Endometrial Cancer Surgical Staging (Role of Lymphadenectomy)
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Endometrial CancerEndometrial Cancer Surgical StagingSurgical Staging
(Role(Role of Lymphadenectomy) of Lymphadenectomy)
Karl Podratz MD PhD FACSKarl Podratz MD PhD FACS
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Endometrial CancerEndometrial CancerSurgical StagingSurgical Staging
Basis for Definitive StagingBasis for Definitive StagingExtent of DiseaseExtent of DiseaseAdjuvant Rx determinantAdjuvant Rx determinantPrognosticationPrognosticationComparative evaluationComparative evaluationPotentially therapeuticPotentially therapeutic
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Endometrial CancerEndometrial Cancer Surgical StagingSurgical Staging
Definitive StagingDefinitive Staging TAH/BSO/Peritoneal cytologyTAH/BSO/Peritoneal cytologyPelvic/Paraaortic LND*Pelvic/Paraaortic LND*Biopsy/OmentectomyBiopsy/OmentectomyCytoreductionCytoreduction (Rx) (Rx)
*LND = Lymph node dissection
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Endometrial CancerEndometrial CancerSurgical StagingSurgical Staging
Definitive StagingDefinitive Staging TAH/BSO/Peritoneal cytologyTAH/BSO/Peritoneal cytology
Pelvic/Paraaortic LND*Pelvic/Paraaortic LND*Biopsy/OmentectomyBiopsy/OmentectomyCytoreductionCytoreduction (Rx) (Rx)
*LND = Lymph node dissection
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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.
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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 2,9002007 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
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Endometrial CancerEndometrial CancerRole of Radiotherapy and LymphadenectomyRole of Radiotherapy and Lymphadenectomy
Paradigm shift necessaryParadigm shift necessaryMinimize overtreatmentMinimize overtreatmentMinimize undertreatmentMinimize undertreatmentMaximize outcomesMaximize outcomes
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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
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Endometrioid Endometrial CancerEndometrioid Endometrial CancerRole of Radiotherapy and LymphadenectomyRole of Radiotherapy and Lymphadenectomy
Modality-based therapy Modality-based therapy Radiotherapy vs. lymphadenectomyRadiotherapy vs. lymphadenectomyUterine histologyUterine histology
Disease-based therapyDisease-based therapyBased on patterns of failureBased on patterns of failure
Predicted by pathologic determinantsPredicted by pathologic determinantsSelective Lymphadenectomy Selective Lymphadenectomy Selective Radiotherapy Selective Radiotherapy Selective ChemotherapySelective Chemotherapy
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Endometrial CancerEndometrial CancerSelective LymphadenectomySelective Lymphadenectomy
(not sampling)(not sampling)
Lymph Node Dissection (LND) Lymph Node Dissection (LND) Low risk: Not indicatedLow risk: Not indicatedAll others: Systematic All others: Systematic
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Endometrial CancerEndometrial CancerSelective LymphadenectomySelective Lymphadenectomy
Lymphadenectomy not indicated*Lymphadenectomy not indicated*Low risk:Low risk:
EndometrioidEndometrioidG 1&2G 1&2MI MI << 50% 50%PTD PTD << 2 cm 2 cm
*Mariani et al. Am J Ob Gyn 2000
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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
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Endometrioid Endometrial CancerEndometrioid Endometrial CancerLow risk:Low risk: G1/2, G1/2, << 2 cm, 2 cm, << 50% MI 50% MI
Pt % 5 yrPt % 5 yrTreatment^ (no.) SurvivalTreatment^ (no.) SurvivalHysterectomy only 59 100Hysterectomy only 59 100Hyst + LND* +/or RT** 64 100Hyst + LND* +/or RT** 64 100Total 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 PPC
Mariani et al. Am J Ob Gyn 2000
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Endometrioid Endometrial CancerEndometrioid Endometrial CancerLow Risk: G 1/2, MI Low Risk: G 1/2, MI << 50%, 50%, PTD PTD << 2 cm 2 cm
Lymphadenectomy not indicatedLymphadenectomy not indicated20% Over all population*20% Over all population*29%29% Endometrioid patients* Endometrioid patients*
*Mariani et al. Am J Ob Gyn 2000
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Endometrioid Endometrial CancerEndometrioid Endometrial CancerSelective 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)
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Endometrioid Endometrial CancerEndometrioid Endometrial CancerSelective LymphadenectomySelective Lymphadenectomy
Lymphadenectomy not indicatedLymphadenectomy not indicatedLow risk:Low risk: G 1/2, MI G 1/2, MI << 50%, PTD 50%, PTD << 2 cm 2 cm
Systematic LymphadenectomySystematic LymphadenectomyAll others (not low risk)All others (not low risk)17%17% positive nodes positive nodes
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Endometrial Cancer FailuresEndometrial Cancer FailuresPelvic 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 ValuePelvic 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 factorsHigh risk = High risk = *CSI and/or LN mets*CSI and/or LN mets
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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 ValuePelvic SidewallPelvic Sidewall Low risk <1 <0.001Low risk <1 <0.001 High risk* 26High risk* 26Para-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 factorsHigh risk = *CSI and/or LN mets; High risk = *CSI and/or LN mets; **LN mets only**LN mets only
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Endometrial Cancer FailuresEndometrial Cancer FailuresParaaortic 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)
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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 determinantsSelective Lymphadenectomy Selective Lymphadenectomy Selective RadiotherapySelective Radiotherapy
12% total population at risk12% total population at riskEBRT indicated in 12%EBRT indicated in 12%47% paraaortic risk47% paraaortic riskRT field to include PA areaRT field to include PA area
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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
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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
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Endometrioid Endometrial CancerEndometrioid Endometrial CancerRole of Radiotherapy and LymphadenectomyRole of Radiotherapy and Lymphadenectomy
Modality-based therapy Modality-based therapy Radiotherapy vs. lymphadenectomyRadiotherapy vs. lymphadenectomyUterine histologyUterine histology
Disease-based therapyDisease-based therapyBased on patterns of failureBased on patterns of failure
Predicted by pathologic determinantsPredicted by pathologic determinantsSelective Lymphadenectomy Selective Lymphadenectomy Selective Radiotherapy Selective Radiotherapy Selective ChemotherapySelective Chemotherapy
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