Stage IA endometrial cancer recurrence around the ureter after laparoscopic surgery

Minimally invasive surgery has become a standard treatment for early-stage endometrial cancer. Its outcomes are not inferior to those of open surgery, and it has a good prognosis. Thus, there have been a few studies on recurrence patterns in low-risk endometrial cancer. We described the case of a 45-year-old multiparous woman with the International Federation of Gynecology and Obstetrics stage IA, grade 1 endometrioid endometrial cancer, who was treated with laparoscopic modified radical hysterectomy with bilateral adnexectomy and pelvic lymph node dissection. The patient developed isolated recurrence around the left ureter 27 months later, which was also laparoscopically resected. Pathologically, she had a low risk of recurrence; therefore, we had to review our surgical procedures. The findings of a recent study have led to the development of the theory that there is a laparoscopy-specific recurrence pattern. We discussed this recurrence pattern in relation to our patient’s case and aimed that our findings will prompt to reconsider laparoscopic surgery in preventing tumor spread and recurrence in early-stage low risk endometrial cancer.

Minimally invasive surgery; Endometrial cancer recurrence; Modified radical hysterectomy;Stage IA endometrial endometrioid cancer

[1] Morice P, Leary A, Creutzberg C, Abu-Rustum N, Darai E. Endometrial cancer. The Lancet. 2016; 387: 1094–1108.

[2] Keys HM, Roberts JA, Brunetto VL, Zaino RJ, Spirtos NM, Bloss JD, et al. A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a Gynecologic Oncology Group study. Gynecologic Oncology. 2004; 92: 744–751.

[3] Creutzberg CL, van Putten WLJ, Koper PC, Lybeert MLM, Jobsen JJ, Wárlám-Rodenhuis CC, et al. Survival after relapse in patients with endometrial cancer: results from a randomized trial. Gynecologic Oncology. 2003; 89: 201–209.

[4] Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, et al. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 study. Journal of Clinical Oncology. 2012; 30: 695–700.

[5] Han KH, Kim HS, Lee M, Chung HH, Song YS. Prognostic factors for tumor recurrence in endometrioid endometrial cancer stages IA and IB. Medicine. 2017; 96: e6976.

[6] Carey MS, O’Connell GJ, Johanson CR, Goodyear MD, Murphy KJ, Daya DM, et al. Good outcome associated with a standardized treatment protocol using selective postoperative radiation in patients with clinical stage I adenocarcinoma of the endometrium. Gynecologic Oncology. 1995; 57: 138–144.

[7] Belinson JL, Lee KR, Badger GJ, Pretorius RG, Jarrell MA. Clinical stage I adenocarcinoma of the endometrium-analysis of recurrences and the potential benefit of staging lymphadenectomy. Gynecologic Oncology. 1992; 44: 17–23.

[8] Ureyen I, Karalok A, Turkmen O, Kimyon G, Akdas YR, Akyol A, et al. Factors predicting recurrence in patients with stage IA endometrioid endometrial cancer: what is the importance of LVSI? Archives of Gynecology and Obstetrics. 2020; 301: 737–744.

[9] Bendifallah S., Ouldamer L, Lavoue L, Canlorbe G, Raimond E, Coutant C, et al. Patterns of recurrence and outcomes in surgically treated women with endometrial cancer acording to ESMOESGO-ESTRO Consensus Conference risk groups: results from the FRANCOGYN study Group. Gynecologic Oncology. 2017; 144: 107–112.

[10] Nikolaos F, Panagiotis A, Konstantinos B, Vassilios S, Iraklis P. Distant ureteral metastasis from colon adenocarcinoma: report of a case and review of literature. Case Reports in Urology. 2014; 2014: 196425.

[11] Shimoyama Y, Ohashi M, Hashiguchi N, Ishihara M, Sakata M, Tamura A, et al. Gastric cancer recognized by metastasis to the ureter. Gastric Cancer. 2000; 3: 102–105.

[12] Amant F, Moerman P, Neven P, Timmerman D, Van Limbergen E, Vergote I. Endometrial cancer. The Lancet. 2005; 366: 491–505.

[13] Turan T, Yilmaz SS, Hizli D, Gündoğdu B, Boran N, Tulunay G, et al. A prospective evaluation of lymphatic dissemination in endometrial cancer: is it adequate to perform lymph node dissection up to the inferior mesenteric artery? International Journal of Gynecological Cancer. 2011; 21: 864–869.

[14] Zhang C, Wang C, Feng W. Clinicopathological risk factors for pelvic lymph node metastasis in clinical early-stage endometrioid endometrial adenocarcinoma. International Journal of Gynecological Cancer. 2012; 22: 1373–1377.

[15] Briët JM, Hollema H, Reesink N, Aalders JG, Mourits MJE, ten Hoor KA, et al. Lymphvascular space involvement: an independent prognostic factor in endometrial cancer. Gynecologic Oncology. 2005; 96: 799–804.

[16] Guntupalli SR, Zighelboim I, Kizer NT, Zhang Q, Powell MA, Thaker PH, et al. Lymphovascular space invasion is an independent risk factor for nodal disease and poor outcomes in endometrioid endometrial cancer. Gynecologic Oncology. 2012; 124: 31–35.

[17] O’Brien DJ, Flannelly G, Mooney EE, Foley M. Lymphovascular space involvement in early stage well-differentiated endometrial cancer is associated with increased mortality. BJOG: An International Journal of Obstetrics and Gynaecology. 2009; 116: 991–994.

[18] Hachisuga T, Kaku T, Enjoji M. Carcinoma of the lower uterine segment. Clinicopathologic analysis of 12 cases. International Journal of Gynecological Pathology. 1989; 8: 26–35.

[19] Phelan C, Montag AG, Rotmensch J, Waggoner SE, Yamada SD, Mundt AJ. Outcome and management of pathological stage I endometrial carcinoma patients with involvement of the lower uterine segment. Gynecologic Oncology. 2001; 83: 513–517.

[20] Gemer O, Gdalevich M, Voldarsky M, Barak F, Ben Arie A, Schneider D, et al. Lower uterine segment involvement is associated with adverse outcome in patients with stage I endometroid endometrial cancer: results of a multicenter study. European Journal of Surgical Oncology. 2009; 35: 865–869.

[21] Galaal K., Donkers H., Bryant A., Lopes A. D. Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database of Systematic Reviews. 2018; 10: Cd006655.

[22] He H, Zeng D, Ou H, Tang Y, Li J, Zhong H. Laparoscopic treatment of endometrial cancer: systematic review. Journal of Minimally Invasive Gynecology. 2013; 20: 413–423.

[23] Onda T, Yoshikawa H, Mizutani K, Mishima M, Yokota H, Nagano H, et al. Treatment of node-positive endometrial cancer with complete node dissection, chemotherapy and radiation therapy. British Journal of Cancer. 1997; 75: 1836–1841.

[24] Lee M, Kim YT, Kim SW, Kim S, Kim JH, Nam EJ. Effects of uterine manipulation on surgical outcomes in laparoscopic management of endometrial cancer: a prospective randomized clinical trial. International Journal of Gynecological Cancer. 2013; 23: 372–379.

[25] Favero G, Miglino G, Köhler C, Pfiffer T, Silva e Silva A, Ribeiro A, et al. Vaginal morcellation inside protective pouch: a safe strategy for uterine extration in cases of bulky endometrial cancers: operative and oncological safety of the method. Journal of Minimally Invasive Gynecology. 2015; 22: 938–943.

[26] Favero G, Anton C, Silva e Silva A, Ribeiro A, Araújo MP, Miglino G, et al. Vaginal morcellation: a new strategy for large gynecological malignant tumor extraction: a pilot study. Gynecologic Oncology. 2012; 126: 443–447.

[27] Seidman MA, Oduyebo T, Muto MG, Crum CP, Nucci MR, Quade BJ. Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms. PLoS ONE. 2012; 7: e50058.

[28] George S, Barysauskas C, Serrano C, Oduyebo T, Rauh–Hain JA, Del Carmen MG, et al. Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma. Cancer. 2014; 120: 3154–3158.

[29] Della Badia C, Karini H. Endometrial stromal sarcoma diagnosed after uterine morcellation in laparoscopic supracervical hysterectomy. Journal of Minimally Invasive Gynecology. 2010; 17: 791– 793.

[30] Palomba S, Falbo A, Russo T, La Sala GB. Port-site metastasis after laparoscopic surgical staging of endometrial cancer: a systematic review of the published and unpublished data. Journal of Minimally Invasive Gynecology. 2012; 19: 531–537.

[31] Hewett PJ, Thomas WM, King G, Eaton M. Intraperitoneal cell movement during abdominal carbon dioxide insufflation and laparoscopy. An in vivo model. Diseases of the Colon & Rectum. 1996; 39: S62–S66.

[32] Jones DB, Guo LW, Reinhard MK, Soper NJ, Philpott GW, Connett J, et al. Impact of pneumoperitoneum on trocar site implantation of colon cancer in hamster model. Diseases of the Colon and Rectum. 1995; 38: 1182–1188.

[33] Lee SW, Southall J, Allendorf J, Bessler M, Whelan RL. Traumatic handling of the tumor independent of pneumoperitoneum increases port site implantation rate of colon cancer in a murine model. Surgical Endoscopy. 1998; 12: 828–834.