Endometrial carcinoma typically occurs in elderly women who frequently have comorbid conditions including diabetes mellitus, hypertension, coronary artery disease, and obesity all of which can adversely impact surgical outcome.1,11–13 Even though total abdominal hysterectomy with lymphadenectomy or lymph node sampling remains the standard surgical approach for most women with endometrial cancers, alternatives such as vaginal hysterectomy, primary radiotherapy, and hormonal therapy have been reported. Unfortunately, the failure rate for nonsurgical approaches is high. On the other hand, although the failure rate for women managed by vaginal hysterectomy may be somewhat higher than for those who undergo an abdominal hysterectomy with staging, it is appreciably less than that reported for the various nonsurgical approaches. Various radiotherapeutic techniques have been employed including external beam therapy and intracavitary radium application. Most of these reports showed an average 5-year disease-free survival rate of 70%.14–19 There was a recent report of primary radiation therapy for early endometrial cancer that showed disease-free survival rates of 87–95%. However, this study was limited by small sample sizes with uterine recurrence rates up to 14%.20 Lastly, hormone therapy for early endometrial cancer as the primary treatment remains unproved.21 A recent case series and review of literature by Kim et al showed that premenopausal women who desired to preserve their fertility may be treated with progestin therapy with initial response rates of 62%.22 Large series of women treated in this manner with curative intent have not been reported.
Vaginal hysterectomy has been employed as a preferred approach for endometrial cancer treatment in some centers in Europe. Massi et al recently reported a multicenter retrospective analysis comparing vaginal hysterectomy to the abdominal approach in early-stage endometrial cancer patients.23,24 The authors showed that vaginal hysterectomy resulted in 5- and 10-year survival rates of 90% and 87%, respectively, in a population consisting of both good and poor candidates for abdominal surgery.
Similar to the European experience, vaginal hysterectomy has been reported to be an effective mode of surgical management in the United States. Pratt et al reported a retrospective analysis of 100 women who underwent a vaginal hysterectomy for endometrial cancer, 23 of whom had minor treatment-related postoperative complications with no mortalities.10 Sixty-three percent of patients in this study received either preoperative or postoperative radiotherapy, and the adjusted 5-year survival rate was 89.3%. Likewise, Peters et al published the combined experience of 60 patients from two institutions with a reported 5-year survival rate of 91.1% with low morbidity and no mortality.25,26 The survival statistics of past studies from Europe and the United States are similar to those reported in the present study.
Morbid obesity can complicate abdominal surgery with a high risk of wound infection, atelectasis, pneumonia, and sources of febrile morbidity that often result in prolonged hospitalization.27 When an open wound requires prolonged care, the ability to administer timely radiotherapy, when indicated, can be compromised. In contrast to the abdominal approach, vaginal hysterectomy rarely causes such postoperative complications and appears to minimize the risk of cardiovascular complications as well.28 Although morbid obesity was the predominant reason for choosing vaginal surgery in this series, most patients also had other medical problems that added to the risks of abdominal surgery including diabetes mellitus, hypertension, and coronary artery disease. Despite this patient profile, complications typically seen with such patients undergoing abdominal surgery were avoided in this group of women.
Despite the potential advantages of the vaginal approach, vaginal hysterectomy for endometrial cancer precludes the surgeon from assessing the upper abdomen and from performing lymph node resections. Furthermore, it may even be difficult to perform an oophorectomy, especially in nulliparous, morbidly obese patients. Nevertheless, the survival advantage from lymph node resection in endometrial cancer is modest at best, as the majority of endometrial cancer patients do not have occult spread and achieve high cure rates even in the absence of surgical staging. Indeed, some studies have failed to demonstrate a survival benefit of adding pelvic and para-aortic lymphadenectomy to an abdominal hysterectomy whereas others have shown a significant survival advantage.29–31 Understandably, the patient profile will have some impact on this issue. For example, patients with unfavorable histology are more likely to benefit from surgical staging than those with favorable histology. It is noteworthy, therefore, that when obesity complicates uterine cancer, the prognosis typically is good, suggesting that the vaginal approach is particularly suited for the obese patient who has an excellent chance of cure with any approach that includes a hysterectomy. Stage Ia and Ib disease account for up to 60% of patients with endometrial cancer for whom the prevalence of lymph node metastases is low. Women with conditions associated with high-circulating estrogen levels, including hormone replacement therapy or obesity, typically present with stage Ia or Ib disease. Accordingly, the benefits of therapeutic lymphadenectomy in this low-risk population remain to be proved. As suggested by the data of Trimble et al, lymph node excision for staging purposes may not provide any survival benefit in patients with stage I, grade 1 or 2 disease.32
In our series, all patients with grade 1 or 2 disease were cured. Clearly, this outcome could not be improved upon with pelvic and/or para-aortic lymphadenectomy. On the other hand, the eight patients with grade 3 disease including four papillary serous and one clear cell cancer, all with deep myometrial invasion, had poor prognoses with only two patients alive at 5 years. Nevertheless, this subset of patients is at high risk to fail any approach to therapy and might have fared no better if managed by the abdominal route. We strongly advocate surgical staging for the routine treatment of endometrial cancer and believe this is best accomplished by a gynecologic oncologist. However, in our small series comprised of obese and medically compromised women, vaginal hysterectomy appears to be a safe alternative to abdominal surgery or other nonsurgical approaches.
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