
==== Front
Int J Surg
Int J Surg
JS9
International Journal of Surgery (London, England)
1743-9191
1743-9159
Lippincott Williams & Wilkins Hagerstown, MD

38814368
IJS-D-24-01982
10.1097/JS9.0000000000001744
00103
3
Correspondence
Letter to the editor: A commentary on ‘Whether surgical procedure can improve the prognosis of endometrial cancer arising in adenomyosis (EC-AIA)? A systematic review and meta-analysis’
Sun Yajing MM s13588289489@163.com
a
Ye Lihong BD aylh9959@163.com

Zhang Chen MM b*zc87084955@163.com

a Department of Gynecology, Shaoxing Central Hospital, Shaoxing
b Department of Gynecology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, People’s Republic of China
* Corresponding author. Address: Department of Gynecology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou 310003, Zhejiang, People’s Republic of China. Tel.: +861 358 828 9489. E-mail: zc87084955@163.com (C. Zhang).
9 2024
29 5 2024
110 9 59495950
11 5 2024
19 5 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

OPEN-ACCESSTRUE
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pmc Dear Editor,

Endometrial carcinoma arising from adenomyosis (EC-AIA) is a rare uterine disease characterized by the malignant transformation of ectopic endometrial tissues within adenomyosis lesions. Clinical and survival data are primarily limited to case reports and a few cohort studies1. The efficacy of supplementary lymphadenectomy in significantly improving survival outcomes for patients with EC-AIA remains unclear. Therefore, Sun et al.2 conducted a study using systematic review and meta-analysis, which included 38 studies involving 56 patients, to analyze the survival outcomes of endometrial cancer patients who underwent supplementary lymphadenectomy.

The study found that supplementary lymphadenectomy significantly improves progression-free survival (PFS) in patients with EC-AIA, providing crucial decision-making support for clinicians treating patients who are incidentally diagnosed with endometrial cancer following adenomyosis. However, while the article emphasizes the statistical significance of the surgical approach’s impact on prognosis, it does not sufficiently discuss its clinical significance. Despite a statistically significant difference in PFS, there was no significant difference in overall survival (OS) between the surgical and non-surgical groups. The tumors in patients with endometrial carcinoma may have highly heterogeneous biological characteristics. Even if the primary tumor burden is removed through procedures such as lymph node dissection, some minor, undetected metastatic foci may still persist3. These micro-metastases may not exhibit activity for a period after the main tumor is removed, thereby prolonging PFS, but they could ultimately cause the disease to recur, affecting the OS. While surgery can physically remove visible lesions and improve PFS, its effectiveness might be limited in controlling systemic disease processes (such as microscopic metastasis and molecular-level changes), thus minimally impacting OS. The authors need to emphasize these issues; otherwise, overly stressing the improvement in PFS while ignoring OS might mislead clinical decision-making, unnecessarily increasing patient burden and reducing patient benefits.

When conducting multivariate Cox regression analysis, the article did not specify which variables were included in the final multivariate model nor how these variables were selected. Without this information, it is difficult for readers to judge whether the model has adequately adjusted for all significant confounding factors. Insufficient handling of potential confounders could affect the interpretation of causal relationships4. For instance, potential confounders when studying the survival of patients with endometrial cancer might include age, pathological staging, tumor grading, baseline health status, and other treatments received. If these factors are not considered in the model, it could lead to biased estimates of treatment effects, reducing the model’s transparency and credibility. Additionally, the relatively small number of cases studied limits the generalizability of the research findings. Results from small samples are easily influenced by the characteristics of individual cases, especially in situations with high heterogeneity among cases, such as differences in patient age, disease duration, and complications. The lack of sufficient sample size also leads to high variance, affecting the generalizability of the conclusions. A small sample size implies low statistical power, reducing the likelihood of detecting an actual effect. In other words, if a true effect (such as the impact of surgery on survival rates) does exist, a small sample might fail to detect this effect due to insufficient statistical power.

In summary, this study provides useful information for clinical decision-making regarding the treatment of patients with EC-AIA, particularly in terms of how surgical interventions can improve survival quality and expectations. It emphasizes the importance of supplementary lymphadenectomy in patients who are incidentally diagnosed with EC-AIA following adenomyosis, suggesting that this practice may help improve patient prognosis. However, future researchers still need to conduct more comprehensive studies to address a series of issues involving OS, confounding factors, and the insufficiency of sample sizes.

Ethical approval

Not applicable.

Consent

Not applicable.

Source of funding

Zhejiang Provincial Traditional Chinese Medicine Science and Technology Program (No.: 2021ZB307).

Author contribution

Y.S., L.Y., and C.Z.: conceptualization, methodology, validation, formal analysis, investigation, resources, data curation, writing – original draft, writing – review and editing, supervision, and project administration.

Conflicts of interest disclosure

There are no conflicts of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Yajing Sun, Lihong Ye, and Chen Zhang.

Data availability statement

Data sharing is not applicable to this article.

Provenance and peer review

Not applicable.

Assistance with the study

Not applicable.

Yajing Sun and Lihong Ye contributed equally to this work.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 29 May 2024
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References

1 Machida H Maeda M Cahoon SS . Endometrial cancer arising in adenomyosis versus endometrial cancer coexisting with adenomyosis: are these two different entities? Arch Gynecol Obstet 2017;295 :1459–1468.28444512
2 Sun Y Lin S Wu W . Whether surgical procedure can improve the prognosis of endometrial cancer arising in adenomyosis (EC-AIA)? A systematic review and meta-analysis. Int J Surg (London, England) 2024;110 :3072–3080.
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