Clinical Pathway for Endometrial Cancer

Valena Wright, MD

Lahey Hospital and Medical Center

March 10, 2014

Objectives

• Diagnosing Endometrial cancer

• Pre-operative testing

• Surgical technique

– Application of new technology

• Patient education

Who develops endometrial cancer?

Clinical Presentation

• Asymptomatic

• Abnormal bleeding

• Genetic screening

Cost effective evaluation

• Office endometrial biopsy

• Morbidly obese BMI greater than 30

consider pelvic ultrasound for uterine size

Chest XRAY PA and Lateral

CA 125 in papillary serous, clear cell histology

Preoperative Teaching

• Expect same day discharge

• Patients with co morbidities scheduled as 3rd

case for expected overnight stay

• Talk to Fran

Multimodal Pain Therapy

• Set expectations/ discuss with anesthesia

• pregabalan

• Tylenol

• Celebrex

• Avoid narcotics

• Gabalin Pregabalan

Celebrex

Laparotomy

• Enlarged uterus > 12 weeks

• Adnexal pathology greater than 7 cm

• Metastatic disease not amenable to surgical resection

MIGS

• TLH BSO, staging

• Robotic assisted TLH BSO staging

Who should be staged?

• Mayo Clinic Protocol

grade 1, 2

less than 1/3 myometrial invasion

tumor size less than 2 cm

How accurate is intraoperative pathology?

• Depends on who is looking

• Depends on gross verses frozen section

NCCN guidelines recommend expert GYN ONC pathology review on all new cancer cases.

How long does it take?

• Depends on OR case load

• Depends on gross verses frozen

• Depends on time of day

Staging

• Bilateral pelvic nodes

– External

– Obturators

– Para-aortic

How long does it take?

• Depends on surgeon

• Depends on resident

• Depends on patient BMI

• Depends on surgical exposure

ICG and infrared imaging

• IRB feasability study for high risk patients

– Grade 3

– Clear cell

– Serous

Robotic sentinel node

Adjuvant Therapy

• Determined by surgical staging

• Chemotherapy

• Radiation IMRT

• Vaginal brachytherapy

GOG

Prognosis

Low risk

High risk

Lynch Syndrome

• Immunohistochemistry for MSM

• Genetic counseling referral if screen positive

Cancer Surveillance

Are Pap smears helpful?

Future directions

• Remote console surgeon

Lindenburg Operation

Patient Education

• Document and counsel BMI

• Medical indications for barietric evaluation

• More likely to die from co-morbidites than cancer