For information about Gynaecology, laparoscopy, hysterectomy, Gynaecologists

ENDOMETRIAL CANCER SURGERY

Endometrial cancer is the fourth commonest female cancer in the UK and commonest gynaecological cancer. The outcome is improved if the disease is diagnosed early (often due to early post-menopausal bleeding). "Tumour Grade" also affects survival for early stage disease (95% Grade 1 vs. 42% Grade 3) (Amant et al., LANCET 2005). Most patients are post-menopausal. Women with the disease may have severe co-morbidities, including obesity (BMI > 29.9) and medical problems, which may be a barrier to surgery.

 

Patients with pre-malignant disease on biopsy (atypical endometrial hyperplasia) are managed as endometrial cancers, as a significant proportion are subsequently found to have endometrial cancer in the hysterectomy specimen.

 

Patients should be referred to the local Gynaecological Cancer Rapid Access Clinic under the 2-week suspected cancer rule for assessment ( pelvic examination; transvaginal ultrasound assessment of endometrial thickness). An endometrial biopsy (and/or hysteroscopy) will be taken for increased endometrial thickness (usually > 5mm).

 

Surgical management for endometrial cancer includes total hysterectomy, bilateral salpingo-oophorectomy and peritoneal washings, to stage and treat the disease. (Selected patients have lymphadenectomy performed in the cancer centres).

 

National "Cancer Peer Review" and “Improving Outcomes" Guidance stipulates that a designated endometrial cancer surgeon performs the surgery in cancer units (lower-risk cancers i.e. low-grade, presumed early-stage) and (by triage of higher-risk cancers) a subspecialist Gynaecological Oncologist in regional cancer centres.

 

Pathological information obtained determines if radiotherapy is needed. Surgery may not be an option for advanced disease or  severe co-morbidities; these patients are offered radiotherapy, chemotherapy or hormonal treatment.

 

Conventionally, the surgery was performed via the open abdominal route, with a large incision, resulting in increased pain, wound complications, delays in mobility and prolonged hospital admission. Vaginal surgery does not allow adequate staging procedures to be performed.

 

Laparoscopic hysterectomy for surgical staging utilizes small "keyhole" operative incisions and reduces the length of hospital stay and recovery time. Hence, many gynaecological oncologists use laparoscopic hysterectomy in the management of the disease, due to the reduction in the afore-mentioned problems (summarized in Palomba et al., 2009). NICE has issued guidance regarding laparoscopic hysterectomy for endometrial cancer, with recommendations for efficacy and safety (Interventional Procedure Guidance 356, NICE, September 2010). These also suggest that “advanced laparoscopic skills are required for this procedure and clinicians should undergo special training and mentorship”.