Uterus Flashcards
Low risk disease
Grade 1 or 2, limited to endometrium OR <50% invasion, no LVSI, endometrioid type
Risk of nodal involvement in low-risk disease
Less than 5%
Risk of local recurrence in low-risk disease
Less than 5% risk of vaginal vault recurrence
Postoperative treatment of low-risk disease
None, VBT/EBRT has no benefit an increased risk of death.
Candidates for fertility-sparing surgery
Grade 1 endometrioid, stage 1A, desires childbearing/reproductive age, no contraindications to hormonal therapy. *Understand they are not fully staged (clinical vs surgical).
Lynch syndrome NOT candidate.
Prognosis for low-risk disease
Excellent, >90% survival
Intermediate risk disease
Not high-risk histology AND:
G1/2, <50% invasion, +LVSI
G1/2, >50% invasion OR cervical stromal invasion (Stage IB or II)
G3, <50% invasion (IA)
High intermediate risk disease (GOG 99)
1) Grade 2/3 tumor
2) LVSI
3) Outer 1/3 myometrial invasion
Age 70+ with 1 RF
Age 50+ with 2 RF
Age <50 with 3 RF
High intermediate risk disease (PORTEC)
Age >60, >50% invasion, G3
Must have 2 out of 3
Adjuvant therapy for low intermediate risk disease
Observation vs RT.
Recommend observation, little benefit (not SS) to RT.
Adjuvant therapy for high intermediate risk disease
Adjuvant RT recommended
GOG 99: in HR group, EBRT reduced risk of recurrence, no OS benefit
PORTEC2: VBT NS different from EBRT for local/distant recurrence or DFS but VBT lower adverse effects
PORTEC1
Adjuvant pelvic RT improves locoregional control without impacting OS in early EC
Pelvic EBRT (4600 cGy), no VBT
Inclusion criteria: S1 G1 >50% MI, G2 any invasion, G3 <50% MI
5yr locoregional recurrence 4% (RT) vs 14% (ctrl) (SS)
5yr OS: 81% vs 85% (NS)
Adverse effects: 25% vs 6% (mostly GI)
GOG 249
[VBT + 3 cycles chemo] is NOT superior to EBRT, and is associated with more toxicity
(HR-ID endometrioid, serous or clear cell Stage I-II)
Prognosis for intermediate risk disease
Low intermediate - excellent, 5-6% recurrence without adjuvant therapy
High intermediate - fair to good, 5-30% recurrence (depends on adjuvant or no), but survival >80%
What is the most common GYN malignancy in the US?
uterine cancer
Type 1 endometrial cancer
Common
Low grade endometrioid histology (G1/2)
Arises from precursor lesion (CAH or EIN)
Associated with elevated/unopposed estrogen (obesity, PCOS), HLD, T2DM
Indolent course
Younger age, higher BMI
Type 2 endometrial cancer
Rare High risk diverse histology (clear cell, serous, ?G3 endometrioid, carcinosarcoma) Arises in atrophic endometrium or polyp Aggressive disease Older patients, low BMI Estrogen independent p53 mutation
What is the association found between grade and depth of invasion per GOG 33?
Lower grade –> less invasive (superficial)
Higher grade –> more invasive (deep)
GOG 33 what is the relation between positive pelvic nodes to aortic nodes?
Pelvic 89% negative –> aortic 2% positive
Pelvic 6% positive –> aortic 3% positive
(If positive pelvic nodes, more likely positive aortic)
GOG 33 relationship between pathologic spread and node positivity?
Increasing grade, depth of invasion –> more likely positive nodes (both pelvic and aortic)
Clinical stage 1 endometrial cancer in GOG33 when surgically staged had what rates of extrauterine involvement?
9% pelvic LN 6% aortic LN (2% isolated aortic LN) 5% adnexal 12% peritoneal cytology 6% other extrauterine disease
Significance of GOG33?
Moved from clinical to surgical staging for endometrial cancer.
(Clinically stage 1 does as poorly in OS as surgically stage 3).
Does LND improve survival in endometrial cancer?
Not really… Good for staging, which will determine adjuvant therapy. But debulking does not improve survival. (Benedetti-Panici 2008, ASTEC 2009)
Mayo criteria for NOT doing LND
Endometrioid histology G1/2, =50% invasive, tumor size =2cm
Validated prospectively by Mayo, LAP2, SEER data
