Management Of Endometrial Cancer Research Articles

Sentinel Lymph Node Mapping in Endometrial Cancer: An Update.

: Lymph node removal for staging, as part of the initial surgical management of patients with endometrial carcinoma, remains a controversial topic in gynecologic oncology. There is currently wide variability among clinical practices, with surgical approaches ranging from no nodal evaluation to comprehensive pelvic and aortic lymphadenectomy. Lymphatic mapping has emerged as an increasingly popular option over the past few years, with several attractive features in its concept, innovative surgical approach, and encouraging preliminary results. At this time, however, several different techniques have been described and used for lymphatic mapping in endometrial cancer, incorporating a variety of mapping agents and injection sites. Although recently published results are encouraging, they are limited to single-institution series or multi-institutional collaborations undertaken without the aegis of a prospective randomized controlled trial. However, the surgical staging of endometrial cancer with lymphadenectomy was historically established based not on randomized trial data but on prospective clinicopathologic studies. Another evolving field in endometrial cancer staging is the interpretation of pathologic ultrastaging of sentinel lymph nodes (SLNs), which can identify low-volume metastases for which the clinical significance and the ideal management remain uncertain. This is particularly an issue with extremely low-volume nodal metastasis and isolated tumor cells. Furthermore, it has become apparent that applying a predefined SLN algorithm can decrease false-negative rates. The Memorial Sloan Kettering Cancer Center SLN algorithm can be used as a checklist to ensure standardization of care and to reduce the chance of missing nodal disease. Prospective trials are under way at many institutions to help establish the definitive role of SLN mapping for staging of endometrial cancer. The objective of this study was to provide an update on the latest clinical data related to lymphatic mapping for the staging and management of endometrial cancer and its role in clinical practice. Lymphatic mapping is an increasingly popular option in the surgical treatment of endometrial cancer. The aim of using this tool is to target the lymph nodes that are the most likely to be involved with metastatic cancer cells (sentinel lymph nodes) and thereby limit the extent of surgery needed and decrease surgical complications and long-term side effects associated with extensive lymph node removal. By examining a limited number of sentinel lymph nodes, a more detailed examination of the node can be done (ultrastaging). This allows for the detection of a small number of cancer cells (low-volume metastasis) that can be missed with standard techniques.

Lymphovascular Space Invasion as a Risk Factor in Early Endometrial Cancer

Management of early endometrial cancer is contentious these days with little agreement between oncologists as well as across MDTs or tumour boards and indeed across countries. This is because of the state of knowledge with regards to risk factors in early endometrial cancer; although we recognise risk factors affect outcome, we haven't yet been able to demonstrate that our treatments make a significant difference. We have reviewed available literature on LVSI and are able to demonstrate that it is an independent risk factor for nodal metastasis as well as distant recurrence. We need a randomised trial integrating grade and LVSI and testing therapeutic options of radiotherapy and chemotherapy. However, it is unlikely to see the light of day. Therefore, we are left with this knowledge of prognostic factors and it is our duty to integrate this into our decision-making during our multidisciplinary team meetings and make decisions tailored to individual patient circumstances.

Predictive Factor of Conversion to Laparotomy in Minimally Invasive Surgical Staging for Endometrial Cancer.

The aim of the study was to identify risk factors associated with laparotomy conversion during total laparoscopic hysterectomy for endometrial cancer. This is a retrospective study examining endometrial cancer cases that underwent hysterectomy-based surgical staging initiated via conventional laparoscopic approach. Factors related to patient, tumor, and surgeon were examined to establish risk of laparotomy conversion using a multivariate logistic regression model. There were 251 cases identified including 30 cases (12.0%) of laparotomy conversion. The most common indication for laparotomy conversion was a large uterus (27.0%), followed by extensive adhesions (24.3%) and surgical complications (18.9%). Outcomes of cases resulting in laparotomy conversion include longer surgical time (333 vs 224 minutes, P < 0.001), larger blood loss (350 vs 100 mL, P < 0.001), longer hospital stay (4 vs 2 days, P < 0.001), and increased risk of hospital readmission (10% vs 1.4%, P = 0.024). In multivariate analysis, morbid obesity (odds ratio [OR], 4.51; P = 0.011), suboptimal pelvic examination or enlarged uterus during preoperative evaluation (OR, 3.55; P = 0.034), para-aortic lymphadenectomy (OR, 10.5; P = 0.001), uterine size 250 g or greater (OR, 3.49; P = 0.026), and extrauterine disease (OR, 4.68; P = 0.012) remained the independent predictors for laparotomy conversion. The following numbers of risk factors were significantly correlated with laparotomy-conversion rate: none, 1.1%; single risk factor, 5.3% (OR, 5.00; P = 0.15); double risk factors, 21.7% (OR, 24.9; P = 0.002); and triple or more risk factors, 50% (OR, 90.0; P < 0.001). Ultrasonographic 3-dimensional volumes of 496 cm in preoperative uterine size correlate with actual uterine weight of 250 g (Y = 61.5 + 0.38X, P < 0.001). Laparotomy conversion significantly impacts outcomes of patients with endometrial cancer. In this setting, our predictive model for laparotomy conversion will be useful to guide the surgical management of endometrial cancer.

Evidence for a Potential Usefulness of Sentinel Lymph Node Biopsy as a Future Standard in the Management of Endometrial Cancer

Evidence for a Potential Usefulness of Sentinel Lymph Node Biopsy as a Future Standard in the Management of Endometrial Cancer

ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: diagnosis, treatment and follow-up

The first joint European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and European Society of Gynaecological Oncology (ESGO) consensus conference on endometrial cancer was held on 11-13 December 2014 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of endometrial cancer. Before the conference, the expert panel prepared three clinically relevant questions about endometrial cancer relating to the following four areas: prevention and screening, surgery, adjuvant treatment and advanced and recurrent disease. All relevant scientific literature, as identified by the experts, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. Results of this consensus conference, together with a summary of evidence supporting each recommendation, are detailed in this article. All participants have approved this final article.

Treatment of Older Women With Endometrial Cancer: Improving Outcomes With Personalized Care

Endometrial cancer is the most common gynecologic cancer, and with a median age of 62 at diagnosis, it affects a significant number of older women. With increasing age and obesity rates in the world’s population, there is an anticipated concomitant increase in older women with endometrial cancer. Older women are more likely to die of endometrial cancer compared with younger patients. Reasons for this include more aggressive tumor biology, less favorable clinicopathologic features, and more advanced disease. Other factors, however, such as reluctance to offer surgical treatment to the older patient and increased complications of treatment are likely to be important. Management of endometrial cancer requires multidisciplinary care (surgery, radiation therapy, and systemic therapy). For each treatment, the feasibility (related to technical aspect of the procedure/treatment), side effects and safety (related to older-patient factors), and the overall benefit as it pertains to older women with endometrial cancer should be assessed carefully with a multidisciplinary approach. Despite the importance of these issues, the data are limited to answer these issues with clarity. In this article, we will review each treatment modality for older women with endometrial cancer. We will introduce the components of comprehensive geriatric assessment and their practical implication for older women with cancer in general and older women with endometrial cancer specifically.

Single-access laparoscopic approach in the surgical treatment of endometrial cancer: A single-institution experience and review of literature.

BACKGROUND:The aim of this study was to assess the surgical and oncological outcome for the management of endometrial cancer (EC) by laparoendoscopic single-site surgery (LESS).PATIENTS AND METHODS:We performed a retrospective chart review of patients who underwent a LESS for EC. All the patients were treated by the same surgical team between July 2009 and June 2013 at the Gynaecologic Oncologic Unit, Regina Elena National Cancer Institute, Rome, Italy.RESULTS:A total of 50 women were included, with a median age of 45 years (range, 39-84 years) and a median body mass index (BMI) of 21.8 kg/m2 (range, 19-48 kg/m2). Median operative time was 100 min (range, 50-240 min), median blood loss was 90 mL (range, 10-300 mL) and median hospital stay was 3 days (range, 2-9 days). The median number of pelvic lymph nodes retrieved was 14 (range, 5-20). No intraoperative complications occurred, but there were 4 postoperative complications. Two patients required a laparoscopic conversion. The median follow-up was 36 months (range, 16-62 months) and no recurrence occurred.CONCLUSION:Our report showed that the LESS approach in the treatment of early EC can be a safe and reliable technique in terms of surgical and oncological outcomes.

Hysterectomy at the time of colpocleisis: a decision analysis.

Colpocleisis is an obliterative procedure for the treatment of pelvic organ prolapse (POP) with success rates nearing 100%. Concomitant hysterectomy is commonly performed to avoid potential difficulty or delay in diagnosis and management of endometrial cancer (EMC). The objective was to assess the utility of vaginal hysterectomy at the time of a colpocleisis using decision analysis. A decision analysis model was constructed to compare the outcomes of Le Fort colpocleisis (C) with those of colpocleisis and concomitant vaginal hysterectomy (CH). Probability and utility values from published data and expert opinions were utilized. As EMC risk changes with age, the total expected utility for each alternative was calculated for each decade using the rollback method. Sensitivity analysis was performed using Monte Carlo simulation. When evaluating specifically the risk of developing EMC in those patients with uterine conservation (C) and the risk of laparotomy in patients undergoing CH, one-way sensitivity analysis was used to determine a threshold for decision reversal. Two-way sensitivity analysis determined a threshold for complications common to both C and CH. The expected overall utility for C was higher than for CH for all ages 30-90years. This difference was statistically significant for ages 40-90, favoring C. The Monte Carlo simulation results confirmed that the difference between the two alternatives was statistically significant. Multiple one-way sensitivity analyses confirmed model robustness. Colpocleisis should be preferred to CH. Concomitant hysterectomy commonly performed for cancer may be justified in patients younger than 40years of age.

ESMO–ESGO–ESTRO consensus conference on endometrial cancer: Diagnosis, treatment and follow-up

The first joint European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and European Society of Gynaecological Oncology (ESGO) consensus conference on endometrial cancer was held on 11–13 December 2014 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of endometrial cancer. Before the conference, the expert panel prepared three clinically-relevant questions about endometrial cancer relating to the following four areas: Prevention and screening, surgery, adjuvant treatment and advanced and recurrent disease. All relevant scientific literature, as identified by the experts, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. Results of this consensus conference, together with a summary of evidence supporting each recommendation, are detailed in this article. All participants have approved this final article.

Management of Endometrial Cancer: A Review.

Endometrial cancer is the most common malignancy of the female genital tract in developed countries and second to cervical cancer in India. Endometrial cancer predominately affects post menopausal women; however 15-25% of cases are diagnosed before menopause. Endometrial cancer is not amenable to screening, hence needs to be managed effectively as soon as diagnosis is made. Though quite a lot of studies have been conducted in this area, still there are controversies regarding few issues in its management. We decided to review the current literature on use of imaging techniques in diagnosing and assessing loco regional spread, mode of surgery, role of lymphadenectomy in early stage disease including sentinel lymph node status, adjuvant treatment and fertility preservation in women with endometrial cancer. Transvaginal ultrasound and MRI help in diagnosing the disease as well as locoregional spread of the tumor. Laparoscopy is replacing the conventional laparotomy without any increase in complication rate. Robotic technology being new has not been critically evaluated. Role of lymphadenectomy in early disease is still controversial. Only few studies have assessed the place of sentinel lymph node biopsy in the management of endometrial cancer. Fertility preservation in young women is the need of the hour and has been used with successful pregnancy outcome. There is need for more randomized controlled trials to clarify certain issues regarding management of endometrial cancer and on-going trials such as PORTEC3 and LACE may answer these queries.

Detection of Sentinel Lymph Node Mapping Using Indocyanine Green in the Management of Endometrial Cancer: A Pilot Study

Detection of Sentinel Lymph Node Mapping Using Indocyanine Green in the Management of Endometrial Cancer: A Pilot Study

Does teaching take time? Resident involvement in laparoscopic and robotic-assisted surgical management for endometrial cancer

Does teaching take time? Resident involvement in laparoscopic and robotic-assisted surgical management for endometrial cancer

Management of recurrent or metastatic endometrial cancer in Germany: results of the nationwide AGO pattern of care studies from the years 2013, 2009 and 2006.

The available literature on the treatment options for recurrent or metastatic endometrial cancer (EC) is full of controversies. Therefore, we explore the results of the AGO pattern of care studies from the years 2013, 2009 and 2006. A questionnaire was developed and sent to all 682 German gynecological departments in 2013 (775 in 2009, 500 in 2006, respectively). The results of the questionnaires were compared with each other using Fisher's exact test. Responses were available in 40.0 % in 2013, 33.3 % in 2009 and 35.8 % in 2006. In 2013 the most preferred endocrine drug was progestin (79.8 %), followed by tamoxifen (42.8 %), aromatase inhibitor (19.8 %), fulvestrant (16.3 %) and a combination (3.9 %) (p < 0.001). 65.3, 59.8, 51.7 and 38.2 % of the participants used platinum, taxane, a combination of cytostatic drugs, anthracycline in metastatic EC, respectively (p = 0.215). 96.2, 92.7, 49.8 and 60.9 % of the participants performed an operation, radiotherapy, endocrine therapy and chemotherapy in 2013 because of a local recurrence, respectively (p < 0.001). Compared to 2009 and 2006 these rates remained stable (no p value <0.05). Because of a distant metastasis 50.4, 64.2, 78.5 and 90.8 % of the participants performed an operation, radiotherapy, endocrine therapy and chemotherapy in 2013, respectively (p < 0.001). Compared to 2009 and 2006 more participants performed an operation or radiotherapy and less an endocrine treatment. Whereas progestin was the favorite drug, the participants of this study did not prefer a specific cytostatic drug for metastatic EC in 2013. This might have reflected the available literature, which did not provide a real standard of care.

Effect of race and histology on patterns of failure in women with early stage endometrial cancer treated with high dose rate brachytherapy

BackgroundClinical trials have helped refine management of early stage endometrial cancer (EC). For patients with intermediate risk features, adjuvant radiation is considered, primarily vaginal cuff brachytherapy. For higher risk patients, there may be a role for chemotherapy and radiation. The purpose of this study is to examine patterns of failure for early stage EC patients treated with postoperative high dose rate brachytherapy. MethodsIn this single institution retrospective cohort study, 208 women with early stage endometrial cancer who received definitive therapy between January 1, 2000 and January 1, 2013 were identified. ResultsMedian follow-up was 46.4 (range, 6.2–137.3) months. Thirteen (6.3%) patients developed with locoregional recurrent disease and 15 (7.2%) patients developed distant metastasis. Freedom from recurrence at 5years was 88.6% for white patients and 60.5% for black patients (p=0.0093). Five year recurrence free survival (RFS) for white vs. black patients was 82.9% vs. 48.9% (p=0.0007). Five year overall survival (OS) was 86.8% for white patients and 59.5% for black patients (p=0.0023). Black patients with unfavorable histology treated with chemotherapy and vaginal brachytherapy had a 15% locoregional recurrence rate, more than double the rate of local recurrence compared to AA patients with endometrioid histology and white patients with any histology (6% locoregional recurrence rate). ConclusionsBlack women with unfavorable histology early stage EC experience increased rates of recurrence and worse survival compared to white patients. Patterns of failure in this group also indicate a high locoregional failure rate for the black patients with unfavorable histology (type II).

Preoperative serum CA125: a useful marker for surgical management of endometrial cancer

BackgroundSurgery plays an important role in the management of endometrial cancer at all stages, particularly early clinical stage. There are still many unanswered questions regarding optimal surgical management of endometrial cancer, particularly regarding which patients should undergo lymphadenectomy. The aim of this study was to evaluate the role of preoperative cancer antigen 125 (CA125) serum levels for surgical management in endometrial cancer patients.MethodsA total of 995 patients with endometrial cancer, according to inclusion criteria of a preoperative serum level of CA125, were selected. The association between clinicopathological factors and CA125 were analyzed. Receiver operating characteristic (ROC) curve was used to evaluate the role of preoperative serum CA125 in predicting lymph node metastasis, adnexal involement, cervical stromal invasion in all patients, especially patients with clinical stage I. Survival analyses were also performed according to the four groups of preoperative CA125 serum levels.ResultsElevated CA125 level was significantly associated with all clinicopathological parameters, including age and menopause, but not histology type. ROC curve analysis results showed the CA125 serum level of 25 U/mL was the best cutoff to predict the lymph node metastasis. It was with 78% of sensitivity, 78% of specificity, 77.6% of false positive rate, 2.3% of false negative rate in all patients. In patients with clinical stage I, it was with 71.7% of sensitivity, 77.6% of specificity, 83.3% of false positive rate, 2.2% of false negative rate. The best cutoff to evaluate adnexal involement in patients with clinical stage I was 30U/ml, with 81% sensitivity, and 78.4% specificity. Survival analysis revealed CA125, FIGO stage, histology grade, and positive peritoneal cytology as independent prognostic factors of endometrial cancer.ConclusionPreoperative serum CA125 is an important predictor for patients with endometrial cancer and it should be taken into consideration when surgical management is determined, especially if a lymphadenectomy should be undertaken in patients with clinical stage I.

Surgical and oncological outcome of robotic surgery compared to laparoscopic and abdominal surgery in the management of endometrial cancer

ObjectiveTo compare different techniques of minimally invasive surgery (laparoscopy and robotics) to abdominal surgery in order to identify the optimal surgical technique in the treatment of endometrial cancer. Methods and materialsA single-institutional, matched, retrospective, cohort study was performed. All patients with clinical stage I or occult stage II endometrial cancer who underwent robotic hysterectomy, bilateral salpingo-oophorectomy ± lymphadenectomy from August 2010 and December 2013 were identified. Surgical and oncological outcomes were compared with patients matched by age, body mass index, tumor histology, and grade, who underwent abdominal or laparoscopic surgery between January 2001 and December 2013. ResultsThree groups were identified: 177 laparotomies (group A), 277 laparoscopies (group B) and 72 robotics (group C). There were no statistically significant differences between the three groups in terms of age, BMI and FIGO stage. The operative time was shortest in group B (p = 0.0001). Blood loss and transfusions were equivalent in group B and C, while they were greater in group A (p = 0.0001). The intra-operative, early and late postoperative complications, rate of conversion, the re-intervention and median hospital stay were lower in group C. The rate of recurrence and death from disease was similar in all three groups. ConclusionsMinimally invasive surgery was superior to abdominal surgery in terms of surgical outcomes. Robotic surgery was superior to laparoscopy in terms of intra- and post-operative complications, conversion rates, length of hospital stay and re-interventions. In terms of oncological outcomes the three groups were equivalent.

Les lymphadénectomies dans le cancer de l’endomètre, bilan après 4 ans de pratique, doit-on poursuivre ?

The aim of this study was to evaluate the complication rate of pelvic and para-aortic lymphadenectomy in the management of endometrial cancer following the changes to the recommendations of INCa 2010. This is a retrospective study of 208 patients operated for endometrial cancer between July 2010 and March 2014 in two referral centers. Eighty lymphadenectomy were performed, 65 with hysterectomy and bilateral annexectomy and 18 lymphadenectomy were performed for restaging. Complications assessment is based on the Dindo Clavien classification. We report 17 severe complications (grade 3a and over) (P<0.001), including 14 among patients receiving lymphadenectomy. Morbidity increases with the number of lymphnodes removed and their positivity (P<0.001). The para-aortic lymphadenectomy is primarily responsible for complications (P <0.001). We describe 7 lower limbs lymphedema, 12 nerve injuries, 8 ileus, 5 venous or arterial thromboembolism, 17 blood transfusions, 13 lymphoceles including 9 infected. The rate of intraoperative complications on a first lymphadenectomy is 8% while it reached 22% for restaging. Restaging is significantly more at risk of serious complications (P=0.03) with two deaths. Twenty-four chronic disorders with impaired quality of life (2 without lymphadenectomy) are reported. They are present in 50% of restaging (P=0.033 compared to first lymphadenectomy). Lymphadenectomy is a source of severe morbidity (17.5%) with 2.5% mortality. The benefit of this surgery should probably be discussed again.

Poor Outcomes After Conservative Management for Low-Grade, Apparent Early-Stage Endometrial Cancer [334

INTRODUCTION: The conservative (fertility preserving) management of low-grade, early-stage endometrial cancer is gaining popularity. Some concerns could be raised in view of the tendency to underreport poor outcomes such as death, progression to advanced stage, or higher grade disease. METHODS: We reviewed published poor outcomes of low-grade, early-stage endometrial cancer and present two women who desired conservative management for fertility-preserving purposes and sustained poor outcomes in one tertiary care facility over a 5-year period. RESULTS: Despite established conservative management, the first patient's low-grade, early-stage endometrial cancer concealed an underlying pathology of clear cell adenocarcinoma. In the second case, a patient with low-grade endometrial cancer refused hysterectomy to attain fertility and when she accepted, was found to have stage IIIC1 (International Federation of Gynecology and Obstetrics 2009) disease. IMPLICATION: These cases indicate that conservative management of endometrial cancer should still be considered with caution, performed by experienced teams, and the potential risks be explained to the patients.

Advances in the Management of Recurrent Endometrial Cancer

Endometrial carcinoma is the most common malignancy of the female reproductive tract. Although most cases are diagnosed at an early stage, endometrial carcinoma carries a poor prognosis when it recurs after previous definitive treatment or when diagnosed at an advanced stage. The purpose of this review is to summarize the contemporary management of recurrent endometrial carcinoma. A literature review was conducted on the management of advanced, recurrent, or metastatic endometrial cancer to determine the best evidence to support the roles of surgery, radiation, and medical therapy. Radiation therapy (RT) has a role in the treatment of a local or regional recurrence, especially in the patient who has not had prior RT. For selected patients who experience a loco-regional recurrence and who have been treated with RT, pelvic exenteration may be an option. Those patients with metastatic disease are not curable and should be considered for palliative chemotherapy. The data support the use of carboplatin and paclitaxel as an acceptable alternative to cisplatin-based regimens. For women who progress after first-line treatment, the options are limited. Current clinical trials are evaluating the role of angiogenesis inhibitors and molecularly targeted therapy (including the mammalian target of rapamycin inhibitors and multitargeted tyrosine kinase inhibitors) with the aim of identifying other novel agents that can be exploited for treatment of advanced disease. The treatment of women with advanced, recurrent, or metastatic endometrial cancer represents an unmet need in oncology. Robust clinical trials are required to explore how to improve on therapy. The incorporation of molecularly targeted agents has the potential to improve outcomes for women who require treatment in both the first-line and second-line settings.

Under-utilization of minimally invasive surgery in the management of endometrial cancer: A Healthcare Cost and Utilization Project-National Inpatient Sample study (HCUP-NIS)

Under-utilization of minimally invasive surgery in the management of endometrial cancer: A Healthcare Cost and Utilization Project-National Inpatient Sample study (HCUP-NIS)