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.     

Prediction model for para-aortic lymph node metastasis in patients with locally advanced cervical cancer

Objective

Concurrent chemoradiotherapy is usually administered to patients with locally advanced cervical cancer (LACC). Extended-field chemoradiotherapy is required if para-aortic lymph node (PALN) metastasis is detected. This study aimed to construct a prediction model for PALN metastasis in patients with LACC before definitive treatment.

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.     

Tumor size in endometrial cancer: a prognostic factor for lymph node metastasis

The association of tumor size and lymph node metastasis in endometrial cancer clinically confined to the uterus was evaluated in 91 patients. Other factors possibly associated with lymph node metastasis were also analyzed. Tumor size was independently associated with lymph node metastasis when analyzed by multivariate analysis (P = .022). Patients with tumors less than or equal to 2 cm in diameter had only a 5.7% incidence of lymphatic metastases. When tumors exceeded 2 cm in diameter or involved the entire endometrial surface, metastases occurred in 21.7 and 40.0% of patients, respectively. Measuring tumor size at surgery, or possibly preoperatively by hysteroscopy, will help predict which patients are at increased risk for lymph node metastasis. There were no lymph node metastases in patients with tumors less than or equal to 2 cm in diameter and invasion of less than half of the myometrium. For these patients, extended surgical staging with pelvic and aortic lymph node biopsies may not be indicated.     

Predicting pelvic lymph node metastasis in endometrial carcinoma

BACKGROUND: To determine the possibility of individualizing the pelvic lymph node dissection in patients with endometrial cancer, the relationship between pelvic lymph node (PLN) metastasis and various prognostic factors was retrospectively investigated. METHODS: From 1979 to 1994, 175 patients with endometrial carcinoma were treated with either total or radical hysterectomy combined with a PLN dissection as initial therapy. The prognostic factors examined included clinical stage, patient age, histological grade, the microscopic degree of myometrial invasion (DMI), cervical invasion, adnexal metastasis, and macroscopic tumor diameter (TD). RESULTS: Of the 175 patients undergoing PLN dissection, 24 (14%) had PLN metastasis. An endometrial cancer with PLN metastasis had a significantly longer diameter than those without PLN metastasis. The frequency of PLN metastasis increased along with increases in tumor diameter. A logistic regression analysis revealed DMI and TD to be independently correlated with PLN metastasis. The formula based on the coefficients of TD and DMI obtained from the analysis also showed a good correlation, which allowed us to estimate the probability of patients having PLN metastasis. CONCLUSIONS: DMI and TD could accurately estimate the status of PLN in endometrial carcinoma patients.     

Sentinel lymph node in endometrial cancer

The aim of this study was to evaluate the possibility of identifying the sentinel lymph node and involvement of neoplastic cells in patients with endometrial carcinoma limited to the uterus, and also its correlation with the conditions of other pelvic and para-aortic lymph nodes. Forty patients with endometrial carcinoma, clinical staging I and II, were submitted to complete surgical staging through laparotomy, as recommended by FIGO in 1988. The sentinel node was investigated using patent blue dye in the myometrial subserosa. The sentinel node was excised and submitted to frozen section examination of specimen, stained with hematoxylin and eosin (H&E). Afterward, selective bilateral para-aortic and pelvic lymphadenectomy, total hysterectomy with bilateral salpingo-oophorectomy were performed. The lymph nodes excised were examined by means of paraffin-embedded slices stained with H&E and of imunohistochemistry with antikeratin antibody AE1/AE3. The sentinel lymph node was identified in 77.5% of patients (31/40), and 16.1% (5/31) presented neoplastic involvement in the node. In 25 cases of negative sentinel node, 96% (24/25) had no neoplastic involvement, and 4% (1/25) had other lymph node affected (false negative). In nine cases with no sentinel node identified, 55.5% (5/9) had lymph node involvement. The results of this study allow us to conclude that it is possible to identify the sentinel node using the methods described, and the pathologic examination significantly represents the same conditions of other pelvic and para-aortic lymph nodes.     

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.     

Nomogram with potential clinical use to predict lymph node metastasis in endometrial cancer patients diagnosed incidentally by postoperative pathological assessment

Purpose

To determine the clinical and pathological risk factors for lymph node metastasis (LNM) in patients with endometrial cancer and to create a nomogram to predict LNM in patients without surgical staging.

Methods

All patients with endometrial adenocarcinoma who were treated surgically at a university based gynecologic oncology clinic between January 2011 and December 2014 were recruited. Women with endometrial adenocarcinoma who were surgically staged including lymphadenectomy were included in the study. Data regarding clinical and pathological risk factors were recorded. The histopathologic slides from the staging surgeries were re-evaluated microscopically by a gynecologic pathologist for all parameters along with lymphovascular space invasion (LVSI).

Results

A total of 279 patients with endometrial cancer were analyzed. Among those, 31 (11.1%) had lymph node metastasis. According to the univariate analyses, elevated CA 125 (>35 U/mL), LVSI, myometrial invasion ≥50%, grade 3 disease, non-endometrioid type, and cervical stromal involvement were significantly associated with LNM. The multivariate logistic regression analysis showed that LVSI, non-endometrioid type, elevated CA 125, and cervical stromal involvement increased the risk of LNM. However, myometrial invasion and grade did not significantly affect the risk of LNM. A nomogram to predict LNM was constructed using these factors (concordance index 0.92).

Conclusions

LVSI is the most important predictor for LNM. The present nomogram can be useful to decide if adjuvant therapy is required for patients who undergo simple hysterectomy for a benign etiology and incidentally diagnosed with endometrial cancer by pathological evaluation.

     

子宫内膜癌淋巴结切除意义及指征

子宫内膜癌采用手术病理分期,然而是否对所有子宫内膜癌患者都行全面分期手术(全子宫切除术+双附件切除术+双侧盆腔淋巴结及腹主动脉旁淋巴结切除)争议广泛,尤其是对于早期子宫内膜癌患者淋巴结切除的价值值得探讨。文章回顾子宫内膜癌淋巴结切除的最新研究进展,进一步讨论淋巴结切除的意义及指征。     

A postoperative scoring system for distant recurrence in node-positive cervical cancer patients after radical hysterectomy and pelvic lymph node dissection with para-aortic lymph node sampling or dissection

Objective

To identify risk factors for distant recurrence in node-positive cervical cancer patients who underwent radical hysterectomy and pelvic lymph node dissection (PLND) with para-aortic lymph node sampling (PALNS) or para-aortic lymph node dissection (PALND).

Predictability of retroperitoneal lymph node metastasis by using clinicopathologic variables in surgically staged endometrial cancer

The purpose of this study was to predict lymphatic involvement in endometrial cancer using clinicopathologic variables of patients treated with surgical staging. Overall, 461 patients treated with an initial surgical staging procedure including complete pelvic-para-aortic lymphadenectomy were included. The mean number of resected lymph nodes was 27 (median 26; range 15-83), and 54 patients (12%) had lymphatic involvement. Of these patients, 32 had only pelvic, 15 had both pelvic and para-aortic, and 7 had isolated para-aortic metastases. In the multivariate analysis, deep myometrial invasion (P= 0.02), lymphvascular space invasion (P= 0.001), positive peritoneal cytology (P= 0.002), and cervical involvement (P= 0.003) predicted retroperitoneal lymph node metastasis (RLN) significantly. Two hundred seventy-four patients (59.4%) had at least one of these poor prognostic factors identified by multivariate analysis. In this patient population, 53 (19.3%) had lymphatic involvement compared to 1 patient in the group of 187 patients with low-risk criteria. Ninety-eight percent of patients with RLN were predicted by this model, and with the advent of accurate diagnostic techniques, 40% of patients could be saved from undergoing lymphadenectomy.     

Magnetic resonance imaging to identify risk of lymph node metastasis in patients with endometrial cancer

Objective

To assess the value of magnetic resonance imaging (MRI) to identify endometrial cancer patients at risk of lymph node metastasis.

Methods

Retrospective review of data from 108 patients with clinical stage I endometrial cancer who underwent preoperative MRI and were treated surgically. Patients at risk of lymph node metastasis were defined as those who had more than 50% myometrial infiltration or cervical invasion. Preoperative MRI reports were compared with final pathologic results.

Results

The mean age of the patients was 69.5 years and most patients had endometrioid cancer. On final pathologic analysis, 59 patients had deep myometrial infiltration or cervical invasion. For diagnosis of deep myometrial infiltration, cervical invasion, or both, MRI sensitivity and specificity were 56% and 85%; 47% and 83%; and 67% and 77%, respectively.

Conclusion

MRI has limited value in identifying patients with endometrial cancer who are at risk of lymph node metastasis. Minimally invasive laparoscopic lymph node staging should be undertaken when it is feasible.     

Incidence of lymph node and adnexal metastasis in endometrial stromal sarcoma

Objective

To determine the incidence of adnexal and lymph node (LN) metastasis in newly diagnosed endometrial stromal sarcoma (ESS).

Methods

We identified all cases with a diagnosis of ESS evaluated at our institution from January 1, 1980 to October 31, 2009. All uterine pathology was reviewed at our center. High-grade or undifferentiated tumors and ESS arising in extrauterine sites were excluded. Pertinent clinical data were abstracted from electronic medical records. Appropriate statistical tests were performed using SPSS16.0.

Results

We identified 94 cases of ESS. LN metastasis was identified in 7 (19%) of 36 patients who underwent LN evaluation. Six of the 7 cases with LN metastasis had lymphovascular invasion (LVI). LVI status was not reported in the other case. Five of the 7 patients with LN metastasis had grossly positive LNs with or without other gross extrauterine disease. Of 20 patients with disease grossly limited to the uterus and grossly normal LNs, 2 (10%) had LN metastasis. Both of these cases had LVI and extensive myoinvasion. Eighty-seven cases (93%) underwent salpingo-oophorectomy. Adnexal metastasis was identified in 11 (13%) of 87 cases, all manifested by gross adnexal tumor and occurring in patients with other gross pelvic extrauterine disease.

Conclusion

The incidence of LN metastasis in ESS is commonly associated with gross extrauterine disease, extensive myoinvasion, and LVI. Since myoinvasion and LVI status often are not assessable at the time of hysterectomy, LN dissection remains a reasonable option at primary surgery. The rate of adnexal metastasis appears to be negligible in the absence of gross adnexal and extrauterine tumor.     

Pelvic lymph node metastasis of uterine cervical cancer

The state of pelvic lymph node metastasis was observed in 627 cases of Okabayashi's radical hysterectomy performed from 1950 to 1984 of which 589 cases with a known 5-year survival rate were examined according to their relationship to prognosis. The incidence of lymph node metastasis was 29.7%, becoming progressively higher with succeeding clinical stages. The metastasis rates according to site were 6.9% hypogastric nodes, 4.9% obturator nodes, 4.4% iliac nodes, and 25.0% parametrial nodes. Among the factors considered in the postoperative classification, lymph node metastasis demonstrated high values in cervical infiltration cancer, positive parametrial infiltration, positive vaginal invasion, and infiltration into the uterine body and L type of CPL classification. The 5-year survival rate was 83.0% in negative cases of pelvic lymph node metastasis, while in positive cases, it was as poor as 45.8%. Considering the relationship of various factors, it is shown that the presence of lymph node metastasis has a great effect on prognosis.     

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.