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Optimal Surgery for Ovarian and Endometrial Cancers. Jason Dodge, MD, FRCSC, MEd April 9 th , 2010. Objectives. At the end of this session, participants will be able to… list the rationales for the surgical management of endometrial and ovarian cancers

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Optimal surgery for ovarian and endometrial cancers

Optimal Surgery for Ovarian and Endometrial Cancers

Jason Dodge, MD, FRCSC, MEd

April 9th, 2010


Objectives
Objectives

At the end of this session, participants will be able to…

  • list the rationales for the surgical management of endometrial and ovarian cancers

  • recognize the optimal components of surgical staging for both endometrial and ovarian cancers

  • understand the importance of surgical staging for endometrial and ovarian cancer in determining prognosis and the role(s) for adjuvant therapy

  • identify the importance of surgical debulking for ovarian cancer



Prototype case
Prototype Case

  • 52 y.o. G3P3 post-menopausal woman

  • Healthy, asymptomatic

  • 7-8 cm pelvic mass on routine exam

  • U/S – 7.5 cm multiloculated, solid/cystic mass arising within right ovary

  • CA-125 – 25

  • Booked for surgery by community gynaecologist


Prototype case1
Prototype Case

  • TAH-BSO through lower transverse incision

  • Solid/cystic ovarian mass resected intact

  • No other abnormalities identified in OR note

  • Final pathology:

    • Grade 2 serous carcinoma of ovary

    • Negative uterus and contralateral adnexa



Optimal surgery for ovarian and endometrial cancers

What is the risk this woman has (undetected) metastatic disease?

  • <1%

  • 10%

  • 30%

  • 50%

  • 80%

Young et al., JAMA, 1983


Optimal surgery for ovarian and endometrial cancers

What is the best approach to her management at this point? disease?

  • Observation

  • Refer back to local gynaecologist for repeat surgery for optimal surgical staging

  • Refer to Gynaecologic oncologist for repeat surgery for optimal surgical staging

  • Adjuvant chemotherapy (Carbo/Taxol IV)

  • Other


Outline
Outline disease?

  • Optimal surgery for ovarian cancer

    • Diagnosis

    • Surgical Staging

    • Debulking

    • Facilitating optimal treatment


Roles of primary surgery in ovarian cancer
Roles of Primary Surgery in disease?Ovarian Cancer

  • Diagnosis (final)

  • Staging (SURGICAL, NOT CT!)

  • Therapy

    • Palliation of symptoms

    • Removal of cancer (debulking)

  • Facilitating optimal adjuvant therapy

    • Prognosis of individual patient

    • Risks/benefits of adjuvant therapy


Surgery in ovarian cancer staging
Surgery in Ovarian Cancer: disease?Staging

Patterns of spread:

  • Intraperitoneal

  • Local

  • Lymphatic

  • Hematogenous

    Optimal surgical staging procedure must rule out metastases by all of these routes


Surgery in ovarian cancer staging1
Surgery in Ovarian Cancer: disease?Staging

Components of optimal surgical staging:

  • Peritoneal washings

  • Inspection and palpation of abdominal and pelvic organs and peritoneal surfaces

    • biopsy of all suspicious lesions

  • BSO (+/- TAH)

  • Omentectomy

  • Pelvic & para-aortic lymphadenectomies

  • Multiple peritoneal biopsies


Figo staging ovary
FIGO staging (ovary) disease?

  • I – confined to ovary/ies

    • A (single ovary)

    • B (bilateral ovaries)

    • C (positive washings, surface disease, ruptured)

  • II – confined to pelvis

    • A (fallopian tube or uterine extension)

    • B (other pelvic metastases)

    • C (pelvic involvement with +washings or tumour rupture)

  • III – abdominal/pelvic cavity extension or nodes +ve

    • A (microscopic only)

    • B (<2 cm nodule(s))

    • C (>2cm nodule(s) or retroperitoneal lymph nodes involved)

  • IV – positive pleural effusion, parenchymal liver or other distant metastases



Key message
KEY MESSAGE! disease?

What is the risk this woman has (undetected) metastatic disease?

  • <1%

  • 10%

  • 30%

  • 50%

  • 80%

Young et al., JAMA, 1983


Surgery in ovarian cancer staging2
Surgery in Ovarian Cancer: disease?Staging

“Stage 1” patients who are not optimally staged at surgery have a poorer survival!

ACTION trial

Trimbos et al., JNCI, 2003


Surgery in ovarian cancer staging3
Surgery in Ovarian Cancer: disease?Staging

No benefit to adjuvant chemoRx in patients who are optimally surgically staged!

ACTION trial

Trimbos et al., JNCI, 2003


Surgery in ovarian cancer debulking
Surgery in Ovarian Cancer: disease?Debulking

  • Optimal debulking of metastatic disease associated with improved survival

    • Best predictor of survival in patients with advanced stage disease

    • Delay in definitive surgical debulking may be associated with decreased survival

Bristow et al., J Clin Oncol, 2002

Bristow & Chi, Gynecol Oncol, 2006


Therapeutic debulking
Therapeutic Debulking disease?

Bristow et al., JCO, 2002


Surgery in ovarian cancer facilitating optimal adjuvant therapy
Surgery in Ovarian Cancer: disease?Facilitating Optimal Adjuvant Therapy

  • “Stage I”

    • If optimally staged, evidence suggests that chemotherapy may not be useful in improving survival

    • If not optimally staged, chemotherapy indicated to improve survival rates (because significant number have undiagnosed advanced staged disease)

ICON1/ACTION trials

Trimbos et al., JNCI, 2003


Surgery in ovarian cancer facilitating optimal adjuvant therapy1
Surgery in Ovarian Cancer: disease?Facilitating Optimal Adjuvant Therapy

  • Advanced Stage

    • Chemotherapy demonstrated to improve overall survival

    • Recent acceptance of intraperitoneal chemotherapy as ideal mode of therapy for women with optimally debulked disease after primary surgery

      • Optimal debulking <1 cm residual

      • Insertion of IP catheter at primary surgery

Covens et al., CCO Guidelines, 2005

Armstrong et al., NEJM, 2006


Surgery in ovarian cancer intraperitoneal chemotherapy
Surgery in Ovarian Cancer: disease?Intraperitoneal Chemotherapy

  • Delivery of chemotherapy directly into peritoneal cavity via implanted catheter

  • Most pronounced survival benefit ever documented in ovarian cancer (17 m)

  • Only patients optimally debulked at primary surgery are eligible

Armstrong et al., NEJM, 2006


Current practice in ontario
Current practice in Ontario… disease?

  • Many ovarian cancer surgery cases in Ontario are not performed optimally

  • Many women with high pre-operative likelihood of ovarian cancer in Ontario would not be referred to a gynaecologic oncologist prior to surgery

Elit et al., JOGC, 2006

Dodge, JOGC, 2007


Role of gyn oncology referral
Role of Gyn Oncology Referral disease?

  • Women with ovarian cancer who have primary surgery performed by a gynaecologic oncologist [at a tertiary centre] have a better outcome (survival)

    • More likely to be optimally staged

    • More likely to be optimally debulked

    • More likely to receive optimal adjuvant therapy

Elit et al., JOGC, 2006

Giede et al., Gynecol Oncol., 2005

Le et al., JOGC, 2009




Optimal surgery for ovarian and endometrial cancers

CCO Quality Indicators - Gagliardi et al., Gynecol Oncol, 2006

SOGC Guidelines – Le et al., JOGC, 2009

SGO Referral Guidelines, Gynecol Oncol, 2000

ACOG Committee Opinion #280, December, 2002


Endometrial cancer
ENDOMETRIAL CANCER should ideally be referred to a gynaecologic oncologist preoperatively to facilitate optimal surgery for ovarian cancer.”


Prototype case2
Prototype Case should ideally be referred to a gynaecologic oncologist preoperatively to facilitate optimal surgery for ovarian cancer.”

  • 61 y.o. G0P0 post-menopausal woman

  • Healthy, bleeding x few weeks

  • No abnormality detected on routine exam

  • Endometrial biopsy reveals grade 3 endometrioid adenocarcinoma of uterus

  • Booked for surgery by community gynaecologist


Prototype case3
Prototype Case should ideally be referred to a gynaecologic oncologist preoperatively to facilitate optimal surgery for ovarian cancer.”

  • TAH-BSO through lower transverse incision

  • No other abnormalities identified in OR note

  • Final pathology:

    • Serous carcinoma of uterus

    • No myometrial invasion, no LVSI/CLS

    • Negative cervix and adnexa



Optimal surgery for ovarian and endometrial cancers

What is the next best step in her management? disease?

  • Observation

  • Refer to Gynaecologic oncologist for repeat surgery for optimal surgical staging

  • Adjuvant chemotherapy (Carbo/Taxol IV)

  • Adjuvant radiotherapy

  • Other


Roles of primary surgery in endometrial cancer
Roles of Primary Surgery in Endometrial Cancer disease?

  • Diagnosis (final)

  • Staging (SURGICAL, NOT CT!)

  • Therapy

    • Palliation of symptoms

    • Removal of cancer (debulking)

  • Facilitating optimal adjuvant therapy

    • Prognosis of individual patient

    • Risks/benefits of adjuvant therapy


Surgery in endometrial cancer staging
Surgery in Endometrial Cancer: disease?Staging

Patterns of spread:

  • Local

  • Lymphatic

  • Intraperitoneal

  • Hematogenous

    Optimal surgical staging procedure must rule out metastases by all of these routes


Surgery in endometrial cancer staging1
Surgery in Endometrial Cancer: disease?Staging

Components of optimal surgical staging:

  • Peritoneal washings

  • Inspection and palpation of abdominal and pelvic organs and peritoneal surfaces

    • biopsy of all suspicious lesions

  • BSO (+/- TH)

  • “extended” surgical staging

    • Omentectomy and peritoneal biopsies

    • Pelvic & para-aortic lymphadenectomies


Staging for endometrial carcinoma
Staging for Endometrial Carcinoma disease?

FIGO 1971

Clinical Staging

FIGO 1988

Surgical Staging

GOG 33, 1987


Surgical staging findings
Surgical staging: Findings disease?

GOG 33 (n=621) – “clinical stage I”

  • exploratory laparotomy, TAH-BSO, pelvic & para-aortic nodes, peritoneal washings

    • positive peritoneal washings 12%

    • positive adnexa 5%

    • positive pelvic nodes 9%

    • positive aortic nodes 6%

    • intraperitoneal disease 6%

  • 22% ADVANCED STAGE DISEASE


Pelvic lymph node metastases
Pelvic lymph node metastases disease?

GOG 33, 1987


Para aortic lymph node metastases
Para-aortic lymph node metastases disease?

GOG 33, 1987


2009 figo staging endometrium
2009 FIGO disease?staging (endometrium)


Benefits of pelvic lymphadenectomy
Benefits of Pelvic disease?Lymphadenectomy

  • Documentation of true nodal status (prognostic)

    • usually only microscopic involvement (~90%)

    • worse prognosis when +ve (50-70% 5-yr OS with Rx)

Randall, 2006

Muggia, 2007


Benefits of pelvic lymphadenectomy1
Benefits of Pelvic disease?Lymphadenectomy

  • Therapeutic value

    • Benefit from chemotherapy +/- RRx if nodes involved

    • Avoidance of whole pelvic RRx if staging negative

    • ? Independent survival benefit

Randall, 2006

Muggia, 2007

PORTEC, EN-5, MRC, GOG 99, NRH

MRC, Italian trial vs.

Kilgore, Fanning, Orr,


Para aortic lymphadenectomy
Para-aortic lymphadenectomy disease?

  • Higher potential for morbidity

  • Prolonged operative time

  • Most cases (98%) can be predicted based on:

    • +ve pelvic nodes, OR

    • +ve adnexa, OR

    • +ve cervix

  • Potential benefit small

GOG 33, 1987

Faught, 1994


What are the risks

GOG LAP-2,2006 disease?

What are the risks?

  • Improved with training (Gyn Onc)

  • These risks not solely due to nodes

  • Much of this risk related to para-aortic node dissection

  • Much improved with laparoscopy (Lap-2)


Perspective from other pelvic cancers
Perspective from Other Pelvic Cancers disease?

  • Adjuvant chemotherapy proven survival benefit in node-positive colorectal cancer  mesorectal excision (node dissection)

  • Adjuvant chemotherapy proven survival benefit in node-positive cervical cancer

  • Risk of pelvic node metastases in cervical cancer managed surgically at PMH:

    5%


Current use of lymphadenectomy for endometrial cancer in toronto
Current Use of disease?Lymphadenectomyfor Endometrial Cancer in Toronto

  • NOT ROUTINE

  • SELECTIVE SAMPLING (suspicious nodes)

  • STAGING (not completely uniform)

    • Grade 2,3 endometrioid

    • Stage IC (with >50% myometrial invasion)

    • High risk histologic subtype without obvious extra-uterine disease


Key message1
KEY MESSAGE! disease?

What is the risk this woman has (undetected) metastatic disease?

  • <1%

  • 10%

  • 30%

  • 50%

  • 80%


Optimal surgery for ovarian and endometrial cancers

  • “Every woman with (endometrial) cancer deserves individualized management that maximizes her prognosis and minimizes her morbidity.”

  • “Documentation of disease extent via surgical staging allows optimal tailoring of adjuvant therapy to an individual patient’s risks.”