Robotic-assisted surgery gained popularity for endometrial cancer treatment (see Chapter 25). Improved instrumentation and visualization allow minimally invasive surgery to be performed by surgeons with less laparoscopic experience, and in patients, particularly obese patients, who otherwise might not be candidates for minimally invasive surgery. In one report limited to obese patients with endometrial carcinoma, the robotic approach offered reduced operating times, less blood loss, higher lymph node yields, and shorter hospital stays compared to laparoscopy (261). The extent of para-aortic dissection was not described in this report, and infrarenal para-aortic lymphadenectomy remains challenging, even with robotic assistance.
When not limited to obese patients, robotic-assisted surgery appears to offer the same benefits as laparoscopy in regards to postoperative morbidity and convalescence compared to laparotomy, but with shorter operative times (262). Althoughoncologic outcomes have yet to be proven in patients with endometrial cancer, robotic surgery is simply an advanced laparoscopic tool, and it can be expected to find equal outcomes. Given the great costs associated with robotic instruments and the absence of differential reimbursement, it is still undetermined which group of patients will benefit most from this approach from a clinical and financial perspective.
Radical hysterectomy, with removal of the parametria and upper vagina, and bilateral pelvic lymphadenectomy, does not improve survival of patients with clinical stage I disease compared with extrafascial hysterectomy and bilateral salpingo-oophorectomy alone (263–266). Radical hysterectomy increases both intraoperative and postoperative morbidity and should not be performed for treatment of apparent early endometrial cancer. In the presence of demonstrable invasion of the cervix, a modified extrafascial hysterectomy may be performed. This may improve outcomes and decrease the risk of local recurrences, especially if postoperative local radiation is not planned in younger patients (267).
Table 35.9 Review of Recent Series of Endometrial Carcinoma Treated with Radiation Alone a For all stages combined. From Kupelian PA, Eifel PJ, Tornos C, et al. Treatment of endometrial carcinoma with radiation therapy alone. Int J Radiat Oncol Biol Phys 1993;27:817–824, with permission.
Radiation Therapy as Primary Treatment
Primary surgery followed by individualized radiation therapy is the most widely accepted treatment for early-stage endometrial cancers. However, about 5% to 15% of endometrial cancer patients have severe medical conditions that render them unsuitable for surgery (131). These patients tend to be elderly and obese with multiple chronic or acute medical illnesses, such as hypertension, cardiac disease, diabetes mellitus, and pulmonary, renal, and neurologic diseases.
Several series show that radiotherapy is effective treatment for patients with inoperable endometrial cancer (268–277) (Table 35.9). One reported on the treatment of 120 patients with clinical stage I and 17 patients with clinical stage II endometrial cancer with radiation alone, 85% of whom received only intracavitary radiation. Because of the high incidence of death caused by intercurrent illness in this group of patients, the 5-and 10-year overall survival rates were only 55% and 28%, respectively, compared with disease-specific survival rates of 87% and 85%, respectively. There was no difference in disease-specific survival rates between patients with stage I and II disease. Intrauterine cancer recurred in 14% of patients, and extrauterine pelvic disease recurred in 3%. The authors treated 15 patients with stage III and IV disease, usually with a combination of external-beam and intracavitary radiation therapy, yielding a 5year disease-specific survival rate of 49%. Five patients (3%) had serious late complications of radiation therapy (277).