Endometrial cancer surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
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.
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.
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.
When to resect lymph nodes?
If the following are present-
- Serous, clear cell or high grade tumor.
- Myometrial invasion >50%
- Large tumor ,i.e >2cm in diameter.
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.
Para-aortic lymph node dissection
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.
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.
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.
Lymphovascular invasion predicts well whether the cancer has spread to the parametrium or not. Earlier, the spread of endometrial cancer to the cervix was considered to be a sign of parametrial extension and patients had undergone radical hysterectomy. With this knowledge, one can now have simple hysterectomy in stage II cancer.
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 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.
Abdominal hysterectomy is recommended over 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.