Evolving Treatment Paradigms in Endometrial Cancer - Episode 13

A Look at Surgical Innovations in EC

Bradley J. Monk, MD, FACS, FACOG, University of Arizona, Creighton University, & Arizona Oncology Practice of US Oncology

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Nicoletta Colombo, MD, PhD, Istituto Europeo di Oncologia

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Vicky Makker, MD, Memorial Sloan Kettering Cancer Center

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Domenica (Ketta) Lorusso, MD, PhD, Fondazione Policlinico Gemelli IRCCS

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David M. O'Malley, MD, The Ohio State University

Nicoletta Colombo, MD, PhD, reviews surgical advancements in endometrial cancer.

Brad Monk, MD, FACOG, FACS: We have talked about I/O [immuno-oncology], DDR, WEE1, PARP inhibitors, FGF, IDO, selinexor—that’s a lot of stuff. Nicoletta, I haven’t heard from you because I was saving this question for you. Is there any surgical innovation in the treatment of endometrial cancer? Everything we just talked about—we began with you guys saying, “Radiation doesn’t do much.” Then we talked for an hour and a half about systemic therapy. We did not even mention the word hysterectomy. Is there anything new in the surgical landscape—you being a high-volume, very respected surgical expert—or is surgery just sort of there? It’s the bread of the sandwich, so to speak. What’s inside?

Nicoletta Colombo, MD, PhD: You’re right. There have been some advances in surgery, of course. The role of minimally invasive surgery is very well recognized, for instance, particularly robotic surgery in the treatment of patients who are obese—which in the United States is a frequent situation. This has been a big advantage. Also, the sentinel lymph nodes—for years, we’ve been debating the role of a lymphadenectomy in the treatment of endometrial cancer. Is it curative? Is it diagnostic? What do we do after that? Now it’s well established that you can use—we perform only sentinel node biopsies in all patients, even patients who are high risk, because we believe that it’s mainly diagnostic and that it can guide us in terms of picking the proper adjuvant treatment.

In fact, you can spare most patients with major cancer from a lymphadenectomy. This is a big advantage if you think of the terrible sequelae that these patients had in the past, particularly if you’re considering the lymphadenectomy plus radiotherapy and the big lymphedema and so on. This isn’t trivial. This is really something important that we achieved in terms of surgical advances.

Brad Monk, MD, FACOG, FACS: Thank you for that expert opinion. In the United States, we say that because lymphedema is generally 2 things—it’s a lymphadenectomy and radiation together—we’re using less radiation. There might be a therapeutic benefit from removing the lymph nodes, not just 1 of them. Is there traction there? Because we’re not using whole pelvic radiation and with the potential therapeutic benefit of lymphadenectomy, should we swing the pendulum the other way, away from sentinel lymph nodes?

Nicoletta Colombo, MD, PhD: I’m not sure. But you’re right: Radiotherapy plays a major role in the lymphedema. Therefore, if you just do a lymphadenectomy—let’s say with chemotherapy; after that, this will be less a problem—I don’t see any evidence that a lymphadenectomy can be curative in endometrial cancer. That’s why I believe that the sentinel node is more than enough.

Brad Monk, MD, FACOG, FACS: Thank you for that.

TRANSCRIPT EDITED FOR CLARITY