Past, Present and Future Perspectives on the Management of Endometrial Cancer— A Comprehensive Review

Abstract

Despite the vast majority of patients diagnosed with endometrial cancer present to clinical attention with early stage disease limited to uterus, metastatic disease is recognized in a substantial proportion when comprehensive surgical staging is carried out [9]. In 1988, the International Federation of Gynecologists and Obstetricians (FIGO) officially suggested surgical staging as part of the primary management plan for endometrial cancer. Despite the recent amendments of the staging system in 2009, comprehensive staging (total hysterectomy, bilateral salpingooophorectomy, peritoneal cytology, intraoperative bilateral pelvic and paraaortic lymph node dissection) continue to be recommended [10-12]. The major advantages of comprehensive surgical staging are directly related to the diagnosis, prognosis, and proper categorization of patients who may benefit from adjuvant therapy. FIGO endometrial cancer staging is chiefly based on surgical pathology and comprehensive surgery permits accurate delineation of disease extent. 2.1. The role of laparotomy, conventional laparoscopy and robotic-assisted laparoscopy in management of endometrial cancer Conventionally, laparotomy has been the primary mode for surgical staging in patients with endometrial cancer [10-12]. However, several studies examined the practicality of minimally invasive approaches such as laparoscopy for surgical staging of endometrial cancer [13,14]. Afterwards, randomized controlled trials endeavored to compare laparotomy versus conventional laparoscopic approaches. In Gynecologic Oncology Group Study (GOG) LAP2, more than 2000 patients with endometrial cancer were randomized to receive comprehensive surgical staging via conventional laparoscopy or laparotomy [15]. Conventional laparoscopic arm experienced fewer post-surgery complications (14% vs 21%, respectively; p=0.0001), shorter hospitalization rates over 2 days (52% vs 94%, respectively; p=0.0001), however, longer operating periods (204 minutes vs 130 minutes, respectively; p=0.001). The incidence of intraoperative adverse events was similar. Operative conversion from conventional laparoscopy to laparotomy happened in roughly 17.5% of patients with body mass index (BMI) of 25, and 26.5% of patients with BMI of 35 and above, mainly due to poor surgical exploration. Over the 6-week recovery period, the conventional laparoscopic arm patients articulated much higher scores on multiple quality-of-life aspects (less pain, more cosmetics, faster resumption of daily and social activities) [16]. A recently published meta-analysis of survival data compiling 3 randomized controlled clinical trials did identify survival differences between the surgical approaches in patients receiving the conventional laparoscopy and laparotomy for surgical staging of endometrial cancer [17]. A secondary survival analysis showed largely comparable 5-year overall survival rate (around 90% in both groups) and 3-year recurrence rate (around 11% vs 10% in conventional laparoscopy and laparotomy groups, respectively). Based on thes...