Tom P. Manolitsas

Surgical staging for patients presenting with grade 1 endometrial carcinoma.

OBJECTIVE: To examine the impact of surgical staging of patients presenting with grade 1 endometrial cancer. METHODS: The charts of all patients who presented for surgery for endometrial cancer between March 1997 and July 2003 were analyzed for demographic data, final tumor histology, grade, stage, and complications. RESULTS: A total of 349 patients underwent surgical management for endometrial cancer. Preoperatively, 181 (52%) were identified with grade 1 disease, with a mean age of 61 years (range 27–89). Surgical staging (pelvic ± para-aortic lymphadenectomy) was performed in 82% of cases and was omitted only in cases when disease was apparently confined to the endometrium and surgical risk was high. In staged patients, 3.2% had severe surgical complications. There were 2 perioperative mortalities (1 pulmonary emboli and 1 myocardial infarct). In comparison of pre- and postoperative histology, 19% of patients were upgraded, with 15% grade 2, 0.5% grade 3, 2.5% serous or clear cell, and 1% mixed mesodermal tumor. Lymph node metastases were found in 3.9% of patients presenting with grade 1 endometrial cancer, and 10.5% had extrauterine spread (> IIb). High-risk uterine features, including myometrial invasion more than 1/2, grade 3 lesions, high-risk histologic variants, and/or cervical involvement, were found in 26% of the patients. No patients with stage Ia–IIb endometrioid cancer received adjuvant teletherapy or chemotherapy. Four patients with low-risk uterine features were found to have extrauterine disease. Twelve percent of patients received adjuvant therapy, and 17% avoided teletherapy and/or chemotherapy based on surgical staging. CONCLUSION: Surgical staging in patients presenting with grade 1 endometrial cancer significantly impacted postoperative treatment decisions in 29% of patients. Omitting lymphadenectomy in patients presenting with grade 1 endometrial cancer may lead to inappropriate postoperative management. LEVEL OF EVIDENCE: II-3

Role of laparoscopy in the management of the adnexal mass and staging of gynecologic cancers.

The introduction of laparoscopic surgery has the potential to revolutionize the practice of gynecologic oncology. In no other field of gynecology are the gains from the introduction of laparoscopic surgery likely to be so great or the pitfalls so profound. The conventional surgical approach to ovarian cancer has almost universally used a generous midline vertical incision of 15 to 30 cm, from above the umbilicus down to the pubis, in contrast to the 5and 10-mm incisions used by a laparoscopic procedure. Patients with ovarian cancer tend to be older, undergo more extensive surgery, and remain as inpatients longer than patients with benign gynecologic conditions. Thus, the introduction of laparoscopic surgery might be expected to have a proportionately greater positive impact on these patients than on the benign group; but at what cost? The most important outcome measures in oncology practice relate to cure rates, survival, and quality of life issues and yet, it is within these parameters that we have the least knowledge regarding the impact of laparoscopic surgery. Possible benefits of the minimally invasive approach include shorter hospitalization, decreased cost and time to recovery, and minimization of patient discomfort and analgesic requirements. However, to become a standard of care for the management of gynecologic malignancies, the procedure should be proven to be a safe alternative for the current standard and must not compromise accurate surgical staging and timely diagnosis of malignancy. When the diagnosis of malignancy is confirmed, survival rates must be at least equivalent to those achieved with open surgery. Correspondence: Tom P. Manolitsas, MD, The James Cancer Hospital, The Ohio State University College Of Medicine, M-210 Starling Loving, 320 West 10 Avenue, Columbus OH 43210-1228. CLINICAL OBSTETRICS AND GYNECOLOGY Volume 44, Number 3, 495–521

Pain in the foot: calcaneal metastasis as the presenting feature of endometrial cancer.

BACKGROUND Ninety percent of endometrial cancer cases present with abnormal bleeding. Bone metastasis as the presenting feature is extremely rare. CASE A 76-year-old woman presented with right heel pain. She had no vaginal bleeding or other symptoms suggestive of endometrial cancer. After failure of conservative therapy, imaging studies demonstrated a calcaneal metastasis. A biopsy showed adenocarcinoma. She received local radiation to her foot, with complete resolution of symptoms. Subsequent computed tomography scans showed multiple pulmonary nodules, pelvic and inguinal lymphadenopathy, and an enlarged uterus. Endometrial biopsy confirmed endometrial adenocarcinoma. She received palliative therapy and died 11 months after the diagnosis was made on the endometrial biopsy. CONCLUSION This case highlights the rare presentation of endometrial cancer with foot pain secondary to calcaneal metastasis. Aggressive treatment of bone metastases can provide effective palliation of symptoms.

Should the Presence of Lymphvascular Space Involvement Be Used to Assign Patients to Adjuvant Therapy Following Hysterectomy for Unstaged Endometrial Cancer

Objective. Thegoal of this study was to determine the influence of LVSI (lymphvascular space involvement) on the risk of lymph node metastases from endometrial cancer.Methods. All patients with surgically staged endometrial cancer from 1998 to 2000 were identified from divisional databases. The influence of LVSI on the risk for nodal metastases was determined after controlling for tumor grade and depth of invasion, and comparisons were made with the chi(2) or Fishers exact tests. Multivariable analysis was performed using a logistic regression model.Results. We identified 366 patients who fit the study criteria. Pathologically, 92/366 (25%) tumors had LVSI, and 46 patients (13%) had evidence of pelvic lymph node metastases. Cancers with LVSI were significantly more likely to have nodal disease (35/92 versus 11/274, P < 0.001). When controlled for tumor grade, the presence of LVSI led to an increased incidence of pelvic node metastases (P < 0.001 for all grades). When stratified by depth of invasion in thirds, the presence of LVSI led to a significantly increased chance of pelvic lymph node metastases (P < 0.05 for each strata). When tumor grade and depth of invasion were evaluated together, LVSI led to a significantly increased risk of pelvic node metastases in patients with deeply invasive tumors. In a multivariable analysis, LVSI led to a significantly increased risk for pelvic lymph node metastases (P < 0.05).Conclusion. LVSI leads to an independent and significantly increased risk for pelvic lymph node metastases. As such, the presence of LVSI may indicate the need for lymphadenectomy or adjuvant therapy for potential regional lymph node metastases in patients with unstaged endometrial cancer.