National Comprehensive Cancer Network

Clinical Recommendations

JNCCN – The Journal of the National Comprehensive Cancer Network

Table of Contents - Volume 7, Number 5: May 2009

• NCCN Clinical Practice Guidelines in Oncology™
• Uterine Neoplasms
• Antiemesis
• Featured Articles
• Chemo- and Radiotherapy in Adjuvant Management of Optimally Debulked Endometrial Cancer
• Carcinosarcomas (Malignant Mixed Müllerian Tumor) of the Uterus: Advances in Elucidation of Biologic and Clinical Characteristics
• Role of Laparoscopic Surgery in the Management of Endometrial Cancer
• Obstacles to the Implementation of Antiemetic Guidelines
• Use of Acupuncture in the Control of Chemotherapy-Induced Nausea and Vomiting

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NCCN Clinical Practice Guidelines in Oncology™

Uterine Neoplasms

Adenocarcinoma of the endometrium is the most common malignancy of the female genital tract in the United States. Many physicians believe that adenocarcinoma of the endometrium is a relatively benign disease because of the early symptoms of irregular vaginal bleeding in this predominantly postmenopausal patient population, the often-localized nature of the disease, and the generally high survival rate. However, the estimated number of deaths from endometrial cancer continues to increase, indicating the need for a critical reassessment of the guidelines for managing endometrial cancer. Physicians must identify high-risk patients and tailor treatment appropriately to provide the best opportunity for long-term survival.

Antiemesis

Chemotherapy-induced nausea and vomiting (emesis) can significantly affect a patient’s quality of life, leading to poor adherence with further chemotherapy treatment. In addition, nausea and vomiting can result in other serious complications and deterioration of the patient’s status. These guidelines explore the prevention, treatment, and management of various types of emesis experienced by cancer patients, such as breakthrough, radiation-induced, and anticipatory.

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Featured Articles

Chemo- and Radiotherapy in Adjuvant Management of Optimally Debulked Endometrial Cancer
David Scott Miller, MD; Gini Fleming, MD; and Marcus E. Randall, MD

The role of chemotherapy and radiotherapy in adjuvant management of optimally debulked endometrial cancer with extrauterine involvement is evolving. Recent studies have suggested an expanded role for chemotherapy and questioned the benefit of radiation therapy. Ongoing and planned clinical trials should provide clarification.

Carcinosarcomas (Malignant Mixed Müllerian Tumor) of the Uterus: Advances in Elucidation of Biologic and Clinical Characteristics
Lauren E. Kernochan, MD, and Rochelle L. Garcia, MD

Carcinosarcoma of the uterus, or malignant mixed Müllerian tumor (MMMT), is a rare, typically extremely aggressive neoplasm histologically composed of malignant epithelial and spindled (stromal) elements. Although some debate exists in the literature, most authors now agree that most MMMTs derive from sarcomatous differentiation in a high-grade carcinoma. This article reviews the clinical and histopathologic features of this neoplasm, with particular emphasis on recent data supporting divergent differentiation of a primarily epithelial neoplasm (carcinoma) as the cause.

Role of Laparoscopic Surgery in the Management of Endometrial Cancer
Meaghan Tenney, MD, and Joan L. Walker, MD

The minimum surgical treatment for endometrial cancer is the removal of the uterus. The operative approach to achieve that goal ranges from vaginal hysterectomy alone to laparotomy with radical hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic, and para-aortic lymphadenectomy with possible omentectomy and resection of all metastatic disease. Stratifying the risk factors for predicting presence of metastatic disease has error rates that exceed tolerance for many gynecologic oncologists. Routine laparoscopic surgical staging with hysterectomy, pelvic and para-aortic lymphadenectomy, and removal of adnexa is accepted by most gynecologic oncologists as standard care for patients with endometrial cancer. Laparoscopic surgery has become the ideal initial surgical approach for this disease, allowing for visual inspection of common metastatic sites, biopsy of abnormal areas, and cytology from peritoneal surfaces. Intraoperative medical decision-making can be individualized, encompassing all known risk factors for metastases and balancing comorbidities and potential adverse outcomes. This article documents the adaptability of laparoscopic surgery to the needs of the individual patients and surgeons treating this disease.

Obstacles to the Implementation of Antiemetic Guidelines
Steven M. Grunberg, MD

Guidelines aid in the delivery of high-quality clinical care. They will, however, have minimal impact unless familiarity and adherence are achieved. Although nausea and vomiting are highly feared toxicities of chemotherapy that markedly decrease patient quality of life, modifications of physician behavior and improvement in standards of care, particularly in preventing delayed emesis, have only been slowly achieved. Variations in format, goals, physician education, and institutional education may all affect guideline implementation and state-of-the-art care. The relationship between these factors and the scientific basis of antiemetic guidelines must be considered to achieve optimal results and compliance.

Use of Acupuncture in the Control of Chemotherapy-Induced Nausea and Vomiting
Ting Bao, MD

Chemotherapy-induced nausea and vomiting is one of the most common and feared side effects of chemotherapy. Despite recent advances in pharmacologic antiemetic therapy, additional treatment for breakthrough chemotherapy-induced nausea and vomiting is needed. Acupuncture is a safe medical procedure with minimal side effects. A recent meta-analysis has shown that acupuncture significantly reduced the proportion of patients experiencing acute chemotherapy-induced vomiting. The trials, however, did not show that acupuncture significantly alleviates acute chemotherapy-induced nausea or delayed chemotherapy-induced nausea and vomiting. The clinical relevance of these results were limited by the fact that the trials predated the use of aprepitant and that only 1 or 2 acupuncture points were stimulated during acupuncture treatment. More clinical trials are needed to study the effect of acupuncture with additional antiemetic acupuncture points as an adjunct to modern pharmacologic antiemetic therapy.