Amant F – Gynecological Oncology - UZ Gasthuisberg, Leuven Indications and technique of pelvic and paraaortic lymphadenectomy Jaarcongres VVOG 8 en 9 okt 2010 Brussel Amant F – Gynecological Oncology - UZ Gasthuisberg, Leuven

Indications Pelvic lymphadenectomy Cervical cancer (Wertheim-Meigs) Endometrial cancer (+/- para aortic LA) Paraaortic lymphadenectomy Bulky or advanced stage cervical ca Endometrial cancer Ovarian cancer (+ pelvic LA)

Pathogenetic types of endometrial carcinoma Amant et al., Lancet 2005;366:591-605 Type 1 Type 2 Unopposed estrogen Present Absent Menopausal status Pre-and peri Post Precursor lesion Atypical hyperplasia Endometrial intraepithelial ca Tumour grade Low High Myometrial invasion Variable, often minimal Variable, often deep Histologic subtypes Endometrioid, gr 1-2 Serous, clear cell, endometrioid gr 3 Behavior Indolent Aggressive Genetic alterations PTEN mutation TP53 mutation Microsatellite instability K-ras mutation

Need for lymphadenectomy in endometrioid endometrial cancer Mariani et al., Am J Obstet Gynecol 2000;182:1506-19 N = 328 grade 1 or 2, myometrial invasion < 50%, no extrauterine disease Pelvic lymphadenectomy in 57%: 9/187 (5%) positive nodes No patient with tumour < 2cm: pos nodes or DOD Hysterectomy only if grade 1-2 < 2cm myometrial invasion < 50% no extra-uterine disease

Endometrial Carcinoma Clinical Stage I – FIGO 2009 Leuven Algorithm 2010 < 2cm, Stage Ia G1-G2 or > 2cm, G1 < 1/3 infiltr AHT/LAVH + BSO Peritoneal Cytology No Adjuvant Therapy Endometrioid Stage Ib, or G3, or > 2cm, G1 > 1/3 or Serous/Clear cell Pelvic Lymphadenectomy Neg Pelvic Ln No Adjuvant Therapy, unles Endometrioid G3: Paclitaxel Carbo x 6 Pos Pelvic Ln Paclitaxel/Carbo 6x+ Macro/frozen section Pelv Ln + Macro Pos Adnex Growth through serosa Paraaortic Lymphadenectomy to renal vessels Neg PAO/Pos Pelvic: Paclitaxel/Carbo Pelvic RT Pos PAO and Pelvic: Paclitaxel/Carbo x 6 Pelvic + PAO RT

Video pelviC LYMPHADENECTOMY

indications Pelvic lymphadenectomy Cervical cancer (Wertheim-Meigs) Endometrial cancer (+/- para aortic LA) Paraaortic lymphadenectomy Bulky or advanced stage cervical ca Endometrial cancer Ovarian cancer (+ pelvic LA)

Incisions for retroperitoneal laparoscopic lymphadenectomy

laparoscopic PARA AORTIC NODE RESECTION

Metastasis above IMA in 77% But: based on 26 patients only paraaortic node metastases in endometrial cancer Mariani et al., Gynecol Oncol 2008 IMA Metastasis above IMA in 77% But: based on 26 patients only

Survival effect of para-aortic lymphadenectomy in endometrial cancer (sepal study): a retrospective cohort analysis Todo et al., Lancet 2010;375:1165-72 N = 671 But: retrospective important differences in adjuvant treatment Overall Survival Disease specific survival

Prognostic importance of degree of differentiation in stage I invasive epithelial ovarian cancer (n=1545) Vergote et al., Lancet 2001 – Zanetta et al., Ann Oncol 1998 – Trimbos et al., JNCI 2003

Impact of surgical staging in early-stage ovarian cancer Trimbos, J.B. et al., J. Natl. Cancer Inst. 2003 95:113-125 – Zanetta G., Ann Oncol 1998 Copyright restrictions may apply.

Pelvic and paraaortic ln in oc (all stages) Burghardt et al., Gynecol Oncol 1991;40:103-6 Stage N P+ Ao+ P+ Ao- P- Ao+ P- Ao- I 20 1(5%) 2(10%) 17(85%) II 7 3(43%) 1(14%) 2(29%) III 67 34(51%) 9(13%) 15(22%) IV 11 8(73%) 1(9%) 2(18%) Total 105 46(44%) 13(12%) 10(9%) 36(35%)

Du Bois, A. et al., J Clin Oncol; 28:1733-1739 2010 Overall survival (OS) in advanced stage ovarian cancer patients with or without lymphadenectomy (LNE) Du Bois, A. et al., J Clin Oncol; 28:1733-1739 2010 Lymphadenectomy should be restricted to patients in whom the removal of clinically suspect lymph node metastases improves The residual disease status

Indications for lymphadenectomy in gynaecological oncology Pelvic lymphadenectomy Cervical cancer (Wertheim-Meigs) Endometrial cancer (high grade, tumor diameter, myometrial invasion) Paraaortic lymphadenectomy Bulky or advanced stage cervical ca Endometrial cancer Ovarian M+ Positive pelvic nodes Serosal involvement Ovarian cancer ( always + pelvic LA) High grade early stage Part of a debulking procedure to R0