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Wider surgery improves endometrial Ca survival

Women at high risk of recurrence need wider removal of lymph nodes

OnMedica staff

Thursday, 25 February 2010

Complete, systematic removal of the para-aortic lymph nodes as well as the pelvic lymph nodes improves survival from endometrial cancer compared with removal of the pelvic lymph nodes alone, in women at medium to high risk of recurrence. These women should be recommended to have the more radical surgery.

The authors of the SEPAL study, published today in The Lancet Online First, aimed to determine whether complete, systematic lymphadenectomy – including the para-aortic lymph nodes – would benefit women at intermediate and high risk of recurrence of endometrial cancer. It was already know that pelvic lymphadenectomy alone has no therapeutic benefit in endometrial cancer.

The retrospective study looked at survival figures for 671 patients who had been treated with complete, systematic pelvic lymphadenectomy (325 women) or combined pelvic and para-aortic lymphadenectomy (346 women) for endometrial cancer at two specialist centres in Japan from 1986 to 2004. Patients who had an intermediate or high risk of recurrence were offered adjuvant radiotherapy or chemotherapy.

Overall, the risk of death in women who had had the complete procedure was about half that of women who had had only their pelvic lymph nodes removed. The 407 patients who were at intermediate-to-high risk of cancer recurrence had a 56% lower risk of death if they had the complete procedure, compared with women who had had pelvic lymphandecotomy only. However, this association between survival and type of lymphadenectomy was not seen in patients at low risk of recurrence.

Analysis of the 328 patients with intermediate or high risk who were treated with adjuvant radiotherapy or chemotherapy showed that risk of death decreased with the complete procedure by 52%, and with adjuvant chemotherapy by 41%, independently of one another.

The authors, Professor Noriaki Sakuragi and Dr Yukiharu Todo, say: “Findings from the SEPAL study have shown that para-aortic lymphadenectomy has survival benefits for patients at intermediate or high risk of recurrence, and that pelvic lymphadenectomy alone might be an insufficient surgical procedure for endometrial cancer in patients at risk of lymph node metastasis. The results also suggest that adjuvant chemotherapy could further improve survival of patients at high risk of lymph node metastasis.”

They conclude: “Combined pelvic and para-aortic lymphadenectomy is recommended as treatment for patients with endometrial carcinoma of intermediate or high risk of recurrence. If a prospective randomised or comparative cohort study is planned to validate the therapeutic effect of lymphadenectomy, it should include both pelvic and para-aortic lymphadenectomy in patients of intermediate or high-risk of recurrence.”

In an accompanying comment, Dr Sean C Dowdy, and Dr Andrea Mariani, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, US, agree that the SEPAL results now need to be validated with a randomised, controlled trial. They say the trial “should also examine differences in morbidity, cost, and quality of life, all of which previous studies have failed to address. Disease-specific survival is but one of many important endpoints because patients will often succumb to other comorbidities.”

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