Impact of uterine manipulator on oncological outcome in endometrial cancer surgery

Controversies in the Surgical Management of Gynecologic Cancer: Balancing the Decision to Operate or Hesitate

Cancer outcomes are largely measured in terms of disease-free survival or overall survival, which is highly dependent on timely diagnosis and access to treatment methods available within the country's existing health care system. Although cancer survival rates have markedly led in the past few decades, any improvement in the 5-year survival of gynecologic cancers has been modest, as in the case of ovarian and cervical cancers, or has declined, as in the case of endometrial cancer. The lack of effective screening options contributes to many women presenting with advanced-stage disease and the need for radical approaches to treatment. Although treatment for early-stage disease can lead to a cure, advanced-stage disease is fraught with a high potential for morbidity and mortality, and recent clinical trials have aimed to assess the noninferiority of minimally invasive options versus aggressive surgical approaches. Of particular interest is fertility-sparing treatments for endometrial and cervical cancers, which have recently been on the rise among younger women. Balancing morbidity with the risk of mortality, and loss of fertility and quality of life requires a targeted patient-centered approach to treatment. This is an ongoing area of intense research and sometimes may challenge current treatment paradigms. In this two-part review, we present an overview of current approaches to gynecologic cancer treatment and the need to de-escalate radical surgical approaches and preserve fertility. We also review the intricacies of ovarian and advanced endometrial cancer treatment, exploring the nuances in surgical debulking timing and its impact on outcomes.

Endometrial cancer: predictors and oncological safety of tumor tissue manipulation

PURPOSE

The main goal of this study is to assess the impact of tumor manipulation on the presence of lympho-vascular space invasion and its influence on oncological results.

METHODS

We performed a retrospective multi-centric study amongst patients who had received primary surgical treatment for apparently early-stage endometrial cancer. A multivariate statistical analysis model was designed to assess the impact that tumor manipulation (with the use of uterine manipulator or preoperative hysteroscopy) has on lympho-vascular development (LVSI) in the final surgical specimen.

RESULTS

A total of 2852 women from 15 centers were included and divided into two groups based on the lympho-vascular status in the final surgical specimen: 2265 (79.4%) had no LVSI and 587 (20.6%) presented LVSI. The use of uterine manipulator was associated with higher chances of lympho-vascular involvement regardless of the type used: Balloon manipulator (HR: 95% CI 4.64 (2.99-7.33); p < 0.001) and No-Balloon manipulator ([HR]: 95% CI 2.54 (1.66-3.96); p < 0.001). There is no evidence of an association between the use of preoperative hysteroscopy and higher chances of lympho-vascular involvement (HR: 95% CI 0.90 (0.68-1.19); p = 0.479).

CONCLUSION

Whilst performing common gynecological procedures, iatrogenic distention and manipulation of the uterine cavity are produced. Our study suggests that the use of uterine manipulator increases the rate of LVSI and, therefore, leads to poorer oncological results. Conversely, preoperative hysteroscopy does not show higher rates of LVSI involvement in the final surgical specimen and can be safely used.

SUrgical Access and Pattern of Recurrence of Endometrial Cancer: The SUPeR Study, a Multicenter Retrospective Observational Study

STUDY OBJECTIVE

To evaluate recurrence rate and pattern in apparently early-stage endometrial cancer (EC) treated with minimally invasive surgery (MIS) and compare it to the "historical" populations treated by laparotomy. Secondary outcomes were to establish if, among MIS recurrent patients, intermediate-high/high-risk patients presented the same recurrence pattern compared to those at low/intermediate-risk and to evaluate time to first recurrence (TTR) of the study population.

DESIGN

Multicenter retrospective observational study.

SETTING

Five Italian Gynecologic Oncology referral centers.

PATIENTS

All patients with proven recurrence of apparently early-stage EC treated with MIS from January 2017 to June 2022 . The laparotomic historical cohort was obtained from Laparoscopy Compared With Laparotomy for Comprehensive Surgical Staging of Uterine Cancer: Gynecologic Oncology Group Study (LAP2) and Laparoscopic Approach to Cancer of the Endometrium trials.

INTERVENTIONS

Evaluation of recurrence rate and pattern.

MEASUREMENTS AND MAIN RESULTS

Seventy-seven recurrences occurred on the total of 1028 patients treated with MIS for apparently early-stage EC during a median follow-up time of 36 months. The rate of recurrence in our cohort did not differ significantly from the rate of the historical cohort (7.4% vs 7.9%, odds ratio 0.9395, 95% CI 0.6901-1.2792). No significant differences were noticed for local, abdominal, nodal, and multiple site recurrence patterns; distant site recurrence appeared more likely in patients from the historical cohort. Postoperative low/intermediate risk patients had a higher likelihood of local recurrence compared to intermediate-high/high risk patients. Mean TTR was 19 months. No significant difference of TTR was observed for each pattern of recurrence compared to others.

CONCLUSION

MIS appears to be safe for the treatment of early-stage EC. We did not identify any recurrence pattern specifically associated with MIS in early-stage EC.

Intrauterine manipulator use during laparoscopic hysterectomy for endometrial cancer: association for pathological factors and oncologic outcomes

OBJECTIVE

To examine the association between intrauterine manipulator use and pathological factors and oncologic outcomes in patients with endometrial cancer who had laparoscopic hysterectomy in Japan.

METHODS

This was a nationwide retrospective cohort study of the tumor registry of the Japan Society of Obstetrics and Gynecology. Study population was 3846 patients who had laparoscopic hysterectomy for endometrial cancer from January 2015 to December 2017. An automated 1-to-1 propensity score matching with preoperative and intraoperative demographics was performed to assess postoperative pathological factors associated with the intrauterine manipulator. Survival outcomes were assessed by accounting for possible pathological mediators related to intrauterine manipulator use.

RESULTS

Most patients had preoperative stage I disease (96.5%) and grade 1-2 endometrioid tumors (81.9%). During the study period, 1607 (41.8%) patients had intrauterine manipulator use and 2239 (58.2%) patients did not. In the matched cohort, the incidences of lymphovascular space invasion in the hysterectomy specimen were 17.8% in the intrauterine manipulator group and 13.3% in the non-manipulator group. Intrauterine manipulator use was associated with a 35% increased odds of lymphovascular space invasion (adjusted odds ratio 1.35, 95% confidence interval (CI) 1.08 to 1.69). The incidences of malignant cells identified in the pelvic peritoneal cytologic sample at hysterectomy were 10.8% for the intrauterine manipulator group and 6.4% for the non-manipulator group. Intrauterine manipulator use was associated with a 77% increased odds of malignant peritoneal cytology (adjusted odds ratio 1.77, 95% Cl 1.29 to 2.31). The 5 year overall survival rates were 94.2% for the intrauterine manipulator group and 96.6% for the non-manipulator group (hazard ratio (HR) 1.64, 95% Cl 1.12 to 2.39). Possible pathological mediators accounted HR was 1.36 (95%Cl 0.93 to 2.00).

CONCLUSION

This nationwide analysis of predominantly early stage, low-grade endometrial cancer in Japan suggested that intrauterine manipulator use during laparoscopic hysterectomy for endometrial cancer may be associated with an increased risk of lymphovascular space invasion and malignant peritoneal cytology. Possible mediator effects of intrauterine manipulator use on survival warrant further investigation, especially with a prospective setting.

The Impact of Intrauterine Manipulators on Outcome and Recurrence Patterns of Endometrial Cancer Patients Undergoing Minimally Invasive Surgery

Objective: To evaluate the use of manipulators on the outcome of women who had minimally invasive surgery for endometrial cancer. Methods: Retrospective analysis of patients operated with or without an intrauterine manipulator. Results: Six hundred ninety-nine patients were included. The median follow-up was 44 months (range, 29-67). Nineteen (8.8%) patients had positive cytology in the manipulator group versus 21 (4.4%) in the comparison group (p = 0.02). Total recurrence rate was similar between the groups (12.3% vs. 11.9%; p = 0.8). Vaginal vault recurrence was the most common site of recurrence with higher incidence in the manipulator group (4.5% vs. 1.3%; p = 0.007). Subgroup analysis of low-risk patients who did not receive adjuvant treatment showed higher recurrence rate (8.3% vs. 3%; p = 0.023) and worse disease-free survival (p = 0.01) for the manipulator group. After controlling for other variables, the use of a manipulator did not affect the risk of recurrence for the whole cohort (hazard ratio [HR], 1.28; confidence interval [95% CI], 0.7-2.1, p = 0.3) and for the low-risk subgroup of patients who did not receive adjuvant treatment (HR, 2.47; 95% CI, 0.8-7, p = 0.08). Conclusion: The use of a manipulator increases the risk of positive cytology as well as vaginal vault recurrences, but it does not reduce the overall survival of patients.

Reviving peritoneal cytology: Exploring its role in endometrial cancer molecular classification

OBJECTIVE

The prognostic significance of positive peritoneal cytology in endometrial cancer has long been debated. In 2009, the Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) removed cytology as a staging criterion from the endometrial cancer staging system. However, there is still evidence that positive peritoneal cytology may decrease survival among patients with endometrial cancer. The aim of this study was to determine the prognostic significance of positive peritoneal cytology among the different molecular subgroups.

METHODS

This study included patients with endometrial cancer who underwent primary surgical treatment between 2004 and 2015 at the Bern University Hospital, Switzerland, with molecular classification of the primary tumor and peritoneal cytology performed.

RESULTS

A total, 250 patients with endometrial cancer were enrolled. Peritoneal cytology was assessed in 206 patients, of whom 24% were positive: 25% of the POLEmut, 16% of the MMRd, 41% of the p53abn, and 24% of the NSMP cases. The mean follow-up was 128.7 months. Presence of positive peritoneal cytology was associated with significantly decreased mean recurrence-free and overall survival in patients with p53abn (p = .003 and p = .001) and NSMP (p = .020 and p = .049) endometrial cancer. In multivariable Cox regression analysis, positive peritoneal cytology remained an independent predictor of recurrence (p = .033) and death (p = .008) in p53abn endometrial cancer patients.

CONCLUSION

Positive peritoneal cytology is associated with worse oncologic outcomes in NSMP and p53abn endometrial cancer and remains an independent predictor of recurrence and death in patients with p53abn endometrial cancer.

Pattern of recurrence in endometrial cancer. The murderer always returns to the scene of the crime

BACKGROUND

Endometrial cancer recurrence occurs in about 18 % of patients. This study aims to analyze the pattern recurrence of endometrial cancer and the relationship between the initial site of primary disease and the relapse site in patients undergoing surgical treatment.

METHODS

We retrospectively reviewed all surgically treated patients with endometrial cancer selecting those with recurrence. We defined primary site disease as uterus, lymph nodes, or peritoneum according to pathology analysis of the surgical specimen. The site of recurrence was defined as vaginal cuff, lymph nodes, peritoneum, and parenchymatous organs. Our primary endpoint was to correlate the site of initial disease with the site of recurrence.

RESULTS

The study enrolled 1416 patients. The overall recurrence rate was 17,5 % with 248 relapses included in the study. An increase of 9.9, 5.7, and 5.7 times in the odds of relapse on the lymph node, peritoneum, and abdominal parenchymatous sites respectively was observed in case of nodal initial disease (p < 0.001). A not significant difference in odds was observed in terms of vaginal cuff relapse (OR 0.9) between lymph node ad uterine primary disease (p = 0.78). An increasing OR of 8.7 times for nodal recurrences, 46.6 times for peritoneum, and 23.3 times for parenchymatous abdominal recurrences were found in the case of primary peritoneal disease (p < 0.001).

CONCLUSION

Endometrial cancer tends to recur at the initial site of the disease. Intraoperative inspection of the adjacent sites of primary disease and targeted instrumental examination of the initial sites of disease during follow-up are strongly recommended.

Intrauterine manipulator during hysterectomy for endometrial cancer: a systematic review and meta-analysis of oncologic outcomes

OBJECTIVE

This study aimed to assess the effects on oncologic outcomes of intrauterine manipulator use during laparoscopic hysterectomy for endometrial cancer.

DATA SOURCES

A systematic literature search was performed by an expert librarian in multiple electronic databases from inception to January 31, 2023.

STUDY ELIGIBILITY CRITERIA

We included all studies in the English language that compared oncologic outcomes (recurrence-free, cause-specific, or overall survival) between endometrial cancer patients who underwent total laparoscopic or robotic hysterectomy for endometrial cancer with vs without the use of an intrauterine manipulator. Studies comparing only peritoneal cytology status or lymphovascular space invasion were summarized for completeness. No selection criteria were applied to the study design.

METHODS

Four reviewers independently reviewed studies for inclusion, assessed their risk of bias, and extracted data. Pooled hazard ratios with 95% confidence intervals were estimated for oncologic outcomes using the random effect model. Heterogeneity was quantified using the I2 tests. Publication bias was assessed by funnel plot and Egger test.

RESULTS

Out of 350 identified references, we included 2 randomized controlled trials and 12 observational studies for a total of 14 studies and 5,019 patients. The use of an intrauterine manipulator during hysterectomy for endometrial cancer was associated with a pooled hazard ratio for recurrence of 1.52 (95% confidence interval, 0.99-2.33; P=.05; I2=31%; chi square P value=.22). Pooled hazard ratio for recurrence was 1.48 (95% confidence interval, 0.25-8.76; P=.62; I2=67%; chi square P value=.08) when only randomized controlled trials were considered. Pooled hazard ratio for overall survival was 1.07 (95% confidence interval, 0.65-1.76; P=0.79; I2=44%; chi square P value=.17). The rate of positive peritoneal cytology or lymphovascular space invasion did not differ using an intrauterine manipulator.

CONCLUSION

Intrauterine manipulator use during hysterectomy for endometrial cancer was neither significantly associated with recurrence-free and overall survival nor with positive peritoneal cytology or lymphovascular space invasion, but further prospective studies are needed.

Impact of surgical approach on progress of disease by type of histology in stage IA endometrial cancer: a matched-pair analysis

BACKGROUND

To compare the impact of surgical approach on progression free survival (PFS) stratified by histologic type in women diagnosed with stage IA endometrial cancer.

METHODS

Myometrial invasion is classified into no myometrial invasion, <50% and ≥50%, with only no myometrial invasion and <50% are included in stage IA patients. A retrospective study is designed by collecting data from women diagnosed as stage IA endometrial cancer from January 2010 to December 2019 in a tertiary hospital. A propensity score is conducted for 1:1 matching in the low-risk histologic patients. Progression free survival and disease-specific survival data are evaluated by the Kaplan-Meier method and compared by the log-rank test in both the whole population and the matched-pair groups. A sub-group analysis is performed to figure out risk factors associated with the effect of surgical approach on PFS and disease-specific survival (DSS).

RESULTS

534 (84.49%) low-risk histologic endometrial cancer women, with 389 (72.85%) operated by minimally invasive surgery and 145 (27.15%) by open approach, and 98 (15.51%) high-risk histology, with 71 (72.45%) by laparoscopy and 27 (27.55%) by open surgery, are included. Compared to open surgery, laparoscopy results in lower progression free survival in low-risk patients before and after matching (p = 0.039 and p = 0.033, respectively), but shows no difference in high-risk patients (p = 0.519). Myometrial invasion is associated with lower progression free survival in laparoscopy in low-risk histology (p = 0.027).

CONCLUSION

Surgical approaches influence progression free survival in stage IA low-risk histologic diseases, especially in those with myometrial invasion, but not in high-risk histologic endometrial cancer.

Multidirectional Traction Method Using SURGICEL NU-KNIT and Surgical Suture in Robot-assisted Laparoscopic Surgery for Endometrial Cancer

OBJECTIVE

To describe a novel approach to robot-assisted laparoscopic total hysterectomy (RH) for endometrial cancer that minimizes cancer sell spillage and develops a stable surgical field.

DESIGN

Demonstration of the multidirectional traction method with narrated video footage.

SETTING

Many reports have indicated that RH for endometrial cancer has the same or superior short-term results compared with conventional laparoscopic hysterectomy (LH), and the long-term prognosis is the same [1,2]. However, there are no randomized controlled trials of RH versus LH, and some previous reports [3] have suggested that RH has a worse prognosis than LH, so the long-term prognosis should be considered with caution. Factors that may affect the long-term prognosis include the use of uterine manipulators [4] and compression of the uterine body with robotic forceps without tactile sensation [3]. However, to the best of our knowledge, no surgical technique capable of avoiding these factors has been established yet. Herein, we report a multidirectional traction method using SURGICEL NU-KNIT (Ethicon; Johnson & Johnson Medical Ltd., Tokyo, Japan), a local hemostatic agent, and surgical sutures.

INTERVENTION

Cut 2-0 Prolene (Ethicon; Johnson & Johnson Medical Ltd., Tokyo, Japan) with straight needles (ST-70) thread to 35 cm, stick a 1 × 2 cm piece of SURGICEL NU-KNIT, and make knots Fig. 1. This implement is used to puncture the incisional margins of the peritoneum and then the abdominal wall to bring the thread to the surface of the body, where it is grasped with forceps and fixed. By repeating this operation, multidirectional traction can be obtained Fig. 2. A manipulating suture is also attached to the uterus to minimize the compression of the uterine body with robotic forceps.

CONCLUSION

The multidirectional traction method allows for reproducible stable surgical field development and minimizes cancer cell spillage by reducing uterine grasping by robotic forceps without the use of uterine manipulators.

Long-term outcome of minimally invasive staging surgery for clinical stage I endometrial cancer: A single institute experience in Taiwan

BACKGROUND

Endometrial cancer is the most common gynecological cancer in developed countries. With recent advances in equipment and knowledge, minimally invasive surgery (MIS) is widely accepted for the treatment of endometrial cancer. This study had the largest number of cases to date in Taiwan, comparing outcomes between MIS and laparotomy staging surgery using real-world data with long-term follow-up.

METHODS

We retrospectively reviewed patients with clinical stage 1 endometrial cancer from 2009 to 2020 in our institute. All patients underwent comprehensive surgical staging procedures by MIS or laparotomy. The safety, morbidity, progression-free survival (PFS), and overall survival (OS) rates of the two groups were compared. Clinical and pathologic factors were compared with Chi-square and Fisher Exact test. PFS and OS were estimated by the Kaplan-Meier method. Differences between survival curves were analyzed using the log-rank test. A p value of <0.05 was considered statistically significant. Using Cox proportional hazards models, all factors found to be significantly associated with risk of recurrence on univariate analyses were then assessed together through multivariable models, resulting in a final oncologic outcome between MIS and laparotomy.

RESULTS

A total of 665 cases (412 cases in MIS group and 253 cases in laparotomy group) were enrolled for data analysis. Median operation time was shorter in MIS group (244 and 265 minutes, p < 0.001). Median blood loss was also less (75 and 430 mL, p < 0.001). Median postoperative hospitalization duration was longer in the laparotomy group (2 and 7 days, p = 0.001). After adjusting presurgery risk factors, the PFS and OS were no significant difference in MIS and laparotomy groups.

CONCLUSION

Using real-world data with long-term follow-up, we could confirm excellent PFS and OS in selective patients with clinical stage 1 endometrial carcinoma who received MIS, and the surgical time, hospital day, and blood loss were also less.

Should laparoscopy be revisited in the management of stage II endometrial cancer in the post-LACC era?

BACKGROUND

A recent randomized trial showed that laparoscopy had poorer outcomes compared with open surgery for early-stage cervical cancer. Whether this is of concern in endometrial cancer, when the cervix is involved has received little attention. This study aimed to investigate whether there is any difference on overall and cancer specific survival between patients treated with laparoscopy and laparotomy for stage II endometrial cancer.

METHODS

Data from patients with histologically proven stage II endometrial cancer who were treated between 2010 and 2019 in a single cancer center were reviewed. Demographic, histopathological characteristics and treatment modalities were recorded. Recurrence rate, cancer specific and overall survival were compared between patients that were treated with laparoscopic and open surgery.

RESULTS

From 47 patients with stage II disease, 33 (70%) were treated with laparoscopy and 14 (30%) with open surgery. There was no difference on age (P=0.86), BMI (P=0.76), Comorbidity Index Score (P=0.96), upstaging/upgrading after surgery (P=0.41), performance of lymphadenectomy (P=0.74), histological type (P=0.32), LVSI (P=0.15), depth of myometrial invasion (P=0.07), postoperative hospital stay (P=0.18) and administration of adjuvant treatment (P=0.11) between the two groups. Recurrence rate (P=0.756), overall (P=0.606) and cancer specific survival (P=0.564) were also comparable between laparoscopy and laparotomy groups.

CONCLUSIONS

Laparoscopic and open surgery seem to have comparable outcomes for stage II endometrial cancer. The oncological safety of laparoscopy for stage II endometrial cancer should be further investigated with a randomized controlled trial.

Mixed Endometrial Epithelial Carcinoma: Epidemiology, Treatment and Survival Rates-A 10-Year Retrospective Cohort Study from a Single Institution

Mixed endometrial carcinoma (MEEC) refers to rare endometrial tumours that are composed of two or more distinct histotypes, at least one of which is serous or clear cell. The aim of this study was to evaluate the epidemiology, treatment outcomes and survival rates of patients with mixed endometrial carcinoma. The medical records of 34 patients diagnosed with MEEC between March 2010 and January 2020 were reviewed retrospectively. Clinicopathological variables and treatment strategies were assessed, and overall survival and disease-free survival rates were evaluated. The histology of endometrioid and serous component was found in 26 (76.5%) patients, followed by serous and clear-cell components (5/34, 14.5%) and mixed endometrioid serous and clear-cell components (3/34, 8.8%). The median age at diagnosis was 70 years (range 52-84), and the median follow-up time was 55 months. The 5-year disease-free survival and the 5-year overall survival were 50.4% and 52.4%, respectively. Advanced disease stage was identified as an independent predictor of inferior disease-free (<0.003) and overall survival (p < 0.001). Except for stage, none of the traditional prognostic factors was associated with disease recurrence or death from disease. MEECs represent rare high-risk endometrial carcinomas with significant diagnostic and treatment challenges. Undoubtedly, the implementation of a molecular analysis can offer further diagnostic and management insights.

Comparison of Minimally Invasive and Open Surgery for the Treatment of Endometrial Cancer with a High Risk of Recurrence: A Propensity Score Matching Study in Korea and Taiwan

BACKGROUND

This study compared oncologic outcomes between minimally invasive surgery (MIS) and open surgery for the treatment of endometrial cancer with a high risk of recurrence.

METHODS

This study included patients with endometrial cancer who underwent primary surgery at two tertiary centers in Korea and Taiwan. Low-grade advanced-stage endometrial cancer (endometrioid grade 1 or 2) or endometrial cancer with aggressive histology (endometrioid grade 3 or non-endometrioid) at any stage was considered to have a high risk of recurrence. We conducted 1:1 propensity score matching between the MIS and open surgery groups to adjust for the baseline characteristics.

RESULTS

Of the total of 582 patients, 284 patients were included in analysis after matching. Compared with open surgery, MIS did not show a difference in disease-free survival [hazard ratio (HR) 1.09; 95% confidence interval (CI) 0.67-1.77, P = 0.717] or overall survival (HR 0.67; 95% CI 0.36-1.24, P = 0.198). In the multivariate analysis, non-endometrioid histology, tumor size, tumor cytology, depth of invasion, and lymphovascular space invasion were risk factors for recurrence. There was no association between the surgical approach and either recurrence or mortality in the subgroup analysis according to stage and histology.

CONCLUSIONS

MIS did not compromise survival outcomes for patients with endometrial cancer with a high risk of recurrence when compared with open surgery.

Questionnaire survey regarding current status of minimally invasive surgery for endometrial cancer in Japan: A cross-sectional survey for JSGOE members

AIM

Minimally invasive surgery (MIS) has been introduced as an alternative to more radical surgical procedures. The Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy conducted a cross-sectional questionnaire survey to ascertain the status of MIS for endometrial cancer.

METHODS

The survey was conducted between May 10 and June 30, 2022. The questionnaire included information on personal attributes, academic affiliations, qualifications, hysterectomies, and intraoperative procedures performed.

RESULTS

The total number of questionnaire respondents was 436 (9.2% of the membership). The hysterectomy methods and percentage performed were as follows: simple total hysterectomy (equivalent to benign surgery), 3%; simple total hysterectomy with care to avoid shaving the cervix, 31%; extended total hysterectomy, 48%; and modified radical hysterectomy, 15%. An analysis of hysterectomies performed using MIS for endometrial cancer by qualified gynecologists of endoscopy or board-certified gynecologic oncologists showed a tendency not to choose simple total hysterectomy compared to the gynecologists who did not hold certification (p = 0.019, p = 0.045, and p = 0.010, respectively). Additionally, 67% of respondents did not use uterine manipulators, and 59% of the respondents did not perform lymph node dissection following the guidelines for treating endometrial cancer in Japan.

CONCLUSION

This study provided the current status of MIS for endometrial cancer in Japan. The hysterectomy method, use of uterine manipulators, and criteria for omitting lymph node dissection were generally in agreement with the guidelines. Currently, an extra-fascial simple hysterectomy, including at least not shaving the cervix, was a major method for early invasive endometrial cancer using MIS.

Use of uterine manipulator and uterine perforation in minimally invasive endometrial cancer surgery

OBJECTIVE

Safety of the uterine manipulator (UM) within endometrial cancer (EC) surgery is being questioned. Its use might be one of the issues for potential tumor dissemination during the procedure, especially in the case of uterine perforation (UP). No prospective data on this surgical complication, nor on the oncological consequences exist. The aim of this study was to assess the rate of UP while using UM when performing surgery for EC and the impact of UP on the choice of adjuvant treatment.

METHODS

We conducted a prospective single-center cohort study from November 2018 to February 2022, considering all EC cases surgically treated by a minimally invasive approach with the help of a UM. Demographic, preoperative, postoperative and adjuvant treatment corresponding to the included patients were collected and comparatively analyzed according to the absence or presence of a UP.

RESULTS

Of the 82 patients included in the study, 9 UPs (11%) occurred during surgery. There was no significant difference in demographics and disease characteristics at diagnosis that may have induced UP. The type of UM used or the approach (laparoscopic vs. robotic) did not influence the occurrence of UP (p = 0.44). No positive peritoneal cytology was found post hysterectomy. There was a statistically significantly higher rate of lymph-vascular space invasion within the perforation group, 67% vs. 25% in the no perforation group, p = 0.02. Two out of nine (22%) adjuvant therapies were changed because of UP. The median follow-up time for patients was 7.6 months (range 0.5-33.1 months). No recurrence was found in the UP group.

CONCLUSION

Our study found a uterine perforation rate of 11%. This information needs to be further integrated to consider the usefulness of MU for EC surgery.

Association of Lymphovascular Space Invasion (LVSI) with Histological Tumor Grade and Myometrial Invasion in Endometrial Carcinoma: A Review Study

Endometrial carcinoma is one of the most frequent gynecological cancers in developed countries. Lymphovascular space invasion (LVSI), histological grade, and myometrial invasion (MMI) are important prognostic factors of endometrial carcinoma. LVSI is considered an independent poor prognostic factor in endometrial carcinoma. Based on the importance of LVSI, this study aimed to discuss the association of LVSI with tumor grade and MMI. A search of PubMed, EMBASE, Web of Science, Scopus, Google Scholar, and Cochrane Library was carried out to collect related studies. Consequently, most studies showed that LVSI is significantly associated with higher histologic grade and deep MMI.

Intra-operative tumor spillage in minimally invasive surgery for endometrial cancer and its impact on recurrence risk

OBJECTIVE

The prognostic impact of intra-operative tumor spillage (ITS) during minimally invasive surgery (MIS) for endometrial cancer (EC) is not well studied. The objective of this study was to determine if there is an association between ITS and EC recurrence.

METHODS

We performed a case-control study of patients with a laparoscopic or robot-assisted hysterectomy with EC on final pathology between 2017 and 2022 and compared those with (case) and without (control) a subsequent EC recurrence. Electronic medical records were reviewed for demographic, intra-operative and pathologic details, and recurrence status. ITS was defined as uterine perforation with a manipulator, presence of extra-uterine tumor after colpotomy or specimen delivery, exposure of uncontained specimen into peritoneum, and/or pathology/operative reports noting specimen fragmentation. Conditional logistic regression was used to determine odds ratios for the association of cancer recurrence with ITS. We adjusted for >50% myoinvasion, tumor size, and adjuvant treatment.

RESULTS

1057 patients underwent MIS for EC. Approximately 8% (n = 86) developed recurrent cancer and 172 patients were selected as controls. Twenty percent of recurrent cases (17/86) had ITS compared with 4% of nonrecurrent controls (7/172). When adjusted for tumor size, deep myoinvasion, and adjuvant treatment, patients with ITS had a 5.6 times increased odds (aOR 5.63, 95% CI 1.52-20.86) of recurrence compared to patients without ITS.

CONCLUSIONS

In patients with EC, we found an association between ITS and cancer recurrence. These findings warrant further investigation to determine if adjuvant therapy or surgical technique should be altered to improve outcomes.

The Prognostic Characteristics and Recurrence Patterns of High Grade Endometrioid Endometrial Cancer: A Large Retrospective Analysis of a Tertiary Center

High grade endometrioid endometrial cancer (HGEEC) is a heterogeneous group of tumors with unclear prognostic features. The aim of the present study is to evaluate the independent risk factors for recurrence and mortality and to describe the recurrence patterns of HGEEC. Ninety-six consecutive cases of HGEEC treated with primary surgery in a single Tertiary Center were retrospectively reviewed. Clinicopathological and treatment details were recorded, and all patients were closely followed up. Disease-free, overall and cancer-specific survival rates were 83.8%, 77.8% and 83.6%, respectively. Cervical stromal involvement was independently related to recurrence (HR = 25.67; 95%CI 2.95-223.30; p = 0.003) and cancer-related death (HR = 15.39; 95%CI 1.29-183.43; p = 0.031) after adjusting for other pathological and treatment variables. Recurrence rate was 16%, with 60% of these cases having lung metastases and only one case with single vaginal vault recurrence. 81.81% of the recurrences presented with symptoms and not a single recurrence was diagnosed in routine follow-up clinical examination. In conclusion, the recurrence pattern may suggest that patient-initiated follow-up (PIFU) could be considered a potential alternative to clinical-based follow-up for HGEEC survivors, especially for patients without cervical involvement and after two years from treatment. Additional caution is needed in patients with cervical stromal involvement.

Clinical characteristics and prognostic characterization of endometrial carcinoma: a comparative analysis of molecular typing protocols

BACKGROUND

Endometrial carcinoma (EC) is one of the most common gynecological malignancies in China and globally, accounting for the fourth-prevalent cancer in women. Although numerous studies have confirmed prognostic value of The Cancer Genome Atlas (TCGA) molecular subgroups, it is unclear how they are combined with histological features. The main objective of this study was to compare ProMisE and TCGA classification for the rapid and accurate prediction of prognosis within EC patients, together with the provision of a revised strategy for individualized diagnosis and treatment of patients.

METHODS

Within this study, 70 patients with EC from Beijing Tsinghua Changgeng Hospital (affiliated to Tsinghua University) were retrospectively examined between July 2015 and December 2021. Samples were processed for determination of clinical markers, together with ProMisE and TCGA classification.

RESULTS

Comparative analysis across four TCGA types (POLE, Low-CN, High-CN, and MSI-H) and age, was statistically significant (χ²= 7.000, p = 0.029). There was no significant difference observed among the four TCGA types and FIGO stage, vascular invasion and depth of invasion, or lymph node metastasis and tumor area. There was no significant association between the expression of Vimentin, Ki-67, PTEN, MSH2, PAX-8, β-catenin, CD10, ER, PR, P16, MLH1, and PMS2 with the four TCGA types. In addition, p63 expression (χ²= 11.09, p = 0.029) and p53 expression (χ²= 11.585, p = 0.005) were statistically significant. Numerous models demonstrated that patients with POLE mutations and low-CN had higher progression free survival (PFS) and overall survival (OS), whereas those with high-CN had lowest values. The log-rank test revealed that the survival rate of PR-positive and ER-positive patients was significantly higher (p < 0.001).

CONCLUSION

Overall, these results can be of additional benefit for clinical applications, in comparison to the ProMisE classification method. In addition, PR, ER, vascular infiltration, hyperlipidemia and atherosclerosis were found to be the key factors affecting EC prognosis.

Clinical Relevance of Uterine Manipulation on Oncologic Outcome in Robot-Assisted versus Open Surgery in the Management of Endometrial Cancer

In this study, we investigated the impact of uterine manipulation on endometrial cancer survival outcomes. We analyzed patients with endometrial cancer who underwent robot-assisted staging and open staging surgery between 2010 and 2020. Either uterine manipulators or vaginal tubes were utilized in robot-assisted staging. Propensity score matching was performed to correct baseline characteristics. Progression-free survival (PFS) and overall survival (OS) were analyzed using Kaplan-Meier curve analysis. In total, 574 patients, including those undergoing robot-assisted staging with a uterine manipulator (n = 213) or vaginal tube (n = 147) and staging laparotomy (n = 214), were analyzed. Propensity score matching was performed for age, histology, and stage as covariates. Before matching, Kaplan-Meier curve analysis showed that PFS and OS were significantly different among the three groups (p < 0.001 and p = 0.009, respectively). In the propensity-matched cohorts of 147 women, the previously suggested differences in PFS and OS were not observed in patients undergoing robot-assisted staging with a uterine manipulator or vaginal tube or open surgery. In conclusion, robotic surgery using a uterine manipulator or vaginal tube did not compromise survival outcomes in endometrial cancer management.

Influence of uterine manipulator use on the incidence of lymphovascular propagation in the treatment of endometrial cancer

BACKGROUND

Endometrial cancers are among the epithelial malignancies of the lining of the uterine cavity. The invasion of carcinoma into the lymphovascular space (LVSI) is considered a risk factor for the course of the disease.

MATERIAL AND METHODS

We evaluated 170 female patients. Our primary objective was to find any difference in the incidence of LVSI in female patients treated with and without an intrauterine manipulator. In addition, we analyzed the effect of the type of intrauterine manipulator used on the incidence of LVSI, tumor grading, myometrial invasion, and the method of obtaining primary histology with regard to the incidence of LVSI.

RESULTS

Using a manipulator during surgery was not associated with LVSI (with a manipulator vs. without, 11.5 vs. 21.7%; OR 1.8; 95% CI 0.73-4.39; p = 0.199). However, the method used to obtain the primary histology had a statistically significant effect on the incidence of LVSI in our set (p-value = 0.011).

CONCLUSIONS

In our study, we did not confirm the effect of a uterine manipulator on the possible increase of LVSI positive cases. The secondary analysis indicated a higher incidence of LVSI in the female patients diagnosed with curettage than in those who underwent hysteroscopy. Trail registration: Trail is registered in ClicincalTrails.gov with identifier: NCT05261165.

Minimally Invasive Compared With Open Surgery in High-Risk Endometrial Cancer: A Systematic Review and Meta-analysis

OBJECTIVE

To compare outcomes between minimally invasive surgery and open surgery in patients with high-risk endometrial cancer.

DATA SOURCES

A cohort study of all patients who underwent surgery for high-risk endometrial cancer between 1999 and 2016 at Mayo Clinic (Rochester, Minnesota) and a literature search of MEDLINE, EMBASE, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, and Scopus of all published studies until December 2020.

METHODS OF STUDY SELECTION

The systematic review identified 2,332 patients (14 studies, all retrospective except a subanalysis of a randomized comparison) and the cohort study identified 542 additional patients. Articles were included if reporting original data on overall survival and disease-free survival among patients with high-risk endometrial cancer, defined as International Federation of Gynecology and Obstetrics grade 3 endometrioid, serous, clear cell, mixed histology, or uterine carcinosarcoma. Studies that did not report at least one of the main outcomes, those in which one surgical technique (robotic or laparoscopic surgery) was missing in the comparison analysis with open surgery, and case reports were excluded. Additional data were extracted from a retrospective cohort of patients from Mayo. A random-effect model was used for meta-analysis.

TABULATION, INTEGRATION, AND RESULTS

This systematic review and meta-analysis was registered in PROSPERO. Literature search and data extraction were performed independently by two reviewers, as well as quality assessment using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology, and the Newcastle-Ottawa Scale. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Meta-analysis showed that disease-free survival and overall survival in patients with high-risk endometrial cancer who underwent minimally invasive surgery were not statistically different from those of patients who underwent open abdominal surgery (relative risk [RR] 0.93, 95% CI 0.82-1.05, I2 20%, P=.23; and RR 0.92, 95% CI 0.77-1.11, I2 31%, P=.12, respectively). Subgroup analysis by stage (early vs advanced) did not identify a difference between surgical approaches.

CONCLUSION

Minimally invasive surgery and open surgery had similar disease-free survival and overall survival in patients with high-risk endometrial cancer.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021275535.

Minimally invasive radical hysterectomy and the importance of avoiding cancer cell spillage for early-stage cervical cancer: a narrative review

Radical hysterectomy is a standard surgery to treat early-stage uterine cervical cancer. The Laparoscopic Approach to Cervical Cancer (LACC) trial has shown that patients receiving minimally invasive radical hysterectomy have a poorer prognosis than those receiving open radical hysterectomy; however, the reason for this remains unclear. The LACC trial had 2 concerns: the learning curve and the procedural effects. Appropriate management of the learning curve effect, including surgeons' skills, is required to correctly interpret the result of surgical randomized controlled trials. Whether the LACC trial managed the learning curve effect remains controversial, based on the surgeons' inclusion criteria and the distribution of institutions with recurrent cases. An appropriate surgical procedure is also needed, and avoiding intraoperative cancer cell spillage plays an important role during cancer surgery. Cancer cell spillage during minimally invasive surgery to treat cervical cancer is caused by several factors, including 1) exposure of tumor, 2) the use of a uterine manipulator, and 3) direct handling of the uterine cervix. Unfortunately, these issues were not addressed by the LACC trial. We evaluated the results of minimally invasive radical hysterectomy while avoiding cancer cell spillage for early-stage cervical cancer. Our findings show that avoiding cancer cell spillage during minimally invasive radical hysterectomy may ensure an equivalent oncologic outcome, comparable to that of open radical hysterectomy. Therefore, evaluating the importance of avoiding cancer cell spillage during minimally invasive surgery with a better control of the learning curve and procedural effects is needed.

Urologic Complication after Laparoscopic Hysterectomy in Gynecology Oncology: A Single-Center Analysis and Narrative Review of the Literature

Background and Objectives: Minimally invasive surgery (MIS) has recently increased its application in the treatment of gynecological malignancies. Despite technological and surgical advances, urologic complications (UC) are still the main concern in gynecology surgery. Current literature reports a wide range of urinary tract injuries, and consistent scientific evidence is still lacking or dated. This study aims to report a large single-center experience of urinary complications during laparoscopic hysterectomy for gynecologic oncologic disease. Materials and Methods: All patients who underwent laparoscopic hysterectomy for gynecologic malignancy at the Department of Medicine and Surgery of the University Hospital of Parma from 2017 to 2021 were retrospectively included. Women with endometrial cancer, cervical cancer, ovarian cancer, uterine sarcoma, or borderline ovarian tumors were included. Patients undergoing robotic surgery with incomplete anatomopathological data or patients lost during follow-up were excluded from the analysis. Intraoperative and postoperative UC were analyzed and ranked according to the Clavien-Dindo classification. Results: Two hundred-sixty patients were included in the study: 180 endometrial cancer, 18 cervical cancer, nine ovarian cancer, two uterine sarcomas, and 60 borderline ovarian tumors. Nine (3.5%) UCs were reported (five intraoperative and four postoperative complications). No anamnestic variables showed a statistical correlation with the surgical complication in the univariable analyses. C1 radical hysterectomy, a higher FIGO stage, and postoperative adjuvant treatment (p-value = 0.001, p-value = 0.046, and p-value = 0.046, respectively) were independent risk factors associated with the occurrence of UC. Conclusions: The urological complication rates in patients with oncological disease are relatively rare events in the expert hands of dedicated surgeons. Radical hysterectomy, FIGO stage, and adjuvant treatment are independent factors associated with urinary complications.

Prospective Multicenter Trial Assessing the Impact of Positive Peritoneal Cytology Conversion on Oncological Outcome in Patients with Endometrial Cancer Undergoing Minimally Invasive Surgery with the use of an Intrauterine Manipulator : Positive Peritoneal Cytology Conversion and Its Association with Oncological Outcome in Endometrial Cancer

BACKGROUND

Minimally invasive surgery is the standard approach in early-stage endometrial cancer according to evidence showing no compromise in oncological outcomes, but lower morbidity compared with open surgery. However, there are limited data available on the oncological safety of the use of intrauterine manipulators in endometrial cancer.

PATIENTS AND METHODS

This prospective multicenter study included patients with endometrial cancer undergoing laparoscopic staging surgery with the use of an intrauterine manipulator. We obtained three different sets of peritoneal washings: at the beginning of the surgical procedure, after the insertion of the intrauterine manipulator, and after the closure of the vaginal vault. The rate of positive peritoneal cytology conversion and its association with oncological outcomes was assessed.

RESULTS

A total of 124 patients were included. Peritoneal cytology was negative in 98 (group 1) and positive in 26 (group 2) patients. In group 2, 16 patients presented with positive cytology at the beginning of the surgery (group 2a) and 10 patients had positive cytology conversion during the procedure (group 2b). Recurrence rate was significantly different among the study groups, amounting to 9.2%, 25.0%, and 60.0% for groups 1, 2a, and 2b, respectively (p < 0.001). Group 1 showed the best recurrence-free and overall survival, followed by group 2a, while patients in group 2b had the worst oncological outcomes (p = 0.002 and p = 0.053, respectively). Peritoneal cytology was an independent predictor of recurrence and death on multivariable analysis.

CONCLUSION

A total of 8.1% of patients with endometrial cancer undergoing minimally invasive surgery with intrauterine manipulation showed positive peritoneal cytology conversion associated with significantly worse oncological outcome.

Therapeutic Benefit of Systematic Lymphadenectomy in Node-Negative Uterine-Confined Endometrioid Endometrial Carcinoma: Omission of Adjuvant Therapy

Simple Summary

Endometrial cancer is the most common gynecological tract malignancy in developed countries. Extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors.

Abstract

Endometrial cancer is the most common gynecological tract malignancy in developed countries, and its incidence has been increasing globally with rising obesity rates and longer life expectancy. In endometrial cancer, extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors. In this review, I discuss the characteristics of lymph node metastasis, the methods of lymph node assessment, and the therapeutic benefits of systematic lymphadenectomy in patients with intermediate- and high-risk endometrioid endometrial carcinoma.

Does Vaginal Cuff Creation and Avoidance of a Uterine Manipulator Improve the Prognosis of Total Laparoscopic Radical Hysterectomy for Early Cervical Cancer? A Retrospective Multicenter Study

Our goal was to compare the treatment outcomes of open-abdominal radical hysterectomy (O-RH) and total laparoscopic hysterectomy (TLRH) with vaginal cuff creation and without using a uterine manipulator in stage IB1-B2 (tumor size < 4 cm) cervical cancer cases. In this retrospective multicenter analysis, 94 cervical cancer stage IB1-B2 patients who underwent O-RH or TLRH in six hospitals in Japan between September 2016 and July 2020 were included; 36 patients underwent TLRH. Propensity score matching was performed because the tumor diameter was large, and positive cases of lymph node metastases were included in the O-RH group due to selection bias. The primary endpoint was progression-free survival (PFS) and recurrence sites of TLRH and O-RH. PFS and OS (overall survival) were not significant in both the TLRH (n = 27) and O-RH (n = 27) groups; none required conversion to laparotomy. The maximum tumor size was <2 and ≥2 cm in 12 (44.4%) and 15 (55.6%) patients, respectively, in both groups. Reportedly, the TLRH group had lesser bleeding than the O-RH group (p < 0.001). Median follow-up was 33.5 (2−65) and 41.5 (6−75) months in the TLRH and O-RH groups, respectively. PFS and OS were not significantly different between the two groups (TLRH: 92.6%, O-RH: 92.6%; log-rank p = 0.985 and 97.2%, 100%; p = 0.317, respectively). The prognosis of early cervical cancer was not significantly different between TLRH and O-RH. Tumor spillage was prevented by creating a vaginal cuff and avoiding the use of a uterine manipulator. Therefore, TLRH might be considered efficient.

Oncological safety of hysteroscopy in endometrial cancer

OBJECTIVE

It has been suggested that the manipulation of neoplastic tissue during hysteroscopy may lead to dissemination of tumor cells into the peritoneal cavity and worsen prognosis and overall survival. The goal of this study was to assess the oncological safety comparing hysteroscopy to Pipelle blind biopsy in the presurgical diagnosis of patients with endometrial cancer.

METHODS

We performed a retrospective multicentric study among patients who had received primary surgical treatment for endometrial cancer. A multivariate statistical analysis model was used to compare relapse and survival rates in patients who had been evaluated preoperatively either by hysteroscopy or Pipelle biopsy. The relapse rate, disease-free survival, and overall survival were assessed as the main outcomes. The histological type, tumor size, myometrial invasion, International Federation of Gynecology and Obstetrics (FIGO) stage, surgical approach, use of a uterine manipulator, and adjuvant treatment were also included in the analysis.

RESULTS

A total of 1731 women from 15 centers were included: 1044 in the hysteroscopy group and 687 in the Pipelle sampling group. 225 patients relapsed during the 10 year follow-up period: 139 (13.3%) in the hysteroscopy group and 86 (12.4%) in the Pipelle sampling group. There is no evidence of an association between the use of hysteroscopy as a diagnostic method and relapse rate (HR 1.24, 95% CI 0.92 to 1.66; p=0.16), lower disease-free survival (HR 1.23, 95% CI 0.92 to 1.66; p=0.15), or overall survival (HR 0.95, 95% CI 0.70 to 1.29; p=0.76).

CONCLUSION

Hysteroscopy is a safe diagnostic method for patients with endometrial cancer with no impact on oncological outcomes when compared with sampling by Pipelle.

Malignant peritoneal cytology in endometrial cancer: a contemporary review

INTRODUCTION

: In endometrial cancer, malignant peritoneal cytology (MPC) refers to the presence of tumor cells in the peritoneal cytologic specimen obtained at hysterectomy. MPC was once a component of uterine cancer staging criteria, but it is no longer included in the current revision. Multiple societies and organizations, however, continue to recommend peritoneal cytologic testing at the time of hysterectomy for endometrial cancer.

AREAS COVERED

This contemporary review provides a clinical summary of recent studies evaluating MPC, including risk factors and prognosis. Compared to prior studies showing a lack of impact on oncologic outcome, recent studies have larger sample sizes, use stricter inclusion criteria, and perform histology/cancer stage-specific analyses to balance risk factors and provide explicit interpretations for oncologic outcomes related to MPC. These newer data provide evidence that MPC does have a prognostic impact.

EXPERT OPINION

Three key domains related to MPC are followings: First, recognition of MPC as a prognostic factor for endometrial cancer irrespective to stage (early and advanced) and histology (endometrioid and non-endometrioid) is necessary. Second, peritoneal cytologic testing at the beginning of each staging surgery is recommended. Last, incorporation of peritoneal cytology status in adjuvant treatment algorithms is useful and merits further development.

Influence of uterine manipulator on oncological outcome in minimally invasive surgery of endometrial cancer: A systematic review and meta-analysis

AIM

The endoscopic approach for early-stage endometrial cancer (EC) treatment is considered gold standard. Some authors expressed their concern regarding uterine manipulator (UM) as a risk factor for tumor spillage and dissemination allowing peritoneal or lympho-vascular spaces invasion (LVSI). This meta-analysis aimed to evaluate the effect of UM on the presence of LVSI, recurrence rate and presence of atypical or malignant peritoneal cytology in patients with endometrial cancer.

METHODS

We searched electronic databases including PubMed, MEDLINE, Embase, Scopus, EBSCO, Google Scholar, and ClinicalTrials.gov. The pooled results were used to evaluate the association between the use of UM and oncological outcomes. This systematic review was reported according to PRISMA statement 2020. Statistical meta-analysis was performed using Review Manager software.

RESULTS

This systematic review included 18 studies (3 prospective studies, 13 retrospective studies, and 2 RCT). The pooled results showed no significant difference (RR: 0.86, 95% CI, 0.69 to 1.08) in the incidence of LVSI between manipulated hysterectomy and total abdominal hysterectomy (TAH) and between UM group and non-UM group in minimally invasive surgery (RR: 1.18, 95% CI, 0.76 to 1.85), no significant difference in the rate of recurrence (RR: 1.11, 95% CI, 0.71 to 1.74), in the incidence of positive peritoneal cytology between manipulated and non-manipulated hysterectomies in minimally invasive surgery (RR: 1.89, 95% CI, 0.74 to 4.83) and before and after the use of uterine manipulator (RR: 1.21, 95% CI, 0.68 to 2.16). We found a positive association between malignant cytology and hysterectomies in which a uterine manipulator had been used in a sub-group analysis where LH/LAVH were compared to TAH. (RR = 2.26, 95% CI, 1.08-4.71. P = 0.03).

CONCLUSIONS

This meta-analysis supports that the use of uterine manipulator for minimally invasive treatment of endometrial cancer does not increase the rate of recurrence and LVSI. Therefore, the opportunity of any other studies on its use in endometrial cancer women should be questioned.

Open Surgery including Lymphadenectomy without Adjuvant Therapy for Uterine-Confined Intermediate- and High-Risk Endometrioid Endometrial Carcinoma

Minimally invasive surgery may not be an appropriate surgical approach in intermediate- and high-risk endometrial carcinoma, even though adjuvant therapy is given. The objective of this study was to evaluate the results of open surgery including lymphadenectomy without adjuvant therapy in patients with uterine-confined intermediate- and high-risk endometrioid endometrial carcinoma. Two hundred fifty-six patients with uterine-confined endometrioid endometrial carcinoma were treated with open surgery, including pelvic with or without para-aortic lymphadenectomy. Of the 81 patients with uterine-confined intermediate- or high-risk disease, 77 were treated with systematic lymphadenectomy without adjuvant therapy. Seven patients developed recurrence, comprising 5.5% (3/55) and 18.2% (4/22) of the intermediate- and high-risk patients, respectively. The time to recurrence was 1–66 months. The sites of recurrence were the vaginal apex (n = 2), lung (n = 2), vaginal sidewall (n = 1), pelvic lymph nodes (n = 1), and para-aortic to supraclavicular nodes (n = 1). Of these, five patients were alive without disease after salvage treatment, but two understaged high-risk patients died of disease. The five-year disease-specific survival rates of intermediate- and high-risk patients were 100% and 90%, respectively. The present study indicated that patients with uterine-confined intermediate- and high-risk endometrioid endometrial carcinoma had excellent survival when treated with open surgery, including lymphadenectomy alone. The safety of omitting adjuvant therapy should be evaluated in prospective randomized trials comparing open surgery with minimally invasive surgery.

Endometrial cancer

Endometrial cancer is the most common gynaecological cancer in high income countries and its incidence is rising globally. Although an ageing population and fewer benign hysterectomies have contributed to this trend, the growing prevalence of obesity is the major underlying cause. Obesity poses challenges for diagnosis and treatment and more research is needed to offer primary prevention to high-risk women and to optimise endometrial cancer survivorship. Early presentation with postmenopausal bleeding ensures most endometrial cancers are cured by hysterectomy but those with advanced disease have a poor prognosis. Minimally invasive surgical staging and sentinel-lymph-node biopsy provides a low morbidity alternative to historical surgical management without compromising oncological outcomes. Adjuvant radiotherapy reduces loco-regional recurrence in intermediate-risk and high-risk cases. Advances in our understanding of the molecular biology of endometrial cancer have paved the way for targeted chemotherapeutic strategies, and clinical trials will establish their benefit in adjuvant, advanced, and recurrent disease settings in the coming years.

Survival Analysis in Endometrial Carcinomas by Type of Surgical Approach: A Matched-Pair Study

Simple Summary

We carried out a retrospective cohort study of 1382 women diagnosed with endometrial cancer (EC). A total of 684 (49.5%) were operated on by minimally invasive surgery (MIS), 233 (34%) by robotic-assisted laparoscopy (RAL), 451 (66%) by conventional laparoscopy (LPS), and 698 (50.5%) by open surgery (OP). Disease-free (DFS), overall (OS), and specific survival related to EC (SS) outcomes were significantly higher for MIS compared to OP. When matched by age, BMI, co-morbidities, ASA score, histological type, grade, myometrial invasion, and FIGO stage, the DFS, OS, and SS amounts were similar between the MIS and OP groups. The surgical approach for women with EC does not impact disease-free or overall survival amounts when matched by homogeneous groups, but laparoscopy seems to offer a higher specific overall survival rate compared to the open surgery approach.

Abstract

(1) Background: This study aimed to analyze the impact of surgical approach on survival rates in women diagnosed with endometrial cancer. (2) Methods: A retrospective multicenter cohort of 1382 women diagnosed with EC was performed. A total of 684 (49.5%) women underwent minimally invasive surgery, 233 (34%) underwent robotic-assisted laparoscopy (RAL), 451 (66%) underwent conventional laparoscopy (LPS), and 698 (50.5%) underwent open surgery (OP). Sociodemographic features, tumor characteristics, and survival rates were analyzed in the whole sample and in a matched-pair model. (3) Results: Women operated on by OP were significantly older, presented more comorbidities, and had more aggressive tumors. Disease-free (DFS), overall (OS), and specific survival related to EC (SS) amounts were significantly higher for MIS compared to OP (p < 0.001). When matched by age, body mass index, comorbidities, ASA score, histological type, grade, myometrial invasion, and FIGO stage, 798 patients were selected. DFS, OS, and SS amounts were similar between the MIS and OP groups. (4) Conclusions: The surgical approach for women with EC does not impact DFS or OS amounts when matched by homogeneous groups.

Radical Hysterectomy for Cervical Cancer: the Right Surgical Approach

OPINION STATEMENT

Radical hysterectomy with pelvic lymph node assessment is the standard initial therapy for early-stage cervical cancer. Radical hysterectomy via laparotomy (an "open" approach) was first described more than 100 years ago and has been the standard for decades. Minimally invasive surgery (MIS) has been increasingly adopted by many surgeons due to its reported perioperative benefits. MIS was deemed safe for radical hysterectomy for many years based on multiple retrospective publications. Recently, the Laparoscopic Approach to Cervical Cancer (LACC) trial reported that patients randomized to MIS had inferior oncologic outcomes. The results of the LACC trial and subsequent retrospective studies led multiple professional societies to state that open radical hysterectomy should remain the gold standard surgical approach. We acknowledge that the open approach for radical hysterectomy is an appropriate option for all cervical cancer patients eligible for surgical treatment. However, considering the limitations of the LACC trial and the available data from other retrospective studies, we feel the MIS approach should not be simply abandoned. There may still be a role for MIS in cervical cancer surgery for properly and carefully selected cases and with detailed counseling; surgeons should analyze their own outcomes closely in order to perform such counseling. Modification of surgical technique and maintaining proper oncologic surgical principles are key for MIS to remain a viable option. Tumor manipulation and contamination should be avoided. Transcervical uterine manipulators should not be used. Cervical and tumor containment prior to colpotomy, as is performed during an open approach, is required. This will all require validation in future trials. We await the results of ongoing randomized trials to further inform us. A one-size-fits-all approach may be short-sighted; we may need to decide treatment strategy based on the notion of the right surgical approach for the right patient by the right surgeon.

Minimally Invasive Surgery for Cervical Cancer in Light of the LACC Trial: What Have We Learned?

Cervical cancer is the most common gynecologic malignancy and the fourth most common cancer in women worldwide. Over the last two decades, minimally invasive surgery (MIS) emerged as the mainstay in the surgical management of cervical cancer, bringing advantages such as lower operative morbidity and shorter hospital stay compared to open surgery while maintaining comparable oncologic outcomes in numerous retrospective studies. However, in 2018, a prospective phase III randomized controlled trial, “Laparoscopic Approach to Carcinoma of the Cervix (LACC)”, unexpectedly reported that MIS was associated with a statistically significant poorer overall survival and disease-free survival compared to open surgery in patients with early-stage cervical cancer. Various hypotheses have been raised by the authors to try to explain these results, but the LACC trial was not powered to answer those questions. In this study, through an exhaustive literature review, we wish to explore some of the potential causes that may explain the poorer oncologic outcomes associated with MIS, including the type of MIS surgery, the size of the lesion, the impact of CO2 pneumoperitoneum, prior conization, the use of uterine manipulator, the use of protective measures, and the effect of surgical expertise/learning curve.

Retrospective Analysis of Cervical Cancer Treatment Outcomes: Ten Years of Experience with the Vaginal Assisted Radical Laparoscopic Hysterectomy VARLH

BACKGROUND

LACC trial demonstrated inferiority of laparoscopic approach for the treatment of early-stage cervical cancer. There are still limited data from retrospective trials regarding whether survival outcomes after laparoscopic radical hysterectomy are equivalent to those after open abdominal radical hysterectomy. In this study, we present results of combined vaginal radical laparoscopic hysterectomy in the treatment of early-stage cervical cancer.

METHODS

This retrospective study was carried out at the Department of Gynecology in Mathilden Hospital (Herford, Germany). Between January 2008 and April 2018, all the patients with invasive cervical cancer who underwent combined vaginal assisted radical laparoscopic hysterectomy (VARLH) without the use of any uterine manipulator were enrolled to the study.

RESULTS

A total number of 124 patients with diagnosis of invasive cervical cancer were enrolled in the study. All of the patients underwent minimally invasive surgery and were divided according to FIGO 2019: stage IA (25.9%), IB1 (25.0%), IB2-IIB (28.4%), and III/IV (20.7%). Overall, the mean age of the patients was 51.84 years. After a study collection, a median follow-up was 45.6 (range 23.7-76.5) months. The 3- and 5-year disease-free survival rates for early-stage cervical cancer were both 98%, and the 3- and 5-year overall survival rates were 100% and 97%, respectively. We have not observed any recurrence in our study group of patients with early-stage cervical cancer.

CONCLUSIONS

Combined VARLH can be considered a safe and effective procedure for the treatment of early-stage cervical cancer. Surgical strategy with oncological principles determines the quality and long-term success of the operation in early cervical cancer regardless of laparoscopic approach.

Laparoscopic surgery for atypical endometrial hyperplasia with awareness regarding the possibility of endometrial cancer

Objectives

Although atypical endometrial hyperplasia (AEH) is considered a precancerous disease, the frequency with which AEH and endometrial cancer (EC) coexist is not low. Broadly, total laparoscopic hysterectomy (TLH) is performed for treating AEH; however, it is unclear what perioperative precautions need to be taken. This study aimed to clarify the points to be considered when performing TLH for AEH.

Materials and Methods

We retrospectively identified 57 patients who underwent TLH for AEH in our hospitals. We extracted data on clinical characteristics, preoperative examinations (endometrial sampling and diagnostic imaging), surgical procedures, and final pathological diagnoses. Then, we statistically analyzed the difference in clinicopathological features and preoperative examinations between patients postoperatively diagnosed with EC and those diagnosed with AEH.

Results

Twenty patients (35%) who underwent TLH for AEH were diagnosed with EC postoperatively (16 [28%] with stage IA EC and four [7.0%] with stage IB EC). We found no significant differences in clinical characteristics and preoperative evaluations between patients postoperatively diagnosed with EC and those diagnosed with AEH. The group with stage IB EC had a significantly higher median age and a significantly higher proportion of postmenopausal patients and patients with adenomyosis.

Conclusion

It is important to recognize the risk of coexisting EC when performing TLH for AEH. High-precision endometrial sampling and contrast-enhanced magnetic resonance imaging are recommended for diagnosing AEH. In addition, surgical procedures for AEH are required to prevent cancer spillage in consideration of its coexistence, such as tubal sealing before manipulator insertion or avoiding using manipulator.

Oncologic Outcomes of Laparoscopic Radical Hysterectomy Using the No-Look No-Touch Technique for Early Stage Cervical Cancer: A Propensity Score-Adjusted Analysis

Simple Summary

Minimally invasive radical hysterectomy is contraindicated in early stage cervical cancer cases because of poor prognosis. The no-look no-touch technique (NLNT) eliminates intraoperative tumor spillage and may improve survival outcomes. We evaluated oncologic outcomes of laparoscopic radical hysterectomy performed using NLNT. We compared the outcomes of abdominal radical hysterectomy and NLNT using inverse probability of treatment weighting. We found no significant differences in disease-free survival between the groups, even in patients with tumor sizes ≥ 2 cm. We also studied NLNT’s non-inferiority to abdominal radical hysterectomy by evaluating heterogeneity between the results of the Laparoscopic Approach to Cervical Cancer (LACC) trial and those of our study. We did not observe significant heterogeneity, although there was a trend toward a lower hazard ratio in our study compared with the non-inferiority margin in the LACC trial. Laparoscopic radical hysterectomy using NLNT is a plausible alternative surgical treatment for early stage cervical cancer.

Abstract

We evaluated oncologic outcomes of laparoscopic radical hysterectomy using the no-look no-touch technique (NLNT). We analyzed patients with early stage (IA2, IB1, and IIA1, FIGO2008) cervical cancer treated between December 2014 and December 2019. The primary endpoint was disease-free survival (DFS). We compared the outcomes of the abdominal radical hysterectomy (ARH) and NLNT groups using a Cox model with inverse probability of treatment weighting (IPTW), according to propensity scores. We also evaluated NLNT’s non-inferiority to ARH using an evaluation of heterogeneity between the results of the Laparoscopic Approach to Cervical Cancer (LACC) trial and our study. ARH and NLNT were performed in 118 and 113 patients, respectively. The median follow-up duration was 3.2 years. After IPTW adjustment, the 3-year DFS rates (NLNT 92.4%; ARH 94.0%) and overall survival rates did not differ significantly between the groups. Furthermore, the 3-year DFS rates for patients with tumor sizes ≥ 2 cm in the NLNT (85.0%) and ARH (90.3%) groups did not differ significantly. No significant heterogeneity was observed between the LACC trial and our study (I² = 60.5%, p = 0.111), although there was a trend toward a lower hazard ratio in our study. Laparoscopic radical hysterectomy using NLNT provides a favorable prognosis for early stage cervical cancer.

Minimally Invasive Compared With Open Hysterectomy in High-Risk Endometrial Cancer

OBJECTIVE

To compare disease-free survival between minimally invasive surgery and open surgery in patients with high-risk endometrial cancer.

METHODS

We conducted a multicentric, propensity-matched study of patients with high-risk endometrial cancer who underwent hysterectomy, bilateral salpingo-oophorectomy, and staging between January 1999 and June 2016 at two centers. High-risk endometrial cancer included grade 3 endometrioid, serous, clear cell, undifferentiated carcinoma or carcinosarcoma with any myometrial invasion. Patients were categorized a priori into two groups based on surgical approach, propensity scores were calculated based on potential confounders and groups were matched 1:1 using nearest neighbor technique. Cox hazard regression analysis and Kaplan-Meier curves evaluated the association of surgical technique with survival.

RESULTS

Of 626 eligible patients, 263 (42%) underwent minimally invasive surgery and 363 (58%) underwent open surgery. In the matched cohort, there were no differences in disease-free survival rates at 5 years between open (53.4% [95% CI 45.6-60.5%]) and minimally invasive surgery (54.6% [95% CI 46.6-61.8]; P=.82). Minimally invasive surgery was not associated with worse disease-free survival (hazard ratio [HR] 0.85, 95% CI 0.63-1.16; P=.30), overall survival (HR 1.04, 95% CI 0.73-1.48, P=.81), or recurrence rate (HR 0.99; 95% CI 0.69-1.44; P=.99) compared with open surgery. Use of uterine manipulator was not associated with worse disease-free survival (HR 1.01, 95% CI 0.65-1.58, P=.96), overall survival (HR 1.18, 95% CI 0.71-1.96, P=.53), or recurrence rate (HR 1.12, 95% CI 0.67-1.87; P=.66).

CONCLUSION

There was no difference in oncologic outcomes comparing minimally invasive and open surgery among patients with high-risk endometrial cancer.

Intraoperative tumor spill during minimally invasive hysterectomy for endometrial cancer: A survey study on experience and practice

OBJECTIVE

Tumor spill during surgical treatment is associated with adverse oncologic outcomes in many solid tumors. However, in minimally invasive hysterectomy for endometrial cancer, intraoperative tumor spill has not been well studied. This study examined surgeon experiences and practices related to intraoperative tumor spill during minimally invasive hysterectomy for endometrial cancer.

METHODS

A cross-sectional survey was conducted to the Society of Gynecologic Oncology. Participants were 220 U.S. gynecologic oncologists practicing minimally invasive hysterectomy for endometrial cancer. Interventions were 20 questions regarding surgeon demographics, surgical practice patterns (fallopian tubal ablation/ligation, intra-uterine manipulator use, and colpotomy approach), and tumor spill experience (uterine perforation with intra-uterine manipulator and tumor exposure during colpotomy).

RESULTS

Nearly half of the responding surgeons completed subspeciality training >10 years ago (50.5%), and 74.1% had annual surgical volume of >40 cases. The majority of surgeons used an intra-uterine manipulator during minimally invasive hysterectomies for endometrial cancer (90.1%), and 87.2% of the users have experienced uterine perforation with an intra-uterine manipulator. Almost all surgeons performed colpotomy laparoscopically (95.9%), and nearly 60% had experienced tumor spill while making colpotomy (59.8%). Nearly 10-15% of surgeons have changed their postoperative therapy as a result of intraoperative uterine perforation (11.8%) or tumor spill (14.5%). Surgeons infrequently ablated or ligated fallopian tubes prior to performing the hysterectomy (14.1%).

CONCLUSION

Our survey study suggests that many surgeons experienced intraoperative tumor spillage during minimally invasive hysterectomy for endometrial cancer. These findings warrant further studies examining its incidence and impact on clinical outcomes.

Minimally invasive approach in endometrial cancer with lower uterine segment involvement in stage ≥ II: A retrospective study

OBJECTIVE

To compare oncological outcomes in women with lower uterine segment involvement (LUSI) in endometrial carcinoma (EC) stage ≥ II - staged by a minimally invasive surgery (MIS) versus laparotomy.

STUDY DESIGN

A retrospective multi-center cohort study. Univariate analysis, Kaplan-Meier survival and Cox proportional hazard analysis were performed to compare between women staged by MIS and those staged by laparotomy.

RESULTS

Over a median follow-up period of 3 years (interquartile range, 1.5-6 years) 212 women were included, 68 (32.1%) were surgically staged by MIS. Stages of disease did not vary between MIS and laparotomy and were 32.1%, 51.9%, and 16.0%, in stages II, III and IV - respectively. Adjuvant radiation and chemotherapy rate did not differ between groups. Overall recurrence rate was comparable (p = 0.084). Locoregional recurrence rate was higher in the MIS group odds ratio 2.17, 95% confidence interval 1.19-4.20). Overall and progression free survival were similar in both groups (log rank test p = 0.08 and p = 0.912 respectively). In Cox regression model adjusting for age, comorbidities, tumor grade, stage and adjuvant therapy, route of surgery (MIS vs. laparotomy) was not associated with overall survival (p = 0.169).

CONCLUSIONS

In women with advanced EC and LUSI, although MIS is associated with locoregional recurrences, survival is comparable to laparotomy.