Newton Wellesley Hospital 20 Standard 4.6 Assessment and Evaluation of Treatment Planning Endometrial Cancer Each year a physician member of the cancer committee conducts a study to ensure that diagnostic evaluations and treatment provided to patients is compliant with evidence based national treatment guidelines and is appropriate for AJCC stage including prognostic indicators. Case Review: Review of Endometrial Cancer cases from 20 at NWH (class of case codes ) to determine that the diagnostic evaluation is adequate and the treatment plan is in accordance with NCCN guidelines. Diagnostic Guidelines Each case assessed for endometrial sampling, appropriate use of radiographic imaging (CXR, CT scan, PET CT, or pelvic MRI), documentation of relevant family history (endometrial, ovarian and colon cancers), consideration of referral for genetic counseling/testing for lynch syndrome/hereditary Non Polyposis Colorectal Cancer (HNPCC), and the involvement of a gynecologic oncologist in the primary management. Diagnostic Assessment: Endometrial sampling: all cases Radiographic studies when indicated: all cases Family history obtained for relevant cancers: o Difficult to obtain this information accurately as the primary data was not always available in the NWH/ records (4/26) o 3/22 cases where full records were available, relevant family history was not mentioned. Referral for genetic counseling/testing: o o 5/26 patients were referred for genetic counseling Based on family history available in medical record, an additional 4 5 cases (4 5/22) might have been appropriate for referral to genetic counseling Involvement of a gynecologic oncologist in the primary management (NCCN suggestion): o 5/26 cases did not involve a GYN oncologist 2 cases initial biopsy did not show cancer (one EIN and another atypical adenomatous hyperplasia) 1 case an 87 y/o patient who transitioned to hospice management 1 case the gynecologists had scheduled the procedure with a gynecologic oncologist but the patient requested a change in her surgery date
1 case no specific explanation in the chart Treatment Guidelines: NCCN 20 guidelines Treatment Assessment: 1/26 cases did not meet treatment guidelines o 82 yo W with stage,, LVI+ endometrial cancer who was only treated with surgery. She did not receive radiation. Details not available but patient did not have a consultation with radiation oncology or medical oncology o Of note, there was a case of an 87 y/o W with stage IIIc, cancer, who received only hormonal therapy for palliation but this met treatment guidelines as the patient was not a surgical candidate and was being treated with palliative intent. Genetic Testing For Lynch Syndrome/HNPCC: Guidelines have evolved over the last several years Consider genetic referral for women with endometrial cancers who have a personal or family history of relevant cancers (endometrial, ovarian and colorectal) As of April 20, NWH pathology is now performing IHC staining for MMR (miss match repair) protein expression on every endometrial cancer processed at NWH. o Loss of MMR protein expression by IHC may be caused by a genetic mutation in one of the MMR genes. This would be suggestive of Lynch Syndrome but further evaluation in warranted. o In the current NWH algorithm, the genetic counselors receive a copy all endometrial cancer MMR IHC results and help guide further evaluation by pathology and the primary gynecologist. Summary Recommendations: Overall the diagnostic evaluation and treatment of endometrial cancers at NWH in 20 were adherent to the NCCN 20 guidelines. There was good collaboration between the primary gynecologist caring for the patients and the gynecologic oncology. There could be improvement in screening for a possible genetic predisposition to endometrial cancer (i.e. Lynch Syndrome) through better solicitation of relevant family history and referral to a genetic counselor. This process will now be aided by pathology s new standard of evaluating of all endometrial cancers for MMR protein expression. Encourage consultation by radiation oncology and medical oncology to discuss adjuvant therapies and other treatments when appropriate. Continue the monthly board at NWH which allows multidisciplinary discussions of new or recurrent endometrial cancer cases.
Cancer Program Newton Wellesley Hospital Physician Review- CoC Standard 4.6 Endometrial Cancers 20 26 cases (Class -) Diagnosed and/or Treated at NWH) Case # Class of case 1 2 Prognostic Factors 54 yrs 59 yrs grade 2? LVI (not confirmed) 3 57 yrs 4 5 68 yrs 70 yrs Stage Involvement of GYN oncologist board -2/20 board -2/20 board -3/20 Endometrial sampling Hysteroscopy D&C 1/20/20 Endometrial biopsy 10/19/2011 Endometrial sampling, removal of a polyp 1/16/ (?) Hysteroscopy, polypectomyy (KI 1/17/) Radiologic Evaluation for extra uterine disease 1 Family History 2 & Genetic Consultation (GC), Father CRC * Not mentioned in Office biopsy Limited hx in 1 st Course of Therapy 3/6/20 (S) pelvic washings 1/3/20 (R)- vaginal brachytherapy 2/20 2//, washings, 2// 2/28/ Treatment concordant with NCCN guidelines
6 68 yrs arising from EIN No but EIN on initial biopsy Hysteroscopy & Endo bx 2/28/ Dx EIN FH obtained, neg 3/5/ 7 8 9 10 61 yrs 76 yrs 61 yrs 64 yrs No comment on LVI (no residual tumor) No (Explanation in chart ) GYN tumor board- 5/20 Discussed GYN TB (?) Discussed GYN TB (?) Hysteroscopy D&C 4/23/ Endometrial bx 5/16/ Hysteroscopy and D&C 5/23/ Hysteroscopy And D&C 6/19/ CXR 5/23/ Mother endometrial ca * FH not on hx for ca assessment FH not at initial dx GC: Not initially (strong fam hx) with onc c/s 3/20 Mother colon ca * 4/27/ 6/5/ and 7/17/, 7/16/
11 11 15 16 68? LVI vs artifact 82 + LVI 82 clear cell 52 67 61 (pt1an0) board 7/20 board 10/20 board 9/20 board 11/20 board 11/20 Hysteroscopy, D&C 7/4/ Hysteroscopy, Dilatation, Polypectomy, bx Endometrial biopsy CT 7/3/ CT 8/30/ CT 9/4/ FH- cannot assess notes not in (not recommended d/t histology) Endometrial biopsy FH prior to dx Hysteroscopy, uterine polypectomy, D&C 10/26/ Hysteroscopy, D&C 11/1/ GC yes prior to diagnosis FH obtained Distant colon cancer * FH- no records in No CG, 8/7/ TAH/BS, no nodes performed, no nodes RT (pelvic, brachytherapy) 10/9/ bilateral complete total pelvic lymphadenectomy 11/20/ No No RT consultation for discussion
17 59 18 19 20 21 22 59 68 56 68 endometriod 61 endometroid (pt1an0) IB (PT1bN0) 70% invasion IB (pt1nx) + peritoneal cytology Hysteroscopy, D&C 11/30/ CT post op FH obtained GC yes 8/20 No Endometrial biopsy FH- records not available - No But Preop dx: Atypical adenomatous hyperplasia Not at NWH Endometrial biopsy Biopsy (8/20) FH not recorded in record Dilation and curettage, hysteroscopy, and polypectomy 9/24/20 Hysteroscopy D&C 11/20 Mother colon ca * HF obtained, neg, referred for GC complete pelvic lymphadenectomy + RT brachytherapy /6/, complete pelvic lymphadenectomy (initial bx - II) 10/16/ + RT (vaginal brachy) (1/4/) No RT (note: RT not considered given prior pelvic RT with colon cancer) ES
23 24 25 59 endometroid grade 2 48 87 unclear histology (too much necrosis) no comment LVI II (pt2nx) +cervical involvement Stage IIIa (fallopian tube involvement) IIIC - Not indicated Discussed board 2/20 Endometrial bx 11// Dilation and curettage, hysteroscopy/17/ Biopsy CT CT chest FH - obtained GC referral FH-obtained, neg RT (external beam -> vaginal brachy) /31/ Chemotherapy RT Endocrine Therapy (megace) (no other therapy given age and co morbid conditions) 26 74 yrs serous node neg (pt1an0) board 3/20 Hysteroscopy and curettage 2/24/ Chest CT 4/20 FH obtained not recommended based on serous path LN dissection 3/6/ + adjuvant platinum based chemotherapy (6/20-9/20) + vaginal brachy Rx (/20) 1 Radiologic Evaluation (CXR, CT scan, PET-CT, MRI) indicated if extrauterine disease is suspected or tumor has high risk features (i.e., deep myometrial invasion,, lymphatic-vascular invasion) associated with extrauterine disease. 2 Family history obtained for endometrial, ovarian and colorectal (CRC) * these cases might have been considered for genetic consultation (GC) based on available history in