Patient Case 1: MMRp Recurrent Endometrial Carcinoma
Opening its discussion on endometrial carcinoma, a panel of experts led by Robert L. Coleman, MD, reflects on a patient with mismatch repair proficient (MMRp) recurrent disease.
Transcript:
Robert L. Coleman, MD, FACOG, FACS: Welcome, everybody. My name is Dr Rob Coleman, and I’m a gynecologic oncologist in Houston [Texas]. It’s great to be with you. I’m excited to have this Virtual Tumor Board® to talk about endometrial cancer. This is a great time to talk about endometrial cancer, a disease we see frequently in our offices. But in recent years we’ve seen an elevation of new therapies and the understanding of the science, and most important, an alignment of new therapy with that science. Today we’re going to discuss 3 cases and annotate those cases with this expert panel. I’m going to have them introduce themselves. Let me start with Dr Birrer.
Michael J. Birrer, MD, PhD: Thank you, Rob. Glad to be here. My name is Michael Birrer. I’m the director of the [University of Arkansas for Medical Sciences] Winthrop P. Rockefeller Cancer Institute in Little Rock. I’m a medical oncologist by training.
Robert L. Coleman, MD, FACOG, FACS: We won’t hold that against you. I’m also joined by nurse practitioner Kimberly Halla. Kimberly, introduce yourself.
Kimberly Halla, MSN, FNP-C: Thanks, Dr Coleman. My name is Kimberly Halla, and I’m a family nurse practitioner working with gynecologic oncology patients since 2009. I practice in Charlotte, North Carolina.
Robert L. Coleman, MD, FACOG, FACS: It’s great to have you to provide the proper perspective. We’re so pleased to have you here. Dr Tewari, please introduce yourself.
Krishnansu S. Tewari, MD: Thank you so much, Rob. I’m so happy to be here. My name is Krish Tewari. I’m a gynecologic oncologist at the University of California, Irvine, where I also serve as division director of gynecologic oncology.
Robert L. Coleman, MD, FACOG, FACS: Wonderful. We’re going to have a lively discussion. I’ll present 3 cases, and we’ll invite commentary along the wayto provide some perspective, on not only why we come up with the therapy we do but how patients tolerate it. We have such a great spectrum of experts to help us with that. I hope you enjoy this and that it provides real context stories, so you can take it into the clinic as you see these patients.
Without further ado, I’m going to get to the first case. Endometrial cancer is very common. Despite its prevalence, which is high globally, we’re still navigating through the best way to treat these patients. For years, we didn’t have anything approved except for hormones, and the standard of care was around chemotherapy. Recently we’ve seen a molecular annotation to this disease that has caused us to think about this disease differently. Fortunately, for the last 10 years or so, we’ve had much more molecular annotation of this disease, and it’s percolating its way into the management of these cases. We’ve chosen 3 cases to discuss that take advantage of our knowledge of the landscape of this disease and how we can best leverage the most effective therapies to provide opportunities for our patients to get the maximal benefit and hopefully with the least amount of toxicity, so they can have better and longer lives.
Our first case is a mismatch-repair proficient [MMRp] recurrent endometrial cancer patient. I’ll present this, and then I’ll have my cohost discuss some of these findings. This is a 67-year-old patient. She’s postmenopausal, and she presents with abnormal uterine bleeding for the past 3 months. She has 2 grown children, and she underwent menopause almost 15 years ago, at age 53, and has no family history. Her BMI [body mass index] is 34, and she has a history of diabetes, but it’s well controlled with medication. On exam, she had a large uterus with some right lower-quadrant tenderness on palpation.
She underwent a work-up. It’s not uncommon for a postmenopausal woman to present with bleeding. With an endometrial aspiration. It was graded as a FIGO [International Federation of Gynaecology and Obstetrics] grade 1 endometrioid histology. She undergoes an exploratory laparotomy TAH [total abdominal hysterectomy] BSO [bilateral salpingo-oophorectomy] and bilateral pelvic lymph node dissection. The pathology was reviewed as a grade 2 endometrial adenocarcinoma, and she had, from her lymphatic dissection, 18 pelvic lymph nodes, which were negative. However, in the uterus, the disease was invasive about 2.1 of 2.3 cm, so it was deeply invasive. The rest of the molecular annotation done on this tumor showed was that it was HER2 [human epidermal growth factor receptor 2] nonamplified and it ER [estrogen receptor] negative by IHC [immunohistochemistry]. As mentioned, the patient was also found to have this microsatellite-stable or MMRp characteristic. She was ultimately graded as grade 2. Based on the old criteria, she was a stage IB, grade 2 endometrial adenocarcinoma.
I want to talk a little about the case. I’m going to add in some the surgical components to provide context for how we approach endometrial cancer first. Then we’ll get into some of the details on the pathology. In this scenario, she had an exploratory laparotomy, total abdominal hysterectomy BSO, and a full pelvic lymph node dissection. This is less frequently done in patients who have a grade 1 histology. Patients who are obese are sometimes more easily cared for by using robotic hysterectomy or minimally invasive surgery to remove the uterus and BSO. Accompanying that is an assessment of the pelvic nodes by sentinel lymph node biopsy. If those of you who are listening in say, “Wait a minute. Why didn’t this patient get sentinel lymph node biopsies.” That’s something we would typically do. That’s done by injecting the cervix with lymphatic tracers that we can identify, predominantly minimally invasive but also in an open case. Ultimately, that helps identify the primary lymphatic space or lymphatic chain that’s draining the uterus.
From mapping studies done in the 1970s, we know that the primary lymphatic drainage out of the uterus goes through 4 different routes, most dominantly through the parametria. That’s why, if it’s going to spread, the pelvic nodes are usually the first place it will locate. There are also posterior chains that could directly drain to periaortic [lymph nodes]. Part of this assessment of looking where the sentinel node is, that gives us an opportunity to leverage all those potential lymphatic draining areas and provide a better alignment with a lymph node sampling, rather than a full lymphadenectomy, which this patient had.
Transcript edited for clarity.
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