endometrial cancer surgical staging (role of lymphadenectomy) karl podratz md phd facs

Endometrial CancerEndometrial Cancer

Surgical StagingSurgical Staging

(Role(Role of Lymphadenectomy) of Lymphadenectomy)

Karl Podratz MD PhD FACSKarl Podratz MD PhD FACS



Basis for Definitive StagingBasis for Definitive StagingExtent of DiseaseExtent of Disease

Adjuvant Rx determinantAdjuvant Rx determinant

PrognosticationPrognostication

Comparative evaluationComparative evaluation

Potentially therapeuticPotentially therapeutic



Definitive StagingDefinitive Staging

TAH/BSO/Peritoneal cytologyTAH/BSO/Peritoneal cytology

Pelvic/Paraaortic LND*Pelvic/Paraaortic LND*

Biopsy/OmentectomyBiopsy/Omentectomy

CytoreductionCytoreduction (Rx) (Rx)

*LND = Lymph node dissection



Definitive StagingDefinitive Staging

TAH/BSO/Peritoneal cytologyTAH/BSO/Peritoneal cytology

Pelvic/Paraaortic LND*Pelvic/Paraaortic LND*Biopsy/OmentectomyBiopsy/Omentectomy

CytoreductionCytoreduction (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 2,900

2007 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 overtreatment

Minimize undertreatmentMinimize undertreatment

Maximize 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


Endometrioid Endometrial CancerEndometrioid Endometrial CancerRole of Radiotherapy and LymphadenectomyRole of Radiotherapy and Lymphadenectomy

Modality-based therapy Modality-based therapy Radiotherapy vs. lymphadenectomyRadiotherapy vs. lymphadenectomy

Uterine histologyUterine histology

Disease-based therapyDisease-based therapyBased on patterns of failureBased on patterns of failure

Predicted by pathologic determinantsPredicted by pathologic determinants

Selective Lymphadenectomy Selective Lymphadenectomy

Selective Radiotherapy Selective Radiotherapy

Selective ChemotherapySelective Chemotherapy


Selective LymphadenectomySelective Lymphadenectomy(not sampling)(not sampling)

Lymph Node Dissection (LND) Lymph Node Dissection (LND)

Low risk: Not indicatedLow risk: Not indicated

All others: Systematic All others: Systematic


Selective LymphadenectomySelective Lymphadenectomy

Lymphadenectomy not indicated*Lymphadenectomy not indicated*

Low risk:Low risk:EndometrioidEndometrioid

G 1&2G 1&2

MI 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


Low risk:Low risk: G1/2, G1/2, << 2 cm, 2 cm, << 50% MI 50% MI

Pt % 5 yrPt % 5 yr

Treatment^ (no.) SurvivalTreatment^ (no.) Survival

Hysterectomy only 59 100Hysterectomy only 59 100

Hyst + LND* +/or RT** 64 100Hyst + LND* +/or RT** 64 100

Total 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 PPCMariani et al. Am J Ob Gyn 2000


Low Risk: G 1/2, MI Low Risk: G 1/2, MI << 50%, 50%, PTD PTD << 2 cm 2 cm

Lymphadenectomy not indicatedLymphadenectomy not indicated

20% Over all population*20% Over all population*

29%29% Endometrioid patients* Endometrioid patients*

*Mariani et al. Am J Ob Gyn 2000



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)



Lymphadenectomy not indicatedLymphadenectomy not indicated

Low risk:Low risk: G 1/2, MI G 1/2, MI << 50%, PTD 50%, PTD << 2 cm 2 cm

Systematic LymphadenectomySystematic Lymphadenectomy

All others (not low risk)All others (not low risk)

17%17% positive nodes positive nodes

Endometrial Cancer FailuresEndometrial Cancer Failures

Pelvic 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 Value

Pelvic 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 factors

High 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 Value

Pelvic SidewallPelvic Sidewall

Low risk <1 <0.001Low risk <1 <0.001

High risk* 26High risk* 26

Para-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 factors

High risk = *CSI and/or LN mets; High risk = *CSI and/or LN mets; **LN mets only**LN mets only

Endometrial Cancer FailuresEndometrial Cancer Failures

Paraaortic 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)





Selective RadiotherapySelective Radiotherapy

12% total population at risk12% total population at risk

EBRT indicated in 12%EBRT indicated in 12%

47% paraaortic risk47% paraaortic risk

RT 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


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



Modality-based therapy Modality-based therapy Radiotherapy vs. lymphadenectomyRadiotherapy vs. lymphadenectomy

Uterine histologyUterine histology




Selective Radiotherapy Selective Radiotherapy

Selective ChemotherapySelective Chemotherapy

endometrial cancer surgical staging (role of lymphadenectomy) karl podratz md phd facs

Documents

low risk slide

lymphadenectomy paradigm

systematic lymphadenectomy

increase slide

systematic slide

therapeutic slide

lymph node dissection

lnd andor rt