The role of lymph node dissection in advanced endometrial
cancer
Advanced EC is defined as stage III or IV endometrial carcinoma of any
histology(5). LND has proved efficacious in diagnosing
advanced cancer in high-risk patients(5), tailoring
adjuvant therapy for those with adverse pathological
features(33) (Table 3). LND also has a vital
prognostic role in advanced EC(25,38). These findings
are supported by a multicentre study, which concluded that LN ratio (the
proportion of metastatic LNs to the total number of removed LNs) is the
strongest independent prognostic parameter in stage IIIC patients. LN
ratio of <10% and >50% are associated with a
significant difference in 5-year OS(25).
In stage IIIC EC, a recent study by Multinu et al. concluded that LND
can be omitted from surgical staging of “non-bulky” nodal disease as
combined adjuvant therapy (chemotherapy and EBRT) proved to be effective
alone(39). This result cannot be extrapolated to
“bulky” and “suspicious nodes”, as these were not included in this
study. This novel finding differentiates “bulky” and “non-bulky”
nodal disease previously unmentioned by ESMO-ESGO-ESTRO 2016, although
Multinu et al. fails to define these terms clearly. Other studies have
defined bulky nodal disease as >1cm(34).
Nonetheless, this may reinforce the therapeutic benefit of LND
specifically in advanced bulky nodal disease. For stage III EC, the
ESMO-ESGO-ESTRO 2016(5) supported by the newer SEOM
guidelines(40) recommend radical cytoreductive surgery
(debulking), which is defined as reducing the volume of a tumour to the
greatest extent possible(41). The Gynaecologic
Oncology Group (GOG) recommends reducing gross residual disease to
≤1cm(41). In addition, LND prior to cytoreductive
surgery resulted in better survival outcomes(42,43).
The effect of LND on non-endometrioid type cancers is not
well-characterised given the low number of this histological
subtype(39). Therapy options are limited for advanced
EC with extra-abdominal metastases, and there is no widely acknowledged
agreement regarding treatment of stage IVB EC(5,44).
Therefore, the prognosis for stage IVB EC remains extremely poor with
the 5-year disease specific survival (DSS) of ~5%. In
this case, aggressive cytoreductive surgery to reduce tumour size could
be beneficial(45).