Juniper Publishers: The Role of Lymphadenectomy in Patients with Endometrial Cancer


Journal of Gynecology and Women’s Health-Juniper Publishers

 

  Authored by Georgios Androutsopoulos


Editorial

Endometrial cancer (EC) represents the most common malignancy of the female genital tract in developed countries [1-10]. Current international guidelines (ACOG, FIGO, SGO, ESGO and ESMO), recommend systematic surgical staging as the initial treatment approach for all types of EC [type I (endometrioid) and type II (serous, clear cell, undifferentiated)] [2-4,6-15]. This is mainly because systematic surgical staging offers many diagnostic, prognostic and therapeutic benefits for these patients [2-4,6-13].

Pelvic and para-aortic lymphadenectomy represents an integral part of the systematic surgical staging [2-4,6-11,16]. Pelvic lymphadenectomy should include the remove of the nodal tissue from the distal half of the common iliac artery, the external iliac artery and vein (down to the deep circumflex iliac vein) and the obturator fat pad (anterior to the obturator nerve) [11]. In para-aortic lymphadenectomy the nodal tissue from the inferior vena cava and aorta (up to the level of either the renal vessels or to the inferior mesenteric artery) is dissected [8-11].

According to the revised FIGO staging system for endometrial cancer, lymphadenectomy represents the only way to accurately diagnose patients with FIGO stage IIIc disease [2-4,6-13,16-18]. Therefore, lymphadenectomy provides important information regarding the need for postoperative adjuvant treatment, in order to maximize the survival and minimize the morbidity of over-treatment (post-radiation effects, chemotherapy related toxicity) and the risks of under-treatment (recurrence) [8,11,18-20].

The implementation of pelvic and para-aortic lymphadenectomy in patients with early stage type I EC, does not affect the overall and the disease free survival [2-11,13,21-23]. According to the results of the ASTEC study, pelvic lymphadenectomy should not be recommended as a routine procedure outside of clinical trials, in patients with early stage type I EC [22]. However, this requires an extensive intraoperative frozen section evaluation of the uterine specimen, an approach usually not available or feasible in many hospitals [11,20,22]. On the contrary, pelvic and para-aortic lymphadenectomy improves overall survival in patients with advanced stage type I EC as well as in all patients with type II EC [2-11,24-28].

There is an ongoing debate regarding the need and the extent of para-aortic lymphadenectomy in EC patients, mainly because the occurrence of isolated para-aortic lymph node metastases with negative pelvic nodes, is approximately only 1-3,5% [8,11,20,29]. Based on the results of the SEPAL study, combined pelvic and para-aortic lymphadenectomy should be recommended in intermediate and high risk EC patients (stage Ib or more in type I EC and any stage in type II EC), as there are essential survival benefits [8,30]. Furthermore, the implementation of para-aortic lymphadenectomy up to the level of renal vessels is preferable, because most patients with para-aortic lymph node involvement have metastases above the level of the inferior mesenteric artery [8,29,31].

The extent of pelvic and para-aortic lymphadenectomy should be confirmed pathologically in the tissue specimen [8,11]. Although there is not any limit regarding the number of the removed lymph nodes, the removal of more than 10-12 lymph nodes is directly correlated with improved prognosis [8,11,24,26,27,32]. Consequently, the total number of the removed lymph nodes, reflects the adequacy of lymphadenectomy [8,24,26].

The most common intraoperative and postoperative complications of pelvic and para-aortic lymphadenectomy, are vessel or nerve injury, pelvic lymphocysts, lymphoedema and cellulitis [2-4,6,7,9-11,21,33,34]. Extended pelvic and paraaortic lymphadenectomy (more than 14 lymph nodes) increases significantly the risk for these perioperative complications [2-4,6,7,9-11,21,33,34]. This is the main reason why, surgeons should carefully balance the increased morbidity and the risk for perioperative complications with any survival benefit, especially in elderly patients and in patients with comorbidities (obesity, diabetes mellitus and coronary artery disease) [2-4,6,7,9- 11,33,35,36].

In recent years, the sentinel lymph node detection and dissection has emerged as an attractive approach, mainly because it could potentially be related to reduced risk of perioperative complications compared to the systematic lymphadenectomy. Particularly in EC, sentinel lymph node dissection still remains experimental and represents a balance between systematic lymphadenectomy and no dissection in low and intermediate risk EC patients [8,37-42]. The approach is based on the theory that lymph drains away from the tumor in a specific centrifugal pattern [38,39]. Consequently, if the sentinel lymph node is negative for metastasis, then the chance that more distal nodes are involved by tumor is very low, and therefore the need for further lymphadenectomy is not necessary [38,39].

There are many arguments regarding the site of injection (cervix, uterine serosa or endometrium), the injection method and the used injected agent (99mTc, patent blue and indocyanine green) [8,13,38,39,41,43-48]. Based on the results of the SENTI-ENDO study, sentinel lymph node mapping could play an essential role in the identification of lymph nodes with micrometastases, especially in EC patients with early stage disease [8,13,38,39,41,43,49,50]. Nevertheless, further prospective randomized clinical trials are needed [8,37,39,40,50].

In conclusion, pelvic and para-aortic lymphadenectomy plays an essential role in the systematic surgical staging of patients with EC [2-4,6-11,16]. Moreover, provides important information for the postoperative adjuvant treatment of these patients, in order to maximize the survival and minimize the morbidity of overtreatment (post-radiation effects, chemotherapy related toxicity) and the risks of under-treatment (recurrence). Provisional results of the sentinel lymph node dissection look promising and future studies would be able to show if this approach could replace the systematic lymphadenectomy.


For more open access journals in JuniperPublishers please click on: https://juniperpublishers.com/

For more articles on Gynecology and Women’s Health please click on: https://juniperpublishers.com/jgwh/

To read more......Fulltext in  Gynecology and Women’s Health in Juniper Publishers




Comments

Post a Comment

Popular posts from this blog

Juniper Publishers | Journal of Gynecology and Women’s Health

Image
Infertility Awareness among UK University Students -Journal of Gynecology and Women’s Health-Juniper Publishers JUNIPER PUBLISHERS- JOURNAL OF GYNECOLOGY AND WOMEN’S HEALTH INFERTILITY AWARENESS AMONG UK UNIVERSITY STUDENTS Authored by Harriet Ribbons The average age of a Mother in 2013 was found to be 30 years older than in 2012. The average family size in 2013 was 1.85 children, lower than in 2012. The factors which are seen to influence the number of births, average age of Mothers and the number of children are timing of child bearing, completion of family size, finance, housing, welfare and employment uncertainty. Statistics show that individuals are delaying child bearing and University Students are seen to delay child bearing further. This is the first study of this kind in the UK and will assess attitudes among UK students. In this study we have 181 randomly selected University Students completed a 20 question fertility questionnaire. 96.1% o...
Read more

Juniper Publishers : Dissemination of Pertussis in Pregnant Women of Iran

Image
  JUNIPER PUBLISHERS- JOURNAL OF GYNECOLOGY AND WOMEN’S HEALTH                              Journal of Gynecology and Women’s Health-Juniper Publishers   Authored by Azardokht Tabatabaei*   Abstract Aim: Pertussis is severe illness and high mortality, especially among infants. The aim of this study was to determine the prevalence of Bordetella pertussis in pregnant women in southern part of Tehran. Methods: Total 303 pregnant women who referred to health centers for periodic pregnancy tests were randomly selected during six months in the year 2017. After receiving conscious consent from mothers, 5 milliliter of blood was sampled. A test to determine quantitative values of IgG-pT, IgA-pT by ELISA method was performed on samples. Results: In total, 177 women (58.2%) were serologically infected with Bordetella pertussis. Only...
Read more

Juniper Publishers Indexing Sites List

Image
Juniper Publishers Indexing Sites List   Index Copernicus : All journals may be registered in the ICI World of Journals database. The database gathers information on international scientific journals which is divided into sections: general information, contents of individual issues, detailed bibliography (references) for every publication, as well as full texts of publications in the form of attached files (optional). Within the ICI World of Journals database, each editorial office may access, free of charge, the IT system which allows you to manage your journal's passport: updating journal’s information, presenting main fields of activity and sharing the publications with almost 200 thousand users from all over the world. The idea behind the ICI World of Journals database is to create a place where scientific journals from all over the world would undergo verification for ‘predatory journals’ practices by scientific community. The ICI World of Journals database all...
Read more