Treatment

Question 0

Do you treat advanced stage with chemo?

Answer 0

GOG 122 show that AP versus whole abdominal Radiation had 11% better overall survival.

Question 1

Is there a role for debulking endometrial cancer?

Answer 1

Bristow and chi found improved overall survival with debulking in stage IV B and Endometrial cancer. If optimally cytoreduced to less than 1 cm the improved median survival was 34 months versus 11 months. If only microscopic residual then survival was 41 months versus 15 months

Question 2

Do you treat advanced stage with chemotherapy? And what is the data?

Answer 2

GOG 177 show that Tap had a three month overall survival improvement over AP. an abstract form of GOG 209, carbotaxol was not inferior to tap and had less side effects.

Question 3

How can Radiation improve patients with high intermediate risk?

Answer 3

Giving pelvic Radiation showed a significant decrease in local recurrence. Patient had a 6% chance of recurrence with Radiation versus 25% in observation group

Question 4

When do you offer Radiation?

Answer 4

GOG99(Keys)defineintermriskasLN”­”stageIB,ICorII(occult)..but1/3depthuse,mightbeunderpoweredtoshowOS
diffb/csomanylowriskptsanddeathduetoothercauses.Only12%recurrencerateinthisgroup.
­­SoDefinedaHighIntermRiskgroup:
1)grade2/3
2)LVSI,or
3)outer1/3invasion.
Anyageall3riskfactors,orAge50with2ofthe3riskfactors,orage70withany1ofthe3riskfactors.
SignifdecrlocalrecurwithpelvicXRTinhighintermriskgroup.

Question 6

How do you treat carcinosarcoma?

Answer 6

IFos/paclitaxel showed increased survival and was less toxic than cisplatin/ifosfamide in a trial of advanced carcinosarcoma. Overall survival was 13.5 months for ifosfamide/paclitaxel versus 8.4 months with ifosfamide alone. carbotaxol in phase II was shown to have 54% RR and is in trial

Question 7

What chemotherapies do you give for recurrent endometrial cancer?

Answer 7

Carbotaxol, Tap, single agent: cisplatin, Adriamycin, Doxil, Taxol, topotecan, avast in. Carbotaxol shown to be non-inferior to tap in an abstract form, GOG 209

Question 8

How do you treat medically inoperable Sarcoma patients?

Answer 8

Offer radiation, possible brachytherapy, and/or chemotherapy, or hormones

Question 9

How do you treat stage 1 endometrial stromal sarcoma?

Answer 9

Hysterectomy BSO, followed by hormone therapy

Question 10

How do you treat stage two through four endometrial stromal sarcoma?

Answer 10

Hormones, consider radiation.

Question 11

What chemotherapies do you offer for leiomyosarcoma?

Answer 11

Gemzar/taxotere, second line: Adria/iFos, Adria/dacarbazine, Gemzar/dacarbazine, Gemzar/vinorelbine. Do not use Adriamycin with docetaxel

Question 12

Do you think that robotic surgery is as safe as open laparotomy?

Answer 12

I consider the data from LAP2 where clinical stage 1 to 2a disease is randomized to laparoscopy versus laparotomy. The overall survival rate was 85% in both arms. Recurrence rate was 11 for laparoscopy and 10 for laparotomy. They were fewer postop adverse events with laparoscopy. In a systematic review comparing robotic laparoscopic laparotomy, EBL was lower for robotic then laparoscopy or laparotomy. Los was shorter for robotic and laparoscopy, conversion to laparotomy was 5% versus 10% and laparoscopy. Rates of vascular bowel bladder cuff dehiscence and DVT or similar(Gaia). Robotic surgery in obese patients offers advantages as well(Gehrig )

Question 18

For recurrent endometrial cancer what hormones would you offer?

Answer 18

Progesterone, tamoxifen, Megace and tamoxifen alternating, aromatase inhibitors.

Question 19

How do you treat stage IB, G3?

Answer 19

Because this subgroup has a high likelihood for distant recurrences, I favor adding systemic chemotherapy to adjuvant RT to reduce this risk. JGOG rct EBRT vs CAP: grade 3 had improved OS 90 vs 75%. Await GOG249 manuscript but abstract showed no difference

Question 20

How do you treat stage III/IV disease?

Answer 20

Previously, GOG 122 randomized WART to AP which showed improved OS/PFS but more toxicity. This established the role of chemo for advanced dz. Then AP vs TAP showed that TAP was better, now GOG 209 showed that CT was not inferior to TAP and had fewer side effects

Question 21

What single Agents to use in recurrent disease?

Answer 21

Paclitaxel is the most active, cisplatin, carboplatin, doxorubicin, Doxil, Topotecan. The response rate for Doxil is 9.5, the response rate for docetaxel is only 7.7 and some argue not to use it

Question 22

Would you offer hormone replacement therapy after hysterectomy BSO?

Answer 22

Its controversial, there has never been proven that there’s a higher relapse rate.

Question 23

How do you treat endometrial stromal sarcoma stage I? All others? What should you not give?

Answer 23

For stage one, you can consider observation or hormonal therapy. For II-IV, hormonal therapy is recommended. Megace, medroxyprogesterone, or aromatase inhibitors or GnRH analogues. Tamoxifen is contraindicated

Question 24

What chemotherapies do you recommend for leiomyosarcoma?

Answer 24

Gemzar/texotere. Adriamycin/ifosfamide, Adriamycin/dacarbazine, gemcitabine/dacarbazine, gemcitabine/Vinorelbine

Question 25

Do you treat stage 1 leiomyosarcoma’s with chemotherapy?

Answer 25

It’s controversial and after complete resection you can give chemotherapy or observe. There’s currently a study assessing the role of postop chemotherapy versus observation in stage one and two LMS GOG 277

Question 26

What is the recurrence rate LMS? And what so you do?

Answer 26

50-70%. Surgery chemo or radiation are all possibilities

Question 27

what is the data for taxol in advanced EC

Answer 27

Never been shown as direct single agen therapy in RCT but in combination. GOG 177: TAP vs AP alone: TAP: improved RR (57% vs 34%), PFS (8.3% OS(15 vs 12 mo) BUT w greater toxicity. GOG 209: T/C not inferior to TAP with less toxicity.