abdominal irradiation (WAI) delivering a median dose of 3000 cGy. Two patients received vaginal cuff boosts of 1000 and 3560 cGy to 0.5 cm from the vaginal surface mucosa via Cs-137 brachytherapy. Two patients also received adjuvant chemotherapy (cis-platinum and doxorubicin) and/or hormonal therapy (megestrol acetate). Disease-free and overall survivals were estimated using the Kaplan-Meier method of statistical analysis and prognostic variables were analyzed using the log-rank test. RESULTS: With a median follow-up of 51 months the actuarial 5-year disease-free survival was 81% and the actuarial 2-year and 5-year overall survival rates were 81 and 72%, respectively. Univariate analysis revealed that positive peritoneal cytology in conjunction with positive pelvic lymph nodes imparts a greater risk of recurrence and decreased overall survival. There were no pelvic and/or upper abdominal failures, but there were recurrences in the para-aortic lymph nodes (two patients) and distantly (two patients). CONCLUSION: Surgery followed by postoperative pelvic RT is a viable treatment option for pathologically staged stage IIIC endometrial carcinoma with disease confined to the pelvic lymph nodes. Failures in the para-aortic region suggest a possible role for extended-field RT. Patients with positive peritoneal cytology in conjunction with nodal metastasis fared poorly with pelvic RT. Studies evaluating the efficacy of WAI are ongoing. Finally, substages within FIGO stage IIIC are recommended in an effort to better understand and define treatment strategies which might be appropriate for these patients.     

Endometrial cancer metastatic to infrarenal aortic lymph nodes unrecognized during laparoscopic inframesenteric aortic lymph node dissection

BACKGROUND: The incidence of isolated aortic nodal metastasis in clinical stages I and II endometrial cancer is generally low. Nevertheless, para-aortic nodes are still assessed during staging procedures, which include hysterectomy, bilateral salpingo-oophorectomy (BSO), and pelvic and para-aortic lymph node sampling up to the level of the inferior mesenteric artery (IMA). The procedure can be performed either abdominally or laparoscopically. It is unclear, however, as to whether infrarenal aortic nodal sampling above the IMA should be routinely performed. CASE: We describe a case of endometrial cancer metastatic to the infrarenal para-aortic lymph nodes above the IMA, missed during laparoscopic inframesenteric lymph node dissection, and found on subsequent laparotomy performed to resect matted pelvic nodes. CONCLUSIONS: The infrarenal para-aortic region above the IMA may be at risk for nodal metastasis in women with endometrial cancer. Consideration should be given to evaluate this area during staging laparotomy or laparoscopy. The role of routine bilateral infrarenal aortic nodal dissection needs further evaluation.     

Resection of bulky positive lymph nodes in patients with cervical carcinoma

From January 1987 to April 1992, 34 patients had resection of bulky positive lymph nodes, detected either at the time of radical hysterectomy ( n = 23) or by computed tomographic (CT) scan of the pelvis and abdomen prior to radiation therapy for more advanced cervical cancer ( n = 11). Following nodal resection, 33 patients received pelvic external beam radiation, 28 received pelvic and para-aortic radiation, and 23 received four cycles of cisplatin chemotherapy. The median number of resected positive nodes was 4, with a range of 1–44. All macroscopic nodal metastases could be resected in each patient and morbidity was acceptably low. Positive nodes were confined to the pelvis in 17 patients, involved the common iliac group in nine patients, and involved the para-aortic area in eight patients. With a mean follow-up of 36 months, 23 patients (67.6%) were alive, of whom 20 were free of disease. For patients having a radical hysterectomy, actuarial 5-year survival was 80% for patients with disease involving pelvic and common iliac lymph nodes, and 48% for those with positive para-aortic nodes. Survival for patients with completely resected bulky pelvic and common iliac nodes was comparable to that for patients with micrometastases. This study suggests that every effort should be made to identify patients with cervical cancer who have bulky positive lymph node metastases, and to remove these nodes surgically prior to radiation therapy.     

Early-stage cervical adenocarcinoma treated by surgical intent: the role of para-aortic lymph node dissection.

OBJECTIVE: Previous reports suggest that cervical adenocarcinomas have a unique pattern of spread and are more apt to metastasize to para-aortic lymph nodes. The purpose of this study was to further define the node of para-aortic lymph node dissection in early-stage cervical adenocarcinoma treated by surgical intent. METHODS: Institutional review board approval was obtained to perform a computerized search of the data of all women diagnosed with cervical adenocarcinoma between 1982 and 2000. Hospital charts were retrospectively reviewed. Follow-up was obtained from the tumor registry, medical records, and correspondence with health care providers. RESULTS: Three hundred (87%) of 345 early-stage (FIGO IA(1)-IIA) cervical adenocarcinoma patients were primarily treated by surgical intent. Two hundred seventy-six underwent pelvic and para-aortic node dissection (n = 69) or pelvic node dissection only (n = 207); 24 had no lymph node dissection. The median number of lymph nodes removed was 13 pelvic (range, 1-58) and 3 para-aortic (range, 1-17). Three (4%) of 69 patients had para-aortic nodal metastases. Each had either grossly evident para-aortic adenopathy (n = 2) or an adnexal metastasis. Thirty-six of 40 women developing recurrent disease had at least some component of pelvic recurrence; 4 had only extrapelvic disease. Three patients undergoing para-aortic node dissection developed an isolated extrapelvic recurrence despite originally negative para-aortic nodes (n = 2) or treatment by extended-field radiation for para-aortic metastases. One woman undergoing only pelvic node dissection had an isolated extrapelvic recurrence despite originally negative nodes. CONCLUSIONS: Early-stage cervical adenocarcinoma primarily treated by surgical intent has a very low risk of para-aortic metastases. These were detected only when there was gross evidence of nodal or adnexal disease.     

Correlation between clinical and histopathologic risk factors and lymph node metastases in early endometrial cancer (a multivariate analysis of 183 cases)

This study includes 183 patients with clinical stage I endometrial cancer subjected to peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymphadenectomy and omental biopsy during a 12-year period in a single institution. The factors analyzed were age, menopausal state, cell type, grade, mitotic activity, myometrial invasion, lymphovascular space invasion, cervical involvement, microscopic vaginal metastases, adnexal metastases, peritoneal cytology, presence of concomitant endometrial hyperplasia and lymph node status. The overall incidences of pelvic and para-aortic lymph node metastases were found to be 15.3% (28/183) and 9.3% (17/183), respectively. In five of 17 patients (29.4%) with para-aortic nodal metastases, pelvic nodes were free of tumor. The most significant prognostic factors for positive pelvic and/or para-aortic nodes were found to be the depth of myometrial invasion, grade of tumor and age.     

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。     

Analysis of clinicopathologic factors predicting para-aortic lymph node metastasis in endometrial cancer

The purposes of this study were to compare the relationships between para-aortic lymph node metastasis and various clinicopathologic factors to evaluate whether para-aortic lymph node dissection is necessary when treating endometrial cancer. A retrospective study was performed on 841 patients with endometrial cancer, who underwent the initial surgery at the Keio University Hospital. Clinicopathologic factors related to para-aortic lymph node metastasis significant on a univariate analysis were analyzed in a multivariate fashion using a logistic model. According to the multivariate analysis, the clinicopathologic factor most strongly related to the existence of para-aortic lymph node metastasis was positive pelvic lymph node metastasis (P < 0.01). Among the 155 patients who underwent pelvic and para-aortic lymph node dissection, the difference of 5-year overall survival by the presence of retroperitoneal lymph node metastasis was examined by Kaplan-Meier method. The prognosis was poor even if para-aortic lymph node dissection was performed in cases of positive para-aortic lymph node metastasis. In conclusion, when deciding whether to perform para-aortic lymph node dissection in patients with endometrial cancer, it is necessary to consider the pelvic lymph nodal status. If there is no pelvic lymph node metastasis, it could not be necessary to perform para-aortic lymph node dissection.     

A new approach to label sentinel nodes in endometrial cancer

PURPOSE: The objective of the study was to determine the feasibility of a new method of labeling sentinel lymph nodes in patients with endometrial cancer using blue dye. PATIENTS AND METHODS: 4 ml of blue dye was subserously administered in 25 patients with endometrial cancer at eight sites. After 8 min, sentinel lymph nodes were harvested. RESULTS: Detection rate was 92.0%, sensitivity was 62.5%, and negative predictive value was 92.5%. In two patients there was no detection of sentinel nodes and in addition in two patients only sentinel nodes were harvested due to minimal disease. No side effects occurred. CONCLUSIONS: This new and simple approach yielded a high pelvic detection rate. This new approach reveals a way to label sentinel nodes in endometrial cancer. Combining a different labeling agent with the proposed new method might overcome the lack of para-aortic sentinel detection.     

Lymph node spread in stage III or IV primary peritoneal serous papillary carcinoma

BACKGROUND: The aim of this study was to determine the rates and topography of pelvic and para-aortic nodal involvement in patients with stage III or IV primary peritoneal serous papillary carcinoma (PSPC). METHODS: Retrospective review of 19 women who underwent a systematic bilateral pelvic and para-aortic lymphadenectomy. RESULTS: The overall frequency of lymph node involvement was 63% (12/19). Eighteen patients underwent complete resection of peritoneal disease. Only 4 patients underwent this procedure as part of their initial surgery (before chemotherapy). The frequency of pelvic and para-aortic metastases was 58% (11/19) and 58% (11/19), respectively. When para-aortic nodes were involved, the left para-aortic chain above the level of the inferior mesenteric artery was the site most frequently involved (72%). The event-free survival of the 18 patients without macroscopic disease at the end of debulking surgery was significantly correlated with the nodal status. None of the patients with positive nodes developed recurrent disease in abdominal nodes. CONCLUSIONS: The rate of nodal involvement in patients with PSPC is high. The topography of nodal spread is similar to that of ovarian cancer. Lymphadenectomy has a prognostic value.     

The impact of pre-therapy extraperitoneal surgical staging on the evaluation and treatment of patients with locally advanced cervical cancer.

OBJECTIVE: The use of extraperitoneal surgical staging prior to treatment in patients with bulky or locally advanced cervical cancer allows the detection and treatment of disease beyond the standard pelvic radiation fields. This study was conducted to evaluate the impact of extraperitoneal surgical staging in the treatment and outcome of patients with locally advanced cervical cancer. METHODS: 51 patients with locally advanced cervical cancer treated between 1985 and 1998 were retrospectively reviewed. Information on morbidity, usefulness, and results of surgery and patterns of disease recurrence were obtained. Survival distributions were calculated by the Kaplan-Meier product limit method and compared with the log-rank test. RESULTS: All 51 women were surgically staged by an extra-peritoneal approach. Preoperative CT scans (n=27) when compared with surgical findings showed sensitivity for pelvic and para-aortic lymph node metastasis of 39%, specificity of 88%, positive predictive value of 39% and negative predictive value of 88%. Lymph node metastases were found in 30/51 patients (59%). There were no significant treatment delays or surgical morbidity as a result of extra-peritoneal surgical staging. In 21 patients (41%), the highest level of involved nodes was in the pelvis and they were treated with pelvic radiation. The para-aortic nodes were involved in nine patients (18%) and were treated with extended field radiation. All patients also received concurrent radiosensitization with chemotherapy. The estimated survival for the entire group was 60% at 5 years. For node negative patients, estimated 5-year survival was 67% while it was 54% for all node positive patients (p=0.17). Analysis according to anatomic site of involved nodes showed that the estimated 2-year and 5-year survival for those with pelvic nodal involvement was 81% and 64%, respectively. However, in the group of nine patients with para-aortic nodal disease, the estimated 2-year survival was 44%. Five (56%) were dead of disease with a median time to death of 16.0 months and four patients (44%) were alive with a median duration of follow up of 16.1 months. There was a statistically significant difference in survival for the group of patients with positive pelvic nodes only compared to the group with positive para-aortic nodes (p=0.03). The estimated 5-year survival by FIGO stage was 80%, 70% and 51% for stages Ib, II, III, disease, respectively. Factors that did not significantly affect survival included age, histology and type of chemotherapy. CONCLUSIONS: Pre-therapy extra-peritoneal surgical staging resulted in treatment modification in 18% of patients with locally advanced cervical cancer. The morbidity from surgery and subsequent radiation therapy was acceptable. The procedure is recommended to allow for individualization of treatment in patients with local-regional cervical cancer.     

Influence of diabetes mellitus and nodal distribution in endometrial cancer and correlation to clinico-pathological prognostic factors

OBJECTIVE: The aim of this study was to describe the relationships between the distribution of nodal disease, clinico-pathological patterns and recurrence and survival in surgically staged cases of endometrial cancer. METHODS: Charts were abstracted from patients with endometrial carcinoma from 1985 to 1995. Data on clinicopathologic variables, adjuvant treatment, site of recurrence and survival were collected. The chi square test was used to test associations between variables. The Kaplan-Meier method was used for survival analysis and Cox's proportional hazards model for multiple regression analysis. RESULTS: Sixty-nine out of 181 patients underwent lymph node dissection. Twenty-three had pelvic lymph node dissection, 23 underwent pelvic and paraaortic lymph node dissection and 20 patients had lymph node sampling. The median count of removed lymph nodes was 22.4. Fifty-four lymph node dissections showed negative lymph nodes and in 15 cases there was a minimum of one positive lymph node. Overall survival was in correlation to nodal involvement with a p value of 0.0017. Patients with lymph node involvement showed significantly more recurrence than patients with negative lymph nodes (p = 0.003). The depth of myometrial invasion correlated with lymph node metastasis (p = 0.01) and patients with additional diabetes mellitus showed significantly more nodal involvement (p = 0.02). CONCLUSION: Endometrial cancer showed pelvic lymph node (PLN) and paraaortic lymph node (PALN) involvement. Under-diagnosis of the disease might result if there was only a PLN, but with or without PALN involvement there was no significant difference in overall survival or recurrence. There was an univariate correlation between lymph node involvement and diabetes.     

Prospective evaluation of FDG-PET for detecting pelvic and para-aortic lymph node metastasis in uterine corpus cancer

OBJECTIVES: To estimate the sensitivity and specificity of positron emission tomography (PET) with 2-[(18)F]fluoro-2-deoxy-d-glucose (FDG) for detecting pelvic and para-aortic lymph node metastasis in patients with uterine corpus carcinoma before surgical staging. METHODS: Patients with newly diagnosed FIGO grade 2 or 3 endometrioid, papillary serous, or clear cell adenocarcinoma or uterine corpus sarcoma scheduled for surgical staging, including bilateral pelvic and para-aortic lymphadenectomy, were eligible. PET was performed within 30 days of surgery and interpreted independently by two nuclear medicine physicians. The imaging, operative, and pathologic findings for each patient and each nodal site were compared, and the sensitivity and specificity of FDG-PET in predicting nodal metastasis were determined. RESULTS: Twenty patients underwent FDG-PET before surgical staging. One patient found to have ovarian carcinoma on final pathology was excluded. Of the 19 primary intrauterine tumors, 16 (84%) exhibited increased FDG uptake. One patient did not undergo lymphadenectomy; her chest CT was suspicious for metastatic disease and FDG-PET showed uptake in multiple nodal and pulmonary foci. Metastatic disease was confirmed by percutaneous nodal biopsy. A total of three pathologically positive nodes were found in 2 of the 18 patients (11%). FDG-PET predicted that 3 patients would have positive lymph nodes (2 true positive and 1 false positive). Analyzed by lymph node regions, FDG-PET had 60% sensitivity and 98% specificity. The sensitivity and specificity by individual patient were 67% and 94%, respectively. CONCLUSIONS: FDG-PET is only moderately sensitive in predicting lymph node metastasis pre-operatively in patients with endometrial cancer. This imaging modality should not replace lymphadenectomy, but may be helpful for patients in whom lymphadenectomy cannot be, or was not, performed.     

Survival of ovarian carcinoma with or without lymph node metastasis

Because of the limited number of reports concerning the influence of retroperitoneal lymph node metastasis upon survival in patients with ovarian carcinoma, a prospective study was conducted between December 1975 and December 1982 to provide such information. This series consisted of 75 unselected patients with epithelial carcinoma of the ovary in all stages. Thirty-three patients had tumor-positive nodes and 42 had negative nodes. The two groups were compared with regard to stage of disease, grade of tumor, histology of tumor, residual disease after initial operation, finding at second-look laparotomy, and survival. All had initial maximal surgery and biopsy of para-aortic and pelvic nodes: most received postoperative chemotherapy. Follow-up was from 36 months to 10 years. Patients with positive nodes preferentially had more advanced disease (Stage III and IV). Grade 3 tumor, papillary serous cystadenocarcinoma, residual disease greater than 2%, low rate of second-look laparotomy, and death. Patients with negative nodes were connected with earlier disease (Stage I and II), nonserous tumor, minimal residual disease, high rate of second-look laparotomy, and survival. No patient with isolated nodal metastasis to pelvic or para-aortic survived. Only 18.2% with concomitant para-aortic and pelvic node involvements are currently alive, opposed to 64.3% with negative node. The results indicate that tumor-positive nodes in ovarian carcinoma are a poor prognostic factor and current combination chemotherapy is not effective. Alternative treatment for these patients should be considered.     

Lymph node metastasis in ovarian cancer: difference between serous and non-serous primary tumors

OBJECTIVE: To investigate the lymph node sites most susceptible to involvement relative to primary tumor histology in ovarian cancer. METHODS: The locations of metastatic lymph nodes were investigated in 208 patients with primary ovarian cancer who underwent systemic lymphadenectomy covering both the pelvic and para-aortic regions. RESULTS: Lymph node metastasis was present in 12.8% (20/156) of patients with stage I (pT1M0), 48.6% (18/37) with stage II (pT2M0), and 60% (9/15) with stage III (pT3M0) disease, thus in 22.6% (47/208) of all study patients. Isolated para-aortic nodal involvement was present in 23.3% (14/60) of patients with serous tumor and 4.1% (6/148) of those with non-serous tumor (P = 0.00002). In an analysis of 35 positive nodes from 25 patients with up to 3 positive nodes, 86.4% (19/22) of metastatic lymph nodes from patients with serous tumor were found in the para-aortic region, with 14 positive nodes located above the inferior mesenteric artery (IMA) and 5 below it, whereas metastasis to para-aortic lymph nodes accounted for 53.8% (7/13) of metastatic lymph nodes from patients with non-serous tumor (P = 0.0334). CONCLUSIONS: The locations of metastatic lymph nodes in ovarian cancer depend upon the histologic type of the primary cancer. In cases of serous tumor, the para-aortic region, particularly above the IMA, is the prime site for the earliest lymph node metastasis. However, the likelihood of pelvic node involvement is almost equal to that of para-aortic node involvement in cases of non-serous tumor.     

Efficacy of systematic lymphadenectomy and adjuvant radiotherapy in node-positive endometrial cancer patients

OBJECTIVE: To assess the efficacy of systematic lymphadenectomy and adjuvant radiotherapy in minimizing pelvic sidewall and para-aortic failures. METHODS: Between January 1984 and December 2001, a total of 146 patients with stage III and IV endometrial cancer and lymph node metastases were treated at our institution. Adequate pelvic lymphadenectomy was defined as the removal of more than 10 pelvic lymph nodes, and adequate para-aortic lymphadenectomy was defined as removal of 5 or more para-aortic lymph nodes. The 24 patients who received adjuvant chemotherapy were excluded. We assessed the ability of adequate pelvic and para-aortic lymphadenectomy, together with radiotherapy, to prevent pelvic and para-aortic recurrences. RESULTS: Of the 122 patients studied, 94 (77%) had adequate pelvic lymphadenectomy and 47 (39%) had adequate para-aortic lymphadenectomy. Pelvic radiotherapy was administered to 78% and para-aortic radiotherapy to 29% of patients. Median follow-up of censored patients was 56 months. Twenty-five percent of patients had pelvic sidewall failure at 5 years. Pelvic sidewall failures at 5 years occurred in 57% of patients who had inadequate node dissection and/or no radiotherapy, compared with 10% for those having both adequate lymphadenectomy and radiotherapy (P < 0.001). After risk factor assessment in a regression model, only treatment with adequate lymphadenectomy and radiotherapy was a significant independent predictor of pelvic control (P = 0.03). The performance of definitive pelvic lymphadenectomy may have increased treatment-related morbidity in the subgroup of patients who had postoperative radiotherapy. For the 41 patients with positive para-aortic lymph nodes, the 5-year para-aortic failure rate was 34% after adequate lymphadenectomy but without adjuvant para-aortic radiotherapy. Likewise, 69% failed in the para-aortic area when adjuvant para-aortic radiotherapy was administered to patients not having adequate para-aortic lymphadenectomy; however, none of the 11 patients failed in the para-aortic area after adequate lymphadenectomy and para-aortic radiotherapy (P = 0.08). CONCLUSIONS: Adequate (pelvic and para-aortic) lymphadenectomy and adjuvant radiotherapy appear complementary in reducing failures in both the pelvis and para-aortic areas in patients with node-positive endometrial cancer.     

The prognostic value of pretreatment 2-[18F]-fluoro-2-deoxy-d-glucose positron emission tomography scan in women with cervical cancer

There is substantial risk that prognosis determined with routine clinical staging for cervical cancer may be inaccurate. This is primarily due to understaging due to the lack of detection of nodal disease. This is particularly true for para-aortic nodal metastases. Treatment based on such staging may also be inadequate for the same reason. Positron emission tomography (PET) has been demonstrated to be useful in the staging of cervical cancer and superior to either computed tomography or magnetic resonance imaging in the detection of nodal disease. Our objective was to determine the prognostic value of pretreatment 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) PET scan in women with cervical cancer. We reviewed the records of 56 women with cervical cancer who underwent FDG PET scan prior to treatment. The primary outcome was the effect of abnormal FDG uptake consistent with metastatic nodal disease on 20-month disease-free survival. The pretreatment PET scan demonstrated abnormal FDG uptake in the pelvic nodes alone in 14 (25%) women, in pelvic and para-aortic nodes in 10 (17.9%), and in neither pelvic nor para-aortic nodes in 32 (57.1%). Women with positive pelvic nodes by PET as well as women with positive para-aortic nodes had significantly poorer 20-month disease-free survival compared to women with negative nodes (P= 0.0003 and P= 0.0017, respectively). We conclude that pretreatment FDG PET scan revealing abnormal FDG uptake consistent with nodal disease is a robust predictor of disease recurrence and may alter the therapeutic management of some patients.     

Interstitial thermoradiotherapy in recurrent gynecologic malignancies

In patients with ovarian carcinoma, the presence of metastatic disease in a retroperitoneal lymph node is indicative of a poor prognosis. Although a “staging laparotomy” is required for proper treatment, definitive information concerning para-aortic and pelvic lymph node metastasis often is not available. To determine the incidence of retroperitoneal lymph node metastases in untreated cases of ovarian carcinoma, a prospective study by selective nodal biopsy was undertaken in 61 unselected patients with the following distribution: Stage I, 11; Stage II, 10; Stage III, 31; and Stage IV, 9. The incidence of para-aortic node metastasis overall was 37.7% and of pelvic node metastasis, 14.8%. Of 23 patients with positive para-aortic nodes, 30.4% had no concomitant pelvic node involvement. Direct relationships between nodal metastasis and clinical stage, tumor grade, and histologic type of tumor were demonstrated. The incidence of positive para-aortic nodes in Stage I disease was 18.2%; in Stage II, 20.0%; in Stage III, 41.9%; and in Stage IV, 66.7%. The corresponding incidence of pelvic node metastasis was 9.1% in Stage I, 10.0% in Stage II, 12.9% in Stage III, and 33.3% in Stage IV. Grade 3 tumors were associated most frequently with nodal involvement, with an incidence of positive para-aortic nodes of 52.5% and of positive pelvic nodes of 15.5%. In patients with a serous type of malignancy, the frequencies of positive para-aortic/pelvic nodes were 44.4%/16.7%, respectively; in the undifferentiated type, 50.0%/10.0%; in the clear cell type, 25.0%/25.0%; and in the mucinous type, 14.3%/ 14.3%. In this small series, 32 patients (52.5%) had positive retroperitoneal nodal involvement. It is concluded that selective biopsies of the para-aortic and pelvic lymph nodes should be part of any “staging laparotomy” for ovarian carcinoma, and that the true incidence of nodal involvement in these patients awaits further investigation.