From the Journals

Laparoscopic and abdominal hysterectomy yield equivalent survival

Publish date: March 28, 2017
By
Mary Ann Moon

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Laparoscopic approach now preferred

This study adds to a growing body of literature that suggests laparoscopic hysterectomy is not only safe, but also the preferred modality of hysterectomy for women with endometrial cancer.

Despite the clear benefits of laparoscopic hysterectomy, the findings from the LACE trial should be interpreted in the context of the study design. Importantly, patients randomized to the study represent a highly select group of women with endometrial cancer. The study entry criteria involved a low-risk population of women with stage I tumors of endometrioid histology with a uterine size of less than 10 weeks’ gestation. In practice, laparoscopic hysterectomy is now routinely used for women with nonendometrioid histologies and in those with more advanced disease.

Dr. Jason Wright

Dr. Jason Wright

The LACE trial reported by Janda et al. provides confirmation that laparoscopic hysterectomy is a safe and effective treatment modality for women with early-stage endometrial cancer. The favorable short-term outcomes along with equivalent oncological outcomes make laparoscopic hysterectomy the preferred surgical modality in this setting. Even though the road to defining the benefits of laparoscopic hysterectomy has been long, efforts to promote the procedure for women with endometrial cancer should now be a priority.

Jason D. Wright, MD, is at the Herbert Irving Comprehensive Cancer Center and the department of ob.gyn. at Columbia University, New York. He reported having no relevant financial disclosures. These comments are excerpted from an accompanying editorial (JAMA 2017;317[12]:1215-6).


 

FROM JAMA

Laparoscopic hysterectomy yields equivalent disease-free and overall survival at 4.5 years, compared with abdominal hysterectomy in stage I endometrial cancer, according to a report published online March 28 in JAMA.

Several short-term advantages with the laparoscopic approach have been well documented, including less pain, less morbidity, better quality of life, decreased risk of surgery-related adverse events, and cost savings. But until now, no large international trial has demonstrated that longer-term survival outcomes are at least as good with laparoscopic as with open abdominal hysterectomy in this patient population, reported Monika Janda, PhD, of Queensland University of Technology, Brisbane (Australia) and her colleagues.

They conducted the Laparoscopic Approach to Cancer of the Endometrium (LACE) trial, a randomized equivalence study involving 760 women treated at 20 medical centers in Australia, New Zealand, and Hong Kong during 2005-2010. The women were followed for a median of 4.5 years.

All of the women had histologically confirmed stage I adenocarcinoma of the endometrium. A total of 407 patients were randomly assigned to undergo total laparoscopic hysterectomy and 353 patients to undergo total abdominal hysterectomy. Medical comorbidities were equally distributed between the two study groups, and there were no significant between-group differences in tumor type, histologic grade, number of involved lymph nodes, or adjuvant treatments.

Disease-free survival at 4.5 years was 81.6% with laparoscopic hysterectomy and 81.3% with abdominal hysterectomy, meeting the criteria for equivalence. Overall survival at 4.5 years was 92.0% and 92.4%, respectively. Cancer recurred near the operative site in 3% of each group and at a regional or distant site in 2% or less of each group. Causes of death also were similar between the two study groups, with 56% of all deaths attributed to endometrial cancer (JAMA. 2017;317[12]:1224-33).

Of note, two patients who underwent laparoscopic surgery developed port-site metastases and two patients who underwent abdominal surgery developed metastases at the site of the abdominal wound.

The study was funded by Cancer Councils in Australia, the National Health and Medical Research Council, Cancer Australia, QLD Health, and numerous others. Dr. Janda reported having no relevant financial disclosures; one of her coauthors reported ties to the O.R. Company, SurgicalPerformance Pty, and Covidien.

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