Should the Presence of Lymphvascular Space Involvement Be Used to Assign Patients to Adjuvant Therapy Following Hysterectomy for Unstaged Endometrial Cancer

The authors conducted a retrospective review of the medical charts of all patients who underwent surgical treatment of invasive adenocarcinoma of the endometrium between 1998 and 2000 at the James Cancer Hospital of Ohio State University College of Medicine. Data from the records of 366 patients who had surgical evaluation of the pelvic lymph nodes were evaluated to investigate the association of lymphvascular space involvement (LVSI) and lymph node metastases from endometrial cancer. The median age at diagnosis was 62 years (range, 27-90). The histological diagnosis was adenocarcinoma in 316 women; 52 patients also had areas of nonendometrioid histology, including uterine papillary serous adenocarcinoma (N = 21 ), clear-cell carcinoma (N = 14), and mixed epithelial adenocarcinoma (N = 17). Forty-four percent of patients were grade 1, 29% were grade 2, and 27% grade 3. Tumor invasion was confined to the inner third of the myometrium in 25% of the women, to the middle third in 43%, and to the outer third in 32%. LVSI was seen in one fourth of the cases, and the mean number of lymph nodes removed was 21.6. Forty-six women (13%) had metastases to the pelvic nodes (pelvic nodes only, N = 32; pelvic and para-aortic nodes, N = 14). More than one third of the patients (245 of 366) had stage 1 disease, 29 had stage II, 80 had stage III, and 12 women were stage IV. Ninety-two patients (25%) had tumor emboli in the lymphvascular spaces of the myometrium, and 46 of these patients had metastatic disease in the pelvic lymph nodes (P <.001). After statistical analysis, the association of LVSI with lymph node metastases remained significant (P <.001). Myometrial invasion was also found to have a significant association with positive pelvic nodes (P <.05 for invasion into the inner third of the myometrium, P <.01 for invasion into the middle third, and P <.001 in the outer third). When both variables were compared, LVSI was significantly associated with deeply invasive tumors (P <.001). Multivariate analysis, which included LVSI, tumor grade, patient age, depth of tumor invasion, and lymph node yield, found depth of invasion and LVSI to be significant predictors of metastatic disease in the pelvic lymph nodes (P <.004 and P <.04, respectively).