Surgical Management of Early Endometrial Cancer: An Update and Proposal of a Therapeutic Algorithm

Abstract

In the last few years technical improvements have produced a dramatic shift from traditional open surgery towards a minimally invasive approach for the management of early endometrial cancer. Advancement in minimally invasive surgical approaches has allowed extensive staging procedures to be performed with significantly reduced patient morbidity. Debate is ongoing regarding the choice of a minimally invasive approach that has the most effective benefit for the patients, the surgeon, and the healthcare system as a whole.Surgical treatment of women with presumed early endometrial cancer should take into account the features of endometrial disease and the general surgical risk of the patient. Women with endometrial cancer are often aged, obese, and with cardiovascular and metabolic comorbidities that increase the risk of peri-operative complications, so it is important to tailor the extent and the radicalness of surgery in order to decrease morbidity and mortality potentially derivable from unnecessary procedures. In this regard women with negative nodes derive no benefit from unnecessary lymphadenectomy, but may develop short- and long-term morbidity related to this procedure. Preoperative and intraoperative techniques could be critical tools for tailoring the extent and the radicalness of surgery in the management of women with presumed early endometrial cancer. In this review we will discuss updates in surgical management of early endometrial cancer and also the role of preoperative and intraoperative evaluation of lymph node status in influencing surgical options, with the aim of proposing a management algorithm based on the literature and our experience.

Usefulness of DWI in preoperative assessment of deep myometrial invasion in patients with endometrial carcinoma: a systematic review and meta-analysis

“…Although some studies (ASTEC, Benedetti-Panici) [ 54 ],[ 55 ] showed no therapeutic benefit of combined pelvic and para-aortic lymphadenectomy for patients with endometrial cancer, these studies had some limitations. While in the ASTEC study, the follow-up period was short, lymphadenectomy was selective rather than systematic (nine or fewer lymph nodes were removed in 35% of patients in the lymphadenectomy group), neither of the studies included para-aortic lymphadenectomy [ 56 ],[ 57 ], which is an important site of endometrial carcinoma metastases as confirmed by sentinel lymph node investigation [ 58 ], and subsequent radiation was not tailored to the nodal status. Hence, it is difficult to draw any definite conclusion from these studies.…”

Fertility preserving treatment with hysteroscopic resection followed by progestin therapy in young women with early endometrial cancer

“…The current therapeutic standard in an early stage EC is preclusive of fertility and consists of staging total hysterectomy, bilateral salpingo-oophorectomy, and eventual pelvic and aortic lymphadenectomy [12]. …”

Chronic Morbidity in Patients with Endometrial Cancer who Received Adjuvant Radiotherapy

“…The surgical specimen will provide data such as depth of invasion, lymphovascular invasion, tumor size, and extrauterine disease (lymphadenectomy and peritoneum biopsy). Therefore, the risk of recurrence of each patient can be estimated, and then a risk-benefit analysis of adjuvant treatment can be performed [8][9].…”