Ask the Experts - Significance of Positive Peritoneal Washings in...
Ask the Experts - Significance of Positive Peritoneal Washings in...
A 60-year-old woman had a staging laparotomy with TAH+BSO because of endometrial carcinoma G2. Pathology revealed a 40% myometrial invasion. Nodes were not examined. Peritoneal washings contain adenocarcinoma cells. General health is excellent. What are the treatment recommendations?
This colleague is actually asking 2 distinct and yet connected questions: (1) what is the prognostic significance of positive peritoneal washings in the face of otherwise low-risk stage I endometrial carcinoma, and (2) is there any adjuvant therapy that will positively influence the outcome? The answer to both questions is not known.
Positive peritoneal cytology with tumor otherwise confined to the uterus has been demonstrated in approximately 5% of such patients, but whether these cancer cells are viable and subsequently able to successfully implant is unknown. Furthermore, the frequency of positive lymph nodes in patients with disease that is otherwise confined to the uterus is less than 1%; therefore, further surgery in the attempt to upstage is not indicated. However, some clinicians regard the presence of these cells as an independent poor prognostic factor.
Although randomly assigned studies have not set out to address the role of adjuvant therapy in this clinical situation, radiotherapy is unlikely to confer a survival benefit, given that extrapelvic recurrence is common in patients with defined high-risk disease (eg, > 50% myometrial invasion, G3 tumor). Moreover, it is known that this treatment modality is unnecessary for patients with resected, low-risk disease. The difficulty in performing randomly assigned trials is that most patients with early-stage disease are likely to survive (generally dying of other causes); therefore, the size of a study to demonstrate a benefit for a treatment would need to be very large and would present difficulties at recruitment.
Published opinions do not give consistent guidance about the most appropriate treatment; therefore, the patient should be made aware of the uncertainty. Systemic treatment with chemotherapy is a reasonable alternative to observation, if the patient is counseled properly. Six courses of platinum/doxorubicin-based treatment would be appropriate, given that these drugs are the most active and useful in the metastatic/advanced disease setting.
A 60-year-old woman had a staging laparotomy with TAH+BSO because of endometrial carcinoma G2. Pathology revealed a 40% myometrial invasion. Nodes were not examined. Peritoneal washings contain adenocarcinoma cells. General health is excellent. What are the treatment recommendations?
This colleague is actually asking 2 distinct and yet connected questions: (1) what is the prognostic significance of positive peritoneal washings in the face of otherwise low-risk stage I endometrial carcinoma, and (2) is there any adjuvant therapy that will positively influence the outcome? The answer to both questions is not known.
Positive peritoneal cytology with tumor otherwise confined to the uterus has been demonstrated in approximately 5% of such patients, but whether these cancer cells are viable and subsequently able to successfully implant is unknown. Furthermore, the frequency of positive lymph nodes in patients with disease that is otherwise confined to the uterus is less than 1%; therefore, further surgery in the attempt to upstage is not indicated. However, some clinicians regard the presence of these cells as an independent poor prognostic factor.
Although randomly assigned studies have not set out to address the role of adjuvant therapy in this clinical situation, radiotherapy is unlikely to confer a survival benefit, given that extrapelvic recurrence is common in patients with defined high-risk disease (eg, > 50% myometrial invasion, G3 tumor). Moreover, it is known that this treatment modality is unnecessary for patients with resected, low-risk disease. The difficulty in performing randomly assigned trials is that most patients with early-stage disease are likely to survive (generally dying of other causes); therefore, the size of a study to demonstrate a benefit for a treatment would need to be very large and would present difficulties at recruitment.
Published opinions do not give consistent guidance about the most appropriate treatment; therefore, the patient should be made aware of the uncertainty. Systemic treatment with chemotherapy is a reasonable alternative to observation, if the patient is counseled properly. Six courses of platinum/doxorubicin-based treatment would be appropriate, given that these drugs are the most active and useful in the metastatic/advanced disease setting.