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Re: A need for laparoscopic evaluation of patients with endometrial carcinoma selected for conservative treatment by P. Morice et al.
Letters to the Editor
C. Bourgain Department of Pathology, Academisch Ziekenhuis, Vrije Universiteit Brussel, Brussels, Belgium 6 April 2005 doi:10.1016/j.ygyno.2005.04.006
Re: A need for laparoscopic evaluation of patients with endometrial carcinoma selected for conservative treatment by P. Morice et al. We read with interest the recent article by P. Morice et al. [1], who reported on the author’s experience about 2 patients with clinically early stage endometrial cancer (EC) selected for fertility sparing treatment. Patient no. 1 had a clinical stage IB G1 tumor, while case no. 2 presented with a clinical stage IB G2 tumor. Both patients opted for conventional therapy (hysterectomy with bilateral salpingooophorectomy and pelvic lymphadenectomy) once informed about the risk of recurrence associated with conservative therapies and the pathologic analysis of the specimens revealed a small ovarian carcinoma in one case and isolated positive peritoneal cytology in the other. The authors concluded suggesting that laparoscopic exploration of the pelvic cavity, collection of peritoneal cytology and possibly pelvic lymphadenectomy should be performed in patients with clinical early stage EC selected for conservative management to confirm the absence of extrauterine spread of the disease. It is our opinion that performing a laparoscopy in adequately clinically staged patients with IA G1 tumors should not be considered mandatory for several reasons: the incidence of adnexal and lymph node metastasis in women with clinical stage I EC, regardless of myometrial invasion and grading, are generally reported to be 5% [2] and 1% [3], respectively. Given the high accuracy of hysteroscopy and MR imaging coupled with contrastenhanced MR imaging [4] or ultrasound in the evaluation of locoregional diffusion of EC, it is conceivable that adequately staged patients presenting with clinical stage IA G1 tumors could have a risk of extrauterine disease significantly lower than those above reported. These considerations imply that we will have to do 100 laparoscopies to potentially benefit less than 5 patients, rather expose all these patients, often suffering from sterility to the risk of pelvic adhesions related to the surgical procedure. Moreover, the occasional finding of positive peritoneal cytology in the absence of evident extrauterine metastasis in these patients could be, in our opinion, a confounding factor rather than a decisional parameter. In fact, Kadar et al. [5] demonstrated that positive peritoneal cytology has an adverse outcome on survival only if endometrial cancer had spread to the adnexa, peritoneum or lymph nodes, but not if disease was confined to the uterus. Are we justified in performing a conventional radical treatment, as advocated by Morice et al., in a adequately staged stage IA G1 EEC
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patients desiring pregnancy, only on the basis of a positive peritoneal cytology? On the other hand, we fully agree with the Authors that patients presenting with G2 tumors invading the myometrium, as case no. 2 of the paper of Morice et al., could be submitted to laparoscopy to search for both intraperitoneal and lymphatic spread. In conclusion, it is our opinion that laparoscopic evaluation should not be considered mandatory in adequately staged patients presenting with stage IA G1 tumor and selected for conservative treatment. By contrast, surgical staging including laparoscopic evaluation of the pelvic cavity, peritoneal cytology and pelvic lymphadenectomy is reasonable in patients presenting with moderately/poorly differentiated tumors and/or myometrial invasion, selected for conservative management considering that they are normally excluded from this therapeutic approach because of the high risk of extrauterine spread of the disease.
References [1] Morice P, Fourchotte V, Sideris L, Gariel C, Duvillard P, Castaigne D. A need for laparoscopic evaluation of patients with endometrial carcinoma selected for conservative treatment. Gynecol Oncol 2005; 96:245 – 8. [2] Creasman WT, Morrow CP, Bundy BN, Homesley HD, Graham JE, Heller PB. Surgical pathologic spread patterns of endometrial cancer. A Gynecologic Oncology Group Study. Cancer 1987;60:2035 – 41. [3] Kilgore LC, Partridge EE, Alvarez RD, Austin JM, Shingleton HM, Noojin III F, et al. Adenocarcinoma of the endometrium: survival comparisons of patients with and without pelvic node sampling. Gynecol Oncol 1995;56:29 – 33. [4] Manfredi R, Mirk P, Maresca G, Margariti PA, Testa A, Zannoni GF, et al. Local–regional staging of endometrial carcinoma: role of MR imaging in surgical planning. Radiology 2004;231:372 – 8. [5] Kadar N, Homesley HD, Malfetano JH. Positive peritoneal cytology is an adverse factor in endometrial carcinoma only if there is other evidence of extrauterine disease. Gynecol Oncol 1992;46:145 – 9.
Giacomo Corrado Alfredo Ercoli Gabriella Ferrandina Gynecologic Oncology Unit, Catholic University of the Sacred Heart, Rome, Italy Giovanni Scambia Department of Oncology, Catholic University of the Sacred Heart, Campobasso, Italy E-mail address: [email protected]. Corresponding author. Gynecologic Oncology Unit, Catholic University, L.go A. Gemelli, 8, 00168, Rome, Italy. Fax: +39 06 35508736 2 February 2005 doi:10.1016/j.ygyno.2005.03.030
C. Bourgain Department of Pathology, Academisch Ziekenhuis, Vrije Universiteit Brussel, Brussels, Belgium 6 April 2005 doi:10.1016/j.ygyno.2005.04.006
Re: A need for laparoscopic evaluation of patients with endometrial carcinoma selected for conservative treatment by P. Morice et al. We read with interest the recent article by P. Morice et al. [1], who reported on the author’s experience about 2 patients with clinically early stage endometrial cancer (EC) selected for fertility sparing treatment. Patient no. 1 had a clinical stage IB G1 tumor, while case no. 2 presented with a clinical stage IB G2 tumor. Both patients opted for conventional therapy (hysterectomy with bilateral salpingooophorectomy and pelvic lymphadenectomy) once informed about the risk of recurrence associated with conservative therapies and the pathologic analysis of the specimens revealed a small ovarian carcinoma in one case and isolated positive peritoneal cytology in the other. The authors concluded suggesting that laparoscopic exploration of the pelvic cavity, collection of peritoneal cytology and possibly pelvic lymphadenectomy should be performed in patients with clinical early stage EC selected for conservative management to confirm the absence of extrauterine spread of the disease. It is our opinion that performing a laparoscopy in adequately clinically staged patients with IA G1 tumors should not be considered mandatory for several reasons: the incidence of adnexal and lymph node metastasis in women with clinical stage I EC, regardless of myometrial invasion and grading, are generally reported to be 5% [2] and 1% [3], respectively. Given the high accuracy of hysteroscopy and MR imaging coupled with contrastenhanced MR imaging [4] or ultrasound in the evaluation of locoregional diffusion of EC, it is conceivable that adequately staged patients presenting with clinical stage IA G1 tumors could have a risk of extrauterine disease significantly lower than those above reported. These considerations imply that we will have to do 100 laparoscopies to potentially benefit less than 5 patients, rather expose all these patients, often suffering from sterility to the risk of pelvic adhesions related to the surgical procedure. Moreover, the occasional finding of positive peritoneal cytology in the absence of evident extrauterine metastasis in these patients could be, in our opinion, a confounding factor rather than a decisional parameter. In fact, Kadar et al. [5] demonstrated that positive peritoneal cytology has an adverse outcome on survival only if endometrial cancer had spread to the adnexa, peritoneum or lymph nodes, but not if disease was confined to the uterus. Are we justified in performing a conventional radical treatment, as advocated by Morice et al., in a adequately staged stage IA G1 EEC
175
patients desiring pregnancy, only on the basis of a positive peritoneal cytology? On the other hand, we fully agree with the Authors that patients presenting with G2 tumors invading the myometrium, as case no. 2 of the paper of Morice et al., could be submitted to laparoscopy to search for both intraperitoneal and lymphatic spread. In conclusion, it is our opinion that laparoscopic evaluation should not be considered mandatory in adequately staged patients presenting with stage IA G1 tumor and selected for conservative treatment. By contrast, surgical staging including laparoscopic evaluation of the pelvic cavity, peritoneal cytology and pelvic lymphadenectomy is reasonable in patients presenting with moderately/poorly differentiated tumors and/or myometrial invasion, selected for conservative management considering that they are normally excluded from this therapeutic approach because of the high risk of extrauterine spread of the disease.
References [1] Morice P, Fourchotte V, Sideris L, Gariel C, Duvillard P, Castaigne D. A need for laparoscopic evaluation of patients with endometrial carcinoma selected for conservative treatment. Gynecol Oncol 2005; 96:245 – 8. [2] Creasman WT, Morrow CP, Bundy BN, Homesley HD, Graham JE, Heller PB. Surgical pathologic spread patterns of endometrial cancer. A Gynecologic Oncology Group Study. Cancer 1987;60:2035 – 41. [3] Kilgore LC, Partridge EE, Alvarez RD, Austin JM, Shingleton HM, Noojin III F, et al. Adenocarcinoma of the endometrium: survival comparisons of patients with and without pelvic node sampling. Gynecol Oncol 1995;56:29 – 33. [4] Manfredi R, Mirk P, Maresca G, Margariti PA, Testa A, Zannoni GF, et al. Local–regional staging of endometrial carcinoma: role of MR imaging in surgical planning. Radiology 2004;231:372 – 8. [5] Kadar N, Homesley HD, Malfetano JH. Positive peritoneal cytology is an adverse factor in endometrial carcinoma only if there is other evidence of extrauterine disease. Gynecol Oncol 1992;46:145 – 9.
Giacomo Corrado Alfredo Ercoli Gabriella Ferrandina Gynecologic Oncology Unit, Catholic University of the Sacred Heart, Rome, Italy Giovanni Scambia Department of Oncology, Catholic University of the Sacred Heart, Campobasso, Italy E-mail address: [email protected]. Corresponding author. Gynecologic Oncology Unit, Catholic University, L.go A. Gemelli, 8, 00168, Rome, Italy. Fax: +39 06 35508736 2 February 2005 doi:10.1016/j.ygyno.2005.03.030