Laparoscopic surgery does not increase the positive peritoneal cytology among women with endometrial carcinoma

Utilization of literature review to evaluate peritoneal cytology as a test for the detection of malignant cells in the peritoneal cavity is limited by the size of the study populations, varied use of preoperative radiation, the lack of consistent methodology for specimen retrieval and processing, and the inherent subjectivity of cytologic interpretation. A standardized methodology for retrieval and processing of peritoneal cytologic specimens should be developed to allow meaningful comparisons of future studies. However, certain conclusions are permitted from published data: 1. The incidence of positive peritoneal cytology is 11.4 per cent among 3091 patients with FIGO stage I endometrial cancer. 2. The depth of the uterus does not influence the incidence of positive peritoneal cytology. 3. Positive peritoneal cytology is predictive of other known prognostic factors including advanced histologic grade, depth of myometrial invasion, and pelvic/periaortic lymph node metastases. 4. The presence of malignant cells in the peritoneal washings from some patients with no myometrial invasion and the high incidence of lymph node metastases in other patients with positive peritoneal cytology suggest that malignant cells gain access to the peritoneal cavity in a variety of ways. It is unclear whether each of these modes of access result in viable tumor cells with the potential for viable metastasis. The high incidence of lymph node metastasis in such patients suggests that lymphatic dissemination of malignant cells plays a significant role in the development of positive peritoneal cytology. In this setting positive peritoneal cytology clearly identifies that individual at high risk for recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

SUMMARYOBJECTIVE:The objective of the study was to evaluate perioperative and oncologic outcomes of laparoscopy without the use of uterine manipulators and laparotomy in high-grade and serous endometrial cancer.METHODS:Patients with grade III endometrioid adenocarcinoma and serous carcinoma between 2018 and 2022 were included in the study. Preoperative staging with positron emission tomography/computed tomography or thoracoabdominal computed tomography and pelvic magnetic resonance imaging was performed. All patients underwent staging surgery including hysterectomy, bilateral salpingo-oophorectomy, peritoneal washing, omentectomy, and pelvic and paraaortic lymphadenectomy up to the renal vein. No uterine manipulator was used for laparoscopic hysterectomy. Age, CA 125 level, body mass index, accompanying diseases, pathologic data including stage, lymphovascular invasion, number of pelvic and paraaortic lymph nodes, and surgical data including surgical time, surgical complications, and adjuvant therapies were collected from the hospital database retrospectively.RESULTS:Notably, 89 patients were included in the study: 34 underwent laparotomy and 55 underwent laparoscopy. Surgical times were similar between the groups. The mean pelvic lymph node count in the laparotomy and laparoscopy groups was 33 and 34, respectively. The mean paraaortic lymph node counts in the laparotomy and laparoscopy groups were 23 and 22, respectively. Red blood cell transfusion, hemorrhage, urinary tract infection, postoperative fever, bladder atony, bladder injury, and chylous leakage showed no significant differences between the groups. However, ileus, intestinal injury, and evisceration were significantly higher in the laparotomy group. Hospital stay was significantly longer in the laparotomy group compared with the laparoscopy group. Overall and recurrence-free survival were similar between the groups.CONCLUSION:Laparoscopic surgery, performed without manipulators, provides comparable oncologic outcomes to open surgery in the treatment of high-grade endometrial cancer, while also offering improved perioperative results.

Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis

Peritoneal cytology: impact on disease-free survival in clinical stage I endometrioid adenocarcinoma of the uterus

BackgroundCervical cancer (CC) occupies fourth place in cancer incidence and mortality worldwide in women, with 560,505 new cases and 284,923 deaths per year. Approximately, nine of every ten (87%) take place in developing countries. When a macroscopic nodal involvement is discovered during a radical hysterectomy (RH), there is controversy in the literature between resect macroscopic lymph node compromise or abandonment of the surgery and sending the patient for standard chemo-radiotherapy treatment. The objective of this study is to compare the prognosis of patients with CC whom RH was abandoned and bilateral pelvic lymphadenectomy and para-aortic lymphadenectomy was performed with that of patients who were only biopsied or with removal of a suspicious lymph node, treated with concomitant radiotherapy/chemotherapy in the standard manner.MethodsA descriptive and retrospective study was conducted in two institutions from Mexico and Colombia. Clinical records of patients with early-stage CC programmed for RH with an intraoperative finding of pelvic lymph, para-aortic nodes, or any extracervical involvement that contraindicates the continuation of surgery were obtained. Between January 2007 and December 2012, 42 clinical patients complied with study inclusion criteria and were selected for analysis.ResultsIn patients with CC whom RH was abandoned due to lymph node affectation, there is no difference in overall survival or in disease-free period between systematic lymphadenectomy and tumor removal or lymph node biopsy, in pelvic lymph nodes as well as in para-aortic lymph nodes, when these patients receive adjuvant treatment with concomitant radiotherapy/chemotherapy.ConclusionsThis is a hypothesis-generator study; thus, the recommendation is made to conduct randomized prospective studies to procure better knowledge on the impact of bilateral pelvic and para-aortic lymphadenectomy on this group of patients.

Positive peritoneal cytology is an independent risk-factor among women diagnosed with endometrial cancer confined to the uterus

Positive peritoneal cytology is highly predictive of prognosis and relapse patterns in stage III (FIGO 2009) endometrial cancer

To investigate the impact of surgical resection extent and other clinicopathological characteristics on the prognosis in patients with clinical stage I endometrial carcinoma. The data of 135 surgically treated patients with clinical stage I endometrial carcinoma were retrospectively analyzed. Fifty-seven patients (group A) underwent simple hysterectomy and salpingo-oophorectomy with or without pelvic lymphadenectomy. The other 78 patients (group B) received sub-radical or radical hysterectomy and salpingo-oophorectomy with or without pelvic lymphadenectomy. The impact of surgery extent and other clinicopathological characteristics on the prognosis in patients with clinical stage I endometrial carcinoma were retrospectively analyzed. There were no significant differences between two groups in the pathological stage, pathologic type, tumor grade, depth of myometrial invasion, vascular tumor emboli, ovary invasion, lymph node metastasis, positive peritoneal cytology and adjuvant therapy (P > 0.05). However, the patients in group A had a significantly shorter operating time (105 vs. 145 min), less estimated blood loss (150 vs. 300 ml) and blood transfusion (0 approximately 600 vs. 0 approximately 1200 ml), and a shorter postoperative hospital stay (12 vs. 13 days) than that in group B (all P < 0.05). The overall rates of post-operative complications were 15.8% in group A versus 26.9% in group B (P > 0.05). The recurrence rate in the group A was 14.0% versus 6.4% in group B (P > 0.05). Furthermore, the five-year survival rate in group A was 76.9% versus 85.8% in group B (P > 0.05). Multivariate analysis demonstrated that the important risk factors for clinical stage I endometrial carcinoma were deep myometrium invasion, high pathological grade, positive peritoneal cytology and ovarian metastasis, rather than surgical resection extent. Surgery extent is not an important factor affecting the prognosis in patients with clinical stage I endometrial carcinoma, and extended surgery does not improve their survival. Therefore, excessive resection should be avoided in such cases.

To highlight the significance of positive peritoneal cytology in uterine papillary serous carcinoma (UPSC). Seventeen consecutive UPSC cases with peritoneal cytology from 1993 to 1997 were reviewed and compared with the original cytologic diagnosis and extent of tumor involvement in tissues. Of the 17 post-menopausal women with UPSC, 11 had early-stage tumors (clinical stage I and II); three cases (27%) with positive peritoneal cytology were upgraded from at least International Federation of Gynecologists and Obstetricians stage IA to IIIA. No change in surgical stage was noted in four of six (67%) advanced cases with positive peritoneal cytology. The review diagnoses of peritoneal cytology did not differ from the original diagnoses. The features of UPSC in peritoneal cytology are those of a high grade malignancy and may be shared by tumors with similar histology from other sites. The malignant features are readily identified, but the site of origin may not be completely ensured. Positive peritoneal cytology upgrades the surgical stage of early-stage UPSC cases and helps with prognostication and treatment. One case with positive washings but without residual tumor probably represented early spread and/or multicentric origin of the tumor.

The aim of this study was to evaluate the relationship between preoperative hemoglobin and platelet count and prognostic factors in patients with endometrial cancer. Sixty-one patients with endometrial carcinoma who underwent surgical treatment consisting of total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, pelvic and para-aortic lymph node dissection, and peritoneal cytology were retrospectively analyzed. Preoperative hemoglobin and platelet count, pelvic and para-aortic lymph node status, depth of myometrial invasion, grade, lymphovascular invasion (LVSI), adnexal involvement, positive peritoneal cytology, cervical stromal invasion, and tumor size were investigated. Kruskal-Wallis, Mann-Whitney U, Fishers Exact and Chi-square tests were used for univariate analyses. The multivariate analysis was performed with logistic regression analyses. Twenty-six (42.6%) patients had a pre-treatment hemoglobin value of < or =12 g/dL. These 26 patients had significantly higher rates of positive cytology (P = 0.008), advanced FIGO stage (P = 0.03), omental metastases (P = 0.01), cervical involvement (P = 0.02), and thrombocytosis (P = 0.02). The multivariate analysis revealed cervical involvement (P = 0.019, OR = 4.030, 95% CI = 1.255-12.947) and positive peritoneal cytology (P = 0.022, OR = 12.509, 95% CI = 1.43-109.36) to be significantly associated with low hemoglobin level. In the univariate analysis, the presence of cervical involvement and lymphatic metastasis were associated with significantly higher median preoperative platelet counts. Low pre-treatment hemoglobin level may reflect poor prognostic factors such as positive cytology and cervical involvement in patients with endometrial cancer that is associated with thrombocytosis.

The objective of this study was to determine if total laparoscopic hysterectomy using a uterine manipulator with an intrauterine balloon increases the risk of positive peritoneal washings in patients with endometrial cancer. Three sets of peritoneal washings were obtained during surgery from 46 women with endometrial cancer at the Center for Uterine Cancer, National Cancer Center, Korea, between May 2004 and July 2006: the first before the insertion of the uterine manipulator (premanipulator), the second after clipping the fallopian tubes and inserting the uterine manipulator (postmanipulator), and the third after the removal of the uterus through the vagina (posthysterectomy). The cytology samples were examined by the same cytopathologist for the presence of malignant cells. Two of 46 (4.3%) patients were upstaged to IIIA disease due to positive cytology conversion after the insertion of the uterine manipulator, one after the insertion of the uterine manipulator, and the other after the hysterectomy. However, during the follow-up for 3-28 months (median 18), neither of the 2 patients experienced a tumor recurrence. In conclusion, using a uterine manipulator with an intrauterine balloon during the laparoscopic surgery for endometrial cancer might be associated with positive cytologic conversion. Possible explanations are retrograde seeding of tumor cells into the peritoneal cavity, the pressure effect of the inflatable manipulator tip, and spillage of preexited tumor cells between the isthmus and the fimbriae. More effective preventive methods such as distal tubal clipping or coagulation of the fimbriae may be necessary in treating women with endometrial cancer.

Lymphovascular Space Invasion Is an Important Prognostic Factor for Lymph Node Metastases in Endometrioid Endometrial Cancer

Serous endometrial intraepithelial carcinoma is the precursor of invasive uterine serous carcinoma. Here, we present two cases of serous endometrial intraepithelial carcinoma with omental micrometastasis and discuss their clinical significance. Two menopausal patients with abnormal endometrial biopsy findings underwent hysterectomy and comprehensive surgical staging (bilateral salpingo-oophorectomy, omentectomy, and pelvic and para-aortic lymphadenectomy). Although gross examination failed to detect tumors, the pathological diagnosis was serous endometrial intraepithelial carcinoma. Both patients had omental micrometastasis; they were diagnosed with International Federation of Gynecology and Obstetrics stage IVB disease and received postoperative chemotherapy. One patient died of the carcinoma 9 months after the hysterectomy, and the other had a recurrence of carcinoma 17 months after the end of the initial therapy. The present cases and literature review highlight the importance of meticulous inspection for micrometastasis in the abdominal cavity, including the omentum and peritoneum, for predicting prognosis.

Objective:We aimed to analyze variables affecting lymph node (LN) involvement and to assess the need for systematic lymphadenectomy in patients with endometrial cancer (EC).Materials and Methods:A single centre retrospective analysis was conducted in a total of 128 consecutive patients with EC who underwent systematic pelvic or combined pelvic and paraaortic lymphadenectomy between 2009 and 2012. Mann-Whitney U, chi-square, and Fisher’s exact test were used for univariate analyses when appropriate. Variables with a p value <0.05 in the univariate analysis were included into a multivariate logistic regression analysis. The effects of variables on LN involvement are reported using adjusted odds ratios (ORs) and 95% confidence intervals (CI).Results:In univariate analysis, grade 2-3, tumor size ≥3 cm, deep (≥50%) myometrial invasion, presence of cervical, adnexal or omental involvement, positive peritoneal cytology, open surgical approach (laparotomy), combined pelvic and paraaortic lymphadenectomy and number of total LNs removed (>30) were found associated with LN involvement. However, the number of total LNs removed (>30) was the only independent variable that predict LN involvement in multivariate analysis [OR: 15.08; 95% CI: (1.28-177.59); p=0.03].Conclusion:This study demonstrates that the more LNs removed during staging of EC, the greater the probability of finding LN metastasis.

Endometrial carcinoma (EC) is one of the most common gynecological malignancies. Its incidence rate has been increasing year by year. The prognostic factors and treatment strategies of EC have aroused wide concern. The effects of peritoneal cytology on the prognosis and treatment of EC remain controversial. Some factors, such as differentiation degree, muscle invasion, and tumor size, are related to positive peritoneal cytology. Hysteroscopy is commonly used in the diagnosis and treatment of endometrial cancer, but hysteroscopic surgery may cause the tumor to spread into the abdominal cavity, resulting in positive peritoneal cytology. In this review, we discuss the factors related to positive peritoneal cytology and the influence of positive peritoneal cytology on the prognosis of endometrial cancer. Suspicious positive peritoneal cytology may be an independent risk factor for endometrial cancer. The positive rate of peritoneal tumor cells in type II endometrial cancer is higher than other cells and is an independent risk factor for type II endometrial cancer. We also discuss the effects of peritoneal cytology on treatment decisions. Aggressive treatments seem to be more beneficial for patients with positive ascites cytology, but there is a lack of large-scale prospective clinical studies on their effectiveness and safety. The application of peritoneal cytology for endometrial cancer has been decreased in recent years. We believe that peritoneal cytology is necessary for this type of cancer. However, more studies on peritoneal cytology in endometrial cancer should be carried out.