Vaginal hysterectomy versus abdominal hysterectomy for the treatment of stage I endometrial adenocarcinoma

Practice guidelines for management of uterine corpus cancer in Korea: a Korean Society of Gynecologic Oncology Consensus Statement

Clinical practice guidelines for gynecologic cancers have been developed by many organizations. Although these guidelines have much in common in terms of the practice of standard of care for uterine corpus cancer, practice guidelines that reflect the characteristics of patients and healthcare and insurance systems are needed for each country. The Korean Society of Gynecologic Oncology (KSGO) published the first edition of practice guidelines for gynecologic cancer treatment in late 2006; the second edition was released in July 2010 as an evidence-based recommendation. The Guidelines Revision Committee was established in 2015 and decided to produce the third edition of the guidelines as an advanced form based on evidence-based medicine, considering up-to-date clinical trials and abundant qualified Korean data. These guidelines cover screening, surgery, adjuvant treatment, and advanced and recurrent disease with respect to endometrial carcinoma and uterine sarcoma. The committee members and many gynecologic oncologists derived key questions from the discussion, and a number of relevant scientific literatures were reviewed in advance. Recommendations for each specific question were developed by the consensus conference, and they are summarized here, together with other details. The objective of these practice guidelines is to establish standard policies on issues in clinical areas related to the management of uterine corpus cancer based on the findings in published papers to date and the consensus of experts as a KSGO Consensus Statement.

Route of hysterectomy and surgical outcomes from a statewide gynecologic oncology population: is there a role for vaginal hysterectomy?

BACKGROUND

Recent policy changes by insurance companies have been instituted to encourage vaginal hysterectomy (VH) as the preferred route for removal of the uterus. It is not known if advantages of VH for benign indications apply to women with gynecologic cancer.

OBJECTIVE

The goal of this study was to assess trends in surgical approach to hysterectomy among gynecologic cancer patients and to evaluate outcomes by approach. We hypothesized that, among gynecologic oncology patients, postoperative complications and hospital stay would differ by surgical approach, and that advantages of VH for benign indications may not apply to gynecologic cancer patients.

STUDY DESIGN

We performed a population-based retrospective cohort study of cervical, endometrial, or ovarian/fallopian tube cancer patients treated surgically in Washington State from 2004 through 2013 using the Comprehensive Hospital Abstract Reporting System. Surgery was categorized as abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), or VH. We determined rate of surgical approach by year and the association with length of stay, 30-day readmission rate, and perioperative complications.

RESULTS

We identified 10,117 patients who underwent surgery for gynecologic cancer, with 346 (3.4%) VH, 2698 (26.7%) LH, and 7073 (69.9%) AH. Patients undergoing AH had more comorbidities than patients with VH or LH (Charlson Comorbidity Index ≥2: 11.3%, 7.9%, and 8.1%, respectively; P < .001). From 2004 through 2013 AH and VH declined (94.4-47.9% and 4.4-0.8%, respectively; P < .001) while LH increased from 1.2-51.4% in 2013 (P < .001). Mean length of stay was 4.6 days for women undergoing AH and was 1.9 days shorter for VH (95% confidence interval, 1.6-2.3 days) and 2.6 days shorter for LH (95% confidence interval, 2.4-2.7 days) (P < .001). Risk of 30-day readmission for patients undergoing LH was 40% less likely compared to AH but not different for VH vs AH.

CONCLUSION

AH and LH remain the preferred routes for hysterectomy in gynecologic oncology. Over the past decade, there has been a significant shift to LH with lower 30-day readmission and complication rates. There may be a limited role for VH in select patients. Current efforts to standardize the surgical approach to hysterectomy should not apply to patients with known or suspected gynecologic cancer.

[Role of laparoscopy in the treatment of early endometrial cancer]

Endometrial cancer is the most frequent malignant tumor of the female genital tract. Traditionally, surgical treatment is performed via laparotomy, but laparoscopy has recently gained wider acceptance. Data regarding survival and recurrence are comparable in case of laparotomy or laparoscopy. Surgical morbidity and postoperative recovery time are significantly lower by laparoscopy. In case of early endometrial cancer laparoscopy is an invaluable alternative method of choice but it has to be performed by skilled laparoscopic surgeons. Authors review the current literature regarding the role of laparoscopy in the treatment of early stage endometrial cancer.

Overcoming extreme obesity with robotic surgery

BACKGROUND

Obesity is often associated with endometrial cancer and has posed a challenge in surgical management. Complications such as wound breakdown, respiratory challenges, cardiac complications and difficult intubations are associated with obesity. For the patient with uterine cancer, surgery is necessary for staging, control of symptoms and cure. With the advent of the da Vinci(™) intuitive robot, alternative surgical options can now be offered to these patients. While surgery is the principal modality for the treatment and management of uterine cancer, the morbidly obese patient faces increased complications and longer postoperative recovery. As studied in the LAP2, comparable outcomes have been noted in laparotomy vs laparoscopic surgery. Recently, minimally invasive surgery has been refined with the advent of the da Vinci robotic system. Applying a minimally invasive technique further enhanced with the da Vinci robotic system, a total laparoscopic hysterectomy with bilateral salpingo-oophorectomy was performed on a patient with a BMI of 98.

METHODS

A 35 year-old G0 woman with a BMI of 98 presented with heavy vaginal bleeding and anaemia. She was diagnosed with endometrioid adenocarcinoma of the uterus, FIGO grade 1. She was treated with a robotically assisted total laparoscopic hysterectomy and bilateral salpingo-oophorectomy.

RESULTS

Her postoperative course was uncomplicated and she was discharged home on post-operative day 1.

CONCLUSIONS

Since obesity is a significant risk factor for endometrial cancer and the prevalence of obesity is increasing, developing surgical techniques to appropriately manage these patients is important. Minimally invasive surgery, specifically with robotic assistance, has increased the possibilities of performing minimally invasive surgery in morbidly obese women. It allows navigation around anatomical barriers and decreases the fatigue experienced by the surgeons. With the increasing obesity of our population and the high prevalence of uterine cancer, further advancement of equipment, anaesthesia and surgical techniques to accommodate the larger patient while decreasing complications have yet to be standardized.

The laparoscopic-assisted vaginal approach to early endometrial cancer

INTRODUCTION

For the surgical treatment of endometrial cancer laparotomy still is regarded as the gold standard. Over the past decade, the laparoscopic approach has gained equivalence in FIGO stage I carcinomas.

RESULTS

Laparoscopic-assisted vaginal hysterectomy and bilateral salpingooophorectomy plus pelvic/paraaortic lymphadenectomy have shown short-term advantages such as reduced blood loss and shorter hospitalization without reducing oncological safety or outcome. This has already been confirmed by numerous smaller studies and recent randomized controlled trials with sufficient numbers of patients are being published.

CONCLUSION

Further acceptance of the technique is necessary to enable every gynecological oncologist to individualize treatment by offering minimal access options.

Laparoscopic Systemic Retroperitoneal Lymphadenectomy for Women with Low-Risk Early Endometrial Cancer

Introduction: There is no consensus on the extent of lymphadenectomy and the appropriate patients for lymphadenectomy in low-risk patients with endometrial cancer. This study aimed to evaluate the feasibility and effectiveness of laparoscopic lymphadenectomy for low-risk patients with endometrial cancer. Materials and Methods: From January 2004 to May 2008, we reviewed the medical records of 28 patients with low-risk, endometrial cancer; endometrioid type, grade 1 or 2, and with a depth of myometrial invasion of less than one-half of the myometrium. All patients underwent laparoscopically-assisted staging surgery. Results: The median age and body mass index were 56 years (range, 28 to 75) and 25.5 kg/m2 (range, 21.3 to 37.2). The median operating time, estimated blood loss, and length of hospital stay were 142 minutes (range, 110 to 410), 215 mL (range, 100 to 700), and 7 days (range, 3 to 19), respectively. No conversion to laparotomy was noted. The median number of harvested lymph nodes was 21 (range, 10 to 48) pelvic nodes and 12 (range, 4 to 21) para-aortic nodes. One (3.6%) patient presented pelvic lymph node metastasis and 2 (7.1%) presented isolated para-aortic lymph node metastasis. The complication rate was 14.3%. No recurrence in the vaginal vault, distant metastasis, port site metastasis was noted up to the last follow-up. Conclusion: Systemic pelvic and para-aortic lymphadenectomy should be considered in all low-risk patients with endometrial cancer until it is concluded to be clinically insignificant through large-scale prospective research in the future. However, it will be difficult to explain statistical differences in survival rates according to lymphadenectomy, because the increase of the survival rate resulting from lymphadenectomy will fall within the margin of statistical error. Key words: Endometrial cancer, Laparoscopy, Lymphadenectomy

The role of vaginal hysterectomy in the treatment of endometrial cancer

OBJECTIVE

The objective of the study was to evaluate the role of vaginal hysterectomy in the treatment of endometrial cancer.

STUDY DESIGN

Medical records were retrospectively reviewed for patients undergoing vaginal hysterectomy for endometrial cancer at the University of South Florida. The medical data were reviewed for medical comorbidities, preoperative and postoperative diagnosis, hospital course, surgical and postoperative complications, adjuvant treatments, and follow-up.

RESULTS

Sixty-three women underwent vaginal hysterectomy for endometrial carcinoma between May 1987-September 2006. Mean age was 62.1 years and body mass index [BMI] was 40; 73% of patients were obese (BMI > or = 30 or greater). Medical comorbidities included hypertension (76.2%), cardiovascular disease (34.9%), diabetes mellitus (31.7%), and pulmonary disease (28.6%). Eighty-one percent of patients had at least 2 and 55.5% had 3 or more comorbid surgical risk factors. Postoperative complications included infection (4.8%), blood transfusion (11.1%), and prolonged hospital stay (6.3%). Of patients with intrauterine pathology, 89.5% had endometrioid adenocarcinoma.

CONCLUSION

Vaginal hysterectomy may be appropriate treatment of endometrial carcinoma for select patients.

Ten-year results of a prospective study on the prognostic role of ploidy in endometrial carcinoma

BACKGROUND

To improve the outcome of endometrial cancer patients, a more accurate prognostic assessment is mandatory. The aims of the study were to evaluate the role of flow cytometric DNA ploidy as an independent prognostic factor in patients with endometrial cancer and to verify if ploidy was able to distinguish patients with different prognosis into homogeneous subgroups for grade of differentiation and stage.

METHODS

In a prospective study, DNA ploidy was evaluated from fresh tumor samples in 174 endometrial cancer patients who underwent surgery as the first treatment. Ploidy, as well as classical parameters, were analyzed in relation to the length of disease-free survival and disease-specific survival.

RESULTS

DNA aneuploidy was found in 49 patients (28.2%). Patients with DNA-aneuploid tumors had a significantly reduced disease-free interval and disease-specific survival (P < .0001). The 10-year survival probability was 53.2% for DNA-aneuploid patients and 91.0% for patients with DNA-diploid tumors. By multivariate analysis DNA-aneuploid type was the strongest independent predictor of poor outcome, followed by age and stage. Patients with DNA-aneuploid tumor had a significantly higher risk ratio for recurrence (5.03) and death due to disease (6.50) than patients with DNA-diploid tumors. Stratification by DNA-ploidy within each group by grade of differentiation allowed identification of patients with significantly different outcome. In grade 2 tumors, 10-year survival was 45.0% in aneuploid cases and 91.9% in diploid cases (P < .0001). Patients with advanced-stage (>I) diploid tumor did significantly better than patients with stage I aneuploid tumor (P = .04).

CONCLUSIONS

The presence of DNA-aneuploid type in endometrial cancer identifies high-risk cases among the patients considered 'low risk' according to stage and grade of differentiation.

Old and new perspectives in the pharmacological treatment of advanced or recurrent endometrial cancer: Hormonal therapy, chemotherapy and molecularly targeted therapies

Hormonal therapy and chemotherapy play a major role in the management of advanced or recurrent endometrial cancer. Progesterone therapy obtains overall response rates ranging from 11% to 25% in patients with endometrioid-type tumours, and oral medroxyprogesterone acetate 200mg daily appears to be a reasonable therapeutic option for those lesions that are well differentiated and/or have a high progesterone receptor (PgR) content. However, the activity of progestins is often compromised by the down-regulation of PgR within the target tissues, and therefore therapeutic strategies designed to enhance PgR expression are warranted. Little data are currently available about the new aromatase inhibitors and selective estrogen receptor modulators. As for chemotherapy, the combination of doxorubicin [DOX]+cisplatin [CDDP] achieves overall response rates ranging from 34% to 60%, and the addition of paclitaxel (TAX) seems to improve response rates, progression-free survival and overall survival, but to worsen toxicity profile. A phase III study is currently comparing TAX+DOX+CDDP versus the less toxic combination of TAX+carboplatin. Chemotherapy is active against both endometrioid-type carcinoma and uterine serous papillary carcinoma. However, this latter endometrial malignancy is less chemosensitive than the histologically similar high-grade serous ovarian carcinoma. Interesting fields of research are represented by investigational agents directed against specific intracellular signal transduction pathways involved in the proliferation, invasiveness and metastatic spread of endometrial cancer. Mammalian target of the rapamycin (mTOR) inhibitors, epidermal growth factor receptor inhibitors (gefitinib, erlotinib, lapatinib, the monoclonal antibody cetuximab), imatinib, the monoclonal antibody trastuzumab, and the Clostridium perfrigens enterotoxin are currently under evaluation as molecularly targeted therapies for endometrial cancer. Further investigations addressed to better understand the signal transduction pathways that are disregulated in endometrial carcinogenesis could identify novel biological targets suitable for tailored therapies.

The impact of obesity on surgery in gynecological oncology: a review

Surgery represents a mainstay in the treatment of gynecological cancers. It is a common belief that operating on obese patients causes more peri- and postoperative complications than operating on nonobese patients. The surgical outcome in gynecological oncology can be evaluated by comparing intra- and postoperative complications, extent of lymphadenectomy, negativity of the specimens' margins, and percentage of optimal debulking between obese and nonobese patients affected by malignancies at the same stage. In this review, we analyze how obesity affects the feasibility of a correct oncologic procedure in case of cervical, endometrial, and ovarian cancer. We also describe the techniques that have been suggested in the literature to improve the surgical outcome on obese patients.

Vaginal hysterectomy

The vaginal route is a safe, feasible, and patient-friendly method of performing a hysterectomy. Proponents and practitioners of vaginal hysterectomy have widened their indications and decreased the contraindications through liberal usage of debulking, performing oophorectomy, laparoscopic evaluation and trial vaginal hysterectomy. This traditional approach with surgical advances can be used more frequently.

Endometrial cancer: magnetic resonance imaging

Carcinoma of the endometrium is the most common invasive gynecologic malignancy of the female genital tract. Clinically, patients with endometrial carcinoma present with abnormal uterine bleeding. The role of magnetic resonance imaging (MRI) in endometrial carcinoma is disease staging and treatment planning. MRI has been shown to be the most valuable imaging mod-ality in this task, compared with endovaginal ultrasound and computed tomography, because of its intrinsic contrast resolution and multiplanar capability. MRI protocol includes axial T1-weighted images; axial, sagittal, and coronal T2-weighted images; and dynamic gadolinium-enhanced T1-weighted imaging. MR examination is usually performed in the supine position with a phased array multicoil using a four-coil configuration. Endometrial carcinoma is isointense with the normal endometrium and myometrium on noncontrast T1-weighted images and has a variable appearance on T2-weighted images demonstrating heterogeneous signal intensity. The appearance of noninvasive endometrial carcinoma on MRI is characterized by a normal or thickened endometrium, with an intact junctional zone and a sharp tumor-myometrium interface. Invasive endometrial carcinoma is characterized disruption or irregularity of the junctional zone by intermediate signal intensity mass on T2-weighted images. Invasion of the cervical stroma is diagnosed when the low signal intensity cervical stroma is disrupted by the higher signal intensity endometrial carcinoma. MRI in endometrial carcinoma performs better than other imaging modalities in disease staging and treatment planning. Further, the accuracy and the cost of MRI are equivalent to those of surgical staging.

Analysis of morbidity in patients with endometrial cancer: is there a commitment to offer laparoscopy?

OBJECTIVE

Benefits of laparoscopy over laparotomy in patients with endometrial cancer (EC) are well known. As many patients with EC carry co-morbid conditions, surgery is exposing them to increased risk of complications. A review of the patients with EC recruited so far in a clinical trial comparing laparoscopy to laparotomy was performed. The goal was to identify patients carrying specific risk factors for complications, who would most benefit of laparoscopy and be the ideal candidates for this surgical approach.

PATIENTS AND METHODS

Between July 1995 and December 2002, 122 patients with uterine cancer entered the study. Sixty-three patients were allocated to the laparoscopy (LPS) arm (group A), while 59 were allocated to the laparotomy (LPT) arm (group B). Rate and type of intra-, early and late post-operative complications were prospectively recorded. Risk factors for complications are analyzed to define a group of patients truly benefiting from laparoscopy.

RESULTS

Overall, 12 patients out of 122 (9.8%) have experienced intra-operative, 43 patients out of 122 (35.2%) early post-operative and 25 patients out of 122 (20.4%) late post-operative complications. Rate of intra-operative complications was 4.7% in group A (3 patients out of 63) vs. 15.2% in group B (9 patients out of 59), P = 0.082. Early post-operative complications rate was 23.8% in group A (15 out of 63) and 47.4% in group B (28 out of 59), P = 0.011. Rate of late post-operative complications was 7.9% (5 out of 63) in group A vs. 35.5% (21 out of 59), P = 0.001. Univariate analysis shows co-morbid medical conditions, weight >80 kg, Quetelet index >30 and age >65 years to be predictive of complications and, in fact, a subgroup of patients presenting with these characteristics (n = 57, 30 in group A and 27 in group B) has been recognized to accumulate 60% of the overall complications. In these patients, multivariate analysis identifies the surgical technique (LPS vs. LPT) to be the only significant risk factor for complications.

CONCLUSION

At least one third of the patients with EC carry serious co-morbidities with an increased surgical risk for complications. For this subgroup of patients, a laparoscopic-vaginal approach significantly reduces the rate of complications and should be the standard of surgical treatment.

Vaginal hysterectomy and abdominal hysterectomy for treatment of endometrial cancer in the elderly

OBJECTIVE

The purpose of this study was to analyze the outcome of vaginal and abdominal hysterectomy for treatment of endometrial cancer in elderly patients.

METHODS

In a retrospective series of 171 patients with age > or =70 years and at stages I-III, we evaluated operative and hospitalization data, as well as morbidity, mortality, and long-term survival associated with vaginal and abdominal hysterectomy. A total of 128 patients were operated on with vaginal hysterectomy and 43 cases underwent abdominal hysterectomy.

RESULTS

Medically compromised patients were significantly more frequent in the vaginal surgery group (P = 0.01). Overall, the 10-year disease-specific survival rates after vaginal and abdominal hysterectomy were 80% and 78%, respectively (P = n.s.). Limiting the analysis to stage I (130 patients), 10-year disease-specific survival was 83% in 95 women operated on by the vaginal route and 84% in 35 patients operated by the abdominal approach (P = n.s.). Patients in the vaginal surgery group had a significantly shorter operative time (P = 0.01), less blood loss (P < 0.05), and were discharged earlier (P < 0.05). Severe complications occurred in 5.4% of the vaginal and in 7.0% of the abdominal procedures. Perioperative mortality was zero after vaginal hysterectomy and 2.3% after abdominal hysterectomy, respectively.

CONCLUSIONS

Vaginal hysterectomy showed a high cure rate, shorter operative time, less blood loss, reduced morbidity, and no mortality and therefore may be considered the elective approach for treatment of elderly patients with endometrial cancer.

The scope of vaginal hysterectomy

OBJECTIVE

The study was designed to check the feasibility of the vaginal route as the primary route for hysterectomy.

STUDY DESIGN

All patients in whom hysterectomy was indicated were first considered for vaginal hysterectomy unless this route was contraindicated. Vaginal hysterectomy (VH) was performed in 5655 patients, and in 90.4% of these no uterine prolapse was present. The operative intervention required, preconditions and any complications were carefully studied.

RESULTS

Of the 6945 cases considered, vaginal hysterectomy was possible in 5655 (81%). Successful simultaneous prophylactic oophorectomy or salpingo-oophorectomy was possible, in 1510 of 1572 cases without laparoscopic assistance. The indications are carefully discussed, with a strong emphasis on examination under anaesthesia, preoperative total uterine volume and, if required, laparoscopic evaluation and surgeons' readiness to reduce the frequency of recourse to laparotomy or laparoscopic assistance.

CONCLUSION

The vaginal route is the least invasive and most economical route for hysterectomy and should be the gynaecological surgeon's first choice. A uterus with a volume up to 300 cm3 or uterine size up to 12 weeks should be dealt with vaginally, and as surgeons become more experienced larger uteri and also the adnexa can be approached in the same manner, at least as trial vaginal hysterectomy.

[Lymph node dissection in the surgical management of stage I endometrial carcinomas]

The indication and extent of lymph node dissection in the surgical management of endometrial cancers remain highly controversial. Randomized studies are badly needed but will probably lack for the next years, considering the large sample size required to show a small difference in survival. The trend towards a reduction in the routine use of external radiation therapy weakens the argument that radiation therapy makes adequate lymph node dissection useless. The balance stays between the risk for node involvement and the expected complications rate of the procedure. Lymph node dissection is advised whenever there is a non-negligible risk of node metastasis in a patient at low surgical risk.

Local-regional staging of endometrial carcinoma: role of MR imaging in surgical planning

PURPOSE

To assess magnetic resonance (MR) imaging in depicting the depth of myometrial infiltration, cervical invasion, and presence of enlarged lymph nodes in patients with endometrial adenocarcinoma compared with surgicopathologic findings.

MATERIALS AND METHODS

Thirty-seven consecutive patients with endometrial carcinoma were included in this prospective study. All patients underwent MR imaging and surgery. Qualitative image analysis included the depth of myometrial infiltration, infiltration of the uterine cervix, and presence of enlarged lymph nodes. Quantitative image analysis included tumor and myometrium contrast-to-noise ratios during different phases of dynamic imaging. MR imaging findings were compared with surgicopathologic findings. Sensitivity, specificity, diagnostic accuracy, and positive and negative predictive values of MR imaging in depicting myometrial and cervical infiltration and in lymph node assessment were calculated.

RESULTS

Respective sensitivity, specificity, diagnostic accuracy, and positive and negative predictive values in assessing myometrial infiltration were 87%, 91%, 89%, 87%, and 91%; those for cervical infiltration, 80%, 96%, 92%, 89%, and 93%; and those for lymph node assessment, 50%, 95%, 90%, 50%, and 95%. There was significant agreement between MR imaging and surgicopathologic findings in assessment of myometrial invasion (P <.001). Myometrial and cervical invasion and lymph node enlargement were correctly assessed with MR imaging in 28 (76%) of 37 patients. Quantitative analysis showed a significant improvement in tumor and myometrium contrast-to-noise ratios during the equilibrium phase compared with the arterial and precontrast phases (P <.001).

CONCLUSION

MR imaging coupled with contrast material-enhanced dynamic MR imaging is highly accurate in local-regional staging of endometrial carcinoma; more challenging is the assessment of pelvic and lumboaortic lymph nodes.

Traitement chirurgical des adénocarcinomes de l’endomètre : voies d’abord. Revue de la littérature

Three surgical approaches have been described for the treatment of women presenting an endometrial cancer. The aim of this study was to appreciate the current criteria that would offer guidelines for this choice. We reviewed the data available in the literature (search Medline). Only laparotomy and laparoscopy permit the carrying out of all the routine surgical staging according to the FIGO's criteria (classification 1988). Only one randomised study compares the results obtained by laparotomy and laparoscopy. Laparoscopy patients had significantly less morbidity. Overall survival did not differ in both groups with a limited follow-up. The other not randomised studies show that laparoscopy is usually proposed to patients having a lower IMC and presenting limited stages. No randomized study had compared laparotomy with the only vaginal surgery. The latter is generally proposed for patients having an associated comorbidity and presenting limited stages. In such cases, no difference in survival is highlighted. Obesity does not represent an absolute contra indication for any way. It makes the surgery generally more complex. A suspicious ovarian lesion, a large uterus are, currently, an indication for laparotomy. Laparoscopy can be accepted only if the uterine volume is lower than 500 g and without deep myometrial infiltration. Laparotomy surgery is the standard. The main indication of vaginal surgery is to permit treatment to high operatory risk patients. Laparoscopy is an option for the early stages. It is not recommended if an ovarian lesion or a deep uterine parietal infiltration are suspected. Whatever the route used, the surgeon must be trained.

Minilaparotomy in early stage endometrial cancer: an alternative to standard and laparoscopic treatment

OBJECTIVE

Our objective was to determine whether minilaparotomy could be a safe and feasible approach for the surgical treatment of early endometrial cancer patients and whether it could be considered a valid alternative to the laparoscopic treatment.

METHODS

A pilot study of 50 consecutive patients with FIGO stage I-IV endometrial cancer undergoing surgery at our Department was performed between May and December 2001. All patients were evaluated for a minimal transabdominal approach. Exclusion criteria were considered: special histotype, poorly differentiated tumors, clinical stage >/=Ic, Ca125 >35 U/ml, BMI >30, lymph nodal involvement assessed by MRI, and severe cardiopulmonary disease precluding steep Trendelenburg position.

RESULTS

Twenty-six (52%) cases were considered eligible for minilaparotomy. The mean age was 55.4 years and the mean BMI was 24.1. All patients underwent TAH, BSO, pelvic lymphadenectomy +/- omental or peritoneal biopsy. A mean number of 28 pelvic lymph nodes were removed. The mean operative time was 113.0 min and the mean intraoperative blood loss was 220.0 ml. There was 1 severe operative hemorrhage and 1 patient needed postoperative blood transfusion. No immediate complications of wound infection or separation occurred. The mean hospital stay was 3.4 days. Intra- and postoperative parameters were compared to laparotomy controls and literature data on laparoscopy, showing substantially comparable results.

CONCLUSION

Minilaparotomy is a feasible alternative to the standard treatment in endometrial cancer patients. It offers the patient a cost-effective procedure that avoids many of the potential complications of standard therapy, prevents long hospital recovery periods, and accomplishes all of the important goals of standard recommendations.

Prognostic Significance of Hysteroscopic Imaging in Endometrioid Endometrial Adenocarcinoma

OBJECTIVE

The aim of this study was to relate hysteroscopic features of endometrioid endometrial adenocarcinoma to stage, grade and overall survival.

METHODS

Sixty women with endometrioid adenocarcinoma underwent laparotomy and staging according to current FIGO classification. Before surgery hysteroscopy was performed in all patients to establish the morphology of neoplasia, the extent of endometrial lining involvement, and endocervical spreading. These hysteroscopic parameters were related to overall survival, surgical stage, and grade of disease.

RESULTS

First-stage carcinomas were found in 50 patients, second-stage in 4, third-stage in 3, and fourth-stage in 3 patients. Well-differentiated tumors were detected in 32, moderately differentiated in 21, and poorly differentiated in 7 patients. The cumulative 48-month probability of survival was 86.6%. The morphology of adenocarcinomas was unrelated to both their stage and their grade; no relationship to survival was found. The extent of carcinomatous spread within the endometrial cavity was significantly related to stage, grade, and survival. Endometrial lining involvement of less than 50% was associated with 100% survival, 97.1% of first-stage diseases, and 96.6% of low-grade carcinomas. These percentages dropped to 73.1, 65.3 (Fisher's exact test, P = 0.001), and 76.9% (Fisher's exact test, P = 0.035), respectively, when tumoral growth involved more than half of the endometrium. Hysteroscopy detected all carcinomas metastasizing to the cervix; in 8 patients we overdiagnosed endocervical spreading, although histology was negative. From these figures, hysteroscopy showed a sensitivity and specificity in predicting cervical spread of 100 and 87.3%, respectively.

CONCLUSIONS

The extent of endometrial lining involvement in patients with endometrioid carcinoma provides preoperative information on the risk of extrauterine spread. We confirm the high accuracy of hysteroscopy in excluding cervical spread.

A vaginal and extraperitoneal approach to surgically stage patients with endometrial cancer

OBJECTIVE

The purpose of this project was to prospectively evaluate the feasibility of an alternative technique for surgically staging patients with endometrial cancer.

METHODS

Patients with endometrial cancer were enrolled in this protocol from September 1999 until August 2000. The staging procedure included pelvic washings via colpotomy, total vaginal hysterectomy, bilateral salpingo-oophorectomy (TVH/BSO), and extraperitoneal pelvic and paraaortic lymphadenectomy (EP-LND) if indicated. Tumor characteristics, time and feasibility of surgical procedures, length of hospital stays, and complications were prospectively recorded.

RESULTS

Twenty-one patients were enrolled. Grade 1, 2, and 3 tumors were identified in 6 (29%), 10 (48%), and 5 (24%) patients, respectively. Pelvic washings and TVH/BSOs were performed on all patients. A total of 21/21 (100%) uterine specimens were removed vaginally and 41/42 (98%) adnexa were resected vaginally. EP-LNDs were performed on 17 (81%) patients due to pathologic findings of the uterine specimens. The median time to perform a TVH/BSO was 68 (47-149) min. The median time to complete a EP-LND was 77 (59-107) min. The median number of postoperative days was 1 (1-5). Complications were infrequent and mild.

CONCLUSIONS

TVH/BSO, pelvic washings, and EP-LND is a feasible alternative to standard surgical staging of endometrial cancer. The minimal amount of exposure to the intraperitoneal space makes this approach arguably the least invasive for endometrial cancer staging and accounts for the decrease in recovery time and shortened hospital stays. The acceptable length of surgical time, short hospital stays, and minimal requirements for surgical instruments make this approach potentially the most cost-effective option for surgically staging patients with endometrial cancer. A randomized trial comparing this technique to standard surgical staging is warranted.

High incidence of positive peritoneal cytology in low-risk endometrial cancer treated by laparoscopically assisted vaginal hysterectomy

OBJECTIVE

Laparoscopically assisted vaginal hysterectomy (LAVH) has evolved into an alternative form of surgical management in the treatment of low-risk endometrial cancer. The purpose of this study was to determine whether low-risk endometrial cancer patients are subject to a higher incidence of positive peritoneal cytology when treated with LAVH compared to total abdominal hysterectomy (TAH).

METHODS

We retrospectively reviewed the medical records of patients with low-risk endometrial cancer (grade 1--2 endometrioid type with no evidence of extrauterine spread or grade 3 with <50% myometrial invasion (MI), no cervical or adnexal involvement, and negative lymph nodes when sampled) treated at Memorial Sloan-Kettering Cancer Center from January 1993 to September 1999. We compared 131 patients treated with LAVH to 246 controls who underwent TAH. The two groups were compared for known prognostic factors including grade, MI, vascular space involvement, and lower uterine segment extension.

RESULTS

The mean age of patients who underwent LAVH (61 years) was similar to that of the controls (62 years). Fourteen (10.3%) of the patients treated with LAVH had positive peritoneal cytology compared to only 7 (2.8%) of the control population. Factors including FIGO grade, myometrial invasion, and preoperative hysteroscopy did not influence the final results. When stratifying for these factors, the odds ratios of having positive peritoneal washings in those patients treated by LAVH were 5.2, 5.2, and 3.7, respectively.

CONCLUSION

Treatment of low-risk endometrial cancer by LAVH is associated with a significantly higher incidence of positive peritoneal cytology. This may be due to the retrograde dissemination of cancer cells into the peritoneal cavity during uterine manipulation. The clinical significance of these findings is yet to be determined.

Microsatellite instability is an independent indicator of recurrence in sporadic stage I-II endometrial adenocarcinoma

PURPOSE

The aim of this study was to define the prognostic role of microsatellite status in 65 stage I-II primary sporadic endometrioid endometrial adenocarcinoma (EEA) patients.

PATIENTS AND METHODS

Familiarity for neoplasia was ascertained in all patients on the basis of a questionnaire. Microsatellite status was assessed by matching normal and tumoral DNA probed for five dinucleotide repeats and one mononucleotide repeat marker. Microsatellite status was analyzed in relation to clinicopathologic characteristics of the patients and length of disease-free survival (DFS).

RESULTS

Eleven tumors (17%) of 65 had instability at two or more loci and were considered as unstable or microsatellite instability (MI). Tumors with no instability or instability at one locus were classified as microsatellite stable (MS). The percentage of MI was significantly higher in poorly than in well to moderately differentiated tumors (50% v 9%; P =.003). The 5-year DFS rate of MI patients was 63% (95% confidence interval [CI], 35% to 91%) versus 96% (95% CI, 91% to 101%) of MS patients (P =.0004). In multivariate analysis, only the presence of MI, stage II of disease, and depth of myometrial invasion greater than 50% retained independent prognostic roles.

CONCLUSION

The assessment of microsatellite status may provide useful information for preoperative prognostic characterization of stage I-II primary sporadic EEA patients in which more individualized treatment options can be attempted.

Laparoscopy as the primary modality for the treatment of women with endometrial carcinoma

BACKGROUND

The current study was conducted to assess the feasibility of laparoscopy in the treatment of women with early stage endometrial carcinoma and to compare the surgical outcome, cost, and quality of life among these patients with those treated with laparotomy.

METHODS

A prospective study was conducted over 2 years in which all women with early stage endometrial carcinoma who could tolerate laparoscopic surgery were treated with laparoscopically assisted vaginal hysterectomy (LAVH), bilateral salpingo-oophorectomy (BSO), and lymphadenectomy. Women with a similar disease stage who underwent similar surgical procedures through laparotomy in the previous 2 years were used as the control group. Both groups were compared with regard to their characteristics, surgical outcome, and cost and were interviewed regarding their quality of life.

RESULTS

Eighty-six of 90 women with endometrial carcinoma underwent LAVH. The procedure was converted to laparotomy in 5 patients (5.8%). Laparoscopic surgery thus was successful in 90% of the women. There were no significant differences noted between those women who underwent LAVH and those who underwent total abdominal hysterectomy (TAH) (n = 57) with regard to patient characteristics, type of surgical procedure, preoperative and postoperative hematocrit, complications, patient recall of postoperative pain, and tumor recurrence. LAVH patients had significantly smaller body mass indices, a longer surgical time, more pelvic lymph nodes, a smaller decrease in postoperative hematocrit, received less pain medication, had a shorter hospital stay, an earlier return to full activity and work, and a higher level of satisfaction with their treatment, although their procedures had a higher cost compared with TAH patients.

CONCLUSIONS

The majority of women with early stage endometrial carcinoma can be treated with laparoscopy with an excellent surgical outcome, shorter hospitalization, earlier recovery, and improved quality of life, but with a higher financial cost.

Extraperitoneal pelvic lymphadenectomy to complement vaginal operations for cervical and endometrial cancer

OBJECTIVE

The aim of the current study was to test the applicability of a personal modification of Mitra extraperitoneal pelvic lymphadenectomy in combination with radical vaginal operations for treatment of endometrial and cervical cancer.

METHOD

In a prospective series, 82 patients were submitted to extraperitoneal pelvic lymphadenectomy. In 34 cases of stage I endometrial cancer the procedure was combined with a class I vaginal hysterectomy and in 48 cases of cervical cancer stage Ib-IIIb lymphadenectomy was associated with a class II or III radical vaginal hysterectomy. Type of anesthesia, number of lymph nodes removed, operating time, blood loss and postoperative complications were recorded.

RESULT

The operation was performed with spinal anesthesia in 43% of the cases. Thirty-seven patients (45%) were high surgical risk because of associated diseases. The median operative time for lymphadenectomy was 20 min for each side; the vaginal procedures took a median of 25 min (class I) and 40 min (class II-III). Blood transfusions were necessary in seven cases (8. 5%). A median of 26 lymph nodes were removed from each patient. Lymphocyst occurred in seven patients (8.5%), retroperitoneal hematoma in two and retroperitoneal abscess in one.

CONCLUSION

Extraperitoneal pelvic lymphadenectomy has proven to be a safe and quick technique to complement vaginal operations for endometrial and cervical cancer. Specific features of this approach are: (1) fast, timesaving procedure; (2) possible use of spinal anesthesia; and (3) applicability in high surgical risk patients.

Preoperative evaluation of tumor ploidy in endometrial carcinoma: An accurate tool to identify patients at risk for extrauterine disease and recurrence

BACKGROUND

Tumor ploidy is a strong prognostic factor in patients with endometrial carcinoma, but generally is evaluated only after surgery. The availability of a simple and reliable method to determine tumor ploidy before any treatment is initiated could be helpful in the selection of patients at high risk for advanced primary disease and subsequent recurrence, with several possible benefits. The objectives of the current study were: 1) to test the accuracy of flow cytometric determination of tumor ploidy from preoperative outpatient endometrial biopsies compared with standard postoperative evaluation from the surgical specimen and 2) to correlate this preoperative parameter with the local recurrence and extrauterine tumor spread.

METHODS

Tumor ploidy from both preoperative biopsy material and the macroscopic surgical specimens was evaluated prospectively in 50 consecutive patients with endometrial carcinoma. DNA analyses were performed in a blind fashion. Patients were followed for a median of 26 months (range, 16-46 months).

RESULTS

In 9 of 50 cases (18%) an aneuploid tumor was found by the standard postoperative analysis. All 9 aneuploid tumors (100%) also were identified correctly by the preoperative test on biopsy material. Occult extrauterine tumor spread was found in 10 patients (20%). The incidence rate of aneuploidy among these tumors was 50% compared with 10% in surgical International Federation of Gynecology and Obstetrics Stage I tumors (P = 0.01). The recurrence rate was 55.5% (5 of 9 tumors) in the aneuploid group and 2.4% (1 of 41 tumors) in the diploid group (P < 0.001). The disease free survival rates of patients with diploid and aneuploid tumors were 97.5% and 44.4%, respectively (P < 0.0001).

CONCLUSIONS

Preoperative tumor ploidy determination based on outpatient endometrial biopsy is as accurate as the standard postoperative evaluation in patients with endometrial carcinoma. Tumor aneuploidy confirms the usefulness of this method in selecting patients at risk for occult extrauterine tumor diffusion and recurrence.

Laparoscopic lymphadenectomy and vaginal or laparoscopic hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer: morbidity and survival

OBJECTIVES

Our goal was to evaluate the morbidity, recurrence, and survival of patients with clinical stage I endometrial cancer treated by laparoscopic lymphadenectomy with vaginal or laparoscopic hysterectomy and bilateral salpingo-oophorectomy.

STUDY DESIGN

This article is a retrospective review of records for 56 patients. The mean follow-up among those alive at last contact was 2.4 years (range, 32 days-5.2 years). Staging according to the International Federation of Gynecology and Obstetrics (1988) was as follows: I, 45 (80.4%); II, 3 (5.4%); III, 6 (10.7%); and IV, 2 (3.6%).

RESULTS

Intraoperative complications occurred in 4 patients (7.1%). Transformation to laparotomy was necessary in 7 patients. Postoperative complications were observed in 9 patients (16.1%). Pelvic irradiation was administered postoperatively to 11 patients (19.6%). Among the 45 patients with surgical stage I disease, the 3-year recurrence rate was 2.5% and the 3-year cause-specific survival was 96.0%.

CONCLUSIONS

Laparoscopic lymphadenectomy and vaginal or laparoscopic hysterectomy with bilateral salpingo-oophorectomy provided 3-year survival and recurrence rates similar to those of the traditional abdominal approach.

Laparoscopic-assisted vaginal hysterectomy for endometrial cancer: clinical outcomes and hospital charges

OBJECTIVE

Our objective was to compare the clinical outcomes and associated hospital charges between two methods of hysterectomy for patients with early-stage endometrial cancer.

METHODS

Retrospective chart review of 320 patients with early-stage endometrial cancer treated by laparoscopic-assisted vaginal hysterectomy (LAVH) or total abdominal hysterectomy (TAH) was performed for the period of July 1, 1991, to September 30, 1996, at Memorial Sloan-Kettering Cancer Center.

RESULTS

Sixty-nine patients (22%) were treated by LAVH, and 251 (78%) were treated by TAH. The majority of the patients (80%) had Stage I disease. The mean age was similar for both groups: 60 years for the LAVH vs 61 years for TAH. The mean weight was significantly lower for the LAVH group, 71 kg (range 43-117 kg), than for the TAH group, 82 kg (range 38-200 kg), (P < 0.05). Overall complication rates were lower among patients treated by LAVH. Operating room time was longer for the LAVH group (214 min) than for the TAH group (144 min) (P < 0.05). The median length of stay was significantly shorter for patients treated by LAVH (2.0 days) compared to TAH (6.0 days) (P < 0.05). Room charges were significantly higher for the TAH patients ($6960) compared to the LAVH patients ($3130) (P < 0.05). Overall mean total charges were significantly less for the LAVH group ($11,826) than for the TAH group ($15,189) (P < 0.05). With a median follow-up of 30 months for the TAH group and 18 months for the LAVH group, there was no significant difference in disease recurrence (P = 0.91).

CONCLUSION

Patients treated by LAVH for early-stage endometrial cancer had significantly shorter hospitalization and fewer complications, resulting in less overall hospital charges when compared to patients treated by TAH. Long-term outcome was similar. Laparoscopic-assisted vaginal hysterectomy is an attractive alternative for selected patients with early-stage endometrial cancer.

Three classes of radical vaginal hysterectomy for treatment of endometrial and cervical cancer

OBJECTIVES

The aims of this study were to (1) describe three types of extended vaginal hysterectomy with different degree of radicality, (2) to identify possible indications for each one of them, and (3) to encourage individualization of the treatment, with special reference to the reevaluation of the role of vaginal surgery in gynecologic oncology.

STUDY DESIGN

The surgical-anatomic principles of radical vaginal surgery and the techniques of three increasingly extended vaginal hysterectomies are illustrated. Possible indications are pointed out on the basis of our personal experience from previously published retrospective studies.

RESULTS

Class I extended vaginal hysterectomy allows the "en bloc" dissection of the uterus along with the upper third of vagina and both the adnexa. The parametria are not removed. This procedure has proved to be of value for treatment of stage I endometrial cancer. In the class II extended vaginal hysterectomy the distal tract of the anterior and posterior parametria are preserved, whereas the cardinal ligament is entirely removed. This operation has shown promising results for treatment of stage IB-IIA cervical cancer of small volume while reducing the incidence of bladder and rectal dysfunctions. The class III procedure includes the complete removal of the parametria (anterior, lateral, and posterior). This operation has been shown to provide a high rate of cure for stage IB-IIA cervical cancer.

CONCLUSIONS

In view of the several advantages of vaginal surgery, this approach should be considered in the individualized treatment of selected cases of endometrial and cervical cancers. The three classes of radical vaginal hysterectomy allow tailoring the type of vaginal operation to the clinical and physical characteristics of the patients. The combined use of extraperitoneal or laparoscopic lymphadenectomy would considerably extend the indications for radical vaginal operations.