Obstet Gynecol Sci.  2014 Jan;57(1):1-10.

Surgical treatment for apparent early stage endometrial cancer

• Sonoda Y

Abstract

Most experts would agree that the standard surgical treatment for endometrial cancer includes a hysterectomy and bilateral salpingo-oophorectomy; however, the benefit of full surgical staging with lymph node dissection in patients with apparent early stage disease remains a topic of debate. Recent prospective data and advances in laparoscopic techniques have transformed this disease into one that can be successfully managed with minimally invasive surgery. This review will discuss the current surgical management of apparent early stage endometrial cancer and some of the new techniques that are being incorporated.

Keyword

Laparoscopy; Minimally invasive; Surgical procedures; Uterine neoplasms

MeSH Terms

Endometrial Neoplasms*
Female
Humans
Hysterectomy
Laparoscopy
Lymph Node Excision
Surgical Procedures, Minimally Invasive
Uterine Neoplasms

Figure

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  Fig. 1 Surgical algorithm for endometrial cancer. LND, lymph node dissection (From Barlin JN, et al. Gynecol Oncol 2012;125:531-5, with permission from Elsevier) [46].

Reference

1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013; 63:11–30.

2. Classification and staging of malignant tumours in the female pelvis. Acta Obstet Gynecol Scand. 1971; 50:1–7.

3. Morrow CP, Bundy BN, Kurman RJ, Creasman WT, Heller P, Homesley HD, et al. Relationship between surgical-pathological risk factors and outcome in clinical stage I and II carcinoma of the endometrium: a Gynecologic Oncology Group study. Gynecol Oncol. 1991; 40:55–65.

4. Creasman WT, Morrow CP, Bundy BN, Homesley HD, Graham JE, Heller PB. Surgical pathologic spread patterns of endometrial cancer: a Gynecologic Oncology Group Study. Cancer. 1987; 60:8 Suppl. 2035–2041.

5. Mann J. AIDS. Int J Gynaecol Obstet. 1989; 28:190–192.

6. Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet. 2009; 105:103–104.

7. Goff BA, Rice LW. Assessment of depth of myometrial invasion in endometrial adenocarcinoma. Gynecol Oncol. 1990; 38:46–48.

8. Franchi M, Ghezzi F, Melpignano M, Cherchi PL, Scarabelli C, Apolloni C, et al. Clinical value of intraoperative gross examination in endometrial cancer. Gynecol Oncol. 2000; 76:357–361.

9. Altintas A, Cosar E, Vardar MA, Demir C, Tuncer I. Intraoperative assessment of depth of myometrial invasion in endometrial carcinoma. Eur J Gynaecol Oncol. 1999; 20:329–331.

10. Doering DL, Barnhill DR, Weiser EB, Burke TW, Woodward JE, Park RC. Intraoperative evaluation of depth of myometrial invasion in stage I endometrial adenocarcinoma. Obstet Gynecol. 1989; 74:930–933.

11. Barakat RR, Grigsby PW, Sabbatini P, Zaino RJ. Corpus: epithelial tumors. In : Hoskins WJ, Perez CA, Young RC, editors. Principles and practice of gynecologic oncology. 2nd ed. Philadelphia (PA): Lippincott-Raven;1997. p. 919–953.

12. Larson DM, Johnson KK, Broste SK, Krawisz BR, Kresl JJ. Comparison of D&C and office endometrial biopsy in predicting final histopathologic grade in endometrial cancer. Obstet Gynecol. 1995; 86:38–42.

13. Obermair A, Geramou M, Gucer F, Denison U, Graf AH, Kapshammer E, et al. Endometrial cancer: accuracy of the finding of a well differentiated tumor at dilatation and curettage compared to the findings at subsequent hysterectomy. Int J Gynecol Cancer. 1999; 9:383–386.

14. Neubauer NL, Havrilesky LJ, Calingaert B, Bulusu A, Bernardini MQ, Fleming ND, et al. The role of lymphadenectomy in the management of preoperative grade 1 endometrial carcinoma. Gynecol Oncol. 2009; 112:511–516.

15. Clements AE, Tierney BJ, Cohn DE, Straughn JM Jr. Is selective lymphadenectomy more cost-effective than routine lymphadenectomy in patients with endometrial cancer? Gynecol Oncol. 2013; 128:166–170.

16. Chan JK, Lin YG, Monk BJ, Tewari K, Bloss JD, Berman ML. Vaginal hysterectomy as primary treatment of endometrial cancer in medically compromised women. Obstet Gynecol. 2001; 97(5 Pt 1):707–711.

17. Childers JM, Brzechffa PR, Hatch KD, Surwit EA. Laparoscopically assisted surgical staging (LASS) of endometrial cancer. Gynecol Oncol. 1993; 51:33–38.

18. Eltabbakh GH, Shamonki MI, Moody JM, Garafano LL. Laparoscopy as the primary modality for the treatment of women with endometrial carcinoma. Cancer. 2001; 91:378–387.

19. Homesley HD, Boike G, Spiegel GW. Feasibility of laparoscopic management of presumed stage I endometrial carcinoma and assessment of accuracy of myoinvasion estimates by frozen section: a gynecologic oncology group study. Int J Gynecol Cancer. 2004; 14:341–347.

20. Kohler C, Klemm P, Schau A, Possover M, Krause N, Tozzi R, et al. Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies. Gynecol Oncol. 2004; 95:52–61.

21. Magrina JF, Mutone NF, Weaver AL, Magtibay PM, Fowler RS, Cornella JL. Laparoscopic lymphadenectomy and vaginal or laparoscopic hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer: morbidity and survival. Am J Obstet Gynecol. 1999; 181:376–381.

22. Gemignani ML, Curtin JP, Zelmanovich J, Patel DA, Venkatraman E, Barakat RR. Laparoscopic-assisted vaginal hysterectomy for endometrial cancer: clinical outcomes and hospital charges. Gynecol Oncol. 1999; 73:5–11.

23. Malur S, Possover M, Schneider A. Laparoscopically assisted radical vaginal versus radical abdominal hysterectomy type II in patients with cervical cancer. Surg Endosc. 2001; 15:289–292.

24. Fram KM. Laparoscopically assisted vaginal hysterectomy versus abdominal hysterectomy in stage I endometrial cancer. Int J Gynecol Cancer. 2002; 12:57–61.

25. Scribner DR Jr, Mannel RS, Walker JL, Johnson GA. Cost analysis of laparoscopy versus laparotomy for early endometrial cancer. Gynecol Oncol. 1999; 75:460–463.

26. Eltabbakh GH. Analysis of survival after laparoscopy in women with endometrial carcinoma. Cancer. 2002; 95:1894–1901.

27. Magrina JF, Weaver AL. Laparoscopic treatment of endometrial cancer: five-year recurrence and survival rates. Eur J Gynaecol Oncol. 2004; 25:439–441.

28. Scribner DR Jr, Walker JL, Johnson GA, McMeekin DS, Gold MA, Mannel RS. Laparoscopic pelvic and paraaortic lymph node dissection in the obese. Gynecol Oncol. 2002; 84:426–430.

29. Scribner DR Jr, Walker JL, Johnson GA, McMeekin SD, Gold MA, Mannel RS. Surgical management of early-stage endometrial cancer in the elderly: is laparoscopy feasible? Gynecol Oncol. 2001; 83:563–568.

30. Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, et al. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol. 2009; 27:5331–5336.

31. Kornblith AB, Huang HQ, Walker JL, Spirtos NM, Rotmensch J, Cella D. Quality of life of patients with endometrial cancer undergoing laparoscopic international federation of gynecology and obstetrics staging compared with laparotomy: a Gynecologic Oncology Group study. J Clin Oncol. 2009; 27:5337–5342.

32. Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, et al. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. J Clin Oncol. 2012; 30:695–700.

33. Einarsson JI, Matteson KA, Schulkin J, Chavan NR, Sangi-Haghpeykar H. Minimally invasive hysterectomies-a survey on attitudes and barriers among practicing gynecologists. J Minim Invasive Gynecol. 2010; 17:167–175.

34. Jacoby VL, Autry A, Jacobson G, Domush R, Nakagawa S, Jacoby A. Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. Obstet Gynecol. 2009; 114:1041–1048.

35. Gehrig PA, Cantrell LA, Shafer A, Abaid LN, Mendivil A, Boggess JF. What is the optimal minimally invasive surgical procedure for endometrial cancer staging in the obese and morbidly obese woman? Gynecol Oncol. 2008; 111:41–45.

36. Seamon LG, Cohn DE, Henretta MS, Kim KH, Carlson MJ, Phillips GS, et al. Minimally invasive comprehensive surgical staging for endometrial cancer: robotics or laparoscopy? Gynecol Oncol. 2009; 113:36–41.

37. Leitao MM Jr, Briscoe G, Santos K, Winder A, Jewell EL, Hoskins WJ, et al. Introduction of a computer-based surgical platform in the surgical care of patients with newly diagnosed uterine cancer: outcomes and impact on approach. Gynecol Oncol. 2012; 125:394–399.

38. Bell MC, Torgerson J, Seshadri-Kreaden U, Suttle AW, Hunt S. Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques. Gynecol Oncol. 2008; 111:407–411.

39. Kilgore LC, Partridge EE, Alvarez RD, Austin JM, Shingleton HM, Noojin F 3rd, et al. Adenocarcinoma of the endometrium: survival comparisons of patients with and without pelvic node sampling. Gynecol Oncol. 1995; 56:29–33.

40. Cragun JM, Havrilesky LJ, Calingaert B, Synan I, Secord AA, Soper JT, et al. Retrospective analysis of selective lymphadenectomy in apparent early-stage endometrial cancer. J Clin Oncol. 2005; 23:3668–3675.

41. Benedetti Panici P, Basile S, Maneschi F, Alberto Lissoni A, Signorelli M, Scambia G, et al. Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial. J Natl Cancer Inst. 2008; 100:1707–1716.

42. ASTEC study group. Kitchener H, Swart AM, Qian Q, Amos C, Parmar MK. Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study. Lancet. 2009; 373:125–136.

43. Chan JK, Kapp DS, Cheung MK, Osann K, Shin JY, Cohn D, et al. The impact of the absolute number and ratio of positive lymph nodes on survival of endometrioid uterine cancer patients. Br J Cancer. 2007; 97:605–611.

44. Burke TW, Levenback C, Tornos C, Morris M, Wharton JT, Gershenson DM. Intraabdominal lymphatic mapping to direct selective pelvic and paraaortic lymphadenectomy in women with high-risk endometrial cancer: results of a pilot study. Gynecol Oncol. 1996; 62:169–173.

45. Ballester M, Dubernard G, Bats AS, Heitz D, Mathevet P, Marret H, et al. Comparison of diagnostic accuracy of frozen section with imprint cytology for intraoperative examination of sentinel lymph node in early-stage endometrial cancer: results of Senti-Endo study. Ann Surg Oncol. 2012; 19:3515–3521.

46. Barlin JN, Khoury-Collado F, Kim CH, Leitao MM Jr, Chi DS, Sonoda Y, et al. The importance of applying a sentinel lymph node mapping algorithm in endometrial cancer staging: beyond removal of blue nodes. Gynecol Oncol. 2012; 125:531–535.

47. Echt ML, Finan MA, Hoffman MS, Kline RC, Roberts WS, Fiorica JV. Detection of sentinel lymph nodes with lymphazurin in cervical, uterine, and vulvar malignancies. South Med J. 1999; 92:204–208.

48. Holub Z, Jabor A, Lukac J, Kliment L. Laparoscopic detection of sentinel lymph nodes using blue dye in women with cervical and endometrial cancer. Med Sci Monit. 2004; 10:CR587–CR591.

49. Gien LT, Kwon JS, Carey MS. Sentinel node mapping with isosulfan blue dye in endometrial cancer. J Obstet Gynaecol Can. 2005; 27:1107–1112.

50. Li B, Li XG, Wu LY, Zhang WH, Li SM, Min C, et al. A pilot study of sentinel lymph nodes identification in patients with endometrial cancer. Bull Cancer. 2007; 94:E1–E4.

51. Frumovitz M, Bodurka DC, Broaddus RR, Coleman RL, Sood AK, Gershenson DM, et al. Lymphatic mapping and sentinel node biopsy in women with high-risk endometrial cancer. Gynecol Oncol. 2007; 104:100–103.

52. Altgassen C, Pagenstecher J, Hornung D, Diedrich K, Hornemann A. A new approach to label sentinel nodes in endometrial cancer. Gynecol Oncol. 2007; 105:457–461.

53. Lopes LA, Nicolau SM, Baracat FF, Baracat EC, Goncalves WJ, Santos HV, et al. Sentinel lymph node in endometrial cancer. Int J Gynecol Cancer. 2007; 17:1113–1117.

54. Robova H, Charvat M, Strnad P, Hrehorcak M, Taborska K, Skapa P, et al. Lymphatic mapping in endometrial cancer: comparison of hysteroscopic and subserosal injection and the distribution of sentinel lymph nodes. Int J Gynecol Cancer. 2009; 19:391–394.

55. Niikura H, Okamura C, Utsunomiya H, Yoshinaga K, Akahira J, Ito K, et al. Sentinel lymph node detection in patients with endometrial cancer. Gynecol Oncol. 2004; 92:669–674.

56. Fersis N, Gruber I, Relakis K, Friedrich M, Becker S, Wallwiener D, et al. Sentinel node identification and intraoperative lymphatic mapping: first results of a pilot study in patients with endometrial cancer. Eur J Gynaecol Oncol. 2004; 25:339–342.

57. Maccauro M, Lucignani G, Aliberti G, Villano C, Castellani MR, Solima E, et al. Sentinel lymph node detection following the hysteroscopic peritumoural injection of 99mTc-labelled albumin nanocolloid in endometrial cancer. Eur J Nucl Med Mol Imaging. 2005; 32:569–574.

58. Delaloye JF, Pampallona S, Chardonnens E, Fiche M, Lehr HA, De Grandi P, et al. Intraoperative lymphatic mapping and sentinel node biopsy using hysteroscopy in patients with endometrial cancer. Gynecol Oncol. 2007; 106:89–93.

59. Solima E, Martinelli F, Ditto A, Maccauro M, Carcangiu M, Mariani L, et al. Diagnostic accuracy of sentinel node in endometrial cancer by using hysteroscopic injection of radiolabeled tracer. Gynecol Oncol. 2012; 126:419–423.

60. Perrone AM, Casadio P, Formelli G, Levorato M, Ghi T, Costa S, et al. Cervical and hysteroscopic injection for identification of sentinel lymph node in endometrial cancer. Gynecol Oncol. 2008; 111:62–67.

61. Bats AS, Clement D, Larousserie F, Le Frere-Belda MA, Pierquet-Ghazzar N, Hignette C, et al. Does sentinel node biopsy improve the management of endometrial cancer?: data from 43 patients. J Surg Oncol. 2008; 97:141–145.

62. Delpech Y, Cortez A, Coutant C, Callard P, Uzan S, Darai E, et al. The sentinel node concept in endometrial cancer: histopathologic validation by serial section and immunohistochemistry. Ann Oncol. 2007; 18:1799–1803.

63. Mais V, Peiretti M, Gargiulo T, Parodo G, Cirronis MG, Melis GB. Intraoperative sentinel lymph node detection by vital dye through laparoscopy or laparotomy in early endometrial cancer. J Surg Oncol. 2010; 101:408–412.

64. Ballester M, Dubernard G, Lecuru F, Heitz D, Mathevet P, Marret H, et al. Detection rate and diagnostic accuracy of sentinel-node biopsy in early stage endometrial cancer: a prospective multicentre study (SENTI-ENDO). Lancet Oncol. 2011; 12:469–476.

65. Gargiulo T, Giusti M, Bottero A, Leo L, Brokaj L, Armellino F, et al. Sentinel Lymph Node (SLN) laparoscopic assessment early stage in endometrial cancer. Minerva Ginecol. 2003; 55:259–262.

66. Pelosi E, Arena V, Baudino B, Bello M, Giusti M, Gargiulo T, et al. Pre-operative lymphatic mapping and intra-operative sentinel lymph node detection in early stage endometrial cancer. Nucl Med Commun. 2003; 24:971–975.

67. Lelievre L, Camatte S, Le Frere-belda MA, Kerrou K, Froissart M, Taurelle R, et al. Sentinel lymph node biopsy in cervix and corpus uteri cancers. Int J Gynecol Cancer. 2004; 14:271–278.