By Ed Susman
TAMPA, Fla -- March 14, 2008 -- When lymph node dissection surgery is performed in patients with advanced endometrial cancer, surgeons should continue to excise nodes up to the renal arteries and not assume para-aortic negative nodes are the end of the story.
"If you are going to do a lymph node dissection, you have to do it completely," said Andrea Mariani, MD, PhD, Associate Professor of Obstetrics and Gynecology, Mayo College of Medicine, Rochester, Minnesota, in his presentation here at the Society of Gynecologic Oncologists (SGO) 2008 Annual Meeting on Women's Cancer.
"Our study suggests that para-aortic lymphadenectomy needs to be extended to the renal vessels," Dr. Mariani said in his oral presentation on March 10. "We found that incomplete lymph node dissection results in missed positive cases."
He said that in cases he has reviewed, 38% to 46% of para-aortic node-positive cases are missed when the lymph node dissection is performed only up to the inferior mesenteric artery.
Dr. Mariani discussed a case series of 422 patients who underwent surgery for endometrial cancer between 2004 and 2006. Patients did not require surgical staging if they had endometrioid lesions, had less than 50% myometrial invasion, had grade 1 or 2 endometrial cancers, had a tumour diameter <2 cm, and had no macroscopic evidence of extrauterine tumour. To be excluded from staging all of the criteria had to be met. The rest of the patients required surgical staging.
By that protocol, 112 women (27%) did not require surgical staging. Despite that, 20% or 22 of these women had the surgery performed. Of the 310 patients who should have had surgery, 29 women (9%) did not have surgical staging.
About 63 (22%) of the 281 women who had surgical staging were found to have positive lymph nodes. Dr. Mariani said 57 of the 63 women were treated with lymph node dissection, including 9 who had para-aortic dissection; 19 had pelvic-only dissections and 29 had both pelvic and para-aortic dissection.
Of 26 patients who had lymph node dissections above the inferior mesenteric artery, 20 had positive nodes. In 12 of 20 cases, positive nodes were found above the inferior mesenteric artery, while nodes lower than the artery were negative, underscoring the need to do a complete lymphadenectomy procedure.
Overall, he said, 62% of cases in which nodes are positive below the inferior mesenteric artery also have positive nodes above the artery.
[Presentation title: Prospective Assessment of Lymphatic Dissemination in Endometrial Cancer: A Paradigm Shift in Surgical Staging. Abstract 21]
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