Picture Endometrium is the inner lining of uterus (womb). Endometrial cancers are seen mainly in the postmenopausal women. It presents with abnormal vaginal bleeding, pelvic pain & weight loss. Diagnosis is confirmed by an endometrial biopsy (dilatation & curettage). This biopsy gives a guideline about the extent of surgery required. Imaging (CT or MRI) is required to plan the surgery.
Concepts Of Endometrial Cancer Management
Type of Surgery Based on Histology & Extent of Disease:
|Low grade (endometroid ) without cervical involvement||Total hysterectomy & bilateral salpingo- oophorectomy with or without pelvic & paraaortic lymphadenectomy|
|Low grade (endometroid ) with cervical involvement||Radical Hysterectomy (like Cervical Cancer), bilateral salpingo- oophorectomy, pelvic & paraaortic lymphadenectomy along with peritoneal cytology|
|Low grade (endometroid ) with extra-uterine disease (omental, nodal, rectum, peritoneal, etc.)||Total hysterectomy, bilateral salpingo- oophorectomy, pelvic & paraaortic lymphadenectomy, debulking.|
|High grade (clear cell, papillary serous & carcinosarcoma)||Comprehensive Surgical Staging (like Ovarian Cancer): Total hysterectomy, bilateral salpingo- oophorectomy, pelvic, paraaortic lymphadenectomy, peritoneal cytology, omentectomy & complete cytoreduction.|
All the above surgeries have been traditionally performed using abdominal incision. Standard abdominal hysterectomy for early stage endometrial cancer is an effective and accepted treatment in patients with early stage endometrial cancer. However, pelvic & paraaortic lymphadenectomy is performed in-order to give better clearance. Treatment options for endometrial cancer differ according to the disease status (Table) and vary from a primary surgical treatment to a combination of surgery and adjuvant radiotherapy or chemotherapy or hormonal therapy. Adjuvant therapy in the form of radiotherapy, chemotherapy & hormonal therapy would be required based on the findings on final histopathology.
The safety & feasibility of MACS for endometrial cancer has been proven. Reports on surgical procedure related parameters have shown insignificant difference between laparotomy and laparoscopic surgeries. Intraoperative and postoperative surgical complications have been studied. As a procedure, MACS is as effective as laparotomy and has the advantage of being a better surgical treatment experience for the patient by expediting the immediate postoperative recovery of patients in terms of reduced pain, quicker ambulation and return to normal daily activities.
In a metaanlysis, Magrina compared findings of various studies on outcomes of laparoscopic vis-à-vis laparotomy for endometrial cancer. The results showed consistency of findings on the benefits of MACS. The operating time for MACS was on average about 45 minutes longer, but the average number of hospital days is shortened by 3 days. Comparative report also showed that survival and recurrence rates by both surgical methods are comparable. A comparison of operating time, lymph node harvested, intraoperative blood transfusion between the initial study and the current study were made. There has been a reduction of operating time and increase in lymph node harvested, which reflects improved performance with increased experience.
Given that laparoscopic surgery does not affect the prognosis of patients with early endometrial cancer when performed properly, it has better or comparable surgical outcomes and added benefits of better patient experience compared to laparotomy (except for operating time). Therefore, MACS should be the choice procedure in the treatment of early endometrial cancer in the absence of contra-indications. However, laparoscopic pelvic lymphadenectomy is a complex procedure that demands good surgical competency.
GOG-LAP2, a randomized controlled trial involving more than 2500 patient in which the effectiveness of a laparoscopic assisted vaginal hysterectomy with BSO and lymphadenectomy in early stage endometrial cancer is compared to the open procedure, has been completed. They concluded that Laparoscopic surgical staging for uterine cancer is feasible and safe in terms of short-term outcomes and results in fewer complications and shorter hospital stay. Long-term results are awaited. A major problem in the GOG-LAP2 study is that no quality control for the laparoscopic procedure is performed. The results of a randomized multi center trial comparing the laparoscopic with the open approach in early stage endometrial cancer called the LACE trial (Australia) & another in Europe are awaited.
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