28<str<strong>on</strong>g>Focused</str<strong>on</strong>g> <strong>on</strong> qualityFigure 4Observed survival rates for low-risk endometrialcancer <strong>patient</strong>s Comparis<strong>on</strong> with NCDB dataCumulative survival rate100%90%80%70%60%50%40%30%20%10%0%<strong>Baylor</strong> data (n=49)NCDB data (n=48679)0 6 12 18 24 30 36 42 48 54 60 66M<strong>on</strong>ths from surgeryfinal pathology. Twenty of <strong>the</strong>se low-risk <strong>patient</strong>s ultimatelyhad a lymphadenectomy, and n<strong>on</strong>e were foundto have nodal metastasis. Fur<strong>the</strong>r, using Kaplan-Meierand log-rank analyses, <strong>the</strong>re was no significant differencein survival when comparing <strong>the</strong> 20 that were completelystaged and <strong>the</strong> 31 that did not have a completelymphadenectomy. In fact, of <strong>the</strong> 51 low-risk <strong>patient</strong>sidentified, <strong>on</strong>ly 1 (2%) developed recurrent disease andultimately died of her disease. The mortality in o<strong>the</strong>r<strong>patient</strong>s was due to comorbidities, including morbidobesity, heart disease, and diabetes. Many of <strong>the</strong> <strong>patient</strong>sare referred to <strong>Baylor</strong> Samm<strong>on</strong>s Cancer Centerbecause <strong>the</strong>y are c<strong>on</strong>sidered poor surgical candidatesin community facilities, and thus it is not surprising thatsurvival rates in a tertiary facility may be slightly lowerthan in some o<strong>the</strong>r centers.The team of fellowship-trained gynecologic pathologists, gynecologic <strong>on</strong>cologists, radiati<strong>on</strong><strong>on</strong>cologists, and medical <strong>on</strong>cologists at <strong>Baylor</strong> Samm<strong>on</strong>s Cancer Center allows for <strong>the</strong>possibility of accurate preoperative and intraoperative assessment, surge<strong>on</strong>s’ ability to act<strong>on</strong> that informati<strong>on</strong>, and <strong>the</strong> expertise to provide appropriate adjuvant <strong>the</strong>rapy. It would,however, be interesting to compare our data to results from similar instituti<strong>on</strong>s.Although <strong>the</strong> NCCN now recommends a complete pelvic and lower para-aortic lymphadenectomyfor all suitable <strong>patient</strong>s undergoing surgery for endometrial cancer, it basedthis recommendati<strong>on</strong> <strong>on</strong> previous reports showing both a high degree of inaccuracy ofintraoperative assessment and a potential survival advantage for <strong>patient</strong>s undergoing completelymphadenectomy. 12, 13 As Creutzberg indicated in his editorial that accompanied <strong>the</strong>Gynecologic Oncology Group-99 study, “The comparis<strong>on</strong> of GOG-99 and PORTEC resultsdoes not support <strong>the</strong> use of routine lymphadenectomy in <strong>the</strong>se <strong>patient</strong>s with mainly lowintermediate risk disease. . . . The potential benefit of lymphadenectomy depends <strong>on</strong> <strong>the</strong> riskof microscopic nodal disease and . . . <strong>the</strong> procedure would be most effective in cases witha substantial risk of pelvic lymph node metastases”. 14 A <strong>the</strong>rapeutic value of lymphadenectomyhas not been proven in this low-risk populati<strong>on</strong>. Through future prospective trials, itmay be possible to rec<strong>on</strong>sider lymphadenectomies in selected low-risk <strong>patient</strong>s to avoid <strong>the</strong>accompanying morbidities, taking into account risk factors for recurrence including histology,grade, depth of myometrial invasi<strong>on</strong> and cervical involvement as well as o<strong>the</strong>rs including<strong>patient</strong> age and lymphovascular space invasi<strong>on</strong>. Selective lymphadenectomy for low-risk<strong>patient</strong>s may not be appropriate at all instituti<strong>on</strong>s; however, it may be appropriate at specificcenters of clinical excellence to decrease morbidity without increasing mortality.
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