EIN/EMCA

Question 1

what defines high grade EMCA

Answer 1

• grade 3 endometroid (Type I)
• papillary
• clear cell
• carcinosarcoma

Question 2

what is traditional surgical staging for EMCA

Answer 2

Hyst, BSO, pelvic and PA LN, and pelvic washings
Lower stages don’t always get this - risk of missed advanced disease. benefit is it reduces morbidity of procedure for majority of patients in lower stage disease who don’t need

Need oncologist to decide if no BSO, no nodes

Question 3

do you get pre-op imaging for EMCA?

Answer 3

• not standard
  yes, if:
• poor surgical candidate
• high grade EMCA

Question 4

what criteria must be met to consider for medical management?

Answer 4

• well differentiated, Gr1 Stage I disease without myometrial involvement (preferrably determined by HSC D&C and MRI)
• desires future fertility
• no contraindications to medical management
• pt accepts limited data

Question 5

adjuvant therapy for stage I and II disease?

Answer 5

• for stage I and II: chemotherapy decreases risk of local recurrence but not overall survival
• for high intermediate risk disease (high grade, LVSI+, outer 1/3 myometrial invasion), RT improves survival.
• vag brachy > whole pelvis. bc equal efficacy but fewer side effects than whole pelvic.

Question 6

what treatments shown to improve survival in advanced stage and recurrent disease?

Answer 6

• surgical cytoreduction (less/equal to 2 or 1 cm)
• chemoradiation with:
• whole pelvic radiation
• carb/tax (equal efficacy to other regimens but fewer side effects)

Question 7

what is recommended surveillance after EMCA treatment?

Answer 7

• sx (bleeding, pain, constitutional), speculum, rectovaginal exam
• q3-6 mo x 2 years, then q6mo x 3 years

Question 8

what is the optimal surgical route for EMCA management?

Answer 8

• minimally invasive, LSC or robotic

- if poor surgical candidate and early stage, can consider vag hyst

Question 9

final path for on hyst incidentally shows EMCA. next steps?

Answer 9

- risk assessment of extrauterine disease, and disease recurrence: 
A) age
B) grade, histology, size of tumor
C) myometrial invasion
D) LVSI

• can consider surgical staging if high risk and pt good surgical candidate to avoid unnecessary adjunctive treatment

Question 10

genetic syndromes to consider

Answer 10

• Lynch- mismatch repair proteins (test with IHC or MSI). 5% of all EMCA. test on every patient with specimen. If MLH 1 negative, then need methylation test.
• Cowden’s sydnrome. AD. PTEN mutation.
• BRCA 1 and BRCA 2 on tamoxifen - consider hyst BSO

Question 11

endometrial cancer staging

Answer 11

1A: no or < 50% myometrial involvement
1B: 50% or greater myometrial invasion
II: endocervical stromal NOT glandular involvement (glandular is stage I)
IIIA: uterine serosa or adnexa
IIIB: parametrial or vaginal
IIIC: lymph nodes
IIIC1: pelvic LN
IIIC2: PA LN
IVA: bladder or bowel
IVB: distant mets