Michael G. Kelly, MD Gynecologic Oncologist University of Colorado Cancer Center

Michael G. Kelly, MD Gynecologic Oncologist University of Colorado Cancer Center

50 yo healthy postmenopausal female with BMI = 35 with screening PAP smear = AGUS. What is the next step? (1) Colposcopy (2) Colposcopy and endometrial biopsy (3) Hysterectomy (4) Surveillance/repeat PAP in 4-6 months

Postmenopausal bleeding, spotting, etc Abnormal uterine bleeding in premenopausal women (> 35yo) AGUS PAP smear (>35 yo) Consider addition of hystersocopy/d&c if office biopsy is negative and there are risk factors for endometrial pathology

Colposcopic directed biopsies, ECC and EMB are performed: Cervical biopsies = Negative for dysplasia ECC = Negative for dysplasia EMC = Endometrioid grade 1 adenocarcinoma

Type 1 Type 2

What is the next step in this patient s management? (1) Surgery (2) Neoadjuvant chemotherapy (3) Radiation therapy (4) Hormones

(1) Surgery Most efficacious (ie associated with highest cure rate Most risk Goal for all/most patients (2) Neoadjuvant chemotherapy Reserved for aggressive(type 2) cancers with metastatic disease and in patients who have significant surgical risk Little data Usually palliative

(3) Radiation Cures appx 70% of patients with disease limited to the uterus (stage 1); cure rate for surgery with stage 1 disease approaches 100% Can have significant short term and long term sequalae (appx 15%) Reserved for patients who have significant surgical risk of perioperative death/major morbidity (4) Hormones Only effective in tumors that are ER/PR+ (ie grade 1 endometrioid tumors) Rule of thirds Rx = megace (weight gain), progesterone containing IUD Good option as a temporizing measure for oocyte preservation, optimization of medical problems (diabetes) and weight loss maneuvers (ie gastric bypass)

Surgery is recommended. A preoperative CA-125 level and CT scan of the C/A/P are normal. What operation should be performed? (1) Cytology, removal of uterus, cervix (2) Cytology, removal of uterus, cervix and adnexa (3) Cytology, removal of uterus, cervix, adnexa and pelvic, para-aortic lymph nodes (4) Cytology, removal of uterus, cervix, adnexa and removal of lymph nodes only if frozen section reveals significant risk factors for nodal involvement

None, perhaps Lymphedema Rates vary in the literature It s a spectrum from slight swelling to quite significant swelling 5-10% Increased surgical time with those inherent risks (ie PE, cardiac event in patients with risk factors etc) Vessel injury Not really an issue for a trained gynecologic oncologist

(1) Preoperative biospy, intraoperative frozen section and final pathology discrepancy (2) Risk of not identifying occult nodal disease (although a lymph node dissection does not eliminate this risk altogether) (3) (1) possibly leads to more patients receiving postoperative pelvic RT versus vaginal RT (the later is less morbid) (4) Training issues

What if the preoperative biopsy = serous adenocarcinoma? What operation should be performed then? (1) Cytology, removal of uterus, cervix (2) Cytology, removal of uterus, cervix and adnexa (3) Cytology, removal of uterus, cervix, adnexa and pelvic, para-aortic lymph nodes (4) Cytology, removal of uterus, cervix, adnexa and removal of lymph nodes only if frozen section reveals significant risk factors for nodal involvement

(1) Aggressive histology (grade 3, possibly grade 2 endometrioid adenocarcinoma, nonendometrioid adenocarcinoma (serous, clear cell) (2) Deep myometrial invasion (> 50%) (3) Cervical involvement (4) Adnexal involvement??? (5) Large (> 2 cm) tumor???

Stage all patients with a non grade 1 endometrioid adenocarcinoma Patients with a grade 1endometrioid adenocarcinoma Offer and discuss benefits/risks of both strategies Often the response is What do you think is best Try to individual strategy for each patient Frozen section indications for lymph node dissection = non grade 1 histology, grade 1 > 50 myometrial invasion, cervical/adnexal involvement

How should this operation be performed? (1) Laparotomy (2) Laparoscopy (3) Robotically

It s been done for a long time with a proven favorable disease outcome Allows for better genuine exploration Can easily perform debulking procedures Quicker Does not require a specialized team of anesthesiologists, assistants, nurses etc

Improved cosmesis Shorter hospital stay Shorter return to work? Quicker initiation of postoperative therapy (chemotherapy) Similar disease/survival outcome (GOG study)

Possibly none Easier/more feasible in patients with an elevated BMI Para-aortic LND easier/more feasible in patients with an elevated BMI Surgeon ergo dynamics

How should this operation be performed? (1) Laparotomy (2) Laparoscopy (3) Robotically

A robotic hysterectomy, BSO and LND are performed. The final pathology reveals a grade 1 endometrioid tumor with 75% myometrial invasion, cervical stromal invasion. All LN and cytology are negative.

What is the next step in this patient s treatment? (1) Surveillance (2) Vaginal radiation (3) Pelvic radiation (4) Chemotherapy

How about if no LN was done (grade 1, 75% MI, + cervical stroma)? (1) Surveillance (2) Vaginal radiation (3) Pelvic radiation (4) Chemotherapy

In essence, a thorough LND obviates the need for pelvic radiation (in my opinion) Easier schedule (3-5 treatments versus daily treatment x 6+ weeks) Less morbidity Vaginal: none; watery discharge; vaginal shortening unlikely with regular use of dilator; dyspareunia Pelvic: none; vaginal shortening;dyspareunia; 15% risk of long-term GU, GI sequelae