Cytoreductive Surgery in Advanced EC Contra Antonio Gonzlez Martn - - PowerPoint PPT Presentation

Cytoreductive Surgery in Advanced EC “Contra”

Antonio González Martín MD Anderson Cancer Center, Madrid GEICO

Surgery in endometrial cancer

Zanfagnin…and Andrea Mariani. Expert review of anticancer therapy 2016

Retrospective evidence for maximal cytoreduction in EC (I)

Author Stage and histology Median OS

• ptimal

Median OS non-optimal Goff Gyn Oncol 1994 47 pts Stage IV 29 complete resection 19 months 8 months Bristow Gyn Oncol 2000 65 pts Stage IVB Optimal (RD < 1 cm) in 55% Endometrioid 34%, serous 32% 34 months 11 months Tanner Gyn Oncol 2011 44 pts IIIC-IV carcinosarcoma Optimal = complete resection 52 months 8.6 months Thomas Gyn Oncol 2007 70 Pts IIIC-IV serous Optimal = complete resection 51 months 12 months

Cytoreductive surgery for advanced or recurrent endometrial cancer: A meta-analysis

• 14 retrospective cohorts, 672 patients
• Huge Heterogeneity

– definition of “optimal”: < 2 cm (3 studies) vs < 1 cm (7 studies) vs no-gross residual (4 studies) – primary surgery (10 studies) vs for recurrent disease (4 studies) – Histology in primary surgery : 5 studies only UPSC and 5 studies included all histologies – Only data of adjuvant therapy in 12 studies

• OS associuated with complete surgical cytoreduction (each

10% increase improving survival by 9.3 months, p=0.04) Joyce N. Barlin, Isha Puri , Robert E. Bristow. Gynecol Oncol 2010

Retrospective evidence for maximal cytoreduction in EC (II)

Author Stage and histology Median OS

• ptimal

Median OS non-optimal Alagkiozidis Int J Surg 2015

168 pts Stage III-IV 54 carcinosarcoma R0 64% 54 serous/clear Cell R0 53% 60 endometrioid R0 68% 25 months 21 months 22 months 36 months 13 months 9 months 12 months 21 months

Limitation of current evidence for upfront surgery

• Bias related to the retrospective nature of the data.
• Lack of good evidence regarding the impact of

histological subtype (type I vs Type II) and endometrioid molecular subtypes in the potential resectability and the outcome after complete resection.

• Impact of adjuvant chemo/radiation therapy.
• The rate of upfront complete cytoreduction is

surgeon dependent.

Impact of surgical skills in outcome

Alagkiozidis Int J Surg 2015 More mid and upper abdominal procedures performed (53% vs 69%) (omentectomy, peritonectomy, diaphragmatic resection and bowel resection)

Neoadjuvant chemotherapy

• Retrospective study
• 44 patients with stage IV uterine serous carcinoma
• 10 NACT followed by IS (interval surgery) vs 34 PCS

(primary cytoreductive surgery)

• Rates of debulking to no gross residual disease

(70%NAC vs 32.3% PCS) or less than 1 cm of disease (30%NAC vs 50%PCS)

• No difference in median PFS (10.4 vs 12months) or

OS (17.3 vs 20.7 months) for NAC and PCS.

Wilkinson-Ryan ey al. Int J Gyn Cancer 2015

Patterns of recurrence in EC

Zanfagnin…and Andrea Mariani. Expert review of anticancer therapy 2016

Factors for considering surgery in recurrent EC

• Site of recurrence
• Duration of the disease-free period
• General medical condition

–Performance status –Co-morbidities

• Prior adjuvant treatment (radiotherapy,

chemotherapy, or both)

Indications of surgery in recurrent EC

Zanfagnin…and Andrea Mariani. Expert review of anticancer therapy 2016

Isolated vaginal or pelvic recurrence and a history of radiotherapy, Recommendation is supported by only low-level evidence.

Indications of surgery in recurrent EC

Zanfagnin…and Andrea Mariani. Expert review of anticancer therapy 2016

If surgery is performed for recurrent EC the aim should be macroscopic complete resection, but there is a lack

• f prospective evidence

Conclusion

• There is a lack of prospective evidence regarding

the value of cytoreductive surgery in advanced endometrial cancer.

• Individual decisions should be made on the basis
• f performance status and clinical situation of the

patient, surgical risks and skills, and histological subtype.

• Neoadjuvant chemotherapy followed by interval

surgery merit further investigation.

• GCIG is an excellent network for leading a surgical

trial in advanced endometrial cancer.

Thank you