Oncology

Endometrial Cancer

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Minimally Invasive Surgery in Endometrial Cancer: Long-term Recurrence and Survival

clinical topic updates by David Scott Miller, MD, FACOG, FACS

Overview

Although not all patients are candidates for laparoscopic or robotic-assisted surgery, available data suggest that these minimally invasive gynecologic surgeries can offer advantages such as shorter hospital stays. New techniques are being evaluated in clinical trials as part of an ongoing effort to reduce morbidity without compromising long-term outcomes.

Expert Commentary

David Scott Miller, MD, FACOG, FACS

Amy and Vernon E. Faulconer Distinguished Chair in Medical Science
Dallas Foundation Chair in Gynecologic Oncology
Professor of Obstetrics and Gynecology
University of Texas Southwestern Medical Center
Dallas, TX

“In many institutions, robotic-assisted surgery is becoming the standard of care, and this approach has many advantages. . . . We hope that the ROCC trial will support the continued uptake of minimally invasive, robotic-assisted radical hysterectomy in cervical and other gynecological cancers.”

David Scott Miller, MD, FACOG, FACS

The Gynecologic Oncology Group's LAP2 study was one of the few randomized trials assessing the value of minimally invasive laparoscopy compared with that of open laparotomy. This study established that minimally invasive laparoscopy was feasible and safe. The operative time was longer with the minimally invasive approach than with the open laparotomy, but the hospital stays were shorter and the complications were fewer. Recurrence and survival outcomes were comparable to the open procedure. Since that time, minimally invasive surgery has become widely adopted. 

Based on the available evidence, the rate of minimally invasive surgery for early-stage endometrial cancers at high-volume centers in the last decade have been quite high (ie, approximately ≥80%), which may reflect the uptake of robotic-assisted surgery rather than laparoscopic surgery. In many institutions, robotic-assisted surgery is becoming the standard of care, and this approach has many advantages, including greater comfort for the surgeon, increased visibility during the procedure, and a greater ability to perform a more directed and nimble dissection. However, there are some concerns in that high-quality studies comparing robotic vs nonrobotic approaches in endometrial cancer are limited and results are conflicting.

Minimally invasive surgery is not for every patient. In those with more advanced disease, our practice is often dictated by what we anticipate will be involved, on more of a case-by-case basis. So, for example, if we have high confidence that it is safe to use minimally invasive surgery to remove the tumors and lymph nodes, then we may try to use a minimally invasive approach.

Additionally, data that emerged from the LACC trial have caused controversy and have raised concerns about minimally invasive surgery in gynecologic oncology. Ramirez et al reported that minimally invasive radical hysterectomy was not as successful as open abdominal radical hysterectomy for cervical cancer, with a 4.5-year disease-free survival (DFS) rate of 86% with the minimally invasive approach and 96.5% with the open surgical approach. Several hypotheses have been advanced as possible explanations. Criticisms of the LACC trial include the lack of proper preoperative imaging and assessment, the use of transcervical uterine manipulators, and the lack of proper tumor containment leading to peritoneal contamination. Some of the techniques used to contain the tumor are a bit more challenging to perform in laparoscopic or robotic-assisted surgeries than in open abdominal radical hysterectomy, so one hypothesis is that containment may underlie the observed differences in DFS rates in LACC.

Fortunately, the ROCC trial (ROCC/GOG-3043) is just getting underway. This study will incorporate several tumor containment measures into the robotic-assisted radical hysterectomy group and will compare outcomes with open radical hysterectomy. The hypothesis is that robotic-assisted radical hysterectomy with tumor containment prior to colpotomy will be noninferior to abdominal radical hysterectomy with respect to DFS. We hope that the ROCC trial will support the continued uptake of minimally invasive, robotic-assisted radical hysterectomy in cervical and other gynecological cancers.

References

Aloisi A, Tseng JH, Sandadi S, et al. Is robotic-assisted surgery safe in the elderly population? An analysis of gynecologic procedures in patients ≥ 65 years old. Ann Surg Oncol. 2019;26(1):244-251. doi:10.1245/s10434-018-6997-1

Argenta PA, Mattson J, Rivard CL, Luther E, Schefter A, Vogel RI. Robot-assisted versus laparoscopic minimally invasive surgery for the treatment of stage I endometrial cancer. Gynecol Oncol. 2022;165(2):347-352. doi:10.1016/j.ygyno.2022.03.007

Bergstrom J, Aloisi A, Armbruster S, et al. Minimally invasive hysterectomy surgery rates for endometrial cancer performed at National Comprehensive Cancer Network (NCCN) centers. Gynecol Oncol. 2018;148(3):480-484. doi:10.1016/j.ygyno.2018.01.002

Bixel KL, Leitao MM, Chase DM, et al. ROCC/GOG-3043: a randomized non-inferiority trial of robotic versus open radical hysterectomy for early-stage cervical cancer. J Clin Oncol. 2022;40(suppl 16):TPS5605. doi:10.1200/JCO.2022.40.16suppl.TPS5605

ClinicalTrials.gov. A trial of robotic versus open hysterectomy surgery in cervix cancer (ROCC). Updated April 18, 2023. Accessed June 5, 2023. https://clinicaltrials.gov/ct2/show/NCT04831580

Eoh K-J, Nam E-J, Kim S-W, et al. Nationwide comparison of surgical and oncologic outcomes in endometrial cancer patients undergoing robotic, laparoscopic, and open surgery: a population-based cohort study. Cancer Res Treat. 2021;53(2):549-557. doi:10.4143/crt.2020.802

Kornblith AB, Huang HQ, Walker JL, Spirtos NM, Rotmensch J, Cella D. Quality of life of patients with endometrial cancer undergoing laparoscopic International Federation of Gynecology and Obstetrics staging compared with laparotomy: a Gynecologic Oncology Group study [published correction appears in J Clin Oncol. 2010;28(16):2805]. J Clin Oncol. 2009;27(32):5337-5342. doi:10.1200/JCO.2009.22.3529

Koskas M, Jozwiak M, Fournier M, et al. Long-term oncological safety of minimally invasive surgery in high-risk endometrial cancer. Eur J Cancer. 2016;65:185-191. doi:10.1016/j.ejca.2016.07.001

Ramirez PT, Frumovitz M, Pareja R, et al. Minimally invasive versus abdominal radical hysterectomy for cervical cancer. N Engl J Med. 2018;379(20):1895-1904. doi:10.1056/NEJMoa1806395

Walker JL, Piedmonte MR, Spirtos NM, et al. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group study LAP2. J Clin Oncol. 2009;27(32):5331-5336. doi:10.1200/JCO.2009.22.3248

Walker JL, Piedmonte MR, Spirtos NM, et al. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 study. J Clin Oncol. 2012;30(7):695-700. doi:10.1200/JCO.2011.38.8645 

David Scott Miller, MD, FACOG, FACS

Amy and Vernon E. Faulconer Distinguished Chair in Medical Science
Dallas Foundation Chair in Gynecologic Oncology
Professor of Obstetrics and Gynecology
University of Texas Southwestern Medical Center
Dallas, TX

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