Staging. Uterine cancer
Many of the prognostic factors noted above require surgical staging for adequate delineation. Until 1988, staging for endometrial cancer was clinical. It became readily apparent that clinical staging failed to identify the true extent of disease in a large number of patients. Up to one fourth of patients who were thought to have clinical stage disease I had extrauterine disease when surgical staging was done. The margin of error for stage II was even greater, with studies suggesting that 50-60% of patients who were thought to have stage II disease in fact did not. In many instances, the patients had only stage I disease. This misclassification resulted in radiation therapy that probably was unnecessary. Because of lack of sensitivity of clinical staging, FIGO in 1988 determined that corpus cancer should be surgically staged (see the box). Initially, concern was voiced that a considerable number of patients with this disease were elderly and could not withstand the surgical procedure or were quite obese, making surgery technically difficult to perform. Experience has shown that this number appears to be very small. With surgical staging, more specific postoperative therapy, if indicated, could be optimally identified and directed. The role of preoperative radiation in this disease entity has become minimal.
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Endometrial cancer is a surgically staged disease, and many of the traditional diagnostic procedures advocated before 1988 are no longer necessary. These include a fractional dilation and curettage and endocervical curettage. A chest X-ray is important pretreatment and could affect final staging. Other scanning techniques, unless clinically indicated, are not advocated on a routine basis.
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Surgical staging consists of primary total abdominal hysterectomy and bilateral salpingo-oophorectomy as well as full surgical staging. This includes peritoneal cytology on opening the abdomen, surgical exploration of the abdominal contents, appropriate biopsies, and bilateral pelvic and paraaortic lymphadenectomy. The universal role of the lymphadenectomy continues to be debated, particularly in patients with well-differentiated adenocarcinomas that are superficially invasive. Data suggest that the chance of lymph node metastasis in this group of patients approaches zero, although some authors have found occasional metastasis in this group of patients. The incidence of nodal metastasis, both pelvic and paraaortic, in patients with poorly differentiated or deeply invasive lesions is high enough to warrant the added surgical procedure. Although this lymphadenectomy was originally termed “selective” or “limited,” it is felt that a fairly thorough lymphadenectomy should be performed. Some investigators have suggested that lymph nodes on top of the vessels from the inguinal ligament to the retroperitoneal duodenum should be removed as well as those from the obturator space above the nerve. Numerous nodes should be obtained with such a procedure. The practice of identifying clinically enlarged nodes as those to be removed should not be advocated because the vast majority of metastases to lymph nodes from carcinoma of the uterus are usually microscopic. Such a practice can create a false sense of security.