Original Research
Gynecology
Surgical outcomes among elderly women with endometrial cancer treated by laparoscopic hysterectomy: a NRG/Gynecologic Oncology Group study

Presented in part at the 44th annual meeting of the Society of Gynecologic Oncologists, March 9–12, 2013, Los Angeles, CA.
https://doi.org/10.1016/j.ajog.2017.09.026Get rights and content

Objective

Tolerance of and complications caused by minimally invasive hysterectomy and staging in the older endometrial cancer population is largely unknown despite the fact that this is the most rapidly growing age group in the United States. The objective of this retrospective review was to compare operative morbidity by age in patients on the Gynecologic Oncology Group Laparoscopic Surgery or Standard Surgery in Treating Patients With Endometrial Cancer or Cancer of the Uterus (LAP2) trial.

Study Design

This is a retrospective analysis of patients from Gynecologic Oncology Group LAP2, a trial that included clinically early-stage uterine cancer patients randomized to laparotomy vs laparoscopy for surgical staging. Differences in the rates and types of intraoperative and perioperative complications were compared by age. Specifically complications between patients <60 vs ≥60 years old were compared caused by toxicity analysis showing a sharp increase in toxicity starting at age 60 years in the laparotomy group.

Results

LAP2 included 1477 patients ≥60 years old. As expected, with increasing age there was worsening performance status and disease characteristics including higher rates of serous histology, high-stage disease, and lymphovascular space invasion. There was no significant difference in lymph node dissection rate by age for the entire population or within the laparotomy or laparoscopy groups. Toxicity analysis showed a sharp increase in toxicity seen in patients ≥60 years old in the laparotomy group. Further analysis showed that when comparing laparotomy with laparoscopy in patients <60 years old vs ≥60 years old and controlling for race, body mass index, stage, grade, and performance status, patients <60 years old undergoing laparotomy had more hospital stays >2 days (odds ratio, 17.48; 95% confidence interval, 11.71–27.00, P < .001) compared with patients <60 years old undergoing laparoscopy. However, when comparing laparotomy with laparoscopy in patients ≥60 years old, in addition to hospital stay >2 days (odds ratio, 12.77; 95% confidence interval, 8.74–19.32, P < .001), there were higher rates of the following postoperative complications: antibiotic administration (odds ratio, 1.63; 95% confidence interval, 1.24–2.14, P < .001), ileus (odds ratio, 2.16; 95% confidence interval, 1.42–3.31, P <0.001), pneumonias (odds ratio, 2.36; 95% confidence interval, 1.01–5.66, P = .048), deep vein thromboses (odds ratio, 2.87; 95% confidence interval, 1.08–8.03, P = .035), and arrhythmias (odds ratio, 3.21; 95% confidence interval, 1.60–6.65, P = .001) in the laparotomy group.

Conclusion

Laparoscopic staging for uterine cancer is associated with decreased morbidity in the immediate postoperative period in patients ≥60 years old. These results allow for more accurate preoperative counseling. A minimally invasive approach to uterine cancer staging may decrease morbidity that could affect long-term survival.

Section snippets

Materials and Methods

This was an analysis of patients who were enrolled in LAP-2, a GOG clinical trial. The details of inclusion and exclusion criteria were reported in the original manuscript.10 Briefly, the study was designed to compare LAVH with LAP for the purpose of complete comprehensive surgical staging of uterine cancer.

The primary outcome of the study was recurrence-free survival. Other endpoints included perioperative adverse events, LAVH conversion to LAP, length of hospital stay after surgery, operative

LAP2 population demographics, pathology, and outcomes

From the total LAP2 population, 762 patients are 60-69 years old, and 715 patients are ≥70 years old. Demographic data, including BMI, performance status, disease characteristics, postoperative therapy, recurrence, and survival by decade of age, are shown in Table 1. As age increases, BMI decreases (P < .001) and performance status worsens (P < .001), and when looking at disease characteristics, there are increasing rates of serous histology (P < .001), higher-stage disease (P < .001), and more

Comment

This analysis shows a clear difference in morbidity associated with surgical approach in older endometrial cancer patients. Results from this analysis show that while there are overall low rates of intraoperative and postoperative complications during complete surgical staging, regardless of surgical approach, patients undergoing LAP experience more postoperative complications with increasing age.

An increased benefit to laparoscopic staging is seen beginning at age 60 years old, with increased

Acknowledgments

The following Gynecologic Oncology Group member institutions participated in the primary treatment studies: Abington Memorial Hospital, Walter Reed Army Medical Center, University of Minnesota Medical School, University of Mississippi Medical Center, University of Pennsylvania Cancer Center, University of California at San Diego, University of Iowa Hospitals and Clinics, University of Texas Southwestern Medical Center at Dallas, Indiana University School of Medicine, University of California

References (20)

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    Citation Excerpt :

    Surgical management with hysterectomy is the cornerstone of EC treatment. The advent of laparoscopy ushered in a new era of minimally invasive surgery for EC, leading to decreased intraoperative and postoperative complications and lower rates of readmission [9–13]. Moreover, oncologic outcomes for women undergoing minimally invasive hysterectomy (MIH) for EC are similar to those undergoing laparotomy [14–16].

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This study was supported by National Cancer Institute grants to the Gynecologic Oncology Group Administrative Office (grant CA 27469), the Gynecologic Oncology Group Statistical and Data Center (grant CA 37517), the NRG Oncology SDMC grant U10 CA180822, and the NRG Oncology Operations grant U10CA 180868.

The authors report no conflict of interest.

Current address for Dr Bishop: Department of Obstetrics and Gynecology, Division of Gynecology Oncology, Medical College of Wisconsin, Milwaukee, WI.

Cite this article as: Bishop EA, Java JJ, Moore KN, et al. Surgical outcomes among elderly women with endometrial cancer treated by laparoscopic hysterectomy: a NRG/Gynecologic Oncology Group study. Am J Obstet Gynecol 2018;218:109.e1-11.

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