Low-risk corpus cancer: Is lymphadenectomy or radiotherapy necessary?
Identifieur interne : 002673 ( Istex/Corpus ); précédent : 002672; suivant : 002674Low-risk corpus cancer: Is lymphadenectomy or radiotherapy necessary?
Auteurs : Andrea Mariani ; Maurice J. Webb ; Gary L. Keeney ; Michael G. Haddock ; Giliola Calori ; Karl C. PodratzSource :
- American Journal of Obstetrics and Gynecology [ 0002-9378 ] ; 2000.
English descriptors
- KwdEn :
Abstract
Objective: The objective of this study was to find readily ascertainable intraoperative pathologic indicators that would discriminate a subgroup of early corpus cancers that would not require lymphadenectomy or adjuvant radiotherapy. Study Design: Between 1984 and 1993, a total of 328 patients with endometrioid corpus cancer, grade 1 or 2 tumor, myometrial invasion ≤50%, and no intraoperative evidence of macroscopic extrauterine spread were treated surgically. Pelvic lymphadenectomy was performed in 187 cases (57%), and nodes were positive in nine cases (5%). Adjuvant radiotherapy was administered to 65 patients (20%). Median follow-up was 88 months. Results: The 5-year overall cancer-related and recurrence-free survivals were 97% and 96%, respectively. Primary tumor diameter and lymphatic or vascular invasion significantly affected longevity. No patient with tumor diameter ≤2 cm had positive lymph nodes or died of disease. Conclusion: Patients who have International Federation of Gynecology and Obstetrics grade 1 or 2 endometrioid corpus cancer with greatest surface dimension ≤2 cm, myometrial invasion ≤50%, and no intraoperative evidence of macroscopic disease can be treated optimally with hysterectomy only. (Am J Obstet Gynecol 2000;182:1506-19.)
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DOI: 10.1067/mob.2000.107335
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ISTEX:53C2189F96F658CB94476A4F274553D54504E047Le document en format XML
<record><TEI wicri:istexFullTextTei="biblStruct"><teiHeader><fileDesc><titleStmt><title xml:lang="en">Low-risk corpus cancer: Is lymphadenectomy or radiotherapy necessary?</title><author><name sortKey="Mariani, Andrea" sort="Mariani, Andrea" uniqKey="Mariani A" first="Andrea" last="Mariani">Andrea Mariani</name><affiliation><mods:affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</mods:affiliation></affiliation></author><author><name sortKey="Webb, Maurice J" sort="Webb, Maurice J" uniqKey="Webb M" first="Maurice J." last="Webb">Maurice J. Webb</name><affiliation><mods:affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</mods:affiliation></affiliation></author><author><name sortKey="Keeney, Gary L" sort="Keeney, Gary L" uniqKey="Keeney G" first="Gary L." last="Keeney">Gary L. Keeney</name><affiliation><mods:affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</mods:affiliation></affiliation></author><author><name sortKey="Haddock, Michael G" sort="Haddock, Michael G" uniqKey="Haddock M" first="Michael G." last="Haddock">Michael G. Haddock</name><affiliation><mods:affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</mods:affiliation></affiliation></author><author><name sortKey="Calori, Giliola" sort="Calori, Giliola" uniqKey="Calori G" first="Giliola" last="Calori">Giliola Calori</name><affiliation><mods:affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</mods:affiliation></affiliation></author><author><name sortKey="Podratz, Karl C" sort="Podratz, Karl C" uniqKey="Podratz K" first="Karl C." last="Podratz">Karl C. Podratz</name><affiliation><mods:affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</mods:affiliation></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">ISTEX</idno><idno type="RBID">ISTEX:53C2189F96F658CB94476A4F274553D54504E047</idno><date when="2000" year="2000">2000</date><idno type="doi">10.1067/mob.2000.107335</idno><idno type="url">https://api.istex.fr/document/53C2189F96F658CB94476A4F274553D54504E047/fulltext/pdf</idno><idno type="wicri:Area/Istex/Corpus">002673</idno><idno type="wicri:explorRef" wicri:stream="Istex" wicri:step="Corpus" wicri:corpus="ISTEX">002673</idno></publicationStmt><sourceDesc><biblStruct><analytic><title level="a" type="main" xml:lang="en">Low-risk corpus cancer: Is lymphadenectomy or radiotherapy necessary?</title><author><name sortKey="Mariani, Andrea" sort="Mariani, Andrea" uniqKey="Mariani A" first="Andrea" last="Mariani">Andrea Mariani</name><affiliation><mods:affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</mods:affiliation></affiliation></author><author><name sortKey="Webb, Maurice J" sort="Webb, Maurice J" uniqKey="Webb M" first="Maurice J." last="Webb">Maurice J. Webb</name><affiliation><mods:affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</mods:affiliation></affiliation></author><author><name sortKey="Keeney, Gary L" sort="Keeney, Gary L" uniqKey="Keeney G" first="Gary L." last="Keeney">Gary L. Keeney</name><affiliation><mods:affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</mods:affiliation></affiliation></author><author><name sortKey="Haddock, Michael G" sort="Haddock, Michael G" uniqKey="Haddock M" first="Michael G." last="Haddock">Michael G. Haddock</name><affiliation><mods:affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</mods:affiliation></affiliation></author><author><name sortKey="Calori, Giliola" sort="Calori, Giliola" uniqKey="Calori G" first="Giliola" last="Calori">Giliola Calori</name><affiliation><mods:affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</mods:affiliation></affiliation></author><author><name sortKey="Podratz, Karl C" sort="Podratz, Karl C" uniqKey="Podratz K" first="Karl C." last="Podratz">Karl C. Podratz</name><affiliation><mods:affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">American Journal of Obstetrics and Gynecology</title><title level="j" type="abbrev">YMOB</title><idno type="ISSN">0002-9378</idno><imprint><publisher>ELSEVIER</publisher><date type="published" when="2000">2000</date><biblScope unit="volume">182</biblScope><biblScope unit="issue">6</biblScope><biblScope unit="page" from="1506">1506</biblScope><biblScope unit="page" to="1519">1519</biblScope></imprint><idno type="ISSN">0002-9378</idno></series></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">0002-9378</idno></seriesStmt></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Endometrial cancer</term><term>low-risk</term><term>lymphadenectomy</term><term>management</term><term>radiotherapy</term></keywords></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Objective: The objective of this study was to find readily ascertainable intraoperative pathologic indicators that would discriminate a subgroup of early corpus cancers that would not require lymphadenectomy or adjuvant radiotherapy. Study Design: Between 1984 and 1993, a total of 328 patients with endometrioid corpus cancer, grade 1 or 2 tumor, myometrial invasion ≤50%, and no intraoperative evidence of macroscopic extrauterine spread were treated surgically. Pelvic lymphadenectomy was performed in 187 cases (57%), and nodes were positive in nine cases (5%). Adjuvant radiotherapy was administered to 65 patients (20%). Median follow-up was 88 months. Results: The 5-year overall cancer-related and recurrence-free survivals were 97% and 96%, respectively. Primary tumor diameter and lymphatic or vascular invasion significantly affected longevity. No patient with tumor diameter ≤2 cm had positive lymph nodes or died of disease. Conclusion: Patients who have International Federation of Gynecology and Obstetrics grade 1 or 2 endometrioid corpus cancer with greatest surface dimension ≤2 cm, myometrial invasion ≤50%, and no intraoperative evidence of macroscopic disease can be treated optimally with hysterectomy only. (Am J Obstet Gynecol 2000;182:1506-19.)</div></front></TEI><istex><corpusName>elsevier</corpusName><keywords><teeft><json:string>endometrial</json:string><json:string>node</json:string><json:string>lymphadenectomy</json:string><json:string>radiotherapy</json:string><json:string>endometrial cancer</json:string><json:string>adjuvant</json:string><json:string>primary tumor diameter</json:string><json:string>myometrial</json:string><json:string>recurrence</json:string><json:string>histologic</json:string><json:string>lymphatic</json:string><json:string>gynecol</json:string><json:string>myometrial invasion</json:string><json:string>vascular invasion</json:string><json:string>cytologic</json:string><json:string>cytologic results</json:string><json:string>postoperative</json:string><json:string>obstet</json:string><json:string>metastasis</json:string><json:string>mariani</json:string><json:string>intraoperative</json:string><json:string>brachytherapy</json:string><json:string>lymph nodes</json:string><json:string>lymph</json:string><json:string>endometrioid</json:string><json:string>histologic grade</json:string><json:string>adjuvant radiotherapy</json:string><json:string>prognostic</json:string><json:string>obstet gynecol</json:string><json:string>surgical</json:string><json:string>oncol</json:string><json:string>morbidity</json:string><json:string>hysterectomy</json:string><json:string>gynecologic</json:string><json:string>tumor diameter</json:string><json:string>clinical stage</json:string><json:string>tumor size</json:string><json:string>endometrial carcinoma</json:string><json:string>figo</json:string><json:string>gynecol oncol</json:string><json:string>endometrioid histologic subtype</json:string><json:string>uterus</json:string><json:string>carcinoma</json:string><json:string>lymph node metastasis</json:string><json:string>preoperative</json:string><json:string>lurain</json:string><json:string>extrauterine</json:string><json:string>positive lymph nodes</json:string><json:string>vaginal recurrences</json:string><json:string>adenocarcinoma</json:string><json:string>hormonal</json:string><json:string>lymph node metastases</json:string><json:string>sidewall</json:string><json:string>hormonal therapy</json:string><json:string>pelvic lymphadenectomy</json:string><json:string>body mass index</json:string><json:string>external radiotherapy</json:string><json:string>vaginal brachytherapy</json:string><json:string>prognostic factors</json:string><json:string>adjuvant therapy</json:string><json:string>pelvic sidewall</json:string><json:string>vascular</json:string><json:string>pelvic</json:string><json:string>mayo</json:string><json:string>local recurrences</json:string><json:string>distant recurrences</json:string><json:string>mayo clinic</json:string><json:string>pelvic lymph nodes</json:string><json:string>figo grade</json:string><json:string>superficial myometrial invasion</json:string><json:string>intraoperative assessment</json:string><json:string>intraoperative analysis</json:string><json:string>distant recurrence</json:string><json:string>tumor grade</json:string><json:string>obstet gynecol table</json:string><json:string>histologic subtype</json:string><json:string>lymph node dissection</json:string><json:string>lymph node sampling</json:string><json:string>endometrial cancers</json:string><json:string>tumor</json:string></teeft></keywords><author><json:item><name>Andrea Mariani MDa</name><affiliations><json:string>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</json:string></affiliations></json:item><json:item><name>Maurice J. Webb MDa</name><affiliations><json:string>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</json:string></affiliations></json:item><json:item><name>Gary L. Keeney MDb</name><affiliations><json:string>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</json:string></affiliations></json:item><json:item><name>Michael G. Haddock MDc</name><affiliations><json:string>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</json:string></affiliations></json:item><json:item><name>Giliola Calori MSd</name><affiliations><json:string>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</json:string></affiliations></json:item><json:item><name>Karl C. Podratz MD, PhDa</name><affiliations><json:string>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</json:string></affiliations></json:item></author><subject><json:item><lang><json:string>eng</json:string></lang><value>Endometrial cancer</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>low-risk</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>lymphadenectomy</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>management</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>radiotherapy</value></json:item></subject><language><json:string>eng</json:string></language><originalGenre><json:string>Full-length article</json:string></originalGenre><abstract>Objective: The objective of this study was to find readily ascertainable intraoperative pathologic indicators that would discriminate a subgroup of early corpus cancers that would not require lymphadenectomy or adjuvant radiotherapy. Study Design: Between 1984 and 1993, a total of 328 patients with endometrioid corpus cancer, grade 1 or 2 tumor, myometrial invasion ≤50%, and no intraoperative evidence of macroscopic extrauterine spread were treated surgically. Pelvic lymphadenectomy was performed in 187 cases (57%), and nodes were positive in nine cases (5%). Adjuvant radiotherapy was administered to 65 patients (20%). Median follow-up was 88 months. Results: The 5-year overall cancer-related and recurrence-free survivals were 97% and 96%, respectively. Primary tumor diameter and lymphatic or vascular invasion significantly affected longevity. No patient with tumor diameter ≤2 cm had positive lymph nodes or died of disease. Conclusion: Patients who have International Federation of Gynecology and Obstetrics grade 1 or 2 endometrioid corpus cancer with greatest surface dimension ≤2 cm, myometrial invasion ≤50%, and no intraoperative evidence of macroscopic disease can be treated optimally with hysterectomy only. (Am J Obstet Gynecol 2000;182:1506-19.)</abstract><qualityIndicators><score>7.636</score><pdfVersion>1.4</pdfVersion><pdfPageSize>612 x 792 pts (letter)</pdfPageSize><refBibsNative>true</refBibsNative><keywordCount>5</keywordCount><abstractCharCount>1269</abstractCharCount><pdfWordCount>9289</pdfWordCount><pdfCharCount>59737</pdfCharCount><pdfPageCount>14</pdfPageCount><abstractWordCount>178</abstractWordCount></qualityIndicators><title>Low-risk corpus cancer: Is lymphadenectomy or radiotherapy necessary?</title><pii><json:string>S0002-9378(00)99038-0</json:string></pii><genre><json:string>research-article</json:string></genre><serie><title>Proceedings of the Twenty-ninth Annual Meeting of the Society of Gynecologic Oncology; 1998 Feb 7-11; Orlando, Florida</title><language><json:string>unknown</json:string></language><pages><first>70</first></pages></serie><host><title>American Journal of Obstetrics and Gynecology</title><language><json:string>unknown</json:string></language><publicationDate>2000</publicationDate><issn><json:string>0002-9378</json:string></issn><pii><json:string>S0002-9378(00)X0048-8</json:string></pii><volume>182</volume><issue>6</issue><pages><first>1506</first><last>1519</last></pages><genre><json:string>journal</json:string></genre></host><categories><wos><json:string>science</json:string><json:string>obstetrics & gynecology</json:string></wos><scienceMetrix><json:string>health sciences</json:string><json:string>clinical medicine</json:string><json:string>obstetrics & reproductive medicine</json:string></scienceMetrix><inist><json:string>sciences appliquees, technologies et medecines</json:string><json:string>sciences biologiques et medicales</json:string><json:string>sciences medicales</json:string><json:string>gynecologie. andrologie. obstetrique</json:string></inist></categories><publicationDate>2000</publicationDate><copyrightDate>2000</copyrightDate><doi><json:string>10.1067/mob.2000.107335</json:string></doi><id>53C2189F96F658CB94476A4F274553D54504E047</id><score>1</score><fulltext><json:item><extension>pdf</extension><original>true</original><mimetype>application/pdf</mimetype><uri>https://api.istex.fr/document/53C2189F96F658CB94476A4F274553D54504E047/fulltext/pdf</uri></json:item><json:item><extension>zip</extension><original>false</original><mimetype>application/zip</mimetype><uri>https://api.istex.fr/document/53C2189F96F658CB94476A4F274553D54504E047/fulltext/zip</uri></json:item><istex:fulltextTEI uri="https://api.istex.fr/document/53C2189F96F658CB94476A4F274553D54504E047/fulltext/tei"><teiHeader><fileDesc><titleStmt><title level="a" type="main" xml:lang="en">Low-risk corpus cancer: Is lymphadenectomy or radiotherapy necessary?</title></titleStmt><publicationStmt><authority>ISTEX</authority><publisher>ELSEVIER</publisher><availability><p>©2000 Mosby, Inc.</p></availability><date>2000</date></publicationStmt><notesStmt><note>Supported by the Mayo Cancer Center (P30CA15083) and the Rochester Research Committee, Mayo Foundation, Rochester, Minnesota.</note><note>Reprint requests: Karl C. Podratz, MD, PhD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.</note><note type="content">Section title: Transactions of the Sixty-Seventh Annual Meeting of the Central Association Of Obstetricians and Gynecologists</note><note type="content">Table II: Characteristics of patients with low-risk endometrial cancer (endometrioid histologic subtype, myometrial invasion ≤50%, and histologic grade 1-2) according to primary tumor diameter and type of additional therapy (all patients underwent hysterectomy)</note><note type="content">Table III: Acute perioperative morbidity among patients with low-risk endometrial cancer (endometrioid histologic subtype, myometrial invasion ≤50%, and histologic grade 1-2)</note><note type="content">Table V: Recurrence and survival among patients with low-risk endometrial cancer (endometrioid histologic subtype,myometrial invasion ≤50%, and histologic grade 1-2) and no lymphadenectomy</note><note type="content">Table VI: Prognosis of isolated vaginal recurrences among patients with low-risk endometrial cancer (endometrioid histologic subtype, myometrial invasion ≤50%, and histologic grade 1-2) who had not previously received radiotherapy</note></notesStmt><sourceDesc><biblStruct type="inbook"><analytic><title level="a" type="main" xml:lang="en">Low-risk corpus cancer: Is lymphadenectomy or radiotherapy necessary?</title><author xml:id="author-0000"><persName><forename type="first">Andrea</forename><surname>Mariani</surname></persName><roleName type="degree">MDa</roleName><affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</affiliation></author><author xml:id="author-0001"><persName><forename type="first">Maurice J.</forename><surname>Webb</surname></persName><roleName type="degree">MDa</roleName><affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</affiliation></author><author xml:id="author-0002"><persName><forename type="first">Gary L.</forename><surname>Keeney</surname></persName><roleName type="degree">MDb</roleName><affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</affiliation></author><author xml:id="author-0003"><persName><forename type="first">Michael G.</forename><surname>Haddock</surname></persName><roleName type="degree">MDc</roleName><affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</affiliation></author><author xml:id="author-0004"><persName><forename type="first">Giliola</forename><surname>Calori</surname></persName><roleName type="degree">MSd</roleName><affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</affiliation></author><author xml:id="author-0005"><persName><forename type="first">Karl C.</forename><surname>Podratz</surname></persName><roleName type="degree">MD, PhDa</roleName><affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</affiliation></author><idno type="istex">53C2189F96F658CB94476A4F274553D54504E047</idno><idno type="DOI">10.1067/mob.2000.107335</idno><idno type="PII">S0002-9378(00)99038-0</idno></analytic><monogr><title level="j">American Journal of Obstetrics and Gynecology</title><title level="j" type="abbrev">YMOB</title><idno type="pISSN">0002-9378</idno><idno type="PII">S0002-9378(00)X0048-8</idno><imprint><publisher>ELSEVIER</publisher><date type="published" when="2000"></date><biblScope unit="volume">182</biblScope><biblScope unit="issue">6</biblScope><biblScope unit="page" from="1506">1506</biblScope><biblScope unit="page" to="1519">1519</biblScope></imprint></monogr></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>2000</date></creation><langUsage><language ident="en">en</language></langUsage><abstract xml:lang="en"><p>Objective: The objective of this study was to find readily ascertainable intraoperative pathologic indicators that would discriminate a subgroup of early corpus cancers that would not require lymphadenectomy or adjuvant radiotherapy. Study Design: Between 1984 and 1993, a total of 328 patients with endometrioid corpus cancer, grade 1 or 2 tumor, myometrial invasion ≤50%, and no intraoperative evidence of macroscopic extrauterine spread were treated surgically. Pelvic lymphadenectomy was performed in 187 cases (57%), and nodes were positive in nine cases (5%). Adjuvant radiotherapy was administered to 65 patients (20%). Median follow-up was 88 months. Results: The 5-year overall cancer-related and recurrence-free survivals were 97% and 96%, respectively. Primary tumor diameter and lymphatic or vascular invasion significantly affected longevity. No patient with tumor diameter ≤2 cm had positive lymph nodes or died of disease. Conclusion: Patients who have International Federation of Gynecology and Obstetrics grade 1 or 2 endometrioid corpus cancer with greatest surface dimension ≤2 cm, myometrial invasion ≤50%, and no intraoperative evidence of macroscopic disease can be treated optimally with hysterectomy only. (Am J Obstet Gynecol 2000;182:1506-19.)</p></abstract><textClass xml:lang="en"><keywords scheme="keyword"><list><head>Keywords</head><item><term>Endometrial cancer</term></item><item><term>low-risk</term></item><item><term>lymphadenectomy</term></item><item><term>management</term></item><item><term>radiotherapy</term></item></list></keywords></textClass></profileDesc><revisionDesc><change when="2000">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/document/53C2189F96F658CB94476A4F274553D54504E047/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="Elsevier doc found" wicri:toSee="Elsevier, no converted or simple article"><istex:xmlDeclaration>version="1.0" encoding="utf-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//ES//DTD journal article DTD version 5.0.1//EN//XML" URI="art501.dtd" name="istex:docType"><istex:entity SYSTEM="gr1" NDATA="IMAGE" name="gr1"></istex:entity></istex:docType><istex:document><article docsubtype="fla" xml:lang="en"><item-info><jid>YMOB</jid><aid>990380</aid><ce:pii>S0002-9378(00)99038-0</ce:pii><ce:doi>10.1067/mob.2000.107335</ce:doi><ce:copyright type="full-transfer" year="2000">Mosby, Inc.</ce:copyright></item-info><ce:floats><ce:table id="tab2" colsep="0" rowsep="0" frame="topbot"><ce:label>Table II</ce:label><ce:caption><ce:simple-para id="sp0010">Characteristics of patients with low-risk endometrial cancer (endometrioid histologic subtype, myometrial invasion ≤50%, and histologic grade 1-2) according to primary tumor diameter and type of additional therapy (all patients underwent hysterectomy)</ce:simple-para></ce:caption><tgroup cols="16"><colspec colname="col1" colsep="0"></colspec><colspec colname="col2" colsep="0"></colspec><colspec colname="col3" colsep="0"></colspec><colspec colname="col4" colsep="0"></colspec><colspec colname="col5" colsep="0"></colspec><colspec colname="col6" colsep="0"></colspec><colspec colname="col7" colsep="0"></colspec><colspec colname="col8" colsep="0"></colspec><colspec colname="col9" colsep="0"></colspec><colspec colname="col10" colsep="0"></colspec><colspec colname="col11" colsep="0"></colspec><colspec colname="col12" colsep="0"></colspec><colspec colname="col13" colsep="0"></colspec><colspec colname="col14" colsep="0"></colspec><colspec colname="col15" colsep="0"></colspec><colspec colname="col16" colsep="0"></colspec><thead><row><entry morerows="1"><ce:hsp sp="1.0"></ce:hsp>Therapy</entry><entry morerows="1" align="center">Cases (No.)</entry><entry namest="col3" nameend="col4" align="center">FIGO grade 1</entry><entry namest="col5" nameend="col6" align="center">FIGO grade 2</entry><entry namest="col7" nameend="col8" align="center">No myometrial invasion</entry><entry namest="col9" nameend="col10" align="center">Superficial myometrial invasion*</entry><entry colname="col11" morerows="1">Other risk factors</entry><entry namest="col12" nameend="col13" align="center">Recurrences</entry><entry colname="col14" morerows="1"><ce:hsp sp="1.0"></ce:hsp>Site of recurrence</entry><entry namest="col15" nameend="col16" align="center">Died of disease</entry></row><row><entry colname="col3" align="center">No.</entry><entry align="center">%</entry><entry align="center">No.</entry><entry align="center">%</entry><entry align="center">No.</entry><entry align="center">%</entry><entry align="center">No.</entry><entry align="center">%</entry><entry colname="col12" align="center">No.</entry><entry align="center">%</entry><entry colname="col15" align="center">No.</entry><entry align="center">%</entry></row></thead><tbody><row><entry>Primary tumor diameter ≤2 cm</entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry></entry><entry align="center"></entry><entry align="center"></entry><entry></entry><entry align="center"></entry><entry align="center"></entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Neither lymphadenectomy nor adjuvant radiotherapy</entry><entry align="center">59</entry><entry align="center">46</entry><entry align="center">78</entry><entry align="center">13</entry><entry align="center">22</entry><entry align="center">21</entry><entry align="center">36</entry><entry align="center">38</entry><entry align="center">64</entry><entry>—</entry><entry align="center">1</entry><entry align="center">2</entry><entry>Vaginal (n = 1)</entry><entry align="center">0</entry><entry align="center">0</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Adjuvant radiotherapy without lymphadenectomy†</entry><entry align="center">5</entry><entry align="center">2</entry><entry align="center">40</entry><entry align="center">3</entry><entry align="center">60</entry><entry align="center">0</entry><entry align="center">0</entry><entry align="center">5</entry><entry align="center">100</entry><entry>Positive peritoneal cytologic results (n = 4)</entry><entry align="center">0</entry><entry align="center">0</entry><entry>—</entry><entry align="center">0</entry><entry align="center">0</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Lymphadenectomy without adjuvant radiotherapy</entry><entry align="center">54</entry><entry align="center">44</entry><entry align="center">81</entry><entry align="center">10</entry><entry align="center">19</entry><entry align="center">15</entry><entry align="center">28</entry><entry align="center">39</entry><entry align="center">72</entry><entry>—</entry><entry align="center">2</entry><entry align="center">4</entry><entry>Vaginal (n = 2)</entry><entry align="center">0</entry><entry align="center">0</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Lymphadenectomy with adjuvant radiotherapy</entry><entry align="center">5</entry><entry align="center">3</entry><entry align="center">60</entry><entry align="center">2</entry><entry align="center">40</entry><entry align="center">1</entry><entry align="center">20</entry><entry align="center">4</entry><entry align="center">80</entry><entry>Positive peritoneal cytologic results (n = 3)</entry><entry align="center">0</entry><entry align="center">0</entry><entry>—</entry><entry align="center">0</entry><entry align="center">0</entry></row><row><entry>Primary tumor diameter >2 cm</entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry></entry><entry align="center"></entry><entry align="center"></entry><entry></entry><entry align="center"></entry><entry align="center"></entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Neither lymphadenectomy nor adjuvant radiotherapy†</entry><entry align="center">52</entry><entry align="center">35</entry><entry align="center">67</entry><entry align="center">17</entry><entry align="center">33</entry><entry align="center">5</entry><entry align="center">10</entry><entry align="center">47</entry><entry align="center">90</entry><entry>—</entry><entry align="center">1</entry><entry align="center">2</entry><entry>Distant (n = 1)</entry><entry align="center">1</entry><entry align="center">2</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Adjuvant radiotherapy without lymphadenectomy</entry><entry align="center">9</entry><entry align="center">3</entry><entry align="center">33</entry><entry align="center">6</entry><entry align="center">67</entry><entry align="center">0</entry><entry align="center">0</entry><entry align="center">9</entry><entry align="center">100</entry><entry>Positive peritoneal cytologic results (n = 1)</entry><entry align="center">2</entry><entry align="center">22</entry><entry>Distant (n = 1), local plus distant (n = 1)</entry><entry align="center">2</entry><entry align="center">22</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Lymphadenectomy without adjuvant radiotherapy‡</entry><entry align="center">66</entry><entry align="center">46</entry><entry align="center">70</entry><entry align="center">20</entry><entry align="center">30</entry><entry align="center">9</entry><entry align="center">14</entry><entry align="center">57</entry><entry align="center">86</entry><entry>Positive para-aortic lymph nodes (n = 1)</entry><entry align="center">5</entry><entry align="center">8</entry><entry>Vaginal (n = 3), Distant (n = 1), local plus distant (n = 1)</entry><entry align="center">2</entry><entry align="center">3</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Lymphadenectomy with adjuvant radiotherapy‡</entry><entry align="center">42</entry><entry align="center">15</entry><entry align="center">36</entry><entry align="center">27</entry><entry align="center">64</entry><entry align="center">1</entry><entry align="center">2</entry><entry align="center">41</entry><entry align="center">98</entry><entry>Positive peritoneal cytologic results (n = 12), positive pelvic lymph nodes (n = 8)</entry><entry align="center">6</entry><entry align="center">14</entry><entry>Distant (n = 3), local plus distant (n = 3)</entry><entry align="center">6</entry><entry align="center">14</entry></row><row><entry namest="col1" nameend="col16">*Defined as ≤50% myometrial invasion. †One patient received adjuvant hormonal therapy. ‡Two patients received adjuvant hormonal therapy.</entry></row></tbody></tgroup></ce:table><ce:table id="tab3" colsep="0" rowsep="0" frame="topbot"><ce:label>Table III</ce:label><ce:caption><ce:simple-para id="sp0015">Acute perioperative morbidity among patients with low-risk endometrial cancer (endometrioid histologic subtype, myometrial invasion ≤50%, and histologic grade 1-2)</ce:simple-para></ce:caption><tgroup cols="4"><colspec colname="col1" colsep="0"></colspec><colspec colname="col2" colsep="0"></colspec><colspec colname="col3" colsep="0"></colspec><colspec colname="col4" colsep="0"></colspec><thead><row><entry><ce:hsp sp="1.0"></ce:hsp>Morbidity</entry><entry align="center">No lymphadenectomy (n = 140)</entry><entry align="center">Lymphadenectomy (n = 188)</entry><entry align="center">Statistical significance</entry></row></thead><tbody><row><entry>American Society of Anesthesiologists status 3-4* (No.)</entry><entry align="center">41/117 (35%)</entry><entry align="center">39/159 (25%)</entry><entry align="center"><ce:italic>P</ce:italic> =.06</entry></row><row><entry>Blood transfusion (No.)</entry><entry align="center">8/131 (6%)</entry><entry align="center">24/171 (14%)</entry><entry align="center"><ce:italic>P</ce:italic> =.02</entry></row><row><entry>Postoperative febrile morbidity† (No.)</entry><entry align="center">24/119 (20%)</entry><entry align="center">31/156 (20%)</entry><entry align="center"><ce:italic>P</ce:italic> =.95</entry></row><row><entry>Operative time (min, mean ± SD)</entry><entry align="center">117.9 ± 42.3</entry><entry align="center">139.5 ± 40.1</entry><entry align="center"><ce:italic>P</ce:italic> <.001</entry></row><row><entry>Estimated blood loss (mL, mean ± SD)</entry><entry align="center">322.2 ± 337.8</entry><entry align="center">442.2 ± 307.0</entry><entry align="center"><ce:italic>P</ce:italic> =.03</entry></row><row><entry>Day of first bowel movement (mean ± SD)</entry><entry align="center">4.8 ± 1.4</entry><entry align="center">5.5 ± 1.1</entry><entry align="center"><ce:italic>P</ce:italic> <.001</entry></row><row><entry>Day of discharge (mean ± SD)</entry><entry align="center">6.9 ± 4.0</entry><entry align="center">7.6 ± 2.1</entry><entry align="center"><ce:italic>P</ce:italic> =.08</entry></row><row><entry namest="col1" nameend="col4">*Preoperative American Society of Anesthesiologists Physical Status score.<ce:cross-ref refid="bib20"><ce:sup>20</ce:sup></ce:cross-ref> †Temperature >38°C according to two different measurements ≥6 hours apart beyond the first 24 hours after the operation.</entry></row></tbody></tgroup><ce:legend><ce:simple-para id="sp0020">Data were not available for all patients; thus the percentages were calculated according to the total number of patients with available data.</ce:simple-para></ce:legend></ce:table><ce:table id="tab5" colsep="0" rowsep="0" frame="topbot"><ce:label>Table V</ce:label><ce:caption><ce:simple-para id="sp0025">Recurrence and survival among patients with low-risk endometrial cancer (endometrioid histologic subtype,myometrial invasion ≤50%, and histologic grade 1-2) and no lymphadenectomy</ce:simple-para></ce:caption><tgroup cols="13"><colspec colname="col1" colsep="0"></colspec><colspec colname="col2" colsep="0"></colspec><colspec colname="col3" colsep="0"></colspec><colspec colname="col4" colsep="0"></colspec><colspec colname="col5" colsep="0"></colspec><colspec colname="col6" colsep="0"></colspec><colspec colname="col7" colsep="0"></colspec><colspec colname="col8" colsep="0"></colspec><colspec colname="col9" colsep="0"></colspec><colspec colname="col10" colsep="0"></colspec><colspec colname="col11" colsep="0"></colspec><colspec colname="col12" colsep="0"></colspec><colspec colname="col13" colsep="0"></colspec><thead><row><entry morerows="1"><ce:hsp sp="1.0"></ce:hsp>Study</entry><entry morerows="1" align="center">Cases (No.)</entry><entry morerows="1" align="center">Adjuvant therapy</entry><entry morerows="1" align="center">Median follow-up (mo)</entry><entry namest="col5" nameend="col6" align="center">Recurrence</entry><entry colname="col7" morerows="1">Site</entry><entry morerows="1" align="center">Vaginal* (No.)</entry><entry morerows="1" align="center">Pelvic sidewall* (No.)</entry><entry namest="col10" nameend="col11" align="center">Died of disease</entry><entry colname="col12" morerows="1" align="center">Vaginal (No.)</entry><entry morerows="1" align="center">Pelvic sidewall (No.)</entry></row><row><entry colname="col5" align="center">No.</entry><entry align="center">%</entry><entry colname="col10" align="center">No.</entry><entry align="center">%</entry></row></thead><tbody><row><entry>No adjuvant therapy</entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Lim et al<ce:cross-ref refid="bib28"><ce:sup>28</ce:sup></ce:cross-ref></entry><entry align="center">315†</entry><entry align="center">None</entry><entry align="center">45</entry><entry align="center">14</entry><entry align="center">4.0</entry><entry>Local (n = 8), distant (n = 6)</entry><entry align="center">8</entry><entry align="center">0</entry><entry align="center">3</entry><entry align="center">1</entry><entry align="center">0</entry><entry align="center">0</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Carey et al<ce:cross-ref refid="bib6"><ce:sup>6</ce:sup></ce:cross-ref></entry><entry align="center">227</entry><entry align="center">None</entry><entry align="center">54</entry><entry align="center">10</entry><entry align="center">4.0</entry><entry>Local (n = 6), distant (n = 3), local plus distant (n = 1)</entry><entry align="center">3</entry><entry align="center">4</entry><entry align="center">9</entry><entry align="center">4</entry><entry align="center">2</entry><entry align="center">3</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Leijon et al<ce:cross-ref refid="bib7"><ce:sup>7</ce:sup></ce:cross-ref></entry><entry align="center">248</entry><entry align="center">None</entry><entry align="center">42</entry><entry align="center">9</entry><entry align="center">4.0</entry><entry>Local (n = 6), distant (n = 3)</entry><entry align="center">5</entry><entry align="center">1</entry><entry align="center">3</entry><entry align="center">1</entry><entry align="center">1</entry><entry align="center">0</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Poulsen et al<ce:cross-ref refid="bib8"><ce:sup>8</ce:sup></ce:cross-ref></entry><entry align="center">641</entry><entry align="center">None</entry><entry align="center">68-92</entry><entry align="center">45</entry><entry align="center">7.0</entry><entry>Local (n = 24), distant (n = 21)</entry><entry align="center">17</entry><entry align="center">7</entry><entry align="center">28</entry><entry align="center">4</entry><entry align="center">2</entry><entry align="center">6</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Larson et al<ce:cross-ref refid="bib29"><ce:sup>29</ce:sup></ce:cross-ref></entry><entry align="center">102‡</entry><entry align="center">None</entry><entry align="center">40-46</entry><entry align="center">3</entry><entry align="center">3.0</entry><entry>Local (n = 3)</entry><entry align="center">1</entry><entry align="center">2</entry><entry align="center">2</entry><entry align="center">2</entry><entry align="center">0</entry><entry align="center">2</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Current study</entry><entry align="center">126</entry><entry align="center">None</entry><entry align="center">88</entry><entry align="center">2</entry><entry align="center">2.0</entry><entry>Local (n = 1), distant (n = 1)</entry><entry align="center">1</entry><entry align="center">0</entry><entry align="center">1</entry><entry align="center">1</entry><entry align="center">0</entry><entry align="center">0</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp><ce:small-caps>TOTAL</ce:small-caps></entry><entry align="center">1659</entry><entry align="center">None</entry><entry align="center"></entry><entry align="center">83</entry><entry align="center">5</entry><entry>Local (n = 48, 3%), distant (n = 34, 2%), local plus distant (n = 1, 0.1%)</entry><entry align="center">35 (2%)</entry><entry align="center">14 (0.8%)</entry><entry align="center">46</entry><entry align="center">3</entry><entry align="center">5 (0.3%)</entry><entry align="center">11 (0.7%)</entry></row><row><entry>Adjuvant therapy</entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Piver and Hempling<ce:cross-ref refid="bib30"><ce:sup>30</ce:sup></ce:cross-ref></entry><entry align="center">90</entry><entry align="center">Brachytherapy§</entry><entry align="center">NA</entry><entry align="center">0</entry><entry align="center">0.0</entry><entry>—</entry><entry align="center">0</entry><entry align="center">0</entry><entry align="center">0</entry><entry align="center">0</entry><entry align="center">0</entry><entry align="center">0</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Lim et al<ce:cross-ref refid="bib28"><ce:sup>28</ce:sup></ce:cross-ref></entry><entry align="center">91ll</entry><entry align="center">Brachytherapy</entry><entry align="center">45</entry><entry align="center">4</entry><entry align="center">4.0</entry><entry>Local (n = 2), distant (n = 2)</entry><entry align="center">2</entry><entry align="center">0</entry><entry align="center">3</entry><entry align="center">3</entry><entry align="center">1</entry><entry align="center">0</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Weiss et al<ce:cross-ref refid="bib26"><ce:sup>26</ce:sup></ce:cross-ref></entry><entry align="center">75</entry><entry align="center">Brachytherapy</entry><entry align="center">48</entry><entry align="center">3</entry><entry align="center">4.0</entry><entry>Local (n = 1), distant (n = 1), local plus distant (n = 1)</entry><entry align="center">0</entry><entry align="center">2</entry><entry align="center">NA</entry><entry align="center">NA</entry><entry align="center">NA</entry><entry align="center">NA</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Aalders et al<ce:cross-ref refid="bib5"><ce:sup>5</ce:sup></ce:cross-ref></entry><entry align="center">126</entry><entry align="center">Brachytherapy</entry><entry align="center">3-10 y</entry><entry align="center">7</entry><entry align="center">6.0</entry><entry>Local (n = 5), distant (n = 2)</entry><entry align="center">NA</entry><entry align="center">NA</entry><entry align="center">3</entry><entry align="center">2</entry><entry align="center">NA</entry><entry align="center">NA</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Faught et al<ce:cross-ref refid="bib31"><ce:sup>31</ce:sup></ce:cross-ref></entry><entry align="center">161</entry><entry align="center">Brachytherapy¶</entry><entry align="center">80% ≥5 y</entry><entry align="center">0</entry><entry align="center">0.0</entry><entry>—</entry><entry align="center">0</entry><entry align="center">0</entry><entry align="center">0</entry><entry align="center">0</entry><entry align="center">0</entry><entry align="center">0</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp><ce:small-caps>TOTAL</ce:small-caps></entry><entry align="center">543</entry><entry align="center"></entry><entry align="center"></entry><entry align="center">14</entry><entry align="center">2.5</entry><entry>Local (n = 8, 1%), distant (n = 5, 1%), local plus distant (n = 1, 0.2%)</entry><entry align="center">2 (0.4%)</entry><entry align="center">2 (0.4%)</entry><entry align="center">6</entry><entry align="center">3</entry><entry align="center">1 (0.2%)</entry><entry align="center">0 (0%)</entry></row><row><entry namest="col1" nameend="col13">*Patients with local plus distant metastases were also included in the analysis. † Diploid. ‡Only patients with grade 1 disease and myometrial invasion ≤50%. §Patients with positive peritoneal cytologic results were treated with brachytherapy and progesterone for 1 year. llAneuploid. ¶Brachytherapy administered to 43 patients with myometrial invasion of more than one third.</entry></row></tbody></tgroup><ce:legend><ce:simple-para id="sp0030"><ce:italic>NA,</ce:italic> Not available.</ce:simple-para></ce:legend></ce:table><ce:table id="tab6" colsep="0" rowsep="0" frame="topbot"><ce:label>Table VI</ce:label><ce:caption><ce:simple-para id="sp0035">Prognosis of isolated vaginal recurrences among patients with low-risk endometrial cancer (endometrioid histologic subtype, myometrial invasion ≤50%, and histologic grade 1-2) who had not previously received radiotherapy</ce:simple-para></ce:caption><tgroup cols="10"><colspec colname="col1" colsep="0"></colspec><colspec colname="col2" colsep="0"></colspec><colspec colname="col3" colsep="0"></colspec><colspec colname="col4" colsep="0"></colspec><colspec colname="col5" colsep="0"></colspec><colspec colname="col6" colsep="0"></colspec><colspec colname="col7" colsep="0"></colspec><colspec colname="col8" colsep="0"></colspec><colspec colname="col9" colsep="0"></colspec><colspec colname="col10" colsep="0"></colspec><thead><row><entry morerows="1"><ce:hsp sp="1.0"></ce:hsp>Study</entry><entry morerows="1" align="center">Cases (No.)</entry><entry morerows="1" align="center">Median follow-up (mo)</entry><entry namest="col4" nameend="col5" align="center">Time to recurrence (mo)</entry><entry namest="col6" nameend="col7" align="center">Isolated vaginal recurrence</entry><entry colname="col8" morerows="1"><ce:hsp sp="1.0"></ce:hsp>Therapy for recurrence</entry><entry namest="col9" nameend="col10" align="center">Died of disease</entry></row><row><entry colname="col4" align="center">Median</entry><entry align="center">Range</entry><entry align="center">No.</entry><entry align="center">%</entry><entry colname="col9" align="center">No.</entry><entry align="center">%</entry></row></thead><tbody><row><entry>Leijon et al<ce:cross-ref refid="bib7"><ce:sup>7</ce:sup></ce:cross-ref></entry><entry align="center">248</entry><entry align="center">42</entry><entry align="center">21</entry><entry align="center">11-49</entry><entry align="center">5</entry><entry align="center">2</entry><entry>Radiotherapy (n = 1), surgery (n = 1), radiotherapy plus hormonal therapy (n = 2), surgery plus hormonal therapy plus chemotherapy (n = 1)</entry><entry align="center">1</entry><entry align="center">0.4</entry></row><row><entry>Poulsen et al<ce:cross-ref refid="bib8"><ce:sup>8</ce:sup></ce:cross-ref></entry><entry align="center">641</entry><entry align="center">68-92</entry><entry align="center">NA</entry><entry align="center"></entry><entry align="center">17</entry><entry align="center">3</entry><entry>Radiotherapy (n = 17)</entry><entry align="center">2</entry><entry align="center">0.3</entry></row><row><entry>Carey et al<ce:cross-ref refid="bib6"><ce:sup>6</ce:sup></ce:cross-ref></entry><entry align="center">227</entry><entry align="center">54</entry><entry align="center">NA</entry><entry align="center"></entry><entry align="center">3</entry><entry align="center">1(?)</entry><entry>Radiotherapy (n = 3)*</entry><entry align="center">2</entry><entry align="center">0.9</entry></row><row><entry>Lim et al<ce:cross-ref refid="bib28"><ce:sup>28</ce:sup></ce:cross-ref></entry><entry align="center">315†</entry><entry align="center">45</entry><entry align="center"></entry><entry align="center">1-40</entry><entry align="center">8</entry><entry align="center">3</entry><entry>Radiotherapy (n = 8)‡</entry><entry align="center">0</entry><entry align="center">0</entry></row><row><entry>Larson et al<ce:cross-ref refid="bib29"><ce:sup>29</ce:sup></ce:cross-ref></entry><entry align="center">102§</entry><entry align="center">40-46</entry><entry align="center">NA</entry><entry align="center"></entry><entry align="center">1</entry><entry align="center">1</entry><entry>Radiotherapy (n = 1)</entry><entry align="center">0</entry><entry align="center">0</entry></row><row><entry>Current study</entry><entry align="center">263</entry><entry align="center">88</entry><entry align="center">51</entry><entry align="center">4-103</entry><entry align="center">6</entry><entry align="center">2</entry><entry>Radiotherapy (n = 1), surgery plus hormonal therapy (n = 1), surgery plus radiotherapy (n = 3), radiotherapy plus hormonal therapy (n = 1)</entry><entry align="center">1</entry><entry align="center">0.4</entry></row><row><entry><ce:small-caps>TOTAL</ce:small-caps></entry><entry align="center">1796</entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center">40</entry><entry align="center">2</entry><entry></entry><entry align="center">6</entry><entry align="center">0.3</entry></row><row><entry namest="col1" nameend="col10">*Site of recurrence not clear. † Diploid. ‡Described as radical radiotherapy. §Only patients with myometrial invasion ≤50% and grade 1 disease.</entry></row></tbody></tgroup><ce:legend><ce:simple-para id="sp0040"><ce:italic>NA,</ce:italic> Not available.</ce:simple-para></ce:legend></ce:table></ce:floats><head><ce:article-footnote><ce:label>☆</ce:label><ce:note-para>Supported by the Mayo Cancer Center (P30CA15083) and the Rochester Research Committee, Mayo Foundation, Rochester, Minnesota.</ce:note-para></ce:article-footnote><ce:article-footnote><ce:label>☆☆</ce:label><ce:note-para>Reprint requests: Karl C. Podratz, MD, PhD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.</ce:note-para></ce:article-footnote><ce:dochead><ce:textfn>Transactions of the Sixty-Seventh Annual Meeting of the Central Association Of Obstetricians and Gynecologists</ce:textfn></ce:dochead><ce:title>Low-risk corpus cancer: Is lymphadenectomy or radiotherapy necessary?</ce:title><ce:presented>Presented at the Sixty-seventh Annual Meeting of The Central Association of Obstetricians and Gynecologists, Maui, Hawaii, October 24-27, 1999.</ce:presented><ce:author-group><ce:author><ce:given-name>Andrea</ce:given-name><ce:surname>Mariani</ce:surname><ce:degrees>MD<ce:sup>a</ce:sup></ce:degrees></ce:author><ce:author><ce:given-name>Maurice J.</ce:given-name><ce:surname>Webb</ce:surname><ce:degrees>MD<ce:sup>a</ce:sup></ce:degrees></ce:author><ce:author><ce:given-name>Gary L.</ce:given-name><ce:surname>Keeney</ce:surname><ce:degrees>MD<ce:sup>b</ce:sup></ce:degrees></ce:author><ce:author><ce:given-name>Michael G.</ce:given-name><ce:surname>Haddock</ce:surname><ce:degrees>MD<ce:sup>c</ce:sup></ce:degrees></ce:author><ce:author><ce:given-name>Giliola</ce:given-name><ce:surname>Calori</ce:surname><ce:degrees>MS<ce:sup>d</ce:sup></ce:degrees></ce:author><ce:author><ce:given-name>Karl C.</ce:given-name><ce:surname>Podratz</ce:surname><ce:degrees>MD, PhD<ce:sup>a</ce:sup></ce:degrees></ce:author><ce:affiliation><ce:textfn>Rochester, Minnesota, and Milan, Italy</ce:textfn></ce:affiliation><ce:affiliation><ce:textfn>From the Department of Obstetrics and Gynecology,<ce:sup>a</ce:sup> the Department of Laboratory Medicine and Pathology,<ce:sup>b</ce:sup> and the Division of Radiation Oncology,<ce:sup>c</ce:sup> Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.<ce:sup>d</ce:sup></ce:textfn></ce:affiliation></ce:author-group><ce:abstract><ce:section-title id="st0010">Abstract</ce:section-title><ce:abstract-sec><ce:simple-para id="sp0045"><ce:bold>Objective:</ce:bold> The objective of this study was to find readily ascertainable intraoperative pathologic indicators that would discriminate a subgroup of early corpus cancers that would not require lymphadenectomy or adjuvant radiotherapy. <ce:bold>Study Design:</ce:bold> Between 1984 and 1993, a total of 328 patients with endometrioid corpus cancer, grade 1 or 2 tumor, myometrial invasion ≤50%, and no intraoperative evidence of macroscopic extrauterine spread were treated surgically. Pelvic lymphadenectomy was performed in 187 cases (57%), and nodes were positive in nine cases (5%). Adjuvant radiotherapy was administered to 65 patients (20%). Median follow-up was 88 months. <ce:bold>Results:</ce:bold> The 5-year overall cancer-related and recurrence-free survivals were 97% and 96%, respectively. Primary tumor diameter and lymphatic or vascular invasion significantly affected longevity. No patient with tumor diameter ≤2 cm had positive lymph nodes or died of disease. <ce:bold>Conclusion:</ce:bold> Patients who have International Federation of Gynecology and Obstetrics grade 1 or 2 endometrioid corpus cancer with greatest surface dimension ≤2 cm, myometrial invasion ≤50%, and no intraoperative evidence of macroscopic disease can be treated optimally with hysterectomy only. (Am J Obstet Gynecol 2000;182:1506-19.)</ce:simple-para></ce:abstract-sec></ce:abstract><ce:keywords class="keyword"><ce:section-title id="st0015">Keywords</ce:section-title><ce:keyword><ce:text>Endometrial cancer</ce:text></ce:keyword><ce:keyword><ce:text>low-risk</ce:text></ce:keyword><ce:keyword><ce:text>lymphadenectomy</ce:text></ce:keyword><ce:keyword><ce:text>management</ce:text></ce:keyword><ce:keyword><ce:text>radiotherapy</ce:text></ce:keyword></ce:keywords></head><body><ce:sections><ce:para id="p0010">Adenocarcinoma of the endometrium is the most common malignancy of the female genital tract, and the endometrium is the fourth most frequent cancer site, accounting for 6% of all cancers among women and exceeded only by cancers of the breast, lung, and colon and rectum. In approximately 75% of cases the tumor is clinically confined to the uterus at diagnosis. It is estimated that 36,100 new cases of endometrial cancer will be diagnosed in the United States during 2000 and that 6500 women will die of this disease.<ce:cross-ref refid="bib1"><ce:sup>1</ce:sup></ce:cross-ref> Overall survival rates for endometrial cancer are 84%.<ce:cross-ref refid="bib1"><ce:sup>1</ce:sup></ce:cross-ref></ce:para><ce:para id="p0015">During the last decade many authors have attempted to identify prognostic factors for stratifying women with endometrial cancer into risk categories so that surgical and adjuvant treatment can be tailored on the basis of the estimated risk for recurrence.<ce:cross-refs refid="bib2 bib3 bib4"><ce:sup>2-4</ce:sup></ce:cross-refs> Various investigators have defined low-risk groups as consisting of patients with disease confined to the uterine corpus, histologic grade 1 or 2, endometrioid histologic subtype, and ≤50% invasion through the myometrial wall.<ce:cross-refs refid="bib4 bib5 bib6"><ce:sup>4-6</ce:sup></ce:cross-refs></ce:para><ce:para id="p0020">Total abdominal hysterectomy, usually associated with bilateral salpingo-oophorectomy, with assessment of peritoneal cytologic characteristics is a well-defined treatment for endometrial cancer. Because of the low pelvic recurrence rates, it is generally accepted that adjuvant external beam radiation is not necessary for low-risk patients.<ce:cross-refs refid="bib6 bib7 bib8"><ce:sup>6-8</ce:sup></ce:cross-refs> However, the utilities of postoperative vaginal brachytherapy and lymph node dissection are still controversial. In the low-risk group 1% to 3% have therapy failure in the vagina, whereas recurrence rates of 4% to 7% have been reported among patients not treated with brachytherapy.<ce:cross-refs refid="bib2 bib6 bib7 bib8"><ce:sup>2,6-8</ce:sup></ce:cross-refs> Moreover, the detection of positive lymph nodes in 4% to 5% of this low-risk group<ce:cross-refs refid="bib9 bib10"><ce:sup>9,10</ce:sup></ce:cross-refs> is still considered significant by some authors and worthy of a lymph node evaluation.<ce:cross-ref refid="bib11"><ce:sup>11</ce:sup></ce:cross-ref> Unfortunately, we continue to lack specific tumor characteristics evaluable before or during the operation that could guide the decision to undertake a pelvic lymphadenectomy.<ce:cross-ref refid="bib12"><ce:sup>12</ce:sup></ce:cross-ref> Tumor diameter is a well-defined predictor of lymph node involvement and prognosis in cervical<ce:cross-ref refid="bib13"><ce:sup>13</ce:sup></ce:cross-ref> and breast cancers.<ce:cross-ref refid="bib14"><ce:sup>14</ce:sup></ce:cross-ref> Primary tumor diameter has been described as a predictor of lymph node invasion<ce:cross-refs refid="bib10 bib15"><ce:sup>10,15</ce:sup></ce:cross-refs> and prognosis<ce:cross-ref refid="bib10"><ce:sup>10</ce:sup></ce:cross-ref> in endometrial cancer.</ce:para><ce:para id="p0025">Although we endorse definitive surgical staging, the objective of this study was to use readily ascertainable intraoperative pathologic indicators that would discriminate a subgroup of early corpus cancers that would not require lymphadenectomy or adjuvant radiotherapy. We hypothesized that primary tumor diameter measured at surgery, histologic subtype, grade, depth of myometrial invasion, and the presence or absence of lymphatic or vascular invasion would discriminate those patients whose cancers could and could not be managed with curative intent with a simple hysterectomy.</ce:para><ce:section id="s0010"><ce:section-title id="st0020">Patients and methods</ce:section-title><ce:para id="p0030">From 1984 to 1993 a total of 815 patients with endometrial cancer underwent surgical treatment of the disease at the Mayo Clinic, Rochester, Minnesota, and their records were retrieved from the Mayo Clinic's database. We selected 612 patients with epithelial endometrial cancer who satisfied the following inclusion criteria: (1) they were treated with hysterectomy and removal of existing adnexal structures, and (2) no other malignancy was diagnosed within 5 years before or after the diagnosis of endometrial cancer (with the exception of patients who had carcinoma in situ or skin cancer other than melanoma). Among the 612 patients 238 underwent hysterectomy only and 374 had lymphadenectomy (at least one pelvic or para-aortic node biopsy specimen was obtained). Among the 612 patients 334 were found to have the following characteristics: (1) tumor confined to the uterine corpus (except for either occult positive lymph nodes or positive peritoneal cytologic results or both), (2) histologic grade 1 or 2, (3) myometrial invasion ≤50%, and (4) endometrioid histologic subtype (patients with areas of squamous differentiation or adenosquamous tumors were also included). We eliminated 6 patients who had been referred to our institution after having received preoperative therapy elsewhere—vaginal brachytherapy in 1 case, external pelvic radiotherapy in 4 cases, and chemotherapy in 1 case. Thus we included 328 patients in this analysis.</ce:para><ce:para id="p0035">Staging was defined according to the International Federation of Gynecology and Obstetrics (FIGO) surgical staging system.<ce:cross-ref refid="bib16"><ce:sup>16</ce:sup></ce:cross-ref> Among patients operated on before 1988, stage was determined retrospectively from postsurgical pathologic assessments. Histologic classification was performed according to the World Health Organization classification.<ce:cross-ref refid="bib17"><ce:sup>17</ce:sup></ce:cross-ref> Architectural grading was based on the degree of glandular differentiation in accordance with the FIGO guidelines.<ce:cross-ref refid="bib16"><ce:sup>16</ce:sup></ce:cross-ref> Lymphatic or vascular invasion was considered to be present when tumor cells were noted within or attached to the wall of a blood vessel or lymphatic space.</ce:para><ce:para id="p0040">Characteristics of the tumors were abstracted from the original pathology reports. All the hematoxylin and eosin–stained slides of the primary tumor were reviewed retrospectively by one of us (Gary L. Kenney, MD) for confirmation of the original diagnosis of adenocarcinoma and determination of FIGO grade, histologic subtype, and presence of lymphatic or vascular invasion.</ce:para><ce:para id="p0045">The histologic subtype, FIGO grade, depth of myometrial invasion, presence of cervical and adnexal invasion, primary tumor diameter, presence of lymphatic or vascular invasion, and lymph node status were determined from frozen sections. Positive peritoneal cytologic results were reported during the operation only if requested; otherwise the result was available the next day. The technique for producing frozen sections at the Mayo Clinic has been described elsewhere.<ce:cross-ref refid="bib18"><ce:sup>18</ce:sup></ce:cross-ref></ce:para><ce:para id="p0050">When frozen sections were prepared, the uterus was bisected along the lateral uterine walls and the endometrial surface was inspected. All tumors were measured by the pathologist, who noted the three largest dimensions. Primary tumor diameter was as the largest of the three dimensions of the tumor. When there was more than one lesion, the lesion with the largest diameter was considered. Invariably the measurement of the greatest surface dimension was easily performed macroscopically. Infrequently, when the tumor was not obvious, an estimate was made from a combination of gross features and microscopic findings. The choice of 2 cm as a determinant for the analysis of primary tumor diameter was selected on the basis of the report by Schink et al.<ce:cross-ref refid="bib10"><ce:sup>10</ce:sup></ce:cross-ref></ce:para><ce:para id="p0055">All surgical procedures were performed by a gynecologic oncologist. Lymphadenectomy was usually performed if patients were considered by the surgeon to be at risk for lymph node metastasis. This decision may have been influenced by characteristics of the patient such as obesity, age, and general condition; by the intraoperative histologic evaluation of the tumor at frozen-section analysis; and by the desire to include patients in study protocols. For this study we considered lymphadenectomy to be the removal of at least one lymph node (pelvic or para-aortic).</ce:para><ce:para id="p0060">After the primary operation some patients who were considered at risk for recurrence received either external pelvic irradiation or vaginal brachytherapy, or both. Patients with positive peritoneal cytologic results as the only sign of extrauterine disease were sometimes treated with intraperitoneally administered phosphorus 32. On occasion oral megestrol acetate (Megace) was prescribed as postoperative hormonal therapy.</ce:para><ce:para id="p0065">Complications of radiotherapy were graded according to the EORTC-SOMA (European Organization for Research and Treatment of Cancer–Subjective, Objective, Management, and Analytic) scale and divided on the basis of the anatomic region involved.<ce:cross-ref refid="bib19"><ce:sup>19</ce:sup></ce:cross-ref> Surgical complications were considered to be those occurring within 1 month after the operation. The presence of either lymphedema or abdominal hernia was considered a surgical complication even when it occurred >1 month after the operation. The following were evaluated as a reflection of surgical morbidity: the preoperative American Society of Anesthesiologists' physical status score,<ce:cross-ref refid="bib20"><ce:sup>20</ce:sup></ce:cross-ref> operative time, estimated blood loss, febrile morbidity (defined as temperature >38°C in two different measurements ≥6 hours apart beyond the first 24 hours after the operation), intraoperative and postoperative transfusions, day of first flatus, day of first bowel movement, and day of release from the hospital.</ce:para><ce:para id="p0070">Follow-up of patients was performed on the basis of information reported in the clinical histories. When information about survival and recurrence was not sufficiently detailed in the histories, death certificates were obtained or letters to patients and family physicians or telephone calls were used to obtain follow-up information. We considered all data from patients who were alive (with or without disease) at the time of follow-up and those from patients who died of a cause not related to the disease as censored. We considered uncensored only the data from those patients who died of disease. Patients unavailable for follow-up were not included in the analysis of survival and recurrence.</ce:para><ce:para id="p0075">We considered a local failure to be any recurrence diagnosed by physical examination, radiologic imaging, or surgery localized to the pelvis, vagina, vaginal cuff, or pelvic sidewall. All other recurrences were considered distant. We considered lymph node recurrences to be all those localized in the pelvic, aortic, inguinal, or scalene node regions. Recurrence in the pelvic and para-aortic nodes was diagnosed when a mass was observed along the pelvic sidewall and when a lesion appeared in the area adjacent to the aorta, respectively. Concomitant metastases in pelvic and para-aortic nodes were considered as local plus distant recurrences.</ce:para><ce:para id="p0080">Statistical analysis was performed with the Fisher exact test, χ<ce:sup>2</ce:sup> analysis, and the Student <ce:italic>t</ce:italic> test. Survival curves were determined by the Kaplan-Meier product-limit method. Analysis of the differences between survival curves was performed with the log-rank test. The Cox model was used to assess the effect of prognostic factors on survival. Differences between groups were considered statistically significant at <ce:italic>P</ce:italic> ≤.05. SAS System 6.10 statistical software (SAS Institute, Inc, Cary, NC) was used for the analysis.</ce:para></ce:section><ce:section id="s0015"><ce:section-title id="st0025">Results</ce:section-title><ce:para id="p0085">Among the 328 patients who entered the study the mean age was 62.8 ± 10.6 years (range, 22-87 years). The mean body mass index was 30.8 ± 8.6 (range, 17.8-65.5).</ce:para><ce:para id="p0090">The surgical and pathologic demographic characteristics are shown in Table I.<ce:display><ce:table id="t5" colsep="0" rowsep="0" frame="topbot"><ce:label>Table I</ce:label><ce:caption><ce:simple-para id="sp0050">Surgical and pathologic characteristics of 328 patients with low-risk endometrial cancer (endometrioid histologic subtype, myometrial invasion ≤50%, and histologic grade 1-2)</ce:simple-para></ce:caption><tgroup cols="3"><colspec colname="col1" colsep="0"></colspec><colspec colname="col2" colsep="0"></colspec><colspec colname="col3" colsep="0"></colspec><thead><row><entry><ce:hsp sp="1.0"></ce:hsp>Characteristic</entry><entry align="center">No.</entry><entry align="center">%*</entry></row></thead><tbody><row><entry>Stage</entry><entry align="center"></entry><entry align="center"></entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>IA</entry><entry align="center">57</entry><entry align="center">17</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>IB</entry><entry align="center">239</entry><entry align="center">73</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>IIIA</entry><entry align="center">23</entry><entry align="center">7</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>IIIC</entry><entry align="center">9</entry><entry align="center">3</entry></row><row><entry>FIGO grade</entry><entry align="center"></entry><entry align="center"></entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>1</entry><entry align="center">223</entry><entry align="center">68</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>2</entry><entry align="center">105</entry><entry align="center">32</entry></row><row><entry>Lymph-vascular invasion</entry><entry align="center"></entry><entry align="center"></entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Yes</entry><entry align="center">18</entry><entry align="center">5</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>No</entry><entry align="center">309</entry><entry align="center">95</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Not available</entry><entry align="center">1</entry><entry align="center">—</entry></row><row><entry>Histologic subtype</entry><entry align="center"></entry><entry align="center"></entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Endometrioid</entry><entry align="center">312</entry><entry align="center">95</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Areas of squamous differentiation</entry><entry align="center">13</entry><entry align="center">4</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Adenosquamous</entry><entry align="center">3</entry><entry align="center">1</entry></row><row><entry>Myometrial invasion</entry><entry align="center"></entry><entry align="center"></entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>None</entry><entry align="center">60</entry><entry align="center">18</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>≤50%</entry><entry align="center">268</entry><entry align="center">82</entry></row><row><entry>Primary tumor diameter (cm)</entry><entry align="center"></entry><entry align="center"></entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>≤2</entry><entry align="center">123</entry><entry align="center">42</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>>2</entry><entry align="center">169</entry><entry align="center">58</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Not available</entry><entry align="center">36</entry><entry align="center">—</entry></row><row><entry>Peritoneal cytologic results</entry><entry align="center"></entry><entry align="center"></entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Positive</entry><entry align="center">23</entry><entry align="center">7</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Negative</entry><entry align="center">285</entry><entry align="center">93</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Not available</entry><entry align="center">18</entry><entry align="center">—</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Unsatisfactory</entry><entry align="center">2</entry><entry align="center">—</entry></row><row><entry>Pelvic lymph nodes</entry><entry align="center"></entry><entry align="center"></entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Positive</entry><entry align="center">9</entry><entry align="center">5</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Negative</entry><entry align="center">178</entry><entry align="center">95</entry></row><row><entry><ce:hsp sp="1.0"></ce:hsp>Not available</entry><entry align="center">141</entry><entry align="center">—</entry></row><row><entry namest="col1" nameend="col3">*Percentage calculations exclude missing cases.</entry></row></tbody></tgroup></ce:table></ce:display>The distribution of the low-risk study criteria such as grade, invasion, and subtype within the patient population is detailed. Within this low-risk group, metastases to pelvic nodes were documented in 9 of 187 patients assessed (5%) and positive peritoneal cytologic results were detected in 23 of 308 (7%). Because these variables might not be immediately ascertainable to determine candidates for simple hysterectomy only, these patients were included in the analyses to avoid any potential favorable bias. Hence 10% of the study population would be designated as having surgical stage III disease. Among the 188 patients who underwent lymphadenectomy, 158 underwent pelvic lymphadenectomy only, 29 underwent pelvic and para-aortic lymphadenectomy, and 1 underwent para-aortic lymphadenectomy only. The mean number of pelvic lymph nodes removed was 14.8 ± 9.3 (range, 1-48). None of the 30 patients who underwent para-aortic lymphadenectomy had positive para-aortic lymph nodes.</ce:para><ce:para id="p0095">Adjuvant radiotherapy was administered to 65 women (20%): 40 received external radiotherapy only, 14 received external radiotherapy plus vaginal brachytherapy, 9 received intraperitoneally administered <ce:sup>32</ce:sup>P, 1 received brachytherapy only, and 1 was reported to have received adjuvant radiotherapy but no additional information was available. Among the patients who received external radiotherapy the whole pelvis was always included; 6 also had the para-aortic area irradiated and 6 had an extended vaginal field. The mean dose of radiation administered to the pelvis was 48.95 ± 7.82 Gy (range, 23.7-59.4 Gy), whereas 26.27 ± 14.51 Gy (range, 12-45 Gy) was delivered to the para-aortic area and 19.61 ± 21.87 Gy (range, 6-54.9 Gy) was delivered to the vaginal cuff. The mean dose of radiation administered with vaginal brachytherapy was 19.2 ± 11.93 Gy (range, 15-60 Gy).</ce:para><ce:para id="p0100">No patients received cytotoxic chemotherapy, but 6 were treated with progestins. Three of these 6 received hormonal therapy only, 2 received hormonal therapy as a supplement to external radiotherapy, and 1 received hormonal therapy after intraperitoneal administration of <ce:sup>32</ce:sup>P.</ce:para><ce:para id="p0105">Definitive treatment was hysterectomy only for 126 patients (38%); the other 202 patients (62%) were treated with hysterectomy in association with lymphadenectomy, adjuvant radiotherapy, or both. Among those 202 patients 14 were treated with adjuvant radiotherapy but without lymphadenectomy, 137 were treated with lymphadenectomy but without radiotherapy, and 51 were treated with both. The distributions of the 123 patients with primary tumor diameter ≤2 cm and of the 169 patients with primary tumor diameter >2 cm according to the definitive method of treatment are shown in Table II.<ce:float-anchor refid="tab2"></ce:float-anchor></ce:para><ce:section id="s0020"><ce:section-title id="st0030">Treatment-related morbidity</ce:section-title><ce:para id="p0110">Information regarding preoperative American Society of Anesthesiologists status<ce:cross-ref refid="bib20"><ce:sup>20</ce:sup></ce:cross-ref> was available for 276 patients, and 80 of them (29%) had a score of 3 or 4. Patients who did not undergo lymphadenectomy had a mean age of 63.9 ± 10.5 years, compared with 62.0 ± 10.6 years among patients who underwent lymphadenectomy (<ce:italic>P</ce:italic> =.1). Mean body mass index was 32.1 ± 9.6 among patients who did not undergo lymphadenectomy and 29.9 ± 7.6 among patients who underwent lymphadenectomy (<ce:italic>P</ce:italic> =.02). Comparison of acute surgical morbidity between patients who did and did not undergo lymphadenectomy is presented in Table III.<ce:float-anchor refid="tab3"></ce:float-anchor>Long-term surgical complications were not significantly different in the two groups.</ce:para><ce:para id="p0115">Grade 3 or 4 complications<ce:cross-ref refid="bib19"><ce:sup>19</ce:sup></ce:cross-ref> were reported in 12 of 65 patients (18%) who received radiotherapy. Previous lymphadenectomy did not significantly influence the percentage of radiation-related complications.</ce:para></ce:section><ce:section id="s0025"><ce:section-title id="st0035">Association with positive pelvic lymph nodes</ce:section-title><ce:para id="p0120">Among the 187 patients who underwent biopsy of pelvic lymph nodes the mean age of patients with positive pelvic lymph nodes (59.7 years) did not differ from that of those with negative nodes (62.1 years; <ce:italic>P</ce:italic> =.51). Furthermore, the presence of positive pelvic lymph nodes did not correlate with either depth of invasion (none vs ≤50%) or histologic grade (1 vs 2). However, although no positive pelvic lymph nodes were detected in 59 patients with primary tumor diameter ≤2 cm, 8 of 107 patients with primary tumor diameter >2 cm (7%) had positive pelvic lymph nodes (<ce:italic>P</ce:italic> =.03). In addition only 5 of the 171 patients without lymphatic or vascular invasion (3%) had positive pelvic lymph nodes, compared with 4 of 16 with lymphatic or vascular invasion (25%; <ce:italic>P</ce:italic> <.0001).</ce:para><ce:para id="p0125">Among the 59 patients with primary tumor diameter ≤2 cm 3 (5%) had lymphatic or vascular invasion; however, none had positive pelvic lymph nodes. In the group of 107 patients with primary tumor diameter >2 cm 5 of 96 patients without lymphatic or vascular invasion (5%) had positive pelvic lymph nodes, compared with 3 of 11 patients with lymphatic or vascular invasion (27%; <ce:italic>P</ce:italic> =.008).</ce:para></ce:section><ce:section id="s0030"><ce:section-title id="st0040">Association with positive peritoneal cytologic results</ce:section-title><ce:para id="p0130">Peritoneal washings for cytologic assessment were available from 308 patients. Patients with positive peritoneal cytologic results were significantly (<ce:italic>P</ce:italic> =.01) younger (57.8 years) than patients with negative results (63.5 years). Mean body mass index, myometrial invasion, histologic grade, and primary tumor diameter did not correlate with positive peritoneal cytologic results. However, the presence of lymphatic or vascular invasion was associated with positive peritoneal cytologic results (<ce:italic>P</ce:italic> <.01).</ce:para></ce:section><ce:section id="s0035"><ce:section-title id="st0045">Analysis of survival and recurrence</ce:section-title><ce:para id="p0135">Median follow-up was 88 months (range, 4-155 months). All censored cases had a follow-up of ≥36 months. Two patients were unavailable for follow-up: one became unavailable for follow-up after 8 months from diagnosis, and the second died of an unknown cause at 97 months after the operation. Overall at the time of our analysis 288 patients (88%) were alive without evidence of disease; 1 (0.3%) was alive with disease; 25 (8%) had died of a cause not related to the disease and were disease free at the time of death; 11 (3%) had died of the disease; and 1 (0.3%) had died of a cause not related to the disease but did have disease at the time of death. Overall 18 relapses (6%) were observed. Median time to recurrence was 26 months (range, 2-103 months). Six patients had isolated local recurrences, 7 had distant recurrences, and 5 had recurrences at both local and distant sites. Of the 18 relapses 6 were in the lymph node–bearing areas. Three relapses in irradiated patients were in the treated field.</ce:para><ce:para id="p0140">The 5-year cancer-related survival was 97%, and the 5-year recurrence-free survival was 96%. Age at diagnosis did not affect either of these variables. Likewise tumor grade (FIGO grade 1 vs grade 2) did not significantly influence 5-year cancer-related survival, recurrence-free survival, or sites of recurrence. Although the mean body mass index of 33.4 ± 11.3 among patients who had a recurrence did not differ statistically from the 30.7 ± 8.4 among the recurrence-free patients (<ce:italic>P</ce:italic> =.19), those who died of disease had a mean body mass index of 35.9 ± 13.1 compared with 30.7 ± 8.3 among patients with censored data (<ce:italic>P</ce:italic> =.05).</ce:para><ce:para id="p0145">Lymphatic or vascular invasion significantly influenced 5-year cancer-related survival, recurrence-free survival, and presence of recurrences with a distant component. In fact, patients without lymphatic or vascular invasion had a 5-year cancer-related survival of 98% and a recurrence-free survival of 97%, which contrasted with 77% (<ce:italic>P</ce:italic> <.0001) and 70% (<ce:italic>P</ce:italic> <.0001), respectively, among patients with lymphatic or vascular invasion. Although no statistically significant difference in local recurrences was demonstrated, 4 patients without lymphatic or vascular invasion (1%) had distant recurrence, compared with 3 patients with lymphatic or vascular invasion (17%; <ce:italic>P</ce:italic> <.0001), and 3 patients without lymphatic or vascular invasion (1%) had local plus distant recurrence compared with 2 patients with lymphatic or vascular invasion (11%; <ce:italic>P</ce:italic> <.001).</ce:para><ce:para id="p0150">All patients with positive pelvic lymph nodes (n = 9) received adjuvant external beam radiotherapy; 3 of them (33%) had recurrences and died of disease. Among the 23 patients with positive peritoneal cytologic results none had positive pelvic lymph nodes. However, 13 were treated with external radiotherapy, 8 were treated with intraperitoneal instillation of <ce:sup>32</ce:sup>P, and 2 were treated with no adjuvant therapy. We observed 2 recurrences (9%); both failures were distant, and both patients died of disease. One of these 2 patients was treated with external radiotherapy and the other was treated with intraperitoneally administered <ce:sup>32</ce:sup>P.</ce:para><ce:para id="p0155">Among the 261 patients who did not receive adjuvant radiotherapy but who had complete follow-up, 10 recurrences (4%) were observed; 6 were isolated local recurrences (2%), 3 were distant (1%), and 1 was local plus distant (0.4%). Five of the 6 patients with local recurrences and the patient with local plus distant recurrence were considered successfully cured after treatment of the recurrence, whereas 2 of the 3 patients with distant recurrences died of disease.</ce:para><ce:para id="p0160">Among the 140 patients who did not undergo lymphadenectomy four recurrences (3%) were documented. One was an isolated local recurrence (0.7%), 2 were distant (1%), and 1 was local plus distant (0.7%). The patient with the local recurrence was considered to have been cured after treatment of the recurrence, whereas the 2 patients with distant recurrences and the patient with local plus distant recurrences died of disease. No lymph nodal recurrences were observed.</ce:para></ce:section><ce:section id="s0040"><ce:section-title id="st0050">Prognostic role of primary tumor diameter</ce:section-title><ce:para id="p0165">Primary tumor diameter measurements were available for 291 patients for whom follow-up information was adequate. Disease-related survival (100% vs 95%) and recurrence-free survival (98% vs 94%) were significantly different between patients with primary tumor diameter ≤2 cm and patients with primary tumor diameter >2 cm (<ce:italic>P</ce:italic> =.003 and <ce:italic>P</ce:italic> =.03 for disease-related survival and recurrence-free survival, respectively; Fig 1).<ce:display><ce:figure id="f0010"><ce:label>Fig. 1</ce:label><ce:caption><ce:simple-para id="sp0055">Recurrence-free survival among patients with endometrial cancer according to primary tumor diameter (<ce:italic>PTD; P</ce:italic> =.03).</ce:simple-para></ce:caption> <ce:link locator="gr1"></ce:link></ce:figure></ce:display></ce:para><ce:para id="p0170">Among patients with primary tumor diameter ≤2 cm there were no significant differences between the treatment subgroups of hysterectomy only and hysterectomy plus either lymphadenectomy or radiotherapy, or both, as a function of mean age (<ce:italic>P</ce:italic> =.17), grade of tumor(<ce:italic>P</ce:italic> =.85), or myometrial invasion (<ce:italic>P</ce:italic> =.2). All patients with positive peritoneal cytologic results (n = 7) were in the group with hysterectomy plus either lymphadenectomy or radiotherapy, or both (<ce:cross-ref refid="tab2">Table II</ce:cross-ref>), and patients treated with hysterectomy only had a significantly higher body mass index (<ce:italic>P</ce:italic> =.02). Overall survival (100% vs 100%) and recurrence-free survival (100% vs 96%) were not significantly different between patients treated with hysterectomy only and those treated with hysterectomy plus either lymphadenectomy or radiotherapy, or both (<ce:italic>P</ce:italic> = 1 and <ce:italic>P</ce:italic> =.4, respectively).</ce:para><ce:para id="p0175">Similar analyses in the group of patients with primary tumor diameter >2 cm failed to detect significant differences between the patients treated with hysterectomy only and those treated with hysterectomy plus either lymphadenectomy or radiotherapy, or both, with respect to mean age (<ce:italic>P</ce:italic> =.47), mean body mass index (<ce:italic>P</ce:italic> =.14), percentage of patients with grade 2 disease (<ce:italic>P</ce:italic> =.12), or percentage of patients without myometrial invasion (<ce:italic>P</ce:italic> =.84). This is noteworthy, because all patients with positive peritoneal cytologic results or positive pelvic lymph nodes were in the group treated with hysterectomy plus either lymphadenectomy or radiotherapy, or both (<ce:cross-ref refid="tab2">Table II</ce:cross-ref>). The differences in the overall survival (100% vs 93%) and recurrence-free survival (100% vs 91%) between patients treated with hysterectomy only and those treated with hysterectomy plus either lymphadenectomy or radiotherapy, or both, were of marginal statistical significance (<ce:italic>P</ce:italic> =.1 and <ce:italic>P</ce:italic> =.05, respectively).</ce:para><ce:para id="p0180">All patients with primary tumor diameter ≤2 cm and positive peritoneal cytologic results (n = 7) received adjuvant radiotherapy (2 received external pelvic radiation and 5 received intraperitoneally administered <ce:sup>32</ce:sup>P). None had a recurrence (<ce:cross-ref refid="tab2">Table II</ce:cross-ref>).</ce:para><ce:para id="p0185">At multivariate analysis we entered into the model primary tumor diameter, myometrial invasion, grade, lymphatic or vascular invasion, treatment with radiotherapy, and lymphadenectomy. The only independent variable predictive of recurrence was lymphatic or vascular invasion (<ce:italic>P</ce:italic> =.0001; relative risk, 14.00).</ce:para><ce:para id="p0190">Among the 122 patients with primary tumor diameter ≤2 cm, including 3 with lymphatic or vascular invasion (none of these had positive peritoneal cytologic results or positive pelvic lymph nodes), 3 recurrences (2%) were observed, including 1 with lymphatic or vascular invasion (33%). All these recurrences were isolated local failures, and none of these patients died of disease. In contrast, among the 169 patients with primary tumor diameter >2 cm, including 12 with lymphatic or vascular invasion (7%; 4 positive peritoneal cytologic results and 3 positive pelvic lymph nodes), 14 recurrences (8%) were observed. Three failures were local (1 patient died of disease), 6 were distant (all 6 patients died of disease), and 5 were local plus distant (4 patients died of disease). Furthermore, 10 of 157 patients without lymphatic or vascular invasion (6%) had recurrence, and 7 (4%) died of disease, whereas 4 of 12 (33%) with lymphatic or vascular invasion had recurrence (<ce:italic>P</ce:italic> =.001), and all died of disease (<ce:italic>P</ce:italic> <.0001). All 4 recurrences observed among patients with primary tumor diameter >2 cm and lymphatic or vascular invasion had a distant component of failure in the lymph nodes.</ce:para></ce:section></ce:section><ce:section id="s0045"><ce:section-title id="st0055">Comment</ce:section-title><ce:para id="p0195">In accord with other authors,<ce:cross-refs refid="bib4 bib5 bib6"><ce:sup>4-6</ce:sup></ce:cross-refs> we described as at low risk for lymph node metastasis and recurrence those patients with endometrioid histologic subtype, myometrial invasion ≤50%, and histologic grade 1 or 2 disease. In fact myometrial invasion and tumor grade are well-recognized prognostic factors in endometrial cancer and are predictors of extrauterine spread.<ce:cross-refs refid="bib9 bib12"><ce:sup>9,12</ce:sup></ce:cross-refs> Moreover, patients with endometrioid tumors have a better prognosis than do those with the other subtypes.</ce:para><ce:para id="p0200">It is generally accepted that total hysterectomy with bilateral salpingo-oophorectomy constitutes minimal primary treatment for endometrial cancer. The need to perform pelvic lymphadenectomy and the use of adjuvant therapy among patients at low risk for lymph node involvement and posttreatment recurrence are still debated.<ce:cross-refs refid="bib6 bib21 bib22"><ce:sup>6,21,22</ce:sup></ce:cross-refs> In particular, we continue to encounter difficulties in selecting the limited subset of patients with superficial myometrial invasion and histologic grade 1 or 2 disease who would potentially benefit from more aggressive treatment while simultaneously avoiding the unnecessary morbidity that such treatment entails in the cohort at large. However, invasion of vascular spaces by tumor cells indicates an aggressive tumor that is likely to demonstrate extrauterine spread, positive lymph nodes, and a propensity to recur, especially at distant sites.<ce:cross-ref refid="bib23"><ce:sup>23</ce:sup></ce:cross-ref> Moreover, primary tumor diameter has been demonstrated as an independent predictor of lymph node metastasis among patients with disease clinically confined to the uterus<ce:cross-ref refid="bib10"><ce:sup>10</ce:sup></ce:cross-ref> and among patients with all stages of disease.<ce:cross-ref refid="bib15"><ce:sup>15</ce:sup></ce:cross-ref> For these reasons we investigated the prognostic roles of lymphatic or vascular invasion and primary tumor diameter among patients with low-risk endometrial cancer.</ce:para><ce:para id="p0205">We initially analyzed the significance of including a pelvic lymphadenectomy in the treatment of low-risk patients. Recognizing that potential factors that could guide the physician's decision to perform a lymphadenectomy must be readily available before or during the operation, we also included in our analysis those cases with potentially occult disease. Therefore low-risk patients with positive peritoneal cytologic results or occult positive pelvic lymph nodes as the only sign of extrauterine disease were included. We reasoned that the results of peritoneal cytologic analysis are frequently unknown during the operation and that the status of the lymph nodes becomes known only after the performance of a lymphadenectomy.</ce:para><ce:para id="p0210">Intraoperative assessment of myometrial invasion with the gross visual examination of the cut tumor surface of the uterus allows reasonably accurate determination of the depth of muscular invasion (expressed as >50% or <50%) in 90% to 91% of cases.<ce:cross-ref refid="bib24"><ce:sup>24</ce:sup></ce:cross-ref> Histologic grade is correctly predicted by frozen-section analysis in 92% of cases, and accuracy in detecting poorly differentiated lesions has been reported as 95%.<ce:cross-ref refid="bib25"><ce:sup>25</ce:sup></ce:cross-ref> Because of the discrepancies between frozen-section and postoperative histologic results, extensive lymphadenectomy has been advocated for all patients.<ce:cross-ref refid="bib11"><ce:sup>11</ce:sup></ce:cross-ref> In our study, however, all of the variables except peritoneal cytologic results were available during the operation, and the overall frozen-section analysis accuracy at the Mayo Clinic has been reported as 97.8%.<ce:cross-ref refid="bib18"><ce:sup>18</ce:sup></ce:cross-ref> In our low-risk population the analysis of histologic grade was not able to discriminate those few patients with positive lymph nodes. On the contrary, no lymph node metastases were reported among patients with primary tumor diameter ≤2 cm. This finding is in accord with the limited data in the literature addressing primary tumor diameter (Table IV).<ce:cross-refs refid="bib10 bib15"><ce:sup>10,15</ce:sup></ce:cross-refs><ce:display><ce:table id="t0010" colsep="0" rowsep="0" frame="topbot"><ce:label>Table IV</ce:label><ce:caption><ce:simple-para id="sp0060">Association of pelvic lymph node metastasis with primary tumor diameter and grade among patients with low-risk endometrial cancer (endometrioid histologic subtype, myometrial invasion ≤ 50%, and histologic grade 1-2)</ce:simple-para></ce:caption><tgroup cols="10"><colspec colname="col1" colsep="0"></colspec><colspec colname="col2" colsep="0"></colspec><colspec colname="col3" colsep="0"></colspec><colspec colname="col4" colsep="0"></colspec><colspec colname="col5" colsep="0"></colspec><colspec colname="col6" colsep="0"></colspec><colspec colname="col7" colsep="0"></colspec><colspec colname="col8" colsep="0"></colspec><colspec colname="col9" colsep="0"></colspec><colspec colname="col10" colsep="0"></colspec><thead><row><entry morerows="2"><ce:hsp sp="1.0"></ce:hsp>Study</entry><entry morerows="2" align="center">Cases (No.)</entry><entry namest="col3" nameend="col10" align="center">Positive pelvic lymph nodes</entry></row><row><entry namest="col3" nameend="col4" align="center">Primary tumor diameter ≤2 cm</entry><entry namest="col5" nameend="col6" align="center">Primary tumor diameter >2 cm</entry><entry namest="col7" nameend="col8" align="center">Histologic grade 1</entry><entry namest="col9" nameend="col10" align="center">Histologic grade 2</entry></row><row><entry colname="col3" align="center">No.</entry><entry align="center">%</entry><entry align="center">No.</entry><entry align="center">%</entry><entry align="center">No.</entry><entry align="center">%</entry><entry align="center">No.</entry><entry align="center">%</entry></row></thead><tbody><row><entry>Schink et al<ce:cross-ref refid="bib10"><ce:sup>10</ce:sup></ce:cross-ref></entry><entry align="center">87</entry><entry align="center">0/39</entry><entry align="center">0</entry><entry align="center">4/48</entry><entry align="center">8</entry><entry align="center">1/57</entry><entry align="center">2</entry><entry align="center">3/30</entry><entry align="center">10</entry></row><row><entry>Current study</entry><entry align="center">187</entry><entry align="center">0/59</entry><entry align="center">0*</entry><entry align="center">8/107</entry><entry align="center">7*</entry><entry align="center">5/126</entry><entry align="center">4</entry><entry align="center">4/61</entry><entry align="center">7</entry></row><row><entry>Creasman et al<ce:cross-ref refid="bib9"><ce:sup>9</ce:sup></ce:cross-ref></entry><entry align="center">393</entry><entry align="center">NA</entry><entry align="center">NA</entry><entry align="center">NA</entry><entry align="center">NA</entry><entry align="center">3/162</entry><entry align="center">2</entry><entry align="center">14/231</entry><entry align="center">6</entry></row><row><entry><ce:small-caps>TOTAL</ce:small-caps></entry><entry align="center">667</entry><entry align="center">0/98</entry><entry align="center">0</entry><entry align="center">12/155</entry><entry align="center">8</entry><entry align="center">9/345</entry><entry align="center">3</entry><entry align="center">21/322</entry><entry align="center">7</entry></row><row><entry namest="col1" nameend="col10">*Calculated for the 166 patients for whom the information about primary tumor diameter was available.</entry></row></tbody></tgroup><ce:legend><ce:simple-para id="sp0065"><ce:italic>NA,</ce:italic> Not available.</ce:simple-para></ce:legend></ce:table></ce:display>We must also emphasize that it is usually more difficult to distinguish grade 1 disease from grade 2 disease in frozen sections than it is to measure tumor diameter macroscopically.</ce:para><ce:para id="p0215">According to our data the intraoperative analysis of tumor diameter would permit foregoing the lymphadenectomy in about a fifth of the patients with endometrial cancer who are treated at our referral center. In fact, in our analysis among the whole population of 612 patients operated on for endometrial cancer, about 20% of those with known primary tumor diameter had low-risk features and primary tumor diameter ≤2 cm. We suggest performance of lymphadenectomy in all cases with primary tumor diameter >2 cm. This would minimize the clinical consequences of the unavoidable errors associated with frozen-section analysis.<ce:cross-ref refid="bib24"><ce:sup>24</ce:sup></ce:cross-ref> In fact, primary tumor diameter is usually measured on fresh tissue,<ce:cross-ref refid="bib15"><ce:sup>15</ce:sup></ce:cross-ref> and thus we can assume that the intraoperative evaluation of primary tumor diameter has an accuracy approaching 100%.</ce:para><ce:para id="p0220">In our study lymphatic or vascular invasion was a strong predictor of positive lymph nodes among patients with large primary tumors. In fact, in the small subgroup of patients with primary tumor diameter >2 cm and lymphatic or vascular invasion, positive pelvic lymph nodes were detected in 27% of cases. None of the 3 patients with primary tumor diameter ≤2 cm and lymphatic or vascular invasion had positive lymph nodes. Therefore the intraoperative evaluation of depth of myometrial invasion, primary tumor diameter, histologic subtype, and grade would probably be sufficient to discriminate those patients who could safely forego lymph node dissection when tumor is apparently confined to the uterus. Because of the relative rarity of lymphatic or vascular invasion among low-risk tumors with diameters ≤2 cm, the questionable significance of lymph node analysis when the other indicators are considered, and the difficulty in accurately obtaining this information from frozen sections in most community hospitals, we do not suggest the widespread use of assessing lymphatic or vascular invasion in formulating the decision to perform a pelvic lymphadenectomy.</ce:para><ce:para id="p0225">With respect to morbidity associated with lymph node dissection, patients who underwent lymphadenectomy had a significantly lower body mass index and fewer preoperative American Society of Anesthesiologists scores of 3 to 4.<ce:cross-ref refid="bib20"><ce:sup>20</ce:sup></ce:cross-ref> Higher mean operative time, mean estimated blood loss, and need for perioperative transfusion and prolonged postoperative ileus were reported among patients who underwent lymphadenectomy (<ce:cross-ref refid="tab3">Table III</ce:cross-ref>). Long-term surgical complications were not significantly different between the two groups. These findings agree with most reports in the literature.<ce:cross-refs refid="bib4 bib11 bib21"><ce:sup>4,11,21</ce:sup></ce:cross-refs></ce:para><ce:para id="p0230">In our population morbidity related to radiotherapy was significant (18%). Because of the added costs and morbidity associated with adjuvant radiotherapy,<ce:cross-ref refid="bib11"><ce:sup>11</ce:sup></ce:cross-ref> it is important to avoid unnecessary treatment by tailoring adjuvant therapy on the basis of risk factors. Because of the low number of patients who received vaginal brachytherapy in our population, we were not able to draw conclusions regarding either efficacy or morbidity. Complications of vaginal brachytherapy alone are usually reported as low,<ce:cross-refs refid="bib11 bib23 bib26"><ce:sup>11,23,26</ce:sup></ce:cross-refs> but a higher rate has been described.<ce:cross-ref refid="bib27"><ce:sup>27</ce:sup></ce:cross-ref> Again, it would be prudent to define the need for adding this modality to the treatment of patients with endometrial cancer at low risk for recurrence and death.</ce:para><ce:para id="p0235">The overall survival and recurrence-free survival among our low-risk patients were comparable with those reported in the literature (Table V).<ce:cross-refs refid="bib4 bib11 bib22 bib26"><ce:sup>4,11,22,26</ce:sup></ce:cross-refs><ce:float-anchor refid="tab5"></ce:float-anchor>Age and histologic grade did not significantly influence prognosis. The measurement of primary tumor diameter was a strong predictor of survival in our study. We therefore considered separately patients with primary tumor diameter ≤2 cm and those with primary tumor diameter >2 cm. It is interesting that all patients with primary tumor diameter ≤2 cm who had recurrences had local failure and were successfully cured at the time of recurrence. With the possible exception of the 7 patients with positive peritoneal cytologic results, who were treated with adjuvant radiotherapy, low-risk patients with primary tumor diameter ≤2 cm can be safely treated with radiation only in the event of failure. Our results agree with the findings of other authors,<ce:cross-refs refid="bib5 bib6 bib7 bib8 bib29"><ce:sup>5-8,29</ce:sup></ce:cross-refs> who have suggested that most local recurrences among low-risk patients without previous radiotherapy are potentially curable (<ce:cross-ref refid="tab5">Table V</ce:cross-ref>).</ce:para><ce:para id="p0240">It has been stated that all patients with superficial myometrial invasion and grade 1 or 2 disease are candidates for vaginal brachytherapy,<ce:cross-refs refid="bib11 bib26"><ce:sup>11,26</ce:sup></ce:cross-refs> which can successfully prevent vaginal recurrences.<ce:cross-refs refid="bib2 bib23 bib26 bib27"><ce:sup>2,23,26,27</ce:sup></ce:cross-refs> We emphasize that vaginal treatment failures among low-risk patients treated with hysterectomy only were uncommon (2%), and most of these (85%) could be treated successfully at recurrence. The addition of local adjuvant therapy appears to diminish the percentage of vaginal recurrences (0.4%) but without significantly increasing survival (<ce:cross-ref refid="tab5">Tables V</ce:cross-ref> and VI).<ce:float-anchor refid="tab6"></ce:float-anchor>For these reasons the routine use of adjuvant vaginal brachytherapy among all patients with low-risk endometrial cancer is questionable, especially in view of its costs.<ce:cross-refs refid="bib8 bib11"><ce:sup>8,11</ce:sup></ce:cross-refs></ce:para><ce:para id="p0245">Recurrences on the pelvic sidewall are potentially preventable by pelvic lymphadenectomy or external pelvic radiotherapy.<ce:cross-refs refid="bib28 bib29 bib31"><ce:sup>28,29,31</ce:sup></ce:cross-refs> However, isolated recurrences on the pelvic sidewall were rare among low-risk patients who did not undergo lymphadenectomy (<1%) but were more difficult to treat at the time of failure (only 31% were treated successfully) than were vaginal recurrences (<ce:cross-refs refid="tab5 tab6">Tables V and VI</ce:cross-refs>).</ce:para><ce:para id="p0250">In the group of low-risk patients with primary tumor diameter >2 cm, 8% of patients had a recurrence and 6.5% died of disease. Lymphatic or vascular invasion significantly influenced death and recurrence rates and was the only independent variable predictive of recurrence; moreover, patients with lymphatic or vascular invasion were at greater risk for a distant recurrence. Thus the presence of lymphatic or vascular invasion would be able to identify, usually after but ideally during the operation, a small subgroup of patients who could potentially benefit from a more aggressive treatment regimen. Potentially the analysis of molecular and cytokinetic determinants may assist in triage of these unfavorable tumors for more innovative therapies.<ce:cross-refs refid="bib28 bib32"><ce:sup>28,32</ce:sup></ce:cross-refs></ce:para><ce:para id="p0255">In conclusion, this study strongly suggests that patients with FIGO grade 1 or 2 endometrioid corpus cancers, with greatest surface dimension ≤2 cm, with myometrial invasion ≤50%, and without intraoperative evidence of macroscopic disease can be treated optimally with hysterectomy only, thereby avoiding the costs and morbidity associated with lymphadenectomy and with radiotherapy. A possible exception is patients with positive peritoneal cytologic results. On the basis of nodal involvement and recurrences, definitive surgical staging and selected adjuvant treatment will continue to be necessary for patients who have a primary tumor diameter >2 cm but otherwise are at low risk until new discriminating diagnostic strategies become available.</ce:para></ce:section></ce:sections><ce:acknowledgment><ce:section-title id="st0060">Acknowledgements</ce:section-title><ce:para id="p0260">Dr Mariani thanks Elio Tucci, MD, for his support and encouragement of her studies on endometrial cancer.</ce:para></ce:acknowledgment><ce:appendices><ce:section id="s0050"><ce:section-title id="st0065">Discussion</ce:section-title><ce:para id="p0265"><ce:bold>D<ce:small-caps>R</ce:small-caps> J<ce:small-caps>OHN</ce:small-caps> R. L<ce:small-caps>URAIN,</ce:small-caps></ce:bold> Chicago, Illinois. Mariani and colleagues from the Mayo Clinic have analyzed a selected group of low-risk endometrial cancers with the purpose of defining a subset that would not require extended surgical staging (lymph node sampling) or postoperative adjuvant radiotherapy. They described low-risk corpus cancer as tumor confined to the uterine corpus (except for occult positive lymph nodes and peritoneal cytologic results), grade 1 or 2 endometrioid histologic subtype, and myometrial invasion ≤50% on the basis of intraoperative frozen-section analysis and retrospective surgical pathologic review. This definition of low-risk endometrial cancer eliminates many cases thought to be low-risk before surgery and ignores the importance of surgical staging when we consider the poor correlation between preoperative evaluation or clinical staging and surgical pathologic findings. Cowles et al<ce:cross-ref refid="bib33"><ce:sup>1</ce:sup></ce:cross-ref> in 1985 compared preoperative findings with surgical pathologic findings and noted that classification of tumor histologic subtype was changed in 27% of patients, estimate of tumor grade was changed in 34% of patients, and assignment of stage was changed in 51% of patients. In the Gynecologic Oncology Group series 22% of patients with clinically estimated stage I endometrial cancer had evidence of extrauterine spread discovered at staging laparotomy, including lymph node metastasis, adnexal spread, peritoneal implants, and positive peritoneal cytologic results.<ce:cross-ref refid="bib34"><ce:sup>2</ce:sup></ce:cross-ref> At Northwestern we reported that surgical staging of clinical stage I disease upwardly revised the stage in 23.5% of cases.<ce:cross-ref refid="bib35"><ce:sup>3</ce:sup></ce:cross-ref> By thus narrowly defining low-risk endometrial cancer, Mariani and associates have eliminated all cancers that were preoperatively presumed to be low risk but were subsequently found to represent more advanced disease—those with higher grade, deeper myometrial invasion, cervical involvement, and extrauterine spread other than occult lymph node metastasis or positive peritoneal cytologic results.</ce:para><ce:para id="p0270">Within the context of this definition of low-risk endometrial cancer they purported to show the following:<ce:list id="l0010"><ce:list-item id="o0010"><ce:para id="p0275">Tumor diameter >2 cm discriminated all patients with lymph node metastases.</ce:para></ce:list-item><ce:list-item id="o0015"><ce:para id="p0280">Tumor diameter >2 cm and lymphatic or vascular space invasion are associated with decreased survival.</ce:para></ce:list-item><ce:list-item id="o0020"><ce:para id="p0285">Patients with grade 1 or 2 endometrioid cancers ≤2 cm in size do not need adjuvant postoperative radiotherapy.</ce:para></ce:list-item></ce:list></ce:para><ce:para id="p0290">The authors found that lymph node metastases were detected in none of the 59 patients with tumors ≤2 cm, compared with 8 (7%) of the 107 patients with tumors >2 cm (<ce:italic>P</ce:italic> =.03), and that the disease-related survival was significantly different among patients with tumors ≤2 cm compared with patients with tumors >2 cm (100% vs 95%; <ce:italic>P</ce:italic> =.003). More than a decade ago we initially investigated the prognostic importance of tumor size in endometrial cancer at Northwestern.<ce:cross-refs refid="bib36 bib37"><ce:sup>4,5</ce:sup></ce:cross-refs> Tumor sizes were determined among 142 patients with clinical stage I endometrial cancer who underwent primary surgical therapy and staging. We found that tumor size was independently associated with risk of lymph node metastasis (multivariate <ce:italic>P</ce:italic> =.01). Only 4% of tumors ≤2 cm were associated with lymph node metastases; this proportion increased to 15% for tumors >2 cm and increased further to 35% when the entire uterine cavity was involved.</ce:para><ce:para id="p0295">In our study the only 2 patients with tumors ≤2 cm in size with lymph node metastases had clear cell and papillary serous histologic types. Tumor size was also a significant prognostic factor for survival (multivariate <ce:italic>P</ce:italic> =.005). Five-year survival was 98% among patients with tumors ≤2 cm, 84% among patients with tumors >2 cm, and 64% among patients with tumors involving the entire endometrial cavity. Tumor size was particularly useful in defining an intermediate-risk group of patients with grade 2 tumors and <50% myometrial invasion. In this subgroup there were no lymph node metastases associated with tumors ≤2 cm compared to 18% with tumors >2 cm. We concluded that intraoperative tumor measurements were easy to obtain, were both less time-consuming and more accurate than assessment of myometrial invasion by frozen-section analysis or gross determination, and could be useful in planning extended surgical staging and directing postoperative adjuvant radiation therapy.</ce:para><ce:para id="p0300">The authors also argued that most patients with low-risk endometrial cancers according to their definition do not need any postoperative adjuvant radiotherapy, although 20% of their patients did receive some type of postoperative irradiation. Recurrences developed in 18 patients (5%)—12 died with cancer, 2 died of another cause, 1 was alive with cancer, and only 3 who had isolated vaginal recurrences were alive without disease. Three (5.1%) of the 59 patients with tumors ≤2 cm had local recurrence; all were apparently cured with subsequent pelvic and vaginal radiation. In the group of 107 patients with tumors >2 cm, 8% had recurrent cancer and 6.5% died of disease. The authors should not and cannot make recommendations regarding the use of adjuvant postoperative radiotherapy for patients with low-risk endometrial cancers in general solely on the basis of an analysis of a selected subset of patients with low-risk endometrial cancers who were not treated in a consistent manner after the primary operation.</ce:para><ce:para id="p0305">There is general agreement that patients with grade 1 and 2 lesions without myometrial invasion (stage IA, grade 1-2) have an excellent prognosis and require no postoperative therapy. On the other hand, numerous studies have shown that the incidence of vaginal recurrence among patients with tumors apparently confined to the uterus can be reduced from as high as 15% to between 1% and 2% by the administration of postoperative vaginal irradiation. This is important, because vaginal vault recurrence carries a poor prognosis, with an estimated salvage probability of 20% to 70%. Patients most likely to benefit from vaginal irradiation are those who have surgical stage I, grade 1 and 2 tumors with superficial (<50%) myometrial invasion (stage IB, grade 1-2) or grade 3 tumors with no invasion (stage IA, grade 3) and some patients with stage IIA disease who otherwise meet the aforementioned criteria. Likewise, external pelvic irradiation decreases the risk of recurrence of pelvic disease after hysterectomy in certain high-risk groups. Patients found to benefit most from adjuvant postoperative whole-pelvis irradiation are those with cervical involvement, those with pelvic lymph node metastases, those with pelvic disease outside the uterus (adnexa, parametrium), and those with clinical stage I disease who are at significant risk for nodal metastasis (grade 3 tumors with any degree of myometrial invasion, grade 1 and 2 tumors with >50% myometrial invasion, large [>2 cm] grade 2 tumors with superficial myometrial invasion, and any grade tumor with lymphatic or vascular space invasion).</ce:para><ce:para id="p0310">Corn et al<ce:cross-ref refid="bib38"><ce:sup>6</ce:sup></ce:cross-ref> noted that patients with endometrial cancer who had local treatment failure had nearly a 4-fold greater risk of distant failure than did those whose disease remained locally controlled (<ce:italic>P</ce:italic> =.02). Local control was also significantly correlated with 5-year survival (<ce:italic>P</ce:italic> =.0002). Corn et al<ce:cross-ref refid="bib38"><ce:sup>6</ce:sup></ce:cross-ref> postulated that distant dissemination of endometrial cancer may develop as a result of local failure and that optimization of local control is therefore necessary if long-term cure is to be achieved.</ce:para><ce:para id="p0315">The Gynecologic Oncology Group recently completed a phase III randomized study of surgery versus surgery plus adjuvant pelvic irradiation among patients with intermediate-risk endometrial cancer (stage IB and IIB occult).<ce:cross-ref refid="bib39"><ce:sup>7</ce:sup></ce:cross-ref> Among patients accrued to the study >80% actually had low-risk disease (90.6% stage I, 81.6% grade 1-2, 82% ≤50% myometrial invasion). The pelvic failure rates were 13% (22/171) in the surgery-alone group and 0.6% (1/179) in the postoperative pelvic irradiation group. Disease-free survival was also significantly better among the patients who received postoperative pelvic irradiation than among those treated only with surgery (93.7% vs 84.7%, <ce:italic>P</ce:italic> =.047).<ce:cross-ref refid="bib39"><ce:sup>7</ce:sup></ce:cross-ref></ce:para><ce:para id="p0320">Both the authors and others, myself included, have spent a great deal of effort in trying to determine which patients with clinical stage I endometrial cancer should undergo extended surgical staging (retroperitoneal lymph node sampling) at the time of hysterectomy and bilateral salpingo-oophorectomy. Although the overall incidence of lymph node metastases in clinical stage I endometrial cancer is approximately 10%, patients with small (≤2 cm) grade 1 and 2 endometrial cancers with only superficial myometrial invasion seem to be at very low risk for lymph node metastasis; however, these patients can only be accurately identified during the operation or on retrospective surgical pathologic review. Extended surgical staging including selective pelvic and para-aortic lymphadenectomy among patients with endometrial cancer does not significantly add to the morbidity from hysterectomy, which is primarily related to such other factors as patient weight, patient age, operating time, and surgeon. In addition, Kilgore et al<ce:cross-ref refid="bib40"><ce:sup>8</ce:sup></ce:cross-ref> noted that patients undergoing lymph node sampling had a significant survival advantage overall and in both low-risk and high-risk groups, which suggests a therapeutic benefit to lymph node sampling. All patients with endometrial cancer who are taken to the operating room for primary therapy should therefore be prepared to undergo extended surgical staging, including selective pelvic and para-aortic lymph node dissection, in addition to hysterectomy and salpingo-oophorectomy on the basis of the <ce:italic>intraoperative</ce:italic> assessment of risk of lymph node metastasis or other extrauterine spread.</ce:para><ce:para id="p0325">Endometrial carcinoma is the most common malignancy of the female genital tract, accounting for almost half of all gynecologic cancers in the United States. As Mariani noted, in 1999 it was estimated that 37,400 new cases would be diagnosed and 6400 deaths would result. This is more than double the number of deaths attributed to endometrial cancer a decade ago. Approximately 75% of patients with endometrial cancer do not receive primary definitive treatment by a gynecologic oncologist. This is because of several factors: (1) limitations of choice (insurance, geography), (2) reluctance to refer patients, (ego, economics), and (3) naïveté of the patient and physician regarding the gravity of the disease and the prognostic significance of definitive primary treatment. Therefore most patients with endometrial cancer are currently not afforded the opportunity for an intraoperative decision regarding the appropriateness of extended surgical staging at the time of primary surgical therapy.</ce:para><ce:para id="p0330">I have several questions for Dr Mariani:<ce:list id="l0015"><ce:list-item id="o0025"><ce:para id="p0335">Why was the average length of hospital stay so long (approximately 7 days)?</ce:para></ce:list-item><ce:list-item id="o0030"><ce:para id="p0340">In light of your data on tumor size, do you still perform and recommend intraoperative frozen-section analysis for determination of grade and depth of myometrial invasion?</ce:para></ce:list-item><ce:list-item id="o0035"><ce:para id="p0345">Do you believe that selective pelvic lymphadenectomy has a therapeutic effect?</ce:para></ce:list-item><ce:list-item id="o0040"><ce:para id="p0350">What are your indications for postoperative adjuvant radiotherapy among patients undergoing surgery for clinical stage I endometrial cancer?</ce:para></ce:list-item><ce:list-item id="o0045"><ce:para id="p0355">How do you envision that intraoperative assessment of tumor size, with or without frozen-section determination of grade and depth of myometrial invasion, will improve survival for the 80% of women with low-risk endometrial cancer according to your definitions who are currently being treated primarily by nononcologic gynecologic surgeons?</ce:para></ce:list-item></ce:list></ce:para></ce:section><ce:section id="s0055"><ce:section-title id="st0070">Appendix</ce:section-title><ce:para id="p0360"><ce:bold>D<ce:small-caps>R</ce:small-caps> D<ce:small-caps>AVID</ce:small-caps> H<ce:small-caps>OOGERLAND,</ce:small-caps></ce:bold> Milwaukee, Wisconsin. Dr Mariani, I am interested in the practicality of how you perform your analysis at the time of surgery. In other words, how is the intraoperative assessment carried out? Is a 3-cm polyp with a 2-mm stalk considered a tumor size >2 cm, or do you look at the stalk and so forth?</ce:para><ce:para id="p0365"><ce:bold>U<ce:small-caps>NIDENTIFIED SPEAKER.</ce:small-caps></ce:bold> I have a follow-up for the preceding question. Could some of this information be obtained before the operation by ultrasonography or other imaging modalities?</ce:para><ce:para id="p0370"><ce:bold>D<ce:small-caps>R</ce:small-caps> M<ce:small-caps>ARIANI</ce:small-caps></ce:bold> (Closing). With respect to Dr Lurain's question on the average length of stay, this retrospective review commenced before the increasing emphasis on decreasing the length of hospital stays. Moreover the significant medical comorbidities of these patients with endometrial cancer treated at our institution as a referral center undoubtedly contributed to longer hospital stays.</ce:para><ce:para id="p0375">Dr Lurain asked about the value of frozen-section analysis to determine risk status during surgery. This value cannot be underestimated. Frozen-section analysis remains important in determining tumor grade, subtype, myometrial invasion, and cervical or adnexal involvement, which together with the estimate of tumor diameter discriminate patients at low risk among whom lymphadenectomy can be omitted. In contrast, on the basis of the current literature and our unpublished observations, we believe that pelvic lymphadenectomy has therapeutic value for high-risk patients with stage I disease, as Dr Lurain suggested. We therefore recommend the incorporation of a formal lymphadenectomy for all patients with endometrial cancer except the 20% noted during the operation to harbor grade 1 or 2 endometrioid tumors with a primary tumor diameter ≤2 cm and ≤50% myometrial invasion.</ce:para><ce:para id="p0380">With respect to Dr Lurain's question about adjuvant therapeutic indications, recommendations for adjuvant therapy are based on surgical, not clinical, stage. This study strongly suggests that low-risk tumors with primary tumor diameter ≤2 cm are adequately managed with hysterectomy only. Possible exceptions might be those patients with positive peritoneal cytologic results. We are unable to address the merits of treating patients with positive peritoneal cytologic results because all such patients during the study interval received postoperative adjuvant therapy.</ce:para><ce:para id="p0385">Caution must be exercised when one is attempting to interpret the literature on vaginal recurrences. Seldom do reports stratify vaginal recurrences according to pathologic risk factors. A more detailed analysis of the literature suggests that vaginal recurrence rates among low-risk patients not treated with radiation are approximately 2% to 3% and that most patients are successfully treated at the time of recurrence. Adjuvant vaginal brachytherapy in this setting reduces the percentage of vaginal recurrences but does not significantly improve survival among low-risk patients. Conversely, pelvic sidewall recurrences are more difficult to treat, and incorporation of accurate lymph node assessment at the primary operation will facilitate selection of appropriate adjuvant treatment. Furthermore, the contemporary literature suggests that adjuvant radiotherapy does not improve survival even among patients with moderate-risk and high-risk stage I disease when formal lymphadenectomy has documented negative nodes. Thus it is important that performance of a complete lymphadenectomy be considered standard treatment for all patients with endometrial cancer except those with low-risk tumors with a primary tumor diameter ≤2 cm.</ce:para><ce:para id="p0390">In response to Dr Lurain's last question, it is important that patients with endometrial cancer be afforded the opportunity for treatment by individuals who possess knowledge of the natural history of this disease process, complete familiarity with the various treatment algorithms, the surgical skills to conduct the definitive staging and cytoreductive procedures, and the ability to manage the potential accompanying postoperative sequelae. The individuals most appropriately trained to optimally manage the treatment of these patients are gynecologic oncologists.</ce:para><ce:para id="p0395">Finally, I agree with Dr Lurain that patients with endometrial cancer who are taken to the operating room for primary therapy should be prepared to undergo extended surgical staging, including complete pelvic and para-aortic lymphadenectomies and cytoreductive surgery when indicated.</ce:para><ce:para id="p0400">Dr Hoogerland presented an example of a possible variant of disease that would require intraoperative frozen-section analysis and the judgment of an experienced surgeon. If all other low-risk factors are favorable, we would recommend estimation of the involved surface area of the polyp with carcinoma and apply similar primary tumor diameter criteria. The judgment of the surgeon would likewise be influenced by the depth of invasion into the polypoid lesion. When doubt exists, however, definitive surgical staging should be considered.</ce:para><ce:para id="p0405">Finally, the cost-effectiveness of extensive preoperative imaging studies would appear to make them difficult to justify. Considering that the surgical removal of the uterus and adnexa allows definitive intraoperative pathologic assessment, the need for complete surgical staging and cytoreduction is predicated on the accurate documentation of grade, subtype, depth of myometrial invasion, primary tumor diameter, and the macroscopic presence or absence of tumor beyond the uterus. 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Oncol</sb:maintitle></sb:title><sb:volume-nr>56</sb:volume-nr></sb:series><sb:date>1995</sb:date></sb:issue><sb:pages><sb:first-page>29</sb:first-page><sb:last-page>33</sb:last-page></sb:pages></sb:host></sb:reference></ce:bib-reference></ce:bibliography-sec></ce:bibliography></tail></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Low-risk corpus cancer: Is lymphadenectomy or radiotherapy necessary?</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Low-risk corpus cancer: Is lymphadenectomy or radiotherapy necessary?</title></titleInfo><name type="personal"><namePart type="given">Andrea</namePart><namePart type="family">Mariani</namePart><namePart type="termsOfAddress">MDa</namePart><affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Maurice J.</namePart><namePart type="family">Webb</namePart><namePart type="termsOfAddress">MDa</namePart><affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Gary L.</namePart><namePart type="family">Keeney</namePart><namePart type="termsOfAddress">MDb</namePart><affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Michael G.</namePart><namePart type="family">Haddock</namePart><namePart type="termsOfAddress">MDc</namePart><affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Giliola</namePart><namePart type="family">Calori</namePart><namePart type="termsOfAddress">MSd</namePart><affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Karl C.</namePart><namePart type="family">Podratz</namePart><namePart type="termsOfAddress">MD, PhDa</namePart><affiliation>Rochester, Minnesota, and Milan, ItalyFrom the Department of Obstetrics and Gynecology,a the Department of Laboratory Medicine and Pathology,b and the Division of Radiation Oncology,c Mayo Clinic and Mayo Foundation, Rochester; and the Department of Medical Biostatistics, San Raffaele Hospital, Milan.d</affiliation><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="Full-length article"></genre><originInfo><publisher>ELSEVIER</publisher><dateIssued encoding="w3cdtf">2000</dateIssued><copyrightDate encoding="w3cdtf">2000</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType></physicalDescription><abstract lang="en">Objective: The objective of this study was to find readily ascertainable intraoperative pathologic indicators that would discriminate a subgroup of early corpus cancers that would not require lymphadenectomy or adjuvant radiotherapy. Study Design: Between 1984 and 1993, a total of 328 patients with endometrioid corpus cancer, grade 1 or 2 tumor, myometrial invasion ≤50%, and no intraoperative evidence of macroscopic extrauterine spread were treated surgically. Pelvic lymphadenectomy was performed in 187 cases (57%), and nodes were positive in nine cases (5%). Adjuvant radiotherapy was administered to 65 patients (20%). Median follow-up was 88 months. Results: The 5-year overall cancer-related and recurrence-free survivals were 97% and 96%, respectively. Primary tumor diameter and lymphatic or vascular invasion significantly affected longevity. No patient with tumor diameter ≤2 cm had positive lymph nodes or died of disease. Conclusion: Patients who have International Federation of Gynecology and Obstetrics grade 1 or 2 endometrioid corpus cancer with greatest surface dimension ≤2 cm, myometrial invasion ≤50%, and no intraoperative evidence of macroscopic disease can be treated optimally with hysterectomy only. (Am J Obstet Gynecol 2000;182:1506-19.)</abstract><note>Supported by the Mayo Cancer Center (P30CA15083) and the Rochester Research Committee, Mayo Foundation, Rochester, Minnesota.</note><note>Reprint requests: Karl C. Podratz, MD, PhD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.</note><note type="content">Section title: Transactions of the Sixty-Seventh Annual Meeting of the Central Association Of Obstetricians and Gynecologists</note><note type="content">Table II: Characteristics of patients with low-risk endometrial cancer (endometrioid histologic subtype, myometrial invasion ≤50%, and histologic grade 1-2) according to primary tumor diameter and type of additional therapy (all patients underwent hysterectomy)</note><note type="content">Table III: Acute perioperative morbidity among patients with low-risk endometrial cancer (endometrioid histologic subtype, myometrial invasion ≤50%, and histologic grade 1-2)</note><note type="content">Table V: Recurrence and survival among patients with low-risk endometrial cancer (endometrioid histologic subtype,myometrial invasion ≤50%, and histologic grade 1-2) and no lymphadenectomy</note><note type="content">Table VI: Prognosis of isolated vaginal recurrences among patients with low-risk endometrial cancer (endometrioid histologic subtype, myometrial invasion ≤50%, and histologic grade 1-2) who had not previously received radiotherapy</note><subject lang="en"><genre>Keywords</genre><topic>Endometrial cancer</topic><topic>low-risk</topic><topic>lymphadenectomy</topic><topic>management</topic><topic>radiotherapy</topic></subject><relatedItem type="host"><titleInfo><title>American Journal of Obstetrics and Gynecology</title></titleInfo><titleInfo type="abbreviated"><title>YMOB</title></titleInfo><genre type="journal">journal</genre><originInfo><dateIssued encoding="w3cdtf">200006</dateIssued></originInfo><identifier type="ISSN">0002-9378</identifier><identifier type="PII">S0002-9378(00)X0048-8</identifier><part><date>200006</date><detail type="volume"><number>182</number><caption>vol.</caption></detail><detail type="issue"><number>6</number><caption>no.</caption></detail><extent unit="issue pages"><start>1275</start><end>1650</end></extent><extent unit="pages"><start>1506</start><end>1519</end></extent></part></relatedItem><identifier type="istex">53C2189F96F658CB94476A4F274553D54504E047</identifier><identifier type="DOI">10.1067/mob.2000.107335</identifier><identifier type="PII">S0002-9378(00)99038-0</identifier><accessCondition type="use and reproduction" contentType="copyright">©2000 Mosby, Inc.</accessCondition><recordInfo><recordContentSource>ELSEVIER</recordContentSource><recordOrigin>Mosby, Inc., ©2000</recordOrigin></recordInfo></mods></metadata></istex></record>Pour manipuler ce document sous Unix (Dilib)
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