Lymph Node Metastasis Lymph node metastasis is the most important prognostic factor in clinical early-stage endometrial cancer. Of patients with clinical stage I disease, about 10% will have pelvic and 6% will have para-aortic lymph node metastases. Patients with lymph node metastases have almost a sixfold higher likelihood of developing recurrent cancer than patients without lymph node metastases. One study reported a recurrence rate of 48% with positive lymph nodes, including 45% with positive pelvic nodes and 64% with positive aortic nodes, compared with 8% with negative nodes. The 5-year disease-free survival rate for patients with lymph node metastases was 54%, compared with 90% for patients without lymph node metastases (148). The GOG found that the presence or absence of para-aortic lymph node metastases was of paramount importance in determining prognosis. Of 48 para-aortic node–positive patients, 28 (58%) developed progressive or recurrent cancer, and only 36% of these patients were alive at 5 years, compared with 85% of patients without para-aortic node involvement (194). One series examined patients with lymph nodes metastases in addition to other extrauterine sites of disease (vagina, uterine serosa, positive peritoneal cytology, adnexal invasion). The recurrence rateswere67% (41% extranodal) for those with lymphatic dissemination versus. 32% (5% extranodal) for those with other sites of extrauterine disease spread (190).
Intraperitoneal Metastases Extrauterine metastasis, excluding peritoneal cytology and lymph node metastasis, occurs in about 4% to 6% of patients with clinical stage I endometrial cancer. Gross intraperitoneal spread is highly correlated with lymph node metastases; one study noted that 51% of patients with intraperitoneal tumor had positive lymph nodes, whereas only 7% of patients without gross peritoneal spread had positive nodes (141). Extrauterine spread other than lymph node metastasis issignificantly associated with tumor recurrence. Another study found that 50% of patients with extrauterine disease developed recurrence, compared with 11% of patients without extrauterine disease, making recurrence almost fivetimes more likely in patients with extrauterine disease spread. The 5-year disease-free survival rate for patients with nonlymphatic extrauterine disease was 50%, compared with 88% in other patients (148). Predictors of peritoneal relapse include stage IV disease or stage II or III disease with two or more of the following risk factors: cervical invasion, positive peritoneal cytology, positive lymph nodes, and nonendometrioid histology (195).
Types I and II Endometrial Carcinoma: Molecular Aberrations