Endometrial CancerEndometrial Cancer
Surgical StagingSurgical Staging
(Role(Role of Lymphadenectomy) of Lymphadenectomy)
Karl Podratz MD PhD FACSKarl Podratz MD PhD FACS
Endometrial CancerEndometrial Cancer
Surgical StagingSurgical Staging
Basis for Definitive StagingBasis for Definitive StagingExtent of DiseaseExtent of Disease
Adjuvant Rx determinantAdjuvant Rx determinant
PrognosticationPrognostication
Comparative evaluationComparative evaluation
Potentially therapeuticPotentially therapeutic
Endometrial CancerEndometrial Cancer
Surgical StagingSurgical Staging
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 Cancer
Surgical StagingSurgical Staging
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
Maximize outcomesMaximize outcomes
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
Endometrial CancerEndometrial Cancer
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
Endometrial CancerEndometrial Cancer
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
Endometrioid Endometrial CancerEndometrioid Endometrial Cancer
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
Endometrioid Endometrial CancerEndometrioid Endometrial Cancer
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
Endometrioid Endometrial CancerEndometrioid Endometrial Cancer
Selective LymphadenectomySelective Lymphadenectomy
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)
Endometrioid Endometrial CancerEndometrioid Endometrial Cancer
Selective LymphadenectomySelective Lymphadenectomy
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)
Endometrioid Endometrial CancerEndometrioid Endometrial CancerRole of Radiotherapy and LymphadenectomyRole of Radiotherapy and Lymphadenectomy
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 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
Endometrioid Endometrial CancerEndometrioid Endometrial 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
Maximize outcomesMaximize outcomes
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
Top Related