Endometrial Cancer Surgical Staging Role of Lymphadenectomy

1
Endometrial Cancer Surgical 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 Cancer Surgical 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 12
• MI lt 50
• PTD lt 2 cm

Mariani et al. Am J Ob Gyn 2000
12
Endometrioid Endometrial Cancer Grade 1 2 and
MI lt 50

• Failures according to PTD
• Sites
  (DOD)
• PTD Pt Failures
  Loc
• (cm) (no.) no. Loc
  Dist Dist
• lt 2 123 3 2 3 (0)
  -- --
• gt 2 169 14 8 3 (1) 6
  (6) 5 (4)
• Primary Tumor Diameter

13
Endometrioid Endometrial CancerLow risk G1/2, lt
2 cm, lt 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 lt 50, PTD lt 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 lt 50, PTD lt 2 cm
• Systematic Lymphadenectomy (71)
• All others (not low risk)

16
Endometrioid Endometrial CancerSelective
Lymphadenectomy

• Lymphadenectomy not indicated
• Low risk G 1/2, MI lt 50, PTD lt 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 lt1
  lt0.001
• 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 lt1
  lt0.001
• High risk 26
• Para-aortic area
• Low risk 1
  lt0.001
• 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

24
(No Transcript)