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.
Minimal Access Cancer Surgery (Macs) For Endometrial Cancer
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.
- Rouzier R, Pomel C. Update on the role of laparoscopy in the treatment of gynaecological malignancy. Curr Opin Obste Gynecol 2005;17:77-82.
- Nour MW, Childers JM. Endometrial carcinoma. In: Laparoscopic Surgery in Gynaecological Oncology. Chap 18. Blackwell Science Ltd, 1999:148-53.
- Childers JM. Operative laparoscopy in gynaecological oncology. Baillieres Clin Obstet Gynaecol 1994;8:831-49.
- Amant F, Moerman P, Neven P, Timmerman D, Limbergen EV, VergoteI. Treatment modalities in endometrial cancer. Curr Opin Oncol 2007;19:479-85.
- Siow A, Beh ST, Tay EH. Initial experience of laparoscopic management of apparent early endometrial cancer. Singapore Med J 2003;44:288-92.
- Kadar N. Present and future role of laparoscopic surgery in gynaecological oncology. In: Laparoscopic Surgery in Gynaecological Oncology. Chap 23. Blackwell Science Ltd, 1999:183-91.
- Schlaerth AC, Abu-Rustum NR. Role of minimally invasive surgery in gynecologic cancers. Oncologist 2006;11:895-901.
- Holub Z. The role of laparoscopy in the surgical treatment of endometrial cancer. Clin Exp Obstet Gynecol 2003;30:7-12.
- Cho YK, Kim DY, Kim JH, Kim YM, Kim YT, Nam JH. Laparoscopic management of early uterine cancer: 10-Year experience in Asan Medical Centre. Gynecol Oncol 2007;106:585-90.
- Kalogiannidis I, Lambrechts S, Amant F, Neven P, Gorp TV, Vergote I. Laparoscopy-assisted vaginal hysterectomy compared with abdominal hysterectomy in clinical stage I endometrial cancer: safety, recurrence,and long-term outcome. Am J Obstet Gynecol 2007;196:248.e1-8.
- O’Hanlan KA, Huang GS, Garnier AC, Dibble SL, Reuland ML, Lopez L, et al. Total laparoscopic hysterectomy versus total abdominal hysterectomy: cohort review of patients with uterine neoplasia. JSLS 2005;9:277-86.
- Childers JM, Nasseri A. Minimal access surgery in gynecologic cancer: we can, but should we? Curr Opin Obstet Gynecol 1995;7:57-62.
- Eltabbakh GH. Effect of surgeon’s experience on the surgical outcome of laparoscopic surgery for women with endometrial cancer. Gynecol Oncol 2000;78:58-61.
- Magrina JF. Outcomes of laparoscopic treatment for endometrial cancer.4Curr Opin Obstet Gynecol 2005;17:343-6.
- Holub Z, Jabor A, Bartos P, Hendl J, Urbanek S. Laparoscopic surgery in women with endometrial cancer: the learning curve. Eur J Obstet Gynecol 2007;107:195-200.
- Childers JM. The virtues and pitfalls of minimally invasive surgery for gynecological malignancies: an update. Curr Opin Obstet Gynecol 1999;11:51-9
- Manolitsas TP, McCartney AJ: Total laparoscopic hysterectomy in the management of endometrial carcinoma. J Am Assoc Gynecol Laparosc 2002, 9:54-62.
- Obermair A, Manolitsas TP, Leung Y, Hammond IG, McCartney AJ: Total laparoscopic hysterectomy versus total abdominal hysterectomy for obese women with endometrial cancer. Int J Gynecol Cancer 2005, 15:319-324
- Obermair A, Manolitsas TP, Leung Y, Hammond IG, McCartney AJ: Total laparoscopic hysterectomy for endometrial cancer: patterns of recurrence and survival. Gynecol Oncol 2004, 92:789-793.
- Eltabbakh GH, Shamonki MI, Moody JM, Garafano LL: Laparoscopy as the primary modality for the treatment of women withendometrial carcinoma. Cancer 2001, 91:378-387.
- Fram KM: Laparoscopically assisted vaginal hysterectomy versus abdominal hysterectomy in stage I endometrial cancer. Int J Gynecol Cancer 2002, 12:57-61.
- Malur S, Possover M, Michels W, Schneider A: Laparoscopic-assisted vaginal versus abdominal surgery in patients with endometrial cancer – a prospective randomized trial. GynecolOncol 2001, 80:239-244.
- Marana R, Busacca M, Zupi E, Garcea N, Paparella P, Catalano GF: Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study. Am J Obstet Gynecol 1999, 180:270-275.
- Lumsden MA, Twaddle S, Hawthorn R, Traynor I, Gilmore D, Davis J, Deeny M, Cameron IT, Wallker JJ: A randomised comparison and economic evaluation of laparoscopic-assisted hysterictomy and abdominal hysterectomy. BJOG 2000, 107:1386-1391.
- Spirtos NM, Schlaerth JB, Gross GM, Spirtos TW, Schlaerth AC, Ballon SC: Cost and quality-of-life analyses of surgery for early endometrial cancer: laparotomy versus laparoscopy. Am J Obstet Gynecol 1996, 174:1795-1799.
- Scribner DR Jr, Walker JL, Johnson GA, McMeekin SD, Gold MA, Mannel RS: Surgical management of early-stage endometrial cancer in the elderly: is laparoscopy feasible? Gynecol Oncol 2001, 83:563-568.
- Tozzi R, Malur S, Koehler C, Schneider A: Analysis of morbidity in patients with endometrial cancer: is there a commitment to offer laparoscopy? Gynecol Oncol 2005, 97:4-9.
- Garry R, Fountain J, Brown J, Manca A, Mason S, Sculpher M, Napp V, Bridgman S, Gray J, Lilford R: EVALUATE hysterectomy trial: a multicentre randomised trial comparing abdominal, vaginal and laparoscopic methods of hysterectomy. Health Technol Assess 2004, 8:1-154.
- Sculpher M, Manca A, Abbott J, Fountain J, Mason S, Garry R: Cost effectiveness analysis of laparoscopic hysterectomy compared with standard hysterectomy: results from a randomised trial. BMJ 2004, 328:134.
- Ellstrom M, Ferraz-Nunes J, Hahlin M, Olsson JH: A randomized trial with a cost-consequence analysis after laparoscopic and abdominal hysterectomy. Obstet Gynecol 1998, 91:30-34.
- Tozzi R, Malur S, Koehler C, Schneider A: Laparoscopy versus laparotomy in endometrial cancer: first analysis of survival of a randomized prospective study. J Minim Invasive Gynecol 2005, 12:130-136.
- Walker JL, Piedmonte MR, Spirtos NM, et al: Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol. 2009 Nov 10;27(32):5331-6. doi: 10.1200/JCO.2009.22.3248. Epub 2009 Oct 5.