Accuracy and Survival Outcomes after National Implementation of Sentinel Lymph Node Biopsy in Early Stage Endometrial Cancer

Accuracy; Sentinel lymph node biopsy; Endometrial cancerPrecisión; Biopsia del ganglio linfático centinela; Cáncer de endometrioPrecisió; Biòpsia del gangli limfàtic sentinella; Càncer d'endometriBackground Sentinel lymph node (SLN) biopsy has recently been accepted to evaluate nodal status in endometrial cancer at early stage, which is key to tailoring adjuvant treatments. Our aim was to evaluate the national implementation of SLN biopsy in terms of accuracy to detect nodal disease in a clinical setting and oncologic outcomes according to the volume of nodal disease. Patients and Methods A total of 29 Spanish centers participated in this retrospective, multicenter registry including patients with endometrial adenocarcinoma at preoperative early stage who had undergone SLN biopsy between 2015 and 2021. Each center collected data regarding demographic, clinical, histologic, therapeutic, and survival characteristics. Results A total of 892 patients were enrolled. After the surgery, 12.9% were suprastaged to FIGO 2009 stages III–IV and 108 patients (12.1%) had nodal involvement: 54.6% macrometastasis, 22.2% micrometastases, and 23.1% isolated tumor cells (ITC). Sensitivity of SLN biopsy was 93.7% and false negative rate was 6.2%. After a median follow up of 1.81 years, overall surivial and disease-free survival were significantly lower in patients who had macrometastases when compared with patients with negative nodes, micrometastases or ITC. Conclusions In our nationwide cohort we obtained high sensitivity of SLN biopsy to detect nodal disease. The oncologic outcomes of patients with negative nodes and low-volume disease were similar after tailoring adjuvant treatments. In total, 22% of patients with macrometastasis and 50% of patients with micrometastasis were at low risk of nodal metastasis according to their preoperative risk factors, revealing the importance of SLN biopsy in the surgical management of patients with early stage EC.Open Access Funding provided by Universitat Autonoma de Barcelona

Accuracy and Survival Outcomes after National Implementation of Sentinel Lymph Node Biopsy in Early Stage Endometrial Cancer

Altres ajuts: acords transformatius de la UABSentinel lymph node (SLN) biopsy has recently been accepted to evaluate nodal status in endometrial cancer at early stage, which is key to tailoring adjuvant treatments. Our aim was to evaluate the national implementation of SLN biopsy in terms of accuracy to detect nodal disease in a clinical setting and oncologic outcomes according to the volume of nodal disease. A total of 29 Spanish centers participated in this retrospective, multicenter registry including patients with endometrial adenocarcinoma at preoperative early stage who had undergone SLN biopsy between 2015 and 2021. Each center collected data regarding demographic, clinical, histologic, therapeutic, and survival characteristics. A total of 892 patients were enrolled. After the surgery, 12.9% were suprastaged to FIGO 2009 stages III-IV and 108 patients (12.1%) had nodal involvement: 54.6% macrometastasis, 22.2% micrometastases, and 23.1% isolated tumor cells (ITC). Sensitivity of SLN biopsy was 93.7% and false negative rate was 6.2%. After a median follow up of 1.81 years, overall surivial and disease-free survival were significantly lower in patients who had macrometastases when compared with patients with negative nodes, micrometastases or ITC. In our nationwide cohort we obtained high sensitivity of SLN biopsy to detect nodal disease. The oncologic outcomes of patients with negative nodes and low-volume disease were similar after tailoring adjuvant treatments. In total, 22% of patients with macrometastasis and 50% of patients with micrometastasis were at low risk of nodal metastasis according to their preoperative risk factors, revealing the importance of SLN biopsy in the surgical management of patients with early stage EC

In silico Approach for Validating and Unveiling New Applications for Prognostic Biomarkers of Endometrial Cancer

Bioinformática; Cáncer de endometrio; Biomarcador pronósticoBioinformàtica; Càncer d'endometri; Biomarcador pronòsticBioinformatics; Endometrial cancer; Prognostic biomarkerEndometrial cancer (EC) mortality is directly associated with the presence of prognostic factors. Current stratification systems are not accurate enough to predict the outcome of patients. Therefore, identifying more accurate prognostic EC biomarkers is crucial. We aimed to validate 255 prognostic biomarkers identified in multiple studies and explore their prognostic application by analyzing them in TCGA and CPTAC datasets. We analyzed the mRNA and proteomic expression data to assess the statistical prognostic performance of the 255 proteins. Significant biomarkers related to overall survival (OS) and recurrence-free survival (RFS) were combined and signatures generated. A total of 30 biomarkers were associated either to one or more of the following prognostic factors: histological type (n = 15), histological grade (n = 6), FIGO stage (n = 1), molecular classification (n = 16), or they were associated to OS (n = 11), and RFS (n = 5). A prognostic signature composed of 11 proteins increased the accuracy to predict OS (AUC = 0.827). The study validates and identifies new potential applications of 30 proteins as prognostic biomarkers and suggests to further study under-studied biomarkers such as TPX2, and confirms already used biomarkers such as MSH6, MSH2, or L1CAM. These results are expected to advance the quest for biomarkers to accurately assess the risk of EC patients.This research was funded by grants from the Instituto de Salud Carlos III (ISCIII) grant number PI17/02155, PI20/00644, and the IFI19/00029 to E.C.-d.l.R., the Ministerio de ciencia, Innovación y Universidades through a RETOS Colaboración (RTC-2017-6261-1), both co-financed by the European Regional Development Fund (FEDER); from Fundación Científica Asociación Española Contra el Cáncer (AECC) grant number GCTRA1804MATI and CIBERONC network grant number CB16/12/00328; and Grups Consolidats de la Generalitat de Catalunya (2017SGR1661). E.C. is supported by an Investigator Grant from AECC (INVES20051COLA). E.M.-G. was supported by Televie grant F5/20/5-TLV/DD

Neoadjuvant Chemotherapy plus Interval Cytoreductive Surgery with or without Hyperthermic Intraperitoneal Chemotherapy (NIHIPEC) in the Treatment of Advanced Ovarian Cancer: A Multicentric Propensity Score Study

Simple Summary Advanced ovarian cancer (Stages III-IV) continues to be one of the gynecological tumors with the highest mortality. Standard treatment consists of debulking surgery and subsequent adjuvant chemotherapy. Recently, some authors have postulated that the administration of hyperthermic chemotherapy during surgery could increase the survival of patients, especially in cases in which chemotherapy had already been administered before surgery to reduce tumor volume. Our study is important because it collects data from 11 tertiary hospitals in Spain, and the data are subjected to a statistical technique that reproduces the data that we would find in a prospective study but using retrospective data (propensity score matching). It also offers a current view of the status of ovarian cancer treatment in our country.Abstract Introduction: Epithelial ovarian cancer (EOC) is primarily confined to the peritoneal cavity. When primary complete surgery is not possible, neoadjuvant chemotherapy (NACT) is provided; however, the peritoneum-plasma barrier hinders the drug effect. The intraperitoneal administration of chemotherapy could eliminate residual microscopic peritoneal tumor cells and increase this effect by hyperthermia. Intraperitoneal hyperthermic chemotherapy (HIPEC) after interval cytoreductive surgery could improve outcomes in terms of disease-free survival (DFS) and overall survival (OS). Materials and Methods: A multicenter, retrospective observational study of advanced EOC patients who underwent interval cytoreductive surgery alone (CRSnoH) or interval cytoreductive surgery plus HIPEC (CRSH) was carried out in Spain between 07/2012 and 12/2021. A total of 515 patients were selected. Progression-free survival (PFS) and OS analyses were performed. The series of patients who underwent CRSH or CRSnoH was balanced regarding the risk factors using a statistical analysis technique called propensity score matching. Results: A total of 170 patients were included in each subgroup. The complete surgery rate was similar in both groups (79.4% vs. 84.7%). The median PFS times were 16 and 13 months in the CRSH and CRSnoH groups, respectively (Hazard ratio (HR) 0.74; 95% CI, 0.58-0.94; p = 0.031). The median OS times were 56 and 50 months in the CRSH and CRSnoH groups, respectively (HR, 0.88; 95% CI, 0.64-1.20; p = 0.44). There was no increase in complications in the CRSH group. Conclusion: The addition of HIPEC after interval cytoreductive surgery is safe and increases DFS in advanced EOC patients

Accuracy and Survival Outcomes after National Implementation of Sentinel Lymph Node Biopsy in Early Stage Endometrial Cancer

Background. Sentinel lymph node (SLN) biopsy has recently been accepted to evaluate nodal status in endometrial cancer at early stage, which is key to tailoring adjuvant treatments. Our aim was to evaluate the national implementation of SLN biopsy in terms of accuracy to detect nodal disease in a clinical setting and oncologic outcomes according to the volume of nodal disease. Patients and Methods. A total of 29 Spanish centers participated in this retrospective, multicenter registry including patients with endometrial adenocarcinoma at preoperative early stage who had undergone SLN biopsy between 2015 and 2021. Each center collected data regarding demographic, clinical, histologic, therapeutic, and survival characteristics. Results. A total of 892 patients were enrolled. After the surgery, 12.9% were suprastaged to FIGO 2009 stages III-IV and 108 patients (12.1%) had nodal involvement: 54.6% macrometastasis, 22.2% micrometastases, and 23.1% isolated tumor cells (ITC). Sensitivity of SLN biopsy was 93.7% and false negative rate was 6.2%. After a median follow up of 1.81 years, overall surivial and disease-free survival were significantly lower in patients who had macrometastases when compared with patients with negative nodes, micrometastases or ITC. Conclusions. In our nationwide cohort we obtained high sensitivity of SLN biopsy to detect nodal disease. The oncologic outcomes of patients with negative nodes and low-volume disease were similar after tailoring adjuvant treatments. In total, 22% of patients with macrometastasis and 50% of patients with micrometastasis were at low risk of nodal metastasis according to their preoperative risk factors, revealing the importance of SLN biopsy in the surgical management of patients with early stage EC

Evaluación prospectiva de complicaciones asociadas a la linfadenectomía paraaórtica mínimamente invasiva de estadificación, mediante comparación de la vía transperitoneal contra la retroperitoneal : Ensayo clínico STELLA-2

El càncer de l'endometri és el més freqüent de les neoplàsies del tracte genital en països occidentals. Un 85% de les pacients que reben un nou diagnòstic de càncer de l'endometri ho faran en una etapa inicial, és a dir, quan el tumor es troba confinat a l'úter. La proporció entre tumors inicials i avançats s'inverteix en el càncer epitelial de l'ovari, en què només un 20% de les pacients es diagnosticaran en estadis inicials. Per aconseguir completar aquesta estadificació en pacients amb càncer epitelial de l'ovari inicial o endometri inicial d'alt risc d'afectació limfàtica, necessitarem realitzar diferents procediments quirúrgics, entre els quals es troba la limfadenectomia aòrtica. La via d'abordatge mínimament invasiva és, avui, l'abordatge de elecció. Es va plantejar demostrar si la limfadenectomia paraaòrtica per via mínimament invasiva extraperitoneal suposava una menor taxa de complicacions quirúrgiques, comparada amb la via transperitoneal, en l'estadificació de les neoplàsies ovàriques epitelials i endometrials en estadi inicial, sense comprometre el recompte ganglionar, el temps quirúrgic, l'estada hospitalària o els resultats oncològics de les pacients intervenides. Per això, es va dissenyar un assaig clínic aleatori i multicèntric en pacients diagnosticades amb neoplàsies ovàriques epitelials i endometrials en estadi inicial que fossin candidates a realitzar una limfadenectomia aòrtica d'estadificació per via mínimament invasiva. Les pacients van ser aleatoritzades, entre 2010 i 2019, a sotmetre's, entre altres procediments d'estadificació, a una limfadenectomia aòrtica per via mínimament invasiva (laparoscòpica o assistida per robot) mitjançant un abordatge extraperitoneal o transperitoneal. No es va realitzar aleatorització per tipus d'abordatge mínimament invasiva (laparoscòpica o robòtica) per impossibilitat tècnica. L'objectiu principal es va mesurar mitjançant un resultat compost, segons el qual es va considerar que una pacient havia patit una complicació si s'havia produït un sagnat major de 500 ml, alguna complicació intraoperatoria o reconversió a laparotomia durant el procediment, una complicació major (Dindo major o igual a IIIA) després del procediment, o si no s'havia pogut completar la cirurgia. Es va aleatoritzar a 203 pacients, de les quals 68 van ser assignades al grup extraperitoneal laparoscòpic, 62 al grup transperitoneal laparoscòpic, 35 al grup extraperitoneal robòtic, i 38 al grup transperitoneal robòtic. En comparar la via d'abordatge, tot i que no es va observar diferències en complicacions entre les pacients intervenides per via extraperitoneal front a transperitoneal (transperitoneal 26,0% vs, extraperitoneal 18,4%; P = 0,195), es va apreciar una tendència a que els grups extraperitoneal i robòtic presentaren una menor taxa de complicacions. Al mateix temps, una major edat, índex de massa corporal o índex cintura-creuada van ser relacionats amb un major risc independent de complicacions. Es va obtenir un major recompte ganglionar en les pacients intervenides mitjançant l'abordatge extraperitoneal ([IQR] 12 [7-17] vs, 14 [10-19]: P = 0,026)). No es va observar diferències en el temps quirúrgic, estada hospitalària o supervivència entre tots dos grups. Donats aquests troballes, es va proposar una anàlisi post-hoc per avaluar si la via extraperitoneal robòtica presentava menor taxa de complicacions. En un anàlisi multivariable, l'abordatge extraperitoneal robòtic es va associar de forma independent a una menor taxa de complicacions (OR 0,13; 95% CI, 0,02-0,64) quan es va comparar amb la resta d'abordatges. Com a consequència, en aquesta tesi doctoral s'ha establert que la via d'abordatge extraperitoneal robòtica per a la limfadenectomia aòrtica d'estadificació en càncer epitelial d'ovari i endometri en estadi inicial s'associa a una menor taxa de complicacions quirúrgiques, segons un resultat compost, quan es compara amb la resta d'abordatges, sense comprometre el recompte de ganglis limfàtics extirpats, el temps quirúrgic, l'estada hospitalària o els resultats oncològics.El cáncer de endometrio es la más frecuente de las neoplasias del tracto genital en países occidentales. Un 85% de las pacientes que reciben un nuevo diagnóstico de cáncer de endometrio lo harán en una etapa inicial, es decir, cuando el tumor se encuentra confinado al útero. La proporción entre tumores iniciales y avanzados se invierte en el cáncer epitelial de ovario, en el que sólo un 20% de las pacientes se diagnosticarán en estadios iniciales. Para conseguir completar dicha estadificación en pacientes con cáncer epitelial de ovario inicial, o endometrio inicial de alto riesgo de afectación linfática, necesitaremos realizar diferentes procedimientos quirúrgicos, entre los que se encuentra la linfadenectomía aórtica. La vía de abordaje mínimamente invasiva es, hoy, el abordaje de elección. Se planteó demostrar si la linfadenectomía paraaórtica por vía mínimamente invasiva extraperitoneal suponía una menor tasa de complicaciones quirúrgicas, comparada a la vía transperitoneal, en la estadificación de las neoplasias ováricas epiteliales y endometriales en estadio inicial, sin comprometer el recuento ganglionar, el tiempo quirúrgico, la estancia hospitalaria o los resultados oncológicos de las pacientes intervenidas. Para ello, se diseñó un ensayo clínico aleatorizado y multicéntrico en pacientes diagnosticadas con neoplasias ováricas epiteliales y endometriales en estadio inicial que fueran candidatas a realizar una linfadenectomía aórtica de estadificación por vía mínimamente invasiva. Las pacientes fueron aleatorizadas, entre 2010 y 2019, a someterse, entre otros procedimientos de estadificación, a una linfadenectomía aórtica por vía mínimamente invasiva (laparoscópica o asistida por robot) mediante un abordaje extraperitoneal o transperitoneal. No se realizó aleatorización por tipo de abordaje mínimamente invasivo (laparoscópico o robótico) por imposibilidad técnica. El objetivo principal se midió mediante un resultado compuesto, según el cual se consideró que una paciente había sufrido una complicación si se había producido un sangrado mayor de 500 ml, alguna complicación intraoperatoria o reconversión a laparotomía durante el procedimiento, una complicación mayor (Dindo mayor o igual a IIIA) tras el procedimiento, o si no se había podido completar la cirugía. Se aleatorizó a 203 pacientes, de las cuales 68 fueron asignadas al grupo extraperitoneal laparoscópico, 62 al grupo transperitoneal laparoscópico, 35 al grupo extraperitoneal robótico, y 38 al grupo transperitoneal robótico. Al comparar la vía de abordaje, si bien no se observó diferencias en complicaciones entre las pacientes intervenidas por vía extraperitoneal frente a transperitoneal (transperitoneal 26.0% vs, extraperitoneal 18.4%; P = 0.195), se apreció una tendencia a que los grupos extraperitoneal y robótico presentaran menor tasa de complicaciones. Al mismo tiempo, una mayor edad, índice de masa corporal o índice cintura-cadera fueron relacionados con un mayor riesgo independiente de complicaciones. Se obtuvo un mayor recuento ganglionar en las pacientes intervenidas mediante el abordaje extraperitoneal ([IQR] 12 [7-17] vs, 14 [10-19]: P=0.026)). No se observó diferencias en el tiempo quirúrgico, estancia hospitalaria o supervivencia entre ambos grupos. Dados estos hallazgos, se propuso un análisis post-hoc para evaluar si la vía extraperitoneal robótica presentaba menor tasa de complicaciones. En un análisis multivariable, el abordaje extraperitoneal robótico se asoció de forma independiente a una menor tasa de complicaciones (OR 0.13; 95% CI, 0.02-0.64) cuando se comparó con el resto de los abordajes. Como consecuencia, en esta tesis doctoral se ha establecido que la vía de abordaje extraperitoneal robótica para la linfadenectomía aórtica de estadificación en cáncer epitelial de ovario y endometrio en estadio inicial se asocia a una menor tasa de complicaciones quirúrgicas, según un resultado compuesto, cuando se compara con el resto de abordajes, sin comprometer el recuento de ganglios linfáticos extirpados, el tiempo quirúrgico, la estancia hospitalaria o los resultados oncológicos.Endometrial cancer is the most common among genital tract neoplasms in Western countries. Eighty-five percent of patients receiving a new diagnosis of endometrial cancer will do so at an early stage, meaning when the tumor is confined to the uterus. The proportion between early and advanced tumors is reversed in epithelial ovarian cancer, where only 20% of patients will be diagnosed at early stages. To complete this staging in patients with early-stage epithelial ovarian cancer or high-risk early-stage endometrial cancer, various surgical procedures, including aortic lymphadenectomy, are required. Minimally invasive approaches are the preferred choice today. The aim was to demonstrate whether minimally invasive extraperitoneal aortic lymphadenectomy resulted in a lower rate of surgical complications compared to the transperitoneal approach in the staging of epithelial ovarian and endometrial neoplasms in early stages, without compromising lymph node count, surgical time, hospital stay, or oncological outcomes of the patients undergoing the procedure. For this purpose, a randomized multicenter clinical trial was designed for patients diagnosed with early-stage epithelial ovarian and endometrial neoplasms who were candidates for minimally invasive aortic lymphadenectomy. Patients were randomized, between 2010 and 2019, to undergo, among other staging procedures, minimally invasive aortic lymphadenectomy (laparoscopic or robot-assisted) through either the extraperitoneal or transperitoneal approach. Randomization by type of minimally invasive approach (laparoscopic or robotic) was not performed due to technical limitations. The primary outcome was measured using a composite result, in which a patient was considered to have experienced a complication if there was bleeding exceeding 500 ml, any intraoperative complication or conversion to laparotomy during the procedure, a major complication (Dindo grade IIIA or higher) after the procedure, or if the surgery could not be completed. Two hundred and three patients were randomized, with 68 assigned to the extraperitoneal laparoscopic group, 62 to the transperitoneal laparoscopic group, 35 to the extraperitoneal robotic group, and 38 to the transperitoneal robotic group. When comparing the approach, while no significant differences in complications were observed between patients treated with the extraperitoneal and transperitoneal approaches (transperitoneal 26.0% vs. extraperitoneal 18.4%; P = 0.195), there was a tendency for the extraperitoneal and robotic groups to have a lower complication rate. Additionally, older age, higher body mass index, or higher waist-to-hip ratio were associated with a greater independent risk of complications. A higher lymph node count was obtained in patients treated with the extraperitoneal approach ([IQR] 12 [7-17] vs. 14 [10-19]: P=0.026)). There were no differences in surgical time, hospital stay, or survival between both groups. Given these findings, a post-hoc analysis was proposed to evaluate whether the robotic extraperitoneal approach had a lower rate of complications. In a multivariable analysis, the robotic extraperitoneal approach was independently associated with a lower rate of complications (OR 0.13; 95% CI, 0.02-0.64) when compared to the other approaches. As a result, this doctoral thesis has established that the robotic extraperitoneal approach for aortic lymphadenectomy staging in early-stage epithelial ovarian and endometrial cancer is associated with a lower rate of surgical complications, according to a composite outcome, when compared to other approaches, without compromising lymph node count, surgical time, hospital stay, or oncological outcomes

In silico Approach for Validating and Unveiling New Applications for Prognostic Biomarkers of Endometrial Cancer

Endometrial cancer (EC) mortality is directly associated with the presence of poor prognostic factors. Molecular prognostic factors have been identified, but none are used in clinical practice due to lack of validation studies. This study aims to validate a set of 255 prognostic biomarkers previously identified in an extensive literature review and explore new prognostic applications by analyzing them in The Cancer Genome Atlas (TCGA) and Clinical Proteomic Tumor Analysis Consortium (CPTAC) databases. A total of 30 biomarkers were validated and associated to a histological type (n = 15), histological grade (n = 6), FIGO stage (n = 1), molecular classification (n = 16), overall survival (n = 11), and recurrence-free survival (n = 5). Our results encourage further studies of understudied biomarkers such as TPX2, and validates already broadly studied biomarkers such as MSH6, MSH2, or L1CAM, among others. Finally, our results present a significant step to advance the quest for biomarkers to accurately assess the risk of EC patients. Endometrial cancer (EC) mortality is directly associated with the presence of prognostic factors. Current stratification systems are not accurate enough to predict the outcome of patients. Therefore, identifying more accurate prognostic EC biomarkers is crucial. We aimed to validate 255 prognostic biomarkers identified in multiple studies and explore their prognostic application by analyzing them in TCGA and CPTAC datasets. We analyzed the mRNA and proteomic expression data to assess the statistical prognostic performance of the 255 proteins. Significant biomarkers related to overall survival (OS) and recurrence-free survival (RFS) were combined and signatures generated. A total of 30 biomarkers were associated either to one or more of the following prognostic factors: histological type (n = 15), histological grade (n = 6), FIGO stage (n = 1), molecular classification (n = 16), or they were associated to OS (n = 11), and RFS (n = 5). A prognostic signature composed of 11 proteins increased the accuracy to predict OS (AUC = 0.827). The study validates and identifies new potential applications of 30 proteins as prognostic biomarkers and suggests to further study under-studied biomarkers such as TPX2, and confirms already used biomarkers such as MSH6, MSH2, or L1CAM. These results are expected to advance the quest for biomarkers to accurately assess the risk of EC patients

Surgical Complications Comparing Extraperitoneal vs Transperitoneal Laparoscopic Aortic Staging in Early Stage Ovarian and Endometrial Cancer. The STELLA-2 Randomized Clinical Trial.

Objective To determine whether the extraperitoneal approach for paraaortic staging lymphadenectomy results in a lower rate of surgical complications compared to the transperitoneal approach, without compromising oncological outcomes. Methods Prospective randomized multicenter study of patients with early endometrial or ovarian cancer undergoing paraaortic lymphadenectomy in 2010-2019. Patients were randomized to minimally invasive surgery (laparoscopy or robotic-assisted) using an extraperitoneal or a transperitoneal approach. The primary end point measure was a composite outcome that included developing one or more of the following surgical complications: bleeding during paraaortic lymphadenectomy ≥500 mL, any intraoperative complication related to paraaortic lymphadenectomy, severe postoperative complication (Dindo ≥ IIIA), impossibility to complete the procedure, or conversion to laparotomy. Results There were 103 patients in the extraperitoneal group and 100 in the transperitoneal group. Differences in the composite outcome (transperitoneal 26.0% vs, extraperitoneal 18.4%; P = 0.195) were not found. Differences in the operative time, conversion to laparotomy, intraoperative bleeding, or survival were not observed. A higher number of lymph nodes were retrieved through the extraperitoneal approached (median, interquartile range [IQR] 12 [7-17] vs, 14 [10-19]: P = 0.026). Older age and greater body mass index (BMI) or waist-to-hip ratio (WHR) increased the risk for surgical complications independently of the laparoscopic approach. Conclusions The extraperitoneal approach did not show differences regarding surgical and oncological parameters compared with the transperitoneal approach, although the number of aortic nodes retrieved was higher. The decision to use one or another laparoscopic route is a matter of the surgeon preference

Robot-assisted Extraperitoneal Para-aortic Lymphadenectomy Is Associated with Fewer Surgical Complications: A Post Hoc Analysis of the STELLA-2 Randomized Trial

Study Objective: To evaluate if extraperitoneal para-aortic lymphadenectomy (PALND) using a robot-assisted approach was associated with fewer complications than all other approaches (conventional laparoscopic transperitoneal or extraperitoneal and robot-assisted transperitoneal) without compromising lymph node yield, operative time, or length of stay. Design: Post hoc analysis of the prospective randomized open-label multicenter trial (STELLA-2). Setting: Three academic referral hospitals. Patients: Two hundred and three eligible patients from the STELLA-2 trial were included. Interventions: The patients were randomized to extraperitoneal or transperitoneal PALND using a minimally invasive approach (either laparoscopic or robot-assisted) for surgical staging of endometrial or ovarian cancer. The minimally invasive approaches were not subjected to randomization. Measurements and Main Results: The primary end point was evaluated through a composite variable that included at least 1 of the following events: blood loss ≥500 mL during PALND, any intraoperative complication related to PALND, severe postoperative complication (Clavien-Dindo ≥grade IIIA), impossibility of completing the procedure, or conversion to laparotomy. Of the 203 patients analyzed, 68 were assigned to the extraperitoneal laparoscopic group (X-L), 62 to the transperitoneal laparoscopic group (T-L), 35 to the extraperitoneal robotic group (X-R), and 38 to the transperitoneal robotic group (T-R