[Survival, prognostic factors and modern tendencies in adjuvant treatment of diagnosed endometrial cancer patients with or without lymph node dissection].

AIM: Our aim was to research and evaluate very big clinical material for 22 years period (1987-2009) at the National Cancer Center, Gynaecological clinic and Medical University--Departement of Obstetrics and Gynaecology-Varna. We studied some of the most important prognostic factors in patients with endometrial cancer, radically operated with or without lymph node dissection. We compared our results with the results of other authors working in this field. Our aim was by examining the prognostic factors and the survival rate to define and help the choice of the most suitable radical surgical treatment, as well as the application of most suitable adjuvant therapy.

MATERIAL AND METHODS: We evaluated for 22 years period--460 endometrial cancer patients radically operated without lymph node dissection, and 460 patients radically operated with lymph node dissection. We studied the following prognostic factors:stage, age group, histological type, tumor grading, invasion of the myometrium, tumor size and volume, peritoneal cytology, cervical cytology, LVSI, hormonal receptor status, nuclear grading, DNA-ploidy, the extent of the lymph node dissection and specific genetic alterations connected with endometrial cancer. For statistic evaluation were used SPSS computer system: variation analysis, corelation analysis, regression analysis and non parametric analysis. We used also Wilcoxon test, log-rank test and the Kaplan-Meier curves.

RESULTS: The surgically evaluated stage was the most important prognostic factor. The age was indipendent factor. The histological type was very important prognostic factor - endometrioid cancers were with better survival rate (89%) compared with the rare papillary-serous and clear cell carcinomas (30%). The tumor grading and myometrial infiltration have very important prognostic significance. In grade 3 and infiltration in myometrium more than 50%--the positive pelvic lymph nodes were 30% and the paraaortal lymph nodes were 20%. The tumor size according to us was independent prognostic factor. In diameter of the tumor less than 2 cm the metastases in the lymph nodes were 3% and in diameter more than 2 cm--18%. When the volume of the tumor occupied the whole endometrial cavity and there was deep infiltration of the myometrium--the lymph node metastases were 40%. The peritoneal cytology had a relative risk. The LVSI was factors indipendent prognostic factor. The nuclear grading according to our results is a significant prognostic factor. Aneuploidy was the strongest indipendent factor for bad survival rate. The extent of the lymph node dissection was considered as an indipendent prognostic factor. In type I endometrioid cancers we discovered microsatelite instability and mutations in PTEN, pikCa etc. The complications that we observed were subileus in 1.9-2%, lymphedema of the legs in 15-20%, DVT-in 0.8-1.2%, lymphocelle in 1.2-2% and hernias in 3%. Some other rare complications were infections, and dehiscence of the wounds, atonia of the bladder, cystitis, intestinal, vesicovaginal and ureteral fistulas. According to our results about the role of adjuvant radiotherapy in radically operated patients with lymph node dissection, we observed a bigger role and importance of brachitherapy giving a better local control. Extended and whole abdominal radiotherapy have only place in suspected, enlarged and proven metastatic pelvic and paraaortal lymph nodes. The role of adjuvant hormonotherapy with gestagens is still contraversial.

DISCUSSION: Examining the survival rate and the prognostic factors in surgically treated endometrial cancer patients with or without lymph node dissection, we wanted to help and give instruction for the most suitable type of surgical treatment (extent, the need of pelvic and/or paraaortal lymph node dissection). The radical surgical treatment with lymph node dissection must become a principle in therapy in specialised oncogynaecological medical units.

CONCLUSIONS: The radical surgical treatment with lymph node dissection (pelvic and/or paraaortal) gives a better survival rate in intermediate and high risky groups. The extent of the lymph node dissection is an independent prognostic factor. In stage IA and IB, grade 1 and 2, a simple total hysterctomy has the same significance for the survival of patients as the radical hysterectomy with lymph node dissection. In stage IIB endometrial cancers the most suitable treatment is radical hysterctomy with lymph node dissection. The lymph node dissection is of benefit for endometrial cancers grade 3, stage IC, stage II, serous and clear cell carcinomas.