Survival after Laparoscopy in Women with Endometrial Cancer
Abstract & Commentary
Synopsis: Although longer follow-up is needed, the survival of women with early-stage endometrial cancer does not appear to be worsened by laparoscopy.
Source: Eltabbakh, GH. Cancer. 2002;95:1894-1901.
Eltabbakh retrospectively reviewed women presenting with clinical stage I endometrial cancer (according to the 1988 FIGO staging) at the University of Vermont. Women treated with laparoscopic surgery were compared with those treated with laparotomy with regard to their characteristics, surgical procedure, treatment, surgical stage, histology, tumor grade, and recurrence-free and overall survival. Factors affecting survival (surgical approach, histology, grade, and surgical stage) were evaluated using multivariate analysis. One hundred women underwent laparoscopy, and 86 underwent laparotomy from January 1996 through June 2001. Both groups were similar with regard to age, parity, menopausal status, lymphadenectomy, surgical stage, tumor grade, histology, and postoperative radiation therapy. Women who underwent laparoscopy and those who underwent laparotomy had similar 2-year and 5-year estimated recurrence-free survival rates (93% vs 94% and 90% vs 92%, respectively), as well as similar 2-year and 5-year overall survival rates (98% vs 96% and 92% vs 92%, respectively). There was no apparent difference with regard to the sites of recurrence between both groups. In univariate and multivariate analyses, surgical stage, tumor grade, and histology (but not the surgical approach) were found to have a significant effect on survival. Eltabbakh concluded that, although longer follow-up is needed, the survival of women with early-stage endometrial cancer does not appear to be worsened by laparoscopy. As one would expect, surgical stage, tumor histology, and tumor grade were found to significantly affect survival regardless of the surgical approach used.
Comment by David M. Gershenson, MD
Surgery remains the cornerstone of treatment for endometrial cancer. With the innovations in optics and equipment associated with laparoscopy over the past decade or so, new surgical approaches using LAVH + BSO and surgical staging have been explored by several groups worldwide. Since the early 1990s, several of these groups, including Dr. Eltabbakh’s, have reported their experience in patients with early-stage endometrial cancer. A summary of the literature to date suggests that, compared with laparotomy, laparoscopic surgery for endometrial cancer is feasible, is associated with shorter length of hospital stays and less time off work, is associated with equivalent complication rates, and is associated with an enhanced quality of life. Furthermore, these groups have demonstrated that comprehensive surgical staging with bilateral pelvic lymphadenectomy and paraaortic lymphadenectomy is also feasible and results in resection of an equivalent number of lymph nodes compared with laparotomy. Some reports have also documented that laparoscopic surgery for endometrial cancer is safe in obese patients and in elderly patients. Based on encouraging information arising from these early reports, the Gynecologic Oncology Group (GOG) initiated a large randomized trial (Lap 2) comparing laparoscopic surgery with traditional laparotomy in women with early-stage endometrial cancer. Although this study is accruing patients at a very high rate, it will likely be a few years before we have mature data regarding sites of recurrence and overall survival. Other small studies have demonstrated equivalent survival rates in patients undergoing laparoscopic surgery vs laparotomy for endometrial cancer. To my knowledge, this is the largest study reported to date. However, the median duration of follow-up among women in the laparoscopy group was only 27 months—too brief to make a determination. In addition, the study is retrospective and likely does not include a large enough number of patients to demonstrate a difference in survival. It should be noted that there have not been any port site recurrences in the present study thus far. The findings of this study are of great interest, but only with the completion of the GOG’s Lap 2 will the survival issue be definitively answered.
Dr. Gershenson is Professor and Chairman Department of Gynecology M.D. Anderson Cancer Center, Houston.