The role of surgery in the management of endometrial cancer

The role of surgery in the management of endometrial cancer
ROBERTO TOZZI, MD, DAVID BENAYOUN, MD, STEFANO CIRILLO, MD, RICCARDO GARRUTO CAMPANILE, MD, RAFFAELLA GIANNICE, MD.
Division of Gynaecologic Oncology and Minimal Invasive Surgery, IRCCS Humanitas Clinical Institute, Milan; Nuffield Department of Obstetrics and Gynaecology, Division of Gynaecologic Oncology, Churchill Cancer Centre, Headington Oxford

ABSTRACT The role of surgery in the treatment of patients with endometrial cancer is of paramount importance. It provides accurate diagnostic information on the extension of disease and, at the same time, it is the single best treatment modality. The adequacy of the surgical staging is based on the compliance with the FIGO guidelines. Such guidelines are equally met by traditional laparotomy and by laparoscopy, as emerged in the last ten years. While there is no evident difference in the survival outcome, the laparoscopic approach is able to reduce the overall morbidity. The use of pelvic and para-aortic lymphadenectomy is still debated, despite several studies, including clinical trials, have been conducted. Currently, the FIGO guidelines delegate to the surgeon the choice of which patients should undergo lymphadenectomy and to which extension. The final issue to resolve is to investigate in a clinical trial if the performance of lymphadenectomy can spare the radiotherapy and provide survival benefit.

Key words endometrial cancer, surgery, lymphadenectomy, hysterectomy


WHY SURGERY? Since 1970s, patients with endometrial cancer (EC) have undergone staging according to the FIGO (International Federation of Gynaecology and Obstetrics) guidelines. Due to co-existing severe medical conditions, initially most patients were not candidate for surgery. Therefore, clinical staging was used based on pre-operative findings. Meanwhile, the refinement of anaesthetic technique together with improvement of pre- and post-operative care has increased the number of patients eligible for surgery. Later on, in the 1980s, the publication of the GOG-33 trial has identified several surgical prognostic factors and has showed a wide discrepancy between clinical and surgical findings (1-2). Finally, the non-surgical treatment (radiotherapy and chemotherapy alone) of patients with EC has not been as successful
as for patients with other gynaecological tumours. Therefore, at the annual meeting in Rio de Janeiro (1988), the FIGO decided to move endometrial cancer patients to a full surgical staging system (3).

The advantages of surgical staging on patients with EC are both diagnostic and therapeutic. In fact, surgery has been demonstrated to be the best single modality of treatment in terms of survival outcomes when compared to radiotherapy or chemotherapy alone. It also has the advantage to address patients for adjuvant treatment (in the form of radiotherapy or chemo-radiotherapy) on the basis of precise surgical findings and prognostic factors.

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