Endometrial cancer: treatment of nodal metastases

Surgical staging has changed the method by which patients with endometrial cancer are managed. Before the routine use of lymph node dissection, patients were presumed to have nodal disease based on imaging studies, palpation, and biopsy. The move to a surgically based staging system in 1988 created a new subgroup of patients who had documented nodal disease. The risk of nodal involvement is related primarily to tumor grade and depth of myometrial invasion. Although patients with nodal disease are uncommon, treatment of these patients poses multiple challenges. It is our belief that unless nodes are surgically assessed, the clinician will not know whether the nodes are involved. A thorough lymphadenectomy with removal of nodal tissue from multiple pelvic sites and from bilateral para-aortic regions is recommended for most patients with endometrial cancer. Identification of positive nodes allows appropriate postoperative therapies to be used, and data support that nodal dissection may be therapeutic and prognostic. Patients with positive nodes should receive radiation therapy directed to the nodal distribution, with patients having involved para-aortic nodes receiving an extended field. Whole abdominal radiation has been used, especially in patients with adnexal disease or positive cytology. The role of whole abdominal radiation remains in question. The most promising treatment option is combination therapy with sequential radiation and chemotherapy. Active chemotherapy agents in endometrial cancer are doxorubicin, cisplatin, and paclitaxel.