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Endometrial Cancer Surgical Staging (Role of Lymphadenectomy)

Endometrial Cancer Surgical Staging (Role of Lymphadenectomy). Karl Podratz MD PhD FACS. Endometrial Cancer Surgical Staging. Basis for Definitive Staging Extent of Disease Adjuvant Rx determinant Prognostication Comparative evaluation Potentially therapeutic.

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Endometrial Cancer Surgical Staging (Role of Lymphadenectomy)

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  1. Endometrial CancerSurgical Staging(Role of Lymphadenectomy) Karl Podratz MD PhD FACS

  2. Endometrial CancerSurgical Staging • Basis for Definitive Staging • Extent of Disease • Adjuvant Rx determinant • Prognostication • Comparative evaluation • Potentially therapeutic

  3. Endometrial CancerSurgical Staging • Definitive Staging • TAH/BSO/Peritoneal cytology • Pelvic/Paraaortic LND* • Biopsy/Omentectomy • Cytoreduction (Rx) *LND = Lymph node dissection

  4. Endometrial CancerSurgical Staging • Definitive Staging • TAH/BSO/Peritoneal cytology • Pelvic/Paraaortic LND* • Biopsy/Omentectomy • Cytoreduction (Rx) *LND = Lymph node dissection

  5. Endometrial CancerRole of Lymphadenectomy vs Radiotherapy • Modality-based therapy* • Lymphadenectomy • Radiotherapy *Traditions, physician preferences, suboptimal study designs, etc.

  6. Endometrial CancerAnnual Incidence Cases and Deaths ACS Estimates* Year Cases Deaths 1987 35,000 2,900 2007 39,080** 7,400*** *Ca 1987; CA 2007 **11.7% increase; ***155% increase

  7. Endometrial CancerRole of Radiotherapy and Lymphadenectomy • Paradigm shift necessary • Minimize overtreatment • Minimize undertreatment • Maximize outcomes

  8. Endometrial CancerRole of Radiotherapy and Lymphadenectomy • Treatment paradigm shift • Minimize overtreatment • Identify pts not requiring LND and/or RT • Minimize undertreatment • Identify pts benefiting from LND and/or RT • Maximize outcomes

  9. Endometrioid Endometrial CancerRole of Radiotherapy and Lymphadenectomy • Modality-based therapy • Radiotherapy vs. lymphadenectomy • Uterine histology • Disease-based therapy • Based on patterns of failure • Predicted by pathologic determinants • Selective Lymphadenectomy • Selective Radiotherapy • Selective Chemotherapy

  10. Endometrial CancerSelective Lymphadenectomy(not sampling) • Lymph Node Dissection (LND) • Low risk: Not indicated • All others: Systematic

  11. Endometrial CancerSelective Lymphadenectomy • Lymphadenectomy not indicated* • Low risk: • Endometrioid • G 1&2 • MI < 50% • PTD < 2 cm *Mariani et al. Am J Ob Gyn 2000

  12. Endometrioid Endometrial Cancer Grade 1 & 2 and MI < 50% Failures according to PTD* Sites (DOD) PTD Pt Failures Loc + (cm) (no.) no. % Loc Dist Dist < 2 123 3 2 3 (0) -- -- > 2 169 14 8 3 (1) 6 (6) 5 (4) *Primary Tumor Diameter

  13. Endometrioid Endometrial CancerLow risk: G1/2, < 2 cm, < 50% MI Pt % 5 yr Treatment^ (no.) Survival Hysterectomy only 59 100 Hyst + LND* +/or RT** 64 100 Total 123 ^3/113 recurred (vagina) without RT; all salvaged *All nodes negative;**10 RT; 7 for PPC Mariani et al. Am J Ob Gyn 2000

  14. Endometrioid Endometrial CancerLow Risk: G 1/2, MI < 50%,PTD < 2 cm • Lymphadenectomy not indicated • 20% Over all population* • 29% Endometrioid patients* *Mariani et al. Am J Ob Gyn 2000

  15. Endometrioid Endometrial CancerSelective Lymphadenectomy • Lymphadenectomy not indicated (29%) • Low risk: G 1/2, MI < 50%, PTD < 2 cm • Systematic Lymphadenectomy (71%) • All others (not low risk)

  16. Endometrioid Endometrial CancerSelective Lymphadenectomy • Lymphadenectomy not indicated • Low risk: G 1/2, MI < 50%, PTD < 2 cm • Systematic Lymphadenectomy • All others (not low risk) • 17% positive nodes

  17. Endometrial Cancer FailuresPelvic Lymphatic Failures Lymphatic failures according to risk factors Lymphatic Failure rate P Site % at 5 years Value Pelvic Sidewall Low risk<1 <0.001 High risk* 26 Low risk = absence of high risk factors High risk = *CSI and/or LN mets

  18. Endometrial Cancer FailuresLymphatic Failures Lymphatic failures according to risk factors Lymphatic Failure rate P Site(s) % at 5 years Value Pelvic Sidewall Low risk <1 <0.001 High risk* 26 Para-aortic area Low risk 1 <0.001 High risk** 33 Low risk = absence of high risk factors High risk = *CSI and/or LN mets; **LN mets only

  19. Endometrial Cancer FailuresParaaortic Lymphatic Involvement • 33% para-aortic failures with pelvic and/or para-aortic LN mets • 47% para-aortic LN mets or para-aortic failures with pelvic LN mets* *Mariani et al 2002 (Mayo series)

  20. Endometrioid Endometrial CancerRole of Radiotherapy and Lymphadenectomy • Disease-based therapy • Based on patterns of failure • Predicted by pathologic determinants • Selective Lymphadenectomy • Selective Radiotherapy • 12% total population at risk • EBRT indicated in 12% • 47% paraaortic risk • RT field to include PA area

  21. Endometrial Cancer Therapy after Lymphadenctomy Conclusions: Absent CSI or pelvic LN mets: adjuvant Rx to pelvic or para-aortic node-bearing areas does not appear indicated Positive (or at-risk* for) pelvic LN mets: adjuvant Rx to both the pelvic and para-aortic nodal areas indicated*Patients at-risk but incompletely staged

  22. Endometrioid Endometrial CancerRole of Radiotherapy and Lymphadenectomy • Treatment paradigm shift • Minimize overtreatment • Identify pts not requiring LND and/or RT • Minimize undertreatment • Identify pts benefiting from LND and/or RT • Maximize outcomes

  23. Endometrioid Endometrial CancerRole of Radiotherapy and Lymphadenectomy • Modality-based therapy • Radiotherapy vs. lymphadenectomy • Uterine histology • Disease-based therapy • Based on patterns of failure • Predicted by pathologic determinants • Selective Lymphadenectomy • Selective Radiotherapy • Selective Chemotherapy

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