Chirurgie in de Gynaecologische Oncologie - AZ … en congressen... · 1. Stadium I-II:...
Transcript of Chirurgie in de Gynaecologische Oncologie - AZ … en congressen... · 1. Stadium I-II:...
Zaterdag 5 oktober 2013
Isabelle Cadron, MD, PhD
Dienst Gynaecologie
Oncologie Kempen 2013
Chirurgie in de Gynaecologische
Oncologie
Ovarium
I. Beperkt tot ovarium
II. Uitbreiding in klein bekken
III. Uitbreiding buiten het klein bekken of aangetaste
lymfeklieren
IV. Aantasting extra-abdominaal (vb pleura) of levermeta’s
→ Beeldvorming +/- diagnostische laparoscopie
Stadium
1. Stadium I-II: stadieringslaparotomie:
TAH+BSO+omentectomie+pelviene en
para-Aortale LAD
2. Stage IIb-IIIb: primaire debulking = standard of care
3. IIIc - IV: neo-adj chemotherapie – intervaldebulking – adjuvante chemotherapie
Voor start therapie : Open scopie
• Altijd eerst biopsie voor diagnose OvC
• evaluatie operabiliteit ?
Behandeling
DEBULKING = wegname van alle macroscopisch zichtbare
tumorhaarden
= cytoreductie
Uitgebreidheid = f(pat en tumorload)
uterus + ovaria
omentum (infra- en/of supracolisch)
peritoneale ziekte (hele abdominale holte moet
geïnspecteerd worden)
evt darm-resectie, milt, galblaas, diafragma
lymfadenectomie (klieren bekken en para-aortaal)
Extraperitoneal hysterectomy with
resection of pelvic peritoneum
Extraperitoneal hysterectomy with
resection of pelvic peritoneum
Lymfeklieraantasting
Voor- en nadelen :
• operatietijd,
• perop verwikkelingen, oa bloeding (7% vs 1%)
• postop mortaliteit (2,7% vs 1,3%)
Cijfers : in OS ?
EORTC studie : neen
Primaire debulking
Intervaldebulking
Rest = 0 is enige doel
IGCS Meeting October 25th 2008 Bangkok;
NEJM 2010
Randomisation
Ovarian, tuba or peritonal cancer: FIGO stage IIIc-IV (n = 718)
Primary Debulking Surgery
Neoadjuvant chemotherapy
3 x Platinum based CT
Interval debulking (not obligatory)
Interval debulking if no PD
3 x Platinum based CT
> 3 x Platinum based CT > 3 x Platinum based CT
similar OS and PFS
NACT + IDS versus PDS: ITT
Median survial
PDS: 29 months
IDS: 30 months
HR for IDS: 0.98
(0.84, 1.13)
Contra-indicaties primaire HK
Neo-adj ChT gevolgd door intervalDS
1. tumor > 2cm rond a mesent sup of aan porta hepatis
2. Intrahepatische (multiple) metastases of verschillende extra-abdominale metastases (uitgezonderd reseceerbare inguinale / supraclaviculaire LK) >2 cm
3. slechte algemene toestand van pat (> 80j, cardiaal belast, dement,…) waardoor R=0 niet haalbaar is
4. Extensieve serosale invasie (plaques) op darmen, waarvoor multipele of grote darmresecties noodzakelijk zijn.
Cervix
Rond de baarmoederhals Stadium Ib = zichtbaar letsel
Ib1: < 4cm
Ib2: > 4cm
II: vag/parametrium
IIA1: ≤ 4 cm
IIA2: > 4cm
A: vagina
B: parametrium
III: vag/parametrium
A: vagina onderste 1/3
B: parametrium tot bekken
IV: buiten bekken of invasie mucosa
Stadium IVa Aantasting van blaas- of rectum-mucosa.
Stadium IVb Metastasen op afstand of ziekte buiten het kleine bekken
Lymfeklieren Lymfeklieraantasting
Stadium Pos LK pelv (%)
Ia1 0,2-0,8
Ia2 6 - 8
Ib 8 - 21
IIa 20 - 31
IIb 30 - 45
III >50
Pos LK para-Ao (%)
Ib 6
II 12
III 30
Behandeling
• Stadium Ia1 (< 1% LN + geen lymphadenectomie):
• Nog kinderwens: conisatie
• Kinderwens voldaan: hysterectomie zonder BSO
• Stadium Ia2-II a
• Wertheim-Meigs:
1) correcte stadiëring
2) verwijderen pathologische klieren (prognose ~ microM+)
3) behoud sexuele/ovariële functie
Wertheim-Meigs
verwijderen baarmoeder
met parametria en pelviene
lymfeklieren
- via laparoscopie
- via laparotomie
(+/- eierstokken)
Zenuwsparend
• Ureter- en blaasfistel (1%)
• Mortaliteit (0.1-0.25%)
• Dysfunctie blaas en rectum
• Dyspareunie
Voordeel HK:
• Bewaren ovariele functie
• Geen fibrose vagina
• LK status
HK + RT 5% fistulisatie en 10-15% lymfoedeem
Complicaties Wertheim-Meigs
↓ bij laparoscopie
• Stadium IIb-IVa:
radiochemotherapie ( pelvien +/- paraAo)
• Stadium IVb:
chemotherapie
Laparoscopische para-Ao lymfadenectomie:
aangetaste klieren?
Uterus
Stage I* Tumor confined to the corpus uteri
IA* No or less than half myometrial invasion (< 50%)
IB* Invasion equal to or more than half of the myometrium
Stage II* Tumor invades cervical stroma, but does not extend beyond the uterus**
Stage III* Local and/or regional spread of the tumor
IIIA* Tumor invades the serosa of the corpus uteri and/or adnexae#
IIIB* Vaginal and/or parametrial involvement#
IIIC* Metastases to pelvic and/or para-aortic lymph nodes#
IIIC1* Positive pelvic nodes
IIIC2* Positive para-aortic nodes with or without positive pelvic nodes
Stage IV* Tumor invades bladder and/or bowel mucosa, and/or distant metastases
IVA* Tumor invasion of bladder and/or bowel mucosa
IVB* Distant metastases, including intra-abdominal metastases and/or inguinal nodes
* G1, G2 of G3
** Endocervical glandular involvement only should be considered as Stage I and no longer as Stage II
# Positive cytology has to be reported separately without changing the stage
Stadium
‘apparent’ early stage endometriumca • Endometrioid
• Serous, clear cell, carcinosarcoma
→ TLH / TAH + BSO +/- pelviene en para-Ao LAD
advanced endometriumca • Stadium IV: beperkt tot peritoneale caviteit: primaire/interval
debulking
• Stadium IV: Parenchymateuse M+: chemotherapie or hormonale behandeling
recidief • Repeat Heelkunde
• Chemotherapie / Radiotherapie
• Hormonale therapie
Behandeling
33
Separate type of endometrial cancer Lauchlan S, Arch Pathol Lab med 1981;105:615-8
Hendrickson M, Am J Surg Pathol 1982;6:93-108
Bokhman J, Gynecol Oncol 1983;15:10-7
Represents 10% of all endometrial cancer diagnoses but accounts
for 39% of endometrial cancer related deaths Ueda et al., AJOG 2008;198:218
Cirisano et al., Gynecol Oncol 1999;74:385-94
Hamilton et al., Br J Cancer 2006;94:642-6
46% stage II-IV at presentation vs 21% in Endometrioid EC Creasman et al., Gynecol Oncol 2004;95:593-6
Sereus endometriumca
Overview on spread pattern in different subtypes of
endometrial cancer as reported in literature
N (%) Peritoneal
cytology
Adnexal Omental Pelvic LN
Grade 3 E 86/668 (13) 41/721 (6) 3/25 (12) 78/734 (11)
Carcinosarcoma 72/373 (19) 75/512 (15) 15/96 (16) 80/423 (19)
Serous 17/57 (13) 27/125 (22) 47/202 (23) 72/244 (30)
Clear cell 7/20 (35) 3/32 (9) 3/6 (50) 9/20 (45)
Amant et al., Gynecol Oncol 2005;98:274-80
Endometrial Carcinoma Clinical Stage I – FIGO 2009
< 2cm, Stage Ia G1-G2 or
> 2cm, G1 < 1/3 infiltr
TAH / TLH + BSO
Peritoneal Cytology
No Adjuvant Therapy
Endometrioid Stage Ib, or G3, or > 2cm, G1 >
1/3 , clear cell or serous
TAH / TLH + BSO
Peritoneal Cytology
Pelvic Lymphadenectomy
Neg Pelvic Ln
No Adjuvant Therapy, unless Endometrioid G3:
Paclitaxel Carbo x 6
Pos Pelvic Ln
Paclitaxel/Carbo 6x
Pelvic RT (?)
Macro/frozen section Pelv Ln + Macro Pos
Adnex Growth through serosa
Paraaortic Lymphadenectomy to
renal vessels
Neg PAO/Pos Pelvic:
Paclitaxel/Carbo
Pelvic RT
Pos PAO and Pelvic: Paclitaxel/Carbo x 6
Pelvic + PAO RT
G1 G2 G3
Endometrium 0% 3% 0%
Inner 1/3 3% 5% 9%
Middle 1/3 0% 9% 4%
Outer 1/3 11% 19% 34%
ENDOMETRIOID (N = 621)
PELVIC LYMPH NODE METASTASES
Creasman et al., Cancer 1987;60:2035-41
N = 328 grade 1 or 2, myometrial invasion < 50%, no extrauterine disease
Pelvic lymphadenectomy in 57%: 9/187 (5%) positive nodes
No patient with tumour < 2cm: pos nodes or DOD
Hysterectomy only if
grade 1-2
< 2cm
myometrial invasion < 50%
no extra-uterine disease
NEED FOR LYMPHADENECTOMY IN
ENDOMETRIOID ENDOMETRIAL CANCER
Mariani et al., Am J Obstet Gynecol 2000;182:1506-19
Compared to TAH, TLH is associated with a significantly
decreased risk of major surgical Aes and shorter hospital stay.
A laparoscopic surgical approach to early stage endometrial
cancer is safe.
Laparoscopie en safety?
LAP2 study, Walker et al. JCO 2009; Kornblith et al . JCO 2009; Mourits et al., Lancet
Oncol 2010; LACE study, Janda et al., Lancet Oncol 2010; Obermair A, Eur J ca 2012;
Walker J L et al. JCO 2012;
Laparotomy or laparoscopy for endometrial cancer:
Gynecologic Oncology Group LAP2 Study. Walker J L et al. JCO 2012;30:695-700
Cumulative incidence of recurrence by randomly
assigned treatment group.
Overall survival by randomly assigned treatment group.
median follow-up time of 59 months for 2,181 patients
Minimally invasive surgery versus laparotomy in women with
high grade endometrial cancer: A multi-site study performed at
high volume cancer center
Fader et al., Gynecol Oncol 2012
FREQUENCY OF OBSERVED METASTASES TO PELVIC
OR PARA-AORTIC OR BOTH NODE-BEARING REGIONS*
Mariani et al., Gynecol Oncol 2008;109:11-18
*In patients with lymphatic dissemination who underwent systematic pelvic and para-aortic lymphadenopathy.
Node site Endometrioid,
number (%) (n=32)
Nonendometrioid,
number (%) (n=25)
Total,
number (%) (n=57)
Pelvic only 12 (37) 7 (28) 19 (33)
Pelvic plus para-aortic 14 (44) 15 (60) 29 (51)
Para-aortic only 6 (19) 3 (12) 9 (16)
47/48 with aortic node metastases had :
a. Grossly positive pelvic lymph nodes (55% + paraAO nodes)
b. Grossly positive adnexal metastases (43% + paraAO nodes)
c. Outer 1/3 myometrial invasion (18% + paraAO nodes)
40 % of patients with aortic node metastases survive
In patients without extra-uterine metastases, grade was the most important prognostic variable
ENDOMETRIOID CARCINOMA, N=895
PARA-AORTIC LYMPHADENECTOMY
Morrow et al., Gynecol Oncol 1991;40:55-65 – Benedetti et al., Int J Gynecol Cancer
1998;8:322-7
Advanced Stage endometrial cancer: NACT + IDS