The Clinical Study And Systematic Review Of The Extent Of Para-aortic Lymphadenectomy In Endometrial Carcinoma

BackgroundThe pathological staging surgery of endometrial carcinoma(EC)includes total hysterectomy,bilateral adnexectomy,pelvic lymphadenectomy and para-aortic lymph node dissection(PALND).PALND is the very important step.However,the scope of PALND is large and the risk is high.In clinical practice,we cannot perform a comprehensive staging operation for every patient.According to the Mayo medical center(Mayo Clinic),hsterectomy will be performed in all patients with primary EC,with fallopian tubes and ovaries resection or not at the same time.Whether to perform lymph node resection is based on the preoperative examination or intraoperative frozen pathology results.The criteria for performing pelvic and para-aortic lymphadenectomy included: deep myometrial invasion(>50%);non-endometrioid carcinoma;tumor size≥2cm or high tumor grade.According to the extent of PALND,inframesenteric PALND is up to inferior mesenteric artery(IMA),supramesenteric PALND is up to renal vessels(RV).Supramesenteric PALND has technical difficulties.And the nodal status may be the most important prognosticator.The formulation of adjuvant treatment is closely related to the pathological results of lymph node dissection.The extent of PALND has always been a controversial topic.Therefore,it is critical to explore the distribution of PALNM,the surgical risk of PALND up to RV and the impact on the prognosis of patients.Objective1.We conducted the systematic review and meta-analysis to explore the distribution of PALNM.2.The incidence of surgical complications and the effect on survival rate of patients with PALND up to RV were investigated by systematic review and Metaanalysis.3.We conducted a retrospective clinical research to compare the complications and lymph node metastasis rate of PALND up to RV and PALND up to IMA.And the result of the study will guide the future clinical work.Materials and methods:1.PubMed,Embase,OVID,the Cochrane Library,CNKI,and Wan Fang database were searched.Each database implements different search strategies.The main results were PALNM rates,isolated PALNM rates,supramesenteric PALNM rates and isolated supramesenteric PALNM rates.We used the Stata version 14 software to conducted the statistical analysis.2.PubMed,Embase,OVID,CNKI,Wan Fang database and other databases were searched.In line with the inclusion and exclusion criteria,we collected the qualified research with respect to surgical complications of higher PALND and lower PALND.At the same time,the prognosis impact on patients were also discussed.We used the Rev Man5.3 software to analyze the collected data.3.A total of 78 patients who underwent PALND were analyzed from December2012 to December 2020 at the Third Affiliated Hospital of Zhengzhou University.According to the range of PALND,these patients were divided into two groups.By analyzing the clinical data of PALND up to RV and up to IMA in EC patients,the operative time,blood loss,surgical complications and other indicators were compared to explore the clinical value and significance of PALND up to RV.We used the SPSS22.0 software to analyze the collected data.The significance level was set at0.05.Results:1.Eleven English articles were gathered.Results suggested PALNM rate was 11%(95% CI: 8–14%).Para-aortic lymph nodes metastasis rate in non-endometrioid carcinoma group and endometrioid carcinoma group were 16%(95% CI: 6–27%)and8%(95% CI: 4–12%),respectively.Isolated para-aortic lymph nodes metastasis rate was 2%(95% CI: 2–3%).The supramesenteric metastasis rate and isolated supramesenteric metastasis rate were 10%(95% CI: 6–13%)and 1%(95% CI: 0–2%),respectively.2.Four literatures in Chinese were gathered.Meta-analysis results showed that the intraoperative blood loss in EC patients with higher PALND was less than that in patients with lower PALND(P < 0.05).The length of hospital stay in higher PALND was shorter than that in lower PALND(P < 0.05).The incidence of postoperative intestinal obstruction(P=0.94>0.05),deep vein thrombosis(P= 0.96>0.05),lymphatic cyst(P= 0.46>0.05)and chylous fistula(P=0.05)were not significantly different between the two groups.Supramesenteric PALND could significantly reduce the postoperative recurrence rate(Z = 4.34,P < 0.001).3.The results of the clinical study indicated that the average operation time of higher PALND group was longer than that of the lower PALND group(P < 0.05).Intraoperative blood loss between the two groups did not have significant difference(P>0.05).In this study,17 of the 78 patients had complications,and 11 of the patients in the higher PALND group had postoperative complications,accounting for 31.4%(11/35).There were 6 patients with postoperative complications in the lower PALND group,accounting for 14.0%(6/43).There was no significant difference between the two groups(P > 0.05).The positive rate of para-aortic lymph nodes in high PALND group was higher than that in low PALND group.In the high PALND group,2 patients had solitary high PALNM.Conclusions:1.The metastasis rate of isolated para-aortic lymph nodes was low.If pelvic lymph node metastasis was found,para-aortic lymph node resection up to the renal vein should be performed.2.Compared with inframesenteric PALND,PALND up to RV could reduce the recurrence rate.3.Compared with inframesenteric PALND,PALND up to RV increased operative time,but did not significantly increase the risk of surgery.