optimal surgery for ovarian and endometrial cancers
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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 - PowerPoint PPT PresentationTRANSCRIPT
Optimal Surgery for Ovarian and Endometrial Optimal Surgery for Ovarian and Endometrial CancersCancers
Jason Dodge, MD, FRCSC, MEdApril 9th, 2010
ObjectivesObjectives
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
OVARIAN CANCEROVARIAN CANCER
Prototype CasePrototype 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 CasePrototype 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
What stage is this woman’s ovarian cancer?
a) 1A
b) 1B
c) 1C
d) 2B
e) 3C
What is the risk this woman has (undetected) metastatic disease?
a) <1%
b) 10%
c) 30%
d) 50%
e) 80%Young et al., JAMA, 1983
What is the best approach to her management at this point?
a) Observation
b) Refer back to local gynaecologist for repeat surgery for optimal surgical staging
c) Refer to Gynaecologic oncologist for repeat surgery for optimal surgical staging
d) Adjuvant chemotherapy (Carbo/Taxol IV)
e) Other
OutlineOutline
• Optimal surgery for ovarian cancer– Diagnosis– Surgical Staging– Debulking– Facilitating optimal treatment
Roles of Primary Surgery in Roles of Primary Surgery in Ovarian CancerOvarian 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:Surgery in Ovarian Cancer:StagingStaging
Patterns of spread:• Intraperitoneal• Local• Lymphatic• Hematogenous
Optimal surgical staging procedure must rule out metastases by all of these routes
Surgery in Ovarian Cancer:Surgery in Ovarian Cancer:StagingStaging
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
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FIGO staging (ovary)FIGO staging (ovary)
• 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
What stage is this woman’s ovarian cancer?
a) 1A
b) 1B
c) 1C
d) 2B
e) 3C
?
KEY MESSAGE!KEY MESSAGE!
What is the risk this woman has (undetected) metastatic disease?
a) <1%
b) 10%
c) 30%
d) 50%
e) 80%Young et al., JAMA, 1983
Surgery in Ovarian Cancer:Surgery in Ovarian Cancer:StagingStaging
“Stage 1” patients who are not optimally staged at surgery have a poorer survival!
ACTION trialTrimbos et al., JNCI, 2003
Surgery in Ovarian Cancer:Surgery in Ovarian Cancer:StagingStaging
No benefit to adjuvant chemoRx in patients who are optimally surgically staged!
ACTION trialTrimbos et al., JNCI, 2003
Surgery in Ovarian Cancer:Surgery in Ovarian Cancer:DebulkingDebulking
• 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 DebulkingTherapeutic Debulking
Bristow et al., JCO, 2002
Surgery in Ovarian Cancer:Surgery in Ovarian Cancer:Facilitating Optimal Adjuvant TherapyFacilitating 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 trialsTrimbos et al., JNCI, 2003
Surgery in Ovarian Cancer:Surgery in Ovarian Cancer:Facilitating Optimal Adjuvant TherapyFacilitating 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
Armstrong et al., NEJM, 2006
Covens et al., CCO Guidelines, 2005
Surgery in Ovarian Cancer:Surgery in Ovarian Cancer:Intraperitoneal ChemotherapyIntraperitoneal 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…
• 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
Dodge, JOGC, 2007
Elit et al., JOGC, 2006
Role of Gyn Oncology ReferralRole of Gyn Oncology Referral
• 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, 2006Giede et al., Gynecol Oncol., 2005
Le et al., JOGC, 2009
Early Stage Ovarian CancerEarly Stage Ovarian Cancer
N Population Question Measurement Results
Puls
Texas
1997
54 Stage 1 Gyne onc vs community gyne
6 yr survival 90% vs 68%
( p=0.04)
Mayer
Conneticut
1992
87 Stage 1 & 2 Gyne onc vs
non onc
5 yr survival 83% vs 76% (p<0.05)
Grossi
2002
156 Gyne onc vs
non onc
Staging lap adequate
47% vs 15%
(p< 0.001)
Le
Saskatchewan
2002
Early stage Minimal staging vs comprehensive staging
Recurrence OR 2.62 favouring
comprehensive
Advanced Ovarian CancerAdvanced Ovarian Cancer
N Population Question Outcome Results
Eisenkop 1992 263 Stage
3C & 4
Gyne onc vs non onc
survival 35vs 17%
(p<0.0001)
Carney 2002 848 All Utah Gyne onc vs non onc
5 yr survival 26 vs 15 mos
(p<.01)
Junor 1999 1866 All Scotland Gyne onc vs non onc
Survival 25 % death reduction
Tingulstad 2003 38 All stages Gyne onc vs non onc
Survival 21 vs 12 mos
(p=0.01)
Engelen 2006 512 All stages Gyne onc vs non onc
Survival
Stages 1-2
Stages 3-4
86% vs 70%
21% vs 13% (p=0.03)
Elit 2006 Ontario High volume vs low volume
Survival Higher volume better
outcome
• “Women with a high likelihood of having ovarian cancer should ideally be referred to a gynaecologic oncologist preoperatively to facilitate optimal surgery for ovarian cancer.”
CCO Quality Indicators - Gagliardi et al., Gynecol Oncol, 2006SOGC Guidelines – Le et al., JOGC, 2009
SGO Referral Guidelines, Gynecol Oncol, 2000 ACOG Committee Opinion #280, December, 2002
ENDOMETRIAL CANCERENDOMETRIAL CANCER
Prototype CasePrototype Case
• 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 CasePrototype Case
• 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
What is the risk this woman has (undetected) metastatic disease?
a) <1%
b) 10%
c) 25%
d) 50%
e) 80%
What is the next best step in her management?
a) Observation
b) Refer to Gynaecologic oncologist for repeat surgery for optimal surgical staging
c) Adjuvant chemotherapy (Carbo/Taxol IV)
d) Adjuvant radiotherapy
e) Other
Roles of Primary Surgery in Roles of Primary Surgery in Endometrial CancerEndometrial 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 Endometrial Cancer:Surgery in Endometrial Cancer:StagingStaging
Patterns of spread:• Local• Lymphatic• Intraperitoneal• Hematogenous
Optimal surgical staging procedure must rule out metastases by all of these routes
Surgery in Endometrial Cancer:Surgery in Endometrial Cancer:StagingStaging
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 CarcinomaStaging for Endometrial Carcinoma
FIGO 1971
Clinical StagingFIGO 1988
Surgical Staging
GOG 33, 1987GOG 33, 1987
Surgical staging: FindingsSurgical staging: Findings
GOG 33 (n=621) – “clinical stage I”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 DISEASE22% ADVANCED STAGE DISEASE
Pelvic lymph node metastasesPelvic lymph node metastases
Grade 1 Grade 2 Grade 3 TOTAL
None 0% 3% 0% 1%
Inner 1/3 3% 5% 9% 5%
Mid 1/3 0% 9% 4% 6%
Outer 1/3 11% 19% 34% 25%
TOTAL 3% 9% 18% 9%
GOG 33, 1987GOG 33, 1987
Para-aortic lymph node metastasesPara-aortic lymph node metastases
Grade 1 Grade 2 Grade 3 TOTAL
None 0% 3% 0% 1%
Inner 1/3 1% 4% 4% 3%
Mid 1/3 5% 0% 0% 1%
Outer 1/3 6% 14% 23% 17%
TOTAL 2% 5% 11% 6%
GOG 33, 1987GOG 33, 1987
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2009 FIGO staging (endometrium)2009 FIGO staging (endometrium)
Benefits of Pelvic LymphadenectomyBenefits of Pelvic 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
Randall, 2006
Muggia, 2007
Benefits of Pelvic LymphadenectomyBenefits of Pelvic Lymphadenectomy
• Therapeutic value– Benefit from chemotherapy +/- RRx
if nodes involved
– Avoidance of whole pelvic RRx if staging negative
– ? Independent survival benefitMRC, Italian trial vs.
Kilgore, Fanning, Orr,
MRC, Italian trial vs.
Kilgore, Fanning, Orr,
Randall, 2006
Muggia, 2007
Randall, 2006
Muggia, 2007
PORTEC, EN-5, MRC, GOG 99, NRH
PORTEC, EN-5, MRC, GOG 99, NRH
Para-aortic lymphadenectomyPara-aortic lymphadenectomy
• 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 Faught, 1994Faught, 1994
GOG 33, 1987GOG 33, 1987
What are the risks?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)
Blood loss > 1 litre
1%
GI injury 2%
GU injury 0.5%
Vascular injury 4%
Ileus 10%
Thrombosis 2%
Fistula 1%
Death 0.5%
GOG LAP-2,2006GOG LAP-2,2006
Perspective from Other Pelvic Perspective from Other Pelvic CancersCancers
• 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 Current Use of Lymphadenectomy for Endometrial Cancer in TorontoEndometrial Cancer in Toronto
• NOT ROUTINE
• SELECTIVE SAMPLINGSELECTIVE SAMPLING (suspicious
nodes)
• STAGING (not completely uniform)STAGING (not completely uniform)
– Grade 2,3 endometrioid
– Stage IC (with >50% myometrial invasion)
– High risk histologic subtype without obvious
extra-uterine disease
KEY MESSAGE!KEY MESSAGE!
What is the risk this woman has (undetected) metastatic disease?
a) <1%
b) 10%
c) 30%
d) 50%
e) 80%
• “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.”