Analysis of treatment outcome in patients with endometrial cancer limited to the uterus

OBJECTIVES: The aim of study was to analyse results of treatment patients with uterine-confined endometrial cancer which underwent surgery and postoperative radiotherapy in Center of Oncology in Kraków between 1985 and 1997. MATERIAL AND METHODS: The research included a group of 650 women. All patients undergo total abdominal hysterectomy with bilateral salpingo-oophorectomy and postoperative radiotherapy. 155 patients with intermediate-risk of recurrence (IA-G3, IB-G1, G2) received postoperative whole pelvic irradiation only. In the group of 495 patients with high-risk of recurrence (IB-G3, IC, II) 210 patients received brachytherapy vaginal cuff only and 285 patients whole pelvic and vaginal cuff irradiation. RESULTS: In the group of patients with intermediate-risk of recurrence five NED survival was 93.5%. In the group of patients with high-risk of recurrence five NED survival was statistically lower in patients treated with brachytherapy vaginal cuff only (83.2% vs. 71.9%). CONCLUSION: In uterine-confined endometrial cancer patients, with intermediate-risk of recurrence treated with surgery and postoperative whole pelvis irradiation, 5-year NED survival is above of 90%. In the group of patients with high-risk of recurrence the adjuvant treatment of choice is whole pelvic and vaginal cuff irradiation.     

The role of radiation therapy in early endometrial cancer.

Few randomized studies have addressed the best choice of adjuvant radiation therapy after surgery for stage I endometrial cancer. Although whole pelvic radiation decreases the incidence of pelvic and vaginal cancer recurrence, there is no convincing evidence that it improves survival in women who have been completely staged. Several studies have indicated that women with high-risk stage I endometrial adenocarcinoma are treated adequately with extended surgical staging and vaginal cuff radiation. In the absence of randomized trials suggesting that whole pelvic radiation improves survival, it should be limited only to the highest risk stage I subgroups. Vaginal cuff brachytherapy appears to provide excellent local control of disease with minimal morbidity.     

Analysis of survival after laparoscopic-assisted vaginal hysterectomy compared with the conventional abdominal approach for early-stage endometrial carcinoma: a review of the literature

STUDY OBJECTIVE: To assess potential differences in perioperative features and survival between laparoscopic-assisted vaginal hysterectomy and conventional transabdominal hysterectomy in stage I endometrial cancer. DESIGN: Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2). SETTING: Acute-care, teaching hospital. PATIENTS: A total of 370 patients undergoing hysterectomy and bilateral salpingo-oophorectomy with surgical staging for primary treatment for clinical stage I endometrial cancer from January 1995 through June 2001. INTERVENTION: Clinical outcomes and survival in patients treated with laparoscopic-assisted vaginal hysterectomy (n = 55) and hysterectomy using the conventional abdominal approach (n = 315) were compared. MEASUREMENTS AND MAIN RESULTS: Baseline characteristics and histopathologic variables were similar in both groups. A total of 91.4% of patients underwent pelvic lymphadenectomy and 49.7% paraaortic lymphadenectomy. The median follow-up was 38.1 months. Blood loss, blood transfusions required, and length of stay were significantly lower in the laparoscopic group, but surgical time was significantly longer. The mean number of pelvic and aortic nodes recovered was higher in the laparoscopic group (p < .001). Differences in overall and recurrence-free survival rates were not observed. CONCLUSION: Surgical staging of early-stage endometrial cancer by laparoscopic-assisted vaginal hysterectomy is feasible, with lower perioperative morbidity and shorter hospital stay compared with transabdominal hysterectomy. Prognosis and survival were not affected by the laparoscopic vaginal approach to hysterectomy.     

Radical vaginal hysterectomy with extraperitoneal pelvic lymphadenectomy in cervical cancer

OBJECTIVE: The aim of this work was to examine three types of radical vaginal hysterectomy with different degrees of radicality, performed in order to reduce surgical complications and sequelae in different indications, and to test the feasibility of a new simple and quick technique for extraperitoneal pelvic lymphadenectomy to be used in combination with radical vaginal hysterectomy for treatment of cervical cancer. In this way the advantages of vaginal surgery (e.g.: unnecessary general anaesthesia, reduced surgical trauma, applicability to obese and poor surgical risk patients, fast time-saving procedure) can be preserved. METHODS: We compared retrospectively the long-term results of radical vaginal and radical abdominal operations in a large series of stage IB-IIA cervical cancer patients treated at our institution in Florence from 1968 to 1983. Furthermore, we analysed the results of our experience from 1995 to 1998, when we performed extraperitoneal pelvic lymphadenectomy, followed by radical vaginal hysterectomy, on 48 patients affected by cervical cancer. Extraperitoneal pelvic lymphadenectomy was performed through two small abdominal incisions (6-7 cm). Twenty-two patients (45%) were obese (BMI>30 kg/m2) and 20 were poor surgical risks. FIGO stage was: IB1 in 18 cases, IB2 in eight, IIA in six, IIB in 12, IIIB in four. Neoadjuvant chemotherapy was given in 12 cases and preoperative irradiation was given in ten. General and regional anaesthesia were used in 30 (62.5%) and in 18 (37.5%) cases, respectively. RESULTS: As for past experience, in stage IB the five-year survival of 356 patients who underwent radical vaginal hysterectomy and that of 288 who had radical abdominal hysterectomy with pelvic lymphadenectomy were 81% and 75%, respectively (p<0.05). Surgical complications were fewer with no mortality in the first group. In stage IIA, survival rates were 68% for radical vaginal hysterectomy and 64% for radical abdominal hysterectomy, in 76 and 64 cases, respectively (p=n.s.). As for the more recent experience, median operative time for extraperitoneal pelvic lymphadenectomy was 20 minutes for each side (range 15-36). In each patient a median of 26 lymph nodes were removed (range 16-48). Positive nodes were found in 12 cases (25%). Median operative time for radical vaginal hysterectomy was 40 minutes (range 30-65). Extraperitoneal pelvic lymphadenectomy complications included: lymphocyst, five cases (10%) and retroperitoneal hematoma, one (2%); all occurred at the beginning of the experience. Radical vaginal hysterectomy complications included: ureteral stenosis, one (2%) and uretero-vaginal fistula, one (2%). All complications occurred in patients who received radiotherapy or chemotherapy preoperatively. Median hospital stay was ten days (range 6-20). CONCLUSIONS: The results of our work demonstrate that our technique for extraperitoneal pelvic lymphadenectomy shows a good applicability to cervical cancer patients submitted to radical vaginal hysterectomy, which has a high rate of cure for stage IB and IIA as shown by our past experience. The procedure of extraperitoneal pelvic lymphadenectomy was quick, easy, and safe, and its realization was not detrimental to the advantages of radical vaginal hysterectomy. Our experience supports the continued use of this combined extraperitoneal and vaginal approach in the treatment of cervical cancer. Moreover, the three classes of radical vaginal hysterectomy allow tailoring the type of the operation to the clinical and physical characteristics of the patients.     

Salvage of isolated vaginal recurrences in women with surgical stage I endometrial cancer: a multiinstitutional experience

The objective of this study was to evaluate the treatment outcomes and risk factors of women with surgical stage I endometrial adenocarcinoma who were initially treated with surgery alone and subsequently developed isolated vaginal recurrences. Patients with surgical stage I endometrial adenocarcinoma diagnosed from 1975 to 2002 were identified from tumor registry databases at seven institutions. All patients were treated with surgery alone including a total hysterectomy, bilateral salpingo-oophorectomy, pelvic (+/- para-aortic) lymph node dissection, and peritoneal cytology and did not receive postoperative radiation therapy. Vaginal recurrences were documented histologically. Metastatic disease in the chest and abdomen was excluded by radiologic studies. Overall survival was calculated by the Kaplan-Meier method. Sixty-nine women with surgical stage I endometrial cancer with isolated vaginal recurrences were identified. Of the 69 patients, 10 (15%) were diagnosed with stage IA disease, 43 (62%) were diagnosed with stage IB disease, and 16 (23%) were diagnosed with stage IC disease. Patients diagnosed with grade 1 disease were 22 (32%), grade 2 disease were 26 (38%), and grade 3 disease were 21 (30%). Among women, 81% with isolated vaginal recurrences were salvaged with radiation therapy. The mean time to recurrence was 24 months, and the mean follow-up was 63 months. Among women, 18% died from subsequent recurrent disease. The 5-year overall survival was 75%. The majority of isolated vaginal recurrences in women with surgical stage I endometrial cancer can be successfully salvaged with radiation therapy, further questioning the role of adjuvant therapy for patients with uterine-confined endometrial cancer at the time of initial diagnosis.     

Improved survival in surgical stage I patients with uterine papillary serous carcinoma (UPSC) treated with adjuvant platinum-based chemotherapy

OBJECTIVE: Uterine papillary serous carcinoma (UPSC) is an aggressive form of endometrial cancer characterized by a high recurrence rate and a poor prognosis. Prior studies evaluating treatment of UPSC have been limited by small numbers of patients and inclusion of partially staged patients. The purpose of this study was to evaluate the efficacy of adjuvant platinum-based chemotherapy and vaginal cuff radiation in a large cohort of surgical stage I UPSC patients. METHODS: We retrospectively reviewed 74 stage I patients with UPSC who underwent complete surgical staging at our institution between 1987 and 2004. RESULTS: Stage IA patients were divided into two groups: patients with no cancer in the hysterectomy specimen (defined as no residual uterine disease) and patients with cancer in the hysterectomy specimen (defined as residual uterine disease). Stage IA patients with no residual uterine disease had no recurrences, regardless of adjuvant therapy (n = 12). Stage IA patients with residual uterine disease who were treated with platinum-based chemotherapy had no recurrences (n = 7). However, 6 of 14 (43%) stage IA patients with residual uterine disease who did not receive chemotherapy recurred. The 15 patients with stage IB UPSC who received platinum-based chemotherapy had no recurrences but 10 of the 13 (77%) stage IB patients who did not receive chemotherapy recurred. One of the 7 patients with stage IC UPSC who received platinum-based chemotherapy recurred and 4 of the 5 (80%) stage IC patients who did not receive chemotherapy recurred. Overall platinum-based chemotherapy was associated with improved disease-free survival (P < 0.01) and improved overall survival (P < 0.05) in patients with stage I UPSC. None of the 43 patients who received radiation to the vaginal cuff recurred locally, but 6 of the 31 (19%) patients who were not treated with vaginal radiation recurred at the cuff. CONCLUSIONS: Platinum-based chemotherapy improves the disease-free and overall survival of patients with stage I UPSC and vaginal cuff radiation provides local control. Stage IA UPSC patients with no residual uterine disease can be observed but concomitant platinum-based chemotherapy and vaginal cuff radiation (referred to as chemoradiation) should be offered to all other stage I UPSC patients.     

The long-term survival of women with surgical stage II endometrioid type endometrial cancer

OBJECTIVES: The aim of this study was to evaluate the survival estimates, treatment outcomes, prognostic factors, and recurrence patterns of patients with surgical stage II endometrial cancer. METHODS: Forty-eight stage II endometrial cancer patients treated between 1982 and 2000 were included. All the patients were subjected to the initial surgical staging procedure consisting of peritoneal cytology, infracolic omentectomy, abdominal hysterectomy (radical or simple), bilateral salpingo-oophorectomy, and complete pelvic-paraaortic lymphadenectomy. Of these 48 patients, 21 (44%) were treated with radical hysterectomy (RH) without adjuvant therapy. The remaining 27 (56%) patients were treated with simple hysterectomy plus adjuvant radiotherapy. With respect to the prognostic factors, no statistically significant difference was found between these two groups. The median follow-up period was 5 years (range, 2-9). RESULTS: The mean age at the time of diagnosis was 55.8 years (range, 34-75). The 5-year disease-free and overall survival (OS) rates of entire group were 83% and 86%, respectively. These figures for 27 (56%) patients treated with simple hysterectomy plus radiation were 81% and 83%, respectively. For 21 (44%) patients who were treated with radical hysterectomy without adjuvant therapy, the 5-year disease-free and overall survival rates were 85% and 90%, respectively. When these two groups were compared, survival rates were not significantly different from each other (P = 0.60 for disease-free survival and P = 0.46 for overall survival). In multivariate analysis, only the high grade predicted poor survival significantly (P = 0.04). Eight patients (17%) had recurrence: two local, five distant, and one both local and distant. Initial therapeutic approach was not related with the subsequent site of relapse. Two patients with only local failure were successively treated, but all the six patients who had distant component of relapse died within the same year. Surgical morbidity was seen in six (12.5%) patients. No surgical mortality was seen, and no patient developed a major complication directly related to the radical hysterectomy or lymphadenectomy. CONCLUSIONS: Without adjuvant radiotherapy, initial surgical staging procedure consisting radical hysterectomy and complete pelvic-paraaortic lymphadenectomy achieved excellent survival and minimal morbidity in stage II endometrial cancer. Distant failure was the main problem.     

Prevention of vaginal recurrence of stage I endometrial adenocarcinoma with postoperative vaginal radiation

From 1975 to 1982 a prospective study was conducted at Roswell Park in 68 patients (group 1) for surgical stage I endometrial cancer, grade 1 or 2, and less than 50% myometrial invasion. These patients were treated by total abdominal hysterectomy, bilateral salpingo-oophorectomy, and postoperative vaginal radium. With median follow-up of 4.8 years, there has not been a single vaginal recurrence. This treatment plan was based on a prospective study at the same institute from 1958 to 1967, which compared patients with stage I endometrial cancer treated by hysterectomy alone, preoperative radium followed by hysterectomy, and hysterectomy followed by postoperative radium. In addition, 19 patients (group 2) were evaluated as to their initial treatment after their referral to Roswell Park with vaginal recurrence after surgical treatment for stage I endometrial cancer. None of these patients were treated initially with postoperative vaginal radium after hysterectomy. Based on the zero incidence of vaginal recurrence in 117 patients with FIGO stage I endometrial cancer, the estimated five-year survival rate of 97.2% for the group 1 patients, and the actuarial five-year survival of 95% in the 1958 to 1967 prospective study, it is concluded that primary surgery should be followed by postoperative vaginal radium (cesium) in those patients with stage I endometrial cancer, grade 1 or 2, with less than 50% myometrial invasion.     

Endometrial carcinoma. Clinical and pathological correlations with survival and surgical treatment

From 1978 to 1985 a total of 151 patients were treated for endometrial carcinoma. Of these, 25 patients underwent extrafascial abdominal hysterectomy and pelvic lymphadenectomy, 25 were treated according to Wertheim procedure and pelvic lymphadenectomy and 32 underwent intrafascial abdominal hysterectomy; 62 women underwent vaginal surgery, 7 of whom according to Shauta. A correlation between the degree of myometrial invasion, histological grading, hystological type and stage of the tumor showed no statistically significant difference. The 5-year actuarial survival rate was found to be 76.5%. A comparison between survival and age of patients showed a significant difference in the survival (p less than .01) of the group less than 55 years as compared to the older age group. As far as the surgical treatment instituted is concerned, no statistical difference in survival was found between patients operated vaginally and those operated abdominally (p greater than .05). The site of recurrences were then analyzed in 22 patients, 50% were local recurrences, and the remaining distant metastases. Of these only one patient was cured and is still free of disease 5 years after recurrence. The criteria used to select patients for vaginal surgery are also indicated.     

Comparison of total laparoscopic and abdominal radical hysterectomy for patients with early-stage cervical cancer

OBJECTIVE: To compare intraoperative, pathologic, and postoperative outcomes of total laparoscopic radical hysterectomy with abdominal radical hysterectomy and pelvic lymphadenectomy for women with early-stage cervical cancer. METHODS: We reviewed all patients who underwent total laparoscopic radical hysterectomy or abdominal radical hysterectomy and pelvic lymphadenectomy between 2004 and 2006. RESULTS: Fifty-four patients underwent abdominal radical hysterectomy, and 35 underwent total laparoscopic radical hysterectomy. Mean age was 41.8 years, and mean body mass index 28.1. There was no difference in demographic or tumor factors between the two groups. Mean estimated blood loss was 548 mL with abdominal radical hysterectomy compared with 319 mL with total laparoscopic radical hysterectomy (P=.009), and 15% of patients who underwent abdominal radical hysterectomy required a blood transfusion compared with 11% who underwent total laparoscopic radical hysterectomy (P=.62). Mean operative time was 307 minutes for abdominal radical hysterectomy compared with 344 minutes for total laparoscopic radical hysterectomy (P=.03). On pathologic examination, there was no significant difference in the amount of parametrial tissue, vaginal cuff, or negative margins obtained. A mean 19 pelvic nodes were obtained during abdominal radical hysterectomy compared with 14 during total laparoscopic radical hysterectomy (P=.001). The median duration of hospital stay was significantly shorter for total laparoscopic radical hysterectomy (2.0 compared with 5.0 days, P<.001). For abdominal radical hysterectomy, 53% of patients experienced postoperative infectious morbidity compared with 18% for total laparoscopic radical hysterectomy (P=.001). There was no difference in postoperative noninfectious morbidity. There was no difference in return of urinary function. CONCLUSION: Total laparoscopic radical hysterectomy reduces operative blood loss, postoperative infectious morbidity, and postoperative length of stay without sacrificing the size of radical hysterectomy specimen margins; however, total laparoscopic radical hysterectomy is associated with increased operative time.     

Laparoscopic-assisted radical parametrectomy including pelvic and/or paraaortic lymphadenectomy in women after prior hysterectomy-three cases

BACKGROUND: Radical abdominal surgery in patients who have previously undergone a hysterectomy is a surgical challenge. This type of surgery for invasive cervical cancer after a hysterectomy or vaginal stump metastasis traditionally requires a major laparotomy; however, a minimal-access approach is now being applied to this type of procedure. CASE: A laparoscopic-assisted radical parametrectomy including a pelvic and/or paraaortic lymphadenectomy was performed on two patients presenting invasive cervical cancer diagnosed after a simple hysterectomy and one patient with recurred endometrial cancer in the vaginal stump. All three patients had an excellent clinical outcome and made a rapid recovery with no major complications, even though two cases involved a bladder laceration. CONCLUSION: A laparoscopic radical parametrectomy including a pelvic and/or paraaortic lymphadenectomy is a viable technique for women with invasive cervical cancer or recurrent endometrial vaginal cancer after a prior hysterectomy.     

Evaluation of different surgical approaches in the treatment of endometrial cancer at FIGO stage I

From January 1, 1970 to December 31, 1979, 425 cases of endometrial carcinoma, FIGO stage I, were treated at the First Department of Obstetrics and Gynecology, University of Milan. Three different surgical approaches were used: total abdominal hysterectomy with bilateral salpingo-oophorectomy and selective pelvic lymphadenectomy was performed in 245 women, total abdominal hysterectomy and bilateral salpingo-oophorectomy without pelvic lymphadenectomy in 100, and vaginal hysterectomy with bilateral salpingo-oophorectomy in 80. Five-year survival was evaluated as a function of risk factors (histological grade, depth of myometrial invasion, metastatic nodes) in the three groups of patients, and we conclude that lymphadenectomy is useful for prognostic purposes but does not confer a therapeutic benefit.     

Interstitial Brachytherapy for Vaginal Recurrences of Endometrial Carcinoma

OBJECTIVE: The aim of this study was to evaluate the efficacy of interstitial brachytherapy in the management of vaginal recurrences of endometrial carcinoma. METHODS: Thirty patients received interstitial irradiation, with or without external beam radiotherapy. They were followed for a minimum of 5 years or until death. RESULTS: The median age was 66 years at initial diagnosis of endometrial cancer. FIGO stages included Stage I (n = 18), Stage II (n = 7), and Stage III (n = 5). All patients were treated originally by total abdominal hysterectomy and bilateral salpingo-oophorectomy, with or without lymphadenectomy, and 13 (43%) also received postoperative adjuvant whole pelvis radiotherapy as part of their primary treatment. Vaginal recurrences were diagnosed at a mean interval of 29 months after hysterectomy (range, 3-119 months). No patient had clinical evidence of pelvic sidewall extension or of distant metastatic disease. All patients were treated with interstitial brachytherapy; each implant delivered a mean maximal tumor dose of 25.5 Gy. Eighteen patients (60%) also received external beam radiotherapy (mean dose, 48 Gy) as part of their treatment for vaginal recurrence. Twenty-eight patients (93%) experienced a complete clinical response. Ten patients relapsed in the vagina (n = 5) or at distant sites (n = 5). Eleven patients are dead of disease. From the time of vaginal recurrence, the median overall survival was 60 months and the cause of death adjusted 5-year survival rate was 65%. Major morbidity included radiation proctitis (n = 2), fistula (n = 2), and radiation stricture (n = 1). CONCLUSION: Interstitial irradiation resulted in favorable local control as well as a 5-year survival rate and morbidity comparable to that reported previously for conventional brachytherapy.     

A new approach to treatment of early-stage cervical carcinoma: entire laparoscopic abdominal radical hysterectomy with bilateral pelvic lymphadenectomy without vaginal cuff closure--case reports

OBJECTIVE: The objective of this study is to describe a new technique of laparoscopic radical hysterectomy without vaginal cuff closure. METHODS: Three patients underwent laparoscopic radical hysterectomy, bilateral salpingo-oophorectomy and bilateral pelvic lymph node dissection using an Argon Beam Coagulator. Four trocars were used: umbilical port for the camera, two ports for the operating surgeon and a fourth port for use by the surgical assistant. RESULTS: All patients were clinically staged IB1. Ages were 53, 64 and 58 and BMI was 19.5, 25.2 and 21.4, respectively. Duration of surgery was 375, 325 and 335 minutes, respectively, from first trocar insertion to last closing stitch. Estimated blood loss was 300, 100 and 400 ml and removed pelvic lymph nodes 18, 15 and 26, respectively. The patients tolerated the surgical technique and recovered satisfactorily. CONCLUSION: These are the first three cases of early-stage cervical carcinoma patients who have been treated with entirely laparoscopic abdominal radical hysterectomy (LARH) and bilateral pelvic lymphadenectomy (BPL) without vaginal cuff closure. To our knowledge, this has not been previously described in the literature. It is feasible and was well tolerated in this small series of patients.     

Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies

OBJECTIVE: Lymphadenectomy is an integral part of staging and treatment of gynecologic malignancies. We evaluated the feasibility and oncologic value of laparoscopic transperitoneal pelvic and paraaortic lymphadenectomy in correlation to complication rate and body mass index. METHODS: Between August 1994 and September 2003, pelvic and/or paraaortic transperitoneal laparoscopic lymphadenectomy was performed in 650 patients at the Department of Gynecology of the Friedrich-Schiller University of Jena. Retrospective and prospective data collection and evaluation of videotapes were possible in 606 patients. Laparoscopic lymphadenectomy was part of the following surgical procedures: staging laparoscopy in patients with advanced cervical cancer (n = 133) or early ovarian cancer (n = 44), trachelectomy in patients with early cervical cancer (n = 42), laparoscopic-assisted radical vaginal hysterectomy in patients with cervical cancer (n = 221), laparoscopy before exenteration in patients with pelvic recurrence (n = 20), laparoscopic-assisted vaginal hysterectomy or laparoscopic-assisted radical vaginal hysterectomy in patients with endometrial cancer (n = 112), and operative procedures for other indications (n = 34). RESULTS: After a learning period of approximately 20 procedures, a constant number of pelvic lymph nodes (16.9-21.9) was removed over the years. Pelvic lymphadenectomy took 28 min, and parametric lymphadenectomy took 18 min for each side. The number of removed paraaortic lymph nodes increased continuously over the years from 5.5 to 18.5. Right-sided paraaortic, left-sided inframesenteric and left-sided infrarenal lymphadenectomy took an average of 36, 28, and 62 min, respectively. The number of removed lymph nodes was independent from the body mass index of the patient. Duration of pelvic lymphadenectomy was independent of body mass index, but right-sided paraaortic lymphadenectomy lasted significantly longer in obese women (35 vs. 41 min, P = 0,011). The overall complication rate was 8.7% with 2.9% intraoperative (vessel or bowel injury) and 5.8% postoperative complications. No major intraoperative complication was encountered during the last 5 years of the study. CONCLUSION: By transperitoneal laparoscopic lymphadenectomy, an adequate number of lymph nodes can be removed in an adequate time and independent from body mass index. The complication rate is low and can be minimized by standardization of the procedure.     

Vaginal cuff recurrence of endometrial cancer treated by laparoscopic-assisted vaginal hysterectomy

BACKGROUND: Laparoscopic-assisted vaginal hysterectomy (LAVH) has been suggested as an alternative to total abdominal hysterectomy (TAH) for the treatment of early endometrial cancer. Although studies have reported good results with equivalent rates of recurrence and survival, the need for use of intrauterine manipulators during the LAVH raises the concern for operative dissemination of tumor cells. CASES: We report three patients with stage I, noninvasive or superficially invasive endometrial cancer with vaginal cuff recurrence within 9 months of treatment by LAVH. CONCLUSION: While LAVH may be a technically acceptable alternative to TAH for the management of early-stage endometrial cancer, its routine use should be undertaken with caution, as the long-term risks for recurrence and survival have yet to be defined in a randomized, controlled fashion.     

不同手术方式对I期子宫内膜癌患者生存及复发的影响

目的：了解不同手术方式对I期子宫内膜癌患者术后生存及复发的影响。方法：回顾性分析1986－1996年行手术治疗的I期子宫内膜癌患者110例,根据手术方式不同将其分为3组,行全子宫＋双侧附件切除术者为A组（54例）;行广泛或次广泛性全子宫切除术者为B组（14例）;行全子宫＋双侧附件切除（或广泛性全子宫切除或次广泛全子宫切除）＋盆腔淋巴结清扫术者为C组（42例）,分析3组的生存和复发情况。结果：A、B、C3组的5年生存率分别为89．5％、90．5％、95．1％,3组间比较,差异无显著性（P＞0．05）。随诊超过2年的71例中9例复发,复发率为12．7％;9例复发者中7例于3年内复发,其中盆腔局部复发8例,远处转移5例;A、B、C3组的复发率分别为13．9％、9．1％、12．5％,其中盆腔局部复发率分别为13．9％、9．1％、8．3％,远处转移率分别为2．8％、9．1％、12．5％,分别比较,差异均无显著性（P＞0．05）。结论：手术方式不是影响I期子宫内膜癌患者生存率的主要因素,扩大手术范围或行淋巴结清扫术并不能显著提高患者的生存率。远处转移在术后复发患者中占有相当的比例,辅助治疗时应考虑术后复发的这种特点。     

Port-site recurrence after laparoscopic surgery for endometrial carcinoma

Background: Women with endometrial carcinoma are being treated with laparoscopic surgery, but the risk of port-site recurrences remains undefined.Case: A 58-year-old woman underwent laparoscopically assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and laparoscopic lymphadenectomy for endometrial cancer. Final surgical stage was IA, with grade 2 histology. Twenty-one months later, she developed a 5-cm recurrent tumor mass at a lateral laparoscopic port site. The mass was resected, and a restaging laparotomy performed, without evidence of other metastases. Radiation therapy was administered to the involved anterior abdominal wall. Two and one half years later, there is no evidence of recurrence.Conclusion: An isolated laparoscopic port-site recurrence might be attributable to the initial laparoscopic management of an otherwise good-prognosis endometrial carcinoma.     

The evolution of a treatment program for adenocarcinoma of the endometrium.

Previous studies at the University of Minnesota suggest that overall survival rates after treatment for adenocarcinoma of the endometrium are related to increased surgical applicability, that vaginal recurrence is frequently related to cervical involvement, and that virtually all women can safely undergo abdominal hysterectomy and radical irradiation therapy. In this program a simple abdominal hysterectomy was applied to as many women with this disease as possible. High-risk patients also received preoprative or postoperative irradiation. This program increased the survival rate for all stages from 58% to 69.7%. The survival rate among women with Stage I high-risk disease treated with supplementary irradiation was significantly lower when compared to that among women with low-risk disease who were treated by surgery alone. No vaginal recurrences were observed in either group and 98.4% were operated upon. The survival rate of women with Stage II disease treated with irradiation and surgery improved significantly. The rate of vaginal recurrence was 2.2%.     

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.