A comparison of disease recurrence between robotic versus laparotomy approach in patients with intermediate-risk endometrial cancer

Comparing oncological outcomes of robotic versus open surgery in the treatment of endometrial cancer

PURPOSE

Robotic surgery has been incorporated in the treatment of endometrial cancer, with evidence suggesting that minimal access surgery offers advantages over laparotomy including less blood loss, lower rate of perioperative complications, and accelerated postoperative recovery. The laparoscopic approach to cervical cancer (LACC) study has recently demonstrated inferior survival outcomes in cervical cancer patients treated with minimal access surgery including robotic surgery. It is, therefore, imperative that further evaluation of the latter in endometrial cancer is performed.

METHODS

A retrospective analysis of clinical data was performed. We compared two different types of surgery performed for the treatment of FIGO stage 1 to 3 endometrial cancer; open surgery performed in the years 2013-2015 vs robotic surgery performed in 2017-2019, after the implementation of the robotic program in our institution. Main outcome measures were recurrence-free survival and overall survival, with secondary outcomes including surgical morbidity and postoperative recovery.

RESULTS

We compared 123 patients who had open surgery with 104 patients who underwent robotic surgery. One case from the second group was converted to open surgery due to the inability to complete it robotically. After a median follow-up of 68 months, there was no difference in recurrence-free survival or overall survival between the two groups. Length of stay after an operation was significantly different with mean hospital stay of 1.6 days after robotic surgery and 5 days after open surgery (p = 0.001). No significant difference was identified in the rate of complications (p = 0.304).

CONCLUSION

Our analysis has demonstrated that robotic surgery offers better perioperative outcomes without compromising the oncological safety.

Comparison of laparoscopy and vNOTES in early-stage endometrial cancer

AIM

To compare the demographic, clinical, surgical, histopathological, and oncological outcomes of vNOTES and conventional laparoscopy (CL)for early-stage endometrial cancer.

METHODS

A retrospective study was carried out in the Gynecologic Clinic of a tertiary hospital from January 2019 to November 2020. Patient demographic characteristics, surgical outcomes, histopathological characteristics, visual analog scale (VAS) pain scores at postoperative 6th, 12th, and 24th, intra- and postoperative complications, and follow-up results were noted.

RESULTS

A total of 45 patients enrolled, of which 16 underwent CL and 29 were vNOTES. The operative time and decrease in hemoglobin levels were similar for both groups (p = 0.202, p = 0.699). Postoperative hospital stay did not differ between the vNOTES group and the CL group (p = 0.549). VAS pain scores at postoperative 6th, 12th, and 24th h were significantly lower in vNOTES group than in the CL group (p < 0.001). The requirement for additional opioid/narcotic analgesic was lower in the vNOTES group than in the CL group (p = 0.037).

CONCLUSION

vNOTES may be a safe and feasible option in early-stage endometrial cancer, having less postoperative pain and less requirement of opioid/narcotic analgesic compared with laparoscopy.

Impact of Robotic Assistance on Minimally Invasive Surgery for Type II Endometrial Cancer: A National Cancer Database Analysis

The objective of this study is to compare the overall survival (OS) and surgical outcomes between conventional laparoscopy and robot-assisted laparoscopy (RAL) in women with type II endometrial cancer. We identified a large cohort of women who underwent hysterectomy for type II endometrial cancer between January 2010 and December 2014 using the National Cancer Database (NCDB). The primary outcome was to compare the OS of conventional laparoscopy versus RAL. Secondary outcomes included the length of hospital stay, 30-day readmission rate, 90-day mortality, rates of lymph node retrieval, rates of node positivity, and rates of conversion to laparotomy. Cohorts were compared and multivariable logistic regression was used to determine characteristics with statistically significant predictors of outcome. We identified 7168 patients with stage I-III type II endometrial cancer who had minimally invasive surgery as primary treatment between 2010 and 2014. A total of 5074 patients underwent RAL. Women who underwent RAL were less likely to have stage III disease (26.4% vs. 29.9%, p = 0.008) and had smaller primary tumors (4.6 vs. 4.1 cm, p < 0.001). In a multivariable model, there was no difference in OS between conventional laparoscopy and RAL. With regard to postoperative outcomes, RAL was associated with a decreased risk for conversion to laparotomy (2.7% vs. 12%, p < 0.001), a shorter hospital stay (1 vs. 2 days, p < 0.001), a decreased 90-day mortality (1.3% vs. 2.2%, p = 0.004), and an increased number of lymph nodes sampled (14 vs. 12, p < 0.001). In multivariable analysis, the use of RAL was independently associated with a reduced rate of conversion to laparotomy. In conclusion, there was no difference in OS between conventional laparoscopy and RAL in type II endometrial cancer in a large retrospective cohort of patients from the NCDB. RAL was associated with a decreased risk of conversion to laparotomy.

Surgical Treatment for Endometrial Cancer, Hysterectomy Performed via Minimally Invasive Routes Compared with Open Surgery: A Systematic Review and Network Meta-Analysis

Background: Total hysterectomy with bilateral salpingo-oophorectomy via minimally invasive surgery (MIS) has emerged as the standard of care for early-stage endometrial cancer (EC). Prior systematic reviews and meta-analyses have focused on outcomes reported solely from randomised controlled trials (RCTs), overlooking valuable data from non-randomised studies. This inaugural systematic review and network meta-analysis comprehensively compares clinical and oncological outcomes between MIS and open surgery for early-stage EC, incorporating evidence from randomised and non-randomised studies. Methods: This study was prospectively registered on PROSPERO (CRD42020186959). All original research of any experimental design reporting clinical and oncological outcomes of surgical treatment for endometrial cancer was included. Study selection was restricted to English-language peer-reviewed journal articles published 1 January 1995-31 December 2021. A Bayesian network meta-analysis was conducted. Results: A total of 99 studies were included in the network meta-analysis, comprising 181,716 women and 14 outcomes. Compared with open surgery, laparoscopic and robotic-assisted surgery demonstrated reduced blood loss and length of hospital stay but increased operating time. Compared with laparoscopic surgery, robotic-assisted surgery was associated with a significant reduction in ileus (OR = 0.40, 95% CrI: 0.17-0.87) and total intra-operative complications (OR = 0.38, 95% CrI: 0.17-0.75) as well as a higher disease-free survival (OR = 2.45, 95% CrI: 1.04-6.34). Conclusions: For treating early endometrial cancer, minimal-access surgery via robotic-assisted or laparoscopic techniques appears safer and more efficacious than open surgery. Robotic-assisted surgery is associated with fewer complications and favourable oncological outcomes.

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.

Comparison of Minimally Invasive Surgery with Open Surgery for Type II Endometrial Cancer: An Analysis of the National Cancer Database

OBJECTIVE

Prior studies comparing minimally invasive surgery with open surgery among patients with endometrial cancer have reported similar survival outcomes and improved perioperative outcomes with minimally invasive surgery (MIS). However, patients with Type II endometrial cancer were underrepresented in these studies. We sought to compare the overall survival and surgical outcomes between open surgery and MIS in a large cohort of women with Type II endometrial cancer.

METHODS

Using data from the National Cancer Database, we identified a cohort of women who underwent hysterectomy for type II endometrial cancer (serous, clear cell, and carcinosarcoma) between January 2010 and December 2014. The primary outcome was a comparison of the overall survival for MIS with that for the open approach. The secondary outcomes included a comparison of the length of hospital stay, readmission within 30 days of discharge, and 30- and 90-day mortality. Outcomes were compared between the cohorts using the Mann-Whitney U test, Pearson's chi-square test, or Fisher's exact test. Multivariable logistic regression with inverse propensity weighting was used to determine clinical characteristics that were statistically significant predictors of outcomes. p values < 0.05 were considered significant.

RESULTS

We identified 12,905 patients with Type II, Stage I-III endometrial cancer that underwent a hysterectomy. In total, 7123 of these women (55.2%) underwent MIS. The rate of MIS increased from 39% to 64% over four years. Women who underwent MIS were more often White, privately insured, older, and had a higher income. The laparotomy group had a higher rate of carcinosarcoma histology (30.9% vs. 23.6%, p < 0.001), stage III disease (38.4% vs. 27.4%, p < 0.001), and larger primary tumors (59 vs. 45 mm, p < 0.001). Lymph node dissection was more commonly performed in the MIS group (89.6% vs. 85.4%, p < 0.001). With regard to adjuvant therapy, subjection to postoperative radiation was more common in the MIS group (37% vs. 40.1%, p < 0.001), while chemotherapy was more common in the laparotomy group (37.6% vs. 33.9%, p < 0.001). The time interval between surgery and the initiation of chemotherapy was shorter in the MIS group (39 vs. 42 days, p < 0.001). According to the results of propensity-score-weighted analysis, MIS was associated with superior overall survival (101.7 vs. 86.7 months, p = 0.0003 determined using the long-rank test), which corresponded to a 10% decreased risk of all-cause mortality (HR 0.9; CI 0.857-0.954, p = 0.0002). The survival benefit was uniform across all three histology types and stages. MIS was associated with superior perioperative outcomes, including shorter length of stay (1 vs. 4 days, p < 0.001), lower 30-day readmission rates (2.5% vs. 5%), and lower 30- and 90-day postoperative mortality (0.5% vs. 1.3% and 1.5% vs. 3.6%, respectively; p < 0.001 for both). The increased adoption of MIS from 2010 to 2014 corresponds to a decrease in 90-day postoperative mortality (2.8% to 2.2%, r = -0.89; p = 0.04) and overall mortality (51% to 38%, r = -0.95; p = 0.006).

CONCLUSIONS

In a large cohort of patients from the National Cancer Database, MIS was associated with improved overall survival and superior perioperative outcomes compared to open surgery among women with Type II endometrial cancer. A decrease in postoperative mortality and a shorter interval between surgery and the initiation of chemotherapy may contribute to the survival benefit of MIS. A racial and economic disparity in the surgical management of Type II endometrial cancer was identified, and further investigation is warranted to narrow this gap and improve patient outcomes.

Comparison of the effects of laparoscopic and open hysterectomy on surgical site wound infections in patients with endometrial cancer: A meta-analysis

This meta-analysis aimed to compare laparoscopic hysterectomy (LH) and open hysterectomy (OH) in terms of surgical site wound infection, length of hospital stay, and postoperative complications in patients with endometrial cancer (EC). PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, VIP, and Wanfang databases were comprehensively searched for studies on OH and LH for EC published between 2008 and July 2023, in any language. The literature was screened according to the inclusion and exclusion criteria, and the quality of the included case-control studies was assessed using the Newcastle-Ottawa Scale. Data were collated and analysed using Stata 17.0 software. A total of 1245 articles were screened according to the search strategy, and ultimately 15 studies were included in this meta-analysis, with a total of 1606 patients with EC, of which 751 were treated with LH and 855 with OH. The results showed that the rate of postoperative wound infection was significantly higher (OR: 0.290; 95% CI: 0.169-0.496, p < 0.001), the length of hospital stay was significantly longer (SMD: -1.976, 95% CI: -2.669 to -1.283, p < 0.001), and the incidence of postoperative complications was significantly higher (OR: 0.366; 95% CI: 0.280-0.478, p < 0.001) in the OH group than in the LH group. This study showed that LH was superior to OH for the treatment of EC and is associated with a lower rate of wound infection, shorter length of hospitalisation, and a reduced risk of complications. Thus, our findings support the choice of LH over OH for EC.

Recurrence and survival in endometrioid endometrial cancer - a population-based cohort study

OBJECTIVE

The aim of this study was to investigate recurrences and survival in endometrioid endometrial cancer (EC) in a complete population-based cohort.

METHODS

A regional population-based study including women with endometrioid EC, identified by the Swedish Quality Registry for Gynecological Cancer (SQRGC), where primary surgery was performed between 2010 and 2017. Patient characteristics and outcomes, including recurrences, were retrieved from the SQRGC and completed by records reviews. Overall (OS), net (NS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. The Fine and Gray proportional subdistribution hazards' regression model was used for risk factors for recurrence.

RESULTS

There were 1630 women included in the study, whereof 136 (8.3%) had a recurrence with a median time to recurrence of 22.5 months (range 3.2-59.3). One site of recurrence was diagnosed in 69.1%, while 27.2% being only vaginal. The total 5-year OS was 88.0%(95% CI:86.4-89.7) and the 5-year NS 98.6%(95% CI:96.5-100.7). If no recurrence occurred, the OS was 91.9%(95% CI:90.4-93.3) and NS 102.8%(95% CI:100.9-104.8). For only vaginal recurrence, 5-year OS was 77.0%(95% CI:64.0-92.6) compared to 36.1%(95% CI:27.5-47.3) for all other recurrences. The total 5-year DFS was 83.9%(95% CI:82.0-85.7). In the multivariable analysis, age, FIGO stage and primary treatment were found independent factors for recurrence with a HR of 1.29(95% CI:1.11-1.51;p = 0.001) for age, 2.78(95% CI:1.80-4.29;p < 0.001) for FIGO stage III and 1.84(95% CI:1.22-2.78;p 0.004) for adjuvant treatment.

CONCLUSION

There is an overall low recurrence rate for endometrioid ECs with a minor portion being only vaginal, associated with a favorable survival in contrast to other recurrences with a poor prognosis. Age, FIGO stage III and adjuvant treatment were found independent prognostic factors for recurrence.

Laparoscopic vs. open procedure for intermediate‑ and high‑risk endometrial cancer: a minimum 4-year follow-up analysis

BACKGROUND

The long-term oncologic outcomes after laparoscopic and open procedures for patients with intermediate‑ and high‑risk endometrial cancer (EC) remain unclear. Accordingly, laparoscopy cannot still be recommended as the standard choice for intermediate‑ and high‑risk EC. This retrospective study aimed to assess the perioperative and long-term oncologic outcomes of laparoscopy and open surgery in patients with intermediate- and high‑risk ECs within a minimum 4-year follow-up.

METHODS

We included 201 patients who underwent laparoscopic or open procedures for intermediate‑ and high‑risk EC between 2010 and 2017. Between-procedure comparisons of perioperative and oncological outcomes were performed using the independent t-test or Pearson's chi-squared test and the Kaplan-Meier method, respectively.

RESULTS

Finally, there were 136 intermediate‑ and 65 high‑risk endometrial tumors in the laparoscopic and open groups, respectively. There were no between-group differences in all baseline characteristics. Compared with the open group, the laparoscopic group had a significantly longer mean operating time (p = 0.005) and a lower mean estimated blood loss (EBL) (p = 0.031). There was a higher possibility of postoperative complication in the open group than in the laparoscopic group (p = 0.048). There were no significant between-group differences in pathological outcomes as well as the recurrence-free survival and overall survival rates (p = 0.626 and p = 0.148, respectively).

CONCLUSIONS

Among patients with intermediate‑ and high‑risk EC, laparoscopic surgery has an advantage over the open surgery in reducing EBL and the rate of postoperative complications without weakening the oncological control. There were no between-procedure differences in the recurrence-free and overall survival rates.

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.

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.

Robot-assisted versus laparoscopic minimally invasive surgery for the treatment of stage I endometrial cancer

OBJECTIVE

Recent reports in both cervical and endometrial cancer suggest that minimally invasive surgery (MIS) had an unanticipated negative impact on long-term clinical outcomes, including recurrence and death. Given increasing use of robotic surgery since the LAP2 trial, we sought to compare the intermediate and long-term outcomes between those who underwent robotic surgery or laparoscopy for Stage I endometrial cancer.

METHODS

We performed a retrospective review of patients from a single, large, academic, urban practice who underwent either laparoscopic or robot-assisted MIS (RA-MIS) for the treatment of endometrial carcinoma between 2006 and 2016, ensuring at least 5 years of potential follow-up. To adjust for differences in confounding variables between groups, propensity score-based inverse probability of treatment weighting (IPTW) was performed. Overall and recurrence-free survival were compared using Cox proportional hazards regression models adjusting for confounding weights.

RESULTS

1027 patients were included; 461 received laparoscopy and 566 received RA-MIS. RA-MIS use increased steadily during the study window, which resulted in longer mean surveillance in laparoscopy group (median 8.7 years versus 6.3 years, p < 0.001). RA-MIS was associated poorer recurrence-free (HR: 1.41, 95% CI: 1.12, 1.77) and overall survival (HR: 1.39, 95% CI: 1.06, 1.83). Disease-specific survival was also poorer in the RA-MIS group (HR: 3.51, 95% CI: 2.19, 5.63). Among those who recurred, median time to first recurrence was shorter in the RA-MIS group than the laparoscopy group (16.3 vs. 28.7 months, p = 0.07).

CONCLUSION

RA-MIS was associated with poorer long-term patient outcomes. Our data in this lower-risk population indicate relevant clinical endpoints may be occurring during intermediate and long-term follow-up windows. These findings support a prospective evaluation of the long-term outcomes of RA-MIS.

Peri-operative and survival outcomes analysis of patients with endometrial cancer managed by three surgical approaches: a long-term Bulgarian experience

The study aim was to assess the peri-operative, oncologic, and survival outcomes for patients with endometrial cancer (EC) managed by abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), or robotic hysterectomy (RH) approaches at premier centers in Bulgaria. We analyzed histologically diagnosed EC cases operated via any of the three surgical methods during 2008-2019. Data analyses included patients and tumor characteristics, peri-operative outcomes, and disease status. We grouped FIGO stages I and II to represent early-stage EC and to investigate their survival. Kaplan-Meier and Cox regression analyses were performed to determine disease-free survival (DFS) and overall survival (OS). Consecutive 917 patients (AH = 466; LH = 60, RH = 391) formed the basis of study analyses. Most of demographics and tumor characteristics of the patients were comparable across the groups except few minor variations (e.g., LH/RH cases were younger, heavier, more stage IA, endometrioid, G1, low-risk group). LH and RH group cases had significantly lower operative time than AH (p < 0.001), shorter hospital length-of-stay (p < 0.001), higher post-operative Hgb (p < 0.001). RH cases had fewer blood transfusions than AH or LH (p < 0.001). Cox multivariate analyses indicate that OS was not influenced by the type of surgical approach. Despite the fact that the DFS in "early-stage" EC is significantly better in AH group than RH, the type of surgery (i.e., AH, LH, or RH) for "all stages" is insignificant factor for DFS. With our long-term experience, minimally invasive surgical approach resulted in superior peri-operative, oncologic, and survival outcomes. Specifically, RH is not only safe in terms of post-operative results, but also for mortality and oncologic rates.

Volume index is a risk factor for recurrence even in patients with clinical stage IA endometrial cancer undergoing either laparotomy or laparoscopy: A retrospective study

Objectives:

The objective of the study was to investigate the long-term outcomes, in particular, recurrence risk, especially tumor volume, for Stage IA endometrial cancer and to identify the risk factors for recurrence.

Materials and Methods:

This single-center retrospective study analyzed women who underwent primary surgical treatment for the International Federation of Gynecology and Obstetrics Stage IA (Grade 1 or 2) endometrioid carcinoma at our institute between January 2010 and July 2018. Patients' demographic characteristics, including age, operative time, number of lymph nodes, final stage, volume index as tumor volume, and final histological type, were reviewed. A total of 168 patients were enrolled, with 95 and 73 patients in the laparotomy and laparoscopy groups, respectively. The Cox proportional hazards model was used to adjust for prognostic factors in the analysis including upstaged patients, tumor histology, lymphovascular invasion, and volume index.

Results:

There was no difference in the recurrence rate between laparoscopic and open surgeries for Stage IA endometrial cancer. The operative time was longer, and the amount of blood loss was lesser in the laparoscopy group than in the laparotomy group. For all patients undergoing either laparoscopy or open surgery, upstaged ≥IB, nonendometrioid Grade 1 or 2, lymphovascular invasion, and volume index ≥36 were significant independent recurrence risk factors.

Conclusion:

Laparoscopic surgery for Stage IA endometrial cancer is technically and oncologically safe. Patients with a high-volume index have a higher recurrence risk. Furthermore, the volume index can be a recurrence predictor in low-risk endometrial cancer patients.

Osthole suppresses the proliferation and induces apoptosis via inhibiting the PI3K/AKT signaling pathway of endometrial cancer JEC cells

Osthole, a natural product extracted mainly from fruits of Fructus Cnidii, possesses multiple pharmacological functions, including anti-inflammatory, anti-convulsant and anticancer effects. However, the effects of osthole in endometrial cancer (EC) is not fully understood. In the present study, EC cell lines, including JEC, KLE and Ishikawa cells and normal human cervical epithelial cells (HcerEpic) were applied to detect the anticancer effect of osthole. The present study demonstrated that osthole inhibited the proliferation of JEC, KLE and Ishikawa cells, but had no cytotoxic effect on HcerEpic. Furthermore, treatment of osthole induced JEC cell apoptosis, while osthole promoted the release of pro-apoptotic proteins, Bax and activated the cleaved caspase-3, caspase-9 and PARP. Additionally, osthole significantly increased the expression of PETN and decreased the phosphorylated form of PI3K and AKT in a concentration-dependent manner. Furthermore, osthole treatment suppressed the JEC tumor cell growth in a nude mouse xenograft model in vivo, and neither renal toxicity nor hepatotoxicity was induced by the indicated concentration. Taken together, the results of the present study suggested that osthole may be a novel and potential therapeutic agent of EC.

Effectiveness of robotic surgery for endometrial cancer: a systematic review and meta-analysis

BACKGROUND

Our current study was performed aimed at determining the efficacy and safety profile of robotic surgery (RS) compared to laparoscopic surgery (LPS) and laparotomy (LT) in the treatment of endometrial cancer on the basis of relevant studies.

PATIENTS AND METHODS

A systematic literature search was conducted based on appropriate keywords, using the Embase, Cochrane library, as well as PubMed. Our studiers also reviewed the key pertinent sources among the publications and included associated literatures published by June 2021. Odds ratios (ORs), mean difference (MD), as well as 95% confidence interval (95% CI) for each study were measured for further assessment and synthesis of outcomes.

RESULTS

Thirty studies involving a total of 12,025 patients were eventually included in the current meta-analysis. Compared with LPS, RS could significantly decrease the estimated blood loss, the incidence of intraoperative complications, the length of hospital stay, and the rate of conversion, and increased the rate of readmission. Compared with LT, RS significantly decreased the estimated blood loss, blood transfusion volume, the length of hospital stay, the rate of total, intraoperative and postoperative complications, and the rate of readmission and re-operation, and increased the operative time.

CONCLUSION

Considering the effects and safety profile of RS in terms of treating endometrial cancer, our study suggest that RS exerts superior outcomes than that of LPS and LT.

Five-Year Experience in the Surgical Treatment of Endometrial Cancer: Comparing Laparotomy With Robotic and Minimally Invasive Hysterectomy

OBJECTIVES

To compare surgical and oncological outcomes in the treatment of endometrial cancer between laparotomy and minimally invasive surgery. The secondary objective was to determine which MIS approach was the most beneficial.

METHODS

This was a single-centre retrospective review of all endometrial cancer surgeries performed between November 1, 2012 and October 31, 2017 in a gynaecologic oncology unit of a university hospital. Descriptive statistics were used to compare histopathologic results and oncological outcomes, and Kaplan-Meier estimates were used to compare survival.

RESULTS

A total of 735 cases were reviewed. The majority of patients (77%) underwent either laparotomy (35%) or robotic-assisted hysterectomy (42%); the remaining patients underwent total laparoscopic hysterectomy (12%) or a laparoscopic-assisted vaginal hysterectomy (8.7%). There was a statistically significant overall survival benefit (P = 0.02), a shorter hospital stay (P < 0.0001), and fewer early surgical complications (<30 d; P = 0.0002), as well as a survival benefit in elderly patients (>70 y) in the robotic-assisted hysterectomy group (P = 0.043) than the laparotomy group. Operating time was shorter in the laparotomy group (P < 0.0001). Recurrence rates in stage 1 low-risk disease were similar between groups.

CONCLUSION

Minimally invasive surgical approaches, particularly robotic surgery, do not compromise oncologic outcomes, especially for early-stage low-risk disease. In addition, these approaches are associated with fewer early surgical complications and shorter hospital stay, with significantly more same-day discharges. Overall survival and survival in a subgroup of elderly patients were significantly better in the robotic-assisted hysterectomy group.

Robotic platforms for endometrial cancer treatment: review of the literature

INTRODUCTION

The cornerstone in the management of endometrial cancer (EC) is surgical staging. Over the last few decades, minimally invasive surgery has been widely accepted as a mainstay in the treatment of endometrial cancer. The first robotic-assisted gynecological surgery was performed in 1998.

EVIDENCE ACQUISITION

The literature search was conducted using MEDLINE, EMBASE and PUBMED databases from January 1998 to September 2020.

EVIDENCE SYNTHESIS

Several studies have reported the advantages of robotic-assisted surgery over laparoscopy in the management of EC. These are most pronounced in obese patients. Robotic-assisted surgery is also associated with a shorter learning curve, particularly for lymphadenectomy, which enables more surgeons to perform minimally invasive surgery for EC.

CONCLUSIONS

The effectiveness and oncological results of robotic surgery for EC appear to be similar to those of other surgical methods, but fewer intraoperative complications occur than with other methods.

Tumor Molecular Features Predict Endometrial Cancer Patients' Survival After Open or Minimally Invasive Surgeries

Background

The Cancer Genome Atlas (TCGA) project shed light on the vital role of tumor molecular features in predicting endometrial cancer patients’ prognosis. This study aims to investigate the survival impact of surgical approaches on patients with different genetic alterations.

Methods

473 endometrial cancer patients from TCGA database were selected. To analyze the prognostic impact of surgical approach, survival analyses were conducted in patients with different molecular features. Finally, a simplified molecular stratification model was established to select patients suitable for open or minimally invasive surgery (MIS).

Results

In our cohort, 291 patients received open surgery and 182 received MIS. Molecular features influenced patients’ survival after different surgical approaches. Based on survival analyses, three molecular subtypes were generated, with subtype 1 harboring POLE mutation (POLE^mt), microsatellite-instability high (MSI-H), homologous recombination repair (HRR) pathway mutation or MUC16 mutation (MUC16^mt); subtype 3 carrying TP53 mutation; and subtype 2 without specific molecular feature. The survival influence of molecular subtypes depended on surgical approaches. In the open surgery cohort, three subtypes showed similar survival outcome, while in the MIS cohort, prognosis varied significantly among three subtypes, with subtype 1 the best and subtype 3 the worst. In stepwise Cox regression, molecular subtype was an independent predictor of recurrence-free survival in patients receiving MIS (p < 0.001).

Conclusion

The molecular features of endometrial cancer are associated with patients’ prognosis after different surgical approaches. MIS should be recommended in patients with POLE^mt, MSI-H, HRR pathway mutation or MUC16^mt, while for patients with TP53 mutation, open surgery is better concerning oncological safety.

Effect of surgical approach on risk of recurrence after vaginal brachytherapy in early-stage high-intermediate risk endometrial cancer

OBJECTIVE

The objective was to determine if surgical approach affects time to recurrence in early-stage high-intermediate risk endometrial cancer (HIR-EC) treated with adjuvant vaginal brachytherapy (VBT).

METHODS

In this retrospective cohort study, HIR-EC patients treated with VBT between 2005 and 2017 were identified and those who received open or minimally invasive hysterectomies (MIS) were included. Clinical and surgical variables were analyzed and time to recurrence was compared between surgical groups.

RESULTS

We identified 494 patients, of which 363 had MIS hysterectomies, 92.5% had endometrioid histology, 45.7% were stage IA and 48.0% stage IB. Open hysterectomy patients had higher BMIs (p = 0.007), lower rates of lymph node sampling (p < 0.001) and lymphovascular space invasion (LVSI) (p = 0.036), however in patients who recurred, no differences were noted between groups. Overall, 65 patients (13.2%) recurred, 14 in the open group (10.7%) and 51 in the MIS group (14.0%) (p = 0.58), while vaginal recurrences were noted in 4.6% and 6.1% respectively. When compared to the open group, the MIS group had a significantly shorter time to any recurrence (p = 0.022), to pelvic (p = 0.05) and locoregional recurrence (p = 0.021) and to death from any cause (p = 0.039). After adjusting for age, BMI, grade, LVSI and surgery date, the MIS group had a higher risk of any recurrence (HR 2.29 (1.07-4.92), p = 0.034) and locoregional recurrence (HR 4.18 (1.44-12.1), p = 0.008).

CONCLUSIONS

Patients with HIR-EC treated with VBT after MIS hysterectomy have a shorter time to recurrence and higher risk of recurrence when compared to open hysterectomy patients. Further studies into the safety of MIS in high-intermediate risk patients are required.

Treatment of Early Stage High-Risk Endometrioid-Type Endometrial Cancer and Patterns of Disease Relapse: A Retrospective Analysis

Purpose

A recently published randomized controlled trial has demonstrated that in patients with endometrial cancer with high-risk features, the addition of chemotherapy to radiation therapy, compared with radiation therapy alone, resulted in a significant improvement in failure-free survival. However, in the study, the effect of chemotherapy was limited to stage III patients, and the benefit was less pronounced in stage I and II patients. Our study aims to investigate the current practice of treatment and clinical outcomes in stage I high-risk endometrioid-type endometrial cancer.

Methods and Materials

A single-center retrospective study was conducted on patients with stage I high-risk endometrioid-type endometrial cancer without serous or clear cell features who have undergone hysterectomy between 1998 and 2015. Data on patients, tumor, and treatments were collected and correlated with clinical outcomes.

Results

A total of 1,572 patients with stage I disease were identified and 46 patients who met the inclusion criteria were selected for final analysis. The median age at diagnosis was 63 years (range, 49-86 years) and median follow-up was 5.9 years. Among the entire cohort, 40 (87.0%) patients underwent adjuvant radiation therapy, of which 36 (78.2%) patients underwent external beam radiation therapy and 4 (8.7%) patients underwent vaginal brachytherapy. Two of the 40 patients who received adjuvant radiation therapy also received adjuvant chemotherapy. Six (13.0%) patients received no adjuvant treatment. Of the 46 patients, the cumulative risk of distant recurrence was 19.6%, and only 1 patient (2.2%) recurred within pelvis (perirectal lymph node). Five-year disease-free survival and overall survival rates were 73.1% and 80.1%, respectively.

Conclusions

Adjuvant radiation therapy in stage I endometrioid-type endometrial cancer patients with high-risk features resulted in high rates of locoregional disease control, and most recurrences occurred at distant sites. Effective systemic therapy may be indicated in this patient population to further reduce the risk of distant relapses and improve survival.

Comparison of minimally invasive versus open surgery in the treatment of endometrial carcinosarcoma

OBJECTIVE

The aim of this study was to compare perioperative and oncologic outcomes between minimally invasive and open surgery in the treatment of endometrial carcinosarcoma.

METHODS

We retrospectively identified all patients with newly diagnosed endometrial carcinosarcoma who underwent primary surgery via any approach at our institution from January 2009 to January 2018. Patients with known bulky disease identified on preoperative imaging were excluded. The χ² and Mann-Whitney U tests were used to compare categorical and continuous variables, respectively. Kaplan-Meier curves were used to estimate survival, and compared using the log rank test.

RESULTS

We identified 147 eligible patients, of whom 37 (25%) underwent an open approach and 110 (75%) underwent minimally invasive surgery. Within the minimally invasive group, 92 (84%) of 110 patients underwent a robotic procedure and 14 (13%) underwent a laparoscopic procedure. Four minimally invasive cases (4%) were converted to open procedures. Median age, body mass index, operative time, stage, complication grade, and use of adjuvant treatment were clinically and statistically similar between groups. Median length of hospital stay in the open group was 4 days (range 3-21) compared with 1 day (range 0-6) in the minimally invasive group (p<0.001). The rates of any 30-day complication were 46% in the open and 8% in the minimally invasive group (p<0.001). The rates of grade 3 or higher complications were 5.4% and 1.8%, respectively (p=0.53). Median follow-up for the entire cohort was 30 months (range 0.4-121). Two-year progression-free survival rates were 52.8% (SE±8.4) in the open group and 58.5% (SE±5.1) in the minimally invasive group (p=0.7). Two-year disease-specific survival rates were 66.1% (SE±8.0) and 81.4% (SE±4.1), respectively (p=0.8).

CONCLUSIONS

In patients with clinical stage I endometrial carcinosarcoma, minimally invasive compared with open surgery was not associated with poor oncologic outcomes, but with a shorter length of hospital stay and a lower rate of overall complications.

Survival of microsatellite-stable endometrioid endometrial cancer patients after minimally invasive surgery: An analysis of the Cancer Genome Atlas data

OBJECTIVE

This study aims to investigate the survival impact of minimally invasive surgery on endometrial cancer (EC) patients with different histology and microsatellite status.

METHODS

This is a retrospective study based on the Cancer Genome Atlas (TCGA) data. 519 eligible EC patients were divided into four subgroups according to histology and microsatellite status. Kaplan-Meier survival analyses were conducted in all patients and four subgroups to compare the survival outcome after two surgeries (open vs. minimally invasive). Propensity score matching and propensity score covariate adjustment models were used to control confounders. To establish survival prediction models for EC patients, multivariate stepwise Cox regressions were conducted.

RESULTS

Among the eligible patients, 318 (61.3%) received open surgery and 201 (38.7%) received minimally invasive surgery. Overall survival was similar between the two groups (p = 0.33), but the latter showed significantly shorter recurrence-free survival (RFS) (p = 0.005). Subgroup analyses revealed the survival influence of surgical approach was only significant in microsatellite-stable (MSS) endometrioid EC patients. These results were verified by Kaplan-Meier survival analyses after propensity score matching and propensity score covariate adjustment models. Finally, the survival influence of multiple clinicopathological factors was analyzed. After stepwise Cox regressions, minimally invasive surgery was found to be independent risk factor for shorter RFS of all patients (hazard ratio [HR] = 2.038, 95% confidence interval [CI] 1.111-3.741, p = 0.02) and MSS patients (HR = 2.449, 95% CI 1.064-5.639, p = 0.04).

CONCLUSIONS

Minimally invasive surgery is associated with more rapid recurrence in MSS endometrioid EC patients, thus indicating the necessity of microsatellite testing for guiding EC surgery.