TLH vs. TAH for Endometrial Cancer – Results from the LACE trial
This study by Janda et al. (JAMA Network, 2017) sought to determine if outcomes following total laparoscopic hysterectomy (TLH) were the same for disease-free survival as total abdominal hysterectomy (TAH) for patients with treatment-naïve endometrial cancer.
Randomized equivalence clinical trial – results from the Laparoscopic Approach to Cancer of the Endometrium (LACE) trial
760 patients with stage I treatment-naïve endometrial cancer were randomized to either receive TLH (407 women) or TAH (353 women). The primary outcome was disease-free survival, defined as the time between surgery and first recurrence (disease progression or development of a new primary cancer or death). At 4.5 years out, 81.3% of the TAH group and 81.6% of the TLH group were disease-free respectively. With a difference of only 0.3%, the two approaches were considered equivalent. There were no statistically significant differences in recurrence of endometrial cancer between the groups nor overall survival. While 2 patients in the TLH group had metastases in the port site, 2 women in the TAH group had metastases in the surgical site. Overall survival was 92.4% in the TAH group and 92.0% in the TLH group. The authors conclude that use of TLH for women with stage I endometrial cancer is supported by the data in this study.
The editorial makes the point that laparoscopic hysterectomy has been available since the 1990’s with demonstrated improved perioperative outcomes compared to abdominal hysterectomy for benign disorders. Previous results from the LACE study likewise showed no difference in intraoperative complications, but shorter hospital stays (2 vs. 5 days), and fewer postoperative adverse events (13% vs. 19%) in addition to overall improvement in quality of life in the TLH group. Also, like some previous studies, TLH procedures tend to take longer compared to TAH. The editorial notes that cases where the uterus is larger than 10 weeks gestation (excluded from this study) should be ‘approached with greater caution’. Likewise, TLH in this study was performed by a highly trained group of gynecologic oncologists and reflect a particular skill set that is not generalizable to all surgeons.
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