Stage Endometrial Cancer Research Articles

Transvaginal ultrasound versus magnetic resonance imaging in local staging of endometrial cancer.

Transvaginal ultrasound versus magnetic resonance imaging in local staging of endometrial cancer.

GPP03 Presentation Time: 8:20 AM: Short Course Adjuvant Vaginal Cuff Brachytherapy (VCB) in Early Endometrial Cancer: Preliminary Results of the SAVE Randomized Clinical Trial

<h3>Purpose</h3> Prospective randomized trials in early stage endometrial cancer demonstrate increased locoregional control with adjuvant radiotherapy for patients with select high risk features. Vaginal cuff brachytherapy (VCB) is widely utilized, yet there is substantial practice variation and limited randomized data examining optimal dose/fractionation. We aimed to study the safety and efficacy of short course VCB compared to commonly used regimens, and herein report on short-term adverse events, patient reported outcomes, and recurrences. <h3>Materials and Methods</h3> We conducted a prospective, multi-center, randomized trial examining short course adjuvant VCB (11 Gy x 2 fractions at the surface delivered in 2 weeks) compared with the commonly used regimens (7 Gy x 3 fractions at 0.5 cm depth, 6 Gy x 5 fractions at the surface, or 5-5.5 Gy x 4 fractions at 0.5 cm depth). Eligible patients underwent hysterectomy and had pathologically confirmed endometrioid adenocarcinoma, serous, clear cell, or carcinosarcoma histology. Patients with stage I and II cancers were included, with additional risk factors required for stage IA (IAG1 with LVSI). The primary outcome was Global Health Status measured by the EORTC QLQ-C30. Secondary outcomes included differences in patient-reported outcomes using the EORTC EN24 for vaginal, bladder, and bowel symptoms, cost effectiveness, toxicities as assessed by CTCAEv4, and patterns of recurrence. Data were collected at each brachytherapy fraction and at 1, 6 and 12 month follow-up with a compliance rate of 94% at 1 month. <h3>Results</h3> 108 patients were enrolled. Of these, 52 patients experienced short-term AEs related to study treatment, 21 in the experimental arm and 31 in the control arm (p=0.05). All study treatment-related AEs were grade 1-2, except for 1 grade 3 urinary symptom in the control arm. In the experimental arm, the most frequent short-term AEs were fatigue (n=6), diarrhea (n=4), vaginal discharge (n=3), and vaginal dryness (n=3). In the control arm, the most frequent short-term AEs were vaginal dryness (n=8), urinary incontinence (n=6), urinary tract infection (n=5), and pelvic pain (n=5). At median follow-up of 12 months, 5 patients experienced recurrence including 2 distant recurrences and 1 distant and pelvic recurrence in the experimental arm and 2 pelvic recurrences in the control arm. There have been no isolated vaginal recurrences in either arm. The QLQ-C30 Global Health Status for the experimental arm was within the predefined boundary and thus 2 fractions was non-inferior to standard of care (p=0.00002) at one month. <h3>Conclusions</h3> Short course VCB is safe and well-tolerated with acceptable acute toxicity and non-inferior patient reported outcomes. Although longer follow-up data is pending, short course VCB shows promise to improve patient convenience and access to care for rural or underserved populations while providing similar local control and toxicity profile.

7490 Perioperative Outcomes of the "Chopsticks Technique" Single-Site Laparoscopy Versus Traditional Laparoscopy for Endometrial Cancer

<h3>Study Objective</h3> To describe the new "chopsticks technique" single-site laparoscopic surgery technology and to compare the perioperative outcomes of the new "chopsticks technique" laparoendoscopic single-site surgery (LESS) versus traditional laparoscopic surgery (TLS) in the staging surgery of endometrial cancer (EC). <h3>Design</h3> Retrospective case-control study based on propensity score matching (PSM). <h3>Setting</h3> Department of gynecology at a tertiary medical center. <h3>Patients or Participants</h3> From August 2018 to August 2020 at Southwest Hospital in Chongqing, China, patients diagnosed with endometrial cancer, a total of 26 cases conducted LESS were matched with a cohort of 52 cases who underwent TLS. <h3>Interventions</h3> A propensity score matching was performed to reduce the bias due to the imbalanced baseline features between the two groups, and the perioperative outcomes were compared between matched cohorts. <h3>Measurements and Main Results</h3> We retrospectively reviewed 535 cases of patients diagnosed with endometrial cancer from our institutional database. A 1:2 propensity score matching was conducted matched by age, BMI, history of surgery, FIGO staging between the two groups. After matching, the variables were well balanced with no differences at baseline between groups. The operations in both groups were successfully completed without conversion to laparotomy. There were no statistically significant differences in the amount of intraoperative blood loss, number of lymph nodes removed, postoperative exhaust time, postoperative indwelling drainage time, postoperative hospital stay, etc. between the two groups (P>0.05). Meanwhile, compared with the TLS group, the LESS group has longer operation time, a lower pain score of 24-hour after surgery and a more satisfactory postoperative cosmetic effect, of which the difference was statistically significant (P <0.05). <h3>Conclusion</h3> It is undoubtedly safe and feasible for staging endometrial cancer to employ the "chopsticks technique" single-site laparoendoscopic with minimum scars from abdominal incisions, which results less pain and outstanding cosmetic effects. However, further prospective, randomized studies with larger samples are needed.

Peculiarities of molecular-biological and hormonal tumor status in patients with endometrial cancer

Endometrial cancer (EC) ranks second in the structure of oncogynecological diseases both in Ukraine and worldwide. More than 80 % of recurrences occur in the first two years after surgical treatment. Molecular biological markers are extensively studied in different oncological diseases, because they allow to understand the etiology and pathogenesis of malignant growth more deeply. Aim. To study molecular biological markers and tumor hormonal status in patients with EC and determine their practical significance. Materials and methods. Molecular biologic markers of the tumor were studied in 89 stage I–IV EC patients. To study the hormonal status of the tumor in EC patients, 119 examinations were carried out. Results. Significant correlations were found between the level of molecular biological marker (MBM) expression, hormonal status of the tumor, the presence of disease recurrence, and the age of EC patients. The novelty of the study lay in the substantiation of treatment individualization for EC patients based on the determination of the tumor molecular biological characteristics and their prognostic value. It has been proven that the expression level of the studied MBM, ER and PR receptors in EC patients differed depending on age, presence, localization and severity of disease recurrence. A group of patients with a high risk of the disease recurrence has been revealed among EC patients. For the first time, a technology has been developed for the combined treatment of patients with I–II (T1-2N0M0) stages of EC with a negative receptor status (EP–, PR–) and a high risk of the disease recurrence to assess MBM levels (VEGF, Bcl-2, Ki-67), degree of differentiation, myometrial invasion depth and tumor localization in the uterine cavity allowing to individualize the choice of adjuvant therapy regimen, thus improving the effectiveness of treatment and preventing the occurrence of locoregional relapses and distant metastases. Conclusions. For the first time, the expression levels of the studied molecular biological markers and ER and PR receptors have been shown to differ depending on age, localization, and relapse severity, which could be used to determine the risk of relapse in EC patients.

Endometrial Cancer in Reproductive Age: Fertility-Sparing Approach and Reproductive Outcomes.

Endometrial cancer is the most common gynecologic malignancy in developed countries and approximately 7% of the women with endometrial cancer are below the age of 45. Management of endometrial cancer in young women who desire to maintain fertility presents a unique set of challenges since the standard surgical treatment based on hysterectomy and salpingo-oophorectomy is often not compatible with the patient's goals. A fertility-preserving approach can be considered in selected patients with early stage and low-grade endometrial cancer. An increasing amount of data suggest that oncologic outcomes are not compromised if a conservative approach is utilized with close monitoring until childbearing is completed. If a fertility-preserving approach is not possible, assisted reproductive technologies can assist patients in achieving their fertility goals.

Locoregional Control Following Adjuvant Chemotherapy and Radiotherapy for Treatment of High-Risk Endometrial Cancer

<h3>Purpose/Objective(s)</h3> Patients with locally advanced stage and aggressive histology endometrial cancer are at high risk of relapse, and usually treatment includes surgery, chemotherapy and radiotherapy. The timing and coordination of chemotherapy and radiotherapy remain controversial, though historically we have delivered adjuvant radiotherapy after completion of chemotherapy. The premise being to avoid delaying chemotherapy, which confers an overall survival benefit. We decided to review oncologic outcomes and patterns of recurrence among our patients and compare them with the published literature. <h3>Materials/Methods</h3> A retrospective review was conducted to evaluate patients who underwent primary surgery for endometrial cancer between 2005 and 2017, had a final pathology demonstrating Stage I-II endometrial cancer of serous or clear cell histology, Stage III endometrial cancer of any histology or Stage IV endometrial cancer of endometrioid adenocarcinoma histology, and were considered appropriate for adjuvant chemotherapy and radiotherapy. Kaplan-Meier analysis was used to calculate progression-free survival (PFS) and overall survival (OS). <h3>Results</h3> A total of 140 patients met the eligibility criteria and were included, with a median age of 65. The distribution according to stage was as follows: 41 (29.3%) Stage I, 24 (17.1%) Stage II, 68 (48.6%) Stage III, and 7 (5.0%) Stage IV. Of these patients, 52 (37.1%) had endometrioid, 75 (53.6%) had serous, and 11 (7.9%) had clear cell histology. All patients received chemotherapy with the median start time being 49 days after initial surgery. In total, 120 (92%) completed 6 cycles of chemotherapy. The median start time for radiotherapy was 35 days after chemotherapy and 192 days after surgery, with 129 (92.1%) completing adjuvant radiotherapy. The median dose of external beam radiotherapy (EBRT) was 4500 cGy in 25 fractions and the median dose of vaginal brachytherapy, when used, was 1800 cGy in 3 fractions. In terms of EBRT technique, 54 were treated with traditional conformal fields and 74 with IMRT techniques. The median follow-up was 63.9 months and the 5-year PFS and OS rates were 69% and 66% respectively. A total of 42 patients (30.0%) developed a recurrence; of which 2 (1.4%) were local, 10 (7.1%) were locoregional (any with component of locoregional failure), 8 (5.7%) were isolated para-aortic and 27 (19.3%) were distant. Among the 129 patients receiving radiotherapy, 6 (4.6%) patients had locoregional failure. Only 7 (5.4%) of patients had an "in-field" recurrence after EBRT, with 4 (3.1%) among patients treated with conformal fields and 3 (2.3%) among those treated with IMRT. <h3>Conclusion</h3> Adjuvant radiotherapy given after completion of surgery and adjuvant chemotherapy leads to favorable outcomes with regards to PFS and OS (compared to published randomized studies), and still results in excellent locoregional control.

Clinical factors associated with failed sentinel lymph node mapping in endometrial cancer

ObjectiveSentinel lymph node (SLN) mapping is a highly accurate surgical technique for detecting metastases in endometrial cancer. The objective of this study was to identify clinical factors associated with failed mapping. MethodsAll patients with endometrial cancer undergoing minimally-invasive staging and planned SLN biopsy from 1/1/2017 to 12/31/2020 at a single institution were identified retrospectively. Demographic, clinicopathologic and treatment data were obtained. Data were compared using descriptive statistics. Univariate and multivariable logistic regression were performed to identify predictors of failed mapping. Results819 patients were identified with a mean age of 64.6 years (range 26–93) and mean BMI of 35.6 kg/m2 (range 18–68). Most (88.5 %, 725/819) had early-stage disease and endometrioid histology (82.3 %, 674/819). A majority (74.2 %, 608/819) had successful bilateral mapping, and 54 (6.6 %) had unsuccessful bilateral mapping. Increasing BMI was significantly associated with unsuccessful bilateral mapping: patients with BMI > 30 were more likely to have unsuccessful SLN mapping (p = 0.033). Among patients with known lymph node status (799/819), patients with macrometastases and micrometastases were more likely to have failed bilateral mapping compared to those with negative SLNs or isolated tumor cells (p = 0.013). On multivariable analysis, higher BMI and histology were associated with failed bilateral mapping (OR = 1.023, 95 % CI (1.005, 1.041) and OR = 1.678, 95 % CI (1.177, 2.394), respectively). ConclusionSLN mapping has a high success in patients undergoing minimally-invasive surgical staging for endometrial cancer. Increasing BMI, high risk histology, and lymph node metastases are risk factors for failed mapping.

Does the character of the hospital of primary management influence outcomes in patients treated for presumed early stage endometrial cancer and atypical endometrial hyperplasia: a comparison of outcomes from a cancer unit and cancer centre

A retrospective study from 2015 to 2020 comparing overall survival (OS) outcomes of a cancer unit and centre for presumed early stage endometrial cancers is presented. Cancer centres manage these presumed early endometrial cancer (EC) in situations of complex co-morbidities, surgical challenges as well as their own local unit patients. Our analysis compares 138 patients at KMH (unit) and 282 patients at RDH (centre) on OS, patient demographics, grading histology and final histology. Patients with presumed early stage EC can be reassured regarding no difference in OS between the cancer unit and centre management (p = .05). However, rates of minimal access surgery were higher at the cancer centre compared to the unit (93.2% versus 68.1%). The rates of upstaged disease were 4% and 8.8% at the cancer unit and centre respectively (p = .096). Sentinel node biopsy and genomic assessment may change future thresholds for centre-level management due to rates of upstaged disease. Impact Statement What is already known on this subject? Presumed lower risk endometrial cancers (endometrioid grades 1 and 2) have a rate of occult nodal involvement of only 1.4%. The BGCS does not recommend lymphadenectomy for low-risk endometrial cancers. These low-risk endometrial cancers should be managed with a hysterectomy and bilateral salpingo-ophrectomy via minimal access surgery. In view of the low rates of occult nodal involvement in low-risk endometrial cancer, surgery can be offered at a cancer unit. What do the results of this study add? Our study demonstrates there is no disadvantage in overall survival in the surgical management of presumed low-risk endometrial cancers at cancer units and centres. However, cancer centres have higher rates of minimal access to surgery despite managing a more elderly population. Our rates of upstaged disease of 4% and 8.8% at the cancer unit and centre indicate a potential benefit of pelvic lymph node assessment. What are the implications of these findings for clinical practice and/or further research? Sentinel lymph node biopsy does not have the surgical morbidity associated with systematic lymph node dissection. Therefore, when applied to presumed early stage endometrial cancer, there are potential changes in the threshold for centre-level management to improve overall survival.

High visceral fat to subcutaneous fat ratios portend a poor prognosis in patients with advanced endometrial cancer

ObjectivesVisceral adiposity has been established as a predictor of outcomes in various cancers. We aimed to determine the association of radiographic measurements of visceral fat with clinical outcomes in patients with endometrial cancer. MethodsA retrospective review of patients with stage III-IV endometrial cancer who underwent surgery between 2004 and 2014 was performed. Visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and total adipose tissue (TAT;VAT+SAT) were assessed on preoperative computed tomography (CT) scans. Exploratory analysis was performed to establish the optimal cut-off values for VAT, SAT, and TAT to identify patients with poor prognostic body composition. Survival rates were analyzed using Kaplan-Meier analysis, log-rank tests, and cox-regression. ResultsEighty-three patients were included. Forty-two (51%) patients had a low VAT/SAT ratio (<0.45) and 41 (49.4%) had a high VAT/SAT ratio (>0.45). There were no significant differences in demographics between the groups. The mean VAT, SAT, and TAT were 176.3 cm2, 379.3 cm2, and 555.3 cm2 respectively. Compared to patients with low VAT/SAT ratios, patients with high VAT/SAT ratios had a shorter recurrence-free survival (median 29.6 vs 32.3 months, P = 0.01) and shorter overall survival (median 56 vs 93.7 months, P = 0.03). ConclusionsVisceral fat measurements are predictive of outcomes in patients with advanced stage endometrial cancer. Specifically, VAT to SAT ratios are predictive of overall survival. Future studies should be pursued to identify potential therapeutic targets and biological mechanisms that underlie obesity's relationship with endometrial cancer.

Single-site robotic, endometrial cancer staging surgery using additional laparoscopic multi-articulating instrument, Artisential

Single-site robotic, endometrial cancer staging surgery using additional laparoscopic multi-articulating instrument, Artisential

A deep learning-based automatic staging method for early endometrial cancer on MRI images.

Early treatment increases the 5-year survival rate of patients with endometrial cancer (EC). Deep learning (DL) as a new computer-aided diagnosis method has been widely used in medical image processing which can reduce the misdiagnosis by radiologists. An automatic staging method based on DL for the early diagnosis of EC will benefit both radiologists and patients. To develop an effective and automatic prediction model for early EC diagnosis on magnetic resonance imaging (MRI) images, we retrospectively enrolled 117 patients (73 of stage IA, 44 of stage IB) with a pathological diagnosis of early EC confirmed by postoperative biopsy at our institution from 1 January 2018, to 31 December 2020. Axial T2-weighted image (T2WI), axial diffusion-weighted image (DWI) and sagittal T2WI images from 117 patients have been classified into stage IA and stage IB according to the patient’s pathological diagnosis. Firstly, a semantic segmentation model based on the U-net network is trained to segment the uterine region and the tumor region on the MRI images. Then, the area ratio of the tumor region to the uterine region (TUR) in the segmentation map is calculated. Finally, the receiver operating characteristic curves (ROCs) are plotted by the TUR and the results of the patient’s pathological diagnosis in the test set to find the optimal staging thresholds for stage IA and stage IB. In the test sets, the trained semantic segmentation model yields the average Dice similarity coefficients of uterus and tumor on axial T2WI, axial DWI, and sagittal T2WI were 0.958 and 0.917, 0.956 and 0.941, 0.972 and 0.910 respectively. With pathological diagnostic results as the gold standard, the classification model on axial T2WI, axial DWI, and sagittal T2WI yielded an area under the curve (AUC) of 0.86, 0.85 and 0.94, respectively. In this study, an automatic DL-based segmentation model combining the ROC analysis of TUR on MRI images presents an effective early EC staging method.

An implementation of the learning curve cumulative summation test to evaluate a practicum for endometrial cancer ultrasound staging.

The learning curve cumulative summation (LC-CUSUM) test is commonly used as a quantitative assessment of the individual learning process. This study aimed to evaluate the skill acquisition process for performing ultrasound staging of endometrial cancer using the LC-CUSUM test. Sixty-seven ultrasound examinations performed by two operators were evaluated using the LC-CUSUM test according to their rate of success or failure to correctly stage myometrial invasion, serosa involvement, and pelvic and para-aortic lymph node involvement. The reference standard was the pathologic result. After the learning phase, the cumulative summation (CUSUM) test was applied to assess performance maintenance. The processes achieved satisfactory performance in the majority of the cases according to the established definitions. Operator 1 reached adequate performance within the 30th procedure for all the locations considered, while operator 2 performed fewer than 30 ultrasound examinations by the audit time. The CUSUM test confirmed that the target quality was preserved after the learning phase. Moreover, the ultrasound staging for endometrial cancer was highly accurate. Using the LC-CUSUM test made it possible to monitor the achievement and maintenance of a satisfactory performance quantitatively. The LC-CUSUM test could be a valuable instrument to survey diagnostic pathways in gynecological ultrasonography quantitatively.

The Role of Sentinel Lymph Node Mapping in High-grade Endometrial Cancer.

Total hysterectomy with lymph node assessment is the current standard-of-care for surgical staging in apparent early-stage endometrial cancer. Compared to the traditional complete pelvic lymphadenectomy with or without para-aortic lymphadenectomy, sentinel lymph node (SLN) mapping results in fewer surgical complications, decreased operative time, and lower rates of chronic lymphedema. The technique is endorsed by the National Comprehensive Cancer Network and the Society of Gynecologic Oncology guidelines, and over the past two decades the majority of gynecologic oncologists worldwide have adopted SLN mapping into their practice. However, as the results of the initial SLN studies were mostly based on low-grade tumors, adoption of the technique in high-grade tumors has been slower and more controversial. In this review, we discuss the most recent studies evaluating the SLN mapping in high-grade endometrial cancers. The results of these studies suggest that the SLN detection rate is acceptably high and the negative predictive value is sufficiently low to support the use of SLN mapping in high-grade endometrial tumors to replace complete lymphadenectomy. Validity of SLN mapping techniques does, however, require following a standard algorithm, and success depends also on surgeon expertise. Moreover, the impact of SLN mapping on overall survival in high-grade tumors requires future prospective randomized studies. Finally, a transition toward near-universal SLN mapping techniques for endometrial cancers could significantly impact on the adequacy of gynecologic oncology fellows' surgical training and competency in lymphadenectomy.

Role of MRI in pre-operative staging of endometrial cancer: A diagnostic accuracy study

Endometrial cancer (EC) is a commonly occurring cancer among post-menopausal women. Pre-treatment imaging of the extent of disease can influence the decisions in the management of EC. MRI with its diffusion weighted (DW) images can help in better depiction of the primary tumour, its local extension and extrauterine spread to the peritoneum and lymph nodes. This study was conducted to know the role of MRI for pre-operative staging of endometrial cancer and as a guide for pelvic lymph nodal dissection.It was a descriptive cross-sectional study conducted at a tertiary care hospital patients diagnosed with primary endometrial adenocarcinoma on biopsy. Patients with advanced disease requiring chemotherapy prior to surgery were excluded. Fifty consecutive patients were subjected to MRI Pelvis with abdominal screening in the week preceding definitive surgery, Findings from imaging were compared with final histopathology for concurrence on tumour size, depth of myometrial invasion, presence of adnexal, nodal and cervical stromal involvement.Majority of the patients in this study were post-menopausal women. Sensitivity of MRI for staging of Endometrial Carcinoma in this study was 91.84% and Accuracy was 90%. When compared to HPE for lymph node positivity, MRI had sensitivity of 100%, specificity of 97.87%, PPV of 75%, NPV of 100% and accuracy of 98%.Pre-operative MRI in the week prior to the planned surgery can help in accurately staging the endometrial carcinoma in terms of myometrial infiltration, cervical stromal infiltration as well as pelvic lymph nodal involvement.

PD-L1 Expression in Endometrial Cancer and Its Association with Clinicopathological Features: A Systematic Review and Meta-Analysis.

Simple SummaryIn women, endometrial cancer is a crucial cancer cause-death, which is still not fully explored in its pathogenesis and immune system. Early detection is essential for proper treatment and follow-up in affected patients. This systematic review and meta-analysis aim to pool the prevalence of PD-L1 in endometrial cancer and its association with clinicopathological features. The pooled prevalence of PD-L1 was 34.26% in tumour cells, and 51.39% in immune cells among endometrial cancer patients. There was significant association of PD-L1 expression in both tumour cells and immune cells with advanced stage endometrial cancer. The presence of lympho-vascular invasion and poor overall survival were also associated with PD-L1 expression in immune cells. These information enable clinicians to stratify endometrial cancer patients for anti-PD-1/PD-L1 immune therapy.Endometrial cancer (EC) is one of the most common malignancies of the female genital tract and its current treatment mainly relies on surgical removal of the tumour bulk, followed by adjuvant radiotherapy with or without chemotherapy/hormonal therapy. However, the outcomes of these approaches are often unsatisfactory and are associated with severe toxicity and a higher recurrence rate of the disease. Thus, more clinical research exploring novel medical intervention is needed. Involvement of the immune pathway in cancer has become important and the finding of a high positive expression of programmed cell death-ligand 1 (PD-L1) in EC may offer a better targeted therapeutic approach. Numerous studies on the PD-L1 role in EC have been conducted, but the results remained inconclusive. Hence, this systematic review was conducted to provide an update and robust analysis in order to determine the pooled prevalence of PD-L1 expression in EC and evaluate its association with clinicopathological features in different focuses of tumour cells (TC) and immune cells (IC). A comprehensive literature search was conducted using the PubMed, Web of Science, and Scopus databases. Twelve articles between 2016 and 2021 with 3023 EC cases met the inclusion criteria. The effect of PD-L1 expression on the outcome parameters was estimated by the odds ratios (ORs) with 95% confidence intervals (CIs) for each study. The pooled prevalence of PD-L1 was 34.26% and 51.39% in the tumour cell and immune cell, respectively, among women with EC. The PD-L1 expression was significantly associated with Stage III/IV disease (in both TC and IC) and correlated to the presence of lympho-vascular invasion in IC. However, the PD-L1 expression in TC was not associated with the age groups, histology types, myometrial invasion, and lympho-vascular invasion. In IC, PD-L1 expression was not associated with age group, histology type, and myometrial invasion. The meta-analysis survival outcomes of PD-L1 high expression had a significant association with worse OS in IC but not in TC.

Sentinel Lymph Node Mapping and Staging Surgery via Gasless Transvaginal Natural Orifice Transluminal Endoscopic Surgery: A Case Report of Patient with Endometrial Cancer Patient and Comorbid Rheumatic Heart Disease

Patient: Female, 43-year-old Final Diagnosis: The stage 1A endometrioid adenocarcinoma and RHD pathology, including the cardiac function of class II, severe MS, and pulmonary hypertension Symptoms: Irregular vaginal bleeding for more than 1 month Medication:— Clinical Procedure: — Specialty: Surgery Objective: Unusual or unexpected effect of treatment Background: Conventional laparoscopic surgery and transvaginal natural orifice transluminal endoscopic surgery (vNOTES) both use CO2 pneumoperitoneum to expose the surgical space. However, CO2 pneumoperitoneum is undoubtedly dangerous for patients with rheumatic heart disease (RHD) and can cause cardiopulmonary impairments. Therefore, we selected the sentinel lymph node (SLN) mapping strategy to guide the staging surgery via gasless vNOTES for an endometrial cancer (EC)-patient with comorbid RHD. Here, we discuss whether our selected surgical method was safe and feasible for this patient.Case Report:A 43-year-old woman with a history of RHD, severe mitral regurgitation, and pulmonary hypertension for more than 30 years received diagnostic curettage for irregular vaginal bleeding for more than 1 month. Pathological examinations revealed the occurrence of highly differentiated intrauterine endometrioid adenocarcinoma. She was admitted to the gynecological ward of our hospital for further surgery. We performed EC staging surgery with SLN mapping via gasless vNOTES and adopted a series of effective measures to solve the intraoperative complications of surgical space exposure. Surgery was successful. The patient recovered well and was discharged 5 days after surgery. She has been followed up in the gynecological clinic for nearly 1 year. At the time of this report, she had good recovery, no recurrence and metastasis, and normal tumor markers.Conclusions:For EC patients with comorbid RHD pathology, application of staging surgery with SLN mapping via gasless vNOTES was shown to be safe and feasible. This approach is expected to be highly effective for patients with contraindications to CO2 pneumoperitoneum laparoscopy.

VNOTES (vaginal natural orifice transluminal endoscopic surgery) staging of endometrial cancer with sentinel lymph nodes (551)

VNOTES (vaginal natural orifice transluminal endoscopic surgery) staging of endometrial cancer with sentinel lymph nodes (551)

The impact of obesity class on perioperative outcomes in minimally invasive surgery for endometrial cancer (594)

<b>Objectives:</b> Minimally invasive surgeries (MIS) have been shown to reduce complication rates and length of hospital stays in patients with obesity. However, there is limited data analyzing outcomes for specific obesity classes (Class I [30-34.9 kg/m2], Class II [35-39.9 kg/ m2], and Class III [≥40.0 kg/m2]). This study aimed to evaluate differences in perioperative outcomes, stratified by obesity class, in obese patients undergoing minimally invasive surgery for endometrial cancer. <b>Methods:</b> This is an IRB-exempt retrospective cohort study investigating women who underwent MIS for treatment and staging of endometrial cancer. Inclusion criteria were age 18 years or older, MIS performed for endometrial cancer, and BMI of 30 kg/m² or greater. We excluded those who underwent neoadjuvant chemotherapy or radiation therapy. Data were collected from the de-identified National Surgical Quality Improvement Program (NSQIP) between 2012-2018. The primary outcome was intraoperative complications, such as bowel injury, urologic injury, and conversion to laparotomy. Secondary outcomes were unplanned re-admission, unplanned reoperation, and postoperative infection. Chi-square and Kruskal- Wallis rank-sum tests were used as appropriate for categorical and continuous variables, respectively. P-values of < 0.05 were considered significant. Statistical analysis was performed using SAS 9.4v (SAS Institute Inc., Cary, NC, USA). <b>Results:</b> We identified 12,956 patients who met the inclusion criteria within NSQIP. Of these, 29.3% (<i>n</i> = 3,801) patients were Class I (avg. BMI 32.5 kg/m²), 26.7% (<i>n</i>= 3,467) were Class II (avg. BMI 37.4 kg/m²), and 43.9% (<i>n</i> = 5,688) were Class III (avg. BMI 47.5 kg/m²) (see Table 1). The average ages were 64.1, 62.7, and 59.2 years old for Class I, II, and III, respectively. Intraoperatively, there were no statistically significant differences among the three classes for bowel injury, urologic injury, or conversion to laparotomy (p= 0.575). Re-admission rates were higher for Class III patients (4.1%) than Class I and II (3.1%, p=0.005). There was a higher rate of superficial surgical site infection in Class III obese patients versus Class I and II (0.6% vs 1.1% vs 1.3%, respectively; p=0.005). There were no significant differences among Class I, Class II, and Class III obesity for deep wound (0.1%, 0.1%, and 0.3%, respectively, p=0.052) and organ space (0.9%, 1.2%, 1.4%, respectively, p=0.101) surgical site infections. <b>Conclusions:</b> In conclusion, among obese women undergoing MIS for endometrial cancer, there were no statistical differences between the risks of intraoperative complications, such as bowel injury, urologic injury, and conversion to laparotomy, when assessing the different obesity classes. However, postoperatively, patients with Class III obesity had higher re-admission rates and superficial surgical site infections when compared to Class I and Class II obese patients.

Effectiveness of transversus abdominis plane block during robotic-assisted endometrial cancer staging in decreasing immediate postoperative pain (557)

Objectives: To assess the effectiveness of intraoperative transversus abdominis plane (TAP) block on immediate postoperative pain and morphine milligram equivalent (MME) use relative to local injection in patients undergoing robotic-assisted endometrial cancer staging. Methods: Patients undergoing robotic staging for endometrial cancer from April 1, 2017, to April 1, 2019, were eligible. Patients were excluded if they were converted to laparotomy. Patients received either local anesthesia prior to skin incision and trocar placement with 10 mL of 0.25% bupivacaine hydrochloride or an intraoperative TAP block with 20 mL of 1.3% bupivacaine liposome injectable solution under direct visualization per surgeon preference. Perioperative and patient information was collected from the EMR. Results: During the study period, 188 patients underwent robotic- assisted endometrial cancer staging. TAP block was used in 96 patients and local bupivacaine in 92 patients. The mean morphine milligram equivalent usage in the immediate 24 hours postoperative period (MME) for the TAP block cohort was 9.47 versus 10.52 with local anesthesia (NS). The mean immediate postoperative pain score (on a scale of 0-10) was 2.8 versus 3.8 (p=0.03) in favor of the TAP block. There were no significant demographic differences. Conclusions: Utilization of an intraoperative TAP block was associated with improved postoperative pain scores. There was no difference in the MME of opioid use compared to preoperative local anesthetic. Further evaluation of the cost-efficiency of TAP blocks is warranted. Objectives: To assess the effectiveness of intraoperative transversus abdominis plane (TAP) block on immediate postoperative pain and morphine milligram equivalent (MME) use relative to local injection in patients undergoing robotic-assisted endometrial cancer staging. Methods: Patients undergoing robotic staging for endometrial cancer from April 1, 2017, to April 1, 2019, were eligible. Patients were excluded if they were converted to laparotomy. Patients received either local anesthesia prior to skin incision and trocar placement with 10 mL of 0.25% bupivacaine hydrochloride or an intraoperative TAP block with 20 mL of 1.3% bupivacaine liposome injectable solution under direct visualization per surgeon preference. Perioperative and patient information was collected from the EMR. Results: During the study period, 188 patients underwent robotic- assisted endometrial cancer staging. TAP block was used in 96 patients and local bupivacaine in 92 patients. The mean morphine milligram equivalent usage in the immediate 24 hours postoperative period (MME) for the TAP block cohort was 9.47 versus 10.52 with local anesthesia (NS). The mean immediate postoperative pain score (on a scale of 0-10) was 2.8 versus 3.8 (p=0.03) in favor of the TAP block. There were no significant demographic differences. Conclusions: Utilization of an intraoperative TAP block was associated with improved postoperative pain scores. There was no difference in the MME of opioid use compared to preoperative local anesthetic. Further evaluation of the cost-efficiency of TAP blocks is warranted.

Clinical factors associated with failed sentinel lymph node mapping in endometrial cancer (527)

Clinical factors associated with failed sentinel lymph node mapping in endometrial cancer (527)