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The relationship between endometrial cancer sentinel lymph node micro and macro metastases and uterine pathology features
Abstracts / Gynecologic Oncology 141 (2016) 2–208
OF
SLN specimens that have been ultrastaged has been questioned. The objective of this analysis is to identify whether patients with positive SLNs demonstrate the previously identified risk factors for lymph node metastases. Methods: The FIRES trial is a multi-institution, prospective cohort study measuring the accuracy of SLN mapping in clinical stage I endometrial cancer (all histologies) in identifying metastatic disease. All patients received a standardized SLN mapping technique with cervical indocyanine green injection and robotic fluorescence imaging, followed by hysterectomy with pelvic and para-aortic lymphadenectomy. All H&E-negative SLN specimens were ultrastaged with immunohistochemistry (IHC) to cytokeratin. Pathologic results of the SLNs (including volume of disease: macro metastases versus micro metastases [b2 mm and isolated tumor cells]) were evaluated along with uterine tumor risk factors. Fisher exact test was used to compare dichotomous variables between groups. Results: Among 308 patients, 37 (12%) had nodal metastases, 30 of whom mapped at least 1 SLN (81%). Twelve patients (32%) with nodal metastases were detected only with IHC (≤2 mm). Compared with patients with macro metastases, micro metastases were less likely to be associated with high grade or nonendometrioid histology (P = .02), para-aortic metastases (P = .05), and lymphovascular space invasion (P = .001). All but 1 node-positive patient (97%) (including all patients with SLN micro metastases) demonstrated at least 1 previously described uterine pathology risk factor for lymphatic spread (grade 3 histology, outer half myometrial invasion or tumor size N2 cm). Conclusions: Micro metastases within SLNs appear to be associated with known uterine risk factors for nodal metastases. This supports the validity of metastatic disease identified in SLNs with ultrastaging techniques. The disease-specific outcomes of patients with lowvolume disease have not yet been established.
DP
tumors overexpress hormone receptors, which represent a potential treatment target. Our study objective was to determine the safety and survival outcomes of patients with advanced-stage LGSC treated with cytoreductive surgery (CRS) and hormone therapy (HT) in the primary setting. Methods: A retrospective study at two academic cancer centers was performed. Patients with stage II–IV LGSC underwent either primary or interval CRS, followed by adjuvant HT, between 2004 and 2014. Expert gynecologic pathologists reviewed all cases. Data on patient, surgical, and treatment variables were collected. Median progressionfree survival (PFS) and OS were calculated. Outcomes were compared with those of an age- and stage-matched LGSC control group treated with CRS and chemotherapy. Results: Twenty-six patients with LGSC were treated with CRS + HT. Primary CRS + HT was administered in 25 patients, and neoadjuvant chemotherapy followed by CRS + HT was administered in 1 patient. The median patient age was 46.5 years, and patients had stage II (n = 4), stage IIIA (n = 6), stage IIIC (n = 15), and stage IV (n = 1) disease. Optimal CRS to no apparent gross residual disease was achieved in 81.5%, optimal CRS less than 1 cm in 14.8%, and suboptimal CRS in 3.7%. The patient treated with neoadjuvant chemotherapy had extensive carcinomatosis and liver metastases (stage IV) that progressed with chemotherapy; after CRS, she has been progression-free for 15 months with shrinking liver implants on HT. Anastrozole was administered postoperatively in 55.6%, letrozole in 37.0%, and tamoxifen in 7.4%. The median time for HT was 18 months. After a median follow-up of 28 months (range, 10–126 months), 4 patients (14.8%) developed a recurrence. All initial abdominopelvic recurrences were salvaged with CRS with or without chemotherapy or HT. Three patients (11.5%) are alive with disease, and 23 (88.5%) have no evidence of disease. The median PFS was 22 months and median OS was not yet reached. Compared with a control group of 44 patients with LGSC treated with CRS + chemotherapy (median PFS: 21 months, median OS: 70 months), the survival of the HT-treated cohort was not significantly different. Conclusions: Our series describes the initial experience with CRS and HT for primary advanced-stage LGSC. Although surgery remains the mainstay of therapy, cytotoxic chemotherapy may not be necessary in the primary setting. These results merit further investigation in a prospective trial.
RO
30
TE
doi:10.1016/j.ygyno.2016.04.101
EC
RR
doi:10.1016/j.ygyno.2016.04.100
70 - Featured Poster Session When does the sentinel lymph node mapping support a less radical surgery in the management of early stage cervical cancer? A single institutional prospective study I. Koutroumpaa, N. Thomakosa, M. Sotiropouloua, D. Haidopoulosa, D.C. Papatheodoroub, M. Davidovic-Grigorakib, A. Bamiasa, G. Vlachosa, A. Rodolakisa. aAlexandra Hospital, University of Athens, Athens, Greece, b University of Athens School of Medicine, Alexandra Hospital, Athens, Greece
CO
Featured Poster Session: Meet the Professor: Connecting Minds for a Better Future
UN
69 - Featured Poster Session The relationship between endometrial cancer sentinel lymph node micro and macro metastases and uterine pathology features H.D. Hinshawa, J.F. Boggessb, L.D. Kowalskic, J.M. Scalicid, L.A. Cantrelle, K.M. Schulerf, R.K. Hannag, A. Ivanovab, D. Mateia, E.C. Rossib. aIndiana University School of Medicine, Indianapolis, IN, USA, b University of North Carolina at Chapel Hill, Chapel Hill, NC, USA, c Nevada Surgery and Cancer Care, Las Vegas, NV, USA, dMitchell Cancer Institute, University of South Alabama, Mobile, AL, USA, eUniversity of Virginia School of Medicine, Charlottesville, VA, USA, fGood Samaritan Hospital, Cincinnati, OH, USA, gHenry Ford Health System, Detroit, MI, USA Objectives: The practice of selective lymphadenectomy based on uterine pathology risk factors has been popularized after risk factors for lymph node metastases were identified in large observational single institution and cooperative group studies. SLN biopsy is an alternative staging technique proposed to overcome the limitations of selective algorithms. The clinical validity of low-volume metastases identified in
Objectives: Lymph node (LN) metastasis is considered an important prognostic factor for recurrence in cervical cancer (CaCx). Therefore, we aim to develop a single algorithm detecting the sentinel lymph nodes (SLNs) and combining their status with other individual prognostic factors for metastasis, to avoid lymphadenectomy and radical parametriectomy in the surgical management of early-stage CaCx. Methods: Our prospective study included patients with CaCx, stage IA1-IIA1 (tumor size, 0.5-3 cm). Intracervical injection of methylene blue was given after induction of anesthesia, followed by detection of LNs that are dyed and sent for frozen section biopsy. Bilateral pelvic lymphadenectomy and radical hysterectomy was then performed and correlated with final histopathology. Results: Thirty-four patients were recruited. At least 1 SLN (range 0-6) was identified in 79.4% (27/34), whereas bilateral involvement was detected in 80% (20/25). SLNs were located at the external (53.8%) or internal iliac region (15.4%), obturator fossa (19.2%), and ventral to the hypogastric vessels (11.6%), whereas 9.1% were found in unexpected areas (parametrium) in cases with tumor sizes (TS) of 2.2 cm or more, positive lymphovascular space invasion, and depth of invasion of 0.5 cm or more. Parametrial involvement was not detected when SLNs were negative. False-negative SLNs and micrometastasis were identified in
OF
SLN specimens that have been ultrastaged has been questioned. The objective of this analysis is to identify whether patients with positive SLNs demonstrate the previously identified risk factors for lymph node metastases. Methods: The FIRES trial is a multi-institution, prospective cohort study measuring the accuracy of SLN mapping in clinical stage I endometrial cancer (all histologies) in identifying metastatic disease. All patients received a standardized SLN mapping technique with cervical indocyanine green injection and robotic fluorescence imaging, followed by hysterectomy with pelvic and para-aortic lymphadenectomy. All H&E-negative SLN specimens were ultrastaged with immunohistochemistry (IHC) to cytokeratin. Pathologic results of the SLNs (including volume of disease: macro metastases versus micro metastases [b2 mm and isolated tumor cells]) were evaluated along with uterine tumor risk factors. Fisher exact test was used to compare dichotomous variables between groups. Results: Among 308 patients, 37 (12%) had nodal metastases, 30 of whom mapped at least 1 SLN (81%). Twelve patients (32%) with nodal metastases were detected only with IHC (≤2 mm). Compared with patients with macro metastases, micro metastases were less likely to be associated with high grade or nonendometrioid histology (P = .02), para-aortic metastases (P = .05), and lymphovascular space invasion (P = .001). All but 1 node-positive patient (97%) (including all patients with SLN micro metastases) demonstrated at least 1 previously described uterine pathology risk factor for lymphatic spread (grade 3 histology, outer half myometrial invasion or tumor size N2 cm). Conclusions: Micro metastases within SLNs appear to be associated with known uterine risk factors for nodal metastases. This supports the validity of metastatic disease identified in SLNs with ultrastaging techniques. The disease-specific outcomes of patients with lowvolume disease have not yet been established.
DP
tumors overexpress hormone receptors, which represent a potential treatment target. Our study objective was to determine the safety and survival outcomes of patients with advanced-stage LGSC treated with cytoreductive surgery (CRS) and hormone therapy (HT) in the primary setting. Methods: A retrospective study at two academic cancer centers was performed. Patients with stage II–IV LGSC underwent either primary or interval CRS, followed by adjuvant HT, between 2004 and 2014. Expert gynecologic pathologists reviewed all cases. Data on patient, surgical, and treatment variables were collected. Median progressionfree survival (PFS) and OS were calculated. Outcomes were compared with those of an age- and stage-matched LGSC control group treated with CRS and chemotherapy. Results: Twenty-six patients with LGSC were treated with CRS + HT. Primary CRS + HT was administered in 25 patients, and neoadjuvant chemotherapy followed by CRS + HT was administered in 1 patient. The median patient age was 46.5 years, and patients had stage II (n = 4), stage IIIA (n = 6), stage IIIC (n = 15), and stage IV (n = 1) disease. Optimal CRS to no apparent gross residual disease was achieved in 81.5%, optimal CRS less than 1 cm in 14.8%, and suboptimal CRS in 3.7%. The patient treated with neoadjuvant chemotherapy had extensive carcinomatosis and liver metastases (stage IV) that progressed with chemotherapy; after CRS, she has been progression-free for 15 months with shrinking liver implants on HT. Anastrozole was administered postoperatively in 55.6%, letrozole in 37.0%, and tamoxifen in 7.4%. The median time for HT was 18 months. After a median follow-up of 28 months (range, 10–126 months), 4 patients (14.8%) developed a recurrence. All initial abdominopelvic recurrences were salvaged with CRS with or without chemotherapy or HT. Three patients (11.5%) are alive with disease, and 23 (88.5%) have no evidence of disease. The median PFS was 22 months and median OS was not yet reached. Compared with a control group of 44 patients with LGSC treated with CRS + chemotherapy (median PFS: 21 months, median OS: 70 months), the survival of the HT-treated cohort was not significantly different. Conclusions: Our series describes the initial experience with CRS and HT for primary advanced-stage LGSC. Although surgery remains the mainstay of therapy, cytotoxic chemotherapy may not be necessary in the primary setting. These results merit further investigation in a prospective trial.
RO
30
TE
doi:10.1016/j.ygyno.2016.04.101
EC
RR
doi:10.1016/j.ygyno.2016.04.100
70 - Featured Poster Session When does the sentinel lymph node mapping support a less radical surgery in the management of early stage cervical cancer? A single institutional prospective study I. Koutroumpaa, N. Thomakosa, M. Sotiropouloua, D. Haidopoulosa, D.C. Papatheodoroub, M. Davidovic-Grigorakib, A. Bamiasa, G. Vlachosa, A. Rodolakisa. aAlexandra Hospital, University of Athens, Athens, Greece, b University of Athens School of Medicine, Alexandra Hospital, Athens, Greece
CO
Featured Poster Session: Meet the Professor: Connecting Minds for a Better Future
UN
69 - Featured Poster Session The relationship between endometrial cancer sentinel lymph node micro and macro metastases and uterine pathology features H.D. Hinshawa, J.F. Boggessb, L.D. Kowalskic, J.M. Scalicid, L.A. Cantrelle, K.M. Schulerf, R.K. Hannag, A. Ivanovab, D. Mateia, E.C. Rossib. aIndiana University School of Medicine, Indianapolis, IN, USA, b University of North Carolina at Chapel Hill, Chapel Hill, NC, USA, c Nevada Surgery and Cancer Care, Las Vegas, NV, USA, dMitchell Cancer Institute, University of South Alabama, Mobile, AL, USA, eUniversity of Virginia School of Medicine, Charlottesville, VA, USA, fGood Samaritan Hospital, Cincinnati, OH, USA, gHenry Ford Health System, Detroit, MI, USA Objectives: The practice of selective lymphadenectomy based on uterine pathology risk factors has been popularized after risk factors for lymph node metastases were identified in large observational single institution and cooperative group studies. SLN biopsy is an alternative staging technique proposed to overcome the limitations of selective algorithms. The clinical validity of low-volume metastases identified in
Objectives: Lymph node (LN) metastasis is considered an important prognostic factor for recurrence in cervical cancer (CaCx). Therefore, we aim to develop a single algorithm detecting the sentinel lymph nodes (SLNs) and combining their status with other individual prognostic factors for metastasis, to avoid lymphadenectomy and radical parametriectomy in the surgical management of early-stage CaCx. Methods: Our prospective study included patients with CaCx, stage IA1-IIA1 (tumor size, 0.5-3 cm). Intracervical injection of methylene blue was given after induction of anesthesia, followed by detection of LNs that are dyed and sent for frozen section biopsy. Bilateral pelvic lymphadenectomy and radical hysterectomy was then performed and correlated with final histopathology. Results: Thirty-four patients were recruited. At least 1 SLN (range 0-6) was identified in 79.4% (27/34), whereas bilateral involvement was detected in 80% (20/25). SLNs were located at the external (53.8%) or internal iliac region (15.4%), obturator fossa (19.2%), and ventral to the hypogastric vessels (11.6%), whereas 9.1% were found in unexpected areas (parametrium) in cases with tumor sizes (TS) of 2.2 cm or more, positive lymphovascular space invasion, and depth of invasion of 0.5 cm or more. Parametrial involvement was not detected when SLNs were negative. False-negative SLNs and micrometastasis were identified in