Modern Surgical and Staging Techniques Coming to Forefront of Endometrial Cancer

Ian S. Hagemann, MD, PhD

Ultrastaging of sentinel lymph nodes has become more of a “go-to” technique in endometrial cancer, explained Ian S. Hagemann, MD, PhD, adding that the removal of fewer lymph nodes is also becoming a more common approach.

“In the past 10 years, we have started to see that instead of taking out an entire lymph node packet, gynecologic surgeons started to take out only single or a few lymph nodes from the basin that drains the tumor,” said Hagemann. “Some of our research suggests that anything, including cutting single, individual sections, is better than cutting a routine section.”

Additionally, Hagemann explained that the pathologist is playing an even more significant role in modern endometrial cancer treatment, and that a multidisciplinary approach is more important now than ever.

In an interview with OncLive during the 2020 SGO Winter Meeting, Hagemann, an assistant professor of pathology and immunology, as well as obstetrics and gynecology, and associate director of Selective (Surgical) Pathology Fellowship at Washington University School of Medicine in St. Louis, discussed identifying resectable lymph nodes via ultrastaging and the importance of multidisciplinary treatment in patients with endometrial cancer.

OncLive: Could you discuss some of the research with sentinel lymph node dissection in endometrial cancer?

Hagemann: [A group of us] jointly developed the idea that we should look at [lymph nodes] more closely to identify smaller metastases by doing ultrastaging. One of the questions that comes up between institutions is how each group of pathologists is handling those single nodes and the best way to do that.

What are the current methods of lymph node dissection?

Most of the institutions, instead of cutting a single section for each lymph node, are cutting at least 3 sections. Usually doing [a further analysis] will add to the cost of the examination but should increase the sensitivity. Some institutions have tried doing even larger numbers of sections. It seems like there is a limit [to this approach], after which the additional sections don't incur additional benefit.

What are some misconceptions in staging for endometrial cancer?

One misconception that I've heard from more than one gynecologic oncologist is that we [don’t] need to perform ultrastaging to find low-volume metastases. Ultrastaging helps us find the low-volume metastases in lymph nodes. There's nothing about routine sectioning that makes it possible to identify micrometastasis or isolated tumor cells. We could probably benefit from clearing up that misconception because it contributes to the perception that doing routine sectioning of lymph nodes is below the standard of care because you cannot find the low-volume metastases — but you can [with ultrastaging].

Moving onto histology, what are the implications of HER2 amplification in endometrial cancer?

A high-impact paper and study has shown that adding trastuzumab (Herceptin) to chemotherapy for uterine serous carcinoma has a survival benefit—mainly in patients whose tumors overexpress HER2. We have assumed that measuring HER2 overexpression in uterine serous cancer is best done in the same way as breast cancer. Pathologists have been arguing for years about how to test for HER2 in breast cancer in an optimal way. It's possible that we should look more closely at how we do that for uterine serous cancer as well, although the approach in breast cancer will likely be the starting point.

How should oncologists work with pathologists on optimal staging and treatment?

The interplay in conversation between pathologists and gynecologic oncologists is so important. I have the benefit of being almost embedded in the Gynecologic Oncology Group at my institution. [All of the pathologists] have my phone number and I talk with them frequently. That helps me provide better services to pathologists and helps them make better use of our services. It's wonderful that the 2020 SGO Winter Meeting includes pathology and, for the past few years, we've had pathologists here to give us perspective.

What advice do you have for community oncologists?

For the community oncologists, I would first recommend keeping tabs with what the academic gynecologic oncology community is doing and talking about. This is a very exciting meeting. The SGO Winter Meeting is another very exciting place to get updates. A lot of the developments in academic gynecologic oncology are meant to be translated into the community. Keeping abreast of the trials is so important.