title: Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis.
abstract: BACKGROUND
  In response to findings that pelvic lymphadenectomy does not have any therapeutic benefit for endometrial cancer, we aimed to establish whether complete, systematic lymphadenectomy, including the para-aortic lymph nodes, should be part of surgical therapy for patients at intermediate and high risk of recurrence.
  
  
  METHODS
  We selected 671 patients with endometrial carcinoma who had been treated with complete, systematic pelvic lymphadenectomy (n=325 patients) or combined pelvic and para-aortic lymphadenectomy (n=346) at two tertiary centres in Japan (January, 1986-June, 2004). Patients at intermediate or high risk of recurrence were offered adjuvant radiotherapy or chemotherapy. The primary outcome measure was overall survival.
  
  
  RESULTS
  Overall survival was significantly longer in the pelvic and para-aortic lymphadenectomy group than in the pelvic lymphadenectomy group (HR 0.53, 95% CI 0.38-0.76; p=0.0005). This association was also recorded in 407 patients at intermediate or high risk (p=0.0009), but overall survival was not related to lymphadenectomy type in low-risk patients. Multivariate analysis of prognostic factors showed that in patients with intermediate or high risk of recurrence, pelvic and para-aortic lymphadenectomy reduced the risk of death compared with pelvic lymphadenectomy (0.44, 0.30-0.64; p<0.0001). Analysis of 328 patients with intermediate or high risk who were treated with adjuvant radiotherapy or chemotherapy showed that patient survival improved with pelvic and para-aortic lymphadenectomy (0.48, 0.29-0.83; p=0.0049) and with adjuvant chemotherapy (0.59, 0.37-1.00; p=0.0465) independently of one another.
  
  
  CONCLUSIONS
  Combined pelvic and para-aortic lymphadenectomy is recommended as treatment for patients with endometrial carcinoma of intermediate or high risk of recurrence. If a prospective randomised or comparative cohort study is planned to validate the therapeutic effect of lymphadenectomy, it should include both pelvic and para-aortic lymphadenectomy in patients of intermediate or high risk of recurrence.
  
  
  BACKGROUND
  Japanese Foundation for Multidisciplinary Treatment of Cancer, and the Japan Society for the Promotion of Science.
authors.affiliation: Division of Gynaecologic Oncology, National Hospital Organization, Hokkaido Cancer Centre, Sapporo, Japan.
authors.forename: Yukiharu
authors.initials: Y
authors.lastname: Todo
authors.forename: Hidenori
authors.initials: H
authors.lastname: Kato
authors.forename: Masanori
authors.initials: M
authors.lastname: Kaneuchi
authors.forename: Hidemichi
authors.initials: H
authors.lastname: Watari
authors.forename: Mahito
authors.initials: M
authors.lastname: Takeda
authors.forename: Noriaki
authors.initials: N
authors.lastname: Sakuragi
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery; D001011:Aorta; D018269:Carcinoma, Endometrioid / Q000401:mortality / Q000473:pathology / Q000601:surgery; D017024:Chemotherapy, Adjuvant; D018572:Disease-Free Survival; D016889:Endometrial Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007044:Hysterectomy; D053208:Kaplan-Meier Estimate; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D010388:Pelvis; D018714:Radiotherapy, Adjuvant; D015996:Survival Rate