Clinical question comments:What is the evidence based surgical approach for hysterectomy in low and high risk apparent early stage endometrial cancer?/Evidence summary and recommendations

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General information on how to comment

• If you have identified any gaps or errors in the content please suggest suitable text for inclusion.
• Statements regarding the inclusion/exclusion of issues should be clearly supported by scientific evidence.

I suggest to write "laparoscopic approach SHOULD be considered. "May be considered" is too weak an expression.

Thank you for providing comment on the draft guidelines.

The Working Party has recently met to consider all the public comments received and review the guidelines.

The following is their response to your comments above:

Changed to "can" instead of may be...

Christine Vuletich

Manager, Clinical Guidelines Network Cancer Council Australia

Recent data suggests lymphedema may be more common after laparoscopic lymphadenectomy....

Michael Quinn

Dear Prof Quin,

Thank you for providing comment on the draft guidelines.

The Working Party has recently met to consider all the public comments received and review the guidelines.

The following is their response to your comments above:

Please provide full citation for consideration.

References provided by Michael Quinn on 17/09/11:

2 Conflicting articles... Laparoscopy seems best for endometrial cancer surgery April 21, 2011 Clinical By Will Boggs, MD NEW YORK (Reuters Health) - Laparoscopy and laparotomy for endometrial cancer have different complication profiles, but laparoscopy looks best to Duke University surgeons who reviewed their experience with both approaches. "While our study showed a potential increased risk of lymphedema with laparoscopy, it is only a retrospective study, and the potential benefits of laparoscopy (or robotic) surgery outweigh the small risks found in our study," Dr. Jason C. Barnett told Reuters Health in an email. Dr. Barnett is currently at the Brooke Army Medical Center at Fort Sam Houston, Texas. When he was still in Durham, North Carolina, he and his colleagues at Duke compared perioperative outcomes and adverse events with laparoscopic and open operations done on 376 women with endometrial cancer. Mean total anesthesia time was significantly longer with laparoscopy vs laparotomy (293 vs 154 minutes), but laparoscopy was associated with a lower mean blood loss (124 vs 310 mL) and a shorter mean hospital stay (2.4 vs 4.5 days), the authors report in the American Journal of Obstetrics and Gynecology online March 16th. The overall proportions of patients with complications were similar after laparoscopy (33%) and laparotomy (43%; p=0.25) - but rates of specific problems did differ. Laparotomy was more often followed by open wound infection (9% vs 2%), whereas laparoscopy was more often complicated by peripheral sensory neuropathy (5% vs 0%) and clinically significant lymphedema (7% vs 1%). The researchers can't explain the higher rate of lymphedema in their laparoscopic cases. "One possible explanation for the increased lymphedema rate may be that a more distal dissection is performed during laparoscopy with the magnification and access afforded allowing more aggressive dissections," they suggest. As for the sensory nerve deficits, the investigators say all were mild and self-limiting. "Based on the Gynecologic Oncology Group LAP2 data, my default approach is a minimally invasive technique," Dr. Barnett said. "Studies looking at sentinel lymph node use in endometrial cancer will be valuable in the future as will studies that continue to define the optimal patients that would benefit from lymphadenectomy," he added. "Future prospective studies that compare surgical approaches should also consider capturing lymphedema rates." SOURCE: http://www.ajog.org/article/S0002-9378(11)00321-8/abstract Am J Obstet Gynecol 2011.

Ann Surg Oncol. 2011 Jun 22. [Epub ahead of print] Lymphoceles, Lymphorrhea, and Lymphedema after Laparoscopic and Open Endometrial Cancer Staging. Ghezzi F, Uccella S, Cromi A, Bogani G, Robba C, Serati M, Bolis P.

WP Response:

In view of the fact that, to date, there are only a few studies with conflicting evidence regarding this topic, it was felt that there was not sufficient evidence to warrant specific comments at present.

Christine Vuletich

Manager, Clinical Guidelines Network Cancer Council Australia