Presentation is loading. Please wait.

Presentation is loading. Please wait.

Carcinoma dellEndometrio CronoprogrammaDiagnostico-Terapeutico.

Similar presentations


Presentation on theme: "Carcinoma dellEndometrio CronoprogrammaDiagnostico-Terapeutico."— Presentation transcript:

1 Carcinoma dellEndometrio CronoprogrammaDiagnostico-Terapeutico

2 CARCINOMA ENDOMETRIALE Sensibile aumento di incidenza In Italia 5-6-% dei tumori femminili 4-5000/ casi anno e 1700 decessi/anno. Diagnosticato in fase iniziale raggiunge tassi di sopravvivenza fino al 90%

3 CARCINOMA ENDOMETRIALE Accuratezza stadiazione clinica Chirurgia adeguata (isterectomia, linfoadenect., etc) Terapie adiuvanti ( sovra-sottotrattamento) Incremento sopravvivenza Riduzione morbilità iatrogena Migliore qualità della vita

4 da riferire urgentemente al Ginecologo Sanguinamento in post-menopausa (no TOS) Sanguinamento in post-menopausa (sospensione TOS >=6 sett.) Sanguinamento in post-menopausa (Tamoxifene)

5 Perdite Ematiche Atipiche Eco Pelvi TV Endometrio <4/5 mm Endometrio >4/5 mm Rassicurante Isteroscopia + biopsia endometriale NormalePat. Ben Cancro RassicuranteTerapiaRiferimento HRT/TAM Endometrio >8/10 mm

6 ENDOMETRIAL CARCINOMA The management of patients with early stage EC is probably the least uniform when compared to that for patients with other gynecological malignancies !

7 EC - Scottish Pop-based Study Staging Quality & Survival (Crawford, 2002) Surgeon CtgNo. Pts%FIGO doc.PWs Non-specialist61688 Gynecol. Oncol.8712p<.001p<.0001 Hospital Caseload (no. EC pts/year) 1-1949370 <=2019930p<.0001p<.002 79% of pts operated on by surgeons with <=5 EC pt caseload

8 Stadiazione FIGO (2009) ITumor confined to the corpus uteri IANo or less than half myometrial invasion IBInvasion equal to or more than half of the myometrium IITumor invades cervical stroma, but does not extend beyond the uterus IIILocal and/or regional spread of the tumor IIIATumor invades the serosa of the corpus uteri and/or adnexae IIIBVaginal and/or parametrial involvement IIICMetastases to pelvic and/or para-aortic LN IIIC1Positive pelvic LN IIIC2Positive para-aortic LN with or without positive pelvic LN IVTumor invades bladder and/or bowel mucosa, and/or distant metastases IVATumor invasion of bladder and/or bowel mucosa IVBDistant metastases, including intra-abdominal metastases and/or inguinal LN

9 Clinical assessmen t Surgical Staging Surgical Approach Adjuvant Therapy Final Pathology

10

11 ENDOMETRIAL CARCINOMA Preoperative Assessment Histotype Grade Myometrial infiltration Risk Profile Extra-uterine spread Lymphnode mets CC inf. Tumor diameter

12 Overview on spread pattern in different EC subtypes Amant et al. Gynecol Oncol, 2005 N (%)Peritoneal cytology AdnexaOmentumPelvic LN Grade 3 E86/668 (13)41/721 (6)3/25 (12)78/734 (11) Ca.sarcom a 72/373 (19)75/512 (15)15/96 (16)80/423 (19) Serous pap. 17/57 (13)27/125 (22)47/202 (23)72/244 (30) Clear cell7/20 (35)3/32 (9)3/6 (50)9/20 (45)

13 ENDOMETRIAL CARCINOMA Serous Papillary/Clear Cell vs End G3 SP & CCG3 No Pts6376 IP mets (%)28.67.9 N + (%)2819 M >50% (%)58.364 Aneuploidia (%)48.630.6 S.Greggi, Int J Gynecol Cancer (in press)

14

15 Endometrial Carcinoma Lymph nodal Status by M & G % G1-G2G3 PAPA M 05-11212n.a. M < 50%7-92-3167 M > 50%10- 17 4-63112 FIGO

16 EC – Upgrading on Final Pathology Preop. G1-2 Endometrioid AuthorNo. Pts% Upgraded Daniel, 1988 20514 Malviya, 1989 5511 Stovall, 1991 3913 Larson, 1995 14527 Obermair, 1999 13721 Frumovitz, 2004 15324 Eltabbakh, 2005 18229 Ben-Schacher, 2005 18119 Case, 2006 4344 Traen, 2007 64 3 Total120421

17 Identification of High Grade EC (Preop. End. Samples vs Final Pathology) % Missed Reference centers8-10 Overall10-25 Literature Review

18 CARCINOMA ENDOMETRIALE Diagnostica per immagini - Accuratezza Infiltrazione Miometrio SensibilitàSpecificità US69%70.6% TC66-86%66-75% RM78-100%83-100% Karen, Genit Imaging 1999 Lara A, Genit Imaging 2000 Hardesty,AJR 2001 Ruangvutilert, J Med Assoc Thai 2004 Manfredi, Rad 2004

19 Clinical Stage I Understaging 19-22 % Endometrial Carcinoma Literature review

20 CARCINOMA ENDOMETRIALE Diagnostica per immagini - Accuratezza Estensione alla Cervice SensibilitàSpecificità TC20-70%70-90% RM80-100%96-100% Karen, 1999 Hardesty, 2001 Manfredi, 2004 Nagar, 2006

21 END CA – Involvement of CC Hysteroscopy Hysteroscopy No Pts200 Accuracy (%)92.5 PPV (%)93.3 NPV (%)92.4 Lo, 2001

22 Analisys of EC Management North America & Western Europe Pre-surgical North America Western Europe Staging n° of center (%) n° of center (%) Hysteroscopy Routinely used 3 (6%) 27 (33%) Usually omit42 (87%) 47 (57%) Maggino et al, 1995-98

23 SIOG – EC Management Survey (99 centers; 2008) % yes Histeroscopy routine in preop staging 92.9 IRCCS/University 90.5 Hospital 93.6 Nord 88.5 Centro-sud100.0 <20 EC/y 93.6 >=20 EC/y 86.4

24 EC - Parametrial Involvement (%) by FIGO Stage AuthorPtsClin St. ISt. II Pathol St. ISt. IISt. IIISt. IV Total Yura 1996 91 Clin I-II --011.552.9-13.2 Tamussino 2000 24 Clin II -8.3-9 16 * --41.6 Sato 2003 269 Clin I-III 1.59.806316.91005.9 Pts undergoing Rad. or Mod. Rad. Hysterectomy * trans. cervix/param. +

25 FIGO Stage II EC Outcome by Type of Hysterectomy AuthorNo.% 5y PFS SHRHp % 5y OS SHRHp Mariani, 200120373100.0180100.01 Cohn, 200716076 94.05--- Cornelison,1999932---8493.05 Sartori, 2001203---7994.03 Ayhan, 2004488185NS8390NS

26

27 CARCINOMA ENDOMETRIALE Diagnostica per immagini - Accuratezza Metastasi linfonodali SensibilitàSpecificità TC57%92% RM50%95% Karen, Genit Imaging 1999 Connor Obstet Gynecol 2000 Manfredi, Rad 2004

28 Nodal Status Assessment? <10 % of +ve N are grossly enlarged (Creasman et al., Cancer 1987) >50 % of +ve nodes < 1 cm (Girardi et al., Gynecol Oncol 1993) (Benedetti et al., Int J Gynecol Cancer 1998)

29

30

31 537 patients randomly assigned 273 allocated Lymphadenectomy 264 allocated NO-Lymphadenectomy 9 patients not eligible intra- operatively Other histotype = 3 Stage IA = 2 Stage IB Grading 1 = 4 14 patients not eligible intra-operatively Other histotype = 5 Stage IA = 3 Stage IB Grading 1 = 6 264 available for Intention To Treat Analysis 250 available for Intention To Treat Analysis 38 protocol violations (< 20 nodes resected) 17 protocol violations (20 nodes resected) 226 patients available for Per-Protocol Analysis 233 patients available for Per-Protocol Analysis ILIADE-2 LIN.CE

32 months % χ 2 =0.45; P=0.50 events total ---- Lymphadenectomy 30 264 ___ No lymphadenectomy 23 250 Lymphad. 264 237 212 173 139 93 No lymph 250 226 193 160 125 93 Figure 3. Overall survival 90.0 85.9

33 months % χ 2 =0.17; P=0.68 events total ---- Lymphadenectomy 42 264 ___ No lymphadenectomy 36250 Lymphad. 264 225 196 159 131 89 No lymph 250 218 184 150 114 85 Figure 2. Disease free survival 81.7 81.0

34 ENDOMETRIAL CANCER INT-NAPLES Jan 2001-June 2005 (No.110 Clinical Stage I Endometrioid EC Pts op. on) BMI >= 35: 43 (39%) ASA >=3: 30 (27%) Uterus sized >12wks (and/or stenotic/deep vagina): 15 (14%) Potentially ineligible for LAVH: 50 (45%)

35 VariableNo.% Potentially eligible for LAVH LAVH performed Previous LPTM 34/61 23 12 55.7 100 52 Median Age (range) Median BMI (range) 63 (52-70) 29 (26-30) Pelvic LA Aortic LA No. Pelvic N 7 - 18 (12-28) 30 - Converted to LPTM Median OR time (min) 2 220 (160-330) 8.5 Lenght of Hospital stay (d)3.5 (3-6) LAVH in Clinical Stage I EC Prospective Analysis – INT Naples (2005-07) (Endometrioid; Age<=70; BMI<35; ASA<3)

36 RANDOMRANDOM LAP-ASS VAGINAL SURGERY ABDOMINAL SURGERY GOG TRIAL LAP2 FIGO Stage I-IIa Endometrial ca or Ut. Sarcoma Planned sample size: 2000; date of activation 1996

37 Careful evaluation of general conditions Co-pathology & ASA Medical Operability Selection for LAVH /TLH

38 S.I.O.G. - Indagine sulla Gestione Clinica del CE (99 centri; 2008) Chirurgia elettiva St. I% Addominale61.6 Vaginale 2.0 Totalmente lpsc11.1 Vaginale lpsc-ass. 6.1 Add o Lpsc17.2 Incl. Lpsc34.4 Missing 2.0

39 END. CANCER IN YOUNG WOMEN - is it possible to preserve fertility in young patients? - is it possible to achieve pregnancy in patients conservatively treated ?

40 EC Pts Treated 1993-95. Distribution of Pts by Age Group and Mode of Staging 0,4% 2.5%

41 EC < 40 year of Age Multivariate Analysis Factors Predicting Stage IA OR95% CI Grade (1 vs 2-3)16.8(5.0 – 69) Duska, 2001

42 Coexisting Ovarian Malignancies in EC Pts <45y-old Author% <45y% >45y Gitsch, 1995295 Evans-Metcalf 1998 112

43 Case Age (years) BMI (Kg/m 2 ) Histotype Grade Hormone Therapy Relapse (months) Pregnancy Follow-up (months) / Current Status 14124 E-G1 Oral MANo 79 / NED 23925 E-G1Oral MANo 77 / NED 33826 E-G1Oral MANo 68 / NED 43627 E-G1Oral MANo NFTD62 / NED 53731 E-G1Oral MANo 56 / NED 63825 E-G1Oral MANo 50 / NED 73723 E-G1 LNG-IUD No 43 / NED 83928 E-G1LNG-IUDNo 37 / NED 93926 E-G1LNG-IUDNo 30 / NED 103948 E-G1LNG-IUDNo 28 / NED 113723 E-G1LNG-IUDNo 26 / NED 124024 E-G1LNG-IUDNo 19 / NED 132853 E-G1LNG-IUD Yes No 17 / NED 142627 E-G1LNG-IUD No 13 / NED G. Laurelli & S. Greggi, Gynecol Oncol (in press)

44 CA ENDOMETRIALE RM addome-pelvi mdc CA 125 Rx Torace (2 pr) Val. Rischio Anestesiologico ASA >=3 T scarsamente diff. Istotipi Speciali Sospetta infiltrazione CC Sospetta/e metastasi LN Val. terapia conservativa Centro Riferimento Oncol Ospedale di II Livello

45 Low-Intermediate Risk EC Mariani, 2000 No benefit from LND or adjuvant RT Podratz, 1998; Keys, 2004 Adjuvant RT reduces local relapses, no impact on survival Adjuvant RT reduces local relapses, no impact on survival ESMO, 2009 IA, G1-2, <2cm

46 Intermediate & High Risk / Early Stage

47 Stage I - Endometrioid G1-2, IA, <2cm G1-2, >2cm G3 IB TH, BSO, Cyto TH, BSO, Cyto, pelvic LND pelvic N- pelvic N+ Ut Serosa /Adnexa + aortic N+ * No adjuvant CT + pelvic RTCT + pelvic/aortic RT aortic N- aortic LND


Download ppt "Carcinoma dellEndometrio CronoprogrammaDiagnostico-Terapeutico."

Similar presentations


Ads by Google