Uterus Flashcards
Low risk disease
Grade 1 or 2, limited to endometrium OR <50% invasion, no LVSI, endometrioid type
Risk of nodal involvement in low-risk disease
Less than 5%
Risk of local recurrence in low-risk disease
Less than 5% risk of vaginal vault recurrence
Postoperative treatment of low-risk disease
None, VBT/EBRT has no benefit an increased risk of death.
Candidates for fertility-sparing surgery
Grade 1 endometrioid, stage 1A, desires childbearing/reproductive age, no contraindications to hormonal therapy. *Understand they are not fully staged (clinical vs surgical).
Lynch syndrome NOT candidate.
Prognosis for low-risk disease
Excellent, >90% survival
Intermediate risk disease
Not high-risk histology AND:
G1/2, <50% invasion, +LVSI
G1/2, >50% invasion OR cervical stromal invasion (Stage IB or II)
G3, <50% invasion (IA)
High intermediate risk disease (GOG 99)
1) Grade 2/3 tumor
2) LVSI
3) Outer 1/3 myometrial invasion
Age 70+ with 1 RF
Age 50+ with 2 RF
Age <50 with 3 RF
High intermediate risk disease (PORTEC)
Age >60, >50% invasion, G3
Must have 2 out of 3
Adjuvant therapy for low intermediate risk disease
Observation vs RT.
Recommend observation, little benefit (not SS) to RT.
Adjuvant therapy for high intermediate risk disease
Adjuvant RT recommended
GOG 99: in HR group, EBRT reduced risk of recurrence, no OS benefit
PORTEC2: VBT NS different from EBRT for local/distant recurrence or DFS but VBT lower adverse effects
PORTEC1
Adjuvant pelvic RT improves locoregional control without impacting OS in early EC
Pelvic EBRT (4600 cGy), no VBT
Inclusion criteria: S1 G1 >50% MI, G2 any invasion, G3 <50% MI
5yr locoregional recurrence 4% (RT) vs 14% (ctrl) (SS)
5yr OS: 81% vs 85% (NS)
Adverse effects: 25% vs 6% (mostly GI)
GOG 249
[VBT + 3 cycles chemo] is NOT superior to EBRT, and is associated with more toxicity
(HR-ID endometrioid, serous or clear cell Stage I-II)
Prognosis for intermediate risk disease
Low intermediate - excellent, 5-6% recurrence without adjuvant therapy
High intermediate - fair to good, 5-30% recurrence (depends on adjuvant or no), but survival >80%
What is the most common GYN malignancy in the US?
uterine cancer
Type 1 endometrial cancer
Common
Low grade endometrioid histology (G1/2)
Arises from precursor lesion (CAH or EIN)
Associated with elevated/unopposed estrogen (obesity, PCOS), HLD, T2DM
Indolent course
Younger age, higher BMI
Type 2 endometrial cancer
Rare High risk diverse histology (clear cell, serous, ?G3 endometrioid, carcinosarcoma) Arises in atrophic endometrium or polyp Aggressive disease Older patients, low BMI Estrogen independent p53 mutation
What is the association found between grade and depth of invasion per GOG 33?
Lower grade –> less invasive (superficial)
Higher grade –> more invasive (deep)
GOG 33 what is the relation between positive pelvic nodes to aortic nodes?
Pelvic 89% negative –> aortic 2% positive
Pelvic 6% positive –> aortic 3% positive
(If positive pelvic nodes, more likely positive aortic)
GOG 33 relationship between pathologic spread and node positivity?
Increasing grade, depth of invasion –> more likely positive nodes (both pelvic and aortic)
Clinical stage 1 endometrial cancer in GOG33 when surgically staged had what rates of extrauterine involvement?
9% pelvic LN 6% aortic LN (2% isolated aortic LN) 5% adnexal 12% peritoneal cytology 6% other extrauterine disease
Significance of GOG33?
Moved from clinical to surgical staging for endometrial cancer.
(Clinically stage 1 does as poorly in OS as surgically stage 3).
Does LND improve survival in endometrial cancer?
Not really… Good for staging, which will determine adjuvant therapy. But debulking does not improve survival. (Benedetti-Panici 2008, ASTEC 2009)
Mayo criteria for NOT doing LND
Endometrioid histology G1/2, =50% invasive, tumor size =2cm
Validated prospectively by Mayo, LAP2, SEER data
Why not do routine full LND?
Lymphedema - significant associated morbidity
FIRES trial
Demonstrated efficacy of sentinel LND for endometrial cancer staging
Identified SLN with ICG, then did full dissection
Inclusion criteria: clinical stage 1, any histology
Exclusion criteria: evidence of extrauterine disease, prior tx, prior hyst or RP surgery, allergy to ICG
97% sensitivity, 99.6% NPV
Is laparoscopic surgery ok for endometrial cancer?
YES - LAP2 demonstrated noninferiority to open. LACE also showed equivalence.
What is the optimal adjuvant therapy for early stage endometrial cancer?
??? No RCT has shown overall survival benefit to ANY adjuvant treatment. RT reduces risk of local recurrence, and chemo used in high risk groups.
Mortality of Type 1 vs Type 2 endometrial cancer
72% patients with T1, 28% with T2
26% death with T2, 74% T2
What is the salvage rate for vaginal relapse?
79% (from PORTEC1, 2 year survival)
GOG 99
Adjuvant pelvic EBRT reduces risk of recurrence in HIR endometrial cancer, without apparent impact on overall survival
EBRT 5040cGy, no VBT
Inclusion: HIR EC
Exclusion: serous or clear cell, LND, ls surgery
2yr recurrence: 3% vs 12% (SS), local 1.6% vs 8.9%
RT associated with increased toxicity
PORTEC 2
VBT should be the adjuvant treatment of choice in high-intermediate patients with endometrioid histology
EBRT 4600cGy vs VBT (2100/2800/3000cGy)
Inclusion: endometrial adenocarcinoma >60 yo AND stage IB grade 3, stage IC grade 1 or 2any age AND stage IIA
Exclusion: serous or clear cell, prior tx, IBD
Results: no SS differences between EBRT/VBT for recurrence or survival
