Introduction of robotic surgery for endometrial cancer into a Brazilian cancer service: a randomized trial evaluating perioperative clinical outcomes and costs

OBJECTIVE: The purpose of this study was to evaluate the clinical outcome and costs after the implementation of robotic surgery in the treatment of endometrial cancer, compared to the traditional laparoscopic approach. METHODS: In this prospective randomized study from 2015 to 2017, eighty-nine patients with endometrial carcinoma that was clinically restricted to the uterus were randomized in robotic surgery (44 cases) and traditional laparoscopic surgery (45 cases). We compared the number of retrieved lymph nodes, total time of surgery, time of each surgical step, blood loss, length of hospital stay, major and minor complications, conversion rates and costs. RESULTS: The ages of the patients ranged from 47 to 69 years. The median body mass index was 31.1 (21.4-54.2) in the robotic surgery arm and 31.6 (22.9-58.6) in the traditional laparoscopic arm. The median tumor sizes were 4.0 (1.5-10.0) cm and 4.0 (0.0-9.0) cm in the robotic and traditional laparoscopic surgery groups, respectively. The median total numbers of lymph nodes retrieved were 19 (3-61) and 20 (4-34) in the robotic and traditional laparoscopic surgery arms, respectively. The median total duration of the whole procedure was 319.5 (170-520) minutes in the robotic surgery arm and 248 (85-465) minutes in the traditional laparoscopic arm. Eight major complications were registered in each group. The total cost was 41% higher for robotic surgery than for traditional laparoscopic surgery. CONCLUSIONS: Robotic surgery for endometrial cancer presented equivalent perioperative morbidity to that of traditional laparoscopic surgery. The duration and total cost of robotic surgery were higher than those of traditional laparoscopic surgery.

A novel model to estimate lymph node metastasis in endometrial cancer patients

OBJECTIVES: To evaluate the postoperative pathological characteristics of hysterectomy specimens, preoperative cancer antigen (CA)-125 levels and imaging modalities in patients with endometrial cancer and to build a risk matrix model to identify and recruit patients for retroperitoneal lymphadenectomy. METHODS: A total of 405 patients undergoing surgical treatment for endometrial cancer were retrospectively reviewed and analyzed. Clinical (age and body mass index), laboratory (CA-125), radiological (lymph node evaluation), and pathological (tumour size, grade, lymphovascular space invasion, lymph node metastasis, and myometrial invasion) parameters were used to test the ability to predict lymph node metastasis. Four parameters were selected by logistic regression to create a risk matrix for nodal metastasis. RESULTS: Of the 405 patients, 236 (58.3%) underwent complete pelvic and para-aortic lymphadenectomy, 96 (23.7%) underwent nodal sampling, and 73 (18%) had no surgical lymph node assessment. The parameters predicting nodal involvement obtained through logistic regression were myometrial infiltration >50%, lymphovascular space involvement, pelvic lymph node involvement by imaging, and a CA-125 value >21.5 U/mL. According to our risk matrix, the absence of these four parameters implied a risk of lymph node metastasis of 2.7%, whereas in the presence of all four parameters the risk was 82.3%. CONCLUSION: Patients without deep myometrial invasion and lymphovascular space involvement on the final pathological examination and with normal CA-125 values and lymph node radiological examinations have a relatively low risk of lymph node involvement. This risk assessment matrix may be able to refer patients with high-risk parameters necessitating lymphadenectomy and to decide the risks and benefits of lymphadenectomy.

Surgical treatment of clinically early-stage endometrial carcinoma without systematic lymphadenectomy / Tratamento cirúrgico do câncer de endométrio em estágio clínico precoce sem linfadenectomia radical.

Objective: the main aim of this study was to describe the authors’ experience with the surgical treatment of endometrial cancer without systematic lymphadenectomy. Methods: a retrospective cohort study was carried out on a subset of patients suffering of clinically early-stage endometrial carcinoma who underwent hysterectomy and salpingo-oophorectomy without systematic (radical) lymph nodes dissection at our centers from June, 2002, to November, 2011. Descriptive statistics were explored as medians (interquartile range) or frequencies (percentages), as appropriated, and the Kaplan–Meier method was applied for survival estimation. Results: eighty-three patients who underwent surgical treatment with no lymph node dissection (n = 20; 24.1%) or with only a sampling procedure (n=63; 75.98%) were selected for analysis. Among these patients, 27 (32.53%) underwent surgery alone and 56 (67.46%) received some adjuvant treatment. Postoperative complications occurred in five patients (6.02%). Over a median follow-up of 27.4 months (Q25 = 13.7 – Q75 = 46.5), 15 (18.07%) patients suffered from relapses and 11 deaths occurred as result of disease recurrence. Cumulative 1, 2 and 3-year disease- free survivals were 97.32, 91.18 and 78.02%, respectively. Conclusion: on a case-by-case basis, the surgical treatment of clinically early-stage endometrial carcinoma without systematic lymphadenectomy did not seem to decrease survival outcomes and presented low rates of surgical morbidity in our experience, but was also related to a high rate use of adjuvant therapy. .

Objetivo: descrever a experiência dos autores com o tratamento cirúrgico do câncer de endométrio em estádio precoce sem linfadenectomia radical. Métodos: realizou-se estudo de coorte retrospectivo envolvendo um subgrupo de pacientes com câncer de endométrio em estágio clínico precoce tratadas com histerectomia e salpingo-ooforectomia sem linfadenectomia radical, em dois centros pernambucanos, de junho de 2002 a novembro de 2011. As variáveis foram descritas como mediana (intervalo interquartílico) ou frequências (percentuais), utilizando- se o método de Kaplan-Meier para a estimativa das taxas de sobrevivência. Resultados: oitenta e três pacientes submetidas a tratamento cirúrgico sem dissecção linfonodal (n = 20, 24,1%) ou com dissecção apenas por amostragem (n = 63; 75,98%) foram selecionadas para análise. Entre essas pacientes, 27 (32,53%) foram tratadas somente com cirurgia e 56 (67,46%) receberam tratamento adjuvante. Cinco pacientes apresentaram complicações pós-operatórias (6,02%). Durante o acompanhamento mediano de 27,4 meses (Q25 = 13,7 - Q75 = 46,5), 15 (18,07%) pacientes apresentaram recorrência, dentre as quais 11 faleceram em decorrência da recidiva neoplásica. Observou-se sobrevivência cumulativa proporcional livre de doença em um, dois e três anos de 97,32, 91,18 e 78,02%, respectivamente. Conclusão: em um contexto de indicação caso-a-caso, o tratamento cirúrgico do câncer de endométrio em estádio precoce sem linfadenectomia radical parece não ter prejudicado a sobrevivência e apresentou baixas taxas de morbidade cirúrgica em nossa experiência, mas também foi acompanhado de elevada utilização de terapia adjuvante. .

Cáncer de endometrio: experiencia de 10 años en el hospital San Juan de Dios / Endometrial cancer: 10 years experience in the San Juan de Dios hospital

Antecedentes: El cáncer de endometrio es uno de los cánceres ginecológicos más frecuentes. La incidencia de esta enfermedad pudiera ir en aumento dado los cambios epidemiológicos de la población femenina. Objetivo: Evaluar resultados clínicos y características de la población atendida por cáncer de endometrio. Método: Se analizaron las historia clínicas de 100 pacientes tratadas por cáncer de endometrio entre enero de 2000 y diciembre de 2009. En el análisis de los datos se consideró como base la etapificación FIGO 1988. Resultados: La edad promedio fue de 62 años, el 75 por ciento de las pacientes consultaron por hemorragia post menopáusica y en el 64 por ciento de las pacientes el diagnóstico se realizó por dilatación y curetaje. En el 60 por ciento se realizó etapificación completa. El 60 por ciento correspondió a etapa I y el 15 por ciento a etapa II. La sobrevida global en etapa I y II fue del 83 por ciento y 66 por ciento, respectivamente. Conclusión: El cáncer de endometrio se presenta preferentemente en pacientes post menopáusicas en etapas precoces. La mayoría accede a tratamiento quirúrgico con escasas complicaciones y alta sobrevida global.

Background: Endometrial cancer is one of the most frecuent gynecological cancer. The incidence of this disease could arise because of epidemiologycal changes in female population. Aims: To evaluate characteristics and clinical results of atended population with endometrial cancer. Method: Clinical histories of 100 patients treated for endometrial cancer between January 2000 to December 2009 were analized. In the data analysis, the FIGO 1988 staging was considered as base. Results: The age average was 62 years. The 75 percent of patients consulted for postmenopausal hemorrhage in the 64 percent of the patients the diagnosis was made by dilation and curettage. Full staging was made in the 60 percent. Stage I was 60 percent and 15 percent for stage II. Overall survival in stage I and II was 83 percent and 66 percent, respectively. Conclusion: Endometrial cancer presents preferably in early stages in postmenopausal patients. The mayority access to surgical treatment with few complications and a high survival rate.

Linfadenectomía lumboaórtica sistemática: Unidad de Ginecología Oncológica, Hospital Carlos Van Buren de Valparaíso / Systematic lumboaortic lymphadenectomy: Oncological Gynecology Unit of Hospital Carlos Van Buren, Valparaiso

Objetivo: Dar a conocer la técnica de linfadenectomía lumboaórtica sistemática (LLS) en el cáncer de endometrio y ovario, así como los resultados quirúrgicos obtenidos con ella en éste grupo de pacientes. Método:Se presenta una cohorte prospectiva de pacientes portadoras de cáncer de endometrio y ovario que requieren LLS entre agosto de 2005 y marzo de 2008. Se describe la técnica empleada y los resultados obtenidos. Resultados: 76 pacientes portadoras de cáncer de endometrio y ovario son sometidas a LLS. La edad promedio es de 57 años; 40 pacientes (52,6%) presentan cáncer de endometrio y 35 (46%) cáncer de ovario. El tiempo operatorio promedio fue de 55 minutos y el sangrado estimado de 120 ml. Se obtiene un recuento ganglionar promedio de 25,4 ganglios. Fallecen 2 pacientes y otra debe ser intervenida en el postoperatorio por hemoperitoneo. Conclusión: La técnica descrita es fácilmente realizable, con mínimas complicaciones y con una adecuada exposición del retroperitoneo, lo que permite obtener un número de ganglios necesarios para la etapificación del cáncer de endometrio y ovario.

Objective: To reports and describes the results of the paraaortic lymphadenectomy technique in the management of endometrial and ovarian cancer. Methods: We report a prospective cohort of patients with diagnosis of endometrial and ovarian cancer that required a systematic paraaortic lymphadenectomy, between August 2005 and March 2008, describing the surgical technique and the main results. Results: During this period seventy-six patients carrying endometrial or ovarian cancer are submitted to a systematic paraaortic lymphadenectomy. The average age was 57 years; 40 patients (52.6%) diagnosed with an endometrial cancer and 35 (46%) with an ovarian one. The average surgical time was 55 minutes, with an estimated bleeding of 120 ml. We obtained an average of 25.4 lymph nodes. Two patients deceased in this cohort and one was reintervened for a hemoperitoneum. Conclusion: The described surgical technique is feasible, with minimal complications and allows an appropriate exposure of the retroperitoneum to obtain an adequate number of lymph nodes for endometrial and ovarian cancer staging.