1. 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

2. 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)

3. Pathogenetic types of endometrial carcinoma
Amant et al., Lancet 2005;366:
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

4. Need for lymphadenectomy in endometrioid endometrial cancer
Mariani et al., Am J Obstet Gynecol 2000;182:
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

5. 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

6. Video pelviC LYMPHADENECTOMY

7. 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)

8. Incisions for retroperitoneal laparoscopic lymphadenectomy

10. laparoscopic PARA AORTIC NODE RESECTION

12. 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

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

14. 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

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

16. 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%)

18. 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:
Lymphadenectomy should be
restricted to patients in whom
the removal of clinically suspect
lymph node metastases improves
The residual disease status

21. 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