Prospective Non-randomized Control Trial on Role of Systematic High Para-Aortic Lymphadenectomy in Endometrial Cancer: Indian Study

Abstract

Background Endometrial cancer (EC) accounts for approximately 10% of all cancers in females and is the second most common gynecologic cancer. The primary goal of surgical staging in EC is to identify extrauterine disease. Pelvic and para-aortic lymph node dissection (PLND and PaLND) is the gold standard in the detection of lymph node metastases in EC. However, there is still no uniformity worldwide regarding the scope and extent of lymph node dissection in EC. The present prospective non-randomized study was conducted to establish the importance of systematic lymphadenectomy (LND), especially PaLND above the inferior mesenteric artery (IMA), and to identify the risk factors associated with lymph node metastasis. Methods A total of 210 patients with EC were included. All patients underwent comprehensive surgical staging which included simultaneous PLND and PaLND. In addition for non-endometrioid, additional omental and peritoneal biopsies were also performed. PLND consisted of complete removal of common iliac, external iliac, internal iliac and obturator lymph nodes as per standard techniques. The extent of PaLND was up to the renal veins. Pelvic lymph nodes (PLN), para-aortic lymph nodes (PaLN) harvested below the IMA and PaLN dissected above the IMA were labeled separately and submitted for histopathological examination (HPE). Patient’s demographic factors, surgical outcomes and tumor histological findings were tabulated for analysis. Results Patients diagnosed with EC were most commonly in their seventh decade (59.5%). The mean time for LND was 35\xa0min. In 66% of the cases with positive PLN, the PaLN was also positive. Twenty-nine (13.8%) patients had both PLN and PaLN involvement. In all cases of positive PaLN, the nodes between IMA and renal veins were the only positive nodes. In 15 (7.1%) patients, PaLN were the only positive nodes. The mean PaLN yield was 9.1. Predictors of PaLN positivity were pelvic node positivity, Grade III tumors and lymphovascular space invasion (LVSI). Major complications observed were wound infection, paralytic ileus and subacute intestinal obstruction. Conclusions In oncology, a good loco-regional control has the greatest impact on survival. Systematic para-aortic lymphadenectomy done with good surgical technique results in minimal morbidity and mortality without any additional blood transfusion requirement. The trend toward greater use of complete surgical staging has been accompanied by a judicious use of adjuvant therapy. This has led to marked decrease in the use of pelvic radiation therapy and its complications and has a significant impact on the cost of treatment.