Skip to main content
Log in

The role of para-aortic lymphadenectomy in endometrial cancer

  • Review Article
  • Published:
International Journal of Clinical Oncology Aims and scope Submit manuscript

Abstract

Endometrial cancer (EC) is the most common malignancy of the female reproductive tract and the fourth most common cancer overall. Approximately 20 % of patients with EC harbor disease outside the uterus, and 10 % of patients initially diagnosed with cancer confined to the uterus are found to have lymph node metastases. Para-aortic lymph node involvement occurs in approximately 7–8 % of EC patients overall and in about 50 % of patients with positive pelvic nodes. Metastases to the para-aortic lymph nodes are associated with poor prognosis. Factors associated with para-aortic lymph node dissemination include advanced stage, high histological grade, deep myometrial invasion, cervical involvement, lymphovascular space involvement, and the presence of pelvic lymph node metastases. Approximately 77 % of patients with para-aortic nodal involvement are found to have metastases above the level of the inferior mesenteric artery. Systematic pelvic and para-aortic lymphadenectomy with dissection optimally carried out to the renal vessels is important in high-risk patients in order to identify nodes present at distant sites, particularly above the inferior mesenteric artery (IMA). While the definitive management of EC varies widely across the gynecological oncology community, there is a consensus that patients at risk for lymphatic metastases (high and intermediate risk) who are targeted with systematic lymphadenectomy may have an improved prognosis. Well-designed prospective studies evaluating the therapeutic role of systematic lymphadenectomy in EC are needed. Herein, we describe the role of para-aortic lymphadenectomy in the surgical staging of EC emphasizing its prerequisites, extent, and diagnostic and potential therapeutic advantages.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Jemal A, Bray F, Center MM et al (2011) Global cancer statistics. CA Cancer J Clin 61:69–90

    Google Scholar 

  2. Creasman WT, Odicino F, Maisonneuve P et al (2006) Carcinoma of the corpus uteri. FIGO 26th Annual Report on the Results of Treatment in Gynecological Cancer. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet 95 Suppl 1: S105–143

  3. Creasman WT, Morrow CP, Bundy BN et al (1987) Surgical pathologic spread patterns of endometrial cancer. Gynecologic Oncology Group Study. Cancer 60:2035–2041

    Article  PubMed  CAS  Google Scholar 

  4. Gray LA (1964) Lymph node excision in the treatment of gynecologic malignancies. Am J Surg 108:660–663

    Article  PubMed  CAS  Google Scholar 

  5. Lewis GC Jr, Bundy B (1981) Surgery for endometrial cancer. Cancer 48:568–574

    Article  PubMed  Google Scholar 

  6. Aalders JG, Thomas G (2007) Endometrial cancer—revisiting the importance of pelvic and para aortic lymph nodes. Gynecol Oncol 104:222–231

    Article  PubMed  Google Scholar 

  7. Creasman WT, Odicino F, Maisonneuve P et al (2001) Carcinoma of the corpus uteri. J Epidemiol Biostat 6:47–86

    PubMed  CAS  Google Scholar 

  8. Soliman PT, Frumovitz M, Spannuth W et al (2010) Lymphadenectomy during endometrial cancer staging: practice patterns among gynecologic oncologists. Gynecol Oncol 119:291–294

    Article  PubMed  Google Scholar 

  9. May K, Bryant A, Dickinson HO et al (2010) Lymphadenectomy for the management of endometrial cancer. Cochrane database of systematic reviews Issue 1. Art. No.: CD007585. doi: 10.1002/14651858 (CD007585.pub2)

  10. Kehoe SM, Miller DS (2011) The role of lymphadenectomy in endometrial cancer. Clin Obstet Gynecol 54:235–244

    Article  PubMed  Google Scholar 

  11. Kitchener H, Swart AM, Qian Q et al (2009) Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study. Lancet 373:125–136

    Article  PubMed  CAS  Google Scholar 

  12. Mariani A, Dowdy SC, Cliby WA et al (2008) Prospective assessment of lymphatic dissemination in endometrial cancer: a paradigm shift in surgical staging. Gynecol Oncol 109:11–18

    Article  PubMed  Google Scholar 

  13. Panici PB, Maggioni A, Hacker N et al (2005) Systematic aortic and pelvic lymphadenectomy versus resection of bulky nodes only in optimally debulked advanced ovarian cancer: a randomized clinical trial. J Natl Cancer Inst 97:560–566

    Article  PubMed  Google Scholar 

  14. Keys HM, Roberts JA, Brunetto VL et al (2004) A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a Gynecologic Oncology Group study. Gynecol Oncol 94:744–751

    Article  Google Scholar 

  15. Nout RA, Smit VT, Putter H et al (2010) Vaginal brachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate risk (PORTEC-2): an open-label, non-inferiority, randomised trial. Lancet 375:816–823

    Article  PubMed  CAS  Google Scholar 

  16. Creutzberg CL, van Putten WL, Koper PC et al (2000) Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomised trial. PORTEC Study Group. Post operative radiation therapy in endometrial carcinoma. Lancet 355:1404–1411

    Article  PubMed  CAS  Google Scholar 

  17. Chan JK, Kapp DS (2007) Role of complete lymphadenectomy in endometrioid uterine cancer. Lancet Oncol 8:831–841

    Article  PubMed  Google Scholar 

  18. Partridge EE, Phillips JL, Menck HR (1996) The National Cancer Data Base report on ovarian cancer treatment in United States hospitals. Cancer 78:2236–2246

    Article  PubMed  CAS  Google Scholar 

  19. McMeekin DS, Lashbrook D, Gold M et al (2001) Nodal distribution and its significance in FIGO stage IIIc endometrial cancer. Gynecol Oncol 82:375–379

    Article  PubMed  CAS  Google Scholar 

  20. Geisler JP, Linnemeier GC, Manahan KJ (2007) Pelvic and para-aortic lymphadenectomy in patients with endometrioid adenocarcinoma of the endometrium. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet 98:39–43

    Article  CAS  Google Scholar 

  21. Mariani A, Webb MJ, Keeney GL et al (2000) Low-risk corpus cancer: is lymphadenectomy or radiotherapy necessary? Am J Obstet Gynecol 182:1506–1519

    Article  PubMed  CAS  Google Scholar 

  22. Mariani A, Dowdy SC, Keeney GL et al (2004) High-risk endometrial cancer subgroups: candidates for target-based adjuvant therapy. Gynecol Oncol 95:120–126

    Article  PubMed  Google Scholar 

  23. Benedetti-Panici P, Maneschi F, Cutillo G (2001) Pelvic and aortic lymphadenectomy. Surg Clin North Am 81:841–858

    Article  PubMed  CAS  Google Scholar 

  24. Chi DS, Barakat RR, Palayekar MJ et al (2008) The incidence of pelvic lymph node metastasis by FIGO staging for patients with adequately surgically staged endometrial adenocarcinoma of endometrioid histology. Int J Gynecol Cancer Off J Int Gynecol Cancer Soc 18:269–273

    Article  CAS  Google Scholar 

  25. Mariani A, Keeney GL, Aletti G et al (2004) Endometrial carcinoma: paraaortic dissemination. Gynecol Oncol 92:833–838

    Article  PubMed  Google Scholar 

  26. Todo Y, Suzuki Y, Azuma M et al (2012) Ultrastaging of para-aortic lymph nodes in stage IIIC1 endometrial cancer: a preliminary report. Gynecol Oncol 127:532–537

    Article  PubMed  Google Scholar 

  27. Mariani A, Dowdy SC, Podratz KC (2009) New surgical staging of endometrial cancer: 20 years later. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet 105:110–111

    Article  Google Scholar 

  28. Creasman W (2009) Revised FIGO staging for carcinoma of the endometrium. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet 105:109

    Article  Google Scholar 

  29. Pecorelli S (2009) Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet 105:103–104

    Article  Google Scholar 

  30. Podratz KC, Mariani A, Webb MJ (1998) Staging and therapeutic value of lymphadenectomy in endometrial cancer. Gynecol Oncol 70:163–164

    Article  PubMed  CAS  Google Scholar 

  31. Keys HM, Roberts JA, Brunetto VL et al (2004) A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a Gynecologic Oncology Group study. Gynecol Oncol 92:744–751

    Article  PubMed  Google Scholar 

  32. Dowdy SC, Borah BJ, Bakkum-Gamez JN et al (2012) Prospective assessment of survival, morbidity, and cost associated with lymphadenectomy in low-risk endometrial cancer. Gynecol Oncol 127:5–10

    Article  PubMed  CAS  Google Scholar 

  33. Alhilli MM, Podratz KC, Dowdy SC et al (2013) Preoperative biopsy and intraoperative tumor diameter predict lymph node dissemination in endometrial cancer. Gynecol Oncol 128: 294–9

    Google Scholar 

  34. Todo Y, Okamoto K, Hayashi M et al (2007) A validation study of a scoring system to estimate the risk of lymph node metastasis for patients with endometrial cancer for tailoring the indication of lymphadenectomy. Gynecol Oncol 104:623–628

    Article  PubMed  Google Scholar 

  35. Rose PG, Cha SD, Tak WK et al (1992) Radiation therapy for surgically proven para-aortic node metastasis in endometrial carcinoma. Int J Radiat Oncol Biol Phys 24:229–233

    Article  PubMed  CAS  Google Scholar 

  36. Mariani A, Webb MJ, Galli L et al (2000) Potential therapeutic role of para-aortic lymphadenectomy in node-positive endometrial cancer. Gynecol Oncol 76:348–356

    Article  PubMed  CAS  Google Scholar 

  37. Fanning J, Nanavati PJ, Hilgers RD (1996) Surgical staging and high dose rate brachytherapy for endometrial cancer: limiting external radiotherapy to node-positive tumors. Obstet Gynecol 87:1041–1044

    Article  PubMed  CAS  Google Scholar 

  38. Hirahatake K, Hareyama H, Sakuragi N et al (1997) A clinical and pathologic study on para-aortic lymph node metastasis in endometrial carcinoma. J Surg Oncol 65:82–87

    Article  PubMed  CAS  Google Scholar 

  39. Mariani A, Webb MJ, Keeney GL et al (2002) Stage IIIC endometrioid corpus cancer includes distinct subgroups. Gynecol Oncol 87:112–117

    Article  PubMed  Google Scholar 

  40. Morrow CP, Bundy BN, Kurman RJ et al (1991) Relationship between surgical pathological risk-factors and outcome in clinical stage-I and stage-II carcinoma of the endometrium—a Gynecologic Oncology Group Study. Gynecol Oncol 40:55–65

    Article  PubMed  CAS  Google Scholar 

  41. Inoue Y, Obata K, Abe K et al (1996) The prognostic significance of vascular invasion by endometrial carcinoma. Cancer 78:1447–1451

    Article  PubMed  CAS  Google Scholar 

  42. Mariani A, Webb MJ, Rao SK et al (2001) Significance of pathologic patterns of pelvic lymph node metastases in endometrial cancer. Gynecol Oncol 80:113–120

    Article  PubMed  CAS  Google Scholar 

  43. Henriksen E (1975) The lymphatic dissemination in endometrial carcinoma. A study of 188 necropsies. Am J Obstet Gynecol 123:570–576

    PubMed  CAS  Google Scholar 

  44. Lecuru F, Neji K, Robin F et al (1997) Lymphatic drainage of the uterus. Preliminary results of an experimental study. J Gynecol Obstet Biol Reprod 26:418–423

    CAS  Google Scholar 

  45. McMeekin DS, Lashbrook D, Gold M et al (2001) Analysis of FIGO Stage IIIc endometrial cancer patients. Gynecol Oncol 81:273–278

    Article  PubMed  CAS  Google Scholar 

  46. Burke TW, Levenback C, Tornos C et al (1996) Intraabdominal lymphatic mapping to direct selective pelvic and paraaortic lymphadenectomy in women with high-risk endometrial cancer: results of a pilot study. Gynecol Oncol 62:169–173

    Article  PubMed  CAS  Google Scholar 

  47. Mariani A, Webb MJ, Keeney GL et al (2001) Routes of lymphatic spread: a study of 112 consecutive patients with endometrial cancer. Gynecol Oncol 81:100–104

    Article  PubMed  CAS  Google Scholar 

  48. Fujimoto T, Fukuda J, Tanaka T (2009) Role of complete para-aortic lymphadenectomy in endometrial cancer. Curr Opin Obstet Gynecol 21:10–14

    Article  PubMed  Google Scholar 

  49. Chuang L, Burke TW, Tornos C et al (1995) Staging laparotomy for endometrial carcinoma: assessment of retroperitoneal lymph nodes. Gynecol Oncol 58:189–193

    Article  PubMed  CAS  Google Scholar 

  50. Mohan DS, Samuels MA, Selim MA et al (1998) Long-term outcomes of therapeutic pelvic lymphadenectomy for stage I endometrial adenocarcinoma. Gynecol Oncol 70:165–171

    Article  PubMed  CAS  Google Scholar 

  51. Weir L, Speers C, D’Yachkova Y et al (2002) Prognostic significance of the number of axillary lymph nodes removed in patients with node-negative breast cancer. J Clin Oncol Off J Am Soc Clin Oncol 20:1793–1799

    Article  CAS  Google Scholar 

  52. Krag DN, Single RM (2003) Breast cancer survival according to number of nodes removed. Ann Surg Oncol 10:1152–1159

    Article  PubMed  Google Scholar 

  53. Chan AD, Essner R, Wanek LA et al (2000) Judging the therapeutic value of lymph node dissections for melanoma. J Am Coll Surg 191: 16–22; discussion 22–3

    Google Scholar 

  54. Tepper JE, O’Connell MJ, Niedzwiecki D et al (2001) Impact of number of nodes retrieved on outcome in patients with rectal cancer. J Clin Oncol Off J Am Soc Clin Oncol 19:157–163

    CAS  Google Scholar 

  55. Lutman CV, Havrilesky LJ, Cragun JM et al (2006) Pelvic lymph node count is an important prognostic variable for FIGO stage I and II endometrial carcinoma with high-risk histology. Gynecol Oncol 102:92–97

    Article  PubMed  Google Scholar 

  56. Abu-Rustum NR, Iasonos A, Zhou Q et al (2008) Is there a therapeutic impact to regional lymphadenectomy in the surgical treatment of endometrial carcinoma? Am J Obstet Gynecol 198: 457.e1–5; discussion 457.e5–6

  57. Bakkum-Gamez JN, Mariani A, Dowdy SC et al (2011) The impact of surgical guidelines and periodic quality assessment on the staging of endometrial cancer. Gynecol Oncol 123:58–64

    Article  PubMed  Google Scholar 

  58. May K, Bryant A, Dickinson HO et al (2010) Lymphadenectomy for the management of endometrial cancer. Cochrane database of systematic reviews

  59. Benedetti Panici P, Basile S, Maneschi F et al (2008) Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial. J Natl Cancer Inst 100: 1707–16

    Google Scholar 

  60. Havrilesky LJ, Cragun JM, Calingaert B et al (2005) Resection of lymph node metastases influences survival in stage IIIC endometrial cancer. Gynecol Oncol 99:689–695

    Article  PubMed  Google Scholar 

  61. Fujimoto T, Tanaka T (2009) Evaluation of the efficacy of systematic pelvic lymphadenectomy in endometrial cancer. Future Oncol 5:459–463

    Article  PubMed  Google Scholar 

  62. Chan JK, Cheung MK, Huh WK et al (2006) Therapeutic role of lymph node resection in endometrioid corpus cancer: a study of 12,333 patients. Cancer 107:1823–1830

    Article  PubMed  Google Scholar 

  63. Todo Y, Kato H, Kaneuchi M et al (2010) Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis. Lancet 375:1165–1172

    Article  PubMed  Google Scholar 

  64. Todo Y, Kato H, Minobe S et al (2011) A validation study of the new revised FIGO staging system to estimate prognosis for patients with stage IIIC endometrial cancer. Gynecol Oncol 121:126–130

    Article  PubMed  Google Scholar 

  65. Girardi F, Petru E, Heydarfadai M et al (1993) Pelvic lymphadenectomy in the surgical treatment of endometrial cancer. Gynecol Oncol 49:177–180

    Article  PubMed  CAS  Google Scholar 

  66. Watari H, Mitamura T, Moriwaki M et al (2009) Survival and failure pattern of patients with endometrial cancer after extensive surgery including systematic pelvic and para-aortic lymphadenectomy followed by adjuvant chemotherapy. Int J Gynecol Cancer Off J Int Gynecol Cancer Soc 19:1585–1590

    Article  Google Scholar 

  67. Randall ME, Filiaci VL, Muss H (2006) Randomized phase III trial of whole-abdominal irradiation versus doxorubicin and cisplatin chemotherapy in advanced endometrial carcinoma: a Gynecologic Oncology Group Study. J Clin Oncol Off J Am Soc Clin Oncol 24:36–44

    Article  CAS  Google Scholar 

  68. Larson DM, Johnson K, Olson KA (1992) Pelvic and para-aortic lymphadenectomy for surgical staging of endometrial cancer: morbidity and mortality. Obstet Gynecol 79:998–1001

    PubMed  CAS  Google Scholar 

  69. Orr JW, Jr., Holimon JL, Orr PF (1997) Stage I corpus cancer: is teletherapy necessary? Am J Obstet Gynecol 176: 777–88; discussion 788–9

    Google Scholar 

  70. Abu-Rustum NR, Alektiar K, Iasonos A et al (2006) The incidence of symptomatic lower-extremity lymphedema following treatment of uterine corpus malignancies: a 12-year experience at Memorial Sloan-Kettering Cancer Center. Gynecol Oncol 103:714–718

    Article  PubMed  Google Scholar 

  71. Todo Y, Yamamoto R, Minobe S et al (2010) Risk factors for postoperative lower-extremity lymphedema in endometrial cancer survivors who had treatment including lymphadenectomy. Gynecol Oncol 119:60–64

    Article  PubMed  Google Scholar 

  72. Dowdy SC, Borah BJ, Bakkum-Gamez JN et al (2012) Factors predictive of postoperative morbidity and cost in patients with endometrial cancer. Obstet Gynecol 120:1419–1427

    PubMed  Google Scholar 

  73. Mariani A, Dowdy SC, Cliby WA et al (2006) Efficacy of systematic lymphadenectomy and adjuvant radiotherapy in node-positive endometrial cancer patients. Gynecol Oncol 101:200–208

    Article  PubMed  Google Scholar 

  74. Rotman M, Aziz H, Halpern J et al (1993) Endometrial carcinoma—influence of prognostic factors on radiation management. Cancer 71:1471–1479

    Article  PubMed  CAS  Google Scholar 

  75. Mariani A, El-Nashar SA, Dowdy SC (2010) Lymphadenectomy in endometrial cancer: which is the right question? Int J Gynecol Cancer Off J Int Gynecol Cancer Soc 20:S52–S54

    Article  Google Scholar 

  76. Kumar S, Medeiros F, Dowdy SC et al (2012) A prospective assessment of the reliability of frozen section to direct intraoperative decision making in endometrial cancer. Gynecol Oncol 127:525–531

    Article  PubMed  Google Scholar 

  77. Todo Y, Sakuragi N (2012) Randomized controlled trial versus comparative cohort study in verifying the therapeutic role of lymphadenectomy in endometrial cancer. Int J Clin Oncol. doi:10.1007/s10147-012-0499-0

Download references

Conflict of interest

None.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Andrea Mariani.

About this article

Cite this article

AlHilli, M.M., Mariani, A. The role of para-aortic lymphadenectomy in endometrial cancer. Int J Clin Oncol 18, 193–199 (2013). https://doi.org/10.1007/s10147-013-0528-7

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10147-013-0528-7

Keywords

Navigation