Endometrial cancer surgery: Difference between revisions

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__NOTOC__
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{{Endometrial cancer}}
{{Endometrial cancer}}
{{CMG}}
{{CMG}}{{AE}}{{RAK}}
==Overview==
Surgery is the mainstay of treatment for endometrial cancer stage I-III.


==Overview==
==Surgery==
==Surgery==
Preoperative evaluation should include a complete medical history and physical examination, pelvic examination and rectal examination with [[stool guaiac test]], chest X-ray, complete blood count, and blood chemistry tests, including liver function tests.
*Surgery is the first-line treatment option for patients with endometrial cancer especially if no [[metastasis]] is suspected.
 
*The treatment approach is based on staging, [[pathology]], and [[Histology|histologic]] features of the cancer:<ref name="pmid1555983">{{cite journal| author=Grigsby PW, Perez CA, Kuten A, Simpson JR, Garcia DM, Camel HM et al.| title=Clinical stage I endometrial cancer: prognostic factors for local control and distant metastasis and implications of the new FIGO surgical staging system. | journal=Int J Radiat Oncol Biol Phys | year= 1992 | volume= 22 | issue= 5 | pages= 905-11 | pmid=1555983 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1555983  }} </ref><ref name="pmid10546716">{{cite journal| author=Connell PP, Rotmensch J, Waggoner SE, Mundt AJ| title=Race and clinical outcome in endometrial carcinoma. | journal=Obstet Gynecol | year= 1999 | volume= 94 | issue= 5 Pt 1 | pages= 713-20 | pmid=10546716 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10546716  }} </ref>
Total [[extrafascial]] [[hysterectomy]] with bilateral salpingo-oopherectomy with pelvic or [[para-aortic lymph node]] dissection is standard procedure. Complete removal of [[omentum]] is warranted for serous or clear cell variety. If a surgeon happens to palpate and find enlarged pelvic or para-aortic lymph nodes, then their sampling or removal is required.
{| class="wikitable"
 
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Risk
In the operating room, the dissected uterine specimen must be grossly visualized to look for [[myometrial]] invasion. In multicenter series of 403 patients who underwent TAH-BSO, the sensitivity , specificity, positive and negative predictive value of gross assessment of myometrial invasion was found to be 73, 93, 85 and 86% respectively. Frozen section of area of invasion is a good practice but it has not shown consistent results.
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Risk definition
 
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Management
===When to resect lymph nodes?===
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Additional notes
If the following are present-
|-
*Serous, clear cell or high grade tumor.
| style="background:#DCDCDC;" align="center" + |Low risk
*Myometrial invasion >50%
| style="background:#F5F5F5;" align="center" + |• Stage IA endometrial cancer <br> • Well [[Cellular differentiation|differentiated]] [[endometroid]] histology <br> • Tumor confined to [[endometrium]]
*Large tumor ,i.e >2cm in diameter.
| style="background:#F5F5F5;" align="center" + |Total [[hysterectomy]], bilateral [[salpingo-oophorectomy]], and lymph node evaluation
 
| style="background:#F5F5F5;" align="center" + |• Women that opt for preservation of fertility may be candidates for medical therapy <br> • [[Adjuvant therapy]] not indicated
===Pelvic lymph node dissection===
|-
Removal of nodes from distal half of each of [[common iliac]] artery, proximal half of [[external iliac]] artery and vein and distal half of [[obturator fat]] pad.
| style="background:#DCDCDC;" align="center" + |Intermediate risk
 
| style="background:#F5F5F5;" align="center" + |• Stage I (tumor invades myometrium) or <br> • Stage II (tumor demonstrates cervical stroma invasion) <br> • Tumor usually moderately differentiated or poorly differentiated
===Para-aortic lymph node dissection===
| style="background:#F5F5F5;" align="center" + |• Total hysterectomy, bilateral salpingo-oophorecomy, and lymph node evaluation <br> • Adjuvant [[radiotherapy]] is indicated for patients with risk factors
Removal of nodes from distal [[inferior vena cava]]. These lymph nodes may be positive even if pelvic are not. Hence there has been some survival benefit in females with immediate or high risk disease from dissection of para-aortic group.
| style="background:#F5F5F5;" align="center" + |• No data available to recommend adjuvant chemotherapy in these patients <br> • Observation recommended instead of adjuvant radiotherapy if patient has no risk factors
 
|-
It is still controversial whether to go for just lymph node sampling or dissection. Even if the surgeon does sampling, it has to be done from multiple sites of lymph node groups draining the uterus. It is vital for surgical staging purposes to have atleast lymph node sampling done during surgery, if not dissection.
| style="background:#DCDCDC;" align="center" + |High risk
 
| style="background:#F5F5F5;" align="center" + |• Stage III or higher  or <br> • Any stage with serous or clear cell carcinoma
Risk of [[lymphedema]] increases as more lymph nodes are resected (>10 is associated with a risk of lymphedema of 3-10%). So, it is logical to have risk versus benefit assessment before going for dissection. 
| style="background:#F5F5F5;" align="center" + |• For stage I and II, surgery may be followed by adjuvant vaginal [[brachytherapy]] <br> • For stage III and IV, surgery should be followed by adjuvant chemotherapy and pelvic radiotherapy
 
| style="background:#F5F5F5;" align="center" + |Giving adjuvant brachytherapy for the high risk early staged tumors depends on patient and provider preferences
The primary treatment is surgical.  Surgical treatment should consist of, at least, cytologic sampling of the peritoneal fluid, abdominal exploration, palpation and biopsy of suspicious lymph nodes, abdominal [[hysterectomy]], and removal of both [[ovary|ovaries]] (bilateral salpingo-oophorectomy).  Lymphadenectomy, or removal of pelvic and para-aortic lymph nodes, is sometimes performed for tumors that have high risk features, such as pathologic grade 3 serous or clear-cell tumors, invasion of more than 1/2 the myometrium, or extension to the cervix or adnexa.  Sometimes, removal of the [[omentum]] is also performed.
|}
 
[[Hysterectomy|Abdominal hysterectomy]] is recommended over [[Hysterectomy|vaginal hysterectomy]] because it affords the opportunity to examine and obtain washings of the abdominal cavity to detect any further evidence of cancer.
 
===Radiation therapy===
Women with stage 1 disease who are at increased risk for recurrence and those with stage 2 disease are often offered surgery in combination with [[radiation therapy]].


==References==
==References==
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Latest revision as of 16:40, 29 November 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Roukoz A. Karam, M.D.[2]

Overview

Surgery is the mainstay of treatment for endometrial cancer stage I-III.

Surgery

  • Surgery is the first-line treatment option for patients with endometrial cancer especially if no metastasis is suspected.
  • The treatment approach is based on staging, pathology, and histologic features of the cancer:[1][2]
Risk Risk definition Management Additional notes
Low risk • Stage IA endometrial cancer
• Well differentiated endometroid histology
• Tumor confined to endometrium 		Total hysterectomy, bilateral salpingo-oophorectomy, and lymph node evaluation • Women that opt for preservation of fertility may be candidates for medical therapy
• Adjuvant therapy not indicated
Intermediate risk • Stage I (tumor invades myometrium) or
• Stage II (tumor demonstrates cervical stroma invasion)
• Tumor usually moderately differentiated or poorly differentiated 		• Total hysterectomy, bilateral salpingo-oophorecomy, and lymph node evaluation
• Adjuvant radiotherapy is indicated for patients with risk factors 		• No data available to recommend adjuvant chemotherapy in these patients
• Observation recommended instead of adjuvant radiotherapy if patient has no risk factors
High risk • Stage III or higher or
• Any stage with serous or clear cell carcinoma 		• For stage I and II, surgery may be followed by adjuvant vaginal brachytherapy
• For stage III and IV, surgery should be followed by adjuvant chemotherapy and pelvic radiotherapy 		Giving adjuvant brachytherapy for the high risk early staged tumors depends on patient and provider preferences

References

  1. ↑ Grigsby PW, Perez CA, Kuten A, Simpson JR, Garcia DM, Camel HM; et al. (1992). "Clinical stage I endometrial cancer: prognostic factors for local control and distant metastasis and implications of the new FIGO surgical staging system". Int J Radiat Oncol Biol Phys. 22 (5): 905–11. PMID 1555983.
  2. ↑ Connell PP, Rotmensch J, Waggoner SE, Mundt AJ (1999). "Race and clinical outcome in endometrial carcinoma". Obstet Gynecol. 94 (5 Pt 1): 713–20. PMID 10546716.


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