Lymphadenectomy in endometrial cancer: when, not if.

The lack of consensus for primary surgical treatment of endometrial cancer, the most common gynaecological cancer, is deplorable. Whether lymphadenectomy should be done together with hysterectomy has been debated at length and passionately. Resolution of this problem has been confounded by several issues, such as selection of patients, the perceived goals of lymphadenectomy, and clinicians’ failure to recognise the known routes of lymphatic spread from the uterus. In practice, lymphadenectomy varies from complete omission, to various iterations of lymph-node sampling, to systematic lymphadenectomy. Furthermore, the extent of lymphadenectomy ranges from pelvic-node dissection alone to dissection of the para-aortic area, which can include the aortic bifurcation to the inferior mesenteric artery and up to the renal vessels. Although the emergence of laparoscopic surgery has resulted in important improvements in short-term morbidity, this approach, even in the best of hands, could restrict the extent of para-aortic lymphadenectomy to the inferior mesenteric artery, an anatomical boundary with no importance in gynaecology other than convenience. This practice pattern has developed despite the fact that 77% of patients with para-aortic metastases harbour disease above the inferior mesenteric artery. In view of the strong association between obesity and endometrial cancer, the indications for and extent of lymphadenectomy are frequently determined more by body habitus than by objective pathological fi ndings or formal risk assessments. The challenges outlined above were evident in two randomised trials investigating the benefi ts of pelvic lymphadenectomy for endometrial cancer. Although neither trial showed diff erences in outcome between patients who did and did not undergo lymphadenectomy, both studies had serious defi ciencies. Perhaps most importantly, both investigations were done in patients with a risk of lymphatic involvement of only 9–13%. Lymphadenectomy is unlikely to be benefi cial unless the cohort studied has substantial risk of lymphatic disease. We have shown that histological subtype, tumour size, tumour grade, and myometrial 21st century. The studies will focus on post-secondary education, with an emphasis on medicine, public health, and nursing, in all regions of the world, encompass ing both instructional and institutional aspects of educational systems as they interact with health systems. The Commission expects to organise consultations in Africa, Asia, and Latin America in mid-2010. Its fi nal report will be submitted to The Lancet for publication in November, 2010. Findings and recommendations will form the basis of enlightened advocacy to accelerate the transformation of professional education for health in the 21st century. The Commission is surveying schools of medicine, nursing, and public health. Readers are encouraged to respond to this survey available on the Commission’s website.