Lymph Node Dissection at Time of Surgery?
Dear OncoLink "Ask The Experts,"
I have a diagnosis of endometrial cancer based on biopsy. Robotic surgery is scheduled in 2 weeks. My question is related to whether or not it is wise to plan ahead and allow lymph node biopsy (removal of 10 - 20 nodes) at time of surgery or wait until uterus is dissected to determine spread.
Should lymph node biopsy/removal be done at time of surgery, even if it is grade 1 and the uterus at surgery does not show deep involvement of layers? If lymph nodes are removed, what is likelihood of lymphedema or related complications to the lymph node removal?
Christina S. Chu, MD, Assistant Professor of the Division of Gynecologic Oncology at the University of Pennsylvania Health System, responds:
There are two different approaches regarding lymph node biopsies in patients undergoing hysterectomy for endometrial cancer. One philosophy advocates lymph node biopsies only based on uterine risk factors identified at the time of surgery (grade of tumor, depth of invasion of the tumor into the muscle wall of the uterus). This has the advantage of sparing patients at low risk the necessity of undergoing the lymph node biopsies. However, this does rely on a "frozen section" diagnosis (an immediate preliminary diagnosis in the operating room based on one or two slides). Not uncommonly, the final diagnosis (which relies on multiple slides), which is not available until several days after surgery, may be different, leaving the potential risk that a patient who should have undergone lymph node staging did not.
A second approach recommends universal lymph node assessment for all patients with endometrial cancer. This approach tries to avoid making clinical decisions based on a frozen section, which may sometimes be inaccurate. Furthermore, because determining "uterine risk factors" such as depth of invasion and grade of tumor were originally designed to help predict whether the lymph nodes would be positive or not--in other words, they are surrogate markers for lymph node positivity -- advocates of universal lymph node assessment would argue that lymph nodes should always be sampled. Since the rate of side effects (such as lymphedema) and overall surgical risk is low, these advocates argue that all patients should have lymph nodes sampled for optimal accuracy. Studies show that patients who have intermediate risk factors for recurrence (like deep invasion, or high grade tumors) but who have negative lymph nodes, may forego adjuvant radiation therapy and still have long-term outcomes similar to patients who do undergo additional adjuvant radiation.
These are complex questions that you should address with your surgeon before you undergo your procedure.