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31 Cards in this Set

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What is the most common female pelvic malignancy?
Endometrial cancer
What factors influence the prominence of endometrial cancer?
1 Declining incidence of cervical cancer
2 Longer life expectancy
3 Earlier diagnosis
What is the most prevalent histologic subtype of endometrial cancer?
Adenocarcinoma of the endometrium
What are the four most common cancers in women?
1 Breast cancer
2 Lung cancer
3 Bowel cancer
4 Adenocarcinoma of the endometrium
Epidemiology of endometrial cancer:
Age?
Geography?
Age: primarily postmenopausal
25% in premenopausal pts
5% in patient < 40 yoa
Geo: Higher in Western nations
Very low in Eastern
countries
Urban > Rural
Whites > Blacks by factor of 2
Two mechanisms of neoplasia
Type I
-Exposed to unopposed estrogen
-Begin as hyperplasia
-Progress to carcinomas
-Better differentiated
-More favorable prognosis
Type II
-Carcinomas appear spontaneously
-Arise in atrophic or inert endometrium
-More undifferentiated
-Poorer prognosis
Risk factors for endometrial cancer
1 Unopposed estrogen
2 Diet
3 Obesity
4 Parity: nullip RR 2
5 DM RR 3, HTN RR 1.5
6 Endometrial hyperplasia
7 FHx endometrial cancer
8 Use of exogenous hormones
Endometrial pathology
Adenocarcinoma: Adenoacanthomas <--> Adenosquamous carcinoma
Mucinous carcinoma
Serous carcinoma
Clear-cell carcinoma
Secretory carcinoma
Adenocarcinoma subtypes
Adenoacanthoma
-Adenocarcinoma with benign squamous differentiation
-Good prognosis
Adenosquamous carcinoma
-If squamous component resembles squamous carcinoma
-Worse prognosis due to poorly differentiated glandular component
Serous carcinoma
<10% of endometrial cancers
Usually found in advanced stage in older women
Clear-cell carcinoma
Generally occur in older women
Have poor prognosis due to their propensity for early intraperitoneal spread
Secretory adenocarcinoma
Uncommon
Resembles secretary endometrium
Usually low grade
Usually good prognosis
Prognostic factor categories
Uterine and Extrauterine
Uterine prognostic factors
1 Histologic cell type
2 Tumor grade
3 Depth of myometrial invasion
4 Occult extension of disease to the cervix
5 Vascular space invasion
Extrauterine prognostic factors
1 Adnexal metastases
2 Intraperitoneal spread to other extrauterine structures
3 Positive peritoneal cytology
4 Pelvic lymph node mets
5 Aortic node involvement
Is uterine size a risk factor?
No.

It was previously thought to be but is no longer an independent risk factor.

Does relate to cell type, grade, and myometrial invasion.
Indications for lymph node sampling if there is no gross residual intraperitoneal tumor
1 Invasion of more than 1/2 of the outer myometrium
2 Presence of tumor in the isthmus-cervix
3 Adnexal or other extra-uterine metastases
4 Presence of serous, clear-cell, undifferentiated or squamous types
5 Visibly or palpably enlarged lymph nodes
If lymph nodes are sampled, what areas should be taken?
1 Distal common iliac artery
2 Superior iliac artery/vein
3 Obturator nerve
Stage I treatment recs
-Adjuvant pelvic radiation if
1 Deep myometrial penetration
2 Grade 2 or 3 histology
3 Evidence of vascular invasion
-45-50 Gy with standard fx
1 Multiple fields tx daily
2 Small bowel protection
Stage II treatment recs
Adjuvant pelvic radiation
-45-50 Gy
-Additional brachytherapy or total 80-90 Gy to vag surface
Outcome expected
-5-yr dz free survival: 80%
-Locoregional control: 90%
Define types of vaginal bleeding as a risk factor
Postmenopausal vaginal bleeding
Perimenopausal women with heavy or prolonged vaginal bleeding
Premenopausal women with abnormal bleeding who are obese or oligoovulatory
Postop endometrium EBRT field
Field
Boundaries
Dose
OARs
Postop endometrium field
Four-field
AP:PA
- L4-5 to mid obturator
- Lateral to include S1-S3
- Anterior 1.5 cm margin
45-50 Gy
Target: Op bed, upper 2cm vagina, pelvic nodes with 1.5 cm margin
OAR: Small bowel, bladder, femoral heads, and bone marrow
Postop endometrium brachy
Dose
Prescription
Postop endometrium brachy

Vaginal cylinder

Dose: 5-7Gy x 3
Prescription
- To top 5 cm of vagina
- Calculated at 0.5 cm from vaginal (cylinder) surface
Def endometrium
EBRT field
EBRT dose
Brachy dose
Def endometrium

EBRT field: Same as postop
EBRT dose: 45 Gy
Brachy dose: T&O 850 cGy x 2
Aadlers Trial
Aadlers Trial: Who gets pelvic RT?

Grade 3 > 50% invasion --> RT
All with LVSI

All others with invasion --> VBT
PORTEC Trial
PORTEC Trial
Stage I
-- G1 > 1/2 MI
-- G2 any MI
-- G3 < 1/2 MI
TAH/BSO without surgical staging
All histologies
Randomized
-- PRT 46Gy/33Fx with no VBT
-- No further treatment
Outcomes
-- 10yr LRR: 5 vs 14% no RT
-- Excluding IB(<1/2 MI)g1: 5 vs 17% no RT
73% LR were vaginal with PRT
GOG 99 (Keys)
GOG 99 (Keys)
Stage IB-II occult
TAH/BSO with surgical staging
Randomized
-- 50.4/28Fx PRT no VBT
-- No further treatment
Outcomes
-- 12% 2yr RR
-- 13/18 LRC in vaginal vault
GOG 99 (Keys)

Unplanned analysis
GOG 99 (Keys) Unplanned analysis

Prognostic factors
1 Advanced age
2 High grade (2 or 3)
3 Outer 1/3 MI
4 LVSI
High intermediate risk
-- 70+ with 1 other risk factor
-- 50+ with 2 other risk factors
-- Any age with other 3 risk factors
Recurrences in HIR:
-- 27% NAT
-- 13% PRT
Recurrence by risk group
-- 67% in HIR
ASTEC Trial (Orton)
ASTEC Trial (Orton)
Surgery = HIR but no macro dz
Randomized
-- No EBRT
-- Yes EBRT
LR 3% vs 6% no RT
PORTEC 2
PORTEC
Stage I-IIA
Age 60+ and ICg1-2 or IBg3
Stage IIA x g3 > 1/2 MI
Surgery: TAH/BSO
Randomized
-- PRT 46/23
-- VBT 21HDR or 30LDR
Outcomes
-- Pelvic rec 0.5 v 3.8% VBT
-- No diff DM, RFS, OS
-- Better QOL with VBT
RTOG 0418
RTOG 0418

G2+ SB toxicity 40 --> 28% IMRT (NS but no powered)
Centralized QA
Contouring SB, nodal, and vag tissues