Laparoscopically assisted surgical staging for endometrial cancer

At the time of diagnosis, the majority of women with endometrial cancer have disease clinically confined to the uterus. Consequently, surgical removal of the uterus is the most important step in the treatment of these patients. However, over 20% of patients with endometrial cancer apparently confined to the uterus will be found to have disease outside the uterus at staging laparotomy(1). Therefore, the staging system recommended by FIGO is a surgical one that requires peritoneal washings, removal of the uterus and adnexae, and retroperitoneal lymph node sampling. For patients with endometrial cancer, the status of the pelvic and para-aortic lymph nodes is the most significant piece of staging information regarding future prognosis and further therapy. By combining operative laparoscopy with simple vaginal hysterectomy, laparoscopically assisted surgical staging (LASS) has been proposed as an alternative to laparotomy for patients with early endometrial cancer(2). Operative laparoscopy allows for the visual assessment of the peritoneal cavity, the ability to obtain peritoneal washings, and the guaranteed removal of the adnexae. Most importantly, lymph node sampling can also be performed laparoscopically in indicated cases. The uterus, cervix, and attached adnexae are removed during the vaginal portion of the procedure as in a laparoscopically assisted vaginal hysterectomy (LAVH) for benign disease. Childers et al.(2) reported the first series of LASS procedures for endometrial cancer in 1993. Fifty-nine patients with endometrial carcinoma clinically confined to the uterus underwent laparoscopic evaluation. Six patients were found to have intraperitoneal disease and did not undergo further laparoscopic staging. Of the remaining 53 patients, 52 underwent an LAVH and 29 were considered candidates for laparoscopic lymph node sampling. The lymphadenectomy was performed successfully by laparoscopy in 93% of these patients. The estimated blood loss was less than 200 ml per patient, and the average hospital stay was 2.9 days. Although this study demonstrated the feasibility of the LASS procedure and identified obesity as a limiting factor, the number of lymph nodes removed laparoscopically, the comparative costs of the procedure, and long-term follow-up were not discussed. Many of these issues have been recently addressed. Gemignani et al.(3) from Memorial Sloan-Kettering Cancer Center compared the clinical outcomes and hospital charges for 320 patients with endometrial cancer staged by laparoscopy versus traditional laparotomy. The patients managed laparoscopically had significantly fewer complications, shorter hospitalizations, and lower overall hospital charges than those who underwent laparotomy. Furthermore, there was no statistically significant difference in the recurrence rates between the two groups. An earlier series of 44 patients presented by Boike et al.(4) demonstrated similar findings and reported no statistical difference in the total number of lymph nodes removed by laparoscopy compared to laparotomy. At the 2004 Annual Meeting of the Society of Gynecologic Oncologists, Tozzi et al.(5) reported preliminary results of a prospective trial comparing 63 patients who underwent laparoscopy with 59 who underwent laparotomy for the management of endometrial cancer. They noted no significant differences recurrences or survival between the groups but this study was underpowered to prove the equivalence of these two approaches. The safety and efficacy of LASS are currently being evaluated in a prospective manner. The Gynecologic Oncology Group is performing a randomized phase III trial of approximately 2100 patients designed to compare the differences between LASS versus staging laparotomy in the management of women with early endometrial cancer. Variables that will be assessed include adequacy of staging, complications, operative time, hospital stay, total procedural costs, and quality of life. This protocol is expected to be completed in early 2005.