Identifying Recurrence in Patients With Endometrial Carcinoma
Key opinion leaders in the field of endometrial carcinoma management share advice on optimal patient monitoring and the identification of recurrent disease.
Transcript:
Robert L. Coleman, MD, FACOG, FACS: We’ll keep moving to this case here, deeply invasive grade 2, she ended up getting cuff brachytherapy, a high dose rate, and did well for about 14 months. Then she presented with ominous symptoms, right lower extremity edema and right hydroureter, on her imaging. Then she’s found to have a mass involving the right pelvic sidewall and has the counting for those symptoms. She does have a percutaneous biopsy, which reveals recurrent disease, so she goes on to therapy. In this situation, she ended up getting paclitaxel and carboplatin. Mike, what are your thoughts on that choice?
Michael J. Birrer, MD, PhD: That would’ve been standard. That is standard, and as you know, that whole process may change in the future.
Robert L. Coleman, MD, FACOG, FACS: That’s right.
Michael J. Birrer, MD, PhD: But it’s standard now. The only thing, I’ll throw this out to be controversial, as a medical oncologist, and the fact that she was grade 2 with fairly impressive invasion, I would’ve given her adjuvant [therapy].
Robert L. Coleman, MD, FACOG, FACS: No, I’m not disagreeing with you. She definitely falls into a high-risk category.
Michael J. Birrer, MD, PhD: I’m impressed that you agree because when you start talking about sentinel node stuff, you lose me.
Robert L. Coleman, MD, FACOG, FACS: It was hard to do, but I got over it. I’m moving on. So she gets carboplatin and paclitaxel, and then does well. She ultimately has an 18-month treatment-free interval and presents now with systemic disease, paraaortic nodes and disease in the lung. I think this brings up…you mentioned, Mike, she was high risk, so you might have been more aggressive with the primary adjuvant therapy. In this particular case, she ends up showing recurrence. What’s your experience with getting a good response with standard of care paclitaxel and carboplatin?
Michael J. Birrer, MD, PhD: It’s all gotten complicated because now we break patients down into different categories. But I consider it a chemotherapy sensitive tumor. I think response rates push 30% to 40%. And any of her prior therapies, her vaginal brachytherapy therapy, wouldn’t change that. Probably if she were mismatched or deficient, she would have a better response rate because those tumors tend to be on the edge of apoptosis to begin with. She’s stable, so that’s a bit lower. As I said, we don’t have any other data, but where the field is migrating toward is to get that panel and begin to look at other things. She had wild-type TP53, and we kind of expected her not to respond as well. If she had mutated TP53, maybe she would respond better. So it’s getting a bit more complicated.
Robert L. Coleman, MD, FACOG, FACS: In this patient, when she had her sidewall recurrence biopsy, would you resend that out for molecular testing?
Michael J. Birrer, MD, PhD: Yes, that’s a great question. I think our habit here is if we get a biopsy, and frankly, one could debate whether you really needed the biopsy in this case, just because you can. But if you get it, and if we can get the insurance to cover it, we will send it out again. Because there are pretty good data that there’s an evolution with these tumors, and we don’t want to miss that. So yes, I think that’s a good point.
Robert L. Coleman, MD, FACOG, FACS: One last question. We had a case recently that was a pMMR [proficient mismatch repair] tumor. Then on her recurrence, she was retested and found to be dMMR [mismatch repair deficient]. So it had converted. I’ve seen it reported happening about 10% of the time; I haven’t personally seen it. But that particular case had it. It’s just something maybe to keep in the back of your mind since the impact of immune therapy in that situation, which we’ll talk about in the next case, can be quite dramatic.
Michael J. Birrer, MD, PhD: You’re absolutely right. It’s a great point, Rob. You’ve just changed the prognosis of that patient if that happens.
Robert L. Coleman, MD, FACOG, FACS: Kimberly, for a patient like this, how do you follow them? Let’s say this is a good case, she gets 6 cycles of chemotherapy, and imaging at the end of 6 cycles shows no evidence of disease. How do you monitor that in your shop?
Kimberly Halla, MSN, FNP-C: It’s a pretty typical response at this point. We’re seeing them every 3 months. We’re doing a physical exam, we’re making sure how things go, but we’re monitoring them with exams. “How are you feeling, how are you doing?” It’s not automatically imaging every 3 months. Because imaging can find all sorts of things that aren’t relevant that cause anxiety So it’s symptom management and making sure we’re doing a good physical exam on our patients.
Robert L. Coleman, MD, FACOG, FACS: Excellent. Do you get routine imaging along with that? I know it’s controversial.
Kimberly Halla, MSN, FNP-C: We really don’t. If we’ve got something going on, like if they’re having symptoms of some sort, absolutely, we have a low threshold for CT imaging. But if patients are doing well, there’s no need for that CT at that time.
Robert L. Coleman, MD, FACOG, FACS: We did a study on that, trying to see if it was cost effective, and we couldn’t find that it turned out to be cost effective. But I find that there’s a lot of variance in the general population about how often this is done. Mike, any difference in your place?
Michael J. Birrer, MD, PhD: The only point I would make, getting back to the original statement on that slide, is that the audience should know that the recurrence rate for these patients is sort of variable. There are studies reporting anything from 4% to 20%. So there’s a heterogeneity in it, and you need to appreciate that, I think. For us, again, I completely concur with Kimberly’s statement, which is sort of from the gyn-onc [gynecology-oncology] standpoint, pelvic exams are done, and there’s a lot of examination. We tend to be a little heavier on the scanning on the med-onc [medical oncology] side. I think the intent is simply to be able to identify the recurrence before they become symptomatic. We want to avoid any symptoms. But I can’t give you level 1 evidence that that changes things.
Robert L. Coleman, MD, FACOG, FACS: I hear you.
Transcript edited for clarity.
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