Management Of Endometrial Cancer Research Articles

Changing trends in the management of early stage endometrial cancer over the past decade: Experience from a tertiary cancer center

Objectives: Treatment of locally advanced endometrial cancer is not well established. The “sandwich” approach offers combination treatment with chemotherapy and radiation. The aim of this study was to evaluate overall survival (OS) and progression-free survival (PFS) between two “sandwich” protocols. Methods: Patients were retrospectively identified between 2006 and 2013 at a single institution. Clinical information was abstracted, including age, body mass index (BMI), surgical debulking method, “sandwich” protocol, disease status, and complications. OS and PFS were calculated using Kaplan–Meier method. Results: A total of 58 patients with high-grade and/or advanced-stage disease were identified who received “sandwich” therapy. The median agewas 61 years (range, 29– years).Median BMIwas 31.9 (range, 19.5– 56.1). All patients had no residual disease after surgical debulking, 19% by laparotomy and 81% by laparoscopy. Twenty-four patients received a “sandwich” protocol of 2 cycles of platinum/taxane chemotherapy followed by radiation and concurrent cisplatin, followed by 2 cycles of platinum/taxane chemotherapy. Thirty-four patients received a 3-cycle platinum/taxane “sandwich” around radiation therapy alone. Among patients treated with the 2-cycle protocol, 75% (18/24) remain with no evidence of disease (NED), 17% are alive with disease (AED), and 8% are dead of disease (DOD). Median time to recurrence was 12 months (range, 1–39 months). Among patients treated with the 3-cycle protocol, 82% (28/34) remain with NED, 6% are AED, and 12% are DOD. Median time to recurrence was 7 months (range, 4–44 months). PFS of the 2-cycle protocol was 12 months (range, 1–39months) compared to 7 months (range, 4–44months) in the 3-cycle protocol (P=0.12). The OS of the 2-cycle protocol was 22 months (range, 7–65 months) compared to 33 months (range, 11–100 months) in the 3-cycle protocol (P= 0.76). Complications included pulmonary embolism in seven patients (4/7 in 2-cycle, 3/7 in 3 cycles) and severe grade 3/4 neutropenia in five patients (4/5 in 2-cycle, 1/5 in 3-cycle). Conclusions: Optimizing care for locally advanced disease is challenging. In our study, no statistically significant difference was shown in PFS and OS between protocols. The concurrent use of cisplatin with radiation therapy needs to be further studied because it may provide the same efficacy in fewer chemotherapy cycles.

Comparison of surgical outcomes in laparoscopic and robotic-assisted surgical management of endometrial cancer

Comparison of surgical outcomes in laparoscopic and robotic-assisted surgical management of endometrial cancer

Hysteroscopic surgery for conservative management in endometrial cancer: a review of the literature.

Endometrial cancer is the most common gynaecologic malignancy, usually diagnosed in postmenopausal women. However, an incidence rate of 2–14% of cases consisting of women under the age of 45 years old has been reported. Multiple reports have described the conservative treatment of this tumour in selected patients with the objective of preserving fertility. In this article, we review the literature to evaluate the results of conservative treatment of endometrial cancer with hysteroscopic resection.

Management of ovarian and endometrial cancers in women belonging to HNPCC carrier families: review of the literature and results of cancer risk assessment in Polish HNPCC families

BackgroundOver half the cancer deaths in HNPCC families are due to extra-colonic malignancies that include endometrial and ovarian cancers. The benefits of surveillance for gynecological cancers are not yet proven and there is no consensus on the optimal surveillance recommendations for women with MMR mutations.MethodsWe performed a systematic review of the literature and evaluated gynecological cancer risk in a series of 631 Polish HNPCC families classified into either Lynch Syndrome (LS, MMR mutations detected) or HNPCC (fulfillment of the Amsterdam or modified Amsterdam criteria).ResultsPublished data clearly indicates no benefit for ovarian cancer screening in contrast to risk reducing surgery.We confirmed a significantly increased risk of OC in Polish LS families (OR = 4,6, p < 0.001) and an especially high risk of OC was found for women under 50 years of age: OR = 32,6, p < 0.0001 (95% CI 12,96-81,87). The cumulative OC risk to 50 year of life was calculated to be 10%. Six out of 19 (32%) early-onset patients from LS families died from OC within 2 years of diagnosis. We confirmed a significantly increased risk of EC (OR = 26, 95% CI 11,36-58,8; p < 0,001). The cumulative risk for EC in Polish LS families was calculated to be 67%.ConclusionsDue to the increased risk of OC and absence of any benefit from gynecological screening reported in the literature it is recommended that prophylactic oophorectomy for female carriers of MMR mutations after 35 year of age should be considered as a risk reducing option. Annual transvaginal ultrasound supported by CA125 or HE4 marker testing should be performed after prophylactic surgery in these women.Due to the high risk of EC it is reasonable to offer, after the age of 35 years, annual clinical gynecologic examinations with transvaginal ultrasound supported by routine aspiration sampling of the endometrium for women from either LS or HNPCC families. An alternative option, which could be taken into consideration for women preferring surgical prevention, is risk reducing total hysterectomy (with bilateral salpingo-oophorectomy) for carriers after childbearing is complete.Electronic supplementary materialThe online version of this article (doi:10.1186/s13053-015-0025-2) contains supplementary material, which is available to authorized users.

Controversies in the management of endometrial cancer: a survey of the Korean Gynecologic Oncology Group.

ObjectiveTo identify current practice patterns for unresolved issues in the surgical and adjuvant management of endometrial cancer in Korea.MethodsWe designed and conducted a survey of all 218 active members of the Korean Gynecologic Oncology Group to try to identify how they would manage various case scenarios for endometrial cancer. Data were collected using an Internet survey database.ResultsA total of 108 members (49.5%) responded to the survey. Laparoscopy (81.6%) was the most commonly used mode of surgery in early-stage endometrial cancer. Of all the respondents, 19.8% stated that lymphadenectomy could be omitted and 21.7% recommended selective lymphadenectomy based on sentinel biopsy or frozen results for patients with presumed stage IA/grade 1 disease. On the other hand, 71.9% of respondents recommended para-aortic lymphadenectomy for patients with presumed stage IB/grade 1 disease and 86.4% recommended this treatment for presumed stage IB/grade 3 disease. The majority of respondents performed adjuvant therapy for stage IB/grade 2 (91.7%), IB/grade 3 (99.0%), and stage II (89.6%). Whole pelvic radiotherapy and vaginal brachytherapy were the most frequently used options among these patients. All respondents administered adjuvant therapy when node metastasis was found, and concurrent chemoradiotherapy (53.2%) was the most preferred option for stage IIIC1 disease.ConclusionThere is broad variation in both the surgical and adjuvant treatment of endometrial cancer among Korean gynecologic oncologists.

Evaluation of treatment outcomes of early-stage endometrial cancer radiotherapy: a single center experience.

Postoperative adjuvant radiotherapy (RT) in the management of early stage endometrial cancer (EC) is still controversial. Here we report our institutional experience with patients who received postoperative RT for stage I-II EC over a period of 35 years and assess potential predictors of local recurrence (LR), distant metastasis (DM), and overall survival (OS). A total of 188 patients undergoing postoperative RT for stage IA-II EC between 1977 and 2012 were evaluated. Some 96 received median 46 Gy whole pelvic radiotherapy (WPRT) (range: 40-60 Gy), 37 were given WPRT with vaginal cuff therapy (VCT), and 55 received only VCT either with brachytherapy (BT) or stereotactic body radiotherapy (SBRT). Chemotherapy was given to 5 patients with uterine papillary serous carcinoma (UPSC). Logistic regression analysis was used to assess the effect of clinicopathological factors on LR, DM, and OS. Median follow-up time was 11 years (range: 1-35 years). At the time of analysis, 34 patients were not alive. Of the 15 patients with LR, 7 (46.7%) recurred in the vaginal stump, 5 (33.3%) in the pelvic region, and 3 (20%) in the paraaortic nodal region, while 12 had distant metastasis. UPSC histology (p=0.027), sole VCT (p=0.041), high histologic grade (p=0.034), and age≥71 (p=0.04) were poor prognostic factors on univariate analysis. In our patients receiving radiotherapy for early-stage EC, grade III disease and age≥71 were associated with shorter OS whereas UPSC histology was an independent predictor for both LR and DM.

Health-Related Quality of Life Following Robotic Surgery: A Pilot Study

ObjectivesTo determine the relationship between BMI, age, and the physical, functional, and psychosocial areas of health-related quality of life (HRQoL) and patient satisfaction in women with endometrial cancer undergoing robotic-assisted surgery. MethodsDuring the first two years of the robotic surgery program, we prospectively collected data concerning patient demographics and surgical outcomes. At the first postoperative visit (21 to 28days after surgery), all participants completed a HRQoL questionnaire. We examined the association between BMI and age, as well as the different areas of HRQoL, using chi-square and ANOVA. ResultsOf 109 participants, 41 were 70years of age or older, and 51 had a BMI of 30kg/m2 or more. Following surgery, the mean (±SD) duration of hospital stay was 1.9±1.5days, and reported pain level was highest on the second postoperative day, with a mean score of 3.4±2.1 on a seven-point scale. Moreover, two thirds of women reported no pain by the first postoperative visit, and only 18.2% of women aged 70years or older used any narcotic for pain control. These results indicated that there was little influence of the surgery on HRQoL, and women resumed typical activities within an average of 11days after surgery. Lastly, participants’ average rating of satisfaction was 6.7 on a seven-point scale. ConclusionThis pilot study has demonstrated the advantages for HRQoL of robotic-assisted surgery in the management of endometrial cancer. Women with endometrial cancer benefited from use of robotic surgery regardless of age or BMI.

The trend towards minimally invasive surgery (MIS) for endometrial cancer: An ACS–NSQIP evaluation of surgical outcomes

ObjectiveOur objective was to evaluate the surgical trend towards increased MIS in the management of endometrial cancer in regard to improvements in patient outcomes. MethodsUsing the American College of Surgeons–National Surgical Quality Improvement Project's database, patients who underwent hysterectomy for endometrial cancer from 2006–2010 were identified and categorized into exploratory laparotomy (XLAP) or MIS. Comparative analyses were performed and stratified by year of surgery to evaluate demographics, surgical outcomes, and 30-day surgical morbidity. ResultsA total of 2076 patients (1269 XLAP and 807 MIS) underwent hysterectomy for endometrial cancer between 2006 and 2010. Longer operative times were seen in MIS compared to XLAP (192 vs. 148min; p<0.001) as well as significant increase in mean hospital stay in the XLAP group of 3.8days compared to 1.6days in MIS (p<0.0001). When controlling for preoperative comorbidities, significant increases in postoperative complications were observed in XLAP compared to MIS group (total 396 vs. 91; p<0.0001). MIS increased from 16% in 2006 to 48% in 2010, which correlated to decreases in complications and hospital stays. Each 10% increase in MIS would save $2.8 million and 41 postoperative complications. If used exclusively, MIS would save 6434 hospital days and 416 complications. ConclusionsDespite increases in operative times, MIS for the treatment of endometrial cancer significantly reduces perioperative complications and hospital stay. Considering the improvements in patient outcomes and the potential savings to the health care system, MIS should be the preferred route for the surgical treatment of this disease when feasible.

Comparing robotic surgery with laparoscopy and laparotomy for endometrial cancer management: A cohort study

Introduction: Robotic surgery has been applied in managing various types of gynecologic cancers. The purpose of this study is to compare the surgical outcomes of robotic surgery, laparoscopy and laparotomy for managing endometrial cancer. Methods: A total of 365 patients received surgical staging for treating IA to IIIC endometrial cancer were retrospectively enrolled. Patient demography, peri-operative parameters, and survival outcomes were studied. Results and discussions: Robotic surgery showed a significant lower blood loss and 24-h pain score as compared to other surgical types. Moreover, compared to laparotomy, robotic and laparoscopic surgeries were associated with reduced operation time, decreased time to full diet resumption, and shortened hospital stay. No significant differences were found between the groups in terms of overall complication rate. Eighteen-month follow-up of the patients indicated no significant differences in disease-free survival and overall survival. Conclusion: Compared to conventional approaches, robotic surgery showed favorable short-term outcomes with comparable survival. It is suggested that robotic surgery is a feasible tool for endometrial cancer management.

Sentinel node biopsy for the management of early stage endometrial cancer: Long-term results of the SENTI-ENDO study

ObjectiveWe report the long-term results of the SENTI-ENDO study evaluating the impact of sentinel lymph node (SLN) biopsy on management and survival in patients with early stages of endometrial cancer (EC). MethodsPatients with FIGO stage I–II EC underwent pelvic SLN biopsy after cervical dual injection (technetium and patent blue) and systematic pelvic node dissection. This study is a secondary endpoint reporting the long-term recurrence free survival (RFS) and the impact of the SLN procedure on adjuvant therapies. ResultsThe median follow-up was 50months (range: 3–77months). Eighteen of the 125 patients (14.4%) experienced a recurrence. The 50-monthrecurrence-free survival (RFS) was 84.7% with no difference between patients with and without detected SLN (p=0.09). Among patients with detected SLN (111), no difference in RFS was observed between those with and without positive SLN (p=0.5). In the whole population, adjuvant therapy was performed in low-, intermediate- and high-risk groups in 31 of 64 patients (48.4%), 28 of 37 patients (75.7%) and 14 of 17 patients (82.3%), respectively (p=0.0001). For the 111 patients with detected SLN, EBRT was performed in 27 of the 89 with negative SLN and in 11 of the 14 with positive SLN (p=0.001). Chemotherapy was performed more frequently in patients with positive SLN (6/12, 50%) than in patients with negative SLN (7/56, 12.5%) (p=0.009). ConclusionsOur results support the impact of SLN biopsy on surgical management and indications for adjuvant therapies. Further studies are required to assess the clinical impact of the SLN biopsy in early stage EC.

Surgical and systemic management of endometrial cancer: an international survey.

To ascertain the spectrum of clinical management of endometrial carcinoma (EC) the largest international survey was conducted to evaluate and identify differences worldwide. After validation of a 15-item questionnaire regarding surgical and adjuvant treatment of EC in Germany, an English-adapted questionnaire was put online and posted to all the major gynecological cancer Societies worldwide for further distribution commencing in 2010 and continued for 26 months. A total of 618 Institutions around the world participated: Central Europe (CE), Southern Europe (SE), Northern Europe (NE), Asia and USA/Canada/UK. Both a therapeutic and staging value was attributed to systematic pelvic and paraaortic lymph node dissection (LND) in CE (74.6%) and in Asia (67.2%), as opposed to USA/UK where LND was mainly for staging purposes (53.5%; p < 0.001). LND was performed up to the renal veins in CE in 86.8%, in Asia in 80.8%, in USA/UK in 51.2% and in SE in 45.1% (p < 0.001) of cases. In advanced disease, centers from Asia were treated most with adjuvant chemotherapy alone (93.6%), as opposed to centers in SE, CE and UK/USA that employed combination chemo-radiotherapy in 90.9% (p < 0.001) of cases. Paclitaxel/carboplatin was mostly used followed by doxorubicin/cisplatin (75 vs. 23.3%; p < 0.001). In total, 94% of all participants supported the concept of treating EC patients within appropriate clinical trials. There is broad range in both the surgical and adjuvant treatment of EC across different countries. Large-scale multicenter prospective trials are warranted to establish consistent, evidence-based guidelines to optimize treatment worldwide.

Comparing Robotic Surgery with Conventional Laparoscopy and Laparotomy for Endometrial Cancer Management

Comparing Robotic Surgery with Conventional Laparoscopy and Laparotomy for Endometrial Cancer Management

927P - Adjuvant Sequential Radiotherapy and Chemotherapy in High-Risk Endometrial Cancer: Preliminary Analysis of a Phase Ii Clinical Trial in One Institution

ABSTRACT Aim: The management of high-risk endometrial cancer (HREC) and the sequence of chemotherapy and radiotherapy remain controversial. A prospective phase-II clinical trial was conducted to evaluate the sequence and toxicity of adjuvant chemoradiotherapy and chemotherapy in patients with HREC. Methods: Eligibility included endometrioid endometrial cancer with histologic grade 3 and greater than 50% myometrial invasion, or stromal invasion of the cervix, or pelvic lymph node metastases, or para-aortic lymph node metastases, or extrauterine disease confined to the pelvis; non-endometrioid endometrial cancer regardless of stage; with no gross residual disease and distant metastases. This study was designed to administer pelvic radiation (45 Gy/ 25 fractions), along with cisplatin (50 mg/m2) on Days 1 and 28. Vaginal afterloading brachytherapy (5 Gy/d, 6 fractions) was given for patients with stromal cervical invasion. External para-aortic intensity-modulated radiation was allowed for patients with confirmed para-aortic lymph nodes metastases. Four courses of paclitaxel (135 mg/m2) and carboplatin (AUC = 5), or cisplatin (50 mg/m2) and cyclophosphamide (600 mg/m2) and epirubicin (60 mg/m2) were allowed at 3-week intervals after RT completion. Results: Number of Events Estimated 3-year rate (%) Estimated 5-year rate (%) Recurrence in the field of radiation 4 5 5 Local-regional failure 7 10 13 Distant metastases failure 17 20 20 Progression-free survival 24 74 72 Overall survival 12 87 83 One hundred and three patients were enrolled between January 2007 and January 2011. Eighty-eight patients (85.4%) completed the planned treatment. Treatment discontinuation was the result of toxicity (4/103, 3.9%), disease progression (4/103, 3.9%), and patients refusal (3/103, 2.9%). Four patients died before completing therapy. There were no treatment-related deaths. Median follow-up was 35 months (range 3-80 months). Twenty-four (23.3%) patients recurred, in which 4 cases recurred in the field of radiation, and 12 cases died of endometrial cancer. The estimated 3-year and 5-year progression-free survival and overall survival were listed in table1. Conclusions: This treatment protocol demonstrated an excellent treatment completion rate and expected toxicity. Subsequent phase-III trials are warranted. Disclosure: All authors have declared no conflicts of interest.

Management of endometrial cancer in Italy: A national survey endorsed by the Italian Society of Gynecologic Oncology

Introduction: Endometrial carcinoma (EC) is a frequent cancer in developed countries, but with evidence for discrepant clinical management. Under the auspices of the Italian Society of Gynecologic Oncology (SIOG), we conducted a survey among Italian centers with ≥20 surgeries for gynecological cancer per year, trying to depict a reliable picture of EC management in our country. Methods: The questionnaire focused on preoperative/surgical staging and adjuvant treatment. Of the 283 questionnaires delivered, 35% were sent back. Results: Diagnostic hysteroscopy is performed in 78% of centers. In clinical stage I, 52% adopt a laparotomic access, 15% totally laparoscopic, 9% laparoscopic/vaginal, 2% vaginal, 22% tailored approach. Elective use of laparoscopy significantly differs between institutions (p < 0.001): 40% (≥20 EC/yr) vs. 12% (<20). Pelvic and aortic lymphadenectomy is selectively performed by 77% and 68% of centers, respectively, depending on pre/intraoperative factors. Non-endometrioid histology, poor-grade and deep myoinvasion are indicated as the highest-risk factors. Adjuvant therapy is given to pathologically node-negative patients by 60%, and to intermediate-risk patients by 47%. Elective adjuvant treatment is still radiotherapy, but chemotherapy is adopted, mostly combined with radiation, by 40%. There is a multidisciplinary team in 64% of centers, but in 59% adjuvant treatment is to be administered outside the institution. Conclusions: These data demonstrate a significant improvement in the clinical care achieved over the last decades in Italy. Centralization of EC treatment would not be feasible neither useful. High-risk cases could be selected by an appropriate clinical screening, and these only referred to reference centers.

Ultrasound deserves to play a prominent role in the diagnosis and management of endometrial cancer

Ultrasound deserves to play a prominent role in the diagnosis and management of endometrial cancer

Activation of PI3K/Akt/mTOR pathway and dual inhibitors of PI3K and mTOR in endometrial cancer.

Endometrial cancer is the third most common cancer in women. Endometrial carcinomas (EC) are clinic histologically classified into two types. Type I tumours, which account for 80% of ECs, are estrogen-dependent and are low grade. Type II tumours are more aggressive with invasion into myometrium. Recently a new classification for endometrial cancer has been proposed based on molecular markers. Whether this classification is helpful for clinical management of endometrial cancer remains to be tested. At present, treatment outcomes of endometrial cancer are not satisfactory. Therefore, more effective approaches are sought. This review summarizes the recent studies about activation of PI3K/Akt pathway in EC and therapeutic implications of the inhibitors of the pathways with emphasis on dual inhibitors of PI3K and mTOR. Both genetic defects and environmental factors are involved in carcinogenesis and progression of EC via activation of multiple signal pathways including the PI3K/Akt pathway. Mutations of major components of the PI3K/Akt pathway are common in EC. Type I tumours usually have mutations in Ras, PTEN, PIK3CA, AKT1, beta-catenin and type II tumours have mutations in TP53. Environmental factor like obesity can also activate the PI3K/Akt pathway to increase the incidence of EC and to cause poorer prognosis. Therefore, inhibition of the PI3K/Akt pathway can be used for therapy of the disease. At present, mTOR inhibitors have been extensively studied and tested in clinical trials. A newly synthesised dual inhibitor of PI3K and mTOR BEZ235 has been shown to be more effective than mTOR inhibitor rapamycin. BEZ235 can inhibit feedback activation of PI3K/Akt pathway by rapamycin. It is promising to include effective PI3K/Akt inhibitors in current treatment regime of endometrial cancer to improve the therapeutic efficacy.

Impact of sentinel lymph node biopsy on the therapeutic management of early-stage endometrial cancer: Results of a retrospective multicenter study

ObjectiveThe aim of this study is to assess the impact of sentinel lymph node (SLN) mapping and ultrastaging on the therapeutic management of early-stage endometrial cancer. MethodsThis retrospective multicenter study covered the period from January 2000 through December 2012 and included 304 women with presumed low- or intermediate-risk endometrial cancer. Node staging, histology results, and the effects of both on therapeutic management were assessed in two groups: those who underwent the SLN mapping and ultrastaging procedure and those treated in accordance with French guidelines. ResultsThe SLN procedure detected metastatic lymph nodes in three times more women than lymphadenectomy did (16.2% versus 5.1%, p=0.03). Specifically, it found 7 macrometastases (5.1%) and 15 micrometastases (11%); 11 of the latter (8.1%) were detected by serial sectioning and immunohistochemistry (IHC), that is, pathologic ultrastaging. The SLN biopsy false-negative rate was 0% (95% CI: 0–1.6%). This ultrastaging enabled us to modify the adjuvant therapy for half the patients. Women with micrometastases detected by the SLN procedure were treated with external beam radiotherapy (EBRT), while those whose SLN biopsies were negative received vaginal brachytherapy (VBT) or clinical follow-up. SLN biopsies had no impact on recurrence-free survival. ConclusionSLN mapping and ultrastaging improved staging and made it possible to adapt adjuvant therapy to risk of recurrence.

Laparoendoscopic Single-Site Versus Conventional Laparoscopic Surgical Staging for Early-Stage Endometrial Cancer

This study aims to compare the feasibility, safety, and efficacy of laparoendoscopic single-site (LESS) surgical staging for early-stage endometrial cancer with conventional laparoscopic surgical staging. The prospective study group consisted of 37 consecutive patients who underwent LESS surgical staging including hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection. The historical control group consisted of 74 consecutive patients who underwent 4-port laparoscopic surgical staging including hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection. Surgical outcomes were compared between the 2 groups. No patient in the LESS or conventional laparoscopic surgery group required an additional trocar or conversion to laparotomy. There were no intergroup differences in mean age, menopause status, body mass index, and previous history of abdominal surgery. Further, there were no inter-group differences in the number of total (LESS vs. conventional, 25.9 ± 10.6 vs. 24.6 ± 9.0, P = 0.497), pelvic (24.6 ± 0.497 vs. 23.3 ± 7.7, P = 0.459), and para-aortic (4.9 ± 2.5 vs. 6.9 ± 7.3, P = 0.494) lymph nodes retrieved; the operating time (183 ± 50 min vs. 173 ± 106, P = 0.388); estimated blood loss (194 ± 149 mL vs. 173 ± 106 mL, P = 0.394); number of patients requiring transfusion (5.4% vs. 8.1%, P = 0.717); postoperative hospital stay (5.0 ± 1.8 days vs. 5.1 ± 1.8 days, P = 0.911); intraoperative complications (2.7% vs. 0%, P = 0.333); and postoperative complications (0% vs. 1.4%, P > 0.999). The postoperative pain scores and analgesic requirements were significantly lower in the LESS surgical staging group. Laparoendoscopic single-site surgical staging was a feasible, safe, and efficacious procedure for surgical management of early-stage endometrial cancer. It was associated with less postoperative pain and analgesic requirements and was comparable to conventional laparoscopic surgical staging in perioperative outcomes.

Risk assessment of lymph node metastasis before surgery in endometrial cancer: Do we need a clinical trial for low‐risk patients?

Due to advances of radiological imaging and tumor biomarkers, the extent of information provided by preoperative assessment is rapidly growing. The Korean Gynecologic Oncology Group (KGOG) recently proposed new preoperative criteria to identify patients at low risk for lymph node metastasis in endometrial cancer. In the multicenter study, serum carbohydrate antigen 125 levels and three magnetic resonance imaging parameters were found to be independent risk factors for nodal metastasis, and classified 53% of patients as part of a low-risk group. The false-negative predictive value (NPV) was 1.7%, and was 1.4% in the validation set. Furthermore, the KGOG low-risk criteria were validated in 319 Japanese patients with endometrial cancer. The criteria identified 181 of 319 patients as a low-risk group (51%), and three false-negative cases were found (1.9%). These results indicate that we are able to identify low-risk patients with a negligible NPV before surgery. In addition, the low false NPV implies that there is great difficulty in performing a randomized trial to determine the efficacy of routine lymphadenectomy in patients at low risk of lymph node metastasis. Based on these data, the challenges and possible solutions for developing a consensus on the optimized management of low-risk endometrial cancer will be discussed in this review.

Prognostic factors of oncologic and reproductive outcomes in fertility-sparing management of endometrial atypical hyperplasia and adenocarcinoma: systematic review and meta-analysis

To evaluate the various possible prognostic factors on the fertility-sparing management of atypical hyperplasia and endometrial cancer; to generate survival curves to estimate remission and recurrence rates according to time. Systematic review and meta-analysis. CRD42013004557. University hospital. Patients who underwent fertility-sparing management for atypical hyperplasia and endometrial cancer. All published studies were identified through MEDLINE and reported according to PRISMA guidelines. Remission, recurrence, progression, and pregnancy rates by age, obesity, infertility, previous pregnancy, histology, and medical treatment. A total of 370 patients from 24 studies were included. The 12- and 24-month remission probabilities were 78.0% and 81.4%, respectively. In multivariate analysis, previous pregnancy (odds ratio [OR] 2.70, 95% confidence interval [CI] 1.23-5.89), infertility (OR 2.26, 95% CI 1.05-4.87), and treatment with megestrol acetate (OR 2.70, 95% CI 1.20-6.02) were associated with higher remission probability. The 12- and 24-month recurrence probabilities were 9.6% and 29.2%, respectively. In multivariate analysis, none of the factors studied was associated with higher recurrence probability. Twenty-two studies totaling 351 patients were used to assess pregnancy rate; 111 subjects (32%) had one pregnancy or more. In multivariate analysis, none of the factors were associated with pregnancy probability. Among the 263 patients used to assess progression rate, 39 (15%) had a tumor with at least myometrial invasion on the hysterectomy specimen. Endometrial cancer and the use of other medical therapies (in comparison with megestrol acetate) were associated with an increased probability of progression. Fertility-sparing management should not be contraindicated in older patients with previous infertility or obesity.