What are the recent developments in surgical oncology for colorectal, breast, ovarian, and endometrial cancers, including new trials and treatment recommendations?

Recent Developments in Surgical Oncology for Gynecological and Colorectal Cancers

Minimally invasive surgical approaches have become the standard of care for early-stage endometrial cancer, with equivalent oncological outcomes and fewer complications compared to open surgery.

Endometrial Cancer Surgical Advances

Minimally Invasive Surgery

• Laparoscopic and robotic approaches have demonstrated equivalent oncological outcomes to laparotomy with significant benefits 1:
  • Shorter hospital stays (1 vs 4 days)
  • Lower complication rates (8.4% vs 31.3%)
  • Less use of pain medications
  • Improved quality of life

Sentinel Lymph Node Mapping

• The FIRES trial demonstrated that sentinel lymph node (SLN) biopsy can safely identify lymph nodes in early-stage endometrial cancer 1
• Indocyanine green is the preferred method for SLN mapping with the best technical results 1
• SLN biopsy is now recommended for staging purposes in patients with low/intermediate-risk disease and may represent an alternative to systematic lymphadenectomy in high-risk disease 1, 2

Risk-Based Surgical Management

• Systematic pelvic lymphadenectomy is not recommended for low-risk endometrial cancer (grade 1-2 with <50% myometrial invasion) 1
• For intermediate-risk disease (>50% myometrial invasion or grade 3 with <50% invasion), lymphadenectomy can be considered for staging purposes 1
• For high-risk disease (grade 3 with >50% invasion), lymphadenectomy is recommended 1

Molecular Classification Integration

• Recent trials are incorporating molecular classification to guide surgical and adjuvant treatment decisions 1
• The PORTEC IV trial is attempting to validate genomic prognosticators to decrease both overtreatment and undertreatment 1

Ovarian Cancer Surgical Advances

Minimally Invasive Staging

• MIS represents a safe and adequate procedure for treating and staging early ovarian cancer despite the absence of randomized controlled trials 3
• Key considerations include:
  • Minimizing tumor disruption or dissemination
  • Removing adnexal mass intact
  • Adequate retroperitoneal staging
  • Fertility-sparing options for young patients

Staging Laparoscopy for Advanced Disease

• Staging laparoscopy is increasingly used in patients with advanced epithelial ovarian cancer to determine optimal treatment strategy 3
• Helps evaluate the feasibility of primary debulking surgery versus neoadjuvant chemotherapy followed by interval debulking

Colorectal Cancer Surgical Advances

Minimally Invasive Techniques

• Several techniques have evolved to decrease the impact of colorectal surgery for neoplasia 4:
  • Standard laparoscopy
  • Robotic surgery
  • Transanal endoscopic surgery (TES)
  • Transanal total mesorectal excision (taTME)
  • Natural orifice specimen extraction (NOSE)
  • Needlescopic surgery

Emerging Approaches

• Single-incision laparoscopic surgery (SILS) aims to decrease the number of incisions 4
• Transanal total mesorectal excision (taTME) eliminates the need for a specimen extraction incision 4

Multiple Primary Malignancies Considerations

• 20% of endometrial cancer patients have a history of another malignancy, most commonly breast (10%), colorectal (3%), and ovarian (4%) 5
• Risk factors for developing colorectal cancer after endometrial cancer include:
  • Family history of hereditary nonpolyposis colorectal cancer (HNPCC)
  • Presence of endometrial cancer in the lower uterine segment 5
• Risk factors for synchronous ovarian cancer with endometrial cancer:
  • Age younger than 50 years (OR 4.27)
  • Family history of breast or ovarian cancer (OR 3.95) 5

Clinical Implications

1. Minimally invasive surgery should be the preferred approach for apparent early-stage endometrial cancer, even in high-risk histologies
2. Sentinel lymph node mapping is replacing complete lymphadenectomy in many clinical scenarios
3. Molecular classification is increasingly important for treatment planning and prognostication
4. Risk stratification should guide the extent of surgical staging in all gynecologic malignancies
5. Careful assessment for synchronous or metachronous malignancies is essential, particularly in young patients and those with family history of cancer

These advances highlight the trend toward more personalized surgical approaches based on risk stratification and molecular profiling while minimizing surgical morbidity through less invasive techniques.