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Published:February 10, 2012DOI:https://doi.org/10.1016/j.ajog.2012.01.042
      We appreciate the interest of Dr Basile and his colleagues in our work. Utilizing a large population-based database of patients with endometrial cancer treated from 1988 to 2006, we noted that those women who underwent lymphadenectomy were less likely to receive adjuvant external beam radiotherapy than those who did not undergo nodal evaluation. The association between lymphadenectomy and avoidance of radiation was strongest for women with intermediate risk tumors (Fédération Internationale de Gynécologie et d'Obstétrique 1988 stage IB grades 2 and 3 and stage IC grades 1 and 2).
      Basile et al suggest that the proper question to ask is not whether lymphadenectomy influences the use of radiation but rather whether lymphadenectomy influences the natural history and survival of patients with endometrial cancer? In theory, we certainly agree with this point. Despite methodalologic issues that have been well discussed, 2 large randomized trials failed to show a survival benefit for lymphadenectomy.
      • Benedetti Panici P.
      • Basile S.
      • Maneschi F.
      • et al.
      Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial.
      • Kitchener H.
      • Swart A.M.
      • Qian Q.
      • Amos C.
      • Parmar M.K.
      Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study.
      Likewise, the Post-Operative Radiation Therapy for Endometrial Carcinoma (PORTEC)-2 investigators noted that vaginal brachytherapy was not inferior to pelvic radiation for women with apparent early-stage endometrial cancer.
      • Nout R.A.
      • Smit V.T.
      • Putter H.
      • et al.
      Vaginal brachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate risk (PORTEC-2): an open-label, non-inferiority, randomised trial.
      However, in clinical practice the issue is not as straightforward and clear-cut as to whether lymphadenectomy influences survival. Decisions regarding adjuvant therapy must be made and a fair question is whether lymphadenectomy helps to guide clinicians in these decisions. Much of the difficulty with these decisions arises from the lack of clear data defining optimal adjuvant therapy for endometrial cancer. The appropriate treatment for high-risk disease confined to the uterus as well as for patients with isolated nodal disease remains a subject of active debate. In the United States, patients with stage IIIC endometrial cancer are frequently treated with multimodality therapy including both chemotherapy and radiation.
      • Alvarez Secord A.
      • Havrilesky L.J.
      • Bae-Jump V.
      • et al.
      The role of multi-modality adjuvant chemotherapy and radiation in women with advanced stage endometrial cancer.
      The purpose of the radiation is to sterilize nodal disease. Is chemoradiation superior to chemotherapy alone? If so, should we omit pelvic radiation in a patient with a grade 2 tumor invading 90% of the endometrium who did not undergo lymphadenectomy but has a nearly 20% risk of nodal disease?
      • Creasman W.T.
      • Morrow C.P.
      • Bundy B.N.
      • Homesley H.D.
      • Graham J.E.
      • Heller P.B.
      Surgical pathologic spread patterns of endometrial cancer A Gynecologic Oncology Group Study.
      Although it is unclear what the correct answers are to these questions, these are decisions faced every day by oncologists.
      A strength of population-based registry studies lies in the ability of these investigations to capture the way patients are actually treated in real world settings. We believe our findings clearly demonstrate that lymphadenectomy influenced treatment planning for endometrial cancer. We recognize that the publication of PORTEC-2 will likely decrease the magnitude of our findings in the coming years. However, in areas of clinical uncertainty, the data provided by lymphadenectomy have an important influence on management.

      References

        • Benedetti Panici P.
        • Basile S.
        • Maneschi F.
        • et al.
        Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial.
        J Natl Cancer Inst. 2008; 100: 1707-1716
        • Kitchener H.
        • Swart A.M.
        • Qian Q.
        • Amos C.
        • Parmar M.K.
        Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study.
        Lancet. 2009; 373: 125-136
        • Nout R.A.
        • Smit V.T.
        • Putter H.
        • et al.
        Vaginal brachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate risk (PORTEC-2): an open-label, non-inferiority, randomised trial.
        Lancet. 2010; 375: 816-823
        • Alvarez Secord A.
        • Havrilesky L.J.
        • Bae-Jump V.
        • et al.
        The role of multi-modality adjuvant chemotherapy and radiation in women with advanced stage endometrial cancer.
        Gynecol Oncol. 2007; 107: 285-291
        • Creasman W.T.
        • Morrow C.P.
        • Bundy B.N.
        • Homesley H.D.
        • Graham J.E.
        • Heller P.B.
        Surgical pathologic spread patterns of endometrial cancer.
        Cancer. 1987; 60: 2035-2041

      Linked Article

      • Lymphadenectomy in endometrial cancer: what's the right question?
        American Journal of Obstetrics & GynecologyVol. 206Issue 5
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          We read, with great interest, the article by Sharma et al,1 in which, in a large retrospective study on data from the National Cancer Institute's Surveillance, Epidemiology, and End Results database, the authors analyzed women with stages I-II endometrioid adenocarcinomas of the uterine corpus treated between 1988 and 2006. Findings suggest that, especially among women with high- to intermediate-risk tumors, patients who undergo lymphadenectomy are less likely to receive external-beam radiation.
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