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Cheng H, Clymer JW, Po-Han Chen B, Sadeghirad B, Ferko NC, Cameron CG, Hinoul P. Prolonged operative duration is associated with complications: a systematic review and meta-analysis. J Surg Res 2018; 229:134-144. [PMID: 29936980 DOI: 10.1016/j.jss.2018.03.022] [Citation(s) in RCA: 398] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 02/27/2018] [Accepted: 03/14/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The aim of this study was to systematically synthesize the large volume of literature reporting on the association between operative duration and complications across various surgical specialties and procedure types. METHODS An electronic search of PubMed, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from January 2005 to January 2015 was conducted. Sixty-six observational studies met the inclusion criteria. RESULTS Pooled analyses showed that the likelihood of complications increased significantly with prolonged operative duration, approximately doubling with operative time thresholds exceeding 2 or more hours. Meta-analyses also demonstrated a 14% increase in the likelihood of complications for every 30 min of additional operating time. CONCLUSIONS Prolonged operative time is associated with an increase in the risk of complications. Given the adverse consequences of complications, decreased operative times should be a universal goal for surgeons, hospitals, and policy-makers. Future study is recommended on the evaluation of interventions targeted to reducing operating time.
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Rodríguez-Trujillo A, Martínez-Serrano MJ, Martínez-Román S, Martí C, Buñesch L, Nicolau C, Pahisa J. Preoperative Assessment of Myometrial Invasion in Endometrial Cancer by 3D Ultrasound and Diffusion-Weighted Magnetic Resonance Imaging: A Comparative Study. Int J Gynecol Cancer 2017; 26:1105-10. [PMID: 27177278 DOI: 10.1097/igc.0000000000000724] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The prognosis of endometrial cancer depends on the correct surgical staging. In early stages, 18% to 30% rate of positive lymph nodes is reported with a myometrial invasion of 50% or more. According to this, patients with International Federation of Gynecology and Obstetrics stage Ib would benefit from staging lymphadenectomy. Therefore, it is important to classify these patients preoperatively to plan the surgery. In the recent years, 3-dimensional (3D) ultrasound and diffusion-weighted magnetic resonance imaging (DW-MRI) have been incorporated in the preoperative management of these patients. The aim of this study was to assess the usefulness of 3D ultrasound and DW-MRI as predictor of myometrial invasion in endometrial cancer. MATERIAL AND METHODS We retrospectively compared the assessment of myometrial invasion by 3D ultrasound and DW-MRI with final pathologic evaluation on hysterectomy specimens, in 98 patients diagnosed of early-stage endometrial cancer, who underwent surgery at the Hospital Clinic of Barcelona between 2012 and 2015. RESULTS Evaluation of the depth of myometrial invasion with 3D ultrasound had a sensitivity, specificity, and accuracy of 77%, 83% and 81%, respectively. Evaluation of the depth of myometrial invasion with DW-MRI had a sensitivity, specificity, and accuracy of 69%, 86%, and 81%, respectively. Association of both techniques improved all the values, showing a sensitivity, specificity, and accuracy of 87%, 93%, and 91%, respectively. In both 3D ultrasound and DW-MRI, the presence of leiomyomas was the first detectable cause of false negative (3% and 4%, respectively) and false-positive (3% and 1%, respectively). CONCLUSIONS We conclude that the implementation of the 2 studies in early-stage endometrial cancer provides low false-negatives and false-positives rates. In cases of patients with leiomyomas, adenomiosis, or intrauterine fluid collection, definitive evaluation of myometrial invasion could be better deferred to intraoperative biopsy in an attempt to reduce false-negatives and false-positives rates.
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Affiliation(s)
- Adriano Rodríguez-Trujillo
- *Department of Gynecology and Obstetrics, Hospital Clìnic i Provincial, University of Barcelona, Spain; and †Department of Radiology, Hospital Clínic i Provincial, University of Barcelona, Barcelona, Spain
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Du J, Li Y, Wang Q, Batchu N, Zou J, Sun C, Lv S, Song Q, Li Q. Sentinel lymph node mapping in gynecological oncology. Oncol Lett 2017; 14:7669-7675. [PMID: 29344213 PMCID: PMC5755034 DOI: 10.3892/ol.2017.7219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 05/18/2017] [Indexed: 01/02/2023] Open
Abstract
The intraoperative mapping of sentinel lymph nodes (SLNs) is part of the treatment strategy for a number of types of tumor. To retrospectively compare results from the mapping of pelvic SLNs for gynecological oncology, using distinct dyes, the present review was conducted to determine the clinical significance of SLN mapping for gynecological oncology. In addition, the present study aimed at identifying an improved choice for SLN mapping tracers in clinical application. Each dye exhibits demerits when applied in the clinical environment. The combination of radioisotopes and blue dyes was identified to exhibit the most accurate detection rate of SLN drainage of gynecological oncology. However, contrast agents were unable to identify whether a SLN is positive or negative for metastasis prior to pathologic examination; additional studies are required.
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Affiliation(s)
- Jiang Du
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Yaling Li
- Gongzhuling Health Workers High School, Gongzhuling, Jilin 136100, P.R. China
| | - Qing Wang
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Nasra Batchu
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Junkai Zou
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Chao Sun
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Shulan Lv
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Qing Song
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China.,Cardiovascular Research Institute, Morehouse School of Medicine, Atlanta, Georgia 30310, USA.,Big Data Center, First Affiliated Hospital, Xi'an Jiatong University, Xi'an, Shaanxi 710061, P.R. China
| | - Qiling Li
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China.,Big Data Center, First Affiliated Hospital, Xi'an Jiatong University, Xi'an, Shaanxi 710061, P.R. China
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Lindqvist E, Wedin M, Fredrikson M, Kjølhede P. Lymphedema after treatment for endometrial cancer − A review of prevalence and risk factors. Eur J Obstet Gynecol Reprod Biol 2017; 211:112-121. [DOI: 10.1016/j.ejogrb.2017.02.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 01/19/2017] [Accepted: 02/17/2017] [Indexed: 11/16/2022]
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Ersoy E, Evliyaoğlu Ö, Erol O, Ersoy AÖ, Akgül MA, Haberal A. Effects of the morbid obesity and skin incision choices on surgical outcomes in patients undergoing total abdominal hysterectomy. Turk J Obstet Gynecol 2016; 13:189-195. [PMID: 28913120 PMCID: PMC5558291 DOI: 10.4274/tjod.67864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 11/06/2016] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the effect of obesity on surgical outcomes in patients who underwent gynecologic surgery. MATERIALS AND METHODS In total, we evaluated 132 patients who underwent total abdominal hysterectomy with or without salpingo-oophorectomy for benign gynecologic procedures at our tertiary referral gynaecology clinic. RESULTS The non-morbid obese group [body mass index (BMI) <40 kg/m2] included 94 patients, and the morbid obese group (BMI ≥40 kg/m2) included 38 patients. The perioperative outcomes of the groups were compared. The mean operative time was significantly longer for morbid obese patients than non-morbid obese patients (p<0.05). Estimated blood loss, the need for blood transfusion, postoperative hemoglobin values, and the need for an intraabdominal drain were similar between the groups. Early and late postoperative complications were significantly more frequent in the morbid obese group than the other group (p<0.05, for each). Early postoperative complications in patients who underwent vertical skin incision were significantly more frequent than in patients who underwent pfannenstiel incision (p<0.05). Late complications were comparable between the two types of skin incision. CONCLUSION Morbid obesity significantly increases the mean operative times and the postoperative complication rates of abdominal hysterectomy operations.
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Affiliation(s)
- Ebru Ersoy
- Etlik Zübeyde Hanım Women's and Children's Health Education and Research Hospital, Clinic of Obstetrics and Gynecology, Ankara, Turkey
| | - Özlem Evliyaoğlu
- Etlik Zübeyde Hanım Women's and Children's Health Education and Research Hospital, Clinic of Obstetrics and Gynecology, Ankara, Turkey
| | - Okyar Erol
- Etlik Zübeyde Hanım Women's and Children's Health Education and Research Hospital, Clinic of Obstetrics and Gynecology, Ankara, Turkey
| | - Ali Özgür Ersoy
- Zekai Tahir Burak Women's Healthcare Training and Research Hospital, Clinic of Obstetrics and Gynecology, Ankara, Turkey
| | - Mehmet Akif Akgül
- Etlik Zübeyde Hanım Women's and Children's Health Education and Research Hospital, Clinic of Obstetrics and Gynecology, Ankara, Turkey
| | - Ali Haberal
- Etlik Zübeyde Hanım Women's and Children's Health Education and Research Hospital, Clinic of Obstetrics and Gynecology, Ankara, Turkey
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Takeshita S, Todo Y, Okamoto K, Sudo S, Yamashiro K, Kato H. Incidence of metastasis in circumflex iliac nodes distal to the external iliac nodes in cervical cancer. J Gynecol Oncol 2016; 27:e42. [PMID: 27102250 PMCID: PMC4864518 DOI: 10.3802/jgo.2016.27.e42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 03/31/2016] [Accepted: 04/11/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE A causal relationship between removal of circumflex iliac nodes distal to the external iliac nodes (CINDEIN) and lower leg edema has been recently suggested. The aim of this study was to elucidate the incidence of CINDEIN metastasis in cervical cancer. METHODS A retrospective chart review was carried out for 531 patients with cervical cancer who underwent lymph node dissection between 1993 and 2014. CINDEIN metastasis was pathologically identified by microscopic investigation. After 2007, sentinel lymph node biopsy was performed selectively in patients with non-bulky cervical cancer. The sentinel node was identified using (99m)Tc-phytate and by scanning the pelvic cavity with a γ probe. RESULTS Two hundred and ninety-seven patients (55.9%) underwent CINDEIN dissection and 234 (44.1%) did not. The percentage of International Federation of Gynecology and Obstetrics stage IIb to IV (42.4% vs. 23.5%, p<0.001) was significantly higher in patients who underwent CINDEIN dissection than those who did not. CINDEIN metastasis was identified in 1.9% overall and in 3.4% of patients who underwent CINDEIN dissection. For patients with stage Ia to IIa disease, CINDEIN metastasis was identified in 0.6% overall and in 1.2% of patients who underwent CINDEIN dissection. Of 115 patients with sentinel node mapping, only one (0.9%) had CINDEIN detected as a sentinel node. In this case, the other three lymph nodes were concurrently detected as sentinel lymph nodes. CONCLUSION CINDEIN dissection can be eliminated in patients with stage Ia to IIa disease. CINDEIN might not be regional lymph nodes in cervical cancer.
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Affiliation(s)
- Sho Takeshita
- Division of Gynecologic Oncology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
| | - Yukiharu Todo
- Division of Gynecologic Oncology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan.
| | - Kazuhira Okamoto
- Division of Gynecologic Oncology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
| | - Satoko Sudo
- Division of Gynecologic Oncology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
| | - Katsushige Yamashiro
- Division of Pathology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
| | - Hidenori Kato
- Division of Gynecologic Oncology, National Hospital Organization, Hokkaido Cancer Center, Sapporo, Japan
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Nhokaew W, Temtanakitpaisan A, Kleebkaow P, Chumworathayi B, Luanratanakorn S, Kietpeerakool C. Wound Complications after Laparotomy for Endometrial Cancer. Asian Pac J Cancer Prev 2015; 16:7765-8. [PMID: 26625795 DOI: 10.7314/apjcp.2015.16.17.7765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This study was conducted to determine the incidence of wound complications after laparotomy for endometrial cancer and significant predictors of risks. Medical records of patients with endometrial cancer undergoing laparotomy for surgical staging at Srinagarind Hospital, Khon Kaen University between January 2007 and December 2013 were reviewed. Intravenous antibiotic prophylaxis was routinely given 30 minutes before surgery. The primary endpoint was wound complications (including seroma, hematoma, separation, or infection) requiring additional medical and/or surgical management within 4 weeks of laparotomy. During the study period, 357 patients with complete medical records were reviewed. The mean age was 56.9 years. Wound complications were observed in 28 patients (7.84%, 95% CI, 5.27% to 11.14%). Body mass index (BMI) ≥ 30 kg/m2, diabetes mellitus (DM), and prior abdominal surgery were observed as significant independent factors predicting an increased risk of wound complications with adjusted odds ratios (95% CIs) of 2.96 (1.23-7.16), 2.43 (1.06-5.54), and 3.05 (1.03-8.98), respectively. In conclusion, the incidence of wound complications after laparotomy for endometrial cancer was 7.8%. Significant independent predictors of risk included BMI, DM and prior abdominal surgery.
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Affiliation(s)
- Wilasinee Nhokaew
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand E-mail :
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Yamazaki H, Todo Y, Takeshita S, Ohba Y, Sudo S, Minobe S, Okamoto K, Yamashiro K, Kato H. Relationship between removal of circumflex iliac nodes distal to the external iliac nodes and postoperative lower-extremity lymphedema in uterine cervical cancer. Gynecol Oncol 2015; 139:295-9. [DOI: 10.1016/j.ygyno.2015.09.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/01/2015] [Accepted: 09/06/2015] [Indexed: 11/25/2022]
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Todo Y, Yamazaki H, Takeshita S, Ohba Y, Sudo S, Minobe S, Okamoto K, Kato H. Close relationship between removal of circumflex iliac nodes to distal external iliac nodes and postoperative lower-extremity lymphedema in uterine corpus malignant tumors. Gynecol Oncol 2015; 139:160-4. [DOI: 10.1016/j.ygyno.2015.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/02/2015] [Accepted: 07/03/2015] [Indexed: 11/15/2022]
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Comparison of lymphedema incidence between 2 lymphadenectomy techniques in patients with uterine cancer undergoing robotic staging. Int J Gynecol Cancer 2015; 25:160-5. [PMID: 25386859 DOI: 10.1097/igc.0000000000000308] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE This study aimed to compare the incidence of lower extremity lymphedema in patients with uterine cancer after robotic staging using the following 2 methods: standard and selective pelvic lymphadenectomy. MATERIALS AND METHODS Three hundred forty-four consecutive patients who presented with endometrial cancer from March 2007 to October 2012 underwent robotic staging. Surgeon A performed standard pelvic lymphadenectomy and surgeon B performed selective lymphadenectomy. Selective pelvic lymphadenectomy spared the lateral chain of the external iliac lymph nodes (LNs). The incidence of lymphedema and staging adequacy between the 2 groups were analyzed. RESULTS Standard pelvic lymphadenectomy was performed in 238/344 (69.2%) patients and selective pelvic lymphadenectomy was performed in 106/344 (30.8%) patients. Conversion to laparotomy occurred in 2/344 cases (0.6%). Mean age for 344 patients was 63.6 (10) years and body mass index was 34.8 (10.1) kg/m(2). The mean operative time was 162.3 (54.6) minutes. Postoperative hospitalization was 1.62 (1.93) days. Histology included 80.8% endometrioid adenocarcinomas and 19.2% clear cell, serous, and carcinosarcomas. Mean pelvic LN counts for the standard and selective pelvic lymphadenectomy groups were 16 (8.6) and 15.5 (7.1), respectively (P = 0.31). Mean numbers of para-aortic LNs retrieved for the standard and selective lymphadenectomy groups were 3.1 (4.1) and 4.9 (4.5), respectively (P < 0.01).Median follow-up was 29.3 months (interquartile range, 15.6-43.1 months). The difference in the incidence of lower extremity lymphedema was statistically significant: 4.6% (11/238 patients) in the standard lymphadenectomy group versus 0.9% (1/106 patients) in the selective lymphadenectomy group (P = 0.03). CONCLUSIONS When compared to the standard technique, selective pelvic lymphadenectomy with sparing of the lateral chain of the external iliac LNs is adequate and results in a lower incidence of lower extremity lymphedema.
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Anton C, di Fávero GM, Köhler C, Carvalho FM, Baracat EC, Carvalho JP. Surgical treatment of endometrial cancer in developing countries: reasons to consider systematic two-step surgical treatment. Clinics (Sao Paulo) 2015; 70. [PMID: 26222815 PMCID: PMC4498149 DOI: 10.6061/clinics/2015(07)02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine the lymph node status in a large cohort of women with endometrial cancer from the public health system who were referred to an oncology reference center in Brazil to identify candidates for the omission of lymphadenectomy based on clinicopathological parameters. METHODS We retrospectively analyzed a cohort of 310 women with endometrial cancer (255 endometrioid, 40 serous, and 15 clear cell tumors) treated between 2009 and 2014. We evaluated the histological type, grade (low vs. high), tumor size (cm), depth of myometrial invasion (≤50%, >50%) and lymphovascular space invasion to determine which factors were correlated with the presence of lymph node metastasis. RESULTS The factors related to lymph node involvement were tumor size (p=0.03), myometrial invasion (p<0.01), tumor grade (p<0.01), and lymphovascular space invasion (p<0.01). The histological type was not associated with the nodal status (p=0.52). Only twelve of 176 patients (6.8%) had low-grade endometrioid carcinoma, tumor size ≤2 cm and <50% myometrial infiltration. CONCLUSIONS The omission of lymphadenectomy based on the histological type, grade, tumor size and depth of myometrial invasion is not likely to have a large impact on the surgical treatment of endometrial cancer in our population because most patients present with large and advanced tumors. New strategies are proposed that prioritize hysterectomy performed in a general hospital as soon as possible after diagnosis, followed by an evaluation of the need for lymph node dissection at a reference center.
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Affiliation(s)
- Cristina Anton
- Faculdade de Medicina da Universidade de São Paulo, Department of Obstetrics and Gynecology, São Paulo/SP, Brazil
| | - Giovanni Mastrantonio di Fávero
- Faculdade de Medicina da Universidade de São Paulo, Department of Obstetrics and Gynecology, São Paulo/SP, Brazil
- Asklepios Hospital Hamburg, Department of Advanced Operative and Oncologic Gynecology. Hamburg, Germany
| | - Christhardt Köhler
- Asklepios Hospital Hamburg, Department of Advanced Operative and Oncologic Gynecology. Hamburg, Germany
| | - Filomena Marino Carvalho
- Instituto do Câncer do Estado de São Paulo – Octavio Frias de Oliveira (ICESP), Department of Pathology, São Paulo/SP, Brazil
| | - Edmund Chada Baracat
- Faculdade de Medicina da Universidade de São Paulo, Department of Obstetrics and Gynecology, São Paulo/SP, Brazil
| | - Jesus Paula Carvalho
- Faculdade de Medicina da Universidade de São Paulo, Department of Obstetrics and Gynecology, São Paulo/SP, Brazil
- Corresponding author: E-mail:
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Canlorbe G, Bendifallah S, Raimond E, Graesslin O, Hudry D, Coutant C, Touboul C, Bleu G, Collinet P, Darai E, Ballester M. Severe Obesity Impacts Recurrence-Free Survival of Women with High-Risk Endometrial Cancer: Results of a French Multicenter Study. Ann Surg Oncol 2014; 22:2714-21. [DOI: 10.1245/s10434-014-4295-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Indexed: 12/28/2022]
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Falcone F, Balbi G, Di Martino L, Grauso F, Salzillo ME, Messalli EM. Surgical management of early endometrial cancer: an update and proposal of a therapeutic algorithm. Med Sci Monit 2014; 20:1298-313. [PMID: 25063051 PMCID: PMC4136932 DOI: 10.12659/msm.890478] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
In the last few years technical improvements have produced a dramatic shift from traditional open surgery towards a minimally invasive approach for the management of early endometrial cancer. Advancement in minimally invasive surgical approaches has allowed extensive staging procedures to be performed with significantly reduced patient morbidity. Debate is ongoing regarding the choice of a minimally invasive approach that has the most effective benefit for the patients, the surgeon, and the healthcare system as a whole. Surgical treatment of women with presumed early endometrial cancer should take into account the features of endometrial disease and the general surgical risk of the patient. Women with endometrial cancer are often aged, obese, and with cardiovascular and metabolic comorbidities that increase the risk of peri-operative complications, so it is important to tailor the extent and the radicalness of surgery in order to decrease morbidity and mortality potentially derivable from unnecessary procedures. In this regard women with negative nodes derive no benefit from unnecessary lymphadenectomy, but may develop short- and long-term morbidity related to this procedure. Preoperative and intraoperative techniques could be critical tools for tailoring the extent and the radicalness of surgery in the management of women with presumed early endometrial cancer. In this review we will discuss updates in surgical management of early endometrial cancer and also the role of preoperative and intraoperative evaluation of lymph node status in influencing surgical options, with the aim of proposing a management algorithm based on the literature and our experience.
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Affiliation(s)
- Francesca Falcone
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Giancarlo Balbi
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Luca Di Martino
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Flavio Grauso
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Maria Elena Salzillo
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Enrico Michelino Messalli
- Department of Woman, Child and of General and Special Surgery, Second University of Naples, Naples, Italy
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Para-aortic Lymph Node Dissection for Women With Endometrial Adenocarcinoma and Intermediate- to High-Risk Tumors: Does It Improve Survival? Int J Gynecol Cancer 2014; 24:91-6. [DOI: 10.1097/igc.0000000000000008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
ObjectiveLiterature suggests that para-aortic lymphadenectomy (para-aortic lymph node dissection [PALND]) has a therapeutic benefit for women with intermediate- to high-risk endometrial adenocarcinoma. We hypothesized that the observed survival advantage of PALND is a reflection of the general health of the patient rather than a therapeutic benefit of surgery.MethodsWomen with intermediate- to high-risk endometrial adenocarcinoma diagnosed from 2002 to 2009 at a single institution were identified. Medical comorbidities, pathology, and survival information were abstracted from the medical record. The χ2 test or the t test was used for univariate analysis. Overall survival (OS) and disease-specific survival (DSS) were calculated using the Kaplan-Meier method.ResultsA total of 253 women with a mean age of 64 years were identified. Of these women, 174 had a pelvic lymphadenectomy (pelvic lymph node dissection [PLND]) and 82 had PLND and PALND. The rate of positive nodes was 13% (23/174) for the women who had PLND and was 7% (6/82) for those who had PLND and PALND. Only 1.2% (1/82) of the women who had PLND and PALND had negative pelvic but positive para-aortic nodes. The patients who had PALND had a lower body mass index and were less likely to have significant medical comorbidities. The patients who had PALND had improved 5-year OS (96% vs 82%, P = 0.007) but no difference in 5-year DSS (96% vs 89%, P value = not significant).ConclusionsWomen with intermediate- to high-risk endometrial adenocarcinoma who undergo PALND have improved OS but no improvement in DSS. The lack of difference in DSS supports the hypothesis that underlying comorbidities as opposed to lack of PALND result in poorer outcome.
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Pelikan HMP, Trum JW, Bakers FCH, Beets-Tan RGH, Smits LJM, Kruitwagen RFPM. Diagnostic accuracy of preoperative tests for lymph node status in endometrial cancer: a systematic review. Cancer Imaging 2013; 13:314-22. [PMID: 23876490 PMCID: PMC3719052 DOI: 10.1102/1470-7330.2013.0032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Approximately 72% of endometrial cancers are FIGO stage I at diagnosis and about 10% have lymph node metastases. An ideal diagnostic test for nodal disease would be able to prevent both overtreatment (i.e. unnecessary lymphadenectomy) and undertreatment (i.e. withholding lymphadenectomy or adjuvant postoperative treatment to patients with lymph node metastases). Objectives: In this review we compare the accuracy of preoperative tests (computed tomography, magnetic resonance imaging, positron emission tomography-computed tomography, CA-125 serum levels, and ultrasonography) for the detection of lymph node metastases in endometrial cancers with the final histopathologic diagnosis after complete pelvic and para-aortic lymphadenectomy as the gold standard. Method: A systematic search in MEDLINE (using PubMed), Embase and The Cochrane Library was performed up to 23 July 2012. Results: We found one article that met our inclusion criteria for computed tomography, none for magnetic resonance imaging, 2 for positron emission tomography/computed tomography), 2 for CA-125 and none for ultrasonography. Conclusions: Due to the lack of high-quality articles on a preoperative test for lymph node status in endometrial cancer, no proper comparison between these modalities can be made.
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Affiliation(s)
- H M P Pelikan
- Department of Obstetrics and Gynaecology, Bronovo Hospital, Bronovolaan 5, 2597 AX Den Haag, The Netherlands.
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Arem H, Chlebowski R, Stefanick ML, Anderson G, Wactawski-Wende J, Sims S, Gunter MJ, Irwin ML. Body mass index, physical activity, and survival after endometrial cancer diagnosis: results from the Women's Health Initiative. Gynecol Oncol 2013; 128:181-6. [PMID: 23127972 PMCID: PMC3552067 DOI: 10.1016/j.ygyno.2012.10.029] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 10/24/2012] [Accepted: 10/29/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVE While low physical activity and high body mass index (BMI) have been associated with higher endometrial cancer incidence, no previous studies have evaluated the association between physical activity and survival after endometrial cancer diagnosis, and studies on BMI and survival have not been performed in a prospective cohort. METHODS We examined pre-diagnosis BMI and moderate- to vigorous-intensity physical activity in relation to overall and disease-specific survival among 983 postmenopausal women who were diagnosed with endometrial cancer in the Women's Health Initiative Observational Study and Clinical Trials. RESULTS Over a median 5.2 (max 14.1) years from diagnosis to death or end of follow-up, 163 total deaths were observed, 66 of which were due to endometrial cancer. We observed a higher all-cause mortality hazard ratio (HR) = 1.85 (95% CI 1.19-2.88) comparing women with a BMI ≥ 35 kg/m(2) to women with BMI< 25 kg/m(2). For endometrial cancer-specific mortality the HR = 2.23 (95% CI 1.09-4.54) comparing extreme BMI categories. To examine histologic subtypes we analyzed type I endometrial tumors separately and found an HR = 1.20 (95% CI 1.07-1.35) associated with all-cause mortality for each 5-unit change in BMI. Moderate- to vigorous-intensity physical activity was not associated with all-cause or endometrial cancer-specific mortality. CONCLUSIONS Pre-diagnosis BMI, but not physical activity, was associated with survival among women with endometrial cancer. Future studies should investigate mechanisms and timing of BMI onset to better understand the burden of disease attributable to BMI.
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Affiliation(s)
- Hannah Arem
- Yale School of Public Health, 60 College St, New Haven, CT
| | - Rowan Chlebowski
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
| | - Marcia L. Stefanick
- Stanford Prevention Research Center, School of Medicine, Stanford University, California
| | - Garnet Anderson
- Division of Public Health Sciences, WHI Clinical Coordinating Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jean Wactawski-Wende
- Department of Social and Preventive Medicine, University at Buffalo, The State University of New York, Buffalo, NY
| | - Stacy Sims
- Stanford Prevention Research Center, School of Medicine, Stanford University, California
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Todo Y, Sakuragi N. Systematic lymphadenectomy in endometrial cancer. J Obstet Gynaecol Res 2012; 39:471-7. [DOI: 10.1111/j.1447-0756.2012.02062.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 09/18/2012] [Indexed: 12/22/2022]
Affiliation(s)
- Yukiharu Todo
- Division of Gynecologic Oncology; National Hospital Organization, Hokkaido Cancer Center; Sapporo; Japan
| | - Noriaki Sakuragi
- Department of Obstetrics and Gynecology; Hokkaido University School of Medicine; Sapporo; Japan
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Giugale LE, Di Santo N, Smolkin ME, Havrilesky LJ, Modesitt SC. Beyond mere obesity: Effect of increasing obesity classifications on hysterectomy outcomes for uterine cancer/hyperplasia. Gynecol Oncol 2012; 127:326-31. [DOI: 10.1016/j.ygyno.2012.08.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 08/09/2012] [Accepted: 08/09/2012] [Indexed: 10/28/2022]
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A Retrospective Analysis of Postoperative Complications With or Without Para-aortic Lymphadenectomy in Endometrial Cancer. Int J Gynecol Cancer 2011; 21:385-90. [DOI: 10.1097/igc.0b013e3182094e09] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction:Although para-aortic lymphadenectomy (PALX) has not been accepted as a standard treatment for patients with endometrial cancer, it is possible that systematic lymphadenectomy including PALX has therapeutic significance for patients with intermediate-/high-risk endometrial cancer. On the other hand, a consensus regarding the safety of PALX has not been reached. The aim of this study was to compare the incidence rates of postoperative complications after pelvic lymphadenectomy (PLX) with or without PALX in patients with uterine corpus cancer.Methods:A retrospective chart review was carried out for all patients with endometrial cancer treated at 2 tertiary centers between 1998 and 2004. Surgery at one institute included both PLX and PALX, whereas PLX alone was routinely performed at the other institute. A total of 142 patients underwent PLX + PALX and 138 patients underwent PLX alone. We evaluated postoperative complications including intraoperative injury, ileus, lymphedema, lymphocyst, and thrombosis.Results:There was no fatal accident associated with surgery. Lymphedema was the most frequent complication. Comparing the PLX + PALX group and the PLX group, there were no significant differences in the rate of cases of lymphedema (23.2% vs 28.3%), lymphocyst (9.2% vs 9.4%), and thrombosis (4.9% vs 2.2%). The rate of cases of mild/moderate ileus in the PLX + PALX group was significantly higher than that in the PLX group (10.5% vs 2.9%; P = 0.011). However, no significant difference in the rates of cases of severe ileus was found between the 2 groups (1.4% vs 0.7%). There were also no significant differences between the 2 groups in the rates of intraoperative organ injury (2.8% vs 2.2%) and secondary operation for postoperative complications (4.9% vs 4.3%).Conclusions:Para-aortic lymphadenectomy can be performed with an acceptable morbidity under the conditions in which it is performed by experienced surgeons, and measures to prevent complications are properly taken.
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Limits of lymphoscintigraphy for sentinel node biopsy in women with endometrial cancer. Gynecol Oncol 2008; 112:348-52. [PMID: 19081610 DOI: 10.1016/j.ygyno.2008.11.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Revised: 10/27/2008] [Accepted: 11/04/2008] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Lymph node status in endometrial cancer is a major prognostic factor. Sentinel lymph node (SLN) biopsy using radiocolloid and blue dye labeling has emerged as an alternative to systematic lymphadenectomy. This technique requires a preoperative lymphoscintigraphy. The aim of this study was to evaluate the limits of day-before preoperative lymphoscintigraphy to SLN biopsy. METHODS Between July 2002 and March 2007, 38 patients with endometrial cancer underwent laparoscopic SLN procedure using radiocolloid and blue dye. Those with early-stage I endometrial cancer (35 patients) underwent a SLN procedure followed by systematic pelvic lymphadenectomy and a hysterectomy with bilateral salpingo-oophorectomy while those with presumed stage IIB on MR imaging (3 patients) underwent a radical hysterectomy. Omentectomy and paraaortic lymphadenectomy were also performed for women with clear cell or serous papillary carcinoma (5 patients). The SLN identification rates and false-negative rates were studied. RESULTS The detection rate of lymphoscintigraphy was 84.5% (32/38), with 1.9 nodes per patient. Eight of 17 patients (47%) with unilateral sentinel lymph node on lymphoscintigraphy had bilateral SLNs at surgery and three of 15 patients (20%) with bilateral SLN on lymphoscintigraphy had unilateral SLN at surgery. The correlation was poor (kappa=0.266). When categorized in <2 and > or =2 sentinel nodes, the correlation between lymphoscintigraphic and surgical SLN mapping was moderate (kappa=0.33). CONCLUSION Our results demonstrated the low correlation between day-before lymphoscintigraphy and surgical SLN mapping raising issues of its usefulness and cost-effectiveness in routine practice.
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Perrone AM, Casadio P, Formelli G, Levorato M, Ghi T, Costa S, Meriggiola MC, Pelusi G. Cervical and hysteroscopic injection for identification of sentinel lymph node in endometrial cancer. Gynecol Oncol 2008; 111:62-7. [DOI: 10.1016/j.ygyno.2008.05.032] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Revised: 05/12/2008] [Accepted: 05/30/2008] [Indexed: 11/29/2022]
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Ballester M, Dubernard G, Rouzier R, Barranger E, Darai E. Use of the Sentinel Node Procedure to Stage Endometrial Cancer. Ann Surg Oncol 2008; 15:1523-9. [DOI: 10.1245/s10434-008-9841-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 12/23/2007] [Accepted: 12/26/2007] [Indexed: 11/18/2022]
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