Minimally Invasive Approach in Type II Endometrial Cancer: Is It Wise and Safe?

doi:10.1016/j.jmig.2016.12.022

Journal of Minimally Invasive Gynecology

Volume 24, Issue 3, March–April 2017, Pages 438-445

https://doi.org/10.1016/j.jmig.2016.12.022 Get rights and content

Abstract

Study Objective

To compare perioperative and survival outcomes in patients with type II endometrial cancer surgically staged by a minimally invasive surgery (MIS) approach and those surgically staged by laparotomy.

Design

Retrospective cohort study (Canadian Task Force classification II-2).

Setting

Catholic University of the Sacred Heart of Rome, University of Insubria, Varese and “Regina Elena” National Cancer Institute of Rome.

Patients

A total of 283 patients with type II endometrial cancer in clinical International Federation of Gynecology and Obstetrics stage I-II and pathological stage III with apparent early-stage disease detected on preoperative instrumental examination.

Interventions

Baseline features and perioperative data were evaluated in 142 patients who underwent hysterectomy via open surgery (laparotomy [LPT] group) and 141 patients who did so via a minimally invasive approach (MIS group).

Measurements and Main Results

The 2 groups were comparable in terms of baseline features and perioperative data except for operative time, which was longer in the LPT group (p < .001) and hospital stay, which was shorter in the MIS group. There were no between-group differences in pathological features, except for myometrial invasion and the rate of positive pelvic lymph nodes. Therefore, we obtained a higher number of early stages in the MIS group (p < .001). In the overall population, significant differences were observed in the recurrence rate, number, and site of relapses, with a higher recurrence rate and number in the LPT group (p < .001). Progression-free and overall survival were not significantly different in the 2 groups.

Conclusion

Women with type II endometrial cancer submitted to MIS for hysterectomy experienced fewer complications and similar survival outcomes compared with those who underwent open surgery. When managed by an expert surgeon, a high-risk histological subtype should not be considered a contraindication for MIS. Further prospectively randomized studies are needed to definitively evaluate the safety and feasibility of MIS in early-stage type II endometrial cancer.

Section snippets

Materials and Methods

This retrospective multicenter analysis was carried out between May 2000 and June 2015 at the Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Catholic University of the Sacred Heart of Rome, the Department of Obstetrics and Gynecology, University of Insubria, Varese; and the Department of Experimental Clinical Oncology, Gynecologic Oncology Unit, “Regina Elena” National Cancer Institute of Rome. Inclusion criteria were the presence of histologically confirmed type II

Results

Demographic data and baseline characteristics are summarized in Table 1. No significant differences were observed between the 2 groups in terms of median patient age, BMI, or previous abdominal surgery. Conversely, statistically significant differences were seen in terms of histology. In particular, we found 49 (34.5%) USCs in the LPT group vs 77 (54.6%) in the MIS group (p < .001), and 62 (43.6%) mixed carcinomas in the LPT group vs 33 (23.4%) in the MIS group (p < .001). No significant

Discussion

As mentioned earlier, previous randomized studies have focused primarily on low-risk patients, specifically those with endometrioid histotype cancers [16]. The present study is the widest retrospective analysis focused on type II endometrial cancer reported to date. In this large series, women submitted to MIS experienced fewer perioperative complications than those who underwent LPT, with similar patterns of recurrence and survival outcomes. The 2 groups also showed no significant differences

Conclusion

In this study, the women with type II endometrial cancers who were staged by MIS experienced fewer complications and similar survival outcomes compared those staged by open surgery. When MIS is managed by expert surgeons, high-risk histological subtype should not be considered a contraindication for MIS in patients with apparent early-stage disease. Further well-designed and prospectively randomized studies are needed to definitively evaluate the surgical safety and feasibility of MIS in

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Minimally invasive surgery versus open surgery in high-risk histologic endometrial cancer patients: A meta-analysis
2022, Gynecologic Oncology
Citation Excerpt :
Pooled HRs were 1.04 (95% CI, 0.70–1.54; p = 0.85) (Table 2) and 0.95 (95% CI, 0.61–1.48; p = 0.83) for recurrence and mortality, respectively, with low cross-study heterogeneity (p = 0.588; I2 = 0.000 and p = 0.917; I2 = 0.000, respectively) (Table 3). There were four studies with the pathologic inclusion criteria restricted to PS and CC [14,16,28,30]. In them, MIS did not show an increase in the pooled HR for recurrence (HR, 0.58; 95% CI, 0.41–0.83; p = 0.003) with low cross-study heterogeneity (p = 0.280; I2 = 21.8) (Table 2) or for mortality (HR, 0.64; 95% CI, 0.27–1.52; p = 0.31) with significant cross-study heterogeneity (p = 0.050; I2 = 61.7) (Table 3).
To compare the effects of minimally invasive surgery (MIS) and open surgery (OPS) on the risk of recurrence and mortality in patients with endometrial cancer (EC) of high-risk histology (grade 3 endometrioid adenocarcinoma, papillary serous carcinoma [PS], clear cell carcinoma [CC], and carcinosarcoma) using meta-analysis.
We systematically reviewed published studies comparing MIS and OPS in EC patients with high-risk histology until January 2022. The endpoints were recurrence and mortality rate. Study design features that may have affected participant selection, recurrence/death detection, and manuscript publication were assessed. For pooled estimates of the effect of MIS on recurrence/mortality, the random- or fixed-effects meta-analytical models were used after assessing the cross-study heterogeneity.
Nine observational studies (eight retrospective and one prospective) fulfilled our search criteria (MIS, 8877 patients; OPS, 5751 patients). The fixed-effects model-based meta-analysis indicated that MIS did not significantly increase the risk of recurrence (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.71–1.05; p = 0.13) and mortality (HR, 0.86; 95% CI, 0.79–0.93; p < 0.001) when compared with OPS. This pattern was also observed in the subgroup analyses based on the stage (early stage vs. all stage), histology (PS and CC), and MIS type (laparoscopy vs. robotic). There was no evidence of publication bias.
This meta-analysis of observational studies revealed that MIS did not compromise the prognosis of EC patients with high-risk histology. Well-designed randomized controlled trials could verify the results of this uncommon but deadly tumor.
Oncological Safety of Laparoscopic Surgery for Women with Apparent Early-stage Uterine Clear Cell Carcinoma: A Multicenter Retrospective Cohort Study
2022, Journal of Minimally Invasive Gynecology
To study the effect of different surgical approaches (laparoscopy and laparotomy) on the oncological outcomes of patients with apparent early-stage uterine clear cell carcinoma (UCCC).
Retrospective cohort study.
Four Chinese teaching hospitals.
A total of 273 women with apparent early-stage UCCC.
All included patients were surgically staged by laparoscopy or laparotomy.
The eligible patients were divided into the laparotomy group and the laparoscopy group. Disease-free survival (DFS) and overall survival (OS) were evaluated by the Kaplan-Meier method and compared by the log-rank test. The Cox proportional hazards regression model was used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for the effect of surgical approach on DFS and OS.
With a median follow-up of 31.0 months, the 3-year DFS rates were 68.82% and 64.27% in the laparotomy group and the laparoscopy group, respectively. The difference in DFS between the 2 groups was not statistically significant (HR, 1.06; 95% CI, 0.72–1.58; p = .758). In addition, the 3-year OS rate (72.76% vs 73.46%; HR, 1.06; 95% CI, 0.65–1.72; p = .823) was not different between the 2 groups. Furthermore, multivariable analysis showed that for patients with apparent early-stage UCCC, the approach of surgical staging was not an independent prognostic factor for OS (adjusted HR, 1.29; 95% CI, 0.78–2.12; p = .321) and DFS (adjusted HR, 1.11; 95% CI, 0.73–1.68; p = .621).
For clinical early-stage clear cell carcinoma of the uterus, staging by laparoscopy is oncologically safe. This needs to be justified by further prospective studies.
Oncologic safety of minimally invasive surgery in non-endometrioid endometrial cancer
2022, Asian Journal of Surgery
Citation Excerpt :
In this multicenter retrospective study, women with non-endometrioid EC who were treated with MIS showed similar or better recurrence and survival outcomes than those treated with open surgery. These results are in concordance with those of previously reported studies.11–14 In both groups, there were no differences in DFS and OS between patients with early and advanced stage disease.
This study was aimed to compare the oncologic outcomes of patients with non-endometrioid endometrial cancer who underwent minimally invasive surgery with the outcomes of patients who underwent open surgery.
This is a retrospective, multi-institutional study of patients with non-endometrioid endometrial cancer who were surgically staged by either minimally invasive surgery or open surgery. Oncologic outcomes of the patients were compared according to surgical approach.
113 patients met the inclusion and exclusion criteria. 57 underwent minimally invasive surgery and 56 underwent open surgery. Patients who underwent minimally invasive surgery had smaller tumors (median size, 3.3 vs. 5.2%, p = 0.0001) and a lower lymphovascular space invasion rate (29.8% vs. 48.2%, p = 0.045). In the overall population, the numbers and rate of recurrence were significantly higher in the open surgery group (p = 0.016). In multivariate analysis, disease stage and tumor size were associated with DFS in contrast to surgical procedure.
Minimally invasive surgery showed similar survival outcomes when compared to open surgery in non-endometrioid endometrial cancer patients, irrespective of disease stage. When minimally invasive surgery is managed by expert surgeons, non-endometrioid histological subtypes should not be considered a contraindication for minimally invasive surgery.
Robot-assisted surgery for women with endometrial cancer: Surgical and oncologic outcomes within a Belgium gynaecological oncology group cohort
2021, European Journal of Surgical Oncology
To evaluate surgical and oncologic outcomes of patients treated by robot-assisted surgery for endometrial cancer within the Belgium Gynaecological Oncology Group (BGOG).
We performed a retrospective analysis of women with clinically Stage I endometrial cancer who underwent surgical treatment from 2007 to 2018 in five institutions of the BGOG group.
A total of 598 consecutive women were identified. The rate of conversion to laparotomy was low (0.8%). The mean postoperative Complication Common Comprehensive Index (CCI) score was 3.4. The rate of perioperative complications did not differ between age groups, however the disease-free survival was significantly lower in patients over 75 years compared to patients under 65 years of age (p=0.008). Per-operative complications, conversion to laparotomy rate, post-operative hospital stay, CCI score and disease-free survival were not impacted by increasing BMI.
Robot-assisted surgery for the surgical treatment of patients suffering from early-stage endometrial cancer is associated with favourable surgical and oncologic outcomes, particularly for unfavourable groups such as elderly and obese women, thus permitting a low morbidity minimally-invasive surgical approach for the majority of patients in expert centres.
ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma
2021, Radiotherapy and Oncology
A European consensus conference on endometrial carcinoma was held in 2014 to produce multidisciplinary evidence-based guidelines on selected questions. Given the large body of literature on the management of endometrial carcinoma published since 2014, the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) jointly decided to update these evidence-based guidelines and to cover new topics in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.
ESGO/ESTRO/ESP nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of endometrial carcinoma (27 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2014, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 191 independent international practitioners in cancer care delivery and patient representatives.
The guidelines comprehensively cover endometrial carcinoma staging, definition of prognostic risk groups integrating molecular markers, pre- and intra-operative work-up, fertility preservation, management for early, advanced, metastatic, and recurrent disease and palliative treatment. Principles of radiotherapy and pathological evaluation are also defined.
Surgical and oncologic outcomes of minimally invasive surgery for stage I high-grade endometrial cancer
2020, Surgical Oncology
To evaluate the prevalence and outcomes of minimally invasive surgery for stage I high grade endometrial cancer. We hypothesized that route of surgery is not associated with survival.
Patients diagnosed between 2010 and 2014, with stage I grade 3 endometrioid, serous, clear cell and carcinosarcoma endometrial carcinoma, who underwent hysterectomy with lymphadenectomy were drawn from the National Cancer Database. Patients converted to open surgery were excluded. Overall survival was assessed with Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for confounders.
A total of 12852 patients were identified. The rate of minimally invasive surgery was 62.2%. An increase in the use between 2010 and 2014 was noted (p < 0.001). Open surgery was associated with longer hospital stay (median 3 vs 1 day, p < 0.001), higher 30-day unplanned re-admission rate (4.5% vs 2.4%, p < 0.001) and 30-day mortality (0.6% vs 0.3%, p = 0.008). There was no difference in overall survival between patients who had open or minimally invasive surgery, p = 0.22; 3-yr overall survival rates were 83.7% and 84.4% respectively. After controlling for patient age, tumor histology, substage, type of insurance, type of reporting facility, receipt of radiation therapy and chemotherapy, extent of lymphadenectomy, the presence of comorbidities and personal history of another tumor, minimally invasive surgery was not associated with a worse survival (hazard ratio: 1.06, 95% confidence interval: 0.97, 1.15).
Minimally invasive surgery for patients with stage I high grade endometrial cancer, was associated with superior short-term outcomes with no difference in overall survival noted.

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: The authors declare that they have no conflicts of interest.

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Original ArticleMinimally Invasive Approach in Type II Endometrial Cancer: Is It Wise and Safe?

Abstract

Study Objective

Design

Setting

Patients

Interventions

Measurements and Main Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Conclusion

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Lancet Oncol

J Minim Invasive Gynecol

Gynecol Oncol

J Minim Invasive Gynecol

Lancet

Original Article
Minimally Invasive Approach in Type II Endometrial Cancer: Is It Wise and Safe?