ESGO 1-st Basic Course in Gynecological Oncology Yerevan, State Medical University 30 th September - 1 st October 2010 The role of the The role of the Lymphadenectomy Lymphadenectomy in in Endometrial Cancer Endometrial Cancer P. Zola Prof. Paolo Zola Department of Gynecologic Oncology University of Turin Mauriziano “ Umberto I ” Hospital
ESGO 1-st Basic Course in Gynecological Oncology. Yerevan, State Medical University 30 th September - 1 st October 2010. The role of the Lymphadenectomy in Endometrial Cancer. P. Zola Prof. Paolo Zola Department of Gynecologic Oncology University of Turin - PowerPoint PPT Presentation
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ESGO 1-st Basic Course in Gynecological Oncology
Yerevan, State Medical University30thSeptember - 1st October 2010
The role of the Lymphadenectomy The role of the Lymphadenectomy in in
Endometrial CancerEndometrial Cancer
P. ZolaProf. Paolo Zola
Department of Gynecologic OncologyUniversity of Turin
Mauriziano “ Umberto I ” Hospital
International Federation International Federation of Gynecologic and Obstetrics (FIGO)of Gynecologic and Obstetrics (FIGO)
Clinical StagingSystem
Clinical StagingSystem
Operative StagingSystem
Operative StagingSystem
1978 1988
inaccuratea paradigm
shift
GOG Study*
Stage migration in 22% (144/621) of clinical stage I patients
after surgical staging
No definite guideline: Type & Extent of LN assessment
*Creasman - Morrow et al, Cancer 1987
FIGO STAGING 2009FIGO STAGING 2009I Tumour confined to the corpus uteri
Ia No or less than half myometrial invasion
Ib Invasion equal to or more than half of the myometrium
II Tumour invades cervical stroma, but does not extend beyond the uterus
III Local and/or regional spread of the tumour
III a Tumour invades the serosa of the corpus uteri and/or adnexae
III b Vaginal and/or parametrial involvement
III cIII c Metastases to pelvic and/or para-aortic lymph nodesMetastases to pelvic and/or para-aortic lymph nodes
III c1III c1 Positive pelvic nodesPositive pelvic nodes
III c2III c2 Positive para-aortic lymph nodes with or without positive pelvic lymphPositive para-aortic lymph nodes with or without positive pelvic lymphnodesnodes
IV Tumour invades bladder and/or bowel mucosa, and/or distant metastases
Iva Tumour invasion of bladder and/or bowel mucosa
IV b Distant
Surgical Staging: LymphadenectomySurgical Staging: Lymphadenectomy Practices around the worldPractices around the world
0
20
40
60
80
NORTH AMERICA NORTH AMERICA NORTH AMERICA NORTH AMERICA WESTERN EUROPE NETHERLANDS SLOVACK REPUBLIC JPAPANWESTERN EUROPE NETHERLANDS SLOVACK REPUBLIC JPAPAN Partride, ‘99 Roland, ‘04 Maggino, ‘95 Creutzberg, ‘00 Uharcek, ‘06 Konno, ‘00Partride, ‘99 Roland, ‘04 Maggino, ‘95 Creutzberg, ‘00 Uharcek, ‘06 Konno, ‘00
Perform it or not perform it?Perform it or not perform it?
What’s new in
Literature…
SURVIVAL BENEFITS REMOVING NODAL METASTASES AUTHOR No. PTS INCLUSION OUTCOME EXENT OF BENEFIT (year) CRITERIA BENEFIT FROM
CHAN 1221 Stages IIIc-IV More extensive lymphadenectomy 5-yrs improved with extent
2006 (1, 2-5, 6-10, 11-20, > 20 nodes) of surgery - p <0.01(51, 53, 53, 69, 72%)
Failing to stage even low risk pts,may miss significant numbersof pts with extra uterine disease, particularly since pre surgical G &Inv is realtive inaccurate. Outcome data do not support this assumption
ONLY 4% of 922 pts low risk disease and no surgical staging oradjuvant therapy subsequently recurred.
STAGE ALL
Failing to stage even low risk pts,may miss significant numbersof pts with extra uterine disease, particularly since pre surgical G &Inv is realtive inaccurate. Outcome data do not support this assumption
ONLY 4% of 922 pts low risk disease and no surgical staging oradjuvant therapy subsequently recurred.
Algorithms Decision-MakingAlgorithms Decision-MakingFrom these data, one can estimate that the number in whomnodal/extra uterine disease was present is about 5%.The patters of failure predict that 3/5 will recur in the pelvis alone and 2/3 will be salvaged with RT at the time of relapse
Thus in low risk negligible gains come from attending accurately know the nodal status by staging
Incidence of N+ is low, morbidity rate for surgical staging is 6-7%, recurences are pelvic, and salvage therapy is significant
From these data, one can estimate that the number in whomnodal/extra uterine disease was present is about 5%.The patters of failure predict that 3/5 will recur in the pelvis alone and 2/3 will be salvaged with RT at the time of relapse
Thus in low risk negligible gains come from attending accurately know the nodal status by staging
Incidence of N+ is low, morbidity rate for surgical staging is 6-7%, recurences are pelvic, and salvage therapy is significant
With unsophisticated techniques (45-50Gy), approx 40%may achieve long term DFS (range 35-75%). Thus 1-2/100 pts are cured by virtue of surgical detection and treating involved PA.
Thomas & Aalders 2007
Percent radiation use after surgery, by surgeon & FIGO stage
Lymph Node Assessment by surgeon:General Gynecologist vs Gynecologic Oncologist
cancer (SEPAL study): a retrospective cohort analysis
Todo et al 2010
• Para-aortic lymphadenectomy has survival benefits for patients at intermediate or high risk of recurrence.
• Pelvic lymphadenectomy alone might be an insufficient surgical procedure in patients at risk of lymph node metastasis
Todo et al 2010
Cox regression analysis of overall survival with pelvic and para-aortic lymphadenectomy compared with pelvic lymphadenectomy alone according to risk of recurrence
• Study over long time change in staging and management
• Are PA nodes involved at preoperative imaging?• Surgical morbidity?
Correspondence Correspondence (The Lancet, August 2010)(The Lancet, August 2010)
Latha Balasubramani, Desiree F Kolomainen, Marielle Nobbenhuis, Jane Bridges, Desmond Barton
Roy Kruitwagen, Harold Pelikan,Hans Trum
• Inguinal lymphadenectomy as part of the routine systematic pelvic lymphadenectomy: low incidence and extend the morbidity
• Include recent FIGO staging• Selection patients and surgery details • Bias: 2 different hospitals
• Retrospective review 2000-08• 352 patiens• “Our data suggest that the
number of lymph node stations sampled, and not the number of nodes removed, is a more accurate predictor of lymph node status in endometrial carcinoma.”
• The purpose of this study was to identify practice patterns among gynecologic oncologists when performing a lymphnode evaluation during staging for endometrial cancer.
• A self-administered survey was sent via email to all SGO members, the survey addressed surgical approach, algorithms used to determine staging, and anatomic landmarks defining lymphadenectomy.
• 40% members responded. • 40% prefer laparotomy, • 31% perform robotic surgery, • 29% use laparoscopy.
• 53% never/rarely use frozen section to determine whether or not to perform lymphadenectomy.
• A majority perform staging on all grade 2 and grade 3 cancers (66% and 90%, respectively).
• When performing paraaortic lymphadenectomy, 50% use the IMA as the upper border and 11% take the dissection to the renal vessels.
ConclusionsCurrent controversies in surgical staging for endometrial
cancer are reflected in the practice patterns among gynecologic oncologists. At this point it is unclear if standardizing surgical practice patterns will improve outcomes for patients with endometrial cancer.
ConclusionsConclusions• In low risk patients no evidence of benefits
perfoming systematic lymphadenectomy
• In high risk patients strong evidence against performing systematic lymphadenectomy except of one retrospective study
• Open question evaluation of nodal status (FIGO stage)