Background and recommendations Flashcards
What are the unfavorable histologies of endometrial cancer?
Papillary serous and clear cell
FIGO Stage I
IA: Tumor localized to endometrium or invades less than one-half of the myometrium IB: Tumor localized to endometrium one-half or more of the myometrium
FIGO Stage II
Tumor invades stromal connective tissue of the cervix but does not extend beyond uterus
FIGO IIIA
Tumor involves serosa and/or adnexa (direct extension or metastasis)
FIGO Stage IIIB
Vaginal involvement (direct extension or metastasis)
parametrial invasion
FIGO IIIC
- Regional pelvic nodal disease 2. Regional paraaortic nodal disease
FIGO Stage IVA
Tumor invades bladder mucosa and/or bowel mucosa (bullous edema does not qualify)
Stage IVB
Distant metastasis including metastasis to inguinal nodes, intraperitoneal disease, lung, liver or bone. (Excludes paraaortic lymph nodes, vagina, pelvic serosa or adexa)
AJCC Nodal stage to FIGO
N1: IIIC1
N2: IIIC2
AJCC T stage to FIGO
T1a and T1b: FIGO IA and IB
T2: FIGO II
T3a and T3B: FIGO IIIA and IIIB
T4: FIGO IVA
What are the poor prognostic signs?
High grade 2-3 Cervix involvement LVSI Age > 60 Deep myometrial invasion
What did the creasman data show is the risk for nodes if you have Deep 1/3rd endometrial wall invasion and you are Grade 1,2,3?
G1: 6%
G2: 14%
G3: 23%
What is the risk for pelvic and paraaortic nodes with Stage II disease?
Pelvic: 30%
Paraaortic: 15%
What imaging and labs are needed at diagnosis?
Imaging:
Transvaginal US
CXR
CT scan of abdomen and pelvis
Labs: CBC, BMP, LFTs, CA-125
What special studies are needed for advanced cases?
Cystoscopy and sigmoidoscopy
How do you treat Stage IA Grade 1-2 disease?
Extrafascial hysterectomy
Peritoneal cytology
Pelvic and paraaortic node sampling
No adjuvant treatment
How do you treat Stage IA grade 3 or IB Grade 1-2?
Vaginal brachytherapy alone
Treatment for Stage IB Grade 3 to II
TAH/BSO
pelvic cytology
PLND + paraaortic sampling
- EBRT
- +Vaginal brachytherapy for Stage II
Stage III treatment options
TAH/BSO
pelvic cytology
PLND + paraaortic sampling
- Chemotherapy alone
- RT alone: pelvis + PA +/- vaginal cuff RT
- Chemo+ RT + chemo (sandwich chemo)
- Concurrent chemoradiation
- EBRT + concurrent cisplatin then carbo/taxol x 4 cycles
Treatment options for Stage IV disease
If Grade 1-2 and ER/PR+: Megace
Treatment for Papillary serous or Clear cell
- Surgery:
TAH/BSO and PAN dissection,
omentectomy
pelvic cytology
- Chemo (cisplatin and doxorubicin)
- Pelvic RT + Vaginal brachytherapy
What chemotherapy is usually used in sandwich chemo?
Carboplatin and taxol x 6 cycles
Small bowel Dose contraints
Small bowel V40 < 30%
CT simulation
Supine
IV contrast
Small bowel contrast
Indexed bag
Mark vaginal cuff
Scan with bladder full, then rescan with empty
Fuse scans together to create ITV
IMRT Volumes
Superior: L4-5 at the bifurcation of the aorta
Include the external iliac, internal iliac and common iliacs Include the presacral nodes if the tumor involves the cervix
Use a 7 mm expansion around the vessels coming off bone, bowel and muscle
Connect Nodal volumes with sacral volume and its inferior border is S3 PTV = 7 mm + CTV
Vaginal/Parametrial ITV volume
Superior border of CTV: When you see tissue between bladder and rectum Inferior border:
Include 3 cm of vaginal cuff- usually to mid pubis
Lateral: edge of nodal CTV of obturator
Anterior: Include 1 cm rim of bladder
Posterior border: curve around the rectum
What doses to you use when you combine EBRT with brachytherapy?
45 Gy at 1.8 Gy/fx 5 Gy x 3 with vaginal cylinder HDR. Precribe to 5 mm from vaginal surface and separate by 1 week each.
What RT dose do you use with HDR brachytherapy alone?
5.5 Gy x 4 fractions. Prescribe to 5 mm from vaginal surface. Separate by 1 week.
What RT dose with pelvic RT alone?
50.4 Gy at 1.8 Gy/fx
Dose constraints for vagina?
Upper vaginal mucosa: 150 Gy
Midvaginal mucosa: 80-90 Gy
Lower vaginal mucosa: 60-70 Gy
Acute complications of RT?
- Frequent and urgent urination
- Diarrhea
Late complications of RT?
- Vaginal stenosis
- Second cancers
- Rectal bleeding
- Hematuria
- SBO
Bladder dose constraints?
V45<35%
Rectum dose constraints
V30<60%
Femoral head constraint?
V30<15%
5 year OS for papillary serous and clear cell histologies?
5 year OS: 50%
What study supports VB alone for patients with high intermediate risk disease?
PORTEC 2
1) Pelvic RT to 46 Gy
vs.
2) Vaginal brachytherapy 7 Gy x 3 or 30 Gy of LDR
5 year risk of pelvic recurrence was 0.5% vs. 3.8%, p=0.02
5 year vaginal recurrence rate was 1.6% vs. 1.8%
5 year OS was 79.6% vs. 84.8%, p=0.57
What is the 5 year OS for patients with Stage III disease?
40-70%
What is the 5 year OS for patients with Stage IV?
5 year OS is 0-10%
What study supports the use of EBRT for patients with high intermediate risk disease?
ASTEC/NCIC: EBRT +/- VB vs. OBS: 3% improvement in locoregional control. No difference in OS.
GOG 99: EBRT vs. OBS (Low and Int): Lower recurrence improved in the high intermediate group only
Aalders: EBRT+/- VB vs. OBS (Low and Int): Lower recurrence only in IC grade 3
PORTEC 1: EBRT vs. OBS: Lower recurrence with EBRT
Treat with bladder full or empty?
Full
What is the typical length of vaginal cuff treated with a vaginal cylinder?
4 cm
PTV margin
CTV + 7 mm
