Routine aortic lymphadenectomy cannot be justified in early stage endometrial and cervical carcinoma.

Nicholas Kadar, MD.
New Margaret Hague Women's Health Institute &
Englewood Hospital Medical Center, New Jersey.


Aortic lymphadenectomy or "sampling" (ALN) has become incorporated into the surgical management of almost every gynecological malignancy, most notably early stage endometrial and cervical carcinoma, including small stage IB and IA2 lesions. [1-10] It is suggested that this practice cannot be justified by the frequency of aortic lymph node metastases in such patients, and given the infrequency of skip lesions, ALN should be reserved for patients who have pelvic lymph node metastases (PLNM). If PLNM are detected only on permanent sections, after the primary operation, ALN is then performed as a separate second procedure.
This two-stage approach to aortic lymphadenectomy was first investigated in endometrial carcinoma. [11] Based on published data, potential criteria for aortic (and pelvic) lymphadenectomy were investigated by calculating the following variables for every possible combination of tumor grade and depth of myometrial invasion:

  • Sensitivity for positive nodes

  • Proportion of women meeting the criterion for lymphadenectomy

  • Proportion of lymph node metastases detected

  • No. lymphadenectomies required to detect one case of positive nodes

  • No. lymphadenectomies required to cure one case of positive nodes

  • No. lymphadenectomies required to cure each additional patient not cured by the next most sensitive criterion.


The findings showed that although pelvic lymphadenectomy could be justified in all cases of endometrial carcinoma except grade I disease confined to uterus, aortic lymphadenectomy could only be justified in women who had deep myometrial invasion. Using this criterion, 22% of women would be subjected to aortic lymphadenectomy, 71% of aortic lymph node metastases would be identified, 6 aortic lymphadenectomies performed to detect one case of positive aortic nodes, and 14 aortic lymphadenectomies to cure one patient with aortic lymph node metastases (assuming a 40% cure rate). However, for every other criterion more than one hundred lymphadenectomies would be required to cure one additional patients with aortic lymph node metastases.
These results were then compared with the outcome expected if aortic lymphadenectomy was predicated on the presence of positive pelvic nodes. Use of the presence of pelvic lymph node metastases rather than deep myometrial invasion as the criterion for aortic lymphadenectomy resulted in a 35% reduction in the number of aortic lymphadenectomies, a 23% increase in the number of aortic lymph node metastases detected. In 7% of cases, however, the aortic lymphadenectomy would have to be performed as a separate second