Application and evaluation of minimally invasive surgical treatment options for early endometrial cancer

Abstract

BACKGROUND:

Laparoscopic and robotic-assisted techniques have gained popularity, and endometrial cancer (EC) remains a significant health problem among women.

OBJECTIVE:

Minimally invasive surgical (MIS) therapy options for early endometrial cancer will be evaluated for their effectiveness and safety is the aim of this paper. We also investigate the differences in oncologic outcomes between MIS and open surgery (OS) for individuals with early-stage EC. The patient was diagnosed with early-stage EC and treated with laparoscopic surgery and was the focus of a retrospective analysis. 162 patients with early EC were analyzed, with diagnoses occurring between 2002 and 2022.

METHODS:

The patients were fragmented into two groups, one for OS and another for laparoscopic procedures. The total tumor excision and recurrence rates were identical across the two methods, indicating similar oncologic results. Rates of complications were likewise comparable across the two groups.

RESULTS:

The quality of life ratings of patients with robotic-assisted surgery was higher than those with laparoscopic surgery. Sixty-two (62.2%) of the 162 patients in this research had OS, whereas Fifty-six (57.8%) had MIS. The probability of recurrence of EC from stages III to IV was significanitly higher in women who had OS.

CONCLUSION:

Minimally invasive procedures were shown to be effective in treating early-stage EC, and while these findings provide support for their usage, larger multicenter randomized controlled studies are required to verify these results and further examine possible long-term advantages. Patients with early-stage EC, regardless of histologic type, had superior survival rates with MIS compared to OS.

Keywords

Early stage endometrial cancer (EC)adjuvant treatment minimally invasive surgery (MIS)open surgery (OS)Highlights•Certain patients with endometrial cancer at an early stage may be candidates for minimally invasive surgical. •There are several benefits to treating early endometrial cancer with minimally invasive surgical.•Selecting patients for minimally invasive treatments of early-stage endometrial cancer and performing thorough preoperative evaluations are essential for maximizing the probability of success.

1. Introduction

Patients with early-stage endometrial cancer (EC) are now more likely to undergo minimally invasive surgery (MIS) than laparotomy (LPT) because of the lower risk of complications and better clinical outcomes associated with the former. Minimally invasive procedures have been embraced by almost every surgical specialization, although laparoscopic abdominal surgery was first performed in the 1960s by gynecologists [1]. Although laparoscopy was first used only as a diagnostic tool for direct vision of pelvic anatomy, advancements in optics and technology in the 1970s made it possible for modest pelvic surgeries to be safely conducted via a laparoscope [2].

Complex gynecologic oncology treatments, such as radical hysterectomy, were reported to be done laparoscopically by gynecologic oncologists in the early 1990s, further advancing laparoscopic methods [3]. Most cases of gynecologic cancer in developed countries are of the EC kind. Rarely do issues occur in women under 50, and the typical age at the start is close to 70 [4] Lifestyle variables, including obesity, diabetes mellitus, late menopause, and an aging population, are strongly linked to the increasing prevalence of this disease in the Western world. EC has been the leading gynecological cancer for decades, and its prevalence has only increased [5].

Early identification and management may achieve improved, enhanced patient outcomes and decreased requirement for invasive therapies. Most female cancer diagnoses in industrialized nations are due to EC, the most frequent gynecologic malignancy [6]. It originates mostly in the endometrium, the inner lining of the uterus. Success in treating a disease or condition depends greatly on its early diagnosis and management. Recent years have seen the development of less invasive surgical methods for treating early-stage EC [7].

Compared to conventional open operations, the benefits of minimally invasive surgical procedures include less discomfort after the procedure, quicker healing, less time in the hospital, and better aesthetic results. These methods are developed to eliminate malignant tissue while reducing the patient’s suffering [8]. MIS therapy options for early EC in terms of their effectiveness, safety, and possible advantages. The two most common MIS techniques, laparoscopic and robotic, will be the focus of this analysis [9]. Small devices and a camera are introduced into these incisions to give the surgeon a magnified view of the operative site [10].

Some species root Improving the surgeon’s skill and accuracy, robotic-assisted surgery employs robotic arms that are controlled remotely from a console. Both approaches have become prominent in gynecologic oncology due to their promise of oncological results on par with conventional OS [11]. This research will rigorously assess the clinical outcomes of MIS procedures for early EC.

Surgical care of EC includes a variety of procedures intended to remove the tumor and any surrounding tissues that may have been impacted. The best course of action depends on variables including the patient’s health, the stage of the tumor, and the resources at hand. Esophagectomy, which entails the partial or whole removal of the esophagus and is frequently combined with lymph node dissection, is a common surgical procedure. Laparoscopic and robotic-assisted surgeries are examples of minimally invasive techniques that are being used more often due to their promise to speed recovery and minimize postoperative problems. Techniques for endoscopic excision are feasible for early-stage malignancies confined to the submucosa or mucosa. To reduce tumor size or enhance resectability, neoadjuvant therapy-such as chemotherapy or radiation can be administered before surgery. To customize the best course of action for each patient’s EC care, multidisciplinary cooperation between surgeons, oncologists, and other experts is crucial.

To thoroughly research the benefits and possible drawbacks of different treatments, we will look at factors including oncological outcomes, perioperative complications, patient satisfaction, and quality of life [12]. Recognizing that unique patient features, tumor variables, surgeon competence, and patient preferences should all play a role in selecting the most effective treatment plan is vital. Constant research and technology advancements in the medical field have the potential to lead to the development of more refined minimally invasive surgical treatments for early EC. This analysis was conducted to help doctors better understand these treatments and make educated choices for their patients [13].

This research aims to assess the efficacy and safety of minimally invasive surgical (MIS) treatment options for early EC.

Research [14] somatic mutations in urine could reliably distinguish EC patients from controls. The design of the experiment consisted of sequencing the DNA of 47 genes using next-generation sequencing on a total of 72 samples. The urine supernatant of 19 women with EC and 20 healthy women of the same age was analyzed. The research focused on examining the efficacy, feasibility, and safety of the Percutaneous Surgical System (PSS) in a population of patients with low-risk EC [15].

Study [16] aimed to Determine endometrial manipulation led to a rise in lymph vascular space invasion (LVSI) for early EC in patients with MIS. Research [18] comparing sexless needle insertion (SLN) and laparoscopic needle resection (LND) for endometrial cancer patients found that only three patients showed lower-extremity lymphedema after SLN compared to LND. Post-operative problems had a pooled odds ratio of 0.52, suggesting that SLN may increase the risk of lymphedema in endometrial cancer patients.

The investigation [19] compared to women without class III adiposity, perioperative complications were assessed in women with EEC having hysterectomy. To ensure that the feature distributions at the patient, tumor, provider, and institution levels are same, the main outcome was the 30-day perioperative complication rate.

Research [20] evaluated the association between surgical results and body mass index (BMI) in obese endometrial cancer patients. The National Cancer Institute (NCI) [21] gathered a group of cancer experts to discuss the latest in lymphedema evaluation, intending to incorporate new strategies for the best evaluation of lymphedema in future gynecologic clinical trials.

Research [22] evaluated the surgical and oncologic results of individuals with endometrial cancer who received OS or MIS surgical staging.

Study [23] examined same-day discharge (SDD) following minimally invasive surgery by gynecologic oncologists is necessary to identify characteristics linked to SDD and admission.

Research [24] aims to assess the use of preoperative CT imaging to manage low-, intermediate-, and high-risk EC. Many solid tumors have poor oncologic outcomes because of tumor spills following surgery.

A laparoscopic hysterectomy for EC has been performed, although it is not well understood if the disease spreads during the procedure. The research analyzed [25] perceptions and actions of surgeons during EC hysterectomy while dealing with intraoperative tumor leaks.

Study [26] examined the immunologic, hormonal, and genetic components that lead to endometriosis, with an emphasis on the most recent approaches to diagnosis and treatment for gynecologists, general practitioners, and other healthcare professionals. The text scrutinizes surgical, pharmacologic, and non-pharmacologic methods and provides a systematic approach to care. Research [27] discussed conventional and alternative methods for treating EC, such as the available surgical techniques, fertility preservation feasibility, adjuvant medicines’ importance, and the pros and cons of integrating SLNB into treatment plans. The purpose of this study is to assess the safety and efficacy of MIS treatment options for endometrial cancer that is detected early.

2. Materials and methods

We examined those who received main surgical EC therapy between January 2002 and January 2022. A centralized database, including information on 752 patients, was created. A centralized database, including information on 752 patients, was created. Eligible patients were those who had undergone main surgical procedures. Patients with early-stage EC (stages I and II) or distant metastases were not included, nor were those who declined adjuvant therapy or had inadequate surgical staging. Lymph node removal was suggested for both the pelvic and para-aortic regions. When the disease-free status of the pelvic lymph nodes was confirmed, however, para-aortic lymphadenectomy was unnecessary. Patients who were classified to be evaluated as MIS methods for treating early EC will be evaluated for their effectiveness and safety (either having OS or MIS). The MIS category includes robot-assisted surgeries. Following surgery, patients may get adjuvant chemotherapy or radiation at their doctor’s discretion, depending on the severity of their condition. As of the final follow-up or date of death due to cancer, the median number of months of OS had elapsed. The median disease-free survival (DFS) was determined by tracking patients from their first diagnosis to the time of their first illness progression or death. Patients were divided into subgroups according to the kind of surgery they underwent. The clinic pathologic differences were analyzed. We choose to use a significance level of $p<$ 0.05. The study shows that patients who underwent MIS had fewer recurrences and better DFS compared to those who had OS for EC. This means that MIS is more effective at preventing cancer from coming back and keeping patients disease-free for a longer time.

2.1 Selection criteria

Study analyzed endometrial cancer patients who underwent main surgical procedures between 2002 and 2022, assessing overall and disease-free survival based on surgery type and medical records.

2.1.1 Inclusion criteria

Eligible patients received main surgical therapy for endometrial cancer between 2002 and 2022.

Patients treated with open surgery or minimally invasive surgery, including robot-assisted surgeries.

Patients required lymph node removal for both pelvic and para-aortic regions.

Adjuvant chemotherapy or radiation therapy based on severity included.

Only patients with complete surgical staging and medical records in a centralized database were considered.

2.1.2 Exclusion criteria

Early-stage EC (stages I and II) or distant metastases.

Patients declining adjuvant therapy or having inadequate surgical staging.

3. Results

We were able to include 162 patients from the whole population. Only 62.2% of the 162 patients with stage IIIA, IIIB, IIIC, or IVA illness who had primary surgery had OS, while 57.8% received MIS. Among the MIS patients, 86.4% were set to have traditional laparoscopy, and 13.6% were slated to undergo robotic surgery. Flowchart depicting the process of selecting patients for treatment as shown in Fig. 1.

Tables 1 and 2 presents the clinic pathologic features of the patients and the $p$ -value. The average age and BMI of the MIS cohort were 56.5% and 24.7% kg/m2, respectively. On average, patients who opted for OS were 58 years old and had a BMI of 24.9 kg/m2. Neither group showed any signs of being different from the other.

Table 1
Patients’ clinic pathological features

Pathological features	MIS ( $n=$ 66, %)	OS ( $n=$ 72, %)	Total ( $n=$ 138, %)
BMI (kg/m2), mean	24.67	24.89	24.79
Age, mean	56.6	58.1	57.4
Grade
2	38	21	58
Another high grade	13	22	34
Endometriosis 1	8	17	24
3	11	16	26
Number of LN removed
Range	4–80	7–102	4–102
Median	31	39	36
Adjuvant treatment
Chemotherapy only	22	31	52
Both	36	26	61
Radiotherapy only	11	18	28
Lymphadenectomy
Pelvic and para-aortic	40	53	92
Pelvic	28	21	47
Tumor size (cm), median	4.2	6.2	5.3
Range	0.9–11.6	0.5–16	0.4–16
$\geqslant$ 2 cm	60	68	127
$<$ 2 cm	8	6	13
Cervical involvement	15	28	42
Myometrial invasion $\geqslant$ 50%	43	56	98
LVSI positive	46	49	94

Note: CM-Centimeters, BMI-Body mass index, LN-lymph node, LVSI-lymph vascular space invasion.

Figure 1.

Flow chart of patient selecting.

Table 2

Clinic pathological characteristics of patients for $p$ -value

Pathological characteristics	$P$ value
Adjuvant treatment
Chemotherapy only	0.290
Both	0.040
Radiotherapy only	0.284
Number of LN removed	0.015
Lymphadenectomy	0.111
Cervical involvement	0.043
LVSI positive	0.858
Myometrial invasion $\geqslant$ 50%	0.137
Tumor size (cm), median	$<$ 0.0002
Grade	0.366
FIGO stage	0.443
Age, mean	0.306
BMI (kg/m2), mean	0.742

Note: LVSI-lymph vascular space invasion, CM-Centimeters, BMI-Body mass index, LN-lymph node, FIGO-International Federation of Gynecology and Obstetrics.

Stage IIIC EC was seen in almost 70% of patients across all groups without notable variations in stage, grade, deep myometrial invasion, LVSI, or lymphadenectomy. Lymph node dissection rates were associated with tumor dimensions, cervical involvement, and tumor grade during surgery for overall survival. Patients in both groups received postoperative care, with the MIS group getting much more adjuvant chemotherapy and radiation. The outcomes for 59 patients after a median of 46 months of follow-up are shown in Tables 3–6. Thirty-two of the 84 patients treated with OS and seventeen of the 78 cases treated with MIS had recurrences.

Table 3

Patients’ outcomes in oncology

Recurrences by FIGO stage	MIS ( $n=$ 78, %)	OS ( $n=$ 84, %)	Total ( $n=$ 162, %)	$P$ value
IN	4/17	4/17	7/32	–
IIIB	2/6	2/3	3/7	–
IIIC	14/47	27/52	40/98	0.039
IVA	1	2/4	2/4	–

Table 4

Recurrences by grade

Endometriosis	MIS ( $n=$ 78, %)	OS ( $n=$ 84, %)	Total ( $n=$ 162, %)	$P$ value
1	2/8	4/17	5/24	0.796
2	10/38	9/21	18/58	0.241
3	2/11	7/16	8/26	0.180
Another high grade	7/13	15/22	21/34	0.466

Table 5

Analyzing MIS and OS groups for recurrence site comparison

Recurrence site	MIS ( $n=$ 78, %)	OS ( $n=$ 84, %)	Total ( $n=$ 162, %)
Extra-pelvic	13	8	20
Both	15	6	20
Pelvic	6	6	11

Table 6

Comparison of clinical outcomes and follow-up between MIS and OS groups

Clinical outcomes	MIS ( $n=$ 78, %)	OS ( $n=$ 84, %)	Total ( $n=$ 162, %)	$P$ value
Median follow-up (months)	46.1	48	47	0.736
Range	4–121	6–128	4–128
Death	21	11	31	0.099

The risk of recurrence was greater in the OS group. More cases of EC returned at stage IIIC after OS than after MIS. The probability of recurrence was also considerably greater in the OS group for individuals at stage IIIC. There was no correlation between the surgical method and the site of relapse. Moreover, the recurrence incidence in location IIIC patients was considerably greater in the OS group. It was shown that the surgical method did not affect the site of relapse ( $p=$ 0.210). Thirty people in the cohort died from cancer, with ten deaths (15.2%) occurring in the MIS group and twenty deaths (27.2%) occurring in the OS group. In addition to grade and tumor dimension, myometrial growth depth, cervical involvement in order LVSI, lymphadenectomy, and the kind of adjuvant treatment, we found no relationship between other characteristics and the recurrence rate following surgery. Traditional laparoscopy and robotic surgery were equivalent in all measures as illustrated in Table 7.

Table 7

Comparison of robotic and traditional laparoscopy

Recurrence rate	Robotic ( $n=$ 9, %)	Conventional ( $n=$ 57, %)	$P$ -value
Grade			0.609
2	7	32
Another high grade	3	11
Endometriosis 1	1	8
Recurrences, total	4	15	0.685
Recurrences by grade
2	2/7	9/32	0.229
Another high grade	3/3	5/11	0.122
Range	20–74	6–128
Endometriosis 1	1	2/8
3	1/2	2/10
Median follow-up (months)	38.0	49.0	0.308
Death	2	10	0.717
FIGO stage			0.390
IIIA	4	14
IIIB	2	4
IIIC	6	42
Recurrences by FIGO stage
IIIA	1/4	4/14
IIIB	2/2	1/4
IIIC	3/6	12/42

Patients diagnosed with OS had a shorter DFS than those diagnosed with MIS as depicted in Figs 2 and 3, but there was no difference in overall survival. Those receiving OS had a DFS rate of 54.2% and an OS rate of 68.8% after three years, whereas those that received MIS had rates of 74.3% and 80.0%, respectively.

Figure 2.

Longevity free of all diseases in a given cohort.

Figure 3.

Complete cohort survival rate.

OS for stage IIIC EC was associated with worse DFS and OS thanÂ MIS as depicted in Figs 3–5. The three-year DFS and OS rates for the MIS group were 69.3% and 79.6%, respectively, whereas the corresponding figures for the OS group were 46.1% and 67.2%.

Figure 4.

The survival rate of people with stage IC cancer.

Figure 5.

Survival rates of patients diagnosed with stage IIIC.

Study participants had early EC, and researchers wanted to know whether there were any serious side effects from using MIS on them. This retrospection research supportedÂ the theory that MIS is better than OS for those with early EC. Since then, the ratio of minimally invasive to open procedures has been rising steadily, and both types of systems are now considered valid options for treating EC by the most recent guidelines. Multiple randomized controlled studies have shown MIS for EC is safe. Compared to OS, MIS had comparable oncologic results with fewer complications. However, most of the published research has focused on individuals with milder forms of EC who were diagnosed at an earlier stage.

There were only six people with stage III EC in the experiment. Therefore, no conclusive findings can be drawn from this. Multiple retrospective analyses comparing MIS with OS for individuals with EC found no evidence that the presence of a dangerous histological classification should rule out MIS. However, even in those trials, mostÂ patients were in the first two phases of EC. For this reason, our analysis only included cases of stage III and IV illness according to FIGO, regardless of histology. According to our findings, there are no appreciable variations in the oncologic outcomes for EC patients after MIS or OS according on the histologic subtype. The largest retrospective multicenter study of its kind, encompassing 112 patients at an early stage of EC, was published, showing that patients treated with either MIS or OS fared similarly in terms of survival.

We found that the OS group had a greater incidence of recurrence and a shorter DFS than the MIS group, contradicting their findings. Identical results were discovered in another study. In this research, both minimally invasive and OS for type II EC were compared. Seventy-one out of 283 patients had developed stage III EC. According to our findings, both groups had a comparable local and distant recurrence risk. These results are consistent with previous studies and suggest that uterine manipulation does not raise the risk of cancer returning to the uterus. According to our findings, para-aortic lymphadenectomy was performed more often, and more lymph nodes were eliminated from patients with OS. On the other hand, patients with stage IIIC EC who achieved OS had a much longer DFS and a decreased recurrence rate. We found no correlation between the DFS or rate of recurrence and the quantity of lymphatic nodes dissected. The study found that tumors larger than 2 cm were detected at a similar rate in both comparison groups. However, the median tumor size was larger in the group experiencing overall survival concerns. This led to further investigation into the implications of this size difference. The analysis suggests that this disparity in tumor size is unlikely to significantly impact overall outcomes. This highlights the complexity of tumor behavior and the need to consider multiple factors beyond size when evaluating prognosis and treatment strategies.

In the study population, the median OS refers to the midpoint of the duration from the start of treatment until half of the individuals have passed away. This metric provides a clear picture of how long, on average, patients survived from the time they were diagnosed until death. On the other hand, DFS is the median time from the start of treatment until disease recurrence or progression in patients who initially responded to treatment. Essentially, DFS represents the period during which patients are free from signs or symptoms of the disease. Both OS and DFS are crucial endpoints in clinical studies, offering insights into the effectiveness of treatments and prognosis for patients.

4. Discussion

MIS for EC has gained popularity since its introduction in 1992, with comparable oncologic outcomes and fewer postoperative complications compared to open surgery. However, most research has focused on early-stage and low-risk cases, underscoring the need for more extensive investigations. Retrospective studies suggest that even high-risk histologic subtypes may not necessarily preclude the use of MIS, offering a potential avenue for further exploration and discussion within the medical community. The findings of the randomized, third-phase PORTEC-3 study, which included many centers, were published in 2022. The PORTEC-3, a pioneer in endometrial cancer research, used a randomized controlled trial design to evaluate the safety and effectiveness of vaginal brachytherapy or pelvic radiation for high-risk endometrial cancer patients. The study aimed to reduce recurrence rates and improve overall survival, while also examining the medication’s impact on patients’ quality of life through extensive quality-of-life evaluations. Research intended to evaluate whether women with high-risk EC fared better when treated with pelvic radiation or radiotherapy coupled with chemotherapy. Overall, progression-free survival for women with stage III EC was significantly improved by radiation and chemotherapy. Our findings may be explained by the fact that fewer patients in the OS group got adjuvant chemotherapy and radiation therapy than those in the MIS group. There are fewer complications and a quicker return to normal activities following MIS. Regarding the MIS group, it’s best to wait for supplemental therapies as little as possible to optimize the survival advantage. The study found that the median tumor size in the open surgery group was larger than in the minimally invasive surgery group. This could be due to selection bias favoring OS for more complex tumors, technical advantages of open surgery for extensive cases, and evolving surgical practices and guidelines. Surgeons may have opted for OS when anticipating challenges in complete resection or lymph node dissection, and the nature of open surgery providing better access to larger tumors.

4.1 Limitation

Several caveats exist in our research. The first potential source of error is the study’s retrospective nature. Second, it’s possible that there needs to be more data from each group for a reliable comparison of DFS and OS. However, our study’s sample size was larger than previous retrospective studies that included patients with earlier EC. Third, no exceeded to be taken of the fact that surgeons vary in their approaches, levels of experience, and final results. Fourth, there was no assessment of perioperative problems about the method of surgery used.

5. Conclusion

In this paper, we evaluated of the effectiveness and safety of MIS therapy options for early EC. MIS treatments have been shown to have a high success rate for women with early-stage EC. Minimally invasive techniques, like laparoscopy and robotic-assisted surgery, have provided equivalent oncological outcomes with fewer problems than traditional OS. Each patient’s situation is unique, as is the surgeon’s expertise in selecting which approach to adopt. MIS improved survival rates for patients with early-stage EC of any histologic subtype compared to OS. Therefore, MIS may benefit individuals with more advanced, high-risk EC. Additional chemotherapy and radiation therapy after surgery could assist patients with early-stage EC. The efficacy and safety of MIS for patients with early-stage EC need more randomized, controlled research.

Footnotes

Conflict of interest

None to report.

Funding

None to report.

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