Introduction of robotic surgery for endometrial cancer into a Brazilian cancer service: a randomized trial evaluating perioperative clinical outcomes and costs

OBJECTIVE: The purpose of this study was to evaluate the clinical outcome and costs after the implementation of robotic surgery in the treatment of endometrial cancer, compared to the traditional laparoscopic approach. METHODS: In this prospective randomized study from 2015 to 2017, eighty-nine patients with endometrial carcinoma that was clinically restricted to the uterus were randomized in robotic surgery (44 cases) and traditional laparoscopic surgery (45 cases). We compared the number of retrieved lymph nodes, total time of surgery, time of each surgical step, blood loss, length of hospital stay, major and minor complications, conversion rates and costs. RESULTS: The ages of the patients ranged from 47 to 69 years. The median body mass index was 31.1 (21.4-54.2) in the robotic surgery arm and 31.6 (22.9-58.6) in the traditional laparoscopic arm. The median tumor sizes were 4.0 (1.5-10.0) cm and 4.0 (0.0-9.0) cm in the robotic and traditional laparoscopic surgery groups, respectively. The median total numbers of lymph nodes retrieved were 19 (3-61) and 20 (4-34) in the robotic and traditional laparoscopic surgery arms, respectively. The median total duration of the whole procedure was 319.5 (170-520) minutes in the robotic surgery arm and 248 (85-465) minutes in the traditional laparoscopic arm. Eight major complications were registered in each group. The total cost was 41% higher for robotic surgery than for traditional laparoscopic surgery. CONCLUSIONS: Robotic surgery for endometrial cancer presented equivalent perioperative morbidity to that of traditional laparoscopic surgery. The duration and total cost of robotic surgery were higher than those of traditional laparoscopic surgery.

A novel model to estimate lymph node metastasis in endometrial cancer patients

OBJECTIVES: To evaluate the postoperative pathological characteristics of hysterectomy specimens, preoperative cancer antigen (CA)-125 levels and imaging modalities in patients with endometrial cancer and to build a risk matrix model to identify and recruit patients for retroperitoneal lymphadenectomy. METHODS: A total of 405 patients undergoing surgical treatment for endometrial cancer were retrospectively reviewed and analyzed. Clinical (age and body mass index), laboratory (CA-125), radiological (lymph node evaluation), and pathological (tumour size, grade, lymphovascular space invasion, lymph node metastasis, and myometrial invasion) parameters were used to test the ability to predict lymph node metastasis. Four parameters were selected by logistic regression to create a risk matrix for nodal metastasis. RESULTS: Of the 405 patients, 236 (58.3%) underwent complete pelvic and para-aortic lymphadenectomy, 96 (23.7%) underwent nodal sampling, and 73 (18%) had no surgical lymph node assessment. The parameters predicting nodal involvement obtained through logistic regression were myometrial infiltration >50%, lymphovascular space involvement, pelvic lymph node involvement by imaging, and a CA-125 value >21.5 U/mL. According to our risk matrix, the absence of these four parameters implied a risk of lymph node metastasis of 2.7%, whereas in the presence of all four parameters the risk was 82.3%. CONCLUSION: Patients without deep myometrial invasion and lymphovascular space involvement on the final pathological examination and with normal CA-125 values and lymph node radiological examinations have a relatively low risk of lymph node involvement. This risk assessment matrix may be able to refer patients with high-risk parameters necessitating lymphadenectomy and to decide the risks and benefits of lymphadenectomy.

Surgical treatment of endometrial cancer in developing countries: reasons to consider systematic two-step surgical treatment

OBJECTIVE : The aim of this study was to determine the lymph node status in a large cohort of women with endometrial cancer from the public health system who were referred to an oncology reference center in Brazil to identify candidates for the omission of lymphadenectomy based on clinicopathological parameters. METHODS : We retrospectively analyzed a cohort of 310 women with endometrial cancer (255 endometrioid, 40 serous, and 15 clear cell tumors) treated between 2009 and 2014. We evaluated the histological type, grade (low vs. high), tumor size (cm), depth of myometrial invasion (≤50%, >50%) and lymphovascular space invasion to determine which factors were correlated with the presence of lymph node metastasis. RESULTS : The factors related to lymph node involvement were tumor size (p=0.03), myometrial invasion (p<0.01), tumor grade (p<0.01), and lymphovascular space invasion (p<0.01). The histological type was not associated with the nodal status (p=0.52). Only twelve of 176 patients (6.8%) had low-grade endometrioid carcinoma, tumor size ≤2 cm and <50% myometrial infiltration. CONCLUSIONS : The omission of lymphadenectomy based on the histological type, grade, tumor size and depth of myometrial invasion is not likely to have a large impact on the surgical treatment of endometrial cancer in our population because most patients present with large and advanced tumors. New strategies are proposed that prioritize hysterectomy performed in a general hospital as soon as possible after diagnosis, followed by an evaluation of the need for lymph node dissection at a reference center. .

Avaliação do risco de metástases linfonodais no câncer do endométrio, através de parâmetros clínicos, laboratoriais, radiológicos e anatomopatológicos / Risk assessment of lymph node metastasis in endometrial cancer through clinical, laboratory, radiological and anatomopathological parameters

INTRODUÇÃO: O câncer de endométrio é a sexta neoplasia maligna mais frequente nas mulheres no mundo. Com o crescimento mundial da obesidade, fator associado ao desenvolvimento do câncer de endométrio, estima-se que haja avanço no número de casos da doença. O tratamento cirúrgico do câncer de endométrio inclui a linfadenectomia pélvica e para-aórtica para o conhecimento do status linfonodal utilizado para determinação do tratamento adjuvante segundo a FIGO. Este é um procedimento que requer profissionais com treinamento cirúrgico avançado e não é isento de complicações. Algumas pacientes não se beneficiam da realização sistemática da linfadenectomia. O estudo das características clínicas, laboratoriais, radiológicas e anatomopatológicas das pacientes com câncer de endométrio em nossa população é fundamental para entendermos quais pacientes poderiam prescindir da linfadenectomia. MÉTODOS: Foram avaliadas 408 pacientes atendidas no Instituto do câncer do Estado de São Paulo entre janeiro de 2009 a março de 2015 com diagnóstico de carcinoma de endométrio submetidas ao tratamento cirúrgico. Foram avaliados parâmetros clínicos, laboratoriais, radiológicos e anatomopatológicos e sua capacidade de predizer metástases linfonodais. Foram construídas curvas Kaplan Meyer de sobrevivência. Além disso, as complicações relacionadas à realização da linfadenectomia também foram avaliadas. RESULTADOS: Das 405 pacientes elegíveis para o estudo 236(58,3%) foram submetidas à linfadenectomia pélvica e para-aórtica e não foi obtida amostra linfonadal em 73(18%). Os parâmetros significativos predição de acometimento linfonodal obtido através de regressão logística foram infiltração miometrial > 50%, presença de invasão linfovascular, presença de acometimento linfonodal pélvico por exame de imagem e CA125 > 21,5U/mL. A ausência dos quatro parâmetros implica em um risco de acometimento linfonodal de 2,7% enquanto que na presença de todos os quatro parâmetros o risco é de 82,3%....

BACKGROUND: Endometrial cancer is the sixth most common malignancy in women worldwide. Obesity is a factor associated with this type of cancer development. Thus, the increase of obesity among women leads to a higher number of endometrial cancer cases. The surgical treatment of endometrial cancer includes pelvic lymphadenectomy and para-aortic to the knowledge of lymph node status used for determining the adjuvant treatment according to FIGO. This procedure requires professionals with advanced surgical training and is associated to complication. Moreover, some patients do not benefit from systematic lymphadenectomy. The study of clinical, laboratory, radiological and pathological data of patients with endometrial cancer in our population is critical to understand which patients could dispense lymphadenectomy. METHODS: This study analyzed 408 patients with the diagnosis of endometrial carcinoma undergoing surgical treatment at the Sao Paulo Cancer Institute between January 2009 and March 2015. Clinical, laboratory, radiologic and pathologic parameters were used to test the ability to predict lymph node metastasis. In addition, Kaplan Meyer survival curves were constructed. Complications related to lymphadenectomy were also evaluated. RESULTS: Out of 405 patients eligible for the study, 236 (58.3%) underwent pelvic and para-aortic lymphadenectomy and 73 (18%) had no lymph node samples. Significant parameters prediction of lymph node involvement obtained through logistic regression were myometrium infiltration > 50%, lymphovascular space invasion, pelvic lymph node involvement by imaging and CA125 > 21,5U/mL. The absence of the four parameters implies a risk of lymph node metastasis of 2.7%, whereas in the presence of all four parameters the risk is 82.3%. The overall survival curves (p = 0.0001) and the disease-free survival curves (p = 0.0004), had a positive impact on patients undergoing lymphadenectomy compared to the subject without...

A comparison of CA125, HE4, risk ovarian malignancy algorithm (ROMA), and risk malignancy index (RMI) for the classification of ovarian masses

OBJECTIVE: Differentiation between benign and malignant ovarian neoplasms is essential for creating a system for patient referrals. Therefore, the contributions of the tumor markers CA125 and human epididymis protein 4 (HE4) as well as the risk ovarian malignancy algorithm (ROMA) and risk malignancy index (RMI) values were considered individually and in combination to evaluate their utility for establishing this type of patient referral system. METHODS: Patients who had been diagnosed with ovarian masses through imaging analyses (n = 128) were assessed for their expression of the tumor markers CA125 and HE4. The ROMA and RMI values were also determined. The sensitivity and specificity of each parameter were calculated using receiver operating characteristic curves according to the area under the curve (AUC) for each method. RESULTS: The sensitivities associated with the ability of CA125, HE4, ROMA, or RMI to distinguish between malignant versus benign ovarian masses were 70.4%, 79.6%, 74.1%, and 63%, respectively. Among carcinomas, the sensitivities of CA125, HE4, ROMA (pre-and post-menopausal), and RMI were 93.5%, 87.1%, 80%, 95.2%, and 87.1%, respectively. The most accurate numerical values were obtained with RMI, although the four parameters were shown to be statistically equivalent. CONCLUSION: There were no differences in accuracy between CA125, HE4, ROMA, and RMI for differentiating between types of ovarian masses. RMI had the lowest sensitivity but was the most numerically accurate method. HE4 demonstrated the best overall sensitivity for the evaluation of malignant ovarian tumors and the differential diagnosis of endometriosis. All of the parameters demonstrated increased sensitivity when tumors with low malignancy potential were considered low-risk, which may be used as an acceptable assessment method for referring patients to reference centers.

Aspectos reprodutivos em mulheres com malformações mullerianas: a propósito de um caso de útero didelfo / Reproductive aspects in women with mullerian deffects: one case of didelfo uterus

Objetivo: Relatar caso de mulher portadora de malformação mulleriana, considerando sua vida reprodutora e eventuais complicações. Casuística e Método: Descrever a evolução de mulher portadora de anomalia mullheriana, com base em seus antecedentes obstétrícos e discutir, com essas informações e análise da literatura pertinente, quais as influências...