Tumor size >2 cm: surgical pearls in endometrial cancer: large lesion, get nodes.(Gynecology)

BIG SKY, MONT. -- A key point for the general gynecologist operating on patients with stage I endometrial carcinoma is that a tumor size greater than 2 cm warrants lymph node sampling. Dr. Ira R. Horowitz said at a meeting on ob.gyn., gynecologic oncology, and reproductive endocrinology.

"When I open up the uterus and it's a grade 1 or 2 tumor and I see a lesion that's more than 2 cm, that lady gets nodes sampled. The size of the lesion is something that's really been important to me. They don't teach this in residency; they do in fellowship. Large lesion: Get nodes," stressed Dr. Horowitz, the Willaford Ransom Leach Professor and director of gynecologic oncology at Emory University in Atlanta.

The risk of nodal metastasis in patients with a 2-cm-or-less tumor is quite low--just 4% in one classic study, jumping to 15% in women with a tumor greater than 2 cm.

Three-quarters of endometrial carcinomas are FIGO surgical stage 1, meaning the tumor is limited to the body of the uterus. Within this stage, as the degree of tumor dedifferentiation as expressed in tumor grade and the extent of myometrial invasion increase, so does the prevalence of positive paraaortic and pelvic lymph nodes. But even in stage I patients with grade 1 tumors and less than 50% myometrial invasion, it's important to sample the regional lymph nodes if the tumor is more than 2 cm.

"Don't think because you've got a well-differentiated cancer that you're out of the woods. I've got a bunch of recurrent stage I grade 1s," the physician cautioned.

In stage I grade 3 disease, lymph node sampling is done routinely because studies have demonstrated a high rate of nodal metastasis. No such studies have ever been completed in patients with grade 2 disease.

"The grade 2 patient is a no-man's-land, but I will always default to node dissection if it's my patient. Some other oncologists may say they're not going to do it if there's no invasion. I think it's easier to do it," Dr. Horowitz said at the meeting, which was sponsored by the Geisinger Health System.