Prospective Multicenter Trial Assessing the Impact of Positive Peritoneal Cytology Conversion on Oncological Outcome in Patients with Endometrial Cancer Undergoing Minimally Invasive Surgery with the use of an Intrauterine Manipulator

Abstract

Background Minimally invasive surgery is the standard approach in early-stage endometrial cancer according to evidence showing no compromise in oncological outcomes, but lower morbidity compared with open surgery. However, there are limited data available on the oncological safety of the use of intrauterine manipulators in endometrial cancer. Patients and Methods This prospective multicenter study included patients with endometrial cancer undergoing laparoscopic staging surgery with the use of an intrauterine manipulator. We obtained three different sets of peritoneal washings: at the beginning of the surgical procedure, after the insertion of the intrauterine manipulator, and after the closure of the vaginal vault. The rate of positive peritoneal cytology conversion and its association with oncological outcomes was assessed. Results A total of 124 patients were included. Peritoneal cytology was negative in 98 (group 1) and positive in 26 (group 2) patients. In group 2, 16 patients presented with positive cytology at the beginning of the surgery (group 2a) and 10 patients had positive cytology conversion during the procedure (group 2b). Recurrence rate was significantly different among the study groups, amounting to 9.2%, 25.0%, and 60.0% for groups 1, 2a, and 2b, respectively (p < 0.001). Group 1 showed the best recurrence-free and overall survival, followed by group 2a, while patients in group 2b had the worst oncological outcomes (p = 0.002 and p = 0.053, respectively). Peritoneal cytology was an independent predictor of recurrence and death on multivariable analysis. Conclusion A total of 8.1% of patients with endometrial cancer undergoing minimally invasive surgery with intrauterine manipulation showed positive peritoneal cytology conversion associated with significantly worse oncological outcome.

The effect of intrauterine manipulator on oncological outcome in early-stage, low-grade endometrial cancer: A retrospective cohort study

“…However, this association was only observed in early-stage cancer 15 . In line with the latter results, Siegenthaler et al showed that positive peritoneal cytology (PPC) conversion occurred in 8% of endometrial cancer patients following laparoscopic surgery with IU manipulators, which had a negative impact on oncological outcome 16 .…”

“…On the contrary, several research groups have indicated that the use of IU manipulators negatively affects oncological outcome 15,16 . Padilla-Iserte et al showed that the recurrence rate (HR 2.31, 95% CI 1.27-4.20) and survival were worse after TLH with IU manipulator than without manipulator, but no difference in recurrence pattern was found.…”

“…In their study, peritoneal washings were taken at three time points: at the beginning of surgery, after manipulator insertion, and after vaginal vault closure. They found that 80% of cytology conversions occurred at the third washing, implying that the presence of the manipulator in the uterine cavity during the whole procedure is the main issue, rather than the insertion of the manipulator itself 16 . Interestingly, hysteroscopy has been associated with higher PPC rates, but without worse oncological outcome [26][27][28][29] .…”

“…This discrepancy might result from different ways of handling the IU device. During hysterectomy, the IU manipulator is in theory more likely to induce trauma, which might lead to cancer recurrence by disrupting the containment barrier, whereas hysteroscopy involves passively rinsing out tumour cells 16 . Our observation of no significant differences in site of recurrence argues against this theory.…”

ASO Author Reflections: Is It Safe to Use Intrauterine Manipulators in Laparoscopic Surgery for Endometrial Cancer?

“…This multicenter prospective trial included 124 endometrial cancer patients undergoing laparoscopic staging surgery with the use of an intrauterine manipulator. 5 Three different sets of peritoneal washings were obtained: at the beginning of the surgical procedure, after insertion of the intrauterine manipulator, and after closure of the vaginal vault. Peritoneal cytology was negative for 98 patients and positive at the beginning of the surgery for 16 patients.…”