endometrial cancer

Question 1

Aetiology

Answer 1

UNOPPOSED OESTROGEN EXPOSURE
-HRT
-polycystic ovary syndrome
-Tamoxifen (selective oestrogen receptor modulator)

Question 2

Aetiology: Reproductive characteristic

Answer 2

-Nullparity (never been pregnant)
-infertile
-early age of menarche
-late age of menopause

Question 3

Aetiology misc.

Answer 3

-obesity due to higher endogenous oestrogen
- Diabetes Mellitus
-increase in age (15% before 50, 5% before 40)
-Lynch type 1I family cancer syndrome

Question 4

Decreases Risk/ Preventative measures

Answer 4

-oral contraceptives (Continuous combined oestrogen-progestin therapy)
-maintaing normal BMI
-high physical activity
-breastfeeding and pregnancy

Question 5

POOR PROGNOSITIC FACTORS

Answer 5

-lymphovascular space invasion
-age
-tumour
-Tumour involvement of the lower uterine segment

Question 6

SIGNS AND SYMPTOMS

Answer 6

-often presents at early stage
-vaginal bleeding-most common after menopause,sex or inbetween periods
-abnormal discharge
-pain during sex

Question 7

Investigations pt1

Answer 7

-full blood count
-full biochemistry (U+E and liver function test)
-screening for genetic mutations (for patients older than 50)

Question 8

Investigations pt2

Answer 8

-hysteroscopic- guided endometrial biospy(10% false negative rate)
-or/and dilation and curettage with hysteroscopic guidance (usually under anesthesia)

Question 9

investigations (imaging): TVU

Answer 9

transvaginal ultrasound
-effective first test
-tests thickness of endometrium (cut off point 4mm)
-100% sensitive and 60% specificty

Question 10

Imaging:
MRI

Answer 10

-assess depth of myometrial invasion
-identifies mestastic lymph nodes

Question 11

imaging:
CT-abdomen and pelvis

Answer 11

-identifies mestastic lymph nodes
-sometimes used with high risk patients
-lack of benefit for local staging-pre operative

Question 12

imaging :
PET/CT

Answer 12

-identifies distant mets
-not recommended for pre-operative assessment
-lack of proven clinical benefit

Question 13

For more advanced cancers

Answer 13

-Cystoscopy if direct extension of bladder is expected

-proctoscopy if direct extension of rectum is expected

Question 14

grading :degrees of histopathological differentation

Answer 14

G1= 5% or less of a nonsquamos or nonmorular solid growth pattern
G2=6-50% “
G3= more than 50%

Question 15

Common sites of spread

Answer 15

lung
liver
bone
brain
vagina
upper abdomen
distant lymph nodes

Question 15

Treatment Options Available

Answer 15

surgery
RT
chemo

Question 16

Surgery

Answer 16

-Total hysterectomy and bilateral salpingo oophorectomy (removal of the fallopian tubes and ovaries) for any grade
-+/- lymphadectomy depending of risk of recurrence

Question 17

Role of Adjuvant Therapy in Early Stage
Endometrial Cancer

Answer 17

-low risk patients dont need AT
-should be 6-8weeks after surgery
-

Question 18

Guide for treatment in early stage
disease:
-intermediate risk

Question 19

Guide for treatment in early stage
disease:
-high-intermediate risk

Answer 19

if nodal status unknown, consider EBRT vs vaginal brachy

if node negative, consider adjuvant brachy therapy vs no adjuvant therapy

Question 20

Guide for treatment in early stage
disease:
-high risk

Answer 20

EBRT vs brachy
or adjuvant chemo

Question 21

Advanced Stage /Extrauterine
disease

Answer 21

-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

Question 22

set up for CT Simulation

Answer 22

comfortably full bladder

Question 23

prone position

Answer 23

-uses lack of bladder filliing protocol
-decreases small bowel toxicty
-

Question 24

Pre- Treatment-CT SCAN

Answer 24

-IV contrast (helps w accurate contouring of nodal volume)
-vaginal contrast

Question 25

Radiation Therapy –Field Arrangements-POST OP:
VMAT/IMRT

Answer 25

-recommended bc of more conformal dose distribution
-increase normal tissue sparing instead of 4f box

Question 26

why use IMRT

Answer 26

-more uniform dose
-reduce early and late toxicities
-minimal dose to small bowel,bladder and rectum

Question 27

IGRT-POST OP PELVIS
What needs to be considered?

Answer 27

-uterus removed means internal motion reduced
-internal motion from bladder and rectum fillinng
-conventional borders (boney match)
-

Question 28

Summary of possible protocols
what to consider

Answer 28

-advanced techniques (daily online)
-total dose , target and OAR (Offline protocol suitable)

Question 29

Brachytherapy Doses
If previous EBRT

Answer 29

-11Gy/2# over 1 week (following EBRT)
-0.5cm fro surface of applicator over a length of 4cm

Question 30

Brachytherapy Doses
If no EBRT:

Answer 30

-21Gy/3# if small bowel is greater than 1cm from vagina
-22Gy/4# if small bowel closer to vagina

Question 31

Image Guided Brachytherapy Technique
PART 1

Answer 31

-vaginal examination
-insertion of uninary catheter with radio-opaque contrast in bladder balloon (1st fraction only
-largest tolerable cylinder size is selected

Question 32

Image Guided Brachytherapy Technique
PART 2

Answer 32

-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

Question 33

Image Guided Brachytherapy Technique
PART 3

Answer 33

-CT images are taken
-plan is created
-patient is treated in HDR suite when plan is ready

Question 34

LATE SIDE EFFECTS

Answer 34

-Proctitis
 Small bowel obstruction
 Lymphodema
 Vaginal stenosis
 Vaginal dryness
 Sexual function (impaired)
 Fistula

Question 35

Patient Management
pt1

Answer 35

-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)