Devita, Hellman, and Rosenberg's Cancer

LWBK1006-23 LWW-Govindan-Review December 12, 2011 19:10

328 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Review

as primary therapy for the treatment of endometrial cancer but is typ-

ically reserved for patients with severe medical comorbidities in whom

surgery is thought to be too high a risk. These patients will still typically

require general anesthesia to allow for brachytherapy implantation into

the uterine fundus.

Answer 23.2.28. The answer is A.

The family history presented is worrisome for Lynch II syndrome.

Approximately 5% of endometrial cancers are hereditary, with the major-

ity being Lynch II (hereditary nonpolyposis colorectal cancer syndrome).

Lynch syndrome is caused by a defect in mismatch repair genes. Women

who carry one of these abnormal genes have a 22% to 60% chance of

developing endometrial cancer, which is similar to their risk of develop-

ing colorectal cancer. Patients with the diagnosis of endometrial cancer

with a strong family history should be counseled and offered genetic test-

ing. Families with BRCA1 or BRCA2 mutations confer an increased risk

in breast and ovarian cancer. There is no convincing evidence that these

patients are at an increased risk for the development of endometrial can-

cer. Endometrial cancer is not related to familial adenomatous polyposis

syndrome.

Answer 23.2.29. The answer is C.

Staging of endometrial cancer is typically surgical. Both a clinical and a

surgical staging system exist. A minority of patients with major medi-

cal comorbidities would typically not undergo surgical management and

require staging via the older clinical staging system. Since 1988, the sur-

gical staging system has been used as directed by FIGO. This patient is

correctly staged as IIIC.

Answer 23.2.30. The answer is D.

Adjuvant therapy for patients with stage IIIC disease remains con-

troversial. GOG-122 compared whole abdomen/pelvic radiation ther-

apy with chemotherapy (cisplatin plus doxorubicin × eight cycles)

and demonstrated a progression-free and overall survival benefit to

chemotherapy. GOG-184 evaluated “volume-directed” radiation ther-

apy that included pelvic and para-aortic lymph nodes when indicated,

followed by chemotherapy. Patients were randomized to two differing

chemotherapy arms (cisplatin plus doxorubicin vs. cisplatin, doxorubicin,

and paclitaxel). There was no significant benefit to the addition of pacli-

taxel for these patients. Methods to reduce toxicity of radiation ther-

apy including intensity-modulated radiotherapy (IMRT) are being inves-

tigated. Lower toxicity with potentially sparing the pelvic bone marrow

should allow for combination of radiation and chemotherapy to maxi-

mize efficacy.

Answer 23.2.31. The answer is D.

Recurrent endometrial cancer occurs most often in patients with high-risk

histologic subtypes (serous, clear cell, or carcinoma) or initial advanced