Nodal distribution and its significance in FIGO stage IIIc endometrial cancer.

The aim of this study was to describe the distribution of nodal disease in FIGO Stage IIIc endometrial cancer (EC) and to evaluate whether nodal distribution is related to recurrence and survival. Charts from EC patients with FIGO Stage IIIc disease from 1989 to 1998 were abstracted for clinicopathologic data, pelvic (PLN) and para-aortic (PALN) nodal involvement, number of positive/removed nodes, and extranodal disease spread. Patterns of nodal distribution were evaluated for site of first recurrence and survival. Associations between variables were tested by chi(2) and Wilcoxon rank sums. Survival analyses were performed by the Kaplan-Meier method. Of 607 EC patients evaluated, 47 were identified with FIGO Stage IIIc disease. All 47 patients underwent hysterectomy and PLN sampling, and 42/47 had PALN sampling. The median number of PLN removed was 16 (range 2-35), and the median number of PALN was 7 (0-18). Stage IIIc disease was defined by positive PLN alone in 43%, positive PLN and PALN in 40%, and positive PALN alone in 17%. Positive peritoneal cytology and/or adnexal metastasis were present in 12 patients. Only 1/12 of these patients had isolated positive PLN whereas 11/12 had positive PALN (P = 0.007). An increasing number of positive PLN was associated with PALN metastasis (P = 0.0001), and of the 10 patients with bilateral PLN involvement, 9/10 also had positive PALN (P = 0.001). Sites of first recurrence were similar regardless of whether PALN were positive. At a median follow-up of 37 months, the 3-year survival estimate was 70% for patients with positive PALN versus 87% for those with isolated PLN disease (P = 0.22). For all patients neither the total number of positive PLN nor the total number of PLN or PALN removed was associated with survival. PALN involvement is common in patients with FIGO Stage IIIc endometrial cancer, suggesting that PLN sampling alone may result in underdiagnosis of disease. Patients with positive PALN had more extensive disease, but survival and patterns of failure were not significantly different from those with disease confined to PLN, suggesting that lymph node dissection may have a therapeutic role.

McMeekin DS ，Lashbrook D ，Gold M ，Scribner DR ，Kamelle S ，Tillmanns TD ，Mannel R ... -  《GYNECOLOGIC ONCOLOGY》

Analysis of FIGO Stage IIIc endometrial cancer patients.

The aim of this study was to analyze FIGO Stage IIIc endometrial cancer (EC) patients to better define clinicopathologic associations, patterns of failure, and survival. Charts were abstracted from EC patients with lymph node metastasis from 1989 to 1998. Data on clinicopathologic variables, adjuvant treatment, site of first recurrence, and survival were collected. Associations between variables were tested by chi(2) and Wilcoxon rank sums. Survival analyses were performed by the Kaplan-Meier method, and multiple regression analysis was done by the Cox proportional hazards model. From 607 EC patients evaluated, 47 (8%) were identified with FIGO Stage IIIc disease. All 47 underwent hysterectomy and pelvic lymph node (PLN) sampling, and 42/47 had para-aortic lymph node (PALN) sampling. Stage IIIc disease was defined by positive PLN alone in 38%, positive PLN and PALN in 41%, and positive PALN alone in 17%. Twelve of 47 also had positive peritoneal cytology and/or adnexal metastases. Grade III tumors were present in 56% and >50% myometrial invasion in 61%. No association between depth of invasion (DOI) and grade was seen, however. Nearly 1/3 of cases had papillary serous or clear cell histology. Postoperative adjuvant treatment included whole abdominal radiation (36%), pelvic radiation with (19%) and without (17%) extended field, chemotherapy (17%), and oral progestins (11%). The 3-year and 5-year survival estimates for all patients were 77 and 65%, respectively. At a median follow-up of 37 months, 5 patients are alive with disease, and 10 are dead of disease. A distant site of first recurrence was most common (21%), followed by pelvic failure (9%). Only 1 patient has had an abdominal recurrence. Univariate predictors of survival included age, DOI, and extranodal disease, but not grade, histology, or PALN involvement. For the 12 patients with nodal disease and positive cytology and/or adnexa, 3-year survival was 39% versus 93% for those patients without evidence of extranodal disease. In a multivariate analysis only DOI was an independent predictor of survival (P = 0.03). Once lymph node involvement occurs, the importance of additional extranodal disease increases. Consideration of substaging Stage IIIc patients based on positive adnexa or cytology is supported by the data. The extent which adjuvant treatments contributed to the 77% 3-year survival remains to be defined. The patterns of failure suggest a possible role for combined modalities in future treatments.

McMeekin DS ，Lashbrook D ，Gold M ，Johnson G ，Walker JL ，Mannel R ... -  《GYNECOLOGIC ONCOLOGY》

Para-aortic lymphadenectomy may improve disease-related survival in patients with multipositive pelvic lymph node stage IIIc endometrial cancer.

Fujimoto T ，Nanjyo H ，Nakamura A ，Yokoyama Y ，Takano T ，Shoji T ，Nakahara K ，Yamada H ，Mizunuma H ，Yaegashi N ，Sugiyama T ，Kurachi H ，Sato A ，Tanaka T ... -  《-》

FIGO stage IIIC endometrial carcinoma: prognostic factors and outcomes.

Hoekstra AV ，Kim RJ ，Small W Jr ，Rademaker AW ，Helenowski IB ，Singh DK ，Schink JC ，Lurain JR ... -  《-》

FIGO stage IIIC endometrial carcinoma with metastases confined to pelvic lymph nodes: analysis of treatment outcomes, prognostic variables, and failure patterns following adjuvant radiation therapy.

This study was undertaken to evaluate the prognostic significance of isolated positive pelvic lymph nodes on survival and to analyze other prognostic variables, overall survival, and failure patterns in surgically staged endometrial carcinoma patients with positive pelvic lymph nodes and negative para-aortic lymph nodes following radiation therapy (RT). Between January 1, 1987, and December 31, 1997, 782 women underwent primary treatment for uterine cancer at Indiana University Medical Center. Through a review of the medical records, we identified 58 patients with pathologic stage IIIA, 27 patients with pathologic stage IIIB, and 77 patients with pathologic stage IIIC endometrial carcinoma. Patients with pathologically positive or unsampled para-aortic lymph nodes and patients who received preoperative radiation therapy were excluded, leaving a study group of 17 patients with nodal metastases confined to pelvic lymph nodes. Thirteen patients received adjuvant pelvic RT using AP-PA or four-field technique. A median dose of 5040 cGy was delivered. Four patients received whole abdominal irradiation (WAI) delivering a median dose of 3000 cGy. Two patients received vaginal cuff boosts of 1000 and 3560 cGy to 0.5 cm from the vaginal surface mucosa via Cs-137 brachytherapy. Two patients also received adjuvant chemotherapy (cis-platinum and doxorubicin) and/or hormonal therapy (megestrol acetate). Disease-free and overall survivals were estimated using the Kaplan-Meier method of statistical analysis and prognostic variables were analyzed using the log-rank test. With a median follow-up of 51 months the actuarial 5-year disease-free survival was 81% and the actuarial 2-year and 5-year overall survival rates were 81 and 72%, respectively. Univariate analysis revealed that positive peritoneal cytology in conjunction with positive pelvic lymph nodes imparts a greater risk of recurrence and decreased overall survival. There were no pelvic and/or upper abdominal failures, but there were recurrences in the para-aortic lymph nodes (two patients) and distantly (two patients). Surgery followed by postoperative pelvic RT is a viable treatment option for pathologically staged stage IIIC endometrial carcinoma with disease confined to the pelvic lymph nodes. Failures in the para-aortic region suggest a possible role for extended-field RT. Patients with positive peritoneal cytology in conjunction with nodal metastasis fared poorly with pelvic RT. Studies evaluating the efficacy of WAI are ongoing. Finally, substages within FIGO stage IIIC are recommended in an effort to better understand and define treatment strategies which might be appropriate for these patients.

Nelson G ，Randall M ，Sutton G ，Moore D ，Hurteau J ，Look K ... -  《GYNECOLOGIC ONCOLOGY》