Lymphadenectomy during endometrial cancer staging: Practice patterns among gynecologic oncologists

Abstract

Objectives Several controversies surround lymphadenectomy for endometrial cancer; surgical approach, who to stage, and the anatomic borders of the lymphadenectomy. The purpose of this study was to identify practice patterns among gynecologic oncologists when performing a lymph node evaluation during staging for endometrial cancer. Methods A self-administered survey was sent via email to all SGO members on 3 occasions between 2/09 and 4/09. The survey addressed surgical approach, algorithms used to determine staging, and anatomic landmarks defining lymphadenectomy. Results Four hundred and six members (40%) responded. Eighty-two percent completed fellowship and 14% were fellows. Thirty-four percent finished fellowship in 2000 or later. Eighty-five percent educate fellows/residents in either academic (65%) or private practice settings (20%). For a majority of cases 40% prefer laparotomy, 31% perform robotic surgery, and 29% use laparoscopy. Minimally invasive surgery was associated with university-based practice (p=0.048). Most (53%) never/rarely use frozen section to determine whether or not to perform lymphadenectomy. A majority perform staging on all grade 2 and grade 3 cancers (66% and 90%, respectively). When performing paraaortic lymphadenectomy, 50% of respondents use the IMA as the upper border and 11% take the dissection to the renal vessels. Participants who completed fellowship in 2000 or later were less likely to go to the renal vessels (p=0.002). Conclusion Current controversies in surgical staging for endometrial cancer are reflected in the practice patterns among gynecologic oncologists. At this point it is unclear if standardizing surgical practice patterns will improve outcomes for patients with endometrial cancer.

Does Preoperative Diagnosis of Endometrial Hyperplasia Necessitate Intraoperative Frozen Section Consultation?

“…The problem is how to determine those patients. Although standard treatment for women with endometrial cancer included a comprehensive staging surgery consisting of total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic and para-aortic lymph node dissection, several studies published over the past several years have questioned the necessity of such a comprehensive surgery for most of the patients with endometrial cancer (7,8,(16)(17)(18)(19). Mariani and coworkers demonstrated that patients with endometrioid type Grade 1 or 2 disease with no or superficial myometrial invasion have a negligible risk for lymphatic metastasis when the tumor diameter is 2 cm or less.…”

“…Conventional surgical staging procedure includes total hysterectomy with bilateral salpingo-oophorectomy and bilateral pelvic and para-aortic lymph node dissection (5). However, approximately 75% of patients with endometrioid type adenocarcinoma of endometrium is confined to the uterus at the time of diagnosis and a more conservative surgery may be considered for those (6,7). Patients with certain well-defined pathologic features are classified as low-risk for extrauterine disease and lymph node spread.…”

Prevention and Therapeutic Strategies in Endometrial Cancer

“…The robotic approach could be a 'benefit' in obese women. (Boggess, 2008], but access to the high para-aortic area appears to be limited compared with the laparoscopic or open surgical approaches [Soliman, 2010]. When surgery is not feasible due to medical contraindications (5-10% of patients), external radiation therapy with or without intracavitary brachytherapy to the uterus and vagina is suitable for individual clinical use [Colombo, 2011].…”

“…(Susumu, 2008) Platinum-based chemotherapy can be considered in this stage. In retrospective series that platinum-based adjuvant chemotherapy for stage II disease improves PFS and overall survival [Soliman, 2010].…”

Survival in patients with uterine carcinosarcoma undergoing sentinel lymph node mapping

“…Traditional staging via lymphadenectomy for uterine cancers involves the removal of pelvic and paraaortic lymph nodes, which has been associated with increased morbidity including lower extremity lymphedema and lymphocyst formation. [7][8][9][10] Recently, however, sentinel lymph node (SLN) mapping has gained greater attention. 11,12 While its role in endometrial cancer remains undetermined, a significant amount of literature has accrued testifying to the benefit it may provide patients through equivalent detection of metastatic disease with lesser morbidity than standard lymphadenectomy.…”