Tailoring lymphadenectomy according to the risk of lymph node metastasis in endometrial cancer
Tailoring lymphadenectomy according to the risk of lymph node metastasis in endometrial cancer
复制标题
根据子宫内膜癌淋巴结转移的风险调整淋巴结清扫术
DOI：
10.1111/jog.12309
复制
发表时间：
2014
影响因子：
1.6
通讯作者：
N. Sakuragi
中科院分区：
文献类型：
--
作者：
Y. Todo;H. Watari;Sokbom Kang;N. Sakuragi
研究强烈建议，淋巴结转移风险低的子宫内膜癌患者不能从淋巴结切除术中获益，中风险/高风险子宫内膜癌患者可以从完全盆腔和主动脉帕拉淋巴结切除术中获益。这一假设需要通过前瞻性研究来验证。对于随机对照试验（RCT），干预的异质性会损害内部效度，而经验丰富的医生的不参与会损害外部效度。由于这些情况很容易发生在针对高风险患者的随机手术试验中，复杂手术（如全淋巴结切除术）的影响可能会被低估。在一项著名的研究中，所有合格患者的数据表明，非随机组的生存结局显著优于随机组。一个合理的解释是，医生的判断和经验比随机选择产生更好的治疗决定。虽然两个来自欧洲国家的RCT显示淋巴结切除术对预后的负面结果，但重视个体患者的护理可能比不加批判地采用RCT的结果更重要。在子宫内膜癌中，淋巴结切除术必须量身定制，以最大限度地提高手术的治疗效果，并最大限度地减少其侵袭性和不良反应。两个战略是：（i）切除最可能隐藏疾病的淋巴结，同时保留不太可能受影响的淋巴结;以及（ii）仅对可能从中受益的患者进行完全淋巴结切除术。在这里，我们重点介绍第二种策略。讨论了在日本和韩国用于选择淋巴结切除术不会受益的低风险患者的术前风险评估。
It has been strongly suggested that patients with endometrial cancer with low risk of lymph node metastasis do not benefit from lymphadenectomy and that intermediate‐risk/high‐risk endometrial cancer patients benefit from complete pelvic and para‐aortic lymphadenectomy. This hypothesis needs to be validated by prospective studies. For randomized controlled trials (RCT), heterogeneity of intervention compromises internal validity and non‐participation of experienced doctors compromises external validity. As these situations easily occur in randomized surgical trials (RST) intended for high‐risk patients, the effects of complicated surgery, such as full lymphadenectomy, might be underestimated in RST. In a famous RST, data for all eligible patients implied that survival outcome for the non‐randomized group was significantly better than that for the randomized group. One plausible explanation is that physicians' judgment and experience produce better treatment decisions than do random choices. Although two RCT from European countries showed negative results of lymphadenectomy on prognosis, valuing the care of individual patients may be more important than uncritically adopting the results of RCT. In endometrial cancer, lymphadenectomy must be tailored to maximize the therapeutic effect of surgery and minimize its invasiveness and adverse effects. Two strategies are: (i) to remove lymph nodes most likely to harbor disease while sparing lymph nodes that are unlikely to be affected; and (ii) to perform full lymphadenectomies only on patients who can potentially benefit from them. Here, we focus on the second strategy. Preoperative risk assessments used in Japan and Korea to select low‐risk patients who would not benefit from lymphadenectomy are discussed.