New Treatments for Endometrial Cancer. Part 3
The way we classify the disease for the purpose of treatment approaches is shown on this slide. We divide the cases into those cases that are associated with local or regional involvement in the pelvic area or the abdominal cavity, and those who have disease that has disseminated to more distant sites. The local regional cases are subdivided into low risk, intermediate risk and high risk groups. Now the basis for this sort of subdivision of the patient population comes mainly from studies done by the gynecologic oncology group. One of these studies, GOG protocol 133, included 1,155 patients who were carefully surgically staged. There were another 222 on so-called GOG pilot 1, also all carefully staged endometrial carcinoma patients. The statisticians at GOG have subjected that database to detailed statistical analysis. The primary uterine risk factors associated with poor prognosis are higher grade, any degree of myometrial invasion – the deeper the greater the risk – and involvement of the cervix. Extrauterine factors that are considered risk factors are the involvement of the adnexae, spread to the peritoneal surface or involvement of the pelvic or periaortic lymph nodes. So those are the principal prognostic factors that are features of the tumor at the time of resection.
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For patients who are deemed to have low risk disease, that is stage Ia – that is disease confined to the endometrium – grade I or grade II. Surgical resection alone has a five year survival that exceeds 90% and in some series goes as high as 98%. So the recommended treatment for these patients is total abdominal hysterectomy plus a careful surgical staging to insure that the disease process is truly stage Ia, that it is confined to the endometrium, grade I or grade II. These constitute the vast majority of patients who present with disease limited to the pelvis, which again accounts for the excellent overall survival rate of endometrial carcinoma. Patients are deemed at intermediate risk for recurrence when they have stage I, stage Ia, grade III. That is, stage I confined to the myometrium, grade III, or any degree of myometrium invasion which would make the patient either stage Ib, involvement of the inner half of the myometrium, or stage Ic, involvement of the outer half of the myometrium. It also includes patients who have cervix involvement, stage II, or who have stage IIIa disease. IIIa disease consists of patients who are stage III by virtue of the serosa of the uterus, the adnexae, or have positive peritoneal cytology. That constitutes the intermediate risk group that has a 15-20% chance of relapse with no further therapy.