Comprehensive surgical staging for endometrial cancer

Despite a shift from clinical to surgical staging of endometrial cancer in 1988, performance of comprehensive surgical staging for clinically early-stage endometrial cancer remains controversial. Low-, intermediate-, and high-risk groups have been defined pathologically. Herein, we describe the risks and benefits of comprehensive surgical staging. Comprehensive surgical staging is encouraged in high-risk histologies, whereas a method of triage should be used to determine who among the low-grade endometrioid histology may benefit from comprehensive staging.     

The significance of surgical staging in intermediate-risk endometrial cancer

Objective

The objective was to evaluate rates of nodal disease in endometrial cancer within risk groups based on uterine factors, and to estimate the rate of potential undertreatment and impact on survival if nodal status was unknown.

Methods

This was a population-based retrospective cohort study of endometrioid-type endometrial cancer in British Columbia from 2005 to 2009. All women with a preoperative grade 2/3 cancer underwent hysterectomy, bilateral salpingo-oophorectomy (HBSO) and lymphadenectomy, and those with intermediate- or high-risk disease based on uterine factors after HBSO alone underwent secondary lymphadenectomy. We compared rates of node-positivity and potential undertreatment in each group if nodal status had been unknown (chi-square test), and estimated the survival benefit from lymphadenectomy.

Results

There were 222 women who underwent primary or secondary lymphadenectomy. Median age was 65 (range 38-86) and median number of lymph nodes was 10 (range 2-39). Of the 66 women with intermediate-risk disease (grade 1 or 2 tumor, deep myometrial invasion), 6 had nodal disease (9.1%) and received adjuvant chemotherapy. They remain disease-free after 24 months (range 8-55). They would not have qualified for chemotherapy based on uterine factors alone, and would have been undertreated compared to other risk groups (chi-square p = 0.071). A 1% survival benefit was estimated from lymphadenectomy.

Conclusion

Women with a grade 1 or 2 tumor and deep myometrial invasion have a 9% risk of nodal disease. Lymphadenectomy is significant for this subgroup as they would have been undertreated based on uterine risk factors alone, although the survival benefit is limited.     

Laparoscopic surgical staging of early ovarian cancer

Since its advent in the early 1990s, laparoscopic surgical staging for early ovarian cancer has been explored as an option with the potential to offer women equivalent cancer control and survival as provided by laparotomy but with the clear benefits of minimally invasive surgery. A limited but expanding body of literature suggests aggressive surgical staging can be performed with equivalent tissue assessment compared with laparotomy. Given the lack of randomized, controlled trials, the risks and benefits of such a procedure remain ambiguous. This review summarizes the current body of literature regarding the role of laparoscopy in upfront surgical staging of ovarian cancer. This review presents the history, rationale, and established benefits and risks of utilizing this approach in women who present with malignancy that appears confined to the ovary. Although retrospective data confirm the feasibility, safety, and efficacy of laparoscopic staging of early ovarian cancer, more prospective data will be required to confirm equivalent survival in a patient population that has the potential to be cured.     

Laparoscopy versus laparotomy for the surgical management of apparent early stage ovarian cancer

OBJECTIVE: To compare the results of laparoscopic staging of apparent early ovarian cancer (EOC) with those obtained with comprehensive surgical staging via laparotomy. METHODS: Consecutive patients undergoing comprehensive laparoscopic staging for presumed EOC (LPS group; N=15) were compared with historical controls selected from consecutive women who have had conventional staging with open surgery (LPT group; N=19). RESULTS: No difference was found in demographics and preoperative variables between the two groups. There were no significant differences between the two groups with regard to median number of lymph nodes and likelihood of identifying metastatic disease. No conversion to laparotomy and no intraoperative complication occurred in the LPS group. Operative time was significantly longer in the LPS group when compared with the LPT group (377+/-47 vs. 272+/-81 min, P=0.002). One patient in the LPS group had a retroperitoneal haematoma recognized in the postoperative period, and this required laparotomy and ligature of the hypogastric arteries to achieve haemostasis. Minor postoperative complications occurred in 1 (6.7%) patient in the LPS group and in 8 (42.1%) patients in the LPT group (P=0.047). Hospital stay was significantly shorter in the LPS group [3 (2-12) vs. 7 (4-14) days, P=0.001]. Median (range) follow-up time was 16 (4-33) and 60 (32-108) months in the LPS and LPT group, respectively. Eleven (73.3%) patients in the LPS group and 13 (68.4%) in the LPT group received adjuvant treatment. There were no recurrences in the LPS group whereas 4 (7.1%) recurrences occurred in the LPT group. Overall survival was 100% in both groups. CONCLUSION: Our results suggest that laparoscopic comprehensive surgical staging of EOC is as safe and adequate as the standard surgical staging performed via laparotomy.     

Surgical pathologic staging in apparent stage I endometrial carcinoma

A multicenter trial on apparent stage I endometrial carcinoma was performed to establish an intensive surgical staging, to formulate a treatment on the basis of the pathological extent of the disease and to determine the effectiveness of adjuvant medroxyprogesterone acetate therapy. The results of the first objective on 1,055 patients are herein reported. All patients had total abdominal hysterectomy, bilateral salpingo-oophorectomy, colpectomy of the superior third, and biopsy of lymph nodes positive or doubtful at radiological imaging or on surgical inspection. On the basis of the pathologic extent of the disease, patients were classified into five categories: disease outside the uterine corpus (RE); disease limited to endometrium (RO); disease with inner myometrial invasion and high or moderate grade (R1); disease with deep myometrial invasion or poor differentiation (R2); disease with positive retroperitoneal nodes (R3). One hundred and forty-six patients were RE, 163 RO, 382 R1, 341 R2 and 23 R3. The results showed a clinical understaging in 16% of the cases. According to the new FIGO classification, the relapse-free survival at 84 months was 96% for patients at stage IA, 92% for patients with stage IB-C, 86% for stage IIA-B, 76% for stage IIIA-B and 74% for patients at stage IIIC. These data confirm the importance of an intensive surgical staging in apparent stage I endometrial carcinoma.     

Laparoscopic-assisted vaginal hysterectomy with laparoscopic pelvic and paraaortic staging for early endometrial cancer

While abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymphadenectomy is still considered the gold standard for the surgical treatment of endometrial cancer, the laparoscopic-assisted vaginal hysterectomy (LAVH) plus laparoscopic lymphadenectomy has been performed in FIGO stage I endometrial cancer in selected centers for about a decade. Clinical studies have shown that the frequency of intra- and postoperative complications, the pelvic and paraaortic lymph node yield, and—more importantly—the overall survival, are similar both with the laparoscopic-assisted vaginal approach and the abdominal approach in stage I disease. Blood loss and duration of hospital stay may even be reduced with the LAVH. In summary, provided there is compliance with established oncologic guidelines, LAVH with pelvic and paraaortic lymphadenectomy can probably be performed in patients with endometrial cancer FIGO stage I without safety loss.     

Revised FIGO staging system for endometrial cancer

In 1988 the International Federation of Gynecologists and Obstetricians (FIGO) developed a surgical staging system for endometrial cancer. The FIGO staging system was recently revised in 2009 to reflect our growing understanding of the natural history of endometrial cancer. In this review, we describe the revised 2009 FIGO staging system for tumors of the uterine corpus and examine the effect of the new changes in the staging criteria.     

Cytokeratin staining of resected lymph nodes may improve the sensitivity of surgical staging for endometrial cancer

OBJECTIVE: The presence of metastases to regional lymph nodes (LN) is the single most important risk factor in endometrial cancer. Advances in molecular biology have provided more sensitive methods for detecting micrometastasis. This was a pilot study to determine whether cytokeratin staining of LN from endometrial cancer patients is more sensitive than traditional histopathologic evaluation for the detection of micrometastasis. METHODS: The inclusion criteria included patients with surgical stage I-II endometrial cancer having >50% myometrial invasion, lesions >2 cm, and negative LN together with one of the following: FIGO grade 3 or cervical or lymph-vascular involvement. A matched control group included patients with LN metastasis. The evaluation of the LN at the time of initial surgery consisted of a frozen section and a reevaluation on permanent sections with H&E. In the study, lymphadenectomy specimens were cut, stained again with H&E and with cytokeratin, and examined. Cytokeratin staining was performed with AE1/AE3 antibodies. There were 16 LN-negative cases and 9 LN-positive controls. RESULTS: There was complete agreement between the LN assessment at time of surgery and the study H&E review prior to the staining for cytokeratin. However, 2 LN-negative cases (12.5%) had micrometastasis by cytokeratin staining. One of these patients developed recurrent disease in the para-aortic LN and died of disease at 2.8 years. CONCLUSION: Cytokeratin staining may improve the sensitivity for detection of metastasis compared to traditional evaluation. This study strongly suggests that these micrometastasis are clinically significant. An approach incorporating cytokeratin analysis could improve the risk assessment of specific patients.     

Laparoscopy compared with laparotomy for the surgical staging of endometrial carcinoma

AIM: To evaluate and compare laparoscopic-assisted surgical staging with conventional laparotomy for the treatment of endometrial carcinoma. METHODS: From July 2001 to December 2003, a retrospective review of patients with endometrial carcinoma was carried out. The medical records of those patients who had undergone surgical staging with hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy (PLN) were evaluated. Primary outcome measures were operating time (OT), estimated blood loss, total number of lymph nodes yielded, intraoperative complications, postoperative complications, and length of hospital stay. RESULT: A total of 64 cases were identified. Two cases were excluded because of incomplete records. Two cases with para-aortic lymphadenectomy and four cases with Wertheim's hysterectomy were excluded from the study. Thirty-six patients underwent laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy and PLN (laparotomy group). Twenty patients underwent the same surgery by laparoscopy, of which 19 were successfully carried out (laparoscopy group). One case was converted to laparotomy. The mean OT in the laparoscopy group was longer when compared with the laparotomy group (211 min vs 94 min, P < 0.001). The mean estimated blood loss in the laparoscopy group was less (200 mL vs 513 mL, P < 0.001). The post-operative hospital stay was shorter in the laparoscopy group (3.6 days vs 7.7 days, P < 0.001). The mean number of lymph nodes yielded was more in the laparoscopy group (26.1 vs 16.7, P = 0.004). Neither group had intraoperative complications and both had similar postoperative complication rates. CONCLUSION: Laparoscopic-assisted surgical staging for endometrial carcinoma is associated with significantly less blood loss, shorter hospital stay, longer OT time, and more lymph nodes yielded when compared with laparotomy.     

Learning curve for laparoscopic staging of early and locally advanced cervical and endometrial cancer

Background

Laparoscopic staging is rapidly evolving as an important surgical approach in the field of gynecology oncology. However, the specific learning curve associated with this approach remains poorly investigated. This study aimed to evaluate the learning curve for laparoscopic staging of uterine cancers.

Methods

A series of 28 consecutive laparoscopic hysterectomies with or without pelvic and/or para-aortic lymph node sampling for the treatment of early and locally advanced endometrial or cervical cancer were performed between July 2008 and January 2011. The analyses of the learning curves of the institution were performed for 20 patients who had undergone pelvic lymphadenectomy and/or para-aortal lymph node sampling. The learning curve period has also been compared with the last 26 patients who received laparotomy staging (“open” group) due to the same diagnosis and by the same surgical team. To assess the short- and long-term outcomes, we used validated questionnaires to record the clinical and follow-up results, any complaints or subjective reports from the patients, and details of their quality of life. All data were collected prospectively in a database and reviewed retrospectively. The learning was evaluated using the cumulative sum (CUSUM) method.

Results

The CUSUM learning curve consisted of two distinct phases: phase 1 (the initial 9 cases) and phase 2 (the subsequent cases) which presented the mastery phase, with the operative time of 397.7 ± 63.5 versus 300.6 ± 19.4 min (p < 0.0001). The significance of the difference between the two phases and “open” group changed in terms of number of lymph nodes retrieved, intra-operative blood loss and hospital stay. The conversion rate of phase 1 was higher than phase 2 [2 (22.2 %) respectively 1 (9 %)].

Conclusions

This series confirms previous study findings concerning the feasibility and the safety of laparoscopic staging and provides information for surgeons in single centers considering adopting an endoscopic strategy to monitor the different aspects of outcomes during the implementation process for internal benchmarking. The operative outcome of laparoscopic staging intervention improves with experience. The data reported in this article suggest that after a learning curve of 9 patients, a relevant improvement at least regarding the duration of the operation can be achieved for experienced surgeons who start performing laparoscopic staging of uterine cancers. However, due to the limited number of patients as well as number of para-aortic lymph node sampling procedures, further studies are required for firm conclusions to be drawn.     

Pelvic and para-aortic lymphadenectomy for surgical staging of endometrial cancer: morbidity and mortality.

This analysis compared retrospectively the morbidity and mortality of patients with endometrial cancer who had total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO) alone or with pelvic and para-aortic lymphadenectomy performed by the same surgeon at one private institution. Between August 1987 and March 1991, 77 women with endometrial cancer were staged surgically by a standard protocol without preoperative radiotherapy. Thirty-five patients (45%) had TAH/BSO alone and 42 (55%) had TAH/BSO with pelvic and para-aortic lymphadenectomy. The median number of lymph nodes removed was 18. Patients having lymphadenectomy had an increased mean (+/- standard deviation) operative time (129 +/- 29 versus 87 +/- 26 minutes; P less than .0001), increased mean estimated blood loss (391 +/- 192 versus 272 +/- 219 mL; P = .013), and a longer postoperative hospital stay (P = .017) compared with patients having TAH/BSO alone. However, there was no difference in transfusion rate, febrile morbidity, postoperative complications, or mortality. We conclude that pelvic and para-aortic lymphadenectomy can be added to TAH/BSO in patients with endometrial cancer without a clinically significant increase in morbidity or mortality.     

The impact of complete surgical staging on adjuvant treatment decisions in endometrial cancer

OBJECTIVE: The aim of this study was to determine the impact of complete surgical staging on adjuvant treatment decisions in endometrial cancer. METHODS: Two hundred ninety-one patients with endometrial cancer treated between 1996 and 2002 were identified through patient registry. Two hundred seventy-one (93%) of these women were completely surgically staged. RESULTS: Average patient age: 64 years (23-92); average weight: 198 lb (99-350+); median follow-up: 12 months (0-77). Eighteen percent of tumors had surgical grade greater than preoperative grade. One hundred forty-nine patients had low-risk uterine factors, three with positive nodes (2%). One hundred forty-six out of 149 patients had negative nodes, received no adjuvant therapy, and four recurred (3%). Ninety-six patients had intermediate risk uterine factors, 16 with positive nodes (17%). Eighty out of 96 patients had negative nodes. Twenty-one out of 80 patients (26%) received whole pelvis radiation or chemotherapy. Three out of 21 patients (14%) had distant recurrences. Fifty out of 80 patients (63%) received no adjuvant therapy. Six out of 50 patients (12%) recurred, three distant and three distant and in the pelvis. The recurrence rate of patients with intermediate risk uterine factors that received adjuvant therapy was not statistically different than that of patients receiving no adjuvant therapy (P = 1.00, Fisher's exact test). Forty-six patients had high-risk uterine factors, 26 with positive nodes (55%). The recurrence rate for stage I disease was 5% (11/211), for stage II disease 14% (2/14), for stage III disease 21% (11/52), and for stage IV disease 50% (7/14). CONCLUSION: Complete surgical staging adds important information that influences adjuvant treatment decisions. Patients with surgical stage I and II endometrial cancer do not benefit from whole pelvis radiation therapy.     

腹腔镜在卵巢癌手术分期与治疗中的应用

腹腔镜在卵巢癌诊治中的应用目前争议较多。文章重点就腹腔镜用于卵巢癌诊断、评估、分期与补充分期手术、监测与随访等方面的现状与共识,以及腹腔镜下卵巢癌肿瘤细胞减灭术的进展和争议等问题做一阐述,希望能为临床应用与研究提供参考。