Lymphadenectomy can be omitted for low-risk endometrial cancer based on preoperative assessments

Abstract

ObjectiveAccording to the International Federation of Gynecology and Obstetrics staging, some surgeons perform lymphadenectomy in all patients with early stage endometrial cancer to enable the accurate staging. However, there are some risks to lymphadenectomy such as lower limb lymphedema. The aim of this study was to investigate whether preoperative assessment is useful to select the patients in whom lymphadenectomy can be safely omitted.MethodsWe evaluated the risk of lymph node metastasis (LNM) using LNM score (histological grade, tumor volume measured in magnetic resonance imaging [MRI], and serum CA-125), myometrial invasion and extrautrerine spread assessed by MRI. Fifty-six patients of which LNM score was 0 and myometrial invasion was less than 50% were consecutively enrolled in the study in which a lymphadenectomy was initially intended not to perform. We analyzed several histological findings and investigated the recurrence rate and overall survival.ResultsFifty-one patients underwent surgery without lymphadenectomy. Five (8.9%) who had obvious myometrial invasion intraoperatively underwent systematic lymphadenectomy. One (1.8%) with endometrial cancer which was considered to arise from adenomyosis had para-aortic LNM. Negative predictive value of deep myometrial invasion was 96.4% (54/56). During the mean follow-up period of 55 months, one patient with deep myometrial invasion who refused an adjuvant therapy had tumor recurrence. The overall survival rate was 100% during the study period.ConclusionThis preoperative assessment is useful to select the early stage endometrial cancer patients without risk of LNM and to safely omit lymphadenectomy.

Preoperative Magnetic Resonance Volumetry in Predicting Myometrial Invasion, Lymphovascular Space Invasion, and Tumor Grade: Is It Valuable in International Federation of Gynecology and Obstetrics Stage I Endometrial Cancer?

“…Polypoid growth pattern into the endometrial cavity in large stage IA tumors might have caused high TVR values, and infiltrative pattern in small stage IB tumors might have caused low TVR values, overall creating overlaps. Moreover, both tumor size and tumor volume were not predictors of negative prognostic factors (deep myometrial invasion, high tumor grade, LVSI, or nonendometrioid type histology) in our study, as opposed to previous studies 8,9,15,16,27. Mean tumor volume in our study was close to results of study of Nougaret et al 15 (14 cm 3 vs 19.9 cm 3 in T2 weighted sagittal images).…”

A preoperative risk-scoring system to predict lymph node metastasis in endometrial cancer and stratify patients for lymphadenectomy

“…In our study, only 1 among the 156 patients in the lymphadenectomy-omitted group had recurrence (0.6%); it was an extremely rare case wherein the extirpated uterine left no remaining lesions, but the patient had rapid spread of systemic LNM despite very early cancer stage and the absence of other recurrence risk factors; she died 58 months post-surgery. The five-year survival rate in the no-lymphadenectomy group was 99.1%, which is similar to that reported by Mitamura et al [19]. However, we used a more stringent cut-off value for tumor volume (6 cm 3 versus 36 cm 3 in [19]) that allowed us to not only identify cases where lymphadenectomy may be omitted, but also to determine the scope of lymph node dissection and, thus, avoid needless PLAX.…”

“…The five-year survival rate in the no-lymphadenectomy group was 99.1%, which is similar to that reported by Mitamura et al [19]. However, we used a more stringent cut-off value for tumor volume (6 cm 3 versus 36 cm 3 in [19]) that allowed us to not only identify cases where lymphadenectomy may be omitted, but also to determine the scope of lymph node dissection and, thus, avoid needless PLAX.…”

“…As a result, they have reported a low recurrence rate (1.8%) and 100% five-year survival rate, although the analyzed sample size (51 patients) was small [19]. In our study, only 1 among the 156 patients in the lymphadenectomy-omitted group had recurrence (0.6%); it was an extremely rare case wherein the extirpated uterine left no remaining lesions, but the patient had rapid spread of systemic LNM despite very early cancer stage and the absence of other recurrence risk factors; she died 58 months post-surgery.…”

“…In a previous study, Mitamura et al have also demonstrated the safety of lymphadenectomy omission using a scoring system based on clinical parameters similar to those of the KCC [19]: tumor volume less than 36 cm 3 , G1 or G2 endometrioid adenocarcinoma, CA125 levels below 28 and 70 U/ml for patients aged N50 and ≤50 years, respectively, and no myometrial invasion. As a result, they have reported a low recurrence rate (1.8%) and 100% five-year survival rate, although the analyzed sample size (51 patients) was small [19].…”