Taner TURAN, Özgür KOÇAK, Alper KARALOK, Işın ÜREYEN, Sevgi KOÇ, Tolga TAŞÇI, Gökhan TULUNAY

Endometrioid Tip Endometrial Kanserde Lenfatik Yayılım ve Bunu Belirleyen Faktörler

Amaç: Endometriyal kanserde lenfadenektominin rutin olarak uygulanması ve cerrahinin sınırları tartışmalıdır. Bu çalışmada endometrioid tip endometriyal kanserde lenfatik yayılımın ve bunu belirleyen faktörlerin tanımlanması amaçlandı. Gereç ve yöntem: Ocak 1993 ve Aralık 2014 tarihleri arasında total histerektomi ve bilateral salpingo-ooferektomiyle birlikte lenfadenektomi yapılmış 452 endometrioid tip endometrium kanseri olgusu çalışmaya alındı. Hastalar FIGO 2009 kriterlerine göre evrelendirildi. Lenf nodu metastazını belirleyen faktörler univaryant analizde kategorik parametreler için chisquare test, sürekli parametreler için Annova Table Test kullanılarak karşılaştırıldı. Univaryant analizde istatistiksel olarak anlamlı olan faktörler Logistic Regresyon Analizi ile multivariate analizde değerlendirildi. Bulgular: Çıkarılan ortanca lenf nodu sayısı 56'ydı. Lenf nodu metastazı saptanan 79 hastada (%17.5) metastaz bölgesi 9 hastada (%2) sadece paraaortik, 32 hastada (%7.1) sadece pelvik bölgede ve 38 (%8.4) hastada her iki bölgedeydi. Univaryant analizde tümör boyutu, myometrial invazyon (MI) derinliği, lenfo-vasküler alan invazyonu (LVAI), servikal yayılım, peritoneal sitoloji pozitifliği, adneksal metastaz tümörün paraaortik bölgeye ve pelvik bölgeye yayılımı için anlamlıydı. Multivaryant analiz sonucunda paraaortik lenf nodu metastazı için LVAI, pelvik lenf nodu metastazı için LVAI yanı sıra, tümör boyutunun, MI derinliğinin ve servikal invazyon varlığının bağımsız prognostik faktör olduğu görüldü. Sonuç: Endometrioid tip endometriyal kanserlerde tümör boyutu, MI derinliğinin >=%50 olması, servikal yayılım varlığı, LVAI, pozitif peritoneal sitoloji, adneksiyel ve omental tutulum hem pelvik hem para-aortik lenf nodu metastazını belirlemektedir. Bu yüksek risk faktörlerinin varlığında lenfadenektomi pelvik ve para-aortik bölgeyi kapsayacak şekilde yapılmalıdır.

The Lymphatic Dissemination and Predictors of Lymph Node Metastasis in Endometrioid Endometrial Cancer

Objective: Both the routine lymphadenectomy in endometrial cancer management is controversial. We aimed to define lymphatic spread and evaluate risk factors for lymphatic metastasis in endometrioid type endometrial cancer. Methods: Between 01/1993 and 12/2014, a total of 452 patients who had total lymphadenectomy for endometrioid type endometrial cancer were included. The staging was defined in accordance with the FIGO 2009 staging system. Chi-square and Annova table tests were used to examine the effect of factors on lymph node metastasis. Results: Median lymph node count was 56. Among the 79 patients (%17.5) who had lymphatic metastasis, 9 patients (%2) had only para-aortic metastasis, 31 patients (%7.1) had only pelvic metastasis, and 38 (%8.4) patients had both pelvic and para-aortic metastasis. Univariate analysis revealed that tumor size, depth of myometrial invasion (DMI), lymphovascular space invasion (LVSI), cervical involvement, positive peritoneal cytology and adnexal metastasis were associated with both pelvic and para-aortic lymphatic metastasis. Independent prognostic factors revealed by multivariate analysis were LVSI for para-aortic metastasis and LVSI, tumor size, DMI and cervical involvement for pelvic metastasis. Conclusion: Tumor size, DMI>=%50, cervical involvement, positive peritoneal cytology, adnexal and omental metastasis were predictors for both pelvic and lymphadenectomy should be performed in the presence of these risk factors.

PDF

___

Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin. 2011; 61:69-90.
Eser SY, Karakılınç H. Cancer Incidence in Turkey. Chapter 1.6 page: 35-51, In: Cancer Control in Turkey. Tuncer AM, Özgül N, Olcayto E and Gültekin M (eds). Ministry Publication Number: 776, Ankara, 2010.
Announcements: FIGO (the International Federation of Obstetricians and Gynecologists) stages: 1988 revision. Gynecol Oncol 1989; 35:125-6.
Meeting Report. The new FIGO staging system for cancers of the vulva, cervix, endometrium and sarcomas. Gynecol Oncol 2009; 115:325-8.
Hidaka T, Kato K, Yonezawa R, Shima T, Nakashima A, Nagira K, et al. Omission of lymphadenectomy is possible for low-risk corpus cancer. Eur J Surg Oncol. 2007; 33:86-90.
Group As, Kitchener H, Swart AM, Qian Q, Amos C, Parmar MK. Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study. Lancet. 2009; 373:125-36.
Soliman PT, Frumovitz M, Spannuth W, Greer MJ, Sharma S, Schmeler KM, et al. Lymphadenectomy during endometrial cancer staging: practice patterns among gynecologic oncologists. Gynecol Oncol. 2010; 119:291-4.
Todo Y, Okamoto K, Hayashi M, Minobe S, Nomura E, Hareyama H, et al. 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. 2007; 104:623-8.
Mariani A, Webb MJ, Keeney GL, Haddock MG, Calori G, Podratz KC. Low- risk corpus cancer: is lymphadenectomy or radiotherapy necessary? Am J Obstet Gynecol. 2000; 182:1506-19.
Mariani A, Dowdy SC, Cliby WA, Gostout BS, Jones MB, Wilson TO, et al. Prospective assessment of lymphatic dissemination in endometrial cancer: a paradigm shift in surgical staging. Gynecol Oncol. 2008; 109:11-8.
AlHilli MM, Podratz KC, Dowdy SC, Bakkum-Gamez JN, Weaver AL, McGree ME, et al. Risk-scoring system for the individualized prediction of lymphatic dissemination in patients with endometrioid endometrial cancer. Gynecol Oncol. 2013; 131:103-8.
Fotopoulou C, Savvatis K, Kraetschell R, Schefold JC, Lichtenegger W, Sehouli J. Systematic pelvic and aortic lymphadenectomy in intermediate and high-risk endometrial cancer: lymph-node mapping and identification of predictive factors for lymph-node status. Eur J Obstet Gynecol Reprod Biol. 2010; 149:199-203.
Turan T, Yilmaz SS, Hizli D, Gundogdu B, Boran N, Tulunay G, et al. A prospective evaluation of lymphatic dissemination in endometrial cancer: is it adequate to perform lymph node dissection up to the inferior mesenteric artery? Int J Gynecol Cancer. 2011; 21:864-9.
Dogan NU, Gungor T, Karsli F, Ozgu E, Besli M. To what extent should para-aortic lymphadenectomy be carried out for surgically staged endometrial cancer? Int J Gynecol Cancer. 2012; 22:607-10.
Kumar S, Podratz KC, Bakkum-Gamez JN, Dowdy SC, Weaver AL, McGree ME, et al. Prospective assessment of the prevalence of pelvic, paraaortic and high paraaortic lymph node metastasis in endometrial cancer. Gynecol Oncol. 2014; 132:38-43.
AlHilli MM, Mariani A. The role of para-aortic lymphadenectomy in endometrial cancer. Int J Clin Oncol. 2013; 18:193-9.
Hirahatake K, Hareyama H, Sakuragi N, Nishiya M, Makinoda S, Fujimoto S. A clinical and pathologic study on para-aortic lymph node metastasis in endometrial carcinoma. J Surg Oncol. 1997; 65:82-7.
Morrow CP, Bundy BN, Kurman RJ, Creasman WT, Heller P, Homesley HD, et al. Relationship between surgical-pathological risk factors and outcome in clinical stage I and II carcinoma of the endometrium: a Gynecologic Oncology Group study. Gynecol Oncol. 1991; 40:55-65.
Creasman WT, Morrow CP, Bundy BN, Homesley HD, Graham JE, Heller PB. Surgical pathologic spread patterns of endometrial cancer. A Gynecologic Oncology Group Study. Cancer. 1987; 60:2035-41.
Kumar S, Mariani A, Bakkum-Gamez JN, Weaver AL, McGree ME, Keeney GL, et al. Risk factors that mitigate the role of paraaortic lymphadenectomy in uterine endometrioid cancer. Gynecol Oncol. 2013; 130:441-5.
Matsumoto K, Yoshikawa H, Yasugi T, Onda T, Nakagawa S, Yamada M, et al. Distinct lymphatic spread of endometrial carcinoma in comparison with cervical and ovarian carcinomas. Cancer Lett. 2002; 180:83-9.
Turan T, Hizli D, Sarici S, Boran N, Gundogdu B, Karadag B, et al. Is it possible to predict para-aortic lymph node metastasis in endometrial cancer? Eur J Obstet Gynecol Reprod Biol. 2011; 158:274-9.
Bezu C, Coutant C, Ballester M, Feron JG, Rouzier R, Uzan S, et al. Ultrastaging of lymph node in uterine cancers. J Exp Clin Cancer Res. 2010; 29:5.