endometrial cancer Flashcards
Aetiology
UNOPPOSED OESTROGEN EXPOSURE
-HRT
-polycystic ovary syndrome
-Tamoxifen (selective oestrogen receptor modulator)
Aetiology: Reproductive characteristic
-Nullparity (never been pregnant)
-infertile
-early age of menarche
-late age of menopause
Aetiology misc.
-obesity due to higher endogenous oestrogen
- Diabetes Mellitus
-increase in age (15% before 50, 5% before 40)
-Lynch type 1I family cancer syndrome
Decreases Risk/ Preventative measures
-oral contraceptives (Continuous combined oestrogen-progestin therapy)
-maintaing normal BMI
-high physical activity
-breastfeeding and pregnancy
POOR PROGNOSITIC FACTORS
-lymphovascular space invasion
-age
-tumour
-Tumour involvement of the lower uterine segment
SIGNS AND SYMPTOMS
-often presents at early stage
-vaginal bleeding-most common after menopause,sex or inbetween periods
-abnormal discharge
-pain during sex
Investigations pt1
-full blood count
-full biochemistry (U+E and liver function test)
-screening for genetic mutations (for patients older than 50)
Investigations pt2
-hysteroscopic- guided endometrial biospy(10% false negative rate)
-or/and dilation and curettage with hysteroscopic guidance (usually under anesthesia)
investigations (imaging): TVU
transvaginal ultrasound
-effective first test
-tests thickness of endometrium (cut off point 4mm)
-100% sensitive and 60% specificty
Imaging:
MRI
-assess depth of myometrial invasion
-identifies mestastic lymph nodes
imaging:
CT-abdomen and pelvis
-identifies mestastic lymph nodes
-sometimes used with high risk patients
-lack of benefit for local staging-pre operative
imaging :
PET/CT
-identifies distant mets
-not recommended for pre-operative assessment
-lack of proven clinical benefit
For more advanced cancers
-Cystoscopy if direct extension of bladder is expected
-proctoscopy if direct extension of rectum is expected
grading :degrees of histopathological differentation
G1= 5% or less of a nonsquamos or nonmorular solid growth pattern
G2=6-50% “
G3= more than 50%
Common sites of spread
lung
liver
bone
brain
vagina
upper abdomen
distant lymph nodes
Treatment Options Available
surgery
RT
chemo
Surgery
-Total hysterectomy and bilateral salpingo oophorectomy (removal of the fallopian tubes and ovaries) for any grade
-+/- lymphadectomy depending of risk of recurrence
Role of Adjuvant Therapy in Early Stage
Endometrial Cancer
-low risk patients dont need AT
-should be 6-8weeks after surgery
-
Guide for treatment in early stage
disease:
-intermediate risk
Guide for treatment in early stage
disease:
-high-intermediate risk
if nodal status unknown, consider EBRT vs vaginal brachy
if node negative, consider adjuvant brachy therapy vs no adjuvant therapy
Guide for treatment in early stage
disease:
-high risk
EBRT vs brachy
or adjuvant chemo
Advanced Stage /Extrauterine
disease
-neoadjuvant chemo if ascites (fluid collects in spaces within your abdomen) present
-Bulky disease( areas of lymphoma that measure above a certain size)= EBRT intracavity brachytherapy
-HT= Adjuvant progestational agents
set up for CT Simulation
comfortably full bladder
prone position
-uses lack of bladder filliing protocol
-decreases small bowel toxicty
-
Pre- Treatment-CT SCAN
-IV contrast (helps w accurate contouring of nodal volume)
-vaginal contrast
Radiation Therapy –Field Arrangements-POST OP:
VMAT/IMRT
-recommended bc of more conformal dose distribution
-increase normal tissue sparing instead of 4f box
why use IMRT
-more uniform dose
-reduce early and late toxicities
-minimal dose to small bowel,bladder and rectum
IGRT-POST OP PELVIS
What needs to be considered?
-uterus removed means internal motion reduced
-internal motion from bladder and rectum fillinng
-conventional borders (boney match)
-
Summary of possible protocols
what to consider
-advanced techniques (daily online)
-total dose , target and OAR (Offline protocol suitable)
Brachytherapy Doses
If previous EBRT
-11Gy/2# over 1 week (following EBRT)
-0.5cm fro surface of applicator over a length of 4cm
Brachytherapy Doses
If no EBRT:
-21Gy/3# if small bowel is greater than 1cm from vagina
-22Gy/4# if small bowel closer to vagina
Image Guided Brachytherapy Technique
PART 1
-vaginal examination
-insertion of uninary catheter with radio-opaque contrast in bladder balloon (1st fraction only
-largest tolerable cylinder size is selected
Image Guided Brachytherapy Technique
PART 2
-inserted to top of vagina and then clamped (ensure there is no movement of clamp when transferring patient)
-Record length of vaginal cylinder protruding for
verification of position and re-insertions
Image Guided Brachytherapy Technique
PART 3
-CT images are taken
-plan is created
-patient is treated in HDR suite when plan is ready
LATE SIDE EFFECTS
-Proctitis
Small bowel obstruction
Lymphodema
Vaginal stenosis
Vaginal dryness
Sexual function (impaired)
Fistula
Patient Management
pt1
-Weekly review- FBC and U and E
-low residue diet with increase fluid for gastrointestinal symptoms
-vaginal dilators several times a day (usually 6 weeks post RT - 3or 5 times a week)
