Compliance of the peri-operative management with the standards of care
| QI 8 - Proportion of cases of early-stage endometrial carcinoma with non ruptured uterus after hysterectomy | |
| Type | Outcome indicator |
| Description | Uterus should be removed intact. Intra-operative rupturing/fragmentation/morcellation of the uterus (including in a bag) must be avoided |
| Specifications | Numerator: number of patients with early-stage endometrial carcinoma after hysterectomy with intact/non-ruptured/non-fragmented/non-morcellated uterus Denominator: all patients with early-stage (I-II) endometrial carcinoma who underwent hysterectomy. |
| Target | 99% |
| QI 9 - Proportion of patients with early-stage endometrial carcinoma who have undergone successful minimally invasive surgery | |
| Type | Outcome indicator |
| Description | Minimally invasive surgery (laparoscopic or robotic) is considered successful if performed without any intra-peritoneal tumor spillage, tumor rupture, or morcellation (including in a bag). If vaginal extraction risks uterine rupture, other measures should be taken (eg, mini-laparotomy, use of endobag). If a mini-laparotomy for such purpose is performed within a minimally invasive procedure, the surgery is still considered a successful minimally invasive surgery |
| Specifications | Numerator: number of patients with presumed early-stage endometrial carcinoma who have undergone successful minimally invasive surgery (as defined above) Denominator: all patients who have undergone surgery for presumed early-stage (I–II) endometrial carcinoma |
| Targets | Optimal target: ≥80% Minimum required target: 60% |
| QI 10 - Proportion of patients with BMI >35 kg/m² who have undergone successful minimally invasive surgery | |
| Type | Outcome indicator |
| Description | Minimally invasive surgery (laparoscopic or robotic surgery) is considered successful if performed without any intra-peritoneal tumor spillage, tumor rupture, or morcellation (including in a bag). If vaginal extraction risks uterine rupture, other measures should be taken (eg, mini-laparotomy, use of endobag). If a mini-laparotomy for such purpose is performed within a minimally invasive procedure, the surgery is still considered a successful minimal invasive surgery |
| Specifications | Numerator: number of patients with BMI >35 kg/m² with presumed early-stage endometrial carcinoma who have undergone successful minimally invasive surgery (as defined above) Denominator: all patients with BMI >35 kg/m² who have undergone surgery for presumed early-stage (I–II) endometrial carcinoma |
| Target | >60% |
| QI 11 - Proportion of conversions from minimally invasive surgery to open surgery | |
| Type | Outcome indicator |
| Description | Minimally invasive surgery includes laparoscopic and robotic surgery. Conversions to laparotomy occur due to intra-operative findings or complications. Mini-laparotomy to extract the uterus is not considered as conversion to laparotomy |
| Specifications | Numerator: number of patients with endometrial carcinoma who have undergone minimally invasive surgery in whom a conversion to open surgery has been required Denominator: all patients with endometrial carcinoma who have undergone minimally invasive surgery |
| Target | <10% |
| QI 12 - Proportion of patients with intra-operative injuries | |
| Type | Outcome indicator |
| Description | Intra-operative injuries include positioning complications and urinary, bowel, vascular, and neural injuries |
| Specifications | Numerator: number of patients with endometrial carcinoma who have undergone a surgery in whom intra-operative injuries as described above have been reported Denominator: all patients with endometrial carcinoma who have undergone a surgery |
| Target | <2% |
| QI 13 - Proportion of infracolic omentectomy in patients with endometrial carcinoma and presumed early-stage serous, undifferentiated carcinoma or carcinosarcoma | |
| Type | Outcome indicator |
| Description | According to the ESGO/ESTRO/ESP guidelines, staging infracolic omentectomy should be performed in apparent uterus-confined serous, undifferentiated carcinoma, or carcinosarcoma |
| Specifications | Numerator: number of patients with endometrial carcinoma and presumed early-stage serous, undifferentiated carcinoma, or carcinosarcoma who underwent infracolic omentectomy Denominator: all patients with endometrial carcinoma and presumed early-stage (I–II) serous, undifferentiated carcinoma, or carcinosarcoma who underwent surgery |
| Target | ≥90% |
| QI 14 - Proportion of lymph node staging performed in patients with presumed early-stage high-intermediate or high-risk endometrial carcinoma | |
| Type | Outcome indicator |
| Description | According to the ESGO/ESTRO/ESP guidelines, surgical lymph node staging should be performed in patients with early-stage endometrial carcinoma deemed pre-operatively as high-intermediate or high risk Sentinel lymph node biopsy is an acceptable alternative to systematic lymphadenectomy for lymph node staging in stage I–II. Sentinel lymph node procedure and lymph node dissection are taken into account for lymph node staging |
| Specifications | Numerator: number of patients with presumed early-stage high-intermediate or high-risk endometrial carcinoma who underwent lymph node staging Denominator: all patients with presumed early-stage (I–II) high-intermediate or high-risk endometrial carcinoma who underwent surgery |
| Target | >85% |
| QI 15 - Proportion of sentinel lymph node procedures in patients undergoing lymph node staging | |
| Type | Outcome indicator |
| Description | Lymph node staging in early-stage (I–II) endometrial carcinoma is defined as sentinel lymph node procedure and/or systematic pelvic lymphadenectomy |
| Specifications | Numerator: number of patients with early-stage endometrial carcinoma for whom sentinel lymph node procedure was attempted or performed Denominator: all patients with early-stage (I–II) endometrial carcinoma who have undergone a lymph node staging |
| Target | 90% |
| QI 16 - Number of sentinel lymph node procedures for endometrial carcinoma performed or supervised per surgeon per year | |
| Type | Outcome indicator |
| Description | Sentinel lymph node procedures require high surgeon skills to improve the identification rate and to minimize the false-negative rate. Sentinel lymph node procedures should be performed by a certified gynecologic oncologist or a trained surgeon specifically dedicated to gynecological cancer management (see QI 3). Surgeons must ensure that their colleagues in radiology, nuclear medicine, and/or pathology are actively involved in the successful implementation of this multi-disciplinary procedure |
| Specifications | Numerator: number of sentinel lymph node procedures performed or supervised in patients with endometrial carcinoma per surgeon per year Denominator: not applicable |
| Target | ≥20 |
| QI 17 - Proportion of indocyanine green cervical injection | |
| Type | Outcome indicator |
| Description | According to the ESGO/ESTRO/ESP guidelines, indocyanine green cervical injection is the preferred detection technique |
| Specifications | Numerator: number of patients with presumed early-stage endometrial carcinoma in whom indocyanine green cervical injection was performed Denominator: all patients with presumed early-stage (stage I–II) endometrial carcinoma who underwent sentinel lymph node procedure |
| Target | ≥95% |
| QI 18 - Proportion of high-intermediate/high-risk patients with side-specific systematic pelvic lymphadenectomy in cases of failed sentinel lymph node detection | |
| Type | Outcome indicator |
| Description | According to the ESGO/ESTRO/ESP guidelines, side-specific systematic lymphadenectomy should be performed in high-intermediate/high-risk patients if sentinel lymph node is not detected on either pelvic side. Low-risk and intermediate-risk patients are not taken into account as systematic lymphadenectomy is not recommended in these patients |
| Specifications | Numerator: number of high-intermediate/high-risk patients who underwent side-specific or bilateral systematic pelvic lymphadenectomy Denominator: all high-intermediate/high-risk patients with unilaterally or bilaterally failed sentinel lymph node detection |
| Target | >90% |
| QI 19 - Proportion of patients who underwent ultrastaging of sentinel lymph nodes | |
| Type | Outcome indicator |
| Description | Intensive pathologic assessment of sentinel lymph node (sentinel lymph node ultrastaging) supports the detection of small metastases which could be missed by standard evaluation. According to the ESGO/ESTRO/ESP guidelines, pathologic ultrastaging of sentinel lymph nodes is recommended, although there is no universal ultrastaging protocol |
| Specifications | Numerator: number of patients who underwent ultrastaging of sentinel lymph nodes Denominator: all patients who underwent a sentinel lymph node procedure |
| Target | ≥99% |
| QI 20 - Proportion of bilateral mapping rate of sentinel lymph node procedures | |
| Type | Outcome indicator |
| Description | The ESGO/ESTRO/ESP guidelines suggest cervical injections of indocyanine green as the preferred technique to detect sentinel lymph nodes. Tracer re-injection is an option if sentinel lymph node is not visualized upfront. The aim is bilateral detection of sentinel lymph nodes |
| Specifications | Numerator: number of patients with presumed early-stage endometrial carcinoma who underwent successful bilateral sentinel lymph node detection Denominator: all patients with presumed early-stage (stage I–II) endometrial carcinoma who underwent sentinel lymph node procedure |
| Target | ≥75% |
| QI 21 - Proportion of complete macroscopic resection for curative intent in patients with primary advanced endometrial carcinoma (stage III–IV) | |
| Type | Outcome indicator |
| Description | In advanced endometrial carcinoma (stage III–IV), surgical tumor debulking, including removal of enlarged lymph nodes, should be considered when complete macroscopic resection (no residual disease) is feasible with an acceptable morbidity and quality of life profile. Debulking surgery should be preceded by a full pre-operative staging and discussion by a multi-disciplinary team. This includes patients with neoadjuvant chemotherapy |
| Specifications | Numerator: number of patients with advanced endometrial carcinoma who have undergone a cytoreductive surgery and in whom complete macroscopic resection was achieved Denominator: all patients with primary advanced endometrial carcinoma (stage III–IV) who have undergone a cytoreductive surgery |
| Target | ≥75% |
| QI 22- Proportion of patients who underwent salvage surgery for loco-regional recurrent disease (isolated pelvic or nodal recurrent disease) in whom complete macroscopic resection is achieved | |
| Type | Outcome indicator |
| Description | Indications of salvage surgery for loco-regional recurrent disease are defined according to the ESGO/ESTRO/ESP guidelines, as follows: Treatment of patients with recurrent endometrial carcinoma involves a multi-disciplinary approach with surgery, radiotherapy, and/or systemic therapy depending on the fitness and wishes of the patient, the tumor dissemination patterns, and prior treatment In radiotherapy naïve patients, a decision about surgery needs to take account of patient morbidity and wishes, available non-surgical treatments, and resources. The interval between primary treatment and recurrences should also be taken into consideration. Patients with recurrent disease (including peritoneal and lymph node relapse) should be considered for surgery only if it is anticipated that complete removal of macroscopic disease can be achieved with acceptable morbidity In radiotherapy pre-treated patients (external beam radiotherapy ±brachytherapy) with loco-regional recurrence, radical surgery, including exenteration, should be considered when the intention is complete resection with clear margins |
| Specifications | Numerator: number of patients in whom complete macroscopic resection and clear margins (if applicable) are achieved Denominator: all patients who underwent salvage surgery for recurrent disease (isolated pelvic or nodal recurrent disease) |
| Target | ≥85% |