GYN Case Poll

[ramsesthenice]

82 y/o female with endometrial adenocarcinoma has TLH/BSO and SLN Bx. Path shows deep myometrial invasion (90%) with grade 3 disease. SLN bx mapped 3 nodes, all negative. No more extensive dissection performed. Margins negative. Good performance status and no major illnesses. What would you do?

1) Whole pelvic
2) VBT alone
3) VBT + chemo
4) Observe

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[Mandelin Rain]

Didn’t mention lvsi, but either way, I’m probably going pelvis

 

[TheWallnerus]

1

 

[macstjo]

Whole pelvis

 

[ramsesthenice]

That didn’t take long to see we are all in the same page. Let me ask a different question: does anyone know of decent data regarding the value of a negative SLN bx in high risk early stage endometrial cancer with regards to predicting nodal involvement? That’s really the question needed to pick between options 1 and 2. I concede to our Gyn Onc that the benefit of whole pelvic RT vs VBT with a negative SLN May well be less than in the key trials. However, I think option 1 remains standard of care until there is convincing data to support that.

 

[Mandelin Rain]

Sentinel Lymph Node Biopsy vs Lymphadenectomy for Endometrial Cancer Staging

This cohort study examines the diagnostic accuracy, performance characteristics, and morbidity associated with sentinel lymph node biopsy in patients with intermediate- and high-grade endometrial cancer.

jamanetwork.com

SLNBx is very good for endometrial cancer, but to my knowledge, no one has changed adjuvant XRT recs based on it

 

[Reaganite]

Sentinel Lymph Node Biopsy vs Lymphadenectomy for Endometrial Cancer Staging

This cohort study examines the diagnostic accuracy, performance characteristics, and morbidity associated with sentinel lymph node biopsy in patients with intermediate- and high-grade endometrial cancer.

jamanetwork.com

SLNBx is very good for endometrial cancer, but to my knowledge, no one has changed adjuvant XRT recs based on it

Was gonna post this article myself. I'm starting to have some gyn oncs ask for cuff only in these cases, although majority still prefer pelvis. Still feel like in the end thisll be another site we lose. Sln being used in pretty advanced breast. We haven't lost xrt there because recurrences happen in the chest wall but the main rationale for pelvis in endo is regional control...

 

[jondunn]

pelvis IMO is the most 'correct answer' but also depending on what type of 82 year old she is (a real 82?) you could justify doing vbt alone.

but yeah whole pelvis. If she can have surgery she can have pelvic imrt.

Would like to see more sentinel data

 

[TheWallnerus]

Sentinel Lymph Node Biopsy vs Lymphadenectomy for Endometrial Cancer Staging

This cohort study examines the diagnostic accuracy, performance characteristics, and morbidity associated with sentinel lymph node biopsy in patients with intermediate- and high-grade endometrial cancer.

jamanetwork.com

SLNBx is very good for endometrial cancer, but to my knowledge, no one has changed adjuvant XRT recs based on it

this trial too...

A comparison of sentinel lymph node biopsy to lymphadenectomy for endometrial cancer staging (FIRES trial): a multicentre, prospective, cohort study

Was gonna post this article myself. I'm starting to have some gyn oncs ask for cuff only in these cases, although majority still prefer pelvis.

I think if gyn onc orders cuff after negative SLN, you serve cuff... but if I am choosing freely, I am going to choose pelvic RT.

 

[madchemist89]

In my mind, a 1b grade 3 has no good data to offer vaginal cuff. These patients were not included in portec 2.

 

[communitydoc13]

Why is nobody bringing up Randall's GOG 0249 trial. Chemo + VCB vs whole pelvic RT for high risk stage I or stage II patients. Mostly endometrioid histology and this patient would qualify (nodal dissection recommended). These were node negative patients. Equivalent survival and PFS numbers with improved pelvic control with pelvic XRT. Pelvic recurrences favored pelvic XRT (9% to 4%) and toxicity favored pelvic XRT.

So whole pelvic prob equivalent to adding 3 cycles of carbo/taxol plus some to VCB for these high risk early stage pts. Unless bad underlying bowel disease, seems straightforward to me.

Of course, there is some line where std treatment just too much. Different for each pt and disease site but often mid 80s is where things go south in my experience.

 

[Palex80]

The new WHO classification defines 4 subgroups of endometrial camcer based on molecular markers.
These 4 subgroups have a different prognosis. I would thus ask for more Information from the pathology.

The recently published ESGO/ESTRO/ESP guidelines call for treatment management based on the molecular profile.

ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma | International Journal of Gynecologic Cancer

With an unknown molecular profile this is a high-intermediate grade tumor (stage IB, high grade), but you see that with a known molecular profile it can anything be from low to high risk. The ESGO/ESTRO/ESP guideline calls to guide treatment in certain subgroups based on the molecular profile.

 

[thecarbonionangle]

Curious if anybody would add vaginal brachy ( 6x3 prescribed to surface) after WPXRT?

 

[ramsesthenice]

The new WHO classification defines 4 subgroups of endometrial camcer based on molecular markers.
These 4 subgroups have a different prognosis. I would thus ask for more Information from the pathology.

The recently published ESGO/ESTRO/ESP guidelines call for treatment management based on the molecular profile.

ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma | International Journal of Gynecologic Cancer

With an unknown molecular profile this is a high-intermediate grade tumor (stage IB, high grade), but you see that with a known molecular profile it can anything be from low to high risk. The ESGO/ESTRO/ESP guideline calls to guide treatment in certain subgroups based on the molecular profile.
View attachment 347934

There are long and short answers to this question and I don't have time for the long answer now (sadly). Essentially, the US isn't there yet. I don't think I have ever seen the results of a POLE analysis for endometrial cancer. I think this is an extremely important point that probably speaks to why it has been so difficult to show a survival benefit with adjuvant chemotherapy. The question we are all leaning towards with SLN Bx and molecular characterization is the same: what level of evidence is needed to start using a diagnostic/prognostic tool to guide adjuvant treatment decisions? What bothers me is inconsistency which I will sum up with 2 brief summaries of previous discussions.

Scenario 1:

Me: "I understand that SLN Bxs are very good at predicting the true risk of pelvic nodal involvement but there are currently no randomized trials which have used the results of a SLN Bx to guide adjuvant decision making. Should we really admit whole pelvic radiation?"

Surgeon: "If the risk of nodal involvement is low then what are you going to accomplish with whole pelvic radiation other than morbidity?"

Scenario 2:

Me: "Before we subject this person with early stage endometrial cancer to chemo and radiation should we consider completing molecular analysis."

Surgeon: "There is no prospective randomized evidence supporting the use of molecular phenotyping to guide adjuvant therapies. Endometrial cancer is surgically staged."

(Sidebar: I really like the surgeons I work with and think for most things they are very reasonable. I admit reasonable people will have differences of opinions regarding EBM).

Curious if anybody would add vaginal brachy ( 6x3 prescribed to surface) after WPXRT?

I typically give 6 x 2 if there is cervical stromal involvement or close margins. I didn't give you that info but in this case neither were applicable.

 

[Mandelin Rain]

Not to make this all about medicolegal analysis, because it likely isn't in this case at all. She's older; I'm sure you can justify doing this or that or nothing if you really wanted in your documentation. But just my general gestalt of situations like this...

I'm not sure of your practice setting, but if you're in the community, I feel like your primary goal should be delivering standard of care treatment based on best evidence and/or well accepted guidelines when available. Obviously, guidelines are slow to adapt and variation is very acceptable based on patient or disease specific factors. I'm not sure this lady has obvious factors with the information presented, at least in my mind.

If your coat says MDACC or MSKCC, you get to take a few more liberties, even off-protocol because who is challenging the GYN "expert" at some prestigious cancer hospital?

 

[metallica81788]

Is there anything we do more complicated than decision of adjuvant endometrial treatment?

Clear as mud

 

[Palex80]

Is there anything we do more complicated than decision of adjuvant endometrial treatment?

Clear as mud

RNI in breast cancer.

 

[ramsesthenice]

Is there anything we do more complicated than decision of adjuvant endometrial treatment?

Clear as mud

Pediatric sarcomas and breast.

To your point, not many. We haven't even brought up chemo. Sandwich vs concurrent + adjuvant. Its a disaster.

 

[Mandelin Rain]

Is there anything we do more complicated than decision of adjuvant endometrial treatment?

Clear as mud

Even the ASCO and ASTRO guidelines didn't seem 100% in lockstep, but I try to abide with the ASCO ones that I find to be pretty reasonable and clear.

Certainly better than NCCN where its all like "Consider tumor directed radiation if you feel like it"

 

[ramsesthenice]

Even the ASCO and ASTRO guidelines didn't seem 100% in lockstep, but I try to abide with the ASCO ones that I find to be pretty reasonable and clear.

Certainly better than NCCN where its all like "Consider tumor directed radiation if you feel like it"

 

[jondunn]

Curious if anybody would add vaginal brachy ( 6x3 prescribed to surface) after WPXRT?

there is no indication for this in this case

 

[TheWallnerus]

RNI in breast cancer.

View attachment 347941

God, grant me the serenity to not include in the PTV the things I cannot change, courage to irradiate the things I can, and wisdom to know the difference.

 

[evilbooyaa]

The new WHO classification defines 4 subgroups of endometrial camcer based on molecular markers.
These 4 subgroups have a different prognosis. I would thus ask for more Information from the pathology.

The recently published ESGO/ESTRO/ESP guidelines call for treatment management based on the molecular profile.

ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma | International Journal of Gynecologic Cancer

With an unknown molecular profile this is a high-intermediate grade tumor (stage IB, high grade), but you see that with a known molecular profile it can anything be from low to high risk. The ESGO/ESTRO/ESP guideline calls to guide treatment in certain subgroups based on the molecular profile.
View attachment 347934

PORTEC-4 is evaluating molecular driven treatment but would not routinely de-intensify treatment off-protocol.

Consideration of intensifying treatment based on p53 mutation status or MELF pattern of invasion not unreasonable IMO.

The case as described, gets WPRT 100% of the time unless severe IBD or something. Not eligible for PORTEC-2 to confirm non-inferiority of VBT. Wouldn't give chemotherapy for IBG3 (although this patient WOULD have been eligible for both GOG 249 and PORTEC-3)

Curious if anybody would add vaginal brachy ( 6x3 prescribed to surface) after WPXRT?

I recommend vaginal brachytherapy boost strongly in instances of cervical stromal involvement or positive vaginal margin. I recommend VBT boost less strongly in situations of lower uterine segment involvement or cervical glandular involvement.

I would not consider LVSI or IBG3 be a consideration for adding VBT boost to WPRT.

 

[Palex80]

PORTEC-4 is evaluating molecular driven treatment but would not routinely de-intensify treatment off-protocol.

Indeed, PORTEC-4 is looking at this but the quoted ESTRO/ESGO guidelines already recommend acting based on molecular subtype:

Adjuvant treatment
Adjuvant treatment recommendations for endometrial carcinoma strongly depend on the prognostic risk group (see Table 2 for definitions of the prognostic risk groups with and without known molecular classification).
For patients with low-risk endometrial carcinoma, no adjuvant treatment is recommended based on data from multiple randomized trials. For patients with stage I–II POLEmut endometrial carcinomas, no adjuvant treatment seems justifiable based on the data from independent series showing very few recurrences and also in cases of observation.

So, basically if this tumor had a POLE-mutation, one could observe.

Yes, it's bold and yes, it's without a prospective randomized trial, but it's what the guideline calls for on this side on the Atlantic ocean.

 

[communitydoc13]

Phenotype of POLE-mutated endometrial cancer

Individualized therapy in endometrial cancer, the most common gynaecologic cancer in the developed world, focuses on identifying specific molecular subtypes. Mutations in the exonuclease domain of the DNA polymerase epsilon (POLE) gene define one such ...

www.ncbi.nlm.nih.gov

Gotta have the POLE info though, can't guess. Pretty rare, younger, smoker types. Very unlikely in this case.

 

[ramsesthenice]

Indeed, PORTEC-4 is looking at this but the quoted ESTRO/ESGO guidelines already recommend acting based on molecular subtype:

Adjuvant treatment
Adjuvant treatment recommendations for endometrial carcinoma strongly depend on the prognostic risk group (see Table 2 for definitions of the prognostic risk groups with and without known molecular classification).
For patients with low-risk endometrial carcinoma, no adjuvant treatment is recommended based on data from multiple randomized trials. For patients with stage I–II POLEmut endometrial carcinomas, no adjuvant treatment seems justifiable based on the data from independent series showing very few recurrences and also in cases of observation.

So, basically if this tumor had a POLE-mutation, one could observe.

Yes, it's bold and yes, it's without a prospective randomized trial, but it's what the guideline calls for on this side on the Atlantic ocean.

It is the future. Its basically oncotype for endometrial cancer. Wait...sentinal lymph nodes, oncotype, confusing chemo data...oh god. Endometrial is turning into breast cancer.

 

[evilbooyaa]

Indeed, PORTEC-4 is looking at this but the quoted ESTRO/ESGO guidelines already recommend acting based on molecular subtype:

Adjuvant treatment
Adjuvant treatment recommendations for endometrial carcinoma strongly depend on the prognostic risk group (see Table 2 for definitions of the prognostic risk groups with and without known molecular classification).
For patients with low-risk endometrial carcinoma, no adjuvant treatment is recommended based on data from multiple randomized trials. For patients with stage I–II POLEmut endometrial carcinomas, no adjuvant treatment seems justifiable based on the data from independent series showing very few recurrences and also in cases of observation.

So, basically if this tumor had a POLE-mutation, one could observe.

Yes, it's bold and yes, it's without a prospective randomized trial, but it's what the guideline calls for on this side on the Atlantic ocean.

Yeah Europeans are more agile in making treatment decisions before trial data comes out I suppose. I suppose I'm like a slow American who awaits the randomized trial data (or at least prospectively collected) data about whether a molecular marker is predictive to benefit of treatment.

 

[deleted1111261]

Yeah Europeans are more agile in making treatment decisions before trial data comes out I suppose. I suppose I'm like a slow American who awaits the randomized trial data (or at least prospectively collected) data about whether a molecular marker is predictive to benefit of treatment.

Ha! If some random Slovenian trial shows a benefit for additional fractions, every podunk center starts touting it as state of the art. If three multi national RCTs with median follow up of 12 years show that less fractions are better, “we need more follow up and an American study”.

As an example, I am seeing a lot of 60/40 for small cell (which is fine). I am all about being at the vanguard for a disease with a terrible prognosis with standard of care. Bring it! But, this was one small study with a very odd outcome. And no worse toxicity!

But, still people going into contortions about 5 fraction breast. Heard in tumor board: “We should probably only use in the very elderly low risk patients that have poor performance status.” Um, maybe we should not treat those patients at all?

 

[evilbooyaa]

Don't de-rail this thread with breast (the worst, as always!), Simul! /s

 

[deleted1111261]

I should be flogged for this! Sorry!

 

[elementaryschooleconomics]

But, still people going into contortions about 5 fraction breast. Heard in tumor board: “We should probably only use in the very elderly low risk patients that have poor performance status.”

Yeah, but come on - is she more than 30cm of separation?

CONVENTIONAL RIDE OR DIE, SON!

(sorry, was temporarily possessed by the spirit of a Radiation Oncologist born in 1949 and still practicing)

 

[thecarbonionangle]

Yeah, but come on - is she more than 30cm of separation?

CONVENTIONAL RIDE OR DIE, SON!

View attachment 348118

(sorry, was temporarily possessed by the spirit of a Radiation Oncologist born in 1949 and still practicing)

As he decides to do standard fractionation, he drops the inferior flash another cm and whispers to himself “yeah you don’t want to miss”