Objective
The purpose of this study was to compare the survival of women with endometrial cancer managed by robotic- and laparoscopic-assisted surgery.
Study Design
This was a retrospective study conducted at 2 academic centers. Primary outcomes were overall survival, disease-free survival (DFS), and disease recurrence.
Results
From 2003 through 2010, 415 women met the study criteria. A total of 183 women had robotic and 232 women had laparoscopic-assisted surgery. Both groups were comparable in age, body mass index, comorbid conditions, histology, surgical stage, tumor grade, total nodes retrieved, and adjuvant therapy. With a median follow-up of 38 months (range, 4–61 months) for the robotic and 58 months (range, 4–118 months) for the traditional laparoscopic group, there were no significant differences in survival (3-year survival 93.3% and 93.6%), DFS (3-year DFS 83.3% and 88.4%), and tumor recurrence (14.8% and 12.1%) for robotic and laparoscopic groups, respectively. Univariate and multivariate analysis showed that surgery is not an independent prognostic factor of survival.
Conclusion
Robotic-assisted surgery yields equivalent oncologic outcomes when compared to traditional laparoscopic surgery for endometrial adenocarcinoma.
Uterine cancer is the most common gynecologic cancer in the United States with 49,560 new cases and 8190 deaths estimated in 2013. There are 606,913 survivors, making it the second most prevalent cancer in women after breast cancer. The survival rate for women with endometrial cancer varies according to disease stage, tumor histology, and grade.
Surgery is the mainstay for staging and optimizing treatment of women with endometrial carcinoma. The International Federation of Gynecology and Obstetrics (FIGO) staging system has been surgical since 1988 and allows the most accurate assessment of disease. The vast majority of women with endometrial carcinoma present at an early stage and surgery alone may be curative. The surgical approach has rapidly evolved since the late 1980s with the introduction of laparoscopy in the surgical staging of endometrial cancer. In the early to mid-2000s, randomized controlled studies confirmed its feasibility, safety, and short- and long-term outcomes. In 2005, the Food and Drug Administration (FDA) cleared the da Vinci robotic computer-based platform (Intuitive Surgical Inc, Sunnyvale, CA) for gynecology, adding another tool to our armamentarium in the management of endometrial cancer. Its safety and feasibility were evaluated in retrospective, prospective, and single and multicenter reports and in metaanalyses. As this technology has only recently been utilized for cancer operations, data on the long-term oncologic outcomes of this approach are limited, moreover data comparing robotic and traditional laparoscopy are lacking.
The primary objective of the current study was to compare the survival outcomes of women with endometrial cancer managed by robotic and traditional laparoscopic-assisted surgery.
Materials and Methods
A retrospective review was conducted of women diagnosed with endometrial carcinoma who underwent surgical staging at 2 academic centers from January 2003 through January 2010. Institutional review board approval was obtained from both institutions.
Patient characteristics such as age, race, body mass index, surgical stage, histologic type, tumor grade, lymph nodes retrieved, survival, and disease-free survival (DFS) were obtained from electronic medical records and recorded on a computerized database. FIGO 2009 staging criteria was mapped to the FIGO 1988 categories using data available from the pathology reports.
Inclusion characteristics comprised women who had a histopathology diagnosis of endometrial cancer who underwent surgical staging for this disease. A follow-up of at least 4 months was also a requirement for inclusion in this study. Specimens were reviewed by an experienced gynecologic pathologist. Exclusion criteria included: inappropriate follow-up, uterine sarcoma, synchronous carcinoma, and open surgical staging. All consecutives robotic and laparoscopic cases that met the inclusion criteria were included. From January 2003 through December 2007 cases were performed by laparoscopic approach and from January 2008 through January 2010 cases were perform by robotic-assisted approach.
The surgical team consisted of a board-certified gynecologic oncologist, gynecologic oncology fellow, obstetrics and gynecology resident, and nurse. Our robotic and laparoscopic approach, perioperative care, and the operative variable definition were previously reported. The first postoperative visit occurred 2-4 weeks after surgery. Follow-up visits were scheduled to occur at every 3 months for the first 2 years, followed by every 6 months for the next 3 years and yearly thereafter.
Recurrence of disease was classified as local recurrence (isolated vaginal cuff or pelvic) and distant recurrence (outside of the pelvis). DFS was defined as the period from surgery until the date of first recurrence or death from any cause, whichever was first, or the date of last contact for the patient remaining alive without recurrent disease. Overall survival (OS) was defined as the time from surgery to death. Data on patients alive were censored at the last follow-up visit.
Adjuvant therapy was tailored to the pathologic findings at primary operation after multidisciplinary tumor board (gynecologic oncology, pathology, radiation oncology, medical oncology) discussion. Treatment was based on the results of prospective randomized clinical trials and National Comprehensive Cancer Network Guidelines. Treatment of recurrent disease was also planned in these multidisciplinary meetings. Postoperative treatment for each patient was recorded and included radiation, chemotherapy, or a combination of both or observation.
Statistical analysis
The primary endpoints of the study were OS and disease recurrence. All data were analyzed by the intention-to-treat method. Variables with a nonnormal distribution were expressed as median and range. For categorical variables, the χ 2 test and the Fisher exact test were used as required. The t test was used to compare variables that were normally distributed. Comparisons of variables not normally distributed were made by the Mann-Whitney U test. Time to recurrences and survival were calculated by the Kaplan-Meier method. The statistical significance of differences in the primary outcomes between the 2 groups was assessed with the log rank test. Multivariate Cox proportional hazards models were calculated to identify independent prognostic factors for DFS and OS. For this purpose the women were divided into 2 groups based on age (<65 vs ≥65 years), surgical stage [early (I and II) vs advanced (III/IV)], unfavorable histology [endometrioid vs nonendometrioid (papillary serous, clear cell, undifferentiated, mixed)], tumor grade [low (1) vs high (2 and 3)], surgery (robotic assisted vs laparoscopy), the use of radiotherapy (yes vs no), and chemotherapy (yes vs no). P values are the result of 2-sided tests and P < .05 was considered to indicate a statistically significant difference. Statistical analysis was performed with software (SPSS, version 19.0; IBM Corp, Armonk, NY).
Results
Between the study period of 2003 through 2010, 455 women underwent minimally invasive surgery by either robotic or laparoscopic approach for treatment of uterine cancer. Forty cases were excluded due to the presence of synchronous tumor on final pathology or inadequate follow-up. In total, 415 patients met the inclusion criteria. A total of 183 women underwent robotic-assisted surgery and 232 women underwent traditional laparoscopic surgery for endometrial cancer.
The median age, body mass index, and presence of comorbid conditions were similar in both groups. On final pathology, both groups were comparable with regard to their surgical stage, tumor histology, and grade ( Table 1 ). Stage I was more common in both groups (84% robotic and 85% laparoscopy); nonendometrioid type was present in 20% in the robotic group and 16% in the laparoscopic group. Tumor grade 2 and 3 was present in 56% and 51% in the robotic and laparoscopic groups, respectively.
| Variable | Robotic (n = 183) | Laparoscopy (n = 232) | P value |
|---|---|---|---|
| Median age, y (range) | 62 (39–86) | 61 (27–86) | .56 |
| BMI, kg/m 2 (range) | 29.2 (17–55) | 29.3 (17–58) | .20 |
| Comorbid condition, n (%) | 118 (65) | 145 (63) | .68 |
| HTN, n (%) | 89 (49) | 120 (52) | |
| Diabetes, n (%) | 29 (16) | 37 (16) | |
| Coronary artery disease, n (%) | 13 (7) | 17 (7) | |
| Hyperlipidemia, n (%) | 61 (33) | 62 (27) | |
| Conversion, n (%) | 5 (2.7) | 12 (5.2) | .21 |
| Surgical stage, n (%) | .25 | ||
| I | 153 (84) | 197 (85) | |
| II | 4 (2) | 12 (5) | |
| III | 23 (13) | 21 (9) | |
| IV | 3 (1.6) | 2 (0.9) | |
| Grade, n (%) | .15 | ||
| 1 | 79 (43) | 113 (49) | |
| 2 | 52 (28) | 72 (31) | |
| 3 | 52 (28) | 47 (20) | |
| Histology, n (%) | .71 | ||
| Endometrioid | 146 (80) | 196 (84) | |
| Serous | 14 (8) | 14 (6) | |
| Clear cell | 4 (2) | 3 (1) | |
| Mixed | 12 (7) | 10 (4) | |
| Carcinosarcoma | 7 (3.6) | 13 (4.8) | |
| Undifferentiated | 0 | 1 (0.4) | |
| Median node counts | |||
| Pelvic (range) | 13 (2–50) | 15 (1–52) | > .05 |
| Paraaortic (range) | 8 (1–27) | 7 (1–29) | > .05 |
| Total (range) | 19 (2–61) | 20 (2–60) | > .05 |
| Adjuvant therapy, n (%) | .11 | ||
| No treatment | 108 (59) | 156 (67) | |
| Radiation only | 24 (13) | 34 (15) | |
| Chemotherapy only | 19 (10) | 19 (8) | |
| Chemotherapy + radiation | 32 (17) | 22 (9) | |
| Refused | 0 | 1 (0.4) |
Patients were followed up from the day of their operation until April 2013. The median duration of follow-up among women who underwent robotic-assisted surgery was 38 months (range, 4–61 months) and for the laparoscopic group, 58 months (range, 4–118 months). No intraoperative or postoperative deaths occurred.
In the current series, 41% in the robotic group and 32% in the laparoscopic group were considered at risk for recurrence and received adjuvant therapy. Overall, postoperative adjuvant therapy received was similar in both groups ( P > .05) ( Table 1 ). In the robotic group, 97% (178/183) underwent pelvic lymph node dissection and 73% (133/183) underwent paraaortic lymph node dissection. In the laparoscopic group, 94% (219/232) underwent pelvic and 63% (147/232) underwent paraaortic lymph node dissection. The median (range) number of pelvic, paraaortic, and total lymph nodes removed was similar in both groups ( Table 1 ).
During follow-up, 55 patients (13%) developed recurrent disease. Twenty-seven of 183 patients (14.8%) in the robotic group and 28 of 232 patients (12.1%) in the laparoscopic group developed recurrence of disease ( P > .05). The pattern of recurrence was similar in both groups ( Table 2 ). No port site recurrence occurred in either group. Nonendometrioid histology recurred in 40% and 39% of robotic and laparoscopy groups, respectively. For endometrioid type, 8% and 7% recurred in the robotic and laparoscopic groups, respectively. Tumor grade 2 and 3 recurred in 25% and 20% of robotic and laparoscopy groups, respectively, while grade 1 recurred in 1.3% and 3.5% in the robotic and laparoscopy group, respectively ( Appendix ; Supplemental Figure 1 ). The most common sites of distant metastasis were liver, lung, and brain. Among women who had recurrence, 44% and 68% in the robotic and laparoscopy group died.
| Variable | Robotic, n = 183 | Laparoscopy, n = 232 | P value |
|---|---|---|---|
| Recurrence, n (%) | 27 (14.8) | 28 (12.1) | .42 |
| Isolated vaginal cuff, n (%) | 1 (0.5) | 5 (2.2) | .17 |
| Pelvis, n (%) | 7 (3.8) | 10 (4.3) | .80 |
| Abdomen ± pelvis, n (%) | 15 (8.2) | 11 (4.7) | .15 |
| Distant ± pelvis ± abdomen, n (%) | 9 (4.9) | 9 (3.9) | .61 |
| Time for surgery to first recurrence | |||
| Median, mo (range) | 19 (2–50) | 11.25 (2–70) | .36 |
The estimated 3-year DFS was similar in both groups (robotic 83.2% vs laparoscopy 88.4%) ( Figure 1 ). The 3-year OS was 93.3% and 93.6% for the robotic and laparoscopic groups, respectively ( P > .05) ( Figure 2 ). There was no significant difference in the estimated OS and DFS at 4 and 5 years ( Supplemental Table ).
In our univariate analysis, advanced age, advanced stage, unfavorable histology, high grade, adjuvant radiotherapy, and adjuvant chemotherapy affected DFS. Advanced stage, unfavorable histology (nonendometrioid), and tumor grade remained significant in affecting DFS by multivariate analysis. For OS, nonendometrioid histology and tumor grade 2/3 affected OS on multivariate analysis. Surgical approach was not an independent prognostic factor for DFS and OS ( Table 3 ).
| Variable | Univariate analysis | Multivariate analysis | ||
|---|---|---|---|---|
| Hazard ratio (95% CI) | P value | Hazard ratio (95% CI) | P value | |
| Disease-free survival | ||||
| Advanced age (>65 y) | 0.53 (0.33–0.89) | .015 | 0.87 (0.52–1.45) | .59 |
| Advanced stage (I/II vs III/IV) | 0.22 (0.13–0.37) | < .001 | 0.49 (0.26–0.93) | .03 |
| Unfavorable histology | 0.14 (0.08–0.24) | < .001 | 0.32 (0.17–0.62) | .001 |
| High grade (1 vs 2/3) | 0.13 (0.064–0.28) | < .001 | 0.32 (0.14–0.76) | .01 |
| Surgery (robotic vs laparoscopy) | 1.5 (0.89–2.55) | .125 | 1.05 (0.61–1.81) | .85 |
| Adjuvant radiotherapy | 0.31 (0.19–0.51) | < .001 | 0.93 (0.54–1.62) | .81 |
| Adjuvant chemotherapy | 0.13 (0.08–0.23) | < .001 | 0.86 (0.49–1.5) | .59 |
| Overall survival | ||||
| Advanced age (>65 y) | 0.36 (0.19–0.67) | .001 | 0.60 (0.31–1.13) | .11 |
| Advanced stage (I/II vs III/IV) | 0.24 (0.12–0.45) | < .001 | 0.66 (0.30–1.48) | .32 |
| Unfavorable histology | 0.15 (0.08–0.28) | < .001 | 0.38 (0.17–0.88) | .02 |
| High grade (1 vs 2/3) | 0.09 (0.03–0.26) | < .001 | 0.25 (0.08–0.79) | .02 |
| Surgery (robotic vs laparoscopy) | 1.23 (0.62–2.44) | .55 | 0.81 (0.40–1.6) | .55 |
| Adjuvant radiotherapy | 0.21 (0.10–0.39) | < .001 | 0.55 (0.27–1.09) | .08 |
| Adjuvant chemotherapy | 0.31 (0.06–0.25) | < .001 | 0.58 (0.22–1.51) | .27 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
