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Endometrial cancer
Most practicing gynecologists will diagnose a patient with endometrial cancer at some point during their careers. While referral to a gynecologic oncologist is indicated for treatment of all endometrial cancers, patients will likely have questions for their gynecologists prior to referral. The backbone of prognosis and treatment depends on the type of endometrial cancer (type 1 or type 2) and the stage of the cancer. The basics of endometrial cancer treatment will be reviewed in this article.
Endometrial cancer can be classified into two distinct subgroups based on histology and clinical behavior. Type 1 tumors are the most common type of endometrial cancer, accounting for nearly 80% of endometrial cancers. These tumors have an endometrioid histology and are well-differentiated, gland-forming tumors. The endometrioid tumors are graded by evaluating the gland formation and/or architecture, with grade 1 tumors having less than 5% solid growth and grade 2 tumors having 6%-50% solid growth. They also are graded based on the degree of nuclear atypia (Gynecol. Oncol. 1983;15:10-17).
Type 1 tumors are estrogen driven and less aggressive than their type 2 counterparts. They tend to be more common in overweight or obese patients, patients with longstanding anovulation or polycystic ovarian syndrome (PCOS), or patients placed on unopposed estrogen. Molecularly, type 1 tumors often exhibit mutations in phosphatase and tensin homolog (PTEN), Kras, and beta-catenin. Microsatellite instability with mutations in MSH2, MSH6, MLH1, and PMS2 also has been observed in 20% of sporadic endometrial cancers, as well as women with Lynch syndrome (also known as hereditary nonpolyposis colorectal cancer syndrome) (J. Clin. Oncol. 2006;24:4783-91).
Type 1 tumors are starkly different from type 2 tumors. While type 2 tumors account for 10%-20% of endometrial cancers, they are responsible for the majority of recurrences and deaths. They include serous, clear cell, mucinous, squamous, transitional cell, carcinosarcomas and undifferentiated tumors. More recently, it has been suggested that grade 3 endometrioid carcinomas be grouped with type 2 tumors. The genetic mutations and clinical behavior of grade 3 endometrioid tumors are more consistent with type 2 tumors. Type 2 tumors are more likely to show mutations in p53, aneuploidy, and overexpression of HER2/neu (Gynecol. Oncol. 2008;108:3-9). Type 2 tumors are more likely to present with advanced stage.
While it is important to understand these two categories of endometrial cancers as two distinct clinical entities with markedly different prognosis and outcomes, there is some histologic crossover. Some endometrioid tumors will have a component of serous or clear cell within the tumor. Investigators have found that up to a 10% serous component within an endometrioid tumor can confer a worse prognosis and likely warrants more aggressive treatment (Cancer 2004;101:2214-21).
Given the relatively indolent clinical course of type 1 tumors, preoperative imaging to evaluate for metastatic disease is not indicated without concerning symptoms. Additionally, often women diagnosed with type 1 tumors are able to be fully treated with hysterectomy, and in circumstances of early-stage disease, most patients with these tumors do not need adjuvant treatment with chemotherapy or radiation. Alternatively, type 2 tumors are more aggressive and may warrant additional imaging prior to hysterectomy to evaluate for distant metastasis, as uterine features may not be indicative of metastatic disease. These women will need additional treatment with radiation and likely chemotherapy following comprehensive surgical staging and hysterectomy, given the aggressive nature of their tumors.
Dividing endometrial cancers into these two distinct groups allows providers to appropriately counsel and treat patients. Having an understanding of this distinction can help practicing gynecologists who will most likely make the diagnosis of endometrial cancer within their practice. Any patient with abnormal bleeding or postmenopausal bleeding should be promptly evaluated to facilitate an early diagnosis. Regardless of whether a patient has a type 1 or type 2 tumor, early-stage diagnosis will improve the patient’s prognosis and survival.
Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. Dr. Clark and Dr. Gehrig had no conflicts of interest to disclose.
Most practicing gynecologists will diagnose a patient with endometrial cancer at some point during their careers. While referral to a gynecologic oncologist is indicated for treatment of all endometrial cancers, patients will likely have questions for their gynecologists prior to referral. The backbone of prognosis and treatment depends on the type of endometrial cancer (type 1 or type 2) and the stage of the cancer. The basics of endometrial cancer treatment will be reviewed in this article.
Endometrial cancer can be classified into two distinct subgroups based on histology and clinical behavior. Type 1 tumors are the most common type of endometrial cancer, accounting for nearly 80% of endometrial cancers. These tumors have an endometrioid histology and are well-differentiated, gland-forming tumors. The endometrioid tumors are graded by evaluating the gland formation and/or architecture, with grade 1 tumors having less than 5% solid growth and grade 2 tumors having 6%-50% solid growth. They also are graded based on the degree of nuclear atypia (Gynecol. Oncol. 1983;15:10-17).
Type 1 tumors are estrogen driven and less aggressive than their type 2 counterparts. They tend to be more common in overweight or obese patients, patients with longstanding anovulation or polycystic ovarian syndrome (PCOS), or patients placed on unopposed estrogen. Molecularly, type 1 tumors often exhibit mutations in phosphatase and tensin homolog (PTEN), Kras, and beta-catenin. Microsatellite instability with mutations in MSH2, MSH6, MLH1, and PMS2 also has been observed in 20% of sporadic endometrial cancers, as well as women with Lynch syndrome (also known as hereditary nonpolyposis colorectal cancer syndrome) (J. Clin. Oncol. 2006;24:4783-91).
Type 1 tumors are starkly different from type 2 tumors. While type 2 tumors account for 10%-20% of endometrial cancers, they are responsible for the majority of recurrences and deaths. They include serous, clear cell, mucinous, squamous, transitional cell, carcinosarcomas and undifferentiated tumors. More recently, it has been suggested that grade 3 endometrioid carcinomas be grouped with type 2 tumors. The genetic mutations and clinical behavior of grade 3 endometrioid tumors are more consistent with type 2 tumors. Type 2 tumors are more likely to show mutations in p53, aneuploidy, and overexpression of HER2/neu (Gynecol. Oncol. 2008;108:3-9). Type 2 tumors are more likely to present with advanced stage.
While it is important to understand these two categories of endometrial cancers as two distinct clinical entities with markedly different prognosis and outcomes, there is some histologic crossover. Some endometrioid tumors will have a component of serous or clear cell within the tumor. Investigators have found that up to a 10% serous component within an endometrioid tumor can confer a worse prognosis and likely warrants more aggressive treatment (Cancer 2004;101:2214-21).
Given the relatively indolent clinical course of type 1 tumors, preoperative imaging to evaluate for metastatic disease is not indicated without concerning symptoms. Additionally, often women diagnosed with type 1 tumors are able to be fully treated with hysterectomy, and in circumstances of early-stage disease, most patients with these tumors do not need adjuvant treatment with chemotherapy or radiation. Alternatively, type 2 tumors are more aggressive and may warrant additional imaging prior to hysterectomy to evaluate for distant metastasis, as uterine features may not be indicative of metastatic disease. These women will need additional treatment with radiation and likely chemotherapy following comprehensive surgical staging and hysterectomy, given the aggressive nature of their tumors.
Dividing endometrial cancers into these two distinct groups allows providers to appropriately counsel and treat patients. Having an understanding of this distinction can help practicing gynecologists who will most likely make the diagnosis of endometrial cancer within their practice. Any patient with abnormal bleeding or postmenopausal bleeding should be promptly evaluated to facilitate an early diagnosis. Regardless of whether a patient has a type 1 or type 2 tumor, early-stage diagnosis will improve the patient’s prognosis and survival.
Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. Dr. Clark and Dr. Gehrig had no conflicts of interest to disclose.
Most practicing gynecologists will diagnose a patient with endometrial cancer at some point during their careers. While referral to a gynecologic oncologist is indicated for treatment of all endometrial cancers, patients will likely have questions for their gynecologists prior to referral. The backbone of prognosis and treatment depends on the type of endometrial cancer (type 1 or type 2) and the stage of the cancer. The basics of endometrial cancer treatment will be reviewed in this article.
Endometrial cancer can be classified into two distinct subgroups based on histology and clinical behavior. Type 1 tumors are the most common type of endometrial cancer, accounting for nearly 80% of endometrial cancers. These tumors have an endometrioid histology and are well-differentiated, gland-forming tumors. The endometrioid tumors are graded by evaluating the gland formation and/or architecture, with grade 1 tumors having less than 5% solid growth and grade 2 tumors having 6%-50% solid growth. They also are graded based on the degree of nuclear atypia (Gynecol. Oncol. 1983;15:10-17).
Type 1 tumors are estrogen driven and less aggressive than their type 2 counterparts. They tend to be more common in overweight or obese patients, patients with longstanding anovulation or polycystic ovarian syndrome (PCOS), or patients placed on unopposed estrogen. Molecularly, type 1 tumors often exhibit mutations in phosphatase and tensin homolog (PTEN), Kras, and beta-catenin. Microsatellite instability with mutations in MSH2, MSH6, MLH1, and PMS2 also has been observed in 20% of sporadic endometrial cancers, as well as women with Lynch syndrome (also known as hereditary nonpolyposis colorectal cancer syndrome) (J. Clin. Oncol. 2006;24:4783-91).
Type 1 tumors are starkly different from type 2 tumors. While type 2 tumors account for 10%-20% of endometrial cancers, they are responsible for the majority of recurrences and deaths. They include serous, clear cell, mucinous, squamous, transitional cell, carcinosarcomas and undifferentiated tumors. More recently, it has been suggested that grade 3 endometrioid carcinomas be grouped with type 2 tumors. The genetic mutations and clinical behavior of grade 3 endometrioid tumors are more consistent with type 2 tumors. Type 2 tumors are more likely to show mutations in p53, aneuploidy, and overexpression of HER2/neu (Gynecol. Oncol. 2008;108:3-9). Type 2 tumors are more likely to present with advanced stage.
While it is important to understand these two categories of endometrial cancers as two distinct clinical entities with markedly different prognosis and outcomes, there is some histologic crossover. Some endometrioid tumors will have a component of serous or clear cell within the tumor. Investigators have found that up to a 10% serous component within an endometrioid tumor can confer a worse prognosis and likely warrants more aggressive treatment (Cancer 2004;101:2214-21).
Given the relatively indolent clinical course of type 1 tumors, preoperative imaging to evaluate for metastatic disease is not indicated without concerning symptoms. Additionally, often women diagnosed with type 1 tumors are able to be fully treated with hysterectomy, and in circumstances of early-stage disease, most patients with these tumors do not need adjuvant treatment with chemotherapy or radiation. Alternatively, type 2 tumors are more aggressive and may warrant additional imaging prior to hysterectomy to evaluate for distant metastasis, as uterine features may not be indicative of metastatic disease. These women will need additional treatment with radiation and likely chemotherapy following comprehensive surgical staging and hysterectomy, given the aggressive nature of their tumors.
Dividing endometrial cancers into these two distinct groups allows providers to appropriately counsel and treat patients. Having an understanding of this distinction can help practicing gynecologists who will most likely make the diagnosis of endometrial cancer within their practice. Any patient with abnormal bleeding or postmenopausal bleeding should be promptly evaluated to facilitate an early diagnosis. Regardless of whether a patient has a type 1 or type 2 tumor, early-stage diagnosis will improve the patient’s prognosis and survival.
Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. Dr. Clark and Dr. Gehrig had no conflicts of interest to disclose.
Obesity and gynecologic surgery, part 2
As previously reported, obesity poses many challenges to gynecologic surgery, from open to minimally invasive to vaginal surgery (Int. J. Gynecol. Cancer 2012;22:76-81; Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2014;21:259-65). Concerns relevant to operative management in the obese include difficulty with patient positioning, access to the abdominal cavity, visualization, and ventilation. This article will review tips for overcoming these challenges.
Positioning of obese patients often requires specialized equipment including bariatric beds, large padded stirrups, bed extenders, and arm sleds. Extra time and care should be taken while positioning obese patients given the increased propensity for pressure ulcers and nerve injuries. The basics of positioning begin with requesting additional help for patient moving and positioning as needed.
With regard to minimally invasive surgery, the use of antislip devices such as egg crate, gel pad, or a surgical beanbag is important for prevention of slippage when the patient is placed in the Trendelenburg position (J. Minim. Invasive Gynecol. 2014;21:182-95). The best laparoscopic positioning for these patients is in low lithotomy, with both arms tucked at the side in the military position and with liberal corporeal padding (Am. J. Obstet. Gynecol. 2004;191:669-74). When placing the patient in lithotomy, care should be taken to avoid hyperflexion of the hip, as obese patients are particularly prone to femoral nerve stretch injuries in this position.
Access to the abdominal cavity can be difficult because of the thickness of the abdominal wall in these patients. In open surgery, this is overcome with deep blades on retractors. In minimally invasive surgery, this requires longer trocars and Veress needles, which are now routinely available. If there is difficulty accessing the abdominal cavity with a Veress needle, a Hassan entry technique or ports with see-through trocars also can be used to ensure safe entry into the abdomen.
It is important to remember that the abdominal wall is the thinnest at the umbilical stalk. Additionally, using the upper abdomen can help assist with entry as the abdominal wall is often thinner above the umbilicus than below. For this reason, a left upper quadrant entry is often utilized at Palmer’s point. Care should be taken that entry is not so high as to limit the operator’s ability to reach the deep pelvis with laparoscopic instruments. Further, anesthesia must decompress the stomach prior to port placement in order to avoid a gastric injury.
Obese patients have a higher concentration of intraperitoneal and visceral fat, which can cause decreased visualization in the pelvis. In addition, the thick abdominal wall creates more torque on laparoscopic instruments, which can impair a surgeon’s ability to easily maneuver instruments. To decrease torque, trocars should be placed in the direction of the operative field. Draping the omentum over the liver can help to increase visualization, and always consider additional trocar placement to assist in visualization (Am. J. Obstet. Gynecol. 2004;191:669-74). Robotic instruments may further assist with feasibility of laparoscopy in the obese by obviating the role of abdominal wall torque.
Finally, patients can be difficult to ventilate in steep Trendelenburg required for laparoscopic surgery, as the weight of the breasts and abdomen shifts onto the thorax (J. Anesth. 2012;26:758-65; Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). By slowly tilting the patient into steep Trendelenburg, the body has a chance to acclimate to ventilation in this position. One needs to remember to insufflate the abdomen in the supine position prior to proceeding with Trendelenburg.
Of course, one should always consider that vaginal surgery provides a "minimally invasive" approach without the difficulty of ventilating an obese patient in steep Trendelenburg position. A recent review of the effect of obesity on vaginal surgery concludes that obesity increases the difficulty of vaginal surgery and may be best performed by high-volume surgeons, given the difficulties that are often encountered (J. Minim. Invasive Gynecol. 2014;21:168-75).
As the obesity epidemic continues, figuring out safe and effective ways to provide surgical care will continue to remain a challenge to surgeons. Utilizing these tips is a start, but continued innovation and experience will be required to provide optimal care to our ever-growing population.
Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clark and Dr. Gehrig said they had no relevant financial disclosures.
As previously reported, obesity poses many challenges to gynecologic surgery, from open to minimally invasive to vaginal surgery (Int. J. Gynecol. Cancer 2012;22:76-81; Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2014;21:259-65). Concerns relevant to operative management in the obese include difficulty with patient positioning, access to the abdominal cavity, visualization, and ventilation. This article will review tips for overcoming these challenges.
Positioning of obese patients often requires specialized equipment including bariatric beds, large padded stirrups, bed extenders, and arm sleds. Extra time and care should be taken while positioning obese patients given the increased propensity for pressure ulcers and nerve injuries. The basics of positioning begin with requesting additional help for patient moving and positioning as needed.
With regard to minimally invasive surgery, the use of antislip devices such as egg crate, gel pad, or a surgical beanbag is important for prevention of slippage when the patient is placed in the Trendelenburg position (J. Minim. Invasive Gynecol. 2014;21:182-95). The best laparoscopic positioning for these patients is in low lithotomy, with both arms tucked at the side in the military position and with liberal corporeal padding (Am. J. Obstet. Gynecol. 2004;191:669-74). When placing the patient in lithotomy, care should be taken to avoid hyperflexion of the hip, as obese patients are particularly prone to femoral nerve stretch injuries in this position.
Access to the abdominal cavity can be difficult because of the thickness of the abdominal wall in these patients. In open surgery, this is overcome with deep blades on retractors. In minimally invasive surgery, this requires longer trocars and Veress needles, which are now routinely available. If there is difficulty accessing the abdominal cavity with a Veress needle, a Hassan entry technique or ports with see-through trocars also can be used to ensure safe entry into the abdomen.
It is important to remember that the abdominal wall is the thinnest at the umbilical stalk. Additionally, using the upper abdomen can help assist with entry as the abdominal wall is often thinner above the umbilicus than below. For this reason, a left upper quadrant entry is often utilized at Palmer’s point. Care should be taken that entry is not so high as to limit the operator’s ability to reach the deep pelvis with laparoscopic instruments. Further, anesthesia must decompress the stomach prior to port placement in order to avoid a gastric injury.
Obese patients have a higher concentration of intraperitoneal and visceral fat, which can cause decreased visualization in the pelvis. In addition, the thick abdominal wall creates more torque on laparoscopic instruments, which can impair a surgeon’s ability to easily maneuver instruments. To decrease torque, trocars should be placed in the direction of the operative field. Draping the omentum over the liver can help to increase visualization, and always consider additional trocar placement to assist in visualization (Am. J. Obstet. Gynecol. 2004;191:669-74). Robotic instruments may further assist with feasibility of laparoscopy in the obese by obviating the role of abdominal wall torque.
Finally, patients can be difficult to ventilate in steep Trendelenburg required for laparoscopic surgery, as the weight of the breasts and abdomen shifts onto the thorax (J. Anesth. 2012;26:758-65; Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). By slowly tilting the patient into steep Trendelenburg, the body has a chance to acclimate to ventilation in this position. One needs to remember to insufflate the abdomen in the supine position prior to proceeding with Trendelenburg.
Of course, one should always consider that vaginal surgery provides a "minimally invasive" approach without the difficulty of ventilating an obese patient in steep Trendelenburg position. A recent review of the effect of obesity on vaginal surgery concludes that obesity increases the difficulty of vaginal surgery and may be best performed by high-volume surgeons, given the difficulties that are often encountered (J. Minim. Invasive Gynecol. 2014;21:168-75).
As the obesity epidemic continues, figuring out safe and effective ways to provide surgical care will continue to remain a challenge to surgeons. Utilizing these tips is a start, but continued innovation and experience will be required to provide optimal care to our ever-growing population.
Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clark and Dr. Gehrig said they had no relevant financial disclosures.
As previously reported, obesity poses many challenges to gynecologic surgery, from open to minimally invasive to vaginal surgery (Int. J. Gynecol. Cancer 2012;22:76-81; Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2014;21:259-65). Concerns relevant to operative management in the obese include difficulty with patient positioning, access to the abdominal cavity, visualization, and ventilation. This article will review tips for overcoming these challenges.
Positioning of obese patients often requires specialized equipment including bariatric beds, large padded stirrups, bed extenders, and arm sleds. Extra time and care should be taken while positioning obese patients given the increased propensity for pressure ulcers and nerve injuries. The basics of positioning begin with requesting additional help for patient moving and positioning as needed.
With regard to minimally invasive surgery, the use of antislip devices such as egg crate, gel pad, or a surgical beanbag is important for prevention of slippage when the patient is placed in the Trendelenburg position (J. Minim. Invasive Gynecol. 2014;21:182-95). The best laparoscopic positioning for these patients is in low lithotomy, with both arms tucked at the side in the military position and with liberal corporeal padding (Am. J. Obstet. Gynecol. 2004;191:669-74). When placing the patient in lithotomy, care should be taken to avoid hyperflexion of the hip, as obese patients are particularly prone to femoral nerve stretch injuries in this position.
Access to the abdominal cavity can be difficult because of the thickness of the abdominal wall in these patients. In open surgery, this is overcome with deep blades on retractors. In minimally invasive surgery, this requires longer trocars and Veress needles, which are now routinely available. If there is difficulty accessing the abdominal cavity with a Veress needle, a Hassan entry technique or ports with see-through trocars also can be used to ensure safe entry into the abdomen.
It is important to remember that the abdominal wall is the thinnest at the umbilical stalk. Additionally, using the upper abdomen can help assist with entry as the abdominal wall is often thinner above the umbilicus than below. For this reason, a left upper quadrant entry is often utilized at Palmer’s point. Care should be taken that entry is not so high as to limit the operator’s ability to reach the deep pelvis with laparoscopic instruments. Further, anesthesia must decompress the stomach prior to port placement in order to avoid a gastric injury.
Obese patients have a higher concentration of intraperitoneal and visceral fat, which can cause decreased visualization in the pelvis. In addition, the thick abdominal wall creates more torque on laparoscopic instruments, which can impair a surgeon’s ability to easily maneuver instruments. To decrease torque, trocars should be placed in the direction of the operative field. Draping the omentum over the liver can help to increase visualization, and always consider additional trocar placement to assist in visualization (Am. J. Obstet. Gynecol. 2004;191:669-74). Robotic instruments may further assist with feasibility of laparoscopy in the obese by obviating the role of abdominal wall torque.
Finally, patients can be difficult to ventilate in steep Trendelenburg required for laparoscopic surgery, as the weight of the breasts and abdomen shifts onto the thorax (J. Anesth. 2012;26:758-65; Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). By slowly tilting the patient into steep Trendelenburg, the body has a chance to acclimate to ventilation in this position. One needs to remember to insufflate the abdomen in the supine position prior to proceeding with Trendelenburg.
Of course, one should always consider that vaginal surgery provides a "minimally invasive" approach without the difficulty of ventilating an obese patient in steep Trendelenburg position. A recent review of the effect of obesity on vaginal surgery concludes that obesity increases the difficulty of vaginal surgery and may be best performed by high-volume surgeons, given the difficulties that are often encountered (J. Minim. Invasive Gynecol. 2014;21:168-75).
As the obesity epidemic continues, figuring out safe and effective ways to provide surgical care will continue to remain a challenge to surgeons. Utilizing these tips is a start, but continued innovation and experience will be required to provide optimal care to our ever-growing population.
Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clark and Dr. Gehrig said they had no relevant financial disclosures.
Gynecologic Oncology Consult: Obesity and gynecologic surgery
Obesity poses challenges to all modes of gynecologic surgery from open to minimally invasive to vaginal procedures. Operating on obese women results in more intraoperative and postoperative complications, particularly with regard to blood loss, wound infections, and venous thromboembolic disease, and contributes to increased length of hospital stay (J. Minim. Invasive Gynecol. 2014;21:259-65). Obesity has also been associated with longer operative and nonoperative times in laparoscopy, compared with those for normal-weight patients (J. Minim. Invasive Gynecol. 2012;19:701-7;Gynecol. Oncol. 2006;103:938-41; J. Minim. Invasive Gynecol. 2014;21:259-65).
While it was initially felt that obese patients were poor candidates for laparoscopic surgery, it is now widely supported that minimally invasive surgery is both feasible and may be the optimal approach in this population (Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2010;17:576-82). When obese patients are able to undergo minimally invasive procedures, the result is shorter hospitalizations, less postoperative pain, a faster return to activity, and fewer postoperative wound infections (10.5% vs. 1.3%) (Ann. Surg. 2006;243:181-8). These improved surgical outcomes are seen with both laparoscopic and robotic surgeries, compared with laparotomy in obese patients (Int. J. Gynecol. Cancer 2012;22:76-81; Ann. Surg. Oncol. 2007;14:2384-91; J. Clin. Oncol. 2009;27:5331-6).
Obesity affects most organ systems, resulting in several challenges for our anesthesiology colleagues. In addition to difficult airway management, hemodynamic concerns and metabolic changes must be considered (J. Anesth. 2012;26:758-65). Physiologically, obesity results in an increased oxygen requirement, which leads to increased cardiac output, increased stroke volume, decreased vascular resistance, and increased cardiac work. These physiologic changes result in a higher incidence of hypertension and cardiomegaly in obese patients. Both oxygen consumption and carbon dioxide production are more marked in obese patients. This requires increased ventilation. Because of the excess chest wall weight with subsequent reduced chest wall compliance, ventilation is even more difficult in obese patients.
In addition to the baseline physiology of obesity, minimally invasive surgery adds the additional obstacle of abdominal insufflation. Insufflation increases the intra-abdominal pressure, leading to venous stasis as well as a further lowering in chest wall compliance and increased airway pressure (Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). Finally, the need for Trendelenburg positioning for pelvic surgery further complicates an already difficult to ventilate patient.
In addition to the anesthetic challenges, obesity poses multiple challenges for the surgeon. With regard to laparoscopic surgery, key challenges for surgeons include safe and effective patient positioning on the operating room table, access to the abdominal cavity, and difficulty with surgical field visualization. Optimal positioning of the patient remains crucial to avoid nerve injuries.
The depth of the abdominal wall makes safely accessing the abdominal cavity more challenging. The thickness of the abdominal wall can place more torque on laparoscopic ports and instruments, which can require contorted positioning on the part of the surgeon. The surgeon risks significant personal ergonomic strain operating on patients, particularly obese patients (Gynecol. Oncol. 2012;126:437-42). Lastly, visualization in obese patients is impaired regardless of mode of surgery. All of these challenges often can be overcome or at least optimized, particularly in the hands of skilled surgical teams.
In addition to making the surgery more challenging for the surgical team, obesity increases the cost of providing surgical care. In fact, hospital-associated surgical costs totaled an additional $160 million spent annually on the care of obese patients, compared with their nonobese counterparts receiving the same services (Ann. Surg. 2013;258:541-53). Given the continued rise in the number of obese patients, particularly those with a BMI greater than 40 kg/m2, the surgical concerns addressed in this column will continue to pose challenges to surgeons.
Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology, at the university. Dr. Clark and Dr. Clarke-Pearson said they had no relevant financial disclosures.
Obesity poses challenges to all modes of gynecologic surgery from open to minimally invasive to vaginal procedures. Operating on obese women results in more intraoperative and postoperative complications, particularly with regard to blood loss, wound infections, and venous thromboembolic disease, and contributes to increased length of hospital stay (J. Minim. Invasive Gynecol. 2014;21:259-65). Obesity has also been associated with longer operative and nonoperative times in laparoscopy, compared with those for normal-weight patients (J. Minim. Invasive Gynecol. 2012;19:701-7;Gynecol. Oncol. 2006;103:938-41; J. Minim. Invasive Gynecol. 2014;21:259-65).
While it was initially felt that obese patients were poor candidates for laparoscopic surgery, it is now widely supported that minimally invasive surgery is both feasible and may be the optimal approach in this population (Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2010;17:576-82). When obese patients are able to undergo minimally invasive procedures, the result is shorter hospitalizations, less postoperative pain, a faster return to activity, and fewer postoperative wound infections (10.5% vs. 1.3%) (Ann. Surg. 2006;243:181-8). These improved surgical outcomes are seen with both laparoscopic and robotic surgeries, compared with laparotomy in obese patients (Int. J. Gynecol. Cancer 2012;22:76-81; Ann. Surg. Oncol. 2007;14:2384-91; J. Clin. Oncol. 2009;27:5331-6).
Obesity affects most organ systems, resulting in several challenges for our anesthesiology colleagues. In addition to difficult airway management, hemodynamic concerns and metabolic changes must be considered (J. Anesth. 2012;26:758-65). Physiologically, obesity results in an increased oxygen requirement, which leads to increased cardiac output, increased stroke volume, decreased vascular resistance, and increased cardiac work. These physiologic changes result in a higher incidence of hypertension and cardiomegaly in obese patients. Both oxygen consumption and carbon dioxide production are more marked in obese patients. This requires increased ventilation. Because of the excess chest wall weight with subsequent reduced chest wall compliance, ventilation is even more difficult in obese patients.
In addition to the baseline physiology of obesity, minimally invasive surgery adds the additional obstacle of abdominal insufflation. Insufflation increases the intra-abdominal pressure, leading to venous stasis as well as a further lowering in chest wall compliance and increased airway pressure (Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). Finally, the need for Trendelenburg positioning for pelvic surgery further complicates an already difficult to ventilate patient.
In addition to the anesthetic challenges, obesity poses multiple challenges for the surgeon. With regard to laparoscopic surgery, key challenges for surgeons include safe and effective patient positioning on the operating room table, access to the abdominal cavity, and difficulty with surgical field visualization. Optimal positioning of the patient remains crucial to avoid nerve injuries.
The depth of the abdominal wall makes safely accessing the abdominal cavity more challenging. The thickness of the abdominal wall can place more torque on laparoscopic ports and instruments, which can require contorted positioning on the part of the surgeon. The surgeon risks significant personal ergonomic strain operating on patients, particularly obese patients (Gynecol. Oncol. 2012;126:437-42). Lastly, visualization in obese patients is impaired regardless of mode of surgery. All of these challenges often can be overcome or at least optimized, particularly in the hands of skilled surgical teams.
In addition to making the surgery more challenging for the surgical team, obesity increases the cost of providing surgical care. In fact, hospital-associated surgical costs totaled an additional $160 million spent annually on the care of obese patients, compared with their nonobese counterparts receiving the same services (Ann. Surg. 2013;258:541-53). Given the continued rise in the number of obese patients, particularly those with a BMI greater than 40 kg/m2, the surgical concerns addressed in this column will continue to pose challenges to surgeons.
Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology, at the university. Dr. Clark and Dr. Clarke-Pearson said they had no relevant financial disclosures.
Obesity poses challenges to all modes of gynecologic surgery from open to minimally invasive to vaginal procedures. Operating on obese women results in more intraoperative and postoperative complications, particularly with regard to blood loss, wound infections, and venous thromboembolic disease, and contributes to increased length of hospital stay (J. Minim. Invasive Gynecol. 2014;21:259-65). Obesity has also been associated with longer operative and nonoperative times in laparoscopy, compared with those for normal-weight patients (J. Minim. Invasive Gynecol. 2012;19:701-7;Gynecol. Oncol. 2006;103:938-41; J. Minim. Invasive Gynecol. 2014;21:259-65).
While it was initially felt that obese patients were poor candidates for laparoscopic surgery, it is now widely supported that minimally invasive surgery is both feasible and may be the optimal approach in this population (Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2010;17:576-82). When obese patients are able to undergo minimally invasive procedures, the result is shorter hospitalizations, less postoperative pain, a faster return to activity, and fewer postoperative wound infections (10.5% vs. 1.3%) (Ann. Surg. 2006;243:181-8). These improved surgical outcomes are seen with both laparoscopic and robotic surgeries, compared with laparotomy in obese patients (Int. J. Gynecol. Cancer 2012;22:76-81; Ann. Surg. Oncol. 2007;14:2384-91; J. Clin. Oncol. 2009;27:5331-6).
Obesity affects most organ systems, resulting in several challenges for our anesthesiology colleagues. In addition to difficult airway management, hemodynamic concerns and metabolic changes must be considered (J. Anesth. 2012;26:758-65). Physiologically, obesity results in an increased oxygen requirement, which leads to increased cardiac output, increased stroke volume, decreased vascular resistance, and increased cardiac work. These physiologic changes result in a higher incidence of hypertension and cardiomegaly in obese patients. Both oxygen consumption and carbon dioxide production are more marked in obese patients. This requires increased ventilation. Because of the excess chest wall weight with subsequent reduced chest wall compliance, ventilation is even more difficult in obese patients.
In addition to the baseline physiology of obesity, minimally invasive surgery adds the additional obstacle of abdominal insufflation. Insufflation increases the intra-abdominal pressure, leading to venous stasis as well as a further lowering in chest wall compliance and increased airway pressure (Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). Finally, the need for Trendelenburg positioning for pelvic surgery further complicates an already difficult to ventilate patient.
In addition to the anesthetic challenges, obesity poses multiple challenges for the surgeon. With regard to laparoscopic surgery, key challenges for surgeons include safe and effective patient positioning on the operating room table, access to the abdominal cavity, and difficulty with surgical field visualization. Optimal positioning of the patient remains crucial to avoid nerve injuries.
The depth of the abdominal wall makes safely accessing the abdominal cavity more challenging. The thickness of the abdominal wall can place more torque on laparoscopic ports and instruments, which can require contorted positioning on the part of the surgeon. The surgeon risks significant personal ergonomic strain operating on patients, particularly obese patients (Gynecol. Oncol. 2012;126:437-42). Lastly, visualization in obese patients is impaired regardless of mode of surgery. All of these challenges often can be overcome or at least optimized, particularly in the hands of skilled surgical teams.
In addition to making the surgery more challenging for the surgical team, obesity increases the cost of providing surgical care. In fact, hospital-associated surgical costs totaled an additional $160 million spent annually on the care of obese patients, compared with their nonobese counterparts receiving the same services (Ann. Surg. 2013;258:541-53). Given the continued rise in the number of obese patients, particularly those with a BMI greater than 40 kg/m2, the surgical concerns addressed in this column will continue to pose challenges to surgeons.
Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology, at the university. Dr. Clark and Dr. Clarke-Pearson said they had no relevant financial disclosures.
Obesity and Gynecologic Cancer
For the last decade, the obesity epidemic in the United States has been well recognized. In 2001, the surgeon general made a call to action to combat obesity. Despite this effort, obesity rates in the United States continued to rise, and in 2009-2010, more than one third (35.7%) of adults in the United States were classified as obese, according to the Centers for Disease Control and Prevention.
The definition of obesity relies on the body mass index. BMI is defined as a person’s weight in kilograms divided by the individual’s height in meters squared. Overweight is defined as a BMI of 25-29.9 kg/m2 and obesity as a BMI of greater than 30 kg/m2. Obesity has been further classified by the World Health Organization into class I (BMI, 30-34.9 kg/m2), class II (BMI, 35-39.9 kg/ m2), and class III (BMI, greater than 40 kg/ m2).
In the United States in 2013, there were approximately 50,000 new cases and more than 8,000 deaths from endometrial cancer (CA Cancer J. Clin. 2013;63:11-30). Rates of endometrial cancer have risen steadily along with the obesity epidemic. This is no surprise, as obesity has been linked to the development of endometrial cancer. It is believed that high levels of circulating estrogen created by adipose tissue convert androstenedione to estrone, and there is aromatization of androgens. For each 5-kg/m2 increase in BMI, there is an increased risk of development of endometrial cancer (relative risk, 1.59) (Lancet 2008;371:569). While many physicians realize the link between obesity and the hyperestrogenic state associated with endometrial cancers, increased BMI is also associated with an increased risk of ovarian cancer (odds ratio, 1.3) (Eur. J. Cancer 2007;43:690).
In addition to increasing the risk of developing gynecologic cancers, obesity also increases the risk of death from all gynecologic malignancies. In the Cancer Prevention Study II, a large prospective cohort study, a BMI greater than 35 was associated with increased mortality compared with normal weight in ovarian (RR, 1.51), endometrial (RR, 2.77), and cervical cancer (RR, 3.20) (N. Engl. J. Med. 2003;348:1625). The same study found that those with a BMI greater than 40 with endometrial cancer had a relative risk of death of 6.25.
The increased mortality seen in obese endometrial cancer patients is particularly striking, given the fact that these women are more likely to have less-aggressive histologies and earlier-stage cancers (Gynecol. Oncol. 2009;90:150-7; Gynecol. Oncol. 2009;114:121-7). This highlights the importance of weight loss and healthy lifestyle choices in this population. The American Cancer Society recommends focusing on healthy lifestyles in cancer survivors. Key recommendations include the maintenance of healthy weight or weight loss for the overweight/obese, physical activity with at least 30 minutes of moderate activity on 5 or more days per week, a healthy diet with at least five servings of fruits and vegetables per day with limited processed foods and red meats, and limited alcohol intake (CA Cancer J. Clin. 2012;62:243).
Practicing gynecologists should appreciate the increasing rates of endometrial cancer and remain highly suspicious of abnormal uterine bleeding in their obese patients. Early detection of cancers and modification of lifestyle remain the mainstay of improving outcomes in obese patients.
Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clark is a chief resident in the department of obstetrics and gynecology at the university. Dr. Gehrig and Dr. Clark have no relevant conflicts of interest.*
* This story was updated 1/27/2014
For the last decade, the obesity epidemic in the United States has been well recognized. In 2001, the surgeon general made a call to action to combat obesity. Despite this effort, obesity rates in the United States continued to rise, and in 2009-2010, more than one third (35.7%) of adults in the United States were classified as obese, according to the Centers for Disease Control and Prevention.
The definition of obesity relies on the body mass index. BMI is defined as a person’s weight in kilograms divided by the individual’s height in meters squared. Overweight is defined as a BMI of 25-29.9 kg/m2 and obesity as a BMI of greater than 30 kg/m2. Obesity has been further classified by the World Health Organization into class I (BMI, 30-34.9 kg/m2), class II (BMI, 35-39.9 kg/ m2), and class III (BMI, greater than 40 kg/ m2).
In the United States in 2013, there were approximately 50,000 new cases and more than 8,000 deaths from endometrial cancer (CA Cancer J. Clin. 2013;63:11-30). Rates of endometrial cancer have risen steadily along with the obesity epidemic. This is no surprise, as obesity has been linked to the development of endometrial cancer. It is believed that high levels of circulating estrogen created by adipose tissue convert androstenedione to estrone, and there is aromatization of androgens. For each 5-kg/m2 increase in BMI, there is an increased risk of development of endometrial cancer (relative risk, 1.59) (Lancet 2008;371:569). While many physicians realize the link between obesity and the hyperestrogenic state associated with endometrial cancers, increased BMI is also associated with an increased risk of ovarian cancer (odds ratio, 1.3) (Eur. J. Cancer 2007;43:690).
In addition to increasing the risk of developing gynecologic cancers, obesity also increases the risk of death from all gynecologic malignancies. In the Cancer Prevention Study II, a large prospective cohort study, a BMI greater than 35 was associated with increased mortality compared with normal weight in ovarian (RR, 1.51), endometrial (RR, 2.77), and cervical cancer (RR, 3.20) (N. Engl. J. Med. 2003;348:1625). The same study found that those with a BMI greater than 40 with endometrial cancer had a relative risk of death of 6.25.
The increased mortality seen in obese endometrial cancer patients is particularly striking, given the fact that these women are more likely to have less-aggressive histologies and earlier-stage cancers (Gynecol. Oncol. 2009;90:150-7; Gynecol. Oncol. 2009;114:121-7). This highlights the importance of weight loss and healthy lifestyle choices in this population. The American Cancer Society recommends focusing on healthy lifestyles in cancer survivors. Key recommendations include the maintenance of healthy weight or weight loss for the overweight/obese, physical activity with at least 30 minutes of moderate activity on 5 or more days per week, a healthy diet with at least five servings of fruits and vegetables per day with limited processed foods and red meats, and limited alcohol intake (CA Cancer J. Clin. 2012;62:243).
Practicing gynecologists should appreciate the increasing rates of endometrial cancer and remain highly suspicious of abnormal uterine bleeding in their obese patients. Early detection of cancers and modification of lifestyle remain the mainstay of improving outcomes in obese patients.
Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clark is a chief resident in the department of obstetrics and gynecology at the university. Dr. Gehrig and Dr. Clark have no relevant conflicts of interest.*
* This story was updated 1/27/2014
For the last decade, the obesity epidemic in the United States has been well recognized. In 2001, the surgeon general made a call to action to combat obesity. Despite this effort, obesity rates in the United States continued to rise, and in 2009-2010, more than one third (35.7%) of adults in the United States were classified as obese, according to the Centers for Disease Control and Prevention.
The definition of obesity relies on the body mass index. BMI is defined as a person’s weight in kilograms divided by the individual’s height in meters squared. Overweight is defined as a BMI of 25-29.9 kg/m2 and obesity as a BMI of greater than 30 kg/m2. Obesity has been further classified by the World Health Organization into class I (BMI, 30-34.9 kg/m2), class II (BMI, 35-39.9 kg/ m2), and class III (BMI, greater than 40 kg/ m2).
In the United States in 2013, there were approximately 50,000 new cases and more than 8,000 deaths from endometrial cancer (CA Cancer J. Clin. 2013;63:11-30). Rates of endometrial cancer have risen steadily along with the obesity epidemic. This is no surprise, as obesity has been linked to the development of endometrial cancer. It is believed that high levels of circulating estrogen created by adipose tissue convert androstenedione to estrone, and there is aromatization of androgens. For each 5-kg/m2 increase in BMI, there is an increased risk of development of endometrial cancer (relative risk, 1.59) (Lancet 2008;371:569). While many physicians realize the link between obesity and the hyperestrogenic state associated with endometrial cancers, increased BMI is also associated with an increased risk of ovarian cancer (odds ratio, 1.3) (Eur. J. Cancer 2007;43:690).
In addition to increasing the risk of developing gynecologic cancers, obesity also increases the risk of death from all gynecologic malignancies. In the Cancer Prevention Study II, a large prospective cohort study, a BMI greater than 35 was associated with increased mortality compared with normal weight in ovarian (RR, 1.51), endometrial (RR, 2.77), and cervical cancer (RR, 3.20) (N. Engl. J. Med. 2003;348:1625). The same study found that those with a BMI greater than 40 with endometrial cancer had a relative risk of death of 6.25.
The increased mortality seen in obese endometrial cancer patients is particularly striking, given the fact that these women are more likely to have less-aggressive histologies and earlier-stage cancers (Gynecol. Oncol. 2009;90:150-7; Gynecol. Oncol. 2009;114:121-7). This highlights the importance of weight loss and healthy lifestyle choices in this population. The American Cancer Society recommends focusing on healthy lifestyles in cancer survivors. Key recommendations include the maintenance of healthy weight or weight loss for the overweight/obese, physical activity with at least 30 minutes of moderate activity on 5 or more days per week, a healthy diet with at least five servings of fruits and vegetables per day with limited processed foods and red meats, and limited alcohol intake (CA Cancer J. Clin. 2012;62:243).
Practicing gynecologists should appreciate the increasing rates of endometrial cancer and remain highly suspicious of abnormal uterine bleeding in their obese patients. Early detection of cancers and modification of lifestyle remain the mainstay of improving outcomes in obese patients.
Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clark is a chief resident in the department of obstetrics and gynecology at the university. Dr. Gehrig and Dr. Clark have no relevant conflicts of interest.*
* This story was updated 1/27/2014
