Endometrial

Cancer
Amanda Cihon
11/21/2014

Patient Information

54 yr old African American female

Endometrial adenocarcinoma FIGO Stage IA
Treated on TB2
Brachytherapy

Medical History

HTN
Obesity (417 lbs)
Colitis 2005
Rectal ulcer 2005
Patent foramen ovale 10/10
Gout 1/11
DJD 1/11
COPD 2/11
HDL deficiency 11/11
Enlarged rt. Ventrical 3/13
OSA on CPAP
Overian teratoma 12/13
Endometroid adenocainome
4/14 (inoperable)

Surgical history
Cesarean sectrion
(1988, 1990, 1992)
Tubal ligation
Female History
Age of menarche: 18 w/
irregular periods
Postmenopausal: early 50s

Family history
Maternal Aunt- colon cancer 2006
Mother- coronary heart disease, stroke,
disbetes, HTN
Sister- coronary artery disease, diabetes
Brother- diabetes

Etiology1

Obesity, excess estrogen, early

menarche, late menopause, nulliparity,
age, oral contraceptives, disbetes,
hypertension, tamoxifen

Epidemiolog
y1

Most common malignancy of female

genital tract
6% of all cancers and 3% CA death in
females
Peak incidence 50-70 years old
80% with early stage disease4

Expected
symptoms1

Abdominal uterine bleeding, foul

smelling discharge, abnormal PAP smear

Anatomy2

Lymphatics1,7

External iliac,
internal iliac,
obturator, common
iliac, presacral
Para-aortic with
extensive disease

Staging1
IA- tumor confined to uterus, no or <50%
myometiral invasion
IB- tumor confined to uterus, >50% myometrial
II-cervicalstromal invasion, but not beyond uterus
IIIA- tumor invades serosa or adnexa
IIIB- vaginal and/or parametrial involvement
IIIC1- pelvic node involvement
IIIC2- para-aortic involvement
IVA- tumor invades bladder and/orbowel mucosa
What stage
IVB- distant mets including abdominal mets
and/or
did my
inguinal LNs
patient

have?

What is
removed in
total hyst.
And radical
hyst.?

Treatment by Stage1,3
IA: total abdominal
hysterectomy +/- LN
disection or vag cuff
brachy alone
IB: radiacal hysterectomy
or EBRT and brachy
IB2-IIIA: concurrent
chemo/RT or EBRT and
brachy
IIIB-IVA: same as IIIA but
may include para aortics
(+)

Stage IA treatment
surgery consisting of total abdominal
hysterectomy and bilateral salpingo-oophrectomy
What is a
salpingo
is normal treatment4
oophrectomy?
She was inoperable
MRI ordered to access myometrium myometrium
invasion
If minimum would be brachy alone but if
extensive brachy and EBRT

30%

Click icon to add picture

EBRT
Supine,PLAN
vacbag
conformal
15 MV
4500 cGy in 25
fx

IMRT or
conforma
l?

Brachytherapy Plan

10 cm Single tandem
20 dewll positions
17 Gy in 2 fx

Alternate Treatments
IUD with
prgesterone

SBRT vs brachy

Intrauterine Progesterone 5
Feasibility of using progesterone containing
intrauterine device (IUD) to treat FIGO Stage !A
endometirial CA in patients with high risk of
surgery complications
Obesity, diabetes melitus, and HTN can all lead to
endometiral CA and can cause an inreased risk of
surgery complications
50% of the patients have severe or fatal
perioperative morbidity
Reason for IUD containing progesterone to reduce
adverse surgery effects

IntrauterineProgesterone 5,8
For patients with risk factors that impede on
surgery normally have an excessivel unopposed
estrogenic stimulation of uterus that leads to CA
Progesterone could eliminate estrogenic effect or
counteract it which could reverse CA process

Intrauterine Progesterone 5

Negative biopsies in 7/11 at 6 months and 6/8 at 12

months

Intrauterine Progesterone 5
Advantages
Provides high dose of
hormone to specific
site
Avoids adverse side
effects from systemic
treatment
Ideal hormone
treatment by
delivering directly
progesterone

Disadvantages
Expulsion leading to
re-insertion
Study only lasted one
year
May not be able to
deliver adequate dose
to surface of
endometrium to treat
CA
Treatment proved to be
effective for first year

Stereotactic Body RT 6
Evaluate dosimetric feasibility of the use of SBRT
treatments for inoperable endometrium tumors
With brachy there is still a risk of side effects to
anthestisa when placing intracavitary applicators
SBRT can give high dose to uterus while avoiding
the risks of anthesia and applicator placement
HDR vs. SBRT using helical tomotherapy for 10
inoperable Stage I-II emdometrium CA
5 previous brachy
5 previous brachy and EBRT

Stereotactic Body RT 6
The same CT scans used for contourins and planning brachy and
SBRT

SBRT

Brachy HDR

90% of CTV
uterus+cervix for 34
34 Gy in 4 fxs to CTV
Gy in 4 fxs
including
uterus+cervix
Higher overall target
coverage of uterus
Greater volume of
uterus received 150%
Gave higher dose to
dose suggesting
sigmoid colon, bowel,
bladder,tumor
rectum,control
sigmoid
and femoral heads but OARs:greater
not outside tolerances colon, other bowel, femoral
heads

Stereotactic Body RT 6
Disadvantages
Only dosimetric comparison
Interfraction uterine movement
Could have overestimated difference since some single tandems
were used which results in inferior coverage compared to Y
applicators
May be more important to have more volume of tumor exposed with
brachy than percentage covered by perscription dose with SBRT

SBRT seems dosimetricly feasible but more

studies should be conducted for clinically

1.
2.
3.
4.

Hackworth,Ruth. Endometrial CA lecture. 1/15/2014

Hackworth, Ruth. Female Reproductive lecture. 1/8/2014
Hackworh, Ruth. Cervix CA lecture. 1/8/2014
Nout, Ra, Vthbm Smit, H. Putter, Im Jrgenliemk-Schulz, Jj Jobsen, Lchw Lutgens,
Em Van Der Steen-Banasik, Jwm Mens, A. Slot, Mc Stenfert Kroese, Bnfm Van
Bunningen, Ac Ansink, Wlj Van Putten, and Cl Creutzberg. "Vaginal
Brachytherapy versus Pelvic External Beam Radiotherapy for Patients with
Endometrial Cancer of High-intermediate Risk (PORTEC-2): An Open-label, Noninferiority, Randomised Trial." The Lancet 375.9717 (2010): 816-23.
ScienceDirect. Web. 20 Nov. 2014.

5. Montz, Fredrick J., Robert E. Bristow, Alessandro Bovicelli, Rafael Tomacruz, and
Robert J. Kurman. "Intrauterine Progesterone Treatment of Early Endometrial
Cancer." American Journal of Obstetrics and Gynecology 186.4 (2002): 651-57.
ScienceDirect. Web. 20 Nov. 2014.
6. Jones, Ryan, Quan Chen, Ryan Best, Bruce Libby, Edwin F. Crandley, and Timothy
N. Showalter. "Dosimetric Feasibility of Stereotactic Body Radiation Therapy as
an Alternative to Brachytherapy for Definitive Treatment of Medically Inoperable
Early Stage Endometrial Cancer." Radiation Oncology (2014): n. pag. Web. 20
Nov. 2014. <http://www.ro-journal.com/content/9/1/164>.
7. http://www.aboutcancer.com/endomet_nodes.htm
8. http://www.zimmernutrition.com/learning-center/healtharticles/article/progesterone-cream-dangers