The role of lymphadenectomy from the point of the clinical oncologist

The role of lymphadenectomy from the point of the clinical oncologist
NAWAZ WALJI, MB, MRCP, FRCR, INDRAJIT N FERNANDO, MB, MRCP, FRCR

The Cancer Centre, Queen Elizabeth Hospital, Birmingham

ABSTRACT Endometrial cancer is the fourth commonest female cancer in the United Kingdom and its incidence continues to rise. Whilst removal of regional lymph nodes remains a cardinal principle of surgical oncology for the management of the majority of invasive cancers, the role of lymphadenectomy in endometrial cancer remains controversial. We examine the current evidence for lymphadenectomy in endometrial cancer from the point of view of a practicing clinical oncologist.

Key words endometrial cancer; lymphadenectomy; radiotherapy; brachytherapy; chemotherapy


INTRODUCTION The incidence of endometrial cancer is ten times higher in North America and Western Europe compared to less developed countries (1). In the United Kingdom it is the fourth commonest female cancer and the incidence is rising (2). The majority of women present with early disease and a good prognosis overall. Table 1 summarizes the current International Federation of Gynaecologists and Obstetricians (FIGO) staging for endometrial cancer (3). Independent prognostic factors include the surgical FIGO stage; lymph node metastasis; myometrial invasion; histological type; and differentiation grade (4). Age greater than sixty years, presence of lymphovascular invasion and tumour distance from serosa are also considered important prognostic factors. Table 2 summarizes the 5-year overall survival (OS) of women with endometrial cancer (5).

In 1988 the criteria for staging endometrial cancer were altered from clinical to pathological staging including pelvic and para-aortic lymphadenectomy (6). The removal of regional lymph nodes remains a cardinal principle in the surgical management of the vast majority of invasive cancers yet its role for the comprehensive staging of all patients with endometrial cancer remains controversial. A wide variation in practices exist, from complete lymphadenectomy in all patients, to selective lymph node sampling in high-risk patients, to no lymphadenectomy being performed in any patients. This chapter reviews the current evidence and presents the point of view of a practicing clinical oncologist for the role of lymphadenectomy in endometrial cancer.

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