This document discusses endometrial cancer staging and management. It covers the 2009 FIGO staging system for endometrial cancer and standard treatment involving total hysterectomy and bilateral salpingo-oophorectomy. Lymph node dissection is also discussed as an important part of diagnosis, staging, and determining need for adjuvant treatment. While pelvic radiation is often given, the document notes that a large percentage of patients do not actually benefit from it due to lack of node involvement or presence of distant metastases. Careful staging is important to determine the most appropriate treatment for each individual patient.

1. Endometrial
Cancer
staging
and
management
update
Khalid
Sait
FRCSC
Professor
Faculty
of
medicine
King
Abdulaziz
University
Director
of
Gynecology
Oncology
Unit

2. new
2009-­‐FIGO
staging
for
endometrial
cancer

3. Stage 1
In
the
face
of
negaIve
nodes
there
was
liJle
survival
difference
between
no
myometrial
invasion
and
less
than
50%
invasion

4. Stage II
Involvement of the endocervix that does not
invade the stoma is not a Stage II lesion

5. Stage III
IIIA:
Involvement of the Serosa or Adnexa
IIIB:
Involvement of the
vagina
Parametrium
Pelvic peritoneum
IIIC:
IIIC1
Pelvic nodes
IIIC2
Paraaortic nodes

6. Stage IV

7. Standard
treatment
for
Endometrial
Cancer
• Total
Hysterectomy
+
BSO
•
Cytology
±
Lymph
node
dissecIon:-­‐
pelvic
and
para
aorIc

8.
To
Stage
or
Not
to
stage
?
That
is
the
QuesIon
(
With
Apologies
to
Sakesspeare)

10. Management
of
Endometrial
cancer
Daily
PracIce!
• Obstetrician
–
gynecologist
performed
a
simple
TH
+
BSO
in
a
paIent
with
‘’early’’
EC
• According
to
prognosIc
factors,
she
proved
to
be
at
high
risk
for
nodal
spread.

11. Management
of
Endometrial
cancer
Daily
PracIce!
} The
advice
will
be:
Adjuvant
radiotherapy
to
the
pelvis
Right
decision?

12. RadiaIon
disadvantage
– Morbidity
– Cost
– DuraIon
of
treatment
– Under
or
over
treatment

13. } 60-­‐70%
with
no
node
metastases;
get
unnecessary
pelvic
RT
i.e.
Pelvic
RT
is
beneficial
in
30-­‐40%
} 14-­‐23%
with
para-­‐aorIc
metastasis,
will
not
benefit
from
pelvic
RT
i.e.
Need
EPR,
Chemo.
Aalders e t al obst-gyneol 1980
Ackerman et al gyn onco 1996

14. } 48-­‐75
%
of
relapse
are
at
distance
sites
Following
adjuvant
pelvic
RT
in
high
risk
early
EC
paIents
with
unknown
node
status
Hoberg
et
al
in
j
gyn
cancer
2004
Creutzberg
et
al
j
clin
oncol
2004

16.
Standard
of
Care

17. Hysterectomy
} The
accepted
first
line
treatment
} Necessary
for
staging
} No
evidence
to
support
TAH+cuff
or
Rad.
Hyst.
for
early
stage.
} Total
Hystrectomy,
open
approach/
Laparosopy
or
RobaIc
does
allow
for
assessment
of
lymph
nodes
&
abdomen

18. Bilateral
salpingo-­‐oophorectomy
} Generally
advised
◦ Can
get
micro-­‐metastases
◦ Can
get
concurrent
ovarian
cancer
◦ Rarely
an
indicaIon
for
leaving
behind

19.
The
removal
of
the
regional
lymph
node
is
sIll
a
cardinal
principle
in
the
management
of
many
cancer
today

20. Purpose
of
the
lymphadnectomy
in
management
of
EC
} DiagnosIcs
(
Staging)
which
is
extremely
important
in
opImizing
individual
care
} TherapeuIcs
(
improve
survival
and
decrease
recurrence)
} Decision
for
post
operaIve
adjuvant
treatment

21. Purpose
of
the
lymphadnectomy
in
management
of
EC
} DiagnosIcs
(Staging)
which
is
extremely
important
in
opImizing
individual
care
} TherapeuIcs
(
improve
survival
and
decrease
recurrence)
} Decision
for
post
operaIve
adjuvant
treatment

22. •
“Pelvic
node
metastasis
does
occurred
in
much
greater
frequency
(28%)
than
does
adenxal
spread
(10-­‐12%),
yet
what
gynecologist
fails
to
remove
the
adnexa
when
operaIng
for
endometrial
cancer?”
Jarvet
CT.
AJOG
1952:
64:780-­‐806

23. • In
1988
the
FIGO
revised
the
staging
system
of
endometrial
cancer
to
mandate
surgical
dissecIon
and
evaluaIon
of
lymph
nodes
FIGO
stages-­‐1988
Revision
.
Gynecol
Oncol
.

24. FIGO ANNUAL REPORT 1998
Risk
of
L.
node
P/P.A
Depth
of
Myoma
G1 G2 G3
I IIB I IIB I IIB
Ø 0.4 %
0%
1%
1%
O.5%
O.5%
0.9%
1%
2.9%
1.9%
2%
6%
< 50 % 1.2%
0.17%
2.4%
0.3%
3.1%
0.8%
6%
1.5%
6%
2.4%
24%
5%
> 50% 15%
3.5%
20%
12%
15.7%
6.1%
6.1%
1.5%
24%
10.2%
30%
20%

25. Purpose
of
the
lymphadnectomy
in
management
of
EC
} DiagnosIcs
(
Staging)
which
is
extremely
important
in
opImizing
individual
care
} TherapeuIcs
(
improve
survival
and
decrease
recurrence)
} Decision
for
post
operaIve
adjuvant
treatment

26. Two
RCTs
on
the
lymphadnectomy
in
management
of
EC

31. • According
to
G
when
do
you
performe
lymphadenectomy
in
endometrioid
hystotype?
• Pelvic
+Para-­‐aorIc
lymphadenectomy
*
Grade3(90%)
*Grade
2(66%)
*Grade
1(35%)
• Do
you
perform
intraopertaive
frozen
secIon
?
Always
/usually(31%)
SomeImes(16%)
Rarely
/never
(53%)
Lymphadenectomy
during
endometrial
cancer
staging
Soliman
et
al
Gyn
onc
2010

33. IDEAL
TRIAL
RCT
P
and
PA
nodes
ObservaIon
Chemotherapy
Radiotherapy
No
node
Chemotherapy
Radiotherapy
ObservaIon
Intermediate
and
high
risk
early
stage
EC

34. Purpose
of
the
lymphadnectomy
in
management
of
EC
} DiagnosIcs
(
Staging)
which
is
extremely
important
in
opImizing
individual
care
} TherapeuIcs
(
improve
survival
and
decrease
recurrence)
} Decision
for
post
operaIve
adjuvant
treatment

35. Risk stratification
• Low risk
• Intermediate risk
• High risk
G1 G2 G3
1A
1B

36. Gynecology
Oncology
Unit(KAUH)
Protocol
Post
operaIve
management

37. I B
II A
( <50 % Myom. )
(G1, G2)
Stage I A
GIIGI GI GII
1%1-3% 0.4% 0.5% 3%RISK OF L .
NODE
RISK OF RECURRENCE= 3%
FOLLOW-UP
If The L.node status is not known , do CT if negative

38. 15%
GI
15%
GII
IC
3%
G3
IA
6%
G3
IB
2.4%
G1
6%
G2
24%
G3
IIB
<50%
brachy
4000
CGY
Node Negative
Brachytheraphy
only to volt
4000 CGY
Retroperineal
All Laparoscopic
Lymphoadenovectomy
If Negative
EBR
4500
CGY to pelvic
Two options
Status if node is not known
RISK OF RECURRENCE IN L. NODE
15%
V. Vault=15%
• Risk Of L.
Node

39. IC
G3
24% 6%
G1
20%
G2
30%
G3
II
>50%
Myoma
RISK OF L.NODE
RECURRENCE IS 30 %
If Node is
negative
EBR +
brachy
If Not Known
status of Node
C.T if negative
EBR + weekly
cisplatinum + brachy

40. Conclusions
• Most
paIents
can
be
cured
with
simple
surgery
alone
,
if
were
properly
surgically
staged
• Complete
staging
will
help
v
Proper
post
operaIve
management
and
avoid
unnecessary
Adjuvant
treatment