Staging. Carcinoma confined to the corpus. Carcinoma confined to the endometrium. Less than ½ myometrial invasion. Greater than ½ myometrial invasion

Size: px

Start display at page:

Download "Staging. Carcinoma confined to the corpus. Carcinoma confined to the endometrium. Less than ½ myometrial invasion. Greater than ½ myometrial invasion"

Frederica Clarke
5 years ago
Views:

1 5 th of June 2009

2 Background Most common gynaecological carcinoma in developed countries Most cases are post-menopausal Increasing incidence in certain age groups Increasing death rates in the USA 5-year survival rates are considered to be good at around 75% At diagnosis 75% have Stage 1 disease

3 Staging Stage Features II Carcinoma confined to the corpus Ia Ib Ic Carcinoma confined to the endometrium Less than ½ myometrial invasion Greater than ½ myometrial invasion II Involving cervix Iia Iib Glandular involvement only Cervical stromal involvement III Disease limited to the pelvis IIIa IIIb Disease involving the serosa or +ve peritoneal cytolog Pelvic or para-aortic node metastases IV Disease spread outside pelvis Iva Ivb Bladder or rectal mucosal involvement Extrapelvic metastases including inguinal lymph nodes

4 Staging Initial staging in 1970 was clinical Intra-operative assessment Pre-operative grade is upgraded Surgical staging was adopted in 1988 with complete surgicopathologic assessment New FIGO staging

5 Prognostic factors Tumour type Tumour grade Myometrial invasion LVI +ve Involvement of the cervix Suspected extra-uterine disease 45-65% have evidence of relapse in the pelvis Most patients die from metastatic disease

6 Importance of nodal disease About 10% of women with apparent Stage 1 disease will have pelvic lymph node mets Low risk (St1a &b, Gr1) 3% Moderate risk (St1b, Gr2&3) 10% High risk (St1c, Gr1-3) -20% Recent study Chi et al., (2008) found Gr 1 0%, Gr %, Gr % In patients with pelvic lymphadenopathy 50% will have aortic disease

7 Importance of nodal disease May be the pattern is important Between 10-30% may be only in the high periaortic area ASTEC trial only examined the pelvic lymph nodes and not comprehensively ll the nodal groups ASTEC radiotherapy would not radiate all the lymph node groups

8 Lymphadenectomy in epithelial cancers Many cancers Prognostic tool?therapeutic Retrospective data, non-randomised and case series proposed therapeutic benefit in Endometrial carcinoma Complex interactions/confounding variables Case selection

9 ASTEC Could lymphadenectomy improve survival 85 centres in four countries 1408 women, randomised to standard surgery (n=704) or standard surgery & lymphadenectomy (n=704) 37 month median follow-up 191 women died (88 SS, 103 LN) 251 died or had recurrence (107SS, 144 LN)

10 ASTEC No difference in overall survival or in recurrence-free survival between the two groups If anything slight favour to SS with survival and recurrence SS had less complications/side-effects Increased lymph-oedema in the LN group Supplemented by Benedetti et al., (2008)

11 ASTEC In ASTEC 35 patients in the SS group had lymph node dissection Lymphadenectomy extent Role of Radiotherapy should be independent There may be a further interaction between lymphadenectomy and radiotherapy

12 New FIGO Staging (2009) Stage 1 Stage 1a Stage 1b Stage 2 Stage 3 Stage 3a Stage 3b Stage 3c1 Stage 3c2 Stage 4 Tumour confined to corpus <50% myometrial invasion >50% myometrial invasion Tumour invades Cx stroma Local/regional tumour spread Invades serosa/+- adnexa Vaginal or parametrial spread Positive pelvic nodes Positive para-aortic nodes Invades bladder/bowel/distant

13 ?Role of lymphadenectomy in our practice Surgical Staging Determinant regarding adjuvant treatment Prognosticator Survival data and audit Selective (as in patient determined) lymphadenectomy In future the role of biological genetic indicators

14 Recommendations Stage 1a & Stage 1b No need Stage 1c questionable dependant on further treatment modality Surgical staging for Serous papillary/clear cell/high grade/p53 positive etc Stage II RHND/BSO if suitable If not for Surgically staging all need Pre-op determination of LN status (Staging)

15 Summary Endometrial carcinoma and the role of lymphadenectomy is there a case for? Selective lymphadenectomy

Adjuvant Therapies in Endometrial Cancer. Emma Hudson

Adjuvant Therapies in Endometrial Cancer Emma Hudson Endometrial Cancer Most common gynaecological cancer Incidence increasing in Western world 1-2% cancer deaths 75% patients postmenopausal 97% epithelial