Endometrial cancer: is surgical staging necessary?

Surgical staging has become the standard of care for the treatment of women with endometrial cancer. Recent scientific publications have confirmed the relative safety of this procedure when performed by subspecialty trained surgeons and have provided compelling evidence that the routine use of postoperative teletherapy is not cost effective, nor does it offer improved survival. New questions as to the safety and effectiveness of a laparoscopic staging approach have been answered in the affirmative. Although the extent of staging has not yet been defined, growing evidence suggests that preoperative studies and intraoperative clinical opinion cannot be consistently counted on to be predictive of postoperative histologic status. Therefore, all patients should be considered at risk and should undergo an operation in a clinical situation that offers the immediate availability of retroperitoneal staging or cytoreductive surgery if necessary.     

Are endometrial cancer radiotherapy results age related?

Objective

To analyze the impact of age on radiotherapy results based on cancer-specific survival (CSS), vaginal-cuff relapses (VCR) and complications analysis in 438 patients with endometrial carcinoma (EC) receiving postoperative radiotherapy (PRT) divided into three age groups for analysis.

Materials and methods

From 2003 to 2015, 438 patients with EC were treated with PRT and divided into three age groups: Group-1: 202 patients <?65 years; Group-2: 210 patients ≥?65 and <?80 years; Group-3: 26 patients ≥?80 years. Vaginal toxicity was assessed using the objective LENT-SOMA criteria and RTOG scores were recorded for the rectum, bladder, and small bowel. Statistics: Chi square and Student’s t tests, Kaplan–Meier survival study for analysis of CSS.

Results

The mean follow-up was 5.6 years in Group-1, 5.6 years in Group-2 and 6.3 years in Group-3 (p?=?0.38). No differences were found among the groups in distribution of stage, grade, myometrial invasion, Type 1 vs. 2 EC and VLSI (p?=?0.97, p?=?0.52, p?=?0.35, p?=?0.48, p?=?0.76, respectively). There were no differences in rectal, bladder and vagina late toxicity (p?=?0.46, p?=?0.17, p?=?0.75, respectively). A better CSS at 5 years was found in Group-1 (p?=?0.006), and significant differences were found in late severe small bowel toxicity in Group-3 (p?=?0.005). VCR was increased in Group-3 (p?=?0.017).

Conclusions

Patients ≥?65 years had a worse outcome in comparison to younger patients. Late vaginal, rectal and bladder toxicities were similar in the three groups, although an increase of severe late small bowel toxicity led to IMRT in patients ≥?80 years. Further larger studies are needed including quality of life analysis in patients ≥?80 years.

     

Does the revised International Federation of Gynecology and Obstetrics staging system for endometrial cancer lead to increased discrimination in patient outcomes?

BACKGROUND:

Recent changes were made to the International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial cancer. The objective of this study was to compare survival outcomes for patients who were staged according to the 1988 FIGO staging system versus the 2009 FIGO staging system.

METHODS:

Data were obtained from the Surveillance, Epidemiology, and End Results Program for the years 1998 to 2006. Patients who had a diagnosis of adenocarcinoma of the uterus with complete staging information were included. Patients were staged according to the 1988 and 2009 FIGO staging systems, and Kaplan‐Meier estimates were derived for cause‐specific survival (CSS). Univariate and multivariate analyses using Cox proportional hazards models were used to identify the factors associated with survival.

RESULTS:

In total, 47,284 patients were included. The median follow‐up was 37 months. The 5‐year CSS rates for patients who had 2009 FIGO stage IA and IB disease were 96.6% and 89.9%, respectively (P < .0001). After accounting for age, grade, and race, this survival difference remained significant (hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.74‐2.24; P < .0001). Patients who had 1988 FIGO stage IIA disease had a 5‐year CSS rate similar to that of patients who had 1988 FIGO stage IC disease (88.6% vs 89.9%, respectively; P = .09). Patients who had positive pelvic washings had a 5‐year CSS rate similar to that of patients who had stage IIIA disease according to the 2009 FIGO system (74.2% vs 72.1%, respectively; P = .37). The 5‐year CSS rate for patients who had stage IIIC1 disease was significantly improved compared with that for patients who had stage IIIC2 disease (68.2% vs 57.3%, respectively; P < .0001). In the multivariate model, the survival difference remained (HR, 1.49; 95% CI, 1.26‐1.76; P < .0001).

CONCLUSIONS:

The 2009 staging system for endometrial cancer produced better discrimination in CSS outcomes compared with the 1988 system. Cancer 2011;. © 2011 American Cancer Society.     

Rectal cancer staging: is there an optimal method?

The staging process in a newly diagnosed rectal cancer is divided into three parts. One essential part is the local staging, in which both endorectal ultrasound and MRI are used to disclose the size of the tumor and its correlation to the perirectal fascia, and to identify lymph node deposits and vascular invasion. This local staging process will guide clinicians to decide upon not only the type of surgery (local excision or radical surgery) but also whether or not some type of neoadjuvant treatment, such as radiotherapy and/or chemotherapy, is indicated. The second part is to evaluate whether or not the tumor has already metastasized at diagnosis. The most important organs to evaluate are the liver and lungs, and imaging techniques such as ultrasound, CT-scan, or sometimes PET-CT, and MRI can be used. The third important part is to investigate the rest of the large bowel for synchronous adenomas or cancers. This will preferably be done with colonoscopy or CT-colonography and sometimes barium enema. This article discusses the imaging techniques used for local staging and distant metastases.     

Lymphadenectomy for endometrial cancer: is paraaortic lymphadenectomy necessary?

Total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) have been performed as a standard surgical treatment for endometrial cancer. Many studies have reported on issues such as whether retroperitoneal lymphadenectomy should also be performed with TAH+BSO, to what extent lymphadenectomy should be performed when TAH+BSO is performed, and in what type of patients should lymphadenectomy be performed. These issues have been actively discussed, but there has not been any consensus. In this review article, the benefits of retroperitoneal lymphadenectomy in the initial surgical treatment for endometrial cancer will be discussed in terms of patients with pelvic lymphadenectomy and those with paraaortic (PA) lymphadenectomy. From the previous data, the establishment of TAH+BSO plus pelvic lymphadenectomy as the standard surgical treatment for endometrial cancer is thought to be reasonable. In this situation, is there benefit in performing PA lymphadenectomy? A discussion will be provided by separating the diagnostic significance from the therapeutic significance of this treatment. At present, there are no established treatments for PA-lymph node-positive patients that can be recommended more than the adjuvant therapies that are already performed at various institutions. A scientific basis that clearly indicates the therapeutic effect of PA lymphadenectomy does not exist at the present time. Despite performing thorough PA lymphadenectomy, the route of progression to extrauterine sites cannot be completely controlled. The standard surgical procedure for endometrial cancer is TAH+BSO+pelvic lymphadenectomy, which is considered necessary and sufficient. At present, the addition of PA lymphadenectomy for endometrial cancer can be regarded as only an investigated protocol.