Uterus

Question 1

Low risk disease

Answer 1

Grade 1 or 2, limited to endometrium OR <50% invasion, no LVSI, endometrioid type

Question 2

Risk of nodal involvement in low-risk disease

Answer 2

Less than 5%

Question 3

Risk of local recurrence in low-risk disease

Answer 3

Less than 5% risk of vaginal vault recurrence

Question 4

Postoperative treatment of low-risk disease

Answer 4

None, VBT/EBRT has no benefit an increased risk of death.

Question 5

Candidates for fertility-sparing surgery

Answer 5

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.

Question 6

Prognosis for low-risk disease

Answer 6

Excellent, >90% survival

Question 7

Intermediate risk disease

Answer 7

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)

Question 8

High intermediate risk disease (GOG 99)

Answer 8

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

Question 9

High intermediate risk disease (PORTEC)

Answer 9

Age >60, >50% invasion, G3

Must have 2 out of 3

Question 10

Adjuvant therapy for low intermediate risk disease

Answer 10

Observation vs RT.

Recommend observation, little benefit (not SS) to RT.

Question 11

Adjuvant therapy for high intermediate risk disease

Answer 11

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

Question 12

PORTEC1

Answer 12

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)

Question 13

GOG 249

Answer 13

[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)

Question 14

Prognosis for intermediate risk disease

Answer 14

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%

Question 15

What is the most common GYN malignancy in the US?

Answer 15

uterine cancer

Question 16

Type 1 endometrial cancer

Answer 16

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

Question 17

Type 2 endometrial cancer

Answer 17

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

Question 18

What is the association found between grade and depth of invasion per GOG 33?

Answer 18

Lower grade –> less invasive (superficial)

Higher grade –> more invasive (deep)

Question 19

GOG 33 what is the relation between positive pelvic nodes to aortic nodes?

Answer 19

Pelvic 89% negative –> aortic 2% positive
Pelvic 6% positive –> aortic 3% positive
(If positive pelvic nodes, more likely positive aortic)

Question 20

GOG 33 relationship between pathologic spread and node positivity?

Answer 20

Increasing grade, depth of invasion –> more likely positive nodes (both pelvic and aortic)

Question 21

Clinical stage 1 endometrial cancer in GOG33 when surgically staged had what rates of extrauterine involvement?

Answer 21

9% pelvic LN
6% aortic LN (2% isolated aortic LN)
5% adnexal 
12% peritoneal cytology
6% other extrauterine disease

Question 22

Significance of GOG33?

Answer 22

Moved from clinical to surgical staging for endometrial cancer.
(Clinically stage 1 does as poorly in OS as surgically stage 3).

Question 23

Does LND improve survival in endometrial cancer?

Answer 23

Not really… Good for staging, which will determine adjuvant therapy. But debulking does not improve survival. (Benedetti-Panici 2008, ASTEC 2009)

Question 24

Mayo criteria for NOT doing LND

Answer 24

Endometrioid histology G1/2, =50% invasive, tumor size =2cm

Validated prospectively by Mayo, LAP2, SEER data

Question 25

Why not do routine full LND?

Answer 25

Lymphedema - significant associated morbidity

Question 26

FIRES trial

Answer 26

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

Question 27

Is laparoscopic surgery ok for endometrial cancer?

Answer 27

YES - LAP2 demonstrated noninferiority to open. LACE also showed equivalence.

Question 28

What is the optimal adjuvant therapy for early stage endometrial cancer?

Answer 28

??? No RCT has shown overall survival benefit to ANY adjuvant treatment. RT reduces risk of local recurrence, and chemo used in high risk groups.

Question 29

Mortality of Type 1 vs Type 2 endometrial cancer

Answer 29

72% patients with T1, 28% with T2

26% death with T2, 74% T2

Question 30

What is the salvage rate for vaginal relapse?

Answer 30

79% (from PORTEC1, 2 year survival)

Question 31

GOG 99

Answer 31

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

Question 32

PORTEC 2

Answer 32

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