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Endometrial Cancer in the Developing World: Isn’t it Reasonable to Perform Surgical Treatment Systematically in 2 Steps?

Favero, Giovanni MD, PhD; Köhler, Christhardt MD, PhD; Carvalho, Jesus Paula MD, PhD

International Journal of Gynecological Cancer: June 2014 - Volume 24 - Issue 5 - p 822–823
doi: 10.1097/IGC.0000000000000132
Letter to the Editor

Department of Gynecology Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

Department of Gynecology, Charité Universitätsmedizin Berlin, Berlin, Germany

Department of Gynecology Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

The authors declare no conflicts of interest.

To the Editor:

Endometrial cancer is the most common malignancy of the female genital tract in Europe and North America.1 Despite the fact that this condition is currently 10 times more frequent in rich countries than in the developing world, the incidence of the neoplasm in underprivileged regions has dramatically increased over the last decades.2 Moreover, the mortality rate related to the disease has considerably risen in the last few years.1 Consequently, significant improvements in treatment strategies are urgently needed.

Remarks concerning the therapeutic importance of systematic lymphadenectomy in the treatment of early-stage endometrial cancer are the frequent subject of fierce debate among specialists worldwide.3 On the other hand, lymph node metastasis is an unequivocally recognized prognostic factor that normally guides the indication for adjuvant therapies.3

Currently, one can clearly identify in the literature 3 different strategies regarding indication for lymphadenectomy, but any of them is universally accepted. The first alternative is a systematic execution of lymphadenectomy in all cases. This strategy, despite formal recommendation by FIGO 2009, is routinely conducted in merely 50% of the reference centers for gynecological cancer in North America.4 Second, the nodal dissection was performed in selected patients according to some histopathological criteria, such as the magnitude of myometrial invasion, histological grade, tumor size, and presence of lymph vascular space involvement (LVSI).5 Third, intraoperative decision was based on propedeutic data and analysis of the frozen section that is particularly dependent on experienced pathologist.

Despite any technical or scientific debate regarding the most appropriate surgical approach for the treatment of this condition, regional disparities in the access to proper oncologic therapies are seldom discussed in the literature. In some areas in Latin America, for example, 20% to 25% of the population reside in remote regions, and most of the reference centers are concentrated in urban areas. This fact results in major difficulties in the implementation of standard oncologic therapies.6 It is intuitive to image that in the developing world, availability of human resources and medical technology is limited. There is an evident lack of professionals with advanced surgical expertise and ability to perform retroperitoneal lymphadenectomy. In addition, vast majority of the cancer institutions do not have capacity to offer adequate operative treatment for the entire demand of patients. Along the years, general gynecologists were progressively discouraged and intimidated to initiate surgical therapy because of concerns related to possible indication for nodal dissection. This sequence of events generates an unacceptable retard in cancer treatment implementation, which may lead to potential tumor progression and negatively impact survival. Therefore, the entire scientific discussion about lymphadenectomy produced in the United States or in Western Europe may be considered futile and distant from the reality of a great number of women affected by the disease in poor countries.

To overcome current obstacles concerning the surgical treatment of the malignancy in underprivileged regions, the authors propose an innovative strategy—the systematic management in 2 steps. Initially, all women affected by type I endometrial cancer shall be submitted exclusively to total extrafascial hysterectomy with bilateral salpingo-oophorectomy without nodal dissection. After primary intervention, every woman must be forwarded to a reference cancer center where specialists will evaluate clinical and pathological risk factors accessed through analysis of the surgical specimen. In the second phase, decision must be made whether an eventual reoperation to retroperitoneal lymphadenectomy is indicated or not. Because nodal dissection is considered necessary, patients must undergo surgery in a tertiary hospital.

Taking Brazil as an example, according to the national guidelines proposed by Instituto Nacional do Câncer, endometrial cancer patients should have retroperitoneal nodal dissection when 1 of the following criteria is present2:

  • all cases of type II (nonendometrioid) tumors;
  • presence of LVSI irrespective of histological grade or myometrial infiltration;
  • G3 tumors with myometrial infiltration of any magnitude;
  • G1/G2 tumors with myometrial invasion greater than 50%; and
  • tumor larger than 2 cm in diameter regardless histological grade or myometrial infiltration.

The here-denominated propedeutical hysterectomy does not necessarily need to be performed in a reference center or exclusively by specialists in gynecologic oncology. General gynecologists trained to perform simple hysterectomies are now welcome and invited to participate as an integral part of the treatment. The flexibilization in therapy logistics may expedite patient’s access to initial oncologic care and, consequently, avoid local progression of the disease. This strategy permits an accurate analysis of the major criteria to nodal dissection, such as tumor size, myometrial invasion, presence of LVSI, histological subtype, and grading without the necessity of expensive diagnostic methods.

A significant number of women will be considered treated with the initial intervention, but it is admissible that some of them will require a second operation. On the other hand, women who preoperatively clearly meet the criteria for nodal dissection such as type II endometrial cancer shall be promptly referred to a tertiary hospital to receive a single and comprehensive surgical intervention.

The second operation to nodal status assessment should be preferably performed via endoscopy. Nevertheless, restricted access to laparoscopy in underprivileged areas cannot limit the operative capacity. Laparotomy is also a valid approach to nodal dissection and may be correctly used when endoscopy is not available. Presently, several cancer centers yet in the developing world routinely use minimally invasive techniques to remove retroperitoneal lymph nodes. Moreover, precise analysis of the risk factors and the consequent achievement of a more reliable hazard of nodal metastasis may motivate and support surgeons to indicate the procedure even in patients at elevated clinical risk or in adverse operative circumstances.

In conclusion, the apparent reduction in morbidity allied to a more feasible and dynamic implementation of surgical therapy provided by this approach should be confronted to the already available strategies in costs and safety. In our opinion, at least from the oncologic point of view, possible delay in lymphatic tissue removal is not as harmful as the potential consequences either from unnecessary procedures or late hysterectomies. Despite several rationales presented here, only large prospective randomized controlled trials can attest the oncologic reliability and other nononcologic advantages of the approach.

Giovanni Favero, MD, PhD

Department of Gynecology

Instituto do Câncer do Estado de São Paulo,

Faculdade de Medicina da Universidade de São

Paulo, São Paulo, Brazil

Christhardt Köhler, MD, PhD

Department of Gynecology, Charite

Universitätsmedizin Berlin, Berlin, Germany

Jesus Paula Carvalho, MD, PhD

Department of Gynecology

Instituto do Câncer do Estado de São Paulo,

Faculdade de Medicina da Universidade de São

Paulo, São Paulo, Brazil

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1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin. 2012; 62: 10–29.
2. Instituto Nacional do Câncer (INCA). Estimativa 2012: Incidência de Câncer no Brasil. Available at: Accessed January 2014.
3. May K, Bryant A, Dickinson HO, et al. Lymphadenectomy for the management of endometrial cancer. Cochrane Database Syst Rev. 2010;Jan 20:CD007585.
4. Maggino T, Romagnolo C, Landoni F, et al. An analysis of approaches to the management of endometrial cancer in North America: a CTF study. Gynecol Oncol. 1998; 68: 274–279.
5. Alhilli MM, Podratz KC, Dowdy SC, et al. Risk-scoring system for the individualized prediction of lymphatic dissemination in patients with endometrioid endometrial cancer. Gynecol Oncol. 2013; 131: 103–108.
6. Goss PE, Lee BL, Badovinac-Crnjevic T, et al. Planning cancer control in Latin America and the Caribbean. Lancet Oncol. 2013; 14: 391–436.
© 2014 by the International Gynecologic Cancer Society and the European Society of Gynaecological Oncology.