Endometrial Cancer
Terms
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- What is the most common female pelvic malignancy?
- Endometrial cancer
- What factors influence the prominence of endometrial cancer?
-
1 Declining incidence of cervical cancer
2 Longer life expectancy
3 Earlier diagnosis - What is the most prevalent histologic subtype of endometrial cancer?
- Adenocarcinoma of the endometrium
- What are the four most common cancers in women?
-
1 Breast cancer
2 Lung cancer
3 Bowel cancer
4 Adenocarcinoma of the endometrium -
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 - Two mechanisms of neoplasia
-
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 - Risk factors for endometrial cancer
-
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 - Endometrial pathology
-
Adenocarcinoma: Adenoacanthomas <--> Adenosquamous carcinoma
Mucinous carcinoma
Serous carcinoma
Clear-cell carcinoma
Secretory carcinoma - Adenocarcinoma subtypes
-
Adenoacanthoma
-Adenocarcinoma with benign squamous differentiation
-Good prognosis
Adenosquamous carcinoma
-If squamous component resembles squamous carcinoma
-Worse prognosis due to poorly differentiated glandular component - Serous carcinoma
-
<10% of endometrial cancers
Usually found in advanced stage in older women - Clear-cell carcinoma
-
Generally occur in older women
Have poor prognosis due to their propensity for early intraperitoneal spread - Secretory adenocarcinoma
-
Uncommon
Resembles secretary endometrium
Usually low grade
Usually good prognosis - Prognostic factor categories
- Uterine and Extrauterine
- Uterine prognostic factors
-
1 Histologic cell type
2 Tumor grade
3 Depth of myometrial invasion
4 Occult extension of disease to the cervix
5 Vascular space invasion - Extrauterine prognostic factors
-
1 Adnexal metastases
2 Intraperitoneal spread to other extrauterine structures
3 Positive peritoneal cytology
4 Pelvic lymph node mets
5 Aortic node involvement - Is uterine size a risk factor?
-
No.
It was previously thought to be but is no longer an independent risk factor.
Does relate to cell type, grade, and myometrial invasion. - Indications for lymph node sampling if there is no gross residual intraperitoneal tumor
-
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 - If lymph nodes are sampled, what areas should be taken?
-
1 Distal common iliac artery
2 Superior iliac artery/vein
3 Obturator nerve - Stage I treatment recs
-
-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 - Stage II treatment recs
-
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% - Define types of vaginal bleeding as a risk factor
-
Postmenopausal vaginal bleeding
Perimenopausal women with heavy or prolonged vaginal bleeding
Premenopausal women with abnormal bleeding who are obese or oligoovulatory -
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 -
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 -
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