Nearly Identical Survival for Laparoscopy vs Laparatomy in Patients with Stage I/IIA Disease

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Building on previously reported results that laparoscopic surgical management of uterine cancer is superior for short-term safety and length-of-stay endpoints, the Gynecologic Oncology Group reported small and lower than anticipated potential for increase risk of cancer recurrence with laparoscopy vs laparotomy. The estimated 3-year recurrence rate was 11.4% with laparoscopy vs 10.2% with laparotomy, a difference of 1.14% for patients with clinical stages I to IIA disease enrolled in the Laparoscopic Surgery or Standard Surgery in Treating Patients with Endometrial Cancer or Cancer of the Uterus (LAP 2) study. The results were reported in the Journal of Clinical Oncology.

Patients in the study were randomly allocated 2:1 to laparoscopy (n = 1,696) or laparotomy (n = 920) for hysterectomy, salpingo-oophorectomy, pelvic cytology, and pelvic and para-aortic lymphadenectomy. The primary study endpoint was “noninferiority of recurrence-free interval defined as no more than a 40% increase in the risk of recurrence with laparoscopy compared with laparotomy,” the authors explained.

At a median follow-up of 59 months, there were 210 recurrences and 229 deaths in the laparoscopy group, compared with 99 recurrences and 121 deaths in the laparotomy group. “The estimated 5-year overall survival was almost identical in both arms at 89.8%,” the authors reported.

Implications of Results

“These results do not demonstrate a survival decrement from laparoscopy, which allows patients and surgeons comfort in choosing the less morbid procedure. The conversion to laparotomy when adequate surgical staging cannot be completed laparoscopically allows for completion of surgical staging without compromising the patient,” the authors concluded. “The results of this trial cannot be generalized to the use of laparoscopic hysterectomy without lymphadenectomy, because thorough surgical staging was required in both arms of this trial, and conversion was required when lymphadenectomy could not be completed using laparoscopy,” they added.

“On the basis of the LAP2 study one can reasonably conclude that there is not a substantial increase in recurrence rates with laparoscopic surgery. However, because the study did not achieve noninferiority, it is important to not dismiss the possibility that a small difference may actually exist,” according to an editorial accompanying the article. “Other trials of minimally invasive surgery are ongoing, and although they are not identical in study design to LAP2, it is hoped that these will provide additional reassurance.” The authors continued, “gynecologic oncologists should continue to consider ways in which minimally invasive surgery for endometrial cancer can be conducted to minimize the potential for dissemination of disease.”

Ongoing Debate

The editorial also pointed out that robotic surgery for endometrial cancer “may be easier to master, is less dependent on the availability of a trained assistant, and has ergonomic advantages for the surgeon” compared to laparoscopic surgery. “Those who are facile with both approaches say that the robot is particularly helpful in morbidly obese patients, in whom exposure and the facility of laparoscopic instruments are compromised. Conversely, robotic surgery typically takes longer than laparoscopy, and expense is also increased by the high cost of the robot, its maintenance, and disposable instruments,” the editorialists wrote.

“The debate regarding the appropriate roles of laparoscopy and robotics in training programs and in practice is ongoing. Both confer major advantages relative to open surgery, and minimally invasive surgical approaches are still evolving and can be expected to continue to improve in the future,” the authors concluded. ■

Walker JL, et al: J Clin Oncol. January 30, 2012 (early release online).

Berchuck AB, et al: J Clin Oncol. January 30, 2012 (early release online).