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31 Cards in this Set
- Front
- Back
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What is the most common female pelvic malignancy?
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Endometrial cancer
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What factors influence the prominence of endometrial cancer?
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1 Declining incidence of cervical cancer
2 Longer life expectancy 3 Earlier diagnosis |
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What is the most prevalent histologic subtype of endometrial cancer?
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Adenocarcinoma of the endometrium
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What are the four most common cancers in women?
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1 Breast cancer
2 Lung cancer 3 Bowel cancer 4 Adenocarcinoma of the endometrium |
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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 |
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Two mechanisms of neoplasia
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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 |
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Risk factors for endometrial cancer
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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 |
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Endometrial pathology
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Adenocarcinoma: Adenoacanthomas <--> Adenosquamous carcinoma
Mucinous carcinoma Serous carcinoma Clear-cell carcinoma Secretory carcinoma |
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Adenocarcinoma subtypes
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Adenoacanthoma
-Adenocarcinoma with benign squamous differentiation -Good prognosis Adenosquamous carcinoma -If squamous component resembles squamous carcinoma -Worse prognosis due to poorly differentiated glandular component |
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Serous carcinoma
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<10% of endometrial cancers
Usually found in advanced stage in older women |
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Clear-cell carcinoma
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Generally occur in older women
Have poor prognosis due to their propensity for early intraperitoneal spread |
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Secretory adenocarcinoma
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Uncommon
Resembles secretary endometrium Usually low grade Usually good prognosis |
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Prognostic factor categories
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Uterine and Extrauterine
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Uterine prognostic factors
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1 Histologic cell type
2 Tumor grade 3 Depth of myometrial invasion 4 Occult extension of disease to the cervix 5 Vascular space invasion |
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Extrauterine prognostic factors
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1 Adnexal metastases
2 Intraperitoneal spread to other extrauterine structures 3 Positive peritoneal cytology 4 Pelvic lymph node mets 5 Aortic node involvement |
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Is uterine size a risk factor?
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No.
It was previously thought to be but is no longer an independent risk factor. Does relate to cell type, grade, and myometrial invasion. |
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Indications for lymph node sampling if there is no gross residual intraperitoneal tumor
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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 |
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If lymph nodes are sampled, what areas should be taken?
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1 Distal common iliac artery
2 Superior iliac artery/vein 3 Obturator nerve |
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Stage I treatment recs
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-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 |
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Stage II treatment recs
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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% |
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Define types of vaginal bleeding as a risk factor
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Postmenopausal vaginal bleeding
Perimenopausal women with heavy or prolonged vaginal bleeding Premenopausal women with abnormal bleeding who are obese or oligoovulatory |
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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 |
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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 |
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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 |
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Aadlers Trial
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Aadlers Trial: Who gets pelvic RT?
Grade 3 > 50% invasion --> RT All with LVSI All others with invasion --> VBT |
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PORTEC Trial
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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 |
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GOG 99 (Keys)
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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 |
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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 |
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ASTEC Trial (Orton)
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ASTEC Trial (Orton)
Surgery = HIR but no macro dz Randomized -- No EBRT -- Yes EBRT LR 3% vs 6% no RT |
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PORTEC 2
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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 |
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RTOG 0418
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RTOG 0418
G2+ SB toxicity 40 --> 28% IMRT (NS but no powered) Centralized QA Contouring SB, nodal, and vag tissues |
