Surgical Staging Of Endometrial Cancer Research Articles

Accuracy of intraoperative frozen section in surgical staging of endometrial cancer

ObjectiveThis study evaluates the role of frozen section (FS) in determining the extent of disease during surgery. Materials and methodsThis study retrospectively analyzed a cohort of patients diagnosed with endometrioid-type endometrial cancer between 2019 and 2022 who underwent surgical intervention. The frozen section (FS) results were compared with the final pathology reports, focusing on tumor grade, depth of myometrial invasion, cervical involvement, and tumor diameter. ResultsThe final analysis included 187 patients. The predictive accuracy of FS in determining PS results was 85.6 % for endometrioid histology, 95.7 % for grade 3 tumors, 90.2 % for depth of myometrial invasion, 89.7 % for cervical involvement, and 95.9 % for tumor diameter. Notably, 9.8 % of cases initially classified as grade 1 intraoperatively were upgraded with the final pathology. Similarly, 6.3 % of grade II cases were upgraded, while 60.4 % were downgraded. ConclusionOur study highlights the effectiveness of FS as a dependable tool for assessing endometrial carcinomas and guiding surgical staging decisions. By utilizing FS, the risk of unnecessary surgeries and associated morbidity in patients can be reduced.

Use of indocyanine green dye for sentinel lymph node mapping in patients with endometrial cancer and a history of iodinated contrast allergy

ObjectivesSentinel lymph node (SLN) mapping is a surgical technique with high accuracy in detecting metastases while limiting morbidity associated with full lymphadenectomy in endometrial cancer. Cervical injection of indocyanine green (ICG) dye is associated with very high SLN detection rates; however, iodinated contrast allergy has traditionally been viewed as a contraindication to ICG use. The objective of this study was to describe the use of ICG in a population of patients with iodinated contrast allergies undergoing surgical staging for endometrial cancer. MethodsIRB approval was obtained. All patients with clinically early-stage endometrial cancer who underwent minimally invasive surgical staging with SLN mapping with ICG at a single academic institution from 1/1/2017 to 12/31/2020 were identified retrospectively. Patients with reported iodinated contrast allergies prior to surgery were identified. Data were collected through electronic medical record review and compared using descriptive statistics. Results820 patients who underwent minimally invasive surgical staging with SLN mapping with ICG were identified, and 25 had documented iodinated contrast allergies. Documented reactions included rash/hives (n = 10, 40 %), anaphylaxis (n = 6, 24 %), shortness of breath (n = 5, 20 %), diarrhea (n = 1, 4 %), and not specified (n = 3, 12 %). A majority (24/25, 96 %) received 4 mg intravenous dexamethasone during induction of general anesthesia as per the institutional enhanced recovery after surgery (ERAS) protocol. No patients experienced allergic reactions or other adverse events after ICG injection. ConclusionsNo patients in this cohort demonstrated an adverse reaction after ICG injection for SLN mapping. This study supports the reasonable safety of ICG in patients with contrast allergies, particularly when routine ERAS protocols containing dexamethasone are utilized.

Recent management of endometrial cancer: a narrative review of the literature.

Endometrial cancer is a common female gynecological neoplasia and its incidence rate has increased in the past years. Due to its predominant symptoms, most women will present uterine bleeding. It is usually diagnosed at an early stage and surgery has an important role in the treatment plan. The prognosis and quality of life of these patients can be quite favorable, if proper treatment is offered by surgeons. Traditionally, more invasive approaches and procedures were offered to these patients, but recent data suggest that more conservative and minimal invasive choices can be adopted in the treatment algorithm. Minimal invasive surgery, such as laparoscopy and robotic surgery, should be considered as an acceptable alternative, compared to laparotomy with less comorbidities and similar oncological and survival outcomes. Furthermore, sentinel lymph node biopsy has emerged in the surgical staging of endometrial cancer, in order to replace comprehensive lymphadenectomy. It is associated with less intra- and postoperative complications, while preliminary data show no difference in survival rates. However, sentinel lymph node biopsy should be offered within a strict algorithm, to avoid residual metastatic disease. The aim of this review is to analyze all the available data for the application of minimal invasive surgery in early endometrial cancer and especially the role of sentinel lymph node biopsy.

Oncologic Outcome of Robotic-Assisted and Laparoscopic Sentinel Node Biopsy in Endometrial Cancer.

Recently, sentinel lymph node biopsy (SLNB) has been introduced in the surgical staging of endometrial cancer as an alternative to systematic lymph node dissection (LND). However, the survival impact of SLNB is not yet well characterised. We performed a retrospective study of 419 patients with endometrial cancer treated with SLNB alone or with pelvic and para-aortic LND. For SLNB mapping, indocyanine green was used. Median follow-up was 66 months. After exclusions, 337 patients were eligible for analysis. Of them, 150 underwent SLNB and 187 LND. During the follow-up time, 27 (24.7%) of the 150 who underwent SLNB and 54 (28.9%) of the 187 who underwent LND were diagnosed with recurrent disease (p = 0.459). The estimated 5-year disease-free survival (DFS) rate was 76.7% and 72.2% for patients in the SLNB and LND group, respectively (p = 0.419). The 5-year overall survival (OS) rates were 80.7% and 77.0% in the SLNB and LND group, respectively (p = 0.895). Survival rates were similar in both groups independent of lymph node status. Multivariable analysis confirmed that the staging approach was not associated with oncological outcome. For patients without lymph node metastases, patient outcome was worsened by advanced tumour stage and non-endometrioid tumour histology. In the group of patients with confirmed lymph node metastases, advanced tumour stage and inadequate adjuvant treatment significantly reduced DFS and OS. Our data suggested that SLNB did not compromise the oncological outcome of patients with endometrial cancer compared to LND.

Let go of the myth: safety of indocyanine green for sentinel lymph node mapping in endometrial cancer

ObjectiveSentinel lymph node mapping by intracervical indocyanine green injection is the preferred method for surgical staging in endometrial cancer. Adverse reactions to indocyanine green are extremely rare, and information about...

Initial experience with the da Vinci SP robot-assisted surgical staging of endometrial cancer: a retrospective comparison with conventional laparotomy.

To compare the perioperative outcomes of surgical staging performed using conventional laparotomy (LT) or the da Vinci SP robotic system (SP) in patients with endometrial cancer. We retrospectively analyzed 180 patients with stage I-III endometrial cancer who underwent surgical staging using LT (n = 126) or SP (n = 54) at the Yonsei Cancer Center between November 2018 and December 2022. Propensity score matching (PSM) was performed to mitigate potential confounding biases. Fifty-one pairs of patients were matched by PSM. SP required longer total operation time than LT (221 vs. 142min in SP vs. LT, respectively, p < 0.001). However, estimated blood loss and postoperative hemoglobin change were lower in SP than in LT (30 vs. 100mL, p < 0.001; 0.6 vs. 1.6g/dL, p < 0.001 for SP vs. LT respectively). Furthermore, postoperative minor complications (13.7% in SP vs. 33.3% in LT, p = 0.02), perioperative transfusion rate (0% in SP vs. 11.8% in LT, p = 0.03), and postoperative hospital stay (2 days for SP vs. 8 days for LT, p < 0.001) were lower in SP than in LT. Although the patient-controlled analgesia administration rate was lower in SP (13.8% in SP vs. 100% in LT, p < 0.001), the median postoperative pain score at 6, 12, and 24h after surgery was lower in SP than in LT (2 vs. 3, p = 0.002; 2 vs. 3, p = 0.005; 2 vs. 3, p = 0.001 for SP vs. LT, respectively). Although SP required longer total operation time, it demonstrated several advantages over LT in endometrial cancer staging.

Extended Venous Thromboembolism Prophylaxis after Robotic Staging for Endometrial Cancer.

Our objectives were to estimate the incidence of venous thromboembolism (VTE) after robotic staging for endometrial cancer and to compare the incidence of VTE in patients who received a single dose of preoperative prophylaxis of enoxaparin with those who received extended postoperative prophylaxis. This study is a retrospective chart review of patients who underwent robot-assisted surgical staging for endometrial cancer. Patients were categorized into two groups: preoperative prophylaxis (PP), patients who received a single dose of enoxaparin preoperatively, and extended prophylaxis (EP), patients who received 28 days of enoxaparin postoperatively. In total, 148 patients were included, with 117 patients in the PP group and 31 patients in the EP group. The overall incidence of VTE within 30 days postoperatively was 0.67%. No significant difference was found between the PP and the EP groups (0.9% and 0%, respectively; P = 1.00). Most patients in the cohort had endometrioid adenocarcinoma (78%) with low-grade disease (70%), although there were a greater number of patients in the PP group with uterine serous carcinoma compared with the EP group (17% vs 10%; P = 0.034). The PP group had higher estimated blood loss (106 vs 81 mL; P = 0.009) and longer operative times (178 vs 151 min; P = 0.028) compared with the EP group. Significantly more patients in the PP group underwent lymph node dissection compared with the EP group (32% vs 7%; P = 0.008). The incidence of VTE following robot-assisted surgical staging for endometrial cancer in this study was 0.67%. No significant difference was found in VTE incidence between the PP group compared with the EP group. Mechanical prophylaxis plus a single dose of preoperative pharmacologic prophylaxis may suffice for low-risk patients following robotic surgical staging for endometrial cancer.

Новый подход к хирургическому стадированию при раке эндометрия. Опыт Национального медицинского исследовательского центра онкологии имени Н.Н. Петрова

Новый подход к хирургическому стадированию при раке эндометрия. Опыт Национального медицинского исследовательского центра онкологии имени Н.Н. Петрова

Ultrasonography, macroscopy, and frozen section: whıch is better for predicting deep myometrial invasıon in endometrial cancer?

The aim of this study was to compare the power of preoperative transvaginal ultrasonography, intraoperative macroscopic examination, and frozen section for predicting deep myometrial invasion in endometrial cancer. This is a retrospective review involving 68 patients who underwent surgical staging for endometrial cancer from 2014 to 2017. Patients with grade 3 endometrial cancer and non-endometrioid tumors were excluded. The findings related to preoperative transvaginal ultrasonography, intraoperative macroscopic examination, and frozen section were compared with definitive histopathological diagnosis. The mean age, gravidity, and body mass index of the patients were 58.1±8.9 years (range: 30-80 years), 3.2±2.1 (range: 0-9), and 33.5±6.6 kg/m2 (range: 20-52 kg/m2), respectively. Only 11 (16.2%) patients were in the premenopausal period, while 57 (83.8%) were in the postmenopausal period. Grade 1 endometrial cancer was found in 29 patients (42.6%) and grade 2 tumors were specified in 39 patients (57.4%). Stage IA disease was found in 45 (66.2%) patients, while stage IB disease was observed in 23 (33.8%) patients. The 5-year survival rate was 91.2%. The sensitivity of preoperative transvaginal ultrasonography, intraoperative macroscopic examination, and frozen section were 56, 34, and 52%, respectively, for predicting deep myometrial invasion. In contrast, the specificity of preoperative ultrasonography, intraoperative macroscopic examination, and frozen section were 86, 100, and 100%, respectively. Transvaginal ultrasonography and intraoperative frozen section were found to have similar sensitivity and specificity for predicting deep myometrial invasion. Preoperative transvaginal ultrasonography appears as an efficient approach for predicting endometrial cancers with deep myometrial invasion.

Case Report: Ductal Breast Cancer with Endometrial Metastases

A retrospective chart review of patients who underwent robot-assisted surgical staging for endometrial cancer between January 1^st, 2012, and June 1^st, 2020, at a single institution. Patients with grade-3 endometrioid adenocarcinoma, uterine serous cancer, clear cell carcinoma, and carcinosarcoma with no clinical evidence of disease outside the uterus were included.

A Therapeutic Comparison of Robotic Vs Open Vs Laparoscopic Hysterectomy in Patients Diagnosed with Endometrial Cancer

The American Cancer Society estimates that 60,050 cases of endometrial cancer will be diagnosed in 2016 and that 10,470 will die from endometrial cancer during 2016. Since 1988, incidence rates have increased by 1.3 per cent per year for women under 50 and by 1.9 per cent per year. In women age 50 and older, uterine cancers are usually treated with surgery, radiation, hormones, and/or chemotherapy. Uterine cancer is the most common form of gynecologic cancer. Surgery is the mainstay for staging and optimizing treatment for women with endometrial carcinoma. The surgical approach has evolved rapidly since the late 1980s with the introduction of laparoscopy in the surgical staging of endometrial cancer. An alternative to conventional laparoscopy or robotic surgery is single-port Laparoendoscopic 3-incision surgery which further enhances the cosmetic benefits of minimally invasive surgery, avoiding the potential morbidity associated with multiple incisions. Since it has been observed that it offers greater visibility and accuracy of the area of operation. Althoughmost of the advantages are in cases, such as patients with previous abdominal surgeries and obesity

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.

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)

Hormonal therapy, chemotherapy, or observation for early- stage, low-grade endometrial cancer with malignant peritoneal cytology: A comparative effectiveness study (316)

<b>Objectives:</b> Since 2009, peritoneal cytology is no longer required for FIGO surgical staging of endometrial cancer. However, guidelines continue to recommend its collection for assistance with postoperative risk stratification, despite not providing treatment guidelines in the case of positive cytology. We thus sought to examine trends, characteristics, and outcomes related to hormonal therapy (HT) or chemotherapy (CT) use for early-stage, low-grade endometrial cancer with malignant peritoneal cytology (MPC). <b>Methods:</b> A comparative effectiveness study querying the National Cancer Database from 2010-2017 was performed. The study population included 2,730 women with stage I, grade 1-2 endometrioid endometrial cancer who had MPC at primary hysterectomy. Exposure allocation was postoperative therapy: none (<i>n</i>=2,270, 83.2%), CT (<i>n</i>=348, 12.7%), and HT (<i>n</i>=112, 4.1%). The main outcome measures were <i>(i)</i> trends and characteristics related to adjuvant therapy, assessed with a multivariable logistic regression model, and <i>(ii)</i> overall survival (OS) assessed with a multivariable Cox proportional hazards regression model. A sensitivity analysis was performed limited to low-risk endometrial cancer (stage IA, grade 1-2 tumors, and no LVSI). <b>Results:</b> The number of women who received HT (2.7% to 4.5%) or no adjuvant therapy (81.8% to 84.4%) increased while those who received CT decreased (15.5% to 11.1%) over the course of the study period (p=0.04). In a multivariable analysis, HT use was associated with older age, more recent year of diagnosis, grade 1 lesions, treatment at academic/research facilities, the performance of minimally invasive surgery, no LVSI, and absence of radiotherapy compared to CT use (all, p<0.05). The median follow-up was 4.0-4.5 years, and neither HT use (adjusted-HR: 0.61, 95% CI: 0.27-1.40) nor CT use (aHR 1.33, 95% CI: 0.92-1.93) was associated with OS compared to no adjuvant therapy in a multivariable analysis. In the low-risk group (<i>n</i>=1,453), 69 (4.7%) women received HT and 117 (8.1%) received CT. OS was similar across the three groups (p=0.89). <b>Conclusions:</b> There has been an increasing utilization of HT and decreasing utilization of CT as adjuvant therapy for early-stage, low-grade endometrial cancer with MPC over time. These two adjuvant therapies are not associated with short-term OS compared to observation.

The percentage of peripheral eosinophils as a sensitive marker for differentiating FIGO grade in endometrial adenocarcinomas

Objective:Studies on eosinophils have mostly been directed to parasitic infections and allergic diseases, but the role of eosinophils in oncology has been largely ignored. Eosinophils are an important modulator of the immune response and components of the inflammatory process against the tumor. This study was performed to investigate the pre-operative peripheral blood eosinophil percentages in patients with a histopathologically diagnosed pure endometrioid type endometrial carcinoma.Material and Methods:Patients’ data were analyzed in two groups as present/absent according to whether there are tumor metastases in the adnexes, lymph nodes, cervical stroma, and whether there was lymphovascular space invasion. FIGO grade was taken as the basis of the tumor grade: Low-grade equated to grade 1 or 2, and high-grade equated to grade 3. The requirement for lymph node dissection was based on the Mayo criteria.Results:The data of a total of 268 patients were included. The mean percentage of eosinophils in high-grade patients (n=29) was 2.75±0.35, and was significantly higher than the mean percentage of eosinophils of found in low-grade patients (n=239), which was 1.79±0.09 (p=0.013). Receiver operator curve analysis showed that a cut-off eosinophil percentage of 1.95% resulted in a sensitivity of 62% and specificity of 67% (p=0.004).Conclusion:Eosinophil percentages, which are a simple, easily accessible, and inexpensive can be an important pre-operative predictive tool. Eosinophil percentages can be used in determining the need for surgical staging in endometrial cancer.

Does sentinel lymph node biopsy in endometrial cancer surgery have an impact on the rate of adjuvant post operative pelvic radiation? An Israeli Gynecologic Oncology Group Study

ObjectiveTo compare the rates of post-operative radiotherapy between two methods of lymph nodes assessment during surgical staging for endometrial cancer (EC). MethodsWe conducted a comparative study of all consecutive women with endometrial cancer who underwent sentinel lymph node detection and biopsy using blue dye and isotope scan (SLNB) at Kaplan Medical Center and patients from the IGOG database, who underwent staging lymphadenectomy (PLND). The primary outcome was the rate of adjuvant and therapeutic radiation. The secondary outcome was a comparison of disease-free survival (DFS) and overall survival (OS). ResultsThere were 138 patients in the SLNB group and 1022 women in the PLND group. The detection rate of SLN was 74% for unilateral detection and 54% for bilateral detection. In the PLND group 57% were high risk patients vs. 47% in SLNB group (p = 0.03). 43% of high-risk patients in the PLND group received adjuvant or therapeutic pelvic radiation vs. 28% of high-risk women in the SLNB arm (p = 0.017). No statistically significant difference in recurrence rates nor in death rates had been observed in the high-risk group patients. The 5-years survival in the high-risk PLND group was 80% and the recurrence rate was 19% vs. 75% 5-year survival and 14% recurrence in high-risk SLNB cohort, log-rank p = 0.82 for survival and long-rank p = 0.25 for recurrence. ConclusionEndometrial cancer patients undergoing lymph node assessment by sentinel lymph node biopsy, receive less pelvic radiotherapy.

Combined panniculectomy and surgical staging of endometrial cancer: the Northern Ireland experience

Background: Endometrial cancer is the most common gynaecological malignancy in the Western world and has a strong association with obesity. The incidence of endometrial cancer is rising and can be attributed, in part, to the ongoing obesity epidemic. The surgical management of endometrial cancer in women with class III obesity, defined as those with a body mass index (BMI) ≥40 kg/m2, can be particularly challenging. Case(s): We report the early experience of panniculectomy as an adjunct to endometrial cancer staging surgery in Northern Ireland (NI). We outline the generic surgical approach and report the outcomes of the first four cases undertaken. We discuss the important role that panniculectomy holds in the surgical management of endometrial cancer in women with III obesity. Conclusion: The initial experience, in NI, of panniculectomy as an adjunct to endometrial cancer staging surgery greatly facilitated surgical exposure and allowed adequate surgical staging to be performed. In carefully selected cases, the surgical procedure can be completed safely and effectively with greater ease.

Association of Peritoneal Cytology with Other Prognostic Factors in Endometrial Cancer.

It is still debatable whether surgical staging of endometrial cancer (EC) should include sampling of peritoneal cytology (PC) and for what purpose this should be done. The aim of our study was to determine the significance of peritoneal cytology in EC and its association with other histological and clinical parameters. This is a retrospective study that comprises of results from 357 patients with EC that were operated in our center in the previous nine years. Patients were divided into two groups: the first group with a positive and the second group with a negative PC. Malignant cells were found in the peritoneal cytology of 23 patients (6.4%), while 334 patients (93.6%) had negative PC. There was no significant difference in patients' age between the two groups (p = 0.20). Peritoneal cytology was more prevalent in the non-endometrioid than the endometrioid subtype of EC (p = 0.00). There was a significant statistical difference (p = 0.00) in malignant PC in stages where cancer is confined to the uterus (International Federation of Gynecologists and Obstetricians (FIGO) stages I and II) compared with those where cancer has metastasized outside the uterus (stages III and IV). Most of the patients with malignant PC (69.6%) had high-grade disease (G3). Malignant peritoneal cytology is associated with other negative prognostic factors in endometrial cancer (histological grade, FIGO stage, and non-endometrioid histological subtypes). Based on these findings, we encourage sampling of peritoneal washing in all EC patients and consider it mandatory in patients with non-endometrioid subtype, high-grade histology, and in advanced FIGO stage.

A phase III randomized clinical trial comparing sentinel node biopsy with no retroperitoneal node dissection in apparent early-stage endometrial cancer – ENDO-3: ANZGOG trial 1911/2020

BackgroundSentinel node biopsy is a surgical technique to explore lymph nodes for surgical staging of endometrial cancer, which has replaced full retroperitoneal lymph node dissection. However, the effectiveness of sentinel...

Sentinel Lymph Node Sampling in Robot-Assisted Staging of Endometrial Cancer.

Sentinel lymph node (SLN) sampling in endometrial cancer staging has become an acceptable standard. Indocyanine green dye injected into the cervix and detected by near-infrared light is technically simple and sensitive. We aimed to evaluate SLN sampling in robot-assisted surgical staging of endometrial cancer at a university-affiliated teaching hospital. A retrospective chart review, from January 2016 to December 2017, of patients who underwent robot-assisted surgical staging with cervical injection of indocyanine green dye detected by near-infrared light. The map rate, sensitivity, false negatives, and negative predictive value were calculated. A total of 105 charts were reviewed; 79 patients met inclusion criteria. The mean age was 65 (range 38-93) and the mean body mass index was 33.3 (range 16-49). Most patients (72.2%) had stage I disease and grade 1 or 2 histology (77.1%). Eight (10.1%) patients had lymph node metastasis. Seventy-two (91.1%) patients had positive mapping to at least 1 SLN. Sixty-two (78.5%) patients had bilateral mapping. Forty-four patients had concurrent pelvic ± para-aortic lymph node dissection and were included in the sensitivity analysis. Five of 44 cases had LN metastasis. The sensitivity was 80%, and the negative predictive value of SLN sampling was 97.5%. SLN mapping and sampling at a university-affiliated teaching hospital have comparable map rate, sensitivity, and negative predictive value as demonstrated in multiple trials. The technique has the potential to standardize endometrial cancer staging across different practice settings.