The Role of Laparoscopy in Endometrial Cancer

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1 The Role of Laparoscopy in Endometrial Cancer Prof. Dr. Tugan BEŞE İstanbul University, Cerrahpaşa Medical Faculty Gynecologic Oncology Department

2 Surgical staging in Endometrial Cancer

3 Laparoscopic surgery in Endometrial Cancer Surgery for primary treatment Surgery for staging in whom hysterectomy was performed before Childers and Survit were the first authors who used laparoscopy for the treatment of endometrial cancer in 1992

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5 Limitations for laparoscopy Bulky uterus which can not be pulled out via vagina Pelvic Radiotherapy because of pnomoperitoneum and trandelenburg position, patients who has severe pulmoner and/or cardiac problems can not tolerate operation time

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7 Advantages of Laparoscopy Early discharge from the hospital can be applied for patients who has BMI > 35

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9 The aim of this study was to investigate the relationship between same day discharge (SDD) and postoperative complications within 30 days of laparoscopic hysterectomy for endometrial cancer 696 patients underwent laparoscopic hysterectomy in period of 2 years. Of these, 37.1 % had pelvic lymphadenectomy, 3.0 % had para aortic lymphadenectomy.

10 The rate of SDD increased from 3.9 to 69.6 % during the study period (p<0.001)

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12 Advantages of Laparoscopy Early discharge from the hospital can be applied for patients who has BMI >

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15 Is Panniculectomy an alternative surgery for patients with BMI >35

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17 Panniculectomy

18 Panniculectomy has a significantly higher postop. major complications Panniculectomy is an independent predictor for increased risk of postoperative major complications.

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25 Laparatomy Laparoscopy Robotic

26 Laparatomy Laparoscopy Robotic

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31 Recommendation Due to grade 3 EC and non endometrioid type cancer has an agressive behavior and poor prognosis, comprehensive surgery should be applied. who begin to use laparoscopic surgery in the near future, laparoscopic surgery for the patients with grade 3 EC and /or nonendometrioid type endometrial cancer, is better not to be used

32 The incidence of port side metastasis among patients with early-stage endometrial cancer is reported at 0.18% to 0.33% Port-site metastases after open laparoscopy: a study in 173 patients with advanced ovarian carcinoma. Thirty (17%) patients developed portsite metastases. However, only 8 (5%) of these portsite metastases were clinically diagnosed, while 22 out of 71 (31%) with complete portsiteexcision were diagnosed on pathologic examination. Int J Gynecol Cancer Sep-Oct;15(5):776-9

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34 Randomized Trial of Laparoscopy vs. Laparotomy for Surgical Staging of Uterine Cancer GOG LAP2 Stage I IIa Laparosopy : 1696 Laparatomy:920 (886) Conversion to laparatomy : 434 ( 25.8%) Visualiation problems : 246 (14.6%) Metastatic cancer : 69 ( 4.1%) Bleeding : 49 ( 2.9%) Others : 70 (4.2%) Walker JL, J Clinical Oncology,2009

35 GOG LAP2 Intraoperative complications p>0.05 Postoperative complications (moderate severe) L/S: % 14 L/T: % 21 p< Operation time (min.) L/S: 204 L/T: 130 p<0.001 Hospital stay > 2 days L/S: % 52 L/T: %94 p< Walker JL, J Clinical Oncology,2009

36 GOG LAP2 Pelvic lymph node L/S: 17 L/T: 18 Paraaortic lymph node L/S: 7 L/T: 7 Walker JL, J Clinical Oncology,2009

37 Laparoscopy & Laparatomy Ghezzi F. 2009

38 Laparoscopy & Laparatomy Ghezzi F. 2009

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40 Laparoscopy (n:87) Laparatomy (n:698) p value Cerrahpaşa Jinekolojik Onkoloji Age 56.6(38 72) 58.5(29 88) Menopozal durum Myometrial invasion Premenopoz (n:205) Postmenopoz (n:580) <1/2(n:505) >1/2(n:280) n (%) n (%) 17(19.6) 70(80.4) 66(75.9) 21(24.1) 188(26.9) 510(73.1) 439(62.9) 259(37.1) Grade I (n:377) II (n:299) III (n:109) 46(52.9) 34(39.1) 7(8.0) 331(47.4) 265(40.0) 102(12.6) Tumor diameter 2 cm (n:245) >2 cm (n:540) 30(34.5) 57(65.5) 215(30.8) 483(69.2) LVSI var (n:319) yok (n:466) 19(21.8) 68(78.2)) 300(43.0) 398(57.0) Hystologic type Endometrioid (n:751 ) Non endometrioid (n: 34) 82(94.3) 5(5.7) 669(95.8) 29(4.2) Lymphadenectomy Yes (n:617 ) No (n:168 ) 74(85) 13(15) 543(77.8) 155(22.2) Lymph node count 15.14± ± * Adjuvant Treatment No (n:367) Yes (n:418) 50(57.5) 37(42.5) 317(45.4) 381(54.6) Tumor recurrence Yes (n:73) No (n:650) 6(6.9) 81(83.1) 67(10.5) 569(89.5) 0.29

41 Conclusion Laparoscopic surgery has advantages such as ; less blood loss less hospital stay less intraoperative and postoperative complications in experienced hands less blood transfusion necessity relaps rate of laparoscopy is same as laparatomy However, operation time is slightly longer Laparascopic approach is feasible and safe in terms of gynecologic outcome. It can be used for endometrial cancer as a standart surgery.

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47 Survival effect of paraaortic lymphadenectomy