Lymphadenectomy in elderly patients with high-intermediate-risk, high-risk or advanced endometrial cancer: Time to move from personalized cancer medicine to personalized patient medicine!

Abstract

BACKGROUND: Pelvic and paraaortic lymphadenectomy are recommended for women with highintermediate, high-risk and advanced endometrial cancer (EC). Lymphadenectomy is less frequently performed in elderly patients than in younger patients. We examined the survival of elderly women diagnosed with high-risk EC according to whether lymphadenectomy was performed or not. METHODS: We selected women over 70 years with high-intermediate risk, high-risk or advanced EC from a multicenter retrospective cohort of women diagnosed between 2001 and 2013. Multivariate logistic regression models and Cox proportional hazards survival methods for overall survival (OS), disease-free survival (DFS) and cancer-specific survival (CSS) were used for analyses. RESULTS: 71 women had lymphadenectomy and were compared with the 213 who did not. Recurrence was similar in both groups (42% vs 33%, respectively, p=0.17) but more deaths were reported in the group without lymphadenectomy (38% vs 23%, respectively, p<0.001). There was no difference in adjuvant treatment in the two groups (17% vs 27%, respectively, p=0.27). Elderly patients without lymphadenectomy had lower 3-year DFS (56% vs 71%, p=0.076), CSS (67% vs 85%, p<0.001) and OS (50% vs 71% p<0.001). The Cox proportional hazard models showed independently poorer prognosis in women without lymphadenectomy (3.027, 95% CI 1.58-5.81, p<0.001), histology type 2 (3.46, 95% CI 1.51-7.97, p=0.003) and lymphovascular space involvement (3.47, 95% CI 1.35-8.98, p=0.01) on 3-year CSS. CONCLUSION: No lymphadenectomy in elderly patients with high-risk or advanced EC is independently associated with poorer prognosis. Elderly patients with EC should benefit from lymphadenectomy when indicated.

Para‐aortic lymphadenectomy did not improve overall survival among women with type I endometrial cancer

“…Similarly, a review in 2015 found no evidence that lymphadenectomy decreases the risk of death or disease recurrence as compared with no lymphadenectomy among women with presumed Stage I disease 13 ; an updated review in 2017 repeated this viewpoint 13 . By contrast, a study in 2019 reported that no lymphadenectomy for elderly women with high‐risk or advanced endometrial cancer was independently associated with poorer prognosis 18 . Whereas the above studies focused on all types of endometrial cancer, the present study found that lymphadenectomy, especially PALD, did not improve the overall survival of women with type I endometrial cancer.…”

Évaluation de l’application des recommandations des cancers de l’endomètre de type 2 : étude rétrospective multicentrique

“…En effet, les curages sont à risque de complications per-opératoires (plaies d’uretère ou vasculaire) et post-opératoire (lymphocèle, douleur, surinfection) pouvant parfois retarder voire empêcher la réalisation d’un traitement adjuvant. De plus, l’intérêt des curages sur la survie est remis en question avec de nombreux articles apportant des informations discordantes [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] . Certaines études se sont intéressées à des méthodes alternatives pour réaliser une stadification.…”

“…Une première réponse était apportée par les recommandations de 2017 aux discussions de la stadification de ces deux premières études, incluant les cancers de l’endomètre à risque faible et intermédiaire, avec la réalisation du ganglion sentinelle. Cette question n’est toujours pas abordée dans les recommandations françaises des carcinomes à risque élevé puisque pour l’instant des études retrouvent un bénéfice dans la survie globale à la réalisation des curages pelviens et lombo-aortiques [26] , [27] , [28] , [29] , [30] . En 2018, les recommandations Américaines soulèvent la question du ganglion sentinelle dans les carcinomes à haut risque avec des premières études rapportant des résultats prometteurs [36] .…”

Surgical and oncological outcomes of sentinel lymph node sampling in elderly patients with intermediate to high-risk endometrial carcinoma

“…Given its role in stratifying patients into risk groups and tailoring post-operative adjuvant treatment, lymph node assessment is recommended for surgical staging of endometrial cancer as per the National Comprehensive Cancer Network (NCCN) guidelines 11 12. Moreover, lymphadenectomy is associated with improved survival outcome in elderly patients with high-intermediate risk and high-risk disease 13. Although lymph node assessment seems more important in elderly patients with endometrial cancer given the increased rate of high-risk disease in this population, recent studies show more than 50% of patients aged over 70 years do not undergo lymphadenectomy at the time of the surgery, likely due to underlying comorbidities 7 14…”