Management of endometrial cancer found on routine hysterectomy for benign disease Prof Dr M Anıl Onan MAY 2017 - ANTALYA

12 850 Benign hysterectomy Unexpected uterine malignancy incidence 0.19 % Unsuspected endometrial cancer incidence 0.12 %

What are the causes of incidental gynecologic malignancy. Ayhan A What are the causes of incidental gynecologic malignancy? Ayhan A. et al.

Important Pathological Issues Histologic type of tumor Myometrial invasion Grade Low segment involvement Tumor size LVI Surgical margines

What have to be done in case of incidental endometrial cancer? With risk factors such as; high grade endometrioid, serous, clear cell, undifferentiated, carcinosarcoma histology MI> 50% Cervical stromal invasion LVI Tumor diameter> 2 cm “Chest/ Abdominopelvic CT” for metastatic disease NCCN-2017

Management in Low Risk Group Stage IA Tm size < 2 cm Just Observe Grade 1-2 No LND Endometrioid histology SEER data LNM 1.4 % in 4095 patients

Based on gross and microscopic evaluation: Endometrioid histology No LND MI< 50% 5 year OS 95.8% Grade I / II DS death 1.1% No cervical involvement No intra-abdominal metastases

Complementary surgIcal stagIng excludIng stage Iag1 recurrence rate DIsease –free survIval

12333 LND(+) vs 27063 LND(-) DSSurvival difference in stage I, G3 disease (90 vs 85%)(p<0.0001) No difference in stage I, G1-2 disease (p=0.26)(p=0.14)

In conclusion, women receiving pelvic lymphadenectomy reported no clinically relevant better HRQL or fewer symptoms compared to women who received radiotherapy or no adjuvant treatment at all. Using lymphadenectomy to tailor external beam radiotherapy and prevent over-treatment in low-risk clinical early stage patients can therefore be debated. Especially since PORTEC-2 [7,14] publications will lead to increased use of brachytherapy and thus even less gastrointestinal symptoms in patients who receive RT when additional risk factors are found after surgery. In addition to the fact that there is no evidence that pelvic lymphadenectomy decreases the risk of death or disease recurrence, pelvic lymphadenectomy cannot be recommended for stage I–II endometrial cancers.

Radiotherapy ? Aalders J(1980) External RT reduced locoregional recurrence more distant metastases no OS benefit Portec I, EBRT provided benefit for uterine- confined disease reduced locoregional recurrence ASTEC/EN .5 ; no improvement in RFS, PFS, OS minimal benefit for pelvic control GOG99 ; adj. Pelvic RT improved locoregional control and PFS without any OS benefit Not formally staged Not formally staged 50 % staged staged

Radiotherapy ? Portec 2, EBRT vs IVRT ; Similar and excellent pelvic and vaginal control rates for uterine-confined disease No OS benefit IVRT has less toxicity and a reasonable method for uterine-confined disease GOG240, high risk uterine-confined disease IVRT+EBRT vs IVRT+Chemo No OSurvival benefit with more toxicity in chemo group PFS improved , distant metastases decreased

Take Home Messages You can avoid incidental uterine malignancy by appropriate preoperative evaluation Imaging by CT indicated especially patients with risk factors In early stage without any/low risk factors, you can observe these patients Restaging have to be done in patients with high risk factors Except stage I; restaging and adjuvant therapy is mandatory

aonan68@yahoo.com