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

Abstract

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.

A preoperative and intraoperative scoring system to predict nodal metastasis in endometrial cancer

“…Building a prediction model for Brazil and other LMICs is critical. Endometrial cancer in Brazil is typically diagnosed at advanced stages when the tumors have become large and deep myometrial invasion has occurred . If the Mayo criteria were applied in the present study population, only 10.2% would fulfil the criteria for omission of lymphadenectomy, and only 6.8% would meet the omission criteria used in another Brazilian study .…”

Ten years of experience with endometrial cancer treatment in a single Brazilian institution: Patient characteristics and outcomes

“…The type of surgery used to treat endometrial carcinomas changed considerably at our institution over the study period, with a marked increase in the performance of minimally invasive (traditional laparoscopic and robotic) surgeries [27][28][29]. Currently, laparoscopy is the treatment of choice, employed in >90% of cases.…”

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

“…In this setting, the management of apparently early-stage Endometrial Cancer (EC) could be offered in a two-step approach to avoid unacceptable delays in operative therapy. The rationale behind this oncological concept is the rapid implementation of a simple hysterectomy and bilateral salpingo-oophorectomy (BSO) without upfront nodal dissection as the first-line treatment, followed by subsequent referral of the patients to cancer reference centres to adequately evaluate the necessity of a secondary lymphadenectomy 14,15.…”