Mariani Andrea, Dowdy Sean C, Cliby William A, Gostout Bobbie S, Jones Monica B, Wilson Timothy O, Podratz Karl C
Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
Gynecol Oncol. 2008 Apr;109(1):11-8. doi: 10.1016/j.ygyno.2008.01.023. Epub 2008 Mar 4.
OBJECTIVE: To prospectively assess pelvic and para-aortic lymph node metastases in endometrial cancer with lymphatic dissemination, emphasizing the examination of para-aortic metastases relative to the inferior mesenteric artery (IMA). METHODS: Over 36 months, 422 consecutive patients were managed by predefined surgical guidelines differentiating low-risk patients from patients at risk for dissemination requiring systematic lymphadenectomy. Low risk was defined as grade 1 or 2 endometrioid type with myometrial invasion (MI) < or = 50% and primary tumor diameter (PTD) < or = 2 cm. Pelvic and para-aortic lymph nodes were submitted separately, with nodes identified from all 8 pelvic and 4 para-aortic node-bearing basins. Surgical quality assessments examined median node counts (primary surrogate for quality) and nodes harvested above and below the IMA and excised gonadal veins (secondary surrogates). RESULTS: Lymphadenectomy was not required in 27% of patients (all low risk) and in 33% (n=112) of endometrioid cases. However, 22 patients (20%) of this latter cohort had lymphadenectomy and all lymph nodes were negative. Sixty-three (22%) of 281 patients undergoing lymphadenectomy had lymph node metastases: both pelvic and para-aortic in 51%, only pelvic in 33%, and isolated to the para-aortic area in 16%. Therefore, 67% of patients with lymphatic dissemination had para-aortic lymph node metastases. Furthermore, 77% of patients with para-aortic node involvement had metastases above the IMA, whereas nodes in the ipsilateral para-aortic area below the IMA and ipsilateral common iliac basin were declared negative in 60% and 71%, respectively. Gonadal veins were excised in 25 patients with para-aortic node metastases; 7 patients (28%) had documented metastatic involvement of gonadal veins or surrounding soft tissue. CONCLUSIONS: The high rate of lymphatic metastasis above the IMA indicates the need for systematic pelvic and para-aortic lymphadenectomy (vs sampling) up to the renal vessels. The latter should include consideration of excision of the gonadal veins. Conversely, lymphadenectomy does not benefit patients with grade 1 and 2 endometrioid lesions with MI < or = 50% and PTD < or = 2 cm.
目的：前瞻性评估发生淋巴转移的子宫内膜癌患者的盆腔及腹主动脉旁淋巴结转移情况，重点检查相对于肠系膜下动脉（IMA）的腹主动脉旁转移情况。 方法：在36个月期间，按照预先定义的手术指南对422例连续患者进行治疗，该指南将低风险患者与有转移风险、需要进行系统性淋巴结清扫术的患者区分开来。低风险定义为1级或2级子宫内膜样类型，肌层浸润（MI）≤50%且原发肿瘤直径（PTD）≤2 cm。盆腔和腹主动脉旁淋巴结分别送检，从所有8个盆腔和4个腹主动脉旁淋巴结区域识别淋巴结。手术质量评估检查淋巴结计数中位数（质量的主要替代指标）以及在IMA上方和下方获取的淋巴结和切除的性腺静脉（次要替代指标）。 结果：27%的患者（均为低风险）和33%（n = 112）的子宫内膜样病例无需进行淋巴结清扫术。然而，后一组队列中的22例患者（20%）进行了淋巴结清扫术，且所有淋巴结均为阴性。在接受淋巴结清扫术的281例患者中，63例（22%）有淋巴结转移：盆腔和腹主动脉旁均有转移的占51%，仅盆腔有转移的占33%，孤立于腹主动脉旁区域的占16%。因此，67%发生淋巴转移的患者有腹主动脉旁淋巴结转移。此外，77%腹主动脉旁淋巴结受累的患者在IMA上方有转移，而IMA下方同侧腹主动脉旁区域和同侧髂总淋巴结区域的淋巴结分别有60%和71%被判定为阴性。25例腹主动脉旁淋巴结转移患者切除了性腺静脉；7例患者（28%）有性腺静脉或周围软组织转移的记录。 结论：IMA上方淋巴转移率高表明需要进行系统性盆腔和腹主动脉旁淋巴结清扫术（相对于取样）直至肾血管。后者应包括考虑切除性腺静脉。相反，对于MI≤50%且PTD≤2 cm的1级和2级子宫内膜样病变患者，淋巴结清扫术并无益处。
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