Surgical Staging Of Uterine Cancer Research Articles

A Comparison of the Clinical Outcomes in Uterine Cancer Surgery After the Introduction of Robotic-Assisted Surgery.

To compare the rates of intraoperative and postoperative complications of open and robotic-assisted surgery in the treatment of endometrial cancer. This retrospective study was performed at a single academic institution from January 2014 to February 2017 in the Department of Gynecology Oncology at Amrita Institute of Medical Science, Kerala, India. The study included patients with clinically early stage uterine malignancy undergoing open or robotic-assisted surgery. Data collected included clinicopathological factors, intraoperative data, length of hospital stay and intraoperative and postoperative (early and late and severity according to Clavien-Dindo classification). Morbidity was compared between two groups. The study included 128 patients, of whom 61 underwent open surgery and 67 underwent robotic-assisted surgery. Mean operative time (P = 0.112), mean estimated blood loss (P < 0.001), number of patients requiring blood transfusion (P < 0.001) and mean length of hospital stay (P < 0.001) were significantly lower in robotic group. None of the patients in robotic group experienced intraoperative hemorrhage (P = 0.010). The early postoperative complications, SSI (P < 0.001), infection (P = 0.002), and urinary complications (P = 0.030) and late postoperative complications lymphoedema (P = 0.002), vault-related complications (1.5% robotic vs. 6.6% open) and incisional hernia (none in robotic vs. 4.9% in open) were significantly lower in robotic group. Grade-II complications (Clavien-Dindo classification) were significantly lower in robotic group (P < 0.001). Robotic-assisted surgical staging for uterine cancer is feasible and safe in terms of short-term outcomes and results in fewer complications and shorter hospital stay.

Progress of treatment of an advanced and recurrent endometrial uterine carcinoma

The purpose of the current study was to detect the potential therapeutic role of a survival benefit for women with advanced and recurrent endometrial carcinoma for their poor prognosis. A number of published studies for women with advanced and recurrent endometrial cancers were reviewed. We found that surgery had been the primary treatment of choice for an endometrial carcinoma. Where disease has spread to the uterine cervix, extended or radical surgery may be curative. The systematic lymph node resection improves the survival of women with intermediate/high-risk endometrioid uterine cancer, especially non-endometrioid carcinoma. The omentectomy may be beneficial for non-endometrioid cancer. A number of studies report a survival benefit from surgical cytoreduction in women with advanced and recurrent disease, although the degree of surgical effort is required in order to achieve an optimal result varies. Laparoscopic and robotic surgical staging for uterine cancer might be considered as a standard of care for endometrial cancer without extra-uterine metastasis. Laparotomy should be the first choice for extra-uterine metastasis and recurrent disease. Adjuvant radiotherapy and chemotherapy have a potential role in the management of high-risk, advanced, and recurrent disease. Efficacy of targeted and endocrinal treatment in women with advanced and recurrent endometrial cancer has been proved. Key words: Endometrial neoplasms/TH; Hysterectomy; Lymph node excision; Omentum; Chemotherapy, adjuvant; Radiotherapy, adjuvant; Review

Comparison of lower extremity lymphedema incidence between two pelvic lymphadenectomy techniques in uterine cancer patients undergoing robotic-assisted staging procedures

Objectives: To compare the difference in incidence of lower extremity lymphedema after robotic surgical staging for uterine cancer employing standard pelvic lymphadenectomy and selective pelvic lymphadenectomy with sparing of the lateral external iliac chain as well as to evaluate the adequacy of selective approach in detecting lymph node metastases.

Recurrence and Survival After Random Assignment to Laparoscopy Versus Laparotomy for Comprehensive Surgical Staging of Uterine Cancer: Gynecologic Oncology Group LAP2 Study

The primary objective was to establish noninferiority of laparoscopy compared with laparotomy for recurrence after surgical staging of uterine cancer. Patients with clinical stages I to IIA disease were randomly allocated (two to one) to laparoscopy (n = 1,696) versus laparotomy (n = 920) for hysterectomy, salpingo-oophorectomy, pelvic cytology, and pelvic and para-aortic lymphadenectomy. The primary study end point was noninferiority of recurrence-free interval defined as no more than a 40% increase in the risk of recurrence with laparoscopy compared with laparotomy. With a median follow-up time of 59 months for 2,181 patients still alive, there were 309 recurrences (210 laparoscopy; 99 laparotomy) and 350 deaths (229 laparoscopy; 121 laparotomy). The estimated hazard ratio for laparoscopy relative to laparotomy was 1.14 (90% lower bound, 0.92; 95% upper bound, 1.46), falling short of the protocol-specified definition of noninferiority. However, the actual recurrence rates were substantially lower than anticipated, resulting in an estimated 3-year recurrence rate of 11.4% with laparoscopy and 10.2% with laparotomy, or a difference of 1.14% (90% lower bound, -1.28; 95% upper bound, 4.0). The estimated 5-year overall survival was almost identical in both arms at 89.8%. This study previously reported that laparoscopic surgical management of uterine cancer is superior for short-term safety and length-of-stay end points. The potential for increased risk of cancer recurrence with laparoscopy versus laparotomy was quantified and found to be small, providing accurate information for decision making for women with uterine cancer.

Laparoscopy Compared With Laparotomy for Comprehensive Surgical Staging of Uterine Cancer: Gynecologic Oncology Group Study LAP2

The conventional method for comprehensive surgical staging in endometrial cancer is open laparotomy. Since the 1990s, minimally invasive laparoscopy has been investigated for comprehensive surgical staging in endometrial cancer in small efficacy and safety studies. This prospective randomized trial was designed to compare use of laparotomy and laparoscopy for complete comprehensive surgical staging of uterine cancer. Between 1996 and 2005, a total of 2616 patients with clinical stage I to IIA uterine cancer were randomly assigned —920 to open laparotomy and 1696 to laparoscopy. The procedures undertaken with both methods included hysterectomy, salpingo-oophorectomy, pelvic and paraaortic lymphadenectomy, and peritoneal cytology. The primary study end points were short-term (6 weeks) surgical outcomes, including recurrence-free survival, intraoperative complications, laparoscopy conversion to laparotomy, length of hospital stay, operative time, patient-reported quality of life, and sites of recurrence. The data was adjusted for patient age, race/ethnicity, body mass index, and performance status. Laparoscopy was completed without conversion to open laparotomy in 1248 patients (74.2%). Conversion to laparotomy was required in 434 participants (25.8%). Reasons for conversion included poor exposure in 246 patients (14.6%), metastatic cancer in 69 patients (4.1%), excessive bleeding in 49 patients (2.9%), and other causes in 70 patients (4.2%). Fewer moderate-to-severe postoperative adverse events occurred with laparoscopy compared to laparotomy (14% versus 21%; P < 0.001). Although the median operative time was shorter for open laparotomy than laparoscopy (130 versus 204 minutes; P < 0.001), there was no statistical difference between the 2 treatment groups in rates of intraoperative complications (laparotomy: 8% versus laparoscopy: 10%; P = 0.106). The percentage of patients requiring more than 2 days of hospitalization after surgery was significantly lower in patients receiving laparoscopy compared with laparotomy (52% versus 94%; P < 0.001). Both pelvic and paraaortic nodes were not removed in 4% of laparotomy patients and 8% of laparoscopy patients (P < 0.0001). The proportion of laparotomy and laparoscopy patients found to have advanced surgical stage (FIGO stage IIIA, IIIC, or IV) was not significantly different (17% for each method; P = 0.851). The investigators conclude from these findings that laparoscopic comprehensive surgical staging for uterine cancer is feasible. Compared to laparotomy, short-term outcomes of laparoscopy show fewer postoperative complications, and shorter hospital stay without increased intraoperative injuries.

Laparoscopy Compared With Laparotomy for Comprehensive Surgical Staging of Uterine Cancer: Gynecologic Oncology Group Study LAP2

Laparoscopy Compared With Laparotomy for Comprehensive Surgical Staging of Uterine Cancer: Gynecologic Oncology Group Study LAP2

Laparoscopy Compared With Laparotomy for Comprehensive Surgical Staging of Uterine Cancer: Gynecologic Oncology Group Study LAP2

Laparoscopy Compared With Laparotomy for Comprehensive Surgical Staging of Uterine Cancer: Gynecologic Oncology Group Study LAP2

The risk of nodal metastasis and survival of various cell types of uterine cancer: A study of 16,640 patients

16589 Background: To investigate the risk of nodal metastasis in various histologic cell types of uterine cancer. Methods: Demographic and clinico-pathologic information were obtained from the Surveillance, Epidemiology, and End Results Program between 1988 and 2001. Data were analyzed using Chi-square tests, Kaplan-Meier analysis with log-rank tests, and Cox proportional hazards model. Results: 16,640 women underwent surgical staging for uterine cancer. The median age was 64 years (range 1–99). 85.4%, 6.8%, and 5.6% were Whites, Blacks, and Asians. Stage I, II, III, and IV diseases were found in 68.4%, 10%, 11.2%, and 10.5% of patients, respectively. Grade 1, 2, and 3 cancers were found in 24.4%, 34.8%, and 31.7% of tumors. 80% of the patients had endometrioid, 8.8% papillary serous (UPSC), 2.3% clear cell, and 8.9% sarcoma. In the overall study group, the risk of nodal metastasis was three-fold higher with UPSC compared to endometrioid (29.8% vs. 10.2%; p<0.001). Of stage I-III patients, the risk of nodal metastases was 5.6%, 15.8%, 12.6%, and 8.6% with endometrioid, UPSC, clear cell, and sarcoma, respectively (p<0.001). Of patients with nodal metastases, the proportion of patients with extensive nodal involvement (more than 5 positive nodes) was 11.8% in endometrioid, 22.7% in UPSC, 12.2% in clear cell, and 14.8% in sarcoma subtypes. The 5-year disease-specific survival of stage IIIC patients with endometrioid, UPSC, clear cell, and sarcoma cancers was 70.6%, 44.8%, 64.9%, and 48.4%, respectively (p<0.001). On multivariate analysis, age, stage, grade, and histology remained significant prognostic factors for survival. Conclusions: Papillary serous, sarcoma, and clear cell uterine cancers have a higher risk for nodal metastasis compared to endometrioid cancers. Uterine cancer patients, in particular those with high-risk cell types, should undergo comprehensive staging with nodal assessment. No significant financial relationships to disclose.

0055: Randomized Trial of Laparoscopy Vs Laparotomy for Surgical Staging of Uterine Cancer: a Gynecologic Oncology Group Study

0055: Randomized Trial of Laparoscopy Vs Laparotomy for Surgical Staging of Uterine Cancer: a Gynecologic Oncology Group Study

Utility of a novel serum tumor biomarker HE4 in patients with uterine cancer

5036 Background: Approximately 40,880 new cases of uterine cancer are diagnosed in the U.S. annually resulting in 7,310 deaths. Uterine cancer is surgically staged and 75% of patients present with stage I disease. Patients with stage I tumors with intermediate to high risk factors have a recurrence rate of 20 to 30%. Serum CA125 is elevated in 75% of patients with advanced stage disease and in only 17% of patients with early stage disease. The use of CA125 for the detection of recurrent disease is limited at best. Only 25% of patients with asymptomatic recurrent disease have an elevated CA125. A better marker indicating early recurrent disease is needed. The objective of this study was to examine the value of a novel serum tumor marker HE4 in endometrial cancer. Methods: Serum samples from two prospective IRB approved studies at two institutions were analyzed to compare HE4 with CA125 in patients who had surgical staging for uterine cancer. Normal controls were obtained from healthy patients. Informed consent was obtained from all patients and blood samples were drawn pre-operatively. HE4 and CA125 levels were determined using assays from Fujirebio Diagnostic Inc. ROC curves were constructed for each tumor marker and the sensitivity at a set specificity of 95% was determined. Results: Serum from 156 controls and 233 patients with surgically staged endometrial cancer; (151 stage I, 21 stage II, 47 stage III and 14 stage IV) were examined. The area under the ROC curves (ROC-AUC) for HE4 and CA125 were determined and compared ( Table1 ). At 95% specificity, the sensitivity for differentiation of controls versus all stages was 44.9% for HE4 compared to 25.2% for CA125 (p = 0.0001). For stage I cases, HE4 showed an improvement in the sensitivity of 20.5% compared to CA125 (37.1% vs 16.6%, p = 0.0001). Conclusions: HE4 is elevated in all stages of endometrial cancer and has a greater sensitivity for discrimination from normal controls compared to CA125. As well, HE4 is elevated in early stage endometrial cancer and should be investigated as a marker for early recurrent disease. [Table: see text] [Table: see text]

Surgical staging of uterine cancer: Randomized phase III trial of laparoscopy vs laparotomy—A Gynecologic Oncology Group Study (GOG): Preliminary results

5010 Background: Feasibility of laparoscopy has been demonstrated, but the toxicity, staging, and survival has not been adequately compared to the traditional open approach. A randomized Phase III trial of 2616 patients was conducted by the GOG from 5/1996 to 9/2005. QOL and complications of surgery were previously reported at SGO. FIGO pathologic staging is the basis of this report. Methods: Clinical Stage I-IIA uterine cancer were eligible, consenting to either technique. The randomization procedures yielded two on laparoscopy arm for every one on the laparotomy arm. Scope participants were required to undergo laparotomy if the complete surgical staging was not feasible, or for resection of cancer. The staging results include: FIGO surgical stage, peritoneal cytology, number of nodes per site, and percent positive nodes at each location: right pelvic, left pelvic, right para-aortic, left para-aortic. Results: 2616 were randomized, 403 were excluded for this analysis: 84 ineligible, 76 sarcoma, 198 incomplete data, 45 were stage IV, leaving 2213 evaluable for lymph node staging of endometrial carcinoma (781 open:1432 scope). Conversion to laparotomy from laparoscopy occurred in 23.7%. Positive or suspicious cytology was found in 5.6% of laparotomy and 7.8% of laparoscopy participants (p = 0.055 n.s.). Pelvic nodes were documented (R 98.8% vs 98.9%, L 98.5% vs 98.1% n.s.) and positive pelvics (any positive 8.8% vs 8.7%; R 5.5% vs 5.8%; L 6.9% vs 6.1% n.s.) were similar. Laparoscopic surgical staging cases were less likely to have para-aortic nodes sampled (L 91.3% vs 85.0% p &lt; 0.001; R 96.0% vs 92.5% P = 0.001), but positve nodes were no different (any positive PA 5.0% vs 4.5%; R 4.1%, 3.4%; L 2.3%, 2.7% n.s.). Final FIGO Staging results (III A: 5.5% vs 5.7% n.s.&amp; IIIC: 9.3% vs 9.5% n.s.) were the same by randomization arm. Conclusion: These results demonstrate that laparoscopic surgical staging of endometrial cancer can be completed in 76.3%. No difference in postive cytology, node positivity rate, or FIGO stage could be attributed to the laparoscopic approach. Conversion to laparotomy is advised when incomplete staging results would yield inadequate information for treatment planning. NCI Funding: UO1CA65221, CA 27469. No significant financial relationships to disclose.

Surgical staging of uterine cancer: An analysis of perioperative morbidity

Surgical staging documented extrauterine disease in 27.9% of 168 patients with apparent early-clinical-stage uterine cancer. An analysis of operative time (78 ± 21 min), blood loss (332 ± 160 cc), and surgical site infection risks (4.7%) indicated little additional risk of lymphadenectomy. The long-term risk of lymphocyst (1.3%) or lymphedema (0.7%) was small. The histologic information obtained from staging was utilized to rationally guide the need for adjunctive teletherapy. The overall risk of recurrence (median follow-up, 26 months) with surgical Stage I disease was 2.6%.