The Gulf Journal of

Oncology

ISSUE 17 JANUARY 2015TAblE of CoNTENTS

Original Articles /StudiesImpact of bMI on locoregional Control among Saudi Patients with breast Cancer after breast Conserving surgery and Modified Radical Mastectomy ...................................................................................................................................... 07E.F. Al Saeed, A.J. Al Ghabbban, M.A. Tunio

A statistical quantification of radiobiological metrics in Intensity Modulated Radiation Therapy evaluation ........................ 15A. Surega, J. Punitha, S. Sajitha, BS Ramesh, A. Pichandi, P. Sasikala

A method for assessment of radiation treatment chain of cervical cancer with combined external and brachy radiation therapy ................................................................................................................................................................................ 24A. Chaparian, P. Shokrani

Role of Lymphadenectomy and Its Impact On Survival In Endometrial Carcinoma – An Institutional Experience .............. 30S. Suchetha, P. Rema, S. Vikram, P.S. George, I. Ahmed

Breast Cancer—Epidemiology, Risk Factors and Tumor Profiles in Bangladeshi underprivileged women.............................. 34M. Rahman, A. Ahsan, F. Begum, K. Rahman

Early hematological effects of chemo-radiation therapy in cancer patients and their pattern of recovery- A prospective single institution study ............................................................................................................................... 43H.N. Lee, M.K. Mahajan, S. Das, P. Jeyaraj, J. Sachdeva, M.S. Tiwana

Platinum-based chemotherapy in metastatic triple negative breast cancer: Experience of a tertiary referral centre in India ....................................................................................................................................................................... 52V.V. Maka, H. Panchal, S.N. Shukla, S.S. Talati, P.M. Sha, K.M. Patel, A.S. Anand, S.A. Shah, A.A. Patel, S. Parikh

A Single Institution 18-Years Retrospective Analysis of Malignant Melanoma ............................................................................ 58A. Mukherji, A.K. Rathi, P.K. Mohanta, K. Singh

MRI and ultrasonography for assessing multifocal disease and tumor size in breast cancer: Comparison with histopathological results. ............................................................................................................................................................ 65V. Rudat, A. Nour, N. Almuraikhi, I. Ghoniemy, I. Brune-Erber, N. Almasri, T. El-Maghraby

Patient’s Compliance On the Use of Extended Low Molecular Weight Heparin Post Major Pelvic Surgeries in Cancer Patients at King Hussein Cancer Center ...................................................................................................... 73M. Baba, M. Al Masri, M. Salhab, M. El Ghanem

Can we use Sorafenib for advanced Hepatocellular Carcinoma (HCC) Child Pugh B? ............................................................. 82K. Rasul, A. Elessam, S. Elazzazi, R. Ghasoub, A. Gulied

Case ReportsThe external auditory canal as an unusual site for metastasis of breast carcinoma: A case report ............................................ 85B.A. Baraka, B.J. Al Bahrani, S.S. Al Kharusi, I. Mehdi, A.M. Nada, N.H. Al Rahabi

Primary Mixed Cellularity Classical Hodgkin lymphoma of the Lumbar spine – An unusual presentation ............................ 88K.R. Anila, R. A. Nair, S. Prem, K. Ramachandran

Subdural hematoma during therapy of gastro-intestinal stromal tumor (GIST) with Imatinib mesylate ................................ 92J. Feki, G. Marrekchi, T. Boudawara, N. Rekik, S. Maatoug, Z. Boudawara, M. Frikha

Conference Highlights /Scientific Contribution • Workshop Highlights –The Second Regional Training Of The Trainers’ (TOT) Workshop On Palliative

Care, Kuwait, 23-26 November 2014 ...........................................................................................................................................96• News Notes ....................................................................................................................................................................................102• Advertisements .............................................................................................................................................................................107• Scientific events in the GCC and the Arab World for the 1st Semester of 2015......................................................................108

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Impact of lymphadenectomy on survival of patients with endometrial cancer., S. Suchetha, et. al.

Role of Lymphadenectomy And Its Impact On Survival In Endometrial Carcinoma – An Institutional

ExperienceS. Suchetha, P. Rema, S. Vikram, P.S. George, I. Ahmed

Regional Cancer Centre, Kerala, India

Corresponding Author: S. Suchetha, DGO, MD (Obstetrics and Gynecology), Associate Professor, Division of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India. Phone: +91 4712522418, Fax: +91 471 2447454. Email: suchethajyothish@gmail.com

AbstractPelvic and para aortic lymph nodes are the

common sites of metastasis in endometrial carcinoma. The role of lymphadenectomy is widely discussed in literature with varying results. In this study we did a retrospective analysis of endometrial cancer patients to correlate lymphadenectomy with overall and disease free survival.

Methods:A retrospective review of 110 patients

with carcinoma endometrium who underwent staging laparotomy at our institute during the period 2006-2010. Patients who underwent node dissections were categorized as group I and the rest as group II. Median lymph node count was 10. Grade of the tumor, nodal status

and lymphadenectomy were correlated with overall and disease free survival.

Conclusion: Lymph node metastasis and grade of

tumor are significant predictors of survival. Lymphadenectomy did not show significant survival benefit. It has helped to upstage the disease so that appropriate adjuvant therapy could be planned. A prospective randomized control trial with complete pelvic and para aortic node dissection and uniform adjuvant therapy considering nodal status may help to answer the confusion regarding lymphadenectomy.

Key words:Endometrial cancer, lymphadenectomy,

tumour grade, survival

IntroductionEndometrial carcinoma is the most common

genital malignancy in postmenopausal females. About 75% of endometrial carcinoma patients present with post-menopausal bleeding at early stage and all of them will be having disease confined to uterus. Early presentation gives a high survival rate for patients with endometrial carcinoma. Endometrial cancer spreads locally to cervix, myometrium and to other pelvic organs; lymphatic spread to pelvic and para aortic nodes and hematogenous spread to lungs, liver and brain. Lymph node metastasis, histological type of the tumor, grade of tumor, and depth of myometrial infiltration are the important prognostic factors. Systematic lymphadenectomy

and adjuvant treatment of endometrial cancer are the controversial topics which are widely discussed across available literature. Those who are against lymphadenectomy argue that extensive lymphadenectomy and adjuvant radiotherapy may increase the morbidity of the patient. Grade of the tumor, nodal status and lymphadenectomy were correlated with overall and disease free survival using data from 110 patients who underwent surgical staging at our institute..

Patients and methodsThis study is a retrospective review of 110

patients with carcinoma endometrium who underwent staging laparotomy at Regional Cancer Centre in Kerala, India during the period 2006-2010. Patients who were surgically fit underwent lymphadenectomy as a part of staging. Group I were those who underwent lymphadenectomy and group II were those who did not have

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Impact of lymphadenectomy on survival of patients with endometrial cancer., S. Suchetha, et. al. G. J. O. Issue 17, 2015

Table 1. Morbidity in the lymphadenectomy group

Figure 2: Disease free survival according to lymphadenectomy (group I vs. group II)Three year survival: group 1 = 86.31; group II = 77.42

Figure 3: Disease free Survival by lymph node status in lymphadenectomy groupThree year Survival: N- (Node negative) = 96.67; N+ (Node positive) = 30.48

Figure 1. Overall Survival according to lymphadenectomy (group I vs. group II)Three year survival: group 1 = 90.17; group II = 94.50

lymphadenectomy. Median lymph node count was 10. Survival rates were analyzed between the two groups and the lymphadenectomy group between histological node positive and node negative patients. Survival rate was also correlated with the grade of tumour. Patients with only endometrioid histology and grades one to three were included. Patients with clear cell carcinoma, uterine papillary serous carcinoma, synchronous ovarian tumor, recurrent disease or those who have received upfront chemotherapy or radiotherapy were excluded from the study. Lymphadenectomy included bilateral Iliac and obturator lymph nodes. Para aortic lymph node sampling was done on patients with clinically significant lymph nodes (>1 cm) if found intra-operatively.

ResultsOf the 110 patients included in the study, 72

(65.5%) were in group I (lymphadenectomy group) and 38 (34.5%) were in group II (no lymphadenectomy group). Mean age was 57 years (range 27-81 years). Follow up period ranged from 6-58 months (median is 18 months). 79 patients were in stage I, 18 in stage II and 13 in stage III. In group I, 61 patients (84.7%) were node negative and 11 patients (15.3%) were node positive (N+) on final histopathological examination. 6 were pelvic lymph node only positive; 1 para aortic lymph node only positive and 4 with both pelvic and para aortic positive.

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Impact of lymphadenectomy on survival of patients with endometrial cancer., S. Suchetha, et. al.Impact of lymphadenectomy on survival of patients with endometrial cancer., S. Suchetha, et. al.

11/11 patients with positive nodes and 14/61 node negative patients had advanced stage (> stage II B; FIGO 1988). Patients with tumour grade 1 and 2 confined to endometrium were kept under follow up. Grade 2 tumor infiltrating less than 50% myometrium received brachytherapy. Tumor involving more than 50% myometrial invasion and grade 3 tumors were treated with external beam radiotherapy and brachytherapy. Three year overall and disease free survival were calculated by lymphadenectomy, node status and grade of tumor. No significant difference was found between group 1 and group II in 3 year overall or disease free survival (Figures 1 and 2). Node positive patients (N+) have a significant lower overall survival (50% vs. 96.2%; p=0.0003) and disease free survival (30.4% vs. 96.7%) (Figure 3) compared with node negative patients (N-). Grade of the tumor was a significant determinant of overall survival and disease free survival in lymphadenectomy patients. Specific complications in the lymphadenectomy group were lymph edema, lymph cyst, post operative deep vein thrombosis, and perihepatic collection (Table 1). One patient in the lymphadenectomy group followed by adjuvant radiotherapy developed sub-acute intestinal obstruction. Exploratory laparotomy was done and found to have distal ileal obstruction due to adhesion to the right pelvic side wall which was resected with ileo transverse anastomosis.

DiscussionPelvic and para aortic lymph nodes are the

most common site of metastasis in endometrial cancer(1). As per literature, our analysis also shows that lymph node metastasis and grade of tumor are significant predictors of survival. Patients with lymph node metastasis have a significantly low overall and disease free survival. But they did not show significant survival benefit with lymphadenectomy. Lymphadenectomy has helped upstage the disease so that appropriate adjuvant therapy can be planned. The role of systematic lymphadenectomy in cancer endometrium is still controversial. Prospective randomized controlled trial investigating survival benefit of lymphadenectomy vs. no lymphadenectomy did not show a positive result

for patients undergoing lymphadenectomy (2). A study by Kilgore et al shows patients undergoing multiple site lymph node sampling have improved survival than those without lymph node sampling (3). The retrospective cohort analysis SEPAL Study shows a survival benefit with para aortic lymphadenectomy along with pelvic lymphadenectomy (4) and has concluded that pelvic and para aortic lymphadenectomy should be included in staging intermediate and high risk group of endometrial cancer. Therapeutic role of lymphadenectomy in endometrial cancer has been demonstrated in a retrospective analysis of 12,333 patients by Chan et al (5). The incidence of isolated para aortic nodal metastasis without pelvic lymph nodes is 1- 1.2% (6, 7) . Whether this low incidence of para aortic lymph node involvement justifies the complete para aortic node dissection in all patients is questionable because most of these patients are elderly obese with multiple co morbidities. Deficiency in comprehensive staging and variation in the adjuvant treatment may be the reason for confusion regarding survival benefit with lymphadenectomy. As in other trials, our patients also underwent para aortic lymphadenectomy only in clinically suspicious nodes seen intraoperatively. A prospective randomized control trial with complete pelvic and para aortic node dissection and uniform adjuvant therapy considering nodal status may help to answer the confusion regarding lymphadenectomy.

Impact of lymphadenectomy on survival of patients with endometrial cancer., S. Suchetha, et. al.

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Impact of lymphadenectomy on survival of patients with endometrial cancer., S. Suchetha, et. al. G. J. O. Issue 17, 2015

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Systematic pelvic lymphadenectomy versus no lymphadenectomy in early stage endometrial carcinoma: J Nati Cancer Institute 2008;100:1707-1716

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3. Larry C, Kilgore M.D, Edward E. Partridge, M.D., Ronald D. Alvarez, M.D., J Maxwell Austin, M.D., Hugh M. Shingilton, M.D., Frank Noojin III, and Wendy Conner, M.S Adenocarcinoma of the endometrium: Survival comparisons of patients with and without pelvic node sampling. Gynecologic oncology 56, 29-33 (1995)

4. Yukiharu Todo, Hidenori Kato, Masanori Kaneuchi Hidemichi Watari, Mahito Takeda, Noriaki Sakuragi, Survival effect of paraaortic lymphadenectomy in endometrial cancer (SEPAL study): A retrospective cohort analysis Lancet 2010;375:1165-72.

5. John K Chan,MD, Michael K Cheung, BA, Warner K Huh,MD, Kathrynn Ossan, PhD, Amreen Husain, MD, Nelson N.Teng, MD, PhD, Daniel S. Kapp, MD, PhD. Therapeutic role of lymph node resection in endometrioid corpus cancer. A Study of 12,333 patients. Cancer 2006;107:1823-30.

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