Morbidly obese patient with endometrial cancer treated by bariatric surgery to enable cancer treatment

Abstract

The case demonstrates the use of bariatric surgery to improve a patient’s candidacy for surgical treatment for endometrial cancer (EC). A 50-year-old morbidly obese woman with early-stage EC was initially treated with levonorgestrel-releasing intrauterine system (52 mg). She had to reduce her body mass index (BMI) to become eligible for definite EC treatment. Using conservative methods, she was unable to lose weight effectively. She then underwent bariatric surgery that reduced her BMI from 71.3 to 54.3 kg/m². She maintained her weight and was eligible for total hysterectomy and bilateral salpingo-oopherectomy. Her procedure was successful and had no complications. She has 6-monthly follow-ups, and the most recent review showed no evidence of recurrence.

Background

In the UK, around 9400 women are diagnosed with endometrial cancer (EC) each year and of those approximately 50% cases are attributed to obesity.¹

The definite management for EC, specifically low grade, is surgery (hysterectomy and removal of adnexal structures) due to its favourable prognosis compared with alternatives.² However, there are scenarios where the patients would not be eligible for the surgical route. Such incidents could be if the patient had a high body mass index (BMI), have multiple medical comorbidities, advanced age or would want to preserve their fertility. This case report looks into the role of bariatric surgery to reduce weight, thus improving the candidacy for the definite surgical EC treatment in an obese inoperable patient.

Case presentation

A 50-year-old woman (2013) presented for a gynaecological care after reporting several months of history of irregular vaginal bleeding. She had a notable oncology medical history for breast cancer and had undergone a left mastectomy, followed by adjuvant chemotherapy and hormonal therapy (tamoxifen for 5 years). She was also diagnosed with a colon carcinoma of her sigmoid colon and underwent sigmoid colectomy. Apart from these medical conditions she had hypertension, type II diabetes (metformin treatment), asthma, osteoarthritis, fibromyalgia and had a venous thromboembolic event following her colorectal surgery (treated with lifelong clopidogrel).

Investigations

To investigate about her abnormal uterine bleeding, she was referred for a transvaginal ultrasound scan that showed endometrial thickness of 9.3 mm and had subserosal fibroid on the posterior uterine wall at the level of the internal orifice of the uterus measuring about 3×4 cm. She was referred for an endometrial biopsy where they discovered that she had grade 1 endometrioid endometrial adenocarcinoma with mucinous differentiation.

Treatment

The case was discussed with the gynaecological oncology multidisciplinary meeting where they advised conservative management with LNG-IUS due to morbid obesity (BMI 71 kg/m², weight 167.4 kg) and other health problems. Additionally, the patient was encouraged to lose dramatic amount of weight before surgery is considered.

After 7 months of EC diagnosis, she gained weight having a BMI of 73.7 kg/m². However, the bleeding greatly improved with the levonorgestrel-releasing intrauterine system (LNG-IUS). Additionally, she did not have any other new health or gynaecological problems. Her recent biopsy showed the presence of hormonal effect secondary to having the LNG-IUS in place.

There was a rediscussion about surgery following bariatric procedure to enable effective weight loss. Other treatment options such as radiotherapy were discussed, however, it is not usually used for grade 1 EC and would not be as curative as surgery. The patient desired the surgical treatment and was motivated to lose weight knowingly that it could take more than a year or so to achieve this goal. So, she was referred to the bariatric services and plan was made to offer surgery once there is reduction of BMI to safe operating levels (about 60 BMI).

Following a year later (2014), she had reduced 14 kg weight (now weighing 166 kg, BMI 71.9) with specialist dietitian. Her exercise was still limited due to her fibromyalgia pain. She was also referred to a psychologist for weight loss hypnosis strategy. However, this did not help her. Instead, she focused on her nutrition plan and improving her exercise regime. Her target weight to be considered eligible for bariatric surgery was 162 kg.

After 2.5 years (December 2017) of her EC diagnosis, she underwent laparoscopic sleeve gastrectomy (LSG). Preoperatively, the patient weighted 166 kg and her BMI was 71.3 kg/m². She had also been on strict liver diet and was admitted a week earlier from her surgery date for strict inpatient dietetic input for liver shrinkage. There were no surgery complications. Postoperatively she was on liquid diet (2500 mL/day) for 2 weeks. After her fourth week, she was moved to solid diet, aiming for five small solid meals. She was also given soluble multivitamin tablet every day and was encouraged to be mobile and wear thromboembolism-deterrent stockings.

On her 8-week postsurgery follow-up, she had lost about 36% of her excess weight. She weighed 135.4 kg and her BMI was 57.8. She had no symptoms and was compliant with her postoperative diet advice. She was also followed up every 6 months to check her weight loss progress and report any changes in her health.

Late 2018, the patient had a CT scan of chest, abdomen and pelvis with contrast. Appearances were non-specific noting slightly increased bulk to the uterus and LNG-IUS located in the endometrial cavity. There were no thoracic nor any mediastinal abnormalities. In the abdominal images, there were no abnormal masses, no focal liver lesions and no ascites. No evidence of bone metastasis nor any distant disease spread. A chest X-ray was also done, reporting no malignancy.

In early 2019, following her bariatric surgery, she had a biopsy taken that showed that her tumour grade was the same. With her BMI at 54.3 kg/m², she was eligible for her total hysterectomy and bilateral salpingo-oopherectomy. Her histology following surgery showed grade 1 stage 1A EC, less than 50% myometrial invasion, two foci of lymphovascular space invasion (LVSI) and negative peritoneal washings. No definitive features of atypia or malignancy were identified.

Outcome and follow-up

The patient had no complications and made good recovery with her healing. She was eligible to receive adjuvant treatment in view of the stage and evidence of LVSI, however, she declined radiotherapy treatment and wanted to focus on improving her fitness following surgery.

In her most recent 2021 follow-up (3 years post-treatment), she had no new symptoms. Her abdomen examination was normal and had no inguinal lymphadenopathy. Her PV examination was normal as well. She weighs 110.4 kg now having lost 69 kg, giving her an excess weight loss percent of 57%.

Discussion

Obesity is a strong risk factor for EC in women, the risk proportionally increases as BMI increases. A study showed that every increase of 5 kg/m² in BMI had a linear correlation of having an almost 50% risk increase for developing EC.³ The aim of this study was to describe the patient’s EC management experience and how bariatric surgery was used as an adjuvant therapy to reduce weight to improve her candidacy for surgical treatment for EC.

The standard treatment for EC is surgery with adjuvant treatment of radiotherapy and/or chemotherapy if indicated.² However, a BMI of more than 40 indicates morbid obesity and is associated with a higher chance of perioperative complications such as venous thrombotic events, acute cardiac events and arrhythmias.⁴ Intraoperative challenges include optimal positioning of patients at the start of the surgery necessitating bariatric beds and bariatric leg supports. There is inadequate exposure of the pelvic organs owing to abdominal adiposity and limited Trendelenburg position (due to undue pressure on the ventilation with head-down position). Also, there is a need for longer instruments, longer ports and increased operating time in theatre. This makes hysterectomy extremely challenging and often involves preoperative planning and constant communication between the gynaecologist and the anaesthetist to offer the optimal outcome for the patients. Laparoscopic hysterectomy is by far the safer approach for hysterectomy in obese women compared with abdominal hysterectomy owing to less complication rates of bleeding, infection, reduced hospital stay, reduced rates of venous thromboembolism secondary to early mobilisation and recovery possible with minimally invasive approach.⁵

Advances in latest laparoscopic techniques have made surgery less challenging in obese patients. Eltabbakh et al study investigated surgical outcomes and safety in obese women (BMI range 28–60 kg/m²) with early-stage EC undergone laparoscopic management.⁶ They reported that 40 out of 42 patients undergone laparoscopic surgery had longer operating times, but had less blood loss, needed less pain medications and shorter hospital stays compared with abdominal hysterectomies. Additionally, a 7-year audit involving 27 women weighing up to more than 100 kg undergone laparoscopic hysterectomy for EC reported no major complications and none required conversion to open operation, reoperation or readmission.⁷ Over the years, the local cancer unit at Ninewells Hospital (Scotland) has invested in developing a dedicated laparoscopic team for offering surgery to women with morbid obesity and EC. Since 2014, there has been a constant upward shift in the BMI cut-off for surgery.⁸ At the start, it was BMI of 40 kg/m² and now it is offered up to a BMI of 65 kg/m².

Hormone therapy such as the LNG-IUS is an EC treatment option especially in terms of preserving fertility. This conservative approach was applied in this patient’s case as hormone therapy is generally used to manage low-grade EC in women with morbid obesity and comorbidity. Nevertheless, the response rate varies from 50% to 70% even after complete compliance with the progestin therapy.⁹ This increases chances for EC recurrence. One of the factors contributing to high recurrence was having a BMI of over 25 that significantly reduced the effectiveness of the progestin treatment.¹⁰ Lastly, the National Health Service also states that new types of hormonal contraceptives such as IUS still carry the risk of breast cancer and this was notable for this patient due to her breast cancer history. Consequently, this was only a temporary treatment until she could be eligible for EC surgery.¹¹

For this patient to qualify for a total hysterectomy and bilateral salpingo-oopherectomy, she had to reduce her BMI by almost 26% from when she was first diagnosed with EC. She had found it extremely challenging, to tackle obesity through diet and exercise. In 2.5 years, she was only able reduce her BMI by 3.3% using conservative weight loss practices. Thus, we had to approach other methods for efficient and safe weight reduction for her to become a suitable candidate for EC surgery.

Bariatric surgery is the only current treatment proven to achieve significant and sustained weight loss in the morbidly obese. Emerging evidence suggests that substantial, sustained weight loss following bariatric surgery reduces risk of EC.¹² In this case, the patient had opted for LSG in 2017. The greatest benefit was seen when comparing her presurgery BMI of 71.3 kg/m² with unsuccessful weight loss with nonsurgical methods to her 8-week postsurgery BMI of 57.3 kg/m². A recent meta-analysis aimed to compare the effectiveness of laparoscopic Roux-en-Y gastric bypass and LSG, found that both resulted in same weight loss.¹³ Nevertheless, sleeve gastrectomy had fewer postoperative complication and preoperative rates. Further on, a systemic review consisting of 5218 patients stated that patients undergone LSG had an average weight loss of 67.3% in their first year following surgery.¹⁴

A 2019 meta-analysis results showed that the overall cancer incidence in patients undergoing bariatric surgery was lower compared with non-surgery patients who had opted for weight loss conservative management.¹² In addition, the biggest risk reduction was seen in obesity-related cancers such as oesophageal, breast, ovary, kidney, colorectal and liver in patients who had undergone bariatric surgery. Supporting these results, a recent New York study involving 302 883 obese female patients stated that patients had undergone bariatric surgery had a lower incidence of endometrial, breast and ovarian cancer than non-surgery obese patients.¹⁵ Therefore, bariatric surgery may provide a risk reduction from other cancers and improve oncological outcomes.

Following the bariatric surgery, our patient had adhered to a strict diet plan and maintained her weight to be able to have the EC surgery a year later. Ward et al study reported that obese women who had undergone bariatric surgery had a 71% reduced risk of uterine malignancy.¹⁶ However, if they maintained their normal weight after surgery their risk reduced to 81%. These study findings suggest that obesity is a modifiable risk factor in relation to developing EC and importance of maintaining a steady weight after surgery.

A similar case report was seen involving a 54-year-old obese woman (BMI of 50 kg/m²), who had a stage IA grade 1 EC.¹⁷ She was already following a prebariatric programme involving psychologist, nutritionist and endocrinologist. She was first treated with intrauterine device. However, she was later treated with dual surgery involving laparoscopic hysterectomy, bilateral salpingo-oophorectomy and Roux-en-Y gastric bypass surgery at the same time unlike our patient. She was also unable to reduce weight using conservative methods. However, she had a 30.8% weight loss after a year of having surgery as well as decreasing her medical requirements for her comorbidities such hypertension and diabetes mellitus.

Conclusion

Bariatric surgery needs to be considered as part of prehabilitation of EC management when a high BMI precludes definitive surgery.

Learning points.

• Bariatric surgery is a potential effective prehabilitation in obese women who are unsuitable for primary endometrial cancer surgical treatment.

• Weight loss following bariatric surgery and maintaining the weight can reduce the risk of endometrial cancer.

• Latest laparoscopic technique advances have made surgery safer in obese patients undergoing early-stage endometrial cancer management.

Ethics statements

Patient consent for publication

Obtained.