Gynecological Cancer – 9 Uterus Cancer – stage 3 and 4

Gynecological Cancer  – 9

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for salient points about Uterine Cancer. 1. Uterus Cancer is frequently associated with Lifestyle changes and Obesity. Two factors also associated with risk of breast, colon, prostate and other cancers. 2. If cancer occurs below age 50 or there is family history of colon cancer, consider genetic testing to rule out HNPCC (Lynch syndrome). 3. Patients with bleeding post menopause must be promptly evaluated, as it could be due to uterine or cervix cancer. 4. Most common subtype is endometrioid (adenocarcinoma) – frequently diagnosed in early stages, and surgery is frequently curative. Depending on pathology factors, additional treatment may be required. 5. Other less common histologies are generally more aggressive and need postoperative chemotherapy as well. 6. ALL PATIENTS UNDERGOING HYSTERECTOMY FOR ANY REASON, SHOULD HAVE SPECIMEN SUBMITTED FOR PATHOLOGY. Occasionally cancer may be detected in this specimen without any symptoms. Such patients must be additionally evaluated by a cancer surgeon, preferably a Gynaec Oncosurgeon, to decide further treatment plan.
Answer: Well summarized. As discussed, early stages require only surgery or surgery followed by radiotherapy (internal or external). Stage 3 and 4 require additional postoperative chemotherapy, most commonly carboplatin and paclitaxel for 6 cycles.
Follow up after completion of treatment includes mainly history, local examination, and probably abdominal sonography. Routing CT scan/ MRI/PET-CT are not recommended, as they rarely improve survival and frequently lead to many false positives as well as unnecessary radiation.
Que: Did I hear you say stage 4 patient undergoing postoperative chemotherapy? But I thought we never operate stage 4 cancers.
Ans: Answer is YES and NO. First principle of oncology is that ALL CANCERS ARE NOT EXACTLY SAME. A number of principles are common but not identical. There are cancers where even stage 4 are operated, with a significant benefit. For example, where all disease is confined to pelvis or abdomen as in uterine cancer and it is technically possible to resect all disease. If you remember, we have discussed in past about other organ sites also where stage 4 cancers are operated, if all disease can be resected. For example, head and neck cancer sites OR colon cancer with few resectable liver metastases.
Similarly, a stage 4 uterine cancer at diagnosis (generally not at relapse) should be operated if it is technically possible to remove all disease. There is no role for debulking i.e. removing majority of disease!
Few localized vaginal relapses are also operable. However radiotherapy is preferred for these if not given earlier.
Que: Thank you for clarifying that. There is always something new and very important to learn. So, it is important that even patients with stage 4 need not be labeled as incurable right away! Can you tell us something about other uncommon histologies like sarcoma?
Ans: Sure. All histologies are essentially treated same way initially i.e. complete surgical resection if feasible. Postoperative treatment is somewhat variable. Sarcomas and other high risk histologies are given postoperative chemotherapy more frequently compared to radiotherapy. Also, even lower stages are more likely to be given postoperative chemotherapy compared with adenocarcinoma. And there are more variations in chemotherapy agents used.
Que: How do you manage inoperable stage 4 or metastatic uterine adenocarcinoma?
Ans: Goal of treatment here is palliative. Some of these are limited to only vagina and may obtain lasting relief with only radiotherapy, especially if not given earlier.
For low grade (grade 1 or 2) and non bulky disease with minimal symptoms, one may even start with hormone therapy like megestrol or tamoxifen. In general, however, chemotherapy is used, such as carboplatin and paclitaxel. If patient has recurred shortly after postoperative chemotherapy, within 6 months, other agents should be used. Other agents include doxorubicin, liposomal doxorubicin, docetaxel, ifosfamide etc. All with limited benefit however in second line setting. Bevacizumab, a monoclonal antibody with antiangiogenesis effect, can be added to chemotherapy with some progression free survival advantage, but not overall survival advantage, similar to many other options in metastatic setting.

August 13th 2017.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com