Ami Vaidya, MD, Gynecologic Oncologist at Hackensack Meridian Health System, talks about endometrial cancer and her latest research as well as her patient Susan.
I want to start by asking you about endometrial cancer for our viewers, again, who may not be familiar with it, what is actually going on?
VAIDYA: Endometrial cancer represents the most common or most prevalent gynecologic malignancy in the United States. It’s part of the uterus, the inner lining of the uterus that’s affected. Cells in the inner lining of the uterus transform and become cancerous, and those cancer cells can affect not just the reproductive organs but, if not identified early, can spread to other parts of the body.
What are the treatments?
VAIDYA: The mainstay for treatment for endometrial cancer involves surgery. That surgery usually includes it’s a hysterectomy. It includes removal of the uterus, the cervix, the fallopian tubes and the ovaries. In many cases, we need to evaluate lymph nodes, and lymph nodes can be removed at the time of surgery as part of staging.
Is that traditionally a large open incision or can it be done in a minimally invasive way these days?
VAIDYA: Years ago it was done almost exclusively as an open procedure, but over the last 15 or so years, we’ve gotten better and better. The technology has allowed us to get better and better at offering minimally invasive surgery to our patients.
if you could tell me a little bit about some of the extra technology that doctors now have available to them that’s making this even more efficient.
VAIDYA: Sure. Robotic surgery has, I think, really revolutionized minimally invasive surgery. It’s allowed us to offer more patients small incisions, which allow patients to have shorter time in the hospital, fewer days of pain and a quicker recovery. We’ve also been able to minimize infection, which is tremendous. The robotic platform has progressed to start to now use fluorescence technology to let us utilize dye that we can inject in through the cervix into the uterus to help us identify what are called sentinel lymph nodes. In the past, we removed almost all comprehensive lymph nodes in the pelvic area even for patients with early stage or what was thought to be early stage cancer. Unfortunately, those patients had a higher risk of blood loss, sometimes longer recoveries, certainly longer surgical procedures, and in some cases lymphedema, which is swelling in the legs. This is a real quality of life issue for women and for women who have true early-stage cancer, we may not need to be that radical or that comprehensive. Studies have been done over the last few years that have shown that we can be very accurate by identifying what are called sentinel lymph nodes, and we do this for various other cancer types. Probably best known is for breast cancer but what we do is we want to identify lymph nodes that are the most likely nodes to be involved if cancer were to spread and leave the uterus. With this special fluorescence technology we call it firefly technology, we are able to identify in the near-infrared spectrum with a special camera glowing lymph nodes, and those are called the sentinel lymph nodes.
Kind of walk me through how doctors do that part of the process? How is the dye injected? How long does it take? Where does it go? And then you said there’s a special camera that picks it up. If you could describe what it looks like.
VAIDYA: So lymphatic system in our body, it’s an organ, helps with water circulation primarily. Now, we’re about 75% water, believe it or not, and every organ in our body, not only does the blood stream travel to and from it, but the lymphatic channels travel with fluid to and from organs. So, for individuals who have cancer and we’re talking about uterine cancer here the water channels can take cells from the uterus unfortunately, cancerous cells from the uterus and have them travel to the lymph nodes. During surgery, after a woman is asleep in the operating room, we are able to inject about five CCs or a tablespoon of green-colored dye. Now, when we look at it, it looks like a dark green color. It’s a water-based dye. It looks like food coloring, to be honest. But we can inject that in through the cervix into the lower part of the uterus where the water-based dye gets taken up by these lymphatic channels. The channels that are most prominent or the ones that are most readily draining the uterus pick up the dye and most readily bring that dye to the lymph nodes. During surgery, we activate a special camera on our robotic lens and we are able to see in the near-infrared spectrum the dye doesn’t just look a dark green like it does to the human eye but, in this near-infrared spectrum, the dye glows. It looks fluorescent, OK? And it really is quite dramatic and remarkable. There are times when we can see these small lymphatic channels that look like little streams and then a tiny little puddle, which would be the lymph node. Then we are able to remove those selected lymph nodes and have them processed by our pathologist.
So you’re taking out just the lymph nodes that are glowing?
VAIDYA: That’s right and as a result, we don’t need to disrupt all the lymphatic channels, we don’t need to remove all of the lymph nodes, patients have a lower rate of having swelling or problems with circulation in their legs after a surgery where we only remove the sentinel lymph nodes. Now, a couple of studies have been done that have shown that this is a very accurate means to evaluate lymph nodes. We at the Hackensack University Medical Center wanted to prove that we were doing things accurately, so we reviewed several hundred patients that we removed sentinel lymph nodes. We had also removed additional lymph nodes. We worked with our pathology department, our radiology department and our anesthesia department to prove that we were as accurate and precise with our techniques as published literature.
And what did you find?
VAIDYA: We found that we were able to accurately identify sentinel lymph nodes and that we were able to bring patients into the operating room with clinical early-stage cancer and use that information from the staging to still impact treatment. We talked about surgical treatment but, for some women, treatment for endometrial cancer can involve radiation therapy and/or even chemotherapy after surgery. Those patients that have lymph nodes involved are individuals who have more advanced stage disease, and those are women who will benefit from additional treatment. It’s really important to know that we’re finding these women, that we’re not missing them or losing them. Our goal is to treat and cure everybody that we can, and now I’m really happy to say that we can do that without compromising quality of life.
So less of a chance of them developing lymphedema and swelling and these other complications from surgery.
VAIDYA: Exactly. We know that about a quarter of all women that have complete or comprehensive lymph node removal for endometrial cancer will develop lymphedema but by selectively picking out the sentinel lymph nodes, we can still accurately stage those women, make treatment recommendations for them, but drop down that lymphedema rate to two, three percent.
If you could tell me a little bit about Susan.
VAIDYA: I feel really fortunate to have met Susan. She really has been an incredible patient because she has been her own best advocate. For all the years that I’ve been taking care of patients, it’s always so humbling to realize that we need to listen to our patients. Susan came to see me with some bleeding. She’d already gone through menopause and she had been having some intermittent spotting and bleeding for over a year. Now, she had been seen by her gynecologist. They had attempted to do tissue sampling, at that time, they’d never identified cancer, but she continued to have these symptoms. This is one of the most important things we can’t ignore symptoms. When she came to see me, we discussed the different possibilities as to what was going on. She had had an ultrasound, but it’s not perfect. There’s no screening tool for endometrial cancer, and that’s something that’s really important for women to know that their symptoms have meaning and we worked together as a team. We talked about monitoring symptoms for a little while. I knew that I could trust Susan to be honest with herself and honest with me. We ultimately brought a plan together to bring her to the operating room for diagnosis. So, we came into the operating room and we did what’s called a DNC, and that’s one of the minor procedures that can be done to sample the lining of the uterus. Once we have a sampling, then we have a diagnosis. For some women, they don’t have cancer. They may have a polyp. They may have what’s called atrophy, which happens to a lot of women during menopause when the estrogen levels drop down lower and those were both possibilities for Susan. But in her particular case, we did identify cancer as the result of doing the DNC. With that diagnosis, we then made a plan to move forward for a robotic staging surgery for her.
You had mentioned the importance of staying after something. How important it sounds like a simple question to catch cancer so early?
VAIDYA: Well, the difference between an excellent prognosis where we cure, in some cases, 98 – 99% of patients when cancers are found really that early versus, unfortunately, not being able to cure that same high, high percentage of patients. In addition, finding cancers early often means that the treatment can be done in a way that’s not so radical. Patients can have fewer side effects because they ultimately end up having less treatment.
In Susan’s case, do you remember what the firefly showed when you turn the camera on? Do you remember what you had to do in terms of lymph nodes?
VAIDYA: It’s something that we’ve been doing so many times now. We’ve taken care of hundreds of patients in this same way and what I can tell you is that, when we activate the camera, we see these little, tiny, I describe them as little streams that are the lymphatic channels. I think of, almost like a little rest stop as the lymph nodes and for Susan, we identified lymph nodes on the left and on the right side. They glowed just the way that they’re supposed to. It allowed us to be so precise in removing them, and I really believe that that’s a huge part of why she was able to recover so quickly.
Is there anything I didn’t ask you, doctor, that you would want to make sure that people know, either about cancer or the treatment options?
VAIDYA: In terms of endometrial cancer, I think the most important thing for women to know is that if they’re experiencing bleeding, especially bleeding after menopause, they need to bring it to the attention of their gynecologist. Even younger women. We are finding cancers in women in their 20s and 30s, believe it or not, of the uterus. Even for women who are experiencing very irregular menstrual cycles, heavier than usual flow, cycles lasting longer than their normal duration those are reasons to talk to your gynecologist. Sometimes you need to have a biopsy, and it’s really your doctor that should be able to advise you as to what the next steps would be in trying to sort out what’s going on. Don’t assume that it’s nothing. Symptoms are so important when we don’t have a screening tool.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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