The IX t h Makassed Medical Congress - American University of Beirut

chemotherapy is the standard in this setting, surgery to resect recurrence has a role especially in
patients with recurrent immature teratomas.
Ovarian sex-cord tumors represent less than 10% of all ovarian malignancies. Granulosa cell
tumors, the more common histologic type, usually present as a pelvic mass and can be hormonally
active. The majority of cases present in early stage disease and the therapy is surgical. Because
of the high incidence of synchronous endometrial pathology (hyperplasia and cancer), it is
essential to evaluate the endometrium by biopsy especially if preservation of the uterus is being
considered.
SURGICAL STATING IN ENDOMETRIAL CANCER
Adnan R Munkarah, MD
Data from World Health Organization places cancer of the uterus as the seventh most common
cancer affecting women with an estimated 189,000 new cases and 45,000 deaths occurring
worldwide each year. The highest incidence rates are in the USA and Canada followed by
Europe, Australia and New Zealand. Lower rates occur in Africa and Asia.
The 1980’s witnessed some important discoveries that improved our understanding of the
biology of this disease. First, Bokhman proposed the hypothesis of two distinctly different forms
of endometrial carcinoma and their associated differences in risk factors and prognosis. Type
1, or endometrioid carcinoma, was thought to represent an estrogen-stimulated progression,
often arising in the setting of endometrial hyperplasia. Features of the type 1 carcinomas include
increased exposure to estrogen (nulliparity, early menarche, chronic anovulation, and unopposed
exogenous estrogen), obesity, and responsiveness to progesterone therapy. In contrast, type 2,
or non-endometrioid carcinoma, often arises in those who are multiparous, and not obese. These
tumors do not respond to progesterone therapy, and their prognosis is worse. The most common
forms of type 2 endometrial cancers include uterine papillary serous carcinoma and clear cell
carcinoma.
The second important milestone was a large prospective study by the Gynecologic Oncology
Group that identified the risk factors and patterns of metastasis of endometrial cancer. The study
showed that lymphatic spread represented the most common route of metastasis for endometrial
cancer. Risk factors associated with increased incidence of lymphatic spread include histologic
type and grade of the tumor, depth of myometrial invasion, lymph-vascular space invasion, ovarian
metastasis and extension to the lower uterine segment and/or cervix. These findings prompted the
International Federation of Gynecology and Obstetrics (FIGO) to implement a surgical staging
system for endometrial cancer that incorporated surgical assessment of the retroperitoneal lymph
nodes. Subsequent to these changes, a number of prospective studies have been conducted trying
to better define the role of lymphadenectomy and adjuvant radiation therapy in the context of early
stage endometrial cancer. Many of these studies have shown that adjuvant pelvic radiation therapy
results in an improvement in progression-free survival but not overall survival. In the United States of
America, most gynecologic oncologists perform surgical staging with lymph node dissection and
use the information of the surgical staging to direct the use of adjuvant therapy postoperatively.
Some cost-benefit studies have shown that such approach will be less costly than the liberal use of
pelvic radiation that was used in the early 1980’s.
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