Endometrial Cancer+ Preoperative Guidelines Treatment

Stage I

General Notes

  • For stage I disease, the addition of vaginal irradiation does not significantly add to local control when EBRT is used, but it does increase toxicity. [1]
  • VB (vaginal brachytherapy)
  • PRT (Pelvic radiation therapy)

Surgery

  • Simple extrafacial hysterectomy
  • Bilateral salpingo-oophorectomy is recommended because the ovary is a relatively common site of occult metastasis and because most women are already post-menopausal and no longer have hormonal function from the ovary.
  • inspect abdominal organs
  • peritoneal washings
  • consider pelvic lymphnode dissection

Surgical Staging of Pelvic LN (> 10-15 nodes taken ) ASTRO 2006

  • > 70% of recurrences are vaginal vault
  • "adequate" PLND should reduce pelvic recurrence, but it must be noted that presacral node are typically samples so very high risk women (ie. stage II) may be a candidate for VB + WPRT.
Stage Grade 1 Grade 2 Grade 3
I A Observe Observe VB1
I B Observe VB1 VB1
I C VB2 VB2 VB2

1. very low risk of pelvic recurrence (data from most retrospective study show 0-7% pelvic recurrence with vaginal brachytherapy alone.)
2. consider pelvic radiation if the dissection is not extensive.
3. Need 28-37 nodes for an adequate pelvic dissection in cervical cancer (BENEDETTI-PANICI GYN ONC 62, 1996).

Limited PLND (< 10-15 nodes taken) ASTRO 2006

Stage Grade 1 Grade 2 Grade 3
I A Observe1 Observe1 VB2
I B Observe1 VB(PRT)2,3 VB(PRT)2,3
I C PRT4 PRT4 PRT4

1. Very low risk of pelvic and vaginal recurrence
2. Low risk of pelvic involvement
3. Consider Pelvic RT for LVI+ or close to IC stage.
4. Some give PRT + VB for IC/G3 but VB give more toxicity with equivalent pelvic control

Stage II and IIIA

Surgery

  • Radical Hysterectomy
  • bilateral salphingo-oophorectomy
  • inspection and palpation of abdominal organs.
  • Peritoneal washings
  • Pelvic and Para-aortc lymphadenectomy

Adjuvant Therapy

Stage Grade 1 Grade 2 Grade 3
II A (II occult) Outcome identical to stage I Treat as stage I (tables above)
II B (II macro) PRT+VB **due to ** increased the risk of parametrial disease
III A, cytology + only Outcome identical to stage I Treat as stage I (tables above)
III A, all other and IV Based on GOG \#122
AP (doxorubicin 60 mg/m2 + cisplatin 50 mg/m2 q3 wks x 7)

In patients with stage I, grade I tumors, postoperative radiation (vaginal brachytherapy and/or external beam irradiation) may be considered if there is deep myometrial invasion to the outer one third or if there is any invasion and the surgical staging was limited. Postoperative irradiation delivered to the vaginal cuff provides a surface dose to the vagina of approximately 5000 to 6000 cGy (50 to 60 Gy). ( Vern L. Katz, MD, Rogerio A. Lobo, MD, Gretchen Lentz, MD, and David Gershenson, MD Katz: Comprehensive Gynecology, 5th ed. 2007 Mosby, Chapter 32.)

Stage III-IV

GOG 122

  • Surgical resection with maximal residual disease <=2 cm after surgery
  • doxorubicin 60 mg/m2 and cisplatin 50 mg/m2 every 3 weeks for seven cycles, followed by one cycle of cisplatin.
  • patients with cervical, adnexal, and/or deep myometrial disease > 60% risk of pelvic failure without the use of RT.
  • However, phase II trials of WAI concurrent with chemotherapy after doxorubicine and cisplatin was too toxic.

IIIA positive cytology only

  • GOG 122 still applies
  • Alternatively, they can be treated as stage I disease ignoring the positive cytology for adjuvant therapy purposes.

Serous Papillary Carcinoma

To be treated like epithelial ovarian tumor with 32p or WART.
EBRT to WA (30.4 Gy), 45 Gy to pelvis.

Bibliography
1. Irwin et al. Gyn Onc 70:247-254, 1998. Randal et al. IJROBP 19:49-54, 1990. Greven et al. IJROBP 42: 101-104, 1998.
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