Endometriosis
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Hysteroscopic Resection of Endometrial Cancer

Hysteroscopic Resection of Endometrial Cancer
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Video Description

This video describes a novel technique for treatment of endometrial cancer in those desiring future fertility or who have medical conditions that preclude them from standard treatment of hysterectomy with bilateral salpingo-oophorectomy. We describe a three step operative approach including hysteroscopic resection of the tumour, resection of underlying myometrium (if affected) and resection/sampling of remaining endometrium. This is then demonstrated in two cases, the first for fertility preservation, and the second in a case of a medical complex patient who is a non-surgical candidate.

Presented By

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Dr. Shannon Fitzpatrick
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Dr. Lauren Andrew
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Dr. Ari Sanders
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Affiliations

University of Calgary

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What is Hysteroscopic Resection of Endometrial Cancer?

Hysteroscopic resection of endometrial cancer is a minimally invasive procedure used to remove cancerous tissue from the endometrium, the inner lining of the uterus. This technique is primarily considered for early-stage endometrial cancer in carefully selected patients, particularly those looking to preserve fertility or avoid more invasive surgeries. Here’s an overview of the procedure:

  • Procedure Details: The surgeon inserts a hysteroscope (a thin, lighted instrument with a camera) through the cervix and into the uterus to visualize the endometrial cavity. Using specialized instruments passed through the hysteroscope, the surgeon removes cancerous tissue in a controlled, targeted manner, aiming for complete resection of the visible tumor.

  • Minimally Invasive Benefits: Hysteroscopic resection avoids abdominal incisions, leading to quicker recovery, minimal scarring, and reduced postoperative pain. It’s performed as an outpatient procedure, often allowing patients to return home the same day.

  • Fertility Preservation: For younger patients who wish to maintain fertility, hysteroscopic resection provides an option to treat endometrial cancer without requiring a hysterectomy (removal of the uterus), preserving reproductive potential.

  • Who is Eligible?: This approach is typically reserved for early-stage, low-grade endometrial cancers confined to the endometrial lining and without deep invasion. Patients may also receive hormonal therapy following resection to manage any remaining microscopic cancer cells.

Hysteroscopic resection of endometrial cancer offers a conservative treatment option, but it requires careful monitoring and follow-up to ensure complete cancer removal and early detection of any recurrence.

What are the Risks of Hysteroscopic Resection of Endometrial Cancer? 

Hysteroscopic resection of endometrial cancer, while minimally invasive, carries specific risks due to the complexity of removing cancerous tissue from the uterine lining. Key risks include:

  • Incomplete Resection: Hysteroscopy may not fully remove all cancerous tissue, especially if cancer cells have spread deeper into the uterine wall, leading to possible recurrence.

  • Uterine Perforation: Manipulating surgical instruments in the uterus can accidentally puncture the uterine wall, potentially causing bleeding, damage to nearby organs, or the need for further surgical intervention.

  • Spread of Cancer Cells: In rare cases, manipulating cancerous tissue during hysteroscopy may lead to the spread of cancer cells to other areas within the uterine cavity or into the pelvic region.

  • Infection: As with any procedure, infection at the surgical site or within the pelvic area is possible, potentially requiring antibiotics or further treatment.

  • Adhesion Formation (Asherman Syndrome): Scar tissue may form within the uterus after the procedure, potentially leading to Asherman Syndrome, which can cause menstrual irregularities, infertility, or pelvic pain.

Due to these risks, hysteroscopic resection is generally considered in select cases where the cancer is limited to the endometrial lining and has not invaded deeper tissue. Careful patient selection and thorough post-operative monitoring are essential to mitigate risks.

Video Transcript: Hysteroscopic Resection of Endometrial Cancer

In this video, we will demonstrate a novel technique for minimally-invasive treatment of endometrial cancer. Our objectives are to present a novel surgical technique and to demonstrate this in two unique patient populations.

Endometrial cancer is the most common gynaecological cancer. In Canada, the standard first line therapy is total hysterectomy with bilateral salpingo-oophorectomy. Hysterectomy is not appropriate for those who desire fertility or have medical conditions that preclude them from major surgery. Second line treatment involves hormone or radiation therapy.

Hysteroscopic resection of endometrial cancer was first described in 2005. Since then, studies have demonstrated efficacy of hysteroscopic resection in the fertility populations with improved complete response rate in time to conception. There is minimal evidence on the optimal treatment for patients who are unable to undergo major surgery or radiation.

We present the following approach to hysteroscopic resection of endometrial cancer. First, you must carefully select the proper patient. In our cases, our patients were both referred to us from our gynae-oncology team. Next, preoperative imaging must be completed to map tumour location and determine degree of myometrial involvement.

Then, in the operating room, we have a three-step approach. Step one is to locate and then resect the tumour. Step two is resection of the underlying myometrium if there is concern for myometrial invasion on imaging. And step three is resection or sampling of the remaining endometrium.

Our first case is a 37-year-old G1P0 female diagnosed with FIGO grade one endometrioid adenocarcinoma. She was initially treated with a levonorgestrel IUS and oral progesterone. Regular biopsies over two years showed persistent FIGO grade one adenocarcinoma.

The patient and her husband wanted to pursue fertility as soon as possible. She was consented for a hysteroscopic resection, understanding that this could potentially pose fertility-related issues in the future if intrauterine adhesions developed. Bipolar resectoscope was selected to provide adequate resection of the endometrium and the affected underlying myometrium.

Preoperative MRI demonstrated an asymmetrical prominence in the left fundal myometrium with suspected focal invasion and myometrial thinning. First, full inspection of the cavity shows an area of abnormally thickened endometrium just inferior to the right tubal ostia. At the fundus, there is abnormal endometrium with irregular architecture and vascularity. Anteriorly, diffuse papillary projections are seen. Finally, in the left lateral lower uterine segment, frond-like projections of the endometrium are visualised.

Step one, resection of the tumour. Using a bipolar loop resectoscope, all areas of concern previously identified are resected to the level of the endometrium. This is started inferior to the right tubal ostia. This is repeated in the left lateral lower uterine segment as well as on the anterior wall of the uterus, as seen here. Finally, the abnormal endometrium at the fundus is resected with care to avoid the tubal ostia. Here, you can see that all previously identified abnormal endometrium has been resected.

Step two, resection of the myometrium. We begin by setting lateral resection margins towards the right tubal ostia, then careful dissection of the fundal myometrium is completed. By palpating the fundus, we can obtain tactile feedback of the strength of the underlying myometrium. Ultrasound or laparoscopic guidance could also be used to guide resection and help reduce risk of perforation. The anterior margin is also resected in a craniocaudal direction to complete resection.

Step three is sampling of the remaining endometrium. Using a cold loop as a curette, a circumferential sample is taken and sent to pathology. At the end of the procedure, the full resection plane is visualised. There is no longer abnormal myometrium, and the underlying myometrium appears normal. A new levonorgestrel IUS was placed at the end of the procedure.

Our patient was discharged home on post-op day zero. Pathology showed FIGO grade one and two adenocarcinoma. An endometrial biopsy, completed six months later, showed no evidence of malignancy, and a follow-up MRI showed only minor residual thickening of the endometrium in the left cornua. The patient is currently seeing our local fertility centre to expedite fertility plans.

Our next case is a 66-year-old G2P2 female with an extensive past medical history, as seen here. Note that she’s on warfarin for a previous mitral valve replacement and has a pelvic kidney after transplantation. She was diagnosed with a grade three endometrioid adenocarcinoma, which was initially successfully treated with a levonorgestrel IUS for four years.

Unfortunately, she had a recurrence of her cancer with IUS in situ. Due to her history of a pelvic kidney, she wished to avoid pelvic radiation, and she was deemed a non-surgical candidate. Anticoagulation was not interrupted for her hysteroscopy as per internal medicine due to the high risk of valvular complications.

Preoperative MRI showed a concerning lesion at the uterine cervical junction with no evidence of metastatic disease. We’ll again demonstrate our three-step approach with resection of the tumour, resection of underlying myometrium, and resection and sampling of the remaining endometrium.

First, to avoid placing a tenaculum and causing cervical bleeding, vaginoscopy is used to enter the cavity. Following the IUS strings allows the cervical os to be found with ease. With gentle pressure at the level of the internal os, the cavity is entered. Here we can visualise the old IUS.

Next, a circumferential inspection of the internal cervical os is completed. At the cervical isthmic junction, there’s an area of abnormally appearing tissue. Cephalad to this is an abnormal ridge of myometrium. Full inspection of the cavity reveals abnormal endometrium adjacent to the right tubal ostia as well as at the uterine fundus.

We then proceed with resection, starting with step one, resection of the tumour. In the area of concern, resection of the abnormal endometrium is completed. In this case, the intrauterine tissue removal device was chosen to eliminate the risk of taking resection margins too deep into the myometrium, as well as to avoid the larger dilation required for operative hysteroscopy in an effort to minimise blood loss and to decrease the risk of perforation. The resection is completed along the ridge of myometrium, at the cervical isthmic junction, and just inferior to this at the level of the internal os, seen here.

Next, we complete resection of the underlying myometrium, starting with targeted resection of the abnormal myometrial ridge identified prior. This is carried caudally until all abnormal myometrium is resected. Here we can visualise our resection. The residual space after resection is consistent with the size of the mass as seen on her MRI.

Finally, we complete step three by completing a circumferential sample of the remaining endometrium. The intrauterine tissue removal device was used to avoid unnecessary bleeding caused by a sharp curette. A levonorgestrel IUS was placed at the end of the procedure.

This patient was discharged home on post-op day three after a mild AKI and warfarin dose adjustments. Pathology showed grade three adenocarcinoma with clear cell changes. Repeat biopsy and MRI are pending at this time.

In summary, hysteroscopic resection is an emerging therapy in fertility and medically-complex populations. Bipolar resection or hysteroscopic intrauterine tissue removal device can be used. Our three-step approach is, step one, resection of the tumour, step two, resection of underlying myometrium, and step three, resection and sampling of the remaining endometrium.