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28<strong>Focused</strong> on qualityFigure 4Observed survival rates for low-risk endometrialcancer patients Comparison with NCDB dataCumulative survival rate100%90%80%70%60%50%40%30%20%10%0%Baylor data (n=49)NCDB data (n=48679)0 6 12 18 24 30 36 42 48 54 60 66Months from surgeryfinal pathology. Twenty of these low-risk patients ultimatelyhad a lymphadenectomy, and none were foundto have nodal metastasis. Further, using Kaplan-Meierand log-rank analyses, there was no significant differencein survival when comparing the 20 that were completelystaged and the 31 that did not have a completelymphadenectomy. In fact, of the 51 low-risk patientsidentified, only 1 (2%) developed recurrent disease andultimately died of her disease. The mortality in otherpatients was due to comorbidities, including morbidobesity, heart disease, and diabetes. Many of the patientsare referred to Baylor Sammons Cancer Centerbecause they are considered poor surgical candidatesin community facilities, and thus it is not surprising thatsurvival rates in a tertiary facility may be slightly lowerthan in some other centers.The team of fellowship-trained gynecologic pathologists, gynecologic oncologists, radiationoncologists, and medical oncologists at Baylor Sammons Cancer Center allows for thepossibility of accurate preoperative and intraoperative assessment, surgeons’ ability to acton that information, and the expertise to provide appropriate adjuvant therapy. It would,however, be interesting to compare our data to results from similar institutions.Although the NCCN now recommends a complete pelvic and lower para-aortic lymphadenectomyfor all suitable patients undergoing surgery for endometrial cancer, it basedthis recommendation on previous reports showing both a high degree of inaccuracy ofintraoperative assessment and a potential survival advantage for patients undergoing completelymphadenectomy. 12, 13 As Creutzberg indicated in his editorial that accompanied theGynecologic Oncology Group-99 study, “The comparison of GOG-99 and PORTEC resultsdoes not support the use of routine lymphadenectomy in these patients with mainly lowintermediate risk disease. . . . The potential benefit of lymphadenectomy depends on the riskof microscopic nodal disease and . . . the procedure would be most effective in cases witha substantial risk of pelvic lymph node metastases”. 14 A therapeutic value of lymphadenectomyhas not been proven in this low-risk population. Through future prospective trials, itmay be possible to reconsider lymphadenectomies in selected low-risk patients to avoid theaccompanying morbidities, taking into account risk factors for recurrence including histology,grade, depth of myometrial invasion and cervical involvement as well as others includingpatient age and lymphovascular space invasion. Selective lymphadenectomy for low-riskpatients may not be appropriate at all institutions; however, it may be appropriate at specificcenters of clinical excellence to decrease morbidity without increasing mortality.
<strong>Focused</strong> on quality 29References1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2007. CA Cancer J Clin 2007(57):43–66.2. Creasman WT, Morrow CP, Bundy BN, et al. Surgical pathologic spread patterns of endometrialcancer: a gynecologic oncology group study. Cancer 1987;60:2035–2041.3. Scholten AN, van Putten WL, Beerman H, et al. Postoperative radiotherapy for Stage 1endometrial carcinoma: long-term outcome of the randomized PORTEC trial with centralpathology review. Int J Radiat Oncol Biol Phys 2005;63(3):834–838.4. Creutzberg CL, van Putten WL, Koper PC, et al. Surgery and postoperative radiotherapyversus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomisedtrial. PORTEC Study Group. Post Operative Radiation Therapy in EndometrialCarcinoma. Lancet 2000;355(9213):1404–1411.5. Keys HM, Roberts JA, Brunetto VL, et al. A phase III trial of surgery with or withoutadjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma:a Gynecologic Oncology Group study. Gynecol Oncol 2004;92(3):744–751.6. Morrow CP, Bundy BM, Kurman RJ, et al. Relationship between surgical-pathological riskfactors and outcome in clinical stage I and II carcinoma of the endometrium: a GynecologicOncology Group study. Gynecol Oncol 1991;40:55–65.7. COSA-NZ-UK Endometrial Cancer Study Groups. Pelvic lymphadenectomy in high riskendometrial cancer. Int J Gynecol Cancer 1996;6:102–107.8. Mohan DS, Samuels MA, Selim MA, et al. Long-term outcomes of therapeutic pelviclymphadenectomy for stage I endometrial adenocarcinoma. Gynecol Oncol 1998;70:165–171.9. Fanning J, Nanavati PJ, Hilgers RD. Surgical staging and high dose rate brachytherapyfor endometrial cancer: limiting external radiotherapy to node-positive tumours. ObstetGynecol 1996;87:1041–1044.10. Trimble EL, Kosary C, Park RC. Lymph node sampling and survival in endometrial cancer.Gynecol Oncol 1998;71:340–343.11. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology:Endometrial Cancer, V.1.2008. Retrieved February 13, 2008, from http://www.nccn.org/professionals/physician_gls/PDF/uterine.pdf.12. Daniel A, Peters W. Accuracy of office and operating room curettage in the grading ofendometrial carcinoma. Obstet Gynecol 1988;71(4):612–614.13. Goff B, Rice L. Assessment of depth of myometrial invasion in endometrial adenocarcinoma.Gynecol Oncol 1990;38(1):46–48.14. Creutzberg C. GOG-99: ending the controversy regarding pelvic radiotherapy for endometrialcarcinoma? Gynecol Oncol 2004;92(3):740–743.
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