endometrial cancer surgical staging (role of lymphadenectomy)
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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. - PowerPoint PPT PresentationTRANSCRIPT
Endometrial CancerEndometrial Cancer Surgical StagingSurgical Staging
(Role(Role of Lymphadenectomy) of Lymphadenectomy)
Karl Podratz MD PhD FACSKarl Podratz MD PhD FACS
Endometrial CancerEndometrial CancerSurgical StagingSurgical Staging
Basis for Definitive StagingBasis for Definitive StagingExtent of DiseaseExtent of DiseaseAdjuvant Rx determinantAdjuvant Rx determinantPrognosticationPrognosticationComparative evaluationComparative evaluationPotentially therapeuticPotentially therapeutic
Endometrial CancerEndometrial Cancer Surgical StagingSurgical Staging
Definitive StagingDefinitive Staging TAH/BSO/Peritoneal cytologyTAH/BSO/Peritoneal cytologyPelvic/Paraaortic LND*Pelvic/Paraaortic LND*Biopsy/OmentectomyBiopsy/OmentectomyCytoreductionCytoreduction (Rx) (Rx)
*LND = Lymph node dissection
Endometrial CancerEndometrial CancerSurgical StagingSurgical Staging
Definitive StagingDefinitive Staging TAH/BSO/Peritoneal cytologyTAH/BSO/Peritoneal cytology
Pelvic/Paraaortic LND*Pelvic/Paraaortic LND*Biopsy/OmentectomyBiopsy/OmentectomyCytoreductionCytoreduction (Rx) (Rx)
*LND = Lymph node dissection
Endometrial CancerEndometrial CancerRole of Lymphadenectomy vs RadiotherapyRole of Lymphadenectomy vs Radiotherapy
Modality-based therapy*Modality-based therapy*
Lymphadenectomy Lymphadenectomy RadiotherapyRadiotherapy
*Traditions, physician preferences, *Traditions, physician preferences, suboptimal study designs, etc.suboptimal study designs, etc.
Endometrial CancerEndometrial CancerAnnual Incidence Cases and DeathsAnnual Incidence Cases and Deaths
ACS Estimates*ACS Estimates*Year Cases DeathsYear Cases Deaths 1987 35,000 2,9001987 35,000 2,9002007 39,080** 7,400***2007 39,080** 7,400***
*Ca 1987; CA 2007*Ca 1987; CA 2007**11.7% increase; ***155% increase **11.7% increase; ***155% increase
Endometrial CancerEndometrial CancerRole of Radiotherapy and LymphadenectomyRole of Radiotherapy and Lymphadenectomy
Paradigm shift necessaryParadigm shift necessaryMinimize overtreatmentMinimize overtreatmentMinimize undertreatmentMinimize undertreatmentMaximize outcomesMaximize outcomes
Endometrial CancerEndometrial CancerRole of Radiotherapy and LymphadenectomyRole of Radiotherapy and Lymphadenectomy
Treatment paradigm shiftTreatment paradigm shift Minimize overtreatmentMinimize overtreatment
– Identify pts not requiring LND and/or RT Identify pts not requiring LND and/or RT Minimize undertreatmentMinimize undertreatment
– Identify pts benefiting from LND and/or Identify pts benefiting from LND and/or RTRT
Maximize outcomesMaximize outcomes
Endometrioid Endometrial CancerEndometrioid Endometrial CancerRole of Radiotherapy and LymphadenectomyRole of Radiotherapy and Lymphadenectomy
Modality-based therapy Modality-based therapy Radiotherapy vs. lymphadenectomyRadiotherapy vs. lymphadenectomyUterine histologyUterine histology
Disease-based therapyDisease-based therapyBased on patterns of failureBased on patterns of failure
Predicted by pathologic determinantsPredicted by pathologic determinantsSelective Lymphadenectomy Selective Lymphadenectomy Selective Radiotherapy Selective Radiotherapy Selective ChemotherapySelective Chemotherapy
Endometrial CancerEndometrial CancerSelective LymphadenectomySelective Lymphadenectomy
(not sampling)(not sampling)
Lymph Node Dissection (LND) Lymph Node Dissection (LND) Low risk: Not indicatedLow risk: Not indicatedAll others: Systematic All others: Systematic
Endometrial CancerEndometrial CancerSelective LymphadenectomySelective Lymphadenectomy
Lymphadenectomy not indicated*Lymphadenectomy not indicated*Low risk:Low risk:
EndometrioidEndometrioidG 1&2G 1&2MI MI << 50% 50%PTD PTD << 2 cm 2 cm
*Mariani et al. Am J Ob Gyn 2000
Endometrioid Endometrial CancerEndometrioid Endometrial Cancer Grade 1 & 2 and MI Grade 1 & 2 and MI << 50% 50%
Failures according to PTD*Failures according to PTD* Sites (DOD)Sites (DOD)
PTD Pt Failures Loc +PTD Pt Failures Loc +(cm) (no.) no. % Loc Dist Dist(cm) (no.) no. % Loc Dist Dist << 2 123 3 2 3 (0) -- -- 2 123 3 2 3 (0) -- -- > 2 169 14 8 3 (1) 6 (6) 5 (4)> 2 169 14 8 3 (1) 6 (6) 5 (4)
*Primary Tumor Diameter*Primary Tumor Diameter
Endometrioid Endometrial CancerEndometrioid Endometrial CancerLow risk:Low risk: G1/2, G1/2, << 2 cm, 2 cm, << 50% MI 50% MI
Pt % 5 yrPt % 5 yrTreatment^ (no.) SurvivalTreatment^ (no.) SurvivalHysterectomy only 59 100Hysterectomy only 59 100Hyst + LND* +/or RT** 64 100Hyst + LND* +/or RT** 64 100Total 123Total 123 ^3/113 recurred (vagina) without RT; all salvaged^3/113 recurred (vagina) without RT; all salvaged *All nodes negative;*All nodes negative; **10 RT; 7 for PPC**10 RT; 7 for PPC
Mariani et al. Am J Ob Gyn 2000
Endometrioid Endometrial CancerEndometrioid Endometrial CancerLow Risk: G 1/2, MI Low Risk: G 1/2, MI << 50%, 50%, PTD PTD << 2 cm 2 cm
Lymphadenectomy not indicatedLymphadenectomy not indicated20% Over all population*20% Over all population*29%29% Endometrioid patients* Endometrioid patients*
*Mariani et al. Am J Ob Gyn 2000
Endometrioid Endometrial CancerEndometrioid Endometrial CancerSelective LymphadenectomySelective Lymphadenectomy
Lymphadenectomy not indicated (29%)Lymphadenectomy not indicated (29%)Low risk:Low risk: G 1/2, MI G 1/2, MI << 50%, PTD 50%, PTD << 2 cm 2 cm
Systematic Lymphadenectomy (71%)Systematic Lymphadenectomy (71%)All others (not low risk)All others (not low risk)
Endometrioid Endometrial CancerEndometrioid Endometrial CancerSelective LymphadenectomySelective Lymphadenectomy
Lymphadenectomy not indicatedLymphadenectomy not indicatedLow risk:Low risk: G 1/2, MI G 1/2, MI << 50%, PTD 50%, PTD << 2 cm 2 cm
Systematic LymphadenectomySystematic LymphadenectomyAll others (not low risk)All others (not low risk)17%17% positive nodes positive nodes
Endometrial Cancer FailuresEndometrial Cancer FailuresPelvic Lymphatic FailuresPelvic Lymphatic Failures
Lymphatic failures according to risk factorsLymphatic failures according to risk factorsLymphatic Failure rate PLymphatic Failure rate P Site % at 5 years ValueSite % at 5 years ValuePelvic SidewallPelvic Sidewall Low riskLow risk <1 <0.001<1 <0.001 High risk* 26High risk* 26
Low risk = absence of high risk factorsLow risk = absence of high risk factorsHigh risk = High risk = *CSI and/or LN mets*CSI and/or LN mets
Endometrial Cancer FailuresEndometrial Cancer FailuresLymphatic FailuresLymphatic Failures
Lymphatic failures according to risk factorsLymphatic failures according to risk factorsLymphatic Failure rate PLymphatic Failure rate P Site(s) % at 5 years ValueSite(s) % at 5 years ValuePelvic SidewallPelvic Sidewall Low risk <1 <0.001Low risk <1 <0.001 High risk* 26High risk* 26Para-aortic areaPara-aortic area Low risk 1 <0.001Low risk 1 <0.001 High risk** 33High risk** 33
Low risk = absence of high risk factorsLow risk = absence of high risk factorsHigh risk = *CSI and/or LN mets; High risk = *CSI and/or LN mets; **LN mets only**LN mets only
Endometrial Cancer FailuresEndometrial Cancer FailuresParaaortic Lymphatic InvolvementParaaortic Lymphatic Involvement
33%33% para-aortic failures with para-aortic failures with pelvic and/or para- pelvic and/or para-
aortic LN aortic LN mets mets 47%47% para-aortic LN mets or para-aortic LN mets or
para-aortic failures para-aortic failures with with pelvic LN mets* pelvic LN mets*
*Mariani et al 2002 (Mayo series)
Endometrioid Endometrial CancerEndometrioid Endometrial CancerRole of Radiotherapy and LymphadenectomyRole of Radiotherapy and Lymphadenectomy
Disease-based therapyDisease-based therapyBased on patterns of failureBased on patterns of failure
Predicted by pathologic determinantsPredicted by pathologic determinantsSelective Lymphadenectomy Selective Lymphadenectomy Selective RadiotherapySelective Radiotherapy
12% total population at risk12% total population at riskEBRT indicated in 12%EBRT indicated in 12%47% paraaortic risk47% paraaortic riskRT field to include PA areaRT field to include PA area
Endometrial Cancer Endometrial Cancer Therapy after LymphadenctomyTherapy after Lymphadenctomy Conclusions:Conclusions: Absent CSI or pelvic LN mets:Absent CSI or pelvic LN mets:
adjuvant Rx to pelvic or para-aorticadjuvant Rx to pelvic or para-aorticnode-bearing areas does not appear node-bearing areas does not appear
indicated indicated Positive (or at-risk* for) pelvic LN mets:Positive (or at-risk* for) pelvic LN mets:
adjuvant Rx to both the pelvic and adjuvant Rx to both the pelvic and para-aortic nodal areaspara-aortic nodal areas indicatedindicated *Patients at-risk but incompletely staged *Patients at-risk but incompletely staged
Endometrioid Endometrial CancerEndometrioid Endometrial CancerRole of Radiotherapy and LymphadenectomyRole of Radiotherapy and Lymphadenectomy
Treatment paradigm shiftTreatment paradigm shift Minimize overtreatmentMinimize overtreatment
– Identify pts not requiring LND and/or RT Identify pts not requiring LND and/or RT Minimize undertreatmentMinimize undertreatment
– Identify pts benefiting from LND and/or Identify pts benefiting from LND and/or RTRT
Maximize outcomesMaximize outcomes
Endometrioid Endometrial CancerEndometrioid Endometrial CancerRole of Radiotherapy and LymphadenectomyRole of Radiotherapy and Lymphadenectomy
Modality-based therapy Modality-based therapy Radiotherapy vs. lymphadenectomyRadiotherapy vs. lymphadenectomyUterine histologyUterine histology
Disease-based therapyDisease-based therapyBased on patterns of failureBased on patterns of failure
Predicted by pathologic determinantsPredicted by pathologic determinantsSelective Lymphadenectomy Selective Lymphadenectomy Selective Radiotherapy Selective Radiotherapy Selective ChemotherapySelective Chemotherapy