| 1. |
- Lindfors, Anna, et al.
(author)
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Robotic vs Open Surgery for Endometrial Cancer in Elderly Patients: Surgical Outcome, Survival, and Cost Analysis.
- 2018
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In: International journal of gynecological cancer : official journal of the International Gynecological Cancer Society. - 1525-1438. ; 28:4, s. 692-699
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Journal article (peer-reviewed)abstract
- This study aimed to compare robotic and open surgery in elderly women diagnosed as having endometrial cancer, in terms of costs, survival, surgical outcome, and operating time.Women 70 years or older undergoing open and robotic surgery for endometrial cancers were included consecutively before and after the introduction of robotic surgery at a tertiary center. Costs were calculated using the case-costing system, cost per patient, including the first 30 postoperative days. Relative and overall survival outcomes were obtained from the Swedish National Cancer Registry and analyzed using the Kaplan-Meier method. Surgical outcomes including operating and anesthesia times, estimated blood loss, hospital stay, and intraoperative and postoperative complications were reviewed.In all, 137 and 141 women 70 years or older were identified to have undergone open and robotic surgery, respectively. The groups showed similar body mass index, comorbidities, and tumor characteristics. No statistically significant differences were seen in costs (robotic &OV0556;11,874 vs open &OV0556;11,521, P = 0.463) or 5-year survival outcomes (robotic 94% [95% confidence interval {CI}, 84-105] vs open 87% [95% CI, 78-98], P = 0.529). Robotic surgery was associated with significantly lower estimated blood loss (P < 0.001) and shorter hospital stay (P < 0.001) but longer anesthesia time (186 vs 174 minutes; P < 0.05) and operating theater time (205 vs 190 minutes; P < 0.05). There were no significant differences in intraoperative complications, but robotic surgery resulted in fewer postoperative Clavien-Dindo grade II complications.Elderly women can safely undergo robotic surgery for endometrial cancer and could be offered this technique to the same extent as younger patients. They may benefit from shorter hospital stay, decreased blood loss, and postoperative complications, without resulting in higher costs to the health care system or jeopardizing their survival.
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| 2. |
- Palmér, Magnus, 1980, et al.
(author)
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Accuracy of transvaginal ultrasound versus MRI in the PreOperative Diagnostics of low-grade Endometrial Cancer (PODEC) study: a prospective multicentre study.
- 2023
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In: Clinical radiology. - : Elsevier BV. - 0009-9260 .- 1365-229X. ; 78:1, s. 70-79
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Journal article (peer-reviewed)abstract
- The purpose was to investigate if the diagnostic accuracy of transvaginal ultrasound (TVUS) performed by gynaecologists is sufficient for preoperative assessment of low-grade endometrial cancer (EC) compared to magnetic resonance imaging (MRI). MRI and TVUS performed by gynaecologists were assessed at the participating centres. The MRI examinations were interpreted by two radiologists at the tertiary centre. Deep myometrial and cervical stroma invasion were visually assessed and compared to postoperative histopathology. Twohundred and fiftynine patients were included. There was a statistically significant difference in specificity assessing deep myometrial invasion between MRI and TVUS (MRI 0.88, TVUS 0.68). There was no difference in sensitivity (MRI 0.73, TVUS 0.68). When assessing cervical stroma infiltration, MRI had a higher specificity (MRI 0.96, TVUS 0.90), but there was no difference in sensitivity (MRI 0.41, TVUS 0.32). MRI has higher specificity than TVUS performed by gynaecologists for assessing deep MI and CSI in low-grade EC, but similar sensitivities. The use of TVUS as a first-line test, rather than MRI, may be supported by this study in centres where access to MRI may be limited.
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| 3. |
- Wedin, Madelene, et al.
(author)
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Impact of lymphadenectomy and lymphoedema on health-related quality of life 1 year after surgery for endometrial cancer. A prospective longitudinal multicentre study
- 2022
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In: Bjog-an International Journal of Obstetrics and Gynaecology. - : Wiley. - 1470-0328 .- 1471-0528. ; 129:3, s. 450-460
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Journal article (peer-reviewed)abstract
- Objective To assess the impact of lymphadenectomy and lymphoedema of the lower limbs (LLL) on health-related quality of life (HRQoL) 1 year after surgery for endometrial cancer (EC). Design Prospective longitudinal cohort multicentre study. Setting Departments of obstetrics and gynaecology at four university hospitals, six central hospitals and four county hospitals in Sweden. Population Two-hundred-and-thirty-five women with early stage EC were included; 116 with high-risk EC underwent surgery including lymphadenectomy (+LA), and 119 with low-risk EC had surgery without lymphadenectomy (-LA). Methods The generic SF-36 and EQ-5D-3L and the lymphoedema-specific LYMQOL questionnaire were used to assess HRQoL. LLL was assessed by systematic circumferential measurements of the legs enabling volume estimation, clinical evaluation and patient-reported perception of leg swelling. All assessments were carried out on four occasions; preoperatively, and 4-6 weeks, 6 months and 1 year postoperatively. Main outcome measure HRQoL scores. Results No significant differences were seen in HRQoL between the +LA and -LA groups 1 year postoperatively. Irrespective of method of determining LLL, women with LLL were significantly more affected in the LYMQOL domains Function, Appearance/body image and Physical symptoms, but not in the domain Emotion/mood, than women without LLL. No such differences were seen in the generic HRQoL or in the LYMQOL global score between the groups with and without LLL. Conclusions Lymphadenectomy did not seem to affect generic HRQoL adversely. Irrespective of the method of measuring, LLL affected the lymphoedema-specific HRQoL negatively, mainly in physical domains, but had no impact on the generic HRQoL. Tweetable abstract Lymphoedema has impact on lymphoedema-specific, but not on generic, HRQoL, 1 year after surgery for EC.
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| 4. |
- Wedin, Madelene, et al.
(author)
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Incidence of lymphedema in the lower limbs and lymphocyst formation within one year of surgery for endometrial cancer: A prospective longitudinal multicenter study
- 2020
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In: Gynecologic Oncology. - : Elsevier BV. - 0090-8258 .- 1095-6859. ; 159:1, s. 201-208
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Journal article (peer-reviewed)abstract
- Objective. The study aimed to determine the incidence of lower limb lymphedema (LLL) after surgery for endometrial cancer (EC) by means of three methods, and to determine the incidence of lymphocysts after one year. Methods. A prospective longitudinal multicenter study was conducted in 14 hospitals in Sweden. Two-hundred-and-thirty-five women with EC were included; 116 underwent surgery that included lymphadenectomy (+LA) and 119 were without lymphadenectomy ( -LA). Lymphedema was assessed objectively on four occasions; preoperatively, at 4-6 weeks, six months and one year postoperatively using systematic measurement of leg circumferences, enabling calculation of leg volumes, and a clinical grading of LLL, and subjectively by the patient's perception of lymphedema measured by a lymphedema-specific quality-of-life instrument. Lymphocyst was evaluated by vaginal ultrasonography. Results. After one year the incidence of LLL after increase in leg volume adjusted for body mass index was 15.8% in +LA women and 3.4% in -IA women. The corresponding figures for clinical grading were 24.1% and 11.8%, and for patient-reported perceived LLL 10.7% and 5.1%. The agreement between the modalities revealed fair to moderate correlation between patient-reported LLL and clinical grading, but poor agreement between volume increase and patient-reported LLL or clinical grading. Lymphocysts were found in 43% after one year. Conclusions. Although the incidence of ILL and lymphocysts after surgery for EC including LA seemed to be relatively high the study demonstrated significant variations in incidence depending on the measurement modality. This emphasizes the need for a 'gold standard' of measurement of LLL in clinical practice and research. (C) 2020 Elsevier Inc. All rights reserved.
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| 5. |
- Wedin, Madelene, 1976-, et al.
(author)
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Risk factors for lymphedema and method of assessment in endometrial cancer: a prospective longitudinal multicenter study
- 2021
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In: International Journal of Gynecological Cancer. - : BMJ. - 1048-891X .- 1525-1438. ; 31:11, s. 1416-1427
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Journal article (peer-reviewed)abstract
- Objective The aim of the study was to determine risk factors for lymphedema of the lower limbs, assessed by four methods, 1 year after surgery for endometrial cancer. Methods A prospective longitudinal multicenter study was conducted in 14 Swedish hospitals. 235 women with endometrial cancer were included; 116 underwent surgery including lymphadenectomy, and 119 had surgery without lymphadenectomy. Lymphedema was assessed preoperatively and 1 year postoperatively objectively by systematic circumferential measurements of the legs, enabling volume estimation addressed as (1) crude volume and (2) body mass index-standardized volume, or (3) clinical grading, and (4) subjectively by patient-reported perception of leg swelling. In volume estimation, lymphedema was defined as a volume increase >= 10%. Risk factors were analyzed using forward stepwise logistic regression models and presented as adjusted odds ratio (aOR) and 95% confidence interval (95% CI). Results Risk factors varied substantially, depending on the method of determining lymphedema. Lymphadenectomy was a risk factor for lymphedema when assessed by body mass index-standardized volume (aOR 14.42, 95% CI 3.49 to 59.62), clinical grading (aOR 2.11, 95% CI 1.04 to 4.29), and patient-perceived swelling (aOR 2.51, 95% CI 1.33 to 4.73), but not when evaluated by crude volume. Adjuvant radiotherapy was only a risk factor for lymphedema when assessed by body mass index-standardized volume (aOR 15.02, 95% CI 2.34 to 96.57). Aging was a risk factor for lymphedema when assessed by body mass index-standardized volume (aOR 1.07, 95% CI 1.00 to 1.15) and patient-perceived swelling (aOR 1.06, 95% CI 1.02 to 1.10), but not when assessed by crude volume or clinical grading. Increase in body mass index was a risk factor for lymphedema when estimated by crude volume (aOR 1.92, 95% CI 1.36 to 2.71) and patient-perceived swelling (aOR 1.36, 95% CI 1.11 to 1.66), but not by body mass index-standardized volume or clinical grading. The extent of lymphadenectomy was strongly predictive for the development of lymphedema when assessed by body mass index-standardized volume and patient-perceived swelling, but not by crude volume or clinical grading. Conclusion Apparent risk factors for lymphedema differed considerably depending on the method used to determine lymphedema. This highlights the need for a 'gold standard' method when addressing lymphedema for determining risk factors.
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| 6. |
- Åkesson, Åsa, 1974
(author)
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Endometrial Cancer - Studies on recurrences, complications and preoperative diagnostics
- 2023
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Doctoral thesis (other academic/artistic)abstract
- Introduction: The most common gynecological cancer is Endometrial Cancer (EC). The prognosis is generally favorable, mainly due to an early diagnosis. However, there are subgroups of EC with a higher risk for metastases and recurrences resulting in poorer survival. Primary treatment for EC is surgical, with hysterectomy and bilateral salpingo-oophorectomy and in higher risk groups adding surgical staging with lymph node assessment for the adjuvant treatment planning. Aim: The overall aim of this thesis was to study recurrence, survival and surgical complications in a population-based cohort and to assess the introduction of the first national guidelines (NGEC), which recommended pelvic and para-aortic lymphadenectomy (PPLND) in high-risk EC. A second aim was to evaluate preoperative risk classification assessment with transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) in low-grade endometrioid EC. Methods: Paper I-III were regional population-based studies in the Western Sweden Health Care Region (WSHCR). Data was retrieved from the Swedish Quality Register for Gynecological Cancer (SQRGC) for all EC patients in the WSHCR 2010-2017. Medical records were reviewed for details of recurrence, complications, and patient characteristics, such as BMI and comorbidities. Patients with primary surgical treatment for pre-operative early- stage EC were included in the studies. Paper I encompassed patients with endometrioid EC and Paper II non-endometrioid EC. In Paper III, patients who underwent surgery at the tertiary center were included and complications 30 days postoperatively were recorded and graded according to the Clavien-Dindo (CD) classification system. Overall (OS), net (NS) and disease- free survival (DFS) were calculated using the Kaplan-Meier method. The Cox proportional hazards regression model was used in Paper I-III to evaluate the effect of identified variables on DFS and OS. Uni- and multivariable logistic regression analyses were performed with complications as outcome in Paper III. Paper IV was a prospective multicenter study in the WSHCR including patients with low-grade EC planned for primary surgery during 2017-2019. The patients were examined preoperatively with both TVUS and MRI to assess deep myometrial infiltration (MI) and cervical stroma invasion (CSI) for the decision on surgery with or without PPLND. The TVUS was performed by gynecologists, and the MRI was performed according to a standardized protocol. The methods were analyzed for sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy. The methods were compared using McNemar’s test and Cohen’s kappa (k). Results: In the endometrioid EC cohort in Paper I, 8.3% (136/1630) experienced a recurrence. In the non-endometrioid EC cohort in Paper II, the recurrence rate was 29% (67/228). The total 5-year DFS was 83.9% for the endometrioid EC cohort (Paper I) and 61.9% for the non- endometrioid EC cohort (Paper II). If no recurrence occurred, the 5-year OS was 91.9% in the endometrioid EC cohort (Paper I) and 88.5% in the non-endometrioid EC cohort (Paper II). When a recurrence occurred the 5-year OS for the endometrioid EC cohort was 77.0% for isolated vaginal recurrences compared to 36.1% for all other recurrences (Paper I). The 5-year OS was 13.4% when a recurrence occurred in the non-endometrioid EC cohort (Paper II). In Paper I, age, FIGO stage and primary treatment were found independent risk factors for recurrence. In Paper II, the OS before the implementation of NGEC was 57.3% compared to 72.0% after. Age, FIGO stage and lymph node dissection were found significant factors for DFS, where having a lymph node dissection decreased the risk of recurrence or death. In Paper III, 19.7% (108/549) had a surgical complications of CD grade II-V. Surgical technique, BMI and lymph node dissection, were found to be risk factors for complications CD. In Paper IV (n=259), MRI and TVUS were compared for the assessment of deep MI and CSI and there was a statistically significant difference in specificity, with MRI having a higher specificity. No difference in sensitivity was found. Conclusions: For endometrioid EC, the recurrence rate was overall low in contrast to non- endometrioid EC where the recurrence rate was rather high. The survival was excellent when no recurrence occurred, in both endometrioid and non-endometrioid EC. However, in cases of recurrence, survival was poor, with the exception of isolated vaginal recurrence, where the prognosis was favorable. A significant improvement in survival was seen in non-endometrioid EC after the NGEC implementation with lymph node staging tailoring adjuvant radiotherapy. However, in Paper III we show that surgical staging with lymphadenectomy is a risk factor for surgical complications. This may be taken into consideration in treatment guidelines for EC, where steps moving towards a less extensive lymph node assessment surgery with the sentinel node procedure may be advocated. For the assessment of deep MI, MRI had a higher accuracy than TVUS. Nevertheless, the sensitivity of TVUS performed by gynecologists was evaluated as acceptable and did not differ from MRI. TVUS is readily available, and Paper IV supports this method for first-hand use in similar settings.
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| 7. |
- Åkesson, Åsa, 1974, et al.
(author)
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Increased survival in non-endometrioid endometrial cancer after introducing lymphadenectomy and tailoring radiotherapy – A population-based cohort study
- 2022
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In: European Journal of Cancer. - : Elsevier BV. - 0959-8049 .- 1879-0852. ; 169:July 2022, s. 54-63
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Journal article (peer-reviewed)abstract
- Objective: To investigate recurrence and survival in non-endometrioid endometrial cancer in a population-based cohort and evaluate the implementation of the first national guidelines (NGEC) recommending pelvic and paraaortic lymphadenectomy for surgical staging and tailored adjuvant therapy. Methods: A population-based cohort study that used the Swedish quality registry for gynaecological cancer for the identification of all women with early-stage non-endometrioid endometrial cancer between 2010 and 2017. Five-year overall (OS) and disease-free survival (DFS) were calculated using the Kaplan–Meier method. The Cox proportional hazards regression model was used to evaluate the effect of age, FIGO stage, primary treatment and lymph node dissection on DFS. Results: There were 228 patients included in the study cohort and 67 (29%) patients had a recurrence within five years. In the recurrence cohort, the OS was 13.4% (95%CI:7.3–24.7) compared to 88.5% (95%CI:83.4–93.9) if no recurrence occurred (log-rank p < 0.001). The DFS for the complete cohort was 61.9% (95%CI:55.7–68.7). The OS before implementation of NGEC was 57.3% (95%CI:48.2–68.1) and the DFS was 52.1% (95%CI:43.0–63.1) compared to an OS of 72.0% (95%CI:64.2–80.7; log-rank p = 0.018) and a DFS of 70.1% (95%CI:62.4–78.7; log-rank p = 0.008) after implementing NGEC. Patients received adjuvant radiotherapy in 92.7% before and 42.4% after NGEC implementation (p < 0.001). In the multivariable regression analysis, age, FIGO stage and lymph node dissection were found to be significant prognostic factors, where having a lymph node dissection decreased the risk of recurrence or death with a HR of 0.58 (95%CI:0.33–1.00). Conclusion: In this population-based cohort of preoperative early-stage non-endometrioid EC, a significant improvement in survival was seen after NGEC implementation where lymph node staging for tailoring adjuvant therapy was introduced and less pelvic radiotherapy was given.
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| 8. |
- Åkesson, Åsa, 1974, et al.
(author)
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Lymphadenectomy, obesity and open surgery are associated with surgical complications in endometrial cancer
- 2021
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In: Ejso. - : Elsevier BV. - 0748-7983. ; 47:11, s. 2907-2914
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Journal article (peer-reviewed)abstract
- Objective: To investigate surgical complications related to the staging procedure for endometrial cancer (EC) and to explore complication associations towards patient characteristics and survival. Methods: A population-based cohort study of women diagnosed with EC where primary surgery was performed at a tertiary centre between 2012 and 2016. The Swedish Quality Registry for Gynecological Cancer was used for identification, medical records reviewed and surgical outcomes, including complications according to Clavien-Dindo (CD), and comorbidity (Charlson's index) registered. Uni-and multivariable logistic regression analyses were performed with complications as outcome and multi variable Cox regression analysis with overall survival (OS) as endpoint. Results: In total 549 women were identified where 108 (19.7%) had CD grade II-V complications. In the multivariable regression analysis; surgical technique, BMI and lymph node dissection, but not comorbidity or age, were found to be risk factors for complications CD grade II-V, with OR of 0.32 (95%CI:0.18-0.56) for minimalinvasive surgery (MIS) compared to open, OR 2.18 (95%CI:1.37-3.49) for BMI >30 and OR 2.63 (95%CI:1.32-5.31) for pelvic and paraaortic lymphnode dissection. In Cox regression analysis, a significant lower OS was found within the first 1.5 years for the cohort of complications (CD II-V) compared to no complications. Conclusion: Surgical staging with lymphadenectomy was found a risk factor for complications together with high BMI in EC. Using MIS was significantly associated with less complications. Overall survival was found to be negatively affected within the first years after complications. Our results may be taken into consideration when performing updated treatment guidelines including surgical staging. (c) 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
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| 9. |
- Åkesson, Åsa, 1974, et al.
(author)
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Recurrence and survival in endometrioid endometrial cancer - a population-based cohort study.
- 2023
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In: Gynecologic oncology. - : Elsevier BV. - 1095-6859 .- 0090-8258. ; 168, s. 127-134
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Journal article (peer-reviewed)abstract
- The aim of this study was to investigate recurrences and survival in endometrioid endometrial cancer (EC) in a complete population-based cohort.A regional population-based study including women with endometrioid EC, identified by the Swedish Quality Registry for Gynecological Cancer (SQRGC), where primary surgery was performed between 2010 and 2017. Patient characteristics and outcomes, including recurrences, were retrieved from the SQRGC and completed by records reviews. Overall (OS), net (NS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. The Fine and Gray proportional subdistribution hazards' regression model was used for risk factors for recurrence.There were 1630 women included in the study, whereof 136 (8.3%) had a recurrence with a median time to recurrence of 22.5 months (range 3.2-59.3). One site of recurrence was diagnosed in 69.1%, while 27.2% being only vaginal. The total 5-year OS was 88.0%(95% CI:86.4-89.7) and the 5-year NS 98.6%(95% CI:96.5-100.7). If no recurrence occurred, the OS was 91.9%(95% CI:90.4-93.3) and NS 102.8%(95% CI:100.9-104.8). For only vaginal recurrence, 5-year OS was 77.0%(95% CI:64.0-92.6) compared to 36.1%(95% CI:27.5-47.3) for all other recurrences. The total 5-year DFS was 83.9%(95% CI:82.0-85.7). In the multivariable analysis, age, FIGO stage and primary treatment were found independent factors for recurrence with a HR of 1.29(95% CI:1.11-1.51;p = 0.001) for age, 2.78(95% CI:1.80-4.29;p < 0.001) for FIGO stage III and 1.84(95% CI:1.22-2.78;p 0.004) for adjuvant treatment.There is an overall low recurrence rate for endometrioid ECs with a minor portion being only vaginal, associated with a favorable survival in contrast to other recurrences with a poor prognosis. Age, FIGO stage III and adjuvant treatment were found independent prognostic factors for recurrence.
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