endometrium clinical guidelines final

8/12/2019 Endometrium Clinical Guidelines Final

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Agreed 2009Review 2012

MEDICAL PROTOCOL

ONCOLOGICAL MANAGEMENT OF UTERINEMALIGNANCIES

These guidelines have been developed b !e!be"s o# $he G nae%ologi%al On%olog

Guidelines G"oup& #o" app"oval b $he Me"se side and Cheshi"e G nae%ologi%al Can%e"

Ne$'o"( G"oup)

1. Backg ro un d .................................................................................................................................................. 22. Diagn os is ...................................................................................................................................................... 3

3. Refer ral to the Gyna eco lo gi ca l Oncology Team ...................................................................................34. Staging .......................................................................................................................................................... 4

. !rognost ic "actors ...................................................................................................................................... 4#. $ffect of indi %id ua l &rognos ti c f acto rs on rel ati %e risk to sur%i% al ....................................................'. !re(o&erat i%e assessme nt .........................................................................................................................

'.1) *istological e+aminat ion of the s&ecimen o,tained for diagnostic &ur&oses. ........................' .2) !re(o&erati%e e+amination either in the out(&atient clinic or &ossi,ly as a formal $- /0(hyster osco &y . ................................................................................................................................................ #'.3 ) magin g stu di es .....................................................................................................................................#

. Treat me nt .................................................................................................................................................... #.1 ) Surge ry ................................................................................................................................................... #.2 ) hoice of ncision .................................................................................................................................. #.3 ) Stage 1 .................................................................................................................................................... '

.4 ) Stage 2 .................................................................................................................................................... '

. ) Stage 3 and 4 ......................................................................................................................................... Radio th er a& y ...............................................................................................................................................

.1 ) Stage disease .......................................................................................................................................1 .1 5o6 risk &atient s .............................................................................................................................1.2 7oderate to *igh Risk !atient s ....................................................................................................

.2 ) Stage Disease .................................................................................................................................. 18.2.1 Trials in &rog ress in stage and dise ase ..............................................................................18

.3 ) Stage disease .................................................................................................................................. 11.3 .1 Stage a.........................................................................................................................................11.3 .2 Stage , disease ..........................................................................................................................11.3 .3 Stage c disease ..........................................................................................................................11

.4 ) Stage 9 disease ................................................................................................................................ 12

.4 .1 Stage 9a ....................................................................................................................................... 12

.4 .2 Stage 9, disease ......................................................................................................................... 12. ) Treatme nt of &ati en ts 6ith unfa%o ura, le histo logy ..................................................................12

. .1 -terine &a&ill ary serous carcinom a :-!S ); and clear cell carcino ma. ..........................12.#) Treatme nt of endom et ri al carcin om a 6ith radio thera& y alone ................................................13.' ) Trea tm en t of recu rren t dise ase .......................................................................................................13. ) d


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13. "ollo6( u& ................................................................................................................................................. 1#14. *orm on e Re&lace me nt ......................................................................................................................... 1'1 . lin ical Trials ...........................................................................................................................................1'

&& en di + 1 ...................................................................................................................................................... 1

1. Background

Endo!e$"ial %an%e" is no' $he se%ond !os$ %o!!on g nae%ologi%al !alignan% in $he U*)

Ove" +&,,, %ases a"e "egis$e"ed annuall 'i$h a li#e$i!e "is( o# -us$ ove" ./) Eigh$ pe"%en$o%%u" in pos$0!enopausal 'o!en 'i$h a !edian age a$ diagnosis o# 1, "s) Less $han +/

o%%u" in 'o!en aged 23+ "s) P"esen$a$ion is p"edo!inan$l 'i$h pos$0!enopausal

bleeding al$hough up $o 4+/ o# endo!e$"ial %an%e"s a"e de$e%$ed in p"e0!enopausal

'o!en) The !o"$ali$ asso%ia$ed 'i$h endo!e$"ial %an%e" is 5,/& %onside"abl less $han

#o" %e"vi%al o" ova"ian %an%e"s) This si!pl "e#le%$s $he ea"l p"esen$a$ion o# disease sin%e

6+/ o# pa$ien$s p"esen$ 'i$h disease $ha$ is appa"en$l %on#ined $o $he u$e"us 7s$age .8)

Indeed s$age "ela$ed su"vival #igu"es a"e& i# an $hing& 'o"se $han #o" $he o$he" !ain

g nae%ologi%al $u!ou"s) Endo!e$"ioid adeno%a"%ino!a is $he !os$ %o!!on #o"!%o!p"ising app"o9i!a$el 6+/ o# $he $o$al 'i$h o$he" va"ian$s in%luding !u%inous& se"ous&

%lea" %ell and s:ua!ous %a"%ino!as& !i9ed !esode"!al $u!ou"s& endo!e$"ial sa"%o!as

and undi##e"en$ia$ed $u!ou"s)

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;is$o"i%all & pa$ien$s 'i$h endo!e$"ial %a"%ino!a 'e"e $"ea$ed 'i$h "adio$he"ap and

%onse:uen$l $he p"ognos$i% #a%$o"s 'hi%h !igh$ be "evealed b his$opa$hologi%al

e9a!ina$ion 'e"e obli$e"a$ed) This 'as "e#le%$ed in $he FIGO s$aging 'hi%h 'as used #"o!

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adve"se his$ologi%al $ pes 7%lea" %ell and UPSC8

an $hing !o"e $han S$age .

'hen $he Uni$ lead is unhapp abou$ "is( #a%$o"s i$ is also app"op"ia$e $hese pa$ien$s a"e

"e#e""ed $o $he Cen$"e

4. Staging

The !e$hod o# s$aging #avou"ed in $his %oun$" is $ha$ in$"odu%ed b FIGO in .


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*ada" e$ al 'ho sho'ed $ha$ #ive ea" su"vival #o" pa$ien$s 'i$h !o"e $han 4 o# $hese "is(

#a%$o"s 'as .6/ %o!pa"ed 'i$h 11/ #o" $hose 'i$h $'o and


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h pe"plasia based on a sa!pling $e%hni:ue !a none $he less be asso%ia$ed 'i$h invasive

endo!e$"ial %an%e" in 4,/ o" !o"e o# %ases)

In so!e %i"%u!s$an%es i$ !a be app"op"ia$e $o pe"#o"! #"a%$ional %u""e$$age in o"de" $o

assis$ in dis$inguishing an endo!e$"ial $u!ou" #"o! one o# endo%e"vi%al o"igin)

'.2) !re(o&erati%e e+amination either in the out(&atient clinic or &ossi,ly as a

formal $- /0( hysterosco&y.

This !a p"ovide addi$ional in#o"!a$ion "ela$ing $o $he si$e and s$age o# disease)

'.3) maging studies

e do no$ %onside" $he "ou$ine use o# inves$iga$ions su%h as MRI o" CT -us$i#ied a$ p"esen$

al$hough $he !a %lea"l be o# use in $he assess!en$ o# %ases o# %lini%all advan%ed

disease o" poo" p"ognosis va"ian$s su%h as u$e"ine papilla" se"ous %a"%ino!a)

P"e0ope"a$ive inves$iga$ions should in%lude

F C& u"ea B ele%$"ol $es and LFTs

lood g"oup and save

Ches$ 0"a

. Treatment

.1) Surgery

he"e su"ge" is indi%a$ed as $he app"op"ia$e $"ea$!en$ and $he pa$ien$ is %onside"ed #i$ #o"

$he p"o%edu"e i$ should $a(e pla%e 5. da s #"o! de%ision $o $"ea$)

.2) hoice of ncision

T"adi$ionall & su"ge" #o" u$e"ine %an%e" has been %a""ied ou$ abdo!inall & using an open

$e%hni:ue& via a lo' $"ansve"se o" ve"$i%al !idline in%ision& as indi%a$ed individuall b

%onside"a$ions o# build and a%%ess $o $he pelvis) Ca"dio0"espi"a$o" %o0!o"bidi$ in $hese

pa$ien$s sugges$s $ha$ $he lo' $"ansve"se in%ision is e!plo ed 'he"eve" possible& aided b

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ap"one%$o! $o #a%ili$a$e a%%ess $o $he pelvis in $he pa$ioen$ 'i$h a pendulous& obese

abdo!en)

Mo"e "e%en$l & lapa"os%opi%all assis$ed vaginal h s$e"e%$o! and oopho"e%$o! has

be%o!e in%"easingl popula" on a%%oun$ o# !o"e "apid "e%ove" $i!e 'i$hou$ %o!p"o!ise

o# e##e%$ive su"gi%al s$aging o" $u!ou" e9%ision) I$ is be%o!ing in%"easingl "ega"ded as $he

app"oa%h o# %hoi%e)

In un#i$ pa$ien$s 'he"e $he"e a"e %on%e"ns $ha$ an su"gi%al $"au!a $o $he abdo!inal 'all

!a signi#i%an$l in%"ease $he "is( o# se"ious %o!pli%a$ions& vaginal h s$e"e%$o! alone is a

"easonable al$e"na$ive 'i$h a%%ep$able "esul$s) 5

.3) Stage 1

Su"ge" is $he p"e#e""ed $"ea$!en$ !odali$ and should in%lude $he #ollo'ing> a8 $ho"ough

assess!en$ o# $he abdo!inal %avi$ b8 pe"i$oneal 'ashings #o" % $olog %8 sele%$ive pelvi%

and pa"a0ao"$i% l !ph node sa!pling !a be app"op"ia$e d8 $o$al abdo!inal h s$e"e%$o!

and bila$e"al salpingo0oopho"e%$o! ) The"e a"e no plans $o in$"odu%e "ou$ine s s$e!a$i%

l !phadene%$o! unless $he #inal published "esul$s o# $he ASTEC T"ial "e%o!!end

o$he"'ise)

The in%iden%e o# l !ph node involve!en$ in s$age one disease is app"o9i!a$el .,/) The

"ole o# l !ph node sa!pling o" l !phadene%$o! "e!ains un%lea")

.4) Stage 2

I# p"e0ope"a$ive diagnosis is S$age 4 su"ge" is $he p"e#e""ed $"ea$!en$ op$ion) I$ is

"e%ognised $ha$ $he !a-o"i$ o# S$age 4 a"e diagnosed pos$0ope"a$ivel ) See "adio$he"ap

belo')

Su"ge" i# unde"$a(en #o" pa$ien$s 'i$h %lini%al involve!en$ o# $he %e"vi9 should in%lude>

a8 lapa"o$o! via !idline in%ision

b8 pe"i$oneal 'ashings #o" % $olog

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%8 "adi%al e9$ended h s$e"e%$o! and bila$e"al salpingo0oopho"e%$o!

d8 pelvi% ?0 pa"a0ao"$i% l !phadene%$o! ) 7In $hese %ases $he "is( o# sp"ead $o pelvi%

l !ph nodes !a be as high as 5,/8

In pa$ien$s no$ sui$able #o" su"ge" 'i$h %lini%al s$age 4 disease& "adio$he"ap is an op$ion)

. ) Stage 3 and 4

These a"e a he$e"ogenous g"oup o# pa$ien$s 'ho !us$ be !anaged on an individual basis)

Re%o!!ended $"ea$!en$s in%lude su"ge" & su"ge" #ollo'ed b "adia$ion& "adio$he"ap &

ho"!onal $"ea$!en$ o" %he!o$he"ap ) i$h "espe%$ $o su"ge" debul(ing su"ge" si!ila" $o

$ha$ unde"$a(en #o" ova"ian %an%e" has been advo%a$ed in advan%ed disease) Go## e$ al

"epo"$ed a s$ud o# 36 pa$ien$s 'hi%h in%luded 4, 'ho p"eope"a$ivel 'e"e %onside"ed $o

have disease %on#ined $o $he u$e"usH) Debul(ing 'as %a""ied ou$ in 4< pa$ien$s 'i$h s$age 3

disease 'i$h a pe"i0ope"a$ive !o"$ali$ o# 6/) Mul$iva"ia$e anal sis sho'ed $ha$ su"gi%al

% $o"edu%$ion 'as $he onl signi#i%an$ p"ognos$i% #a%$o" #o" su"vival and al$hough !edian

su"vival 'as onl .4 !on$hs $his 'as e9$ended $o 4. !on$hs in $hose pa$ien$s 'ho 'e"e

op$i!all debul(ed and had %he!o$he"ap ) This agg"essive su"gi%al app"oa%h #o" pa$ien$s

'i$h advan%ed disease is also suppo"$ed b $he GOG .44 s$ud 7 "e#e"en%e8 3)

. Radiothera&y

The"e a"e %on$"ove"sies "ega"ding $he !anage!en$ o# all s$ages o# endo!e$"ial %an%e")

The"e a"e no' $h"ee "ando!ised s$udies o# pos$0ope"a$ive "adio$he"ap in ea"l

endo!e$"ial %an%e" E""o"> Re#e"en%e sou"%e no$ #ound &E""o"> Re#e"en%e sou"%e no$ #ound&+) The ASTEC

s$ud has been published in abs$"a%$ and Po"$e%05 is due $o be in$"odu%ed i!!inen$l )

.1) Stage disease

.1.1 5o6 risk &atientsPa$ien$s 'i$h a lo' "is( o# "e%u""en%e do no$ "e%eive pos$ope"a$ive "adio$he"ap 7 RT8)

These in%lude $hose pa$ien$s 'ho a#$e" TA;? SO have>

G"ade.?g"ade4 7G.?G48 $u!ou"s 'i$h less $han +,/ ! o!e$"ial invasion 7s$age .A o" . 8

748 G"ade 5 7G58 $u!ou"s li!i$ed $o $he endo!e$"iu! 7s$age .A8

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.1.2 7oderate to *igh Risk !atients

These in%lude all o$he" pa$ien$s) Th"ee "ando!ised $"ials have sho'n $ha$ 'hile

"adio$he"ap "edu%es $he "is( o# pelvi% "elapse& i$ does no$ signi#i%an$l a##e%$ ove"all

su"vival E""o"> Re#e"en%e sou"%e no$ #ound ,Error: Reference source not found,Error: Reference source not found ) In

subse$ anal sis o# one o# $hese s$udies 7Aalde"s8 $he"e 'as a su"vival advan$age #o"

"adio$he"ap in pa$ien$s 'i$h G5 disease and deep ! o!e$"ial invasion 7S$age .C8) In $he

o$he" $'o s$udies 7GOG


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The op$ions #o" $hese highe" "is( pa$ien$s a"e

7.8 pos$ope"a$ive RT o"

748 obse"va$ion 'i$h "adio$he"ap #o" pelvi% "elapse

T"ea$!en$ de%isions a"e !ade on an individual basis $a(ing pa$ien$ p"e#e"en%es and

%o!o"bid %ondi$ions in$o %onside"a$ion) Radio$he"ap is asso%ia$ed 'i$h a s!all "is( o#

!a-o" bo'el?bladde" !o"bidi$ in addi$ion $o long $e"! !ino" $o9i%i$ ) The "a$ionale #o"

o##e"ing obse"va$ion 'i$h "adio$he"ap #o" "elapse is $ha$ vaul$ "e%u""en%e %an be salvaged

'i$h "adio$he"ap in a high p"opo"$ion o# %ases 1)

.2) Stage Disease

The"e is !u%h less da$a #o" s$age II disease %o!pa"ed 'i$h s$age I) These pa$ien$s have a

highe" "is( o# involve!en$ o# pelvi% nodes and a highe" "is( #o" #ailu"e 6 S$udies $end $o be

s!all "e$"ospe%$ive se"ies 'he"e pa$ien$s "e%eived ad-uvan$ "adio$he"ap ) So!e pa$ien$s

'i$h s$age II disease !a be ove"s$aged as a "esul$ o# %e"vi%al i!plan$a$ion a#$e"

%u""e$$age)

I# $he"e is onl #o%al involve!en$ o# $he %e"vi9 and o$he"'ise $he pa$ien$ #alls in$o a lo' "is(

g"oup obse"va$ion is an op$ion) In gene"al all o$he" pa$ien$s a"e o##e"ed pos$ope"a$ive

"adio$he"ap )

.2.1 Trials in &rogress in stage and disease

The PORTEC05 $"ial is a "ando!ised phase III $"ial %o!pa"ing %on%u""en$

%he!o"adio$he"ap and ad-uvan$ %he!o$he"ap 'i$h pelvi% "adio$he"ap alone in high "is(

and advan%ed s$age endo!e$"ial %an%e" #ollo'ing h s$e"e%$o! ) I$ is an in$e"na$ional

%ollabo"a$ion led b $he Du$%h Coope"a$ive G nae%ologi% On%olog G"oup and hopes $o

"e%"ui$ +,, pa$ien$s ove" + ea"s)The p"i!a" ob-e%$ive o# $his s$ud is $o es$ablish ove"all su"vival and #ailu"e0#"ee su"vival

'he"e #ailu"e is de#ined as "elapse o" dea$h due $o endo!e$"ial %an%e" o" due $o $"ea$!en$

%o!pli%a$ions)

The se%onda" ob-e%$ives a"e $o es$ablish and %o!pa"e $he "a$es o# $"ea$!en$0"ela$ed

$o9i%i$ & :uali$ o# li#e and pelvi% and dis$an%e "e%u""en%e)

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Pa$ien$s "ando!ised $o "e%eive $he e9pe"i!en$al a"! o# $he $"ial& 'ill have %ispla$in on da

. and 44 o# "adio$he"ap and $he e9$e"nal "adio$he"ap dose 'ill be 3=)1G in 46 ) Then 3

% %les o# ad-uvan$ %he!o$he"ap 'i$h %a"bopla$in and pa%li$a9el eve" 5 'ee(s) A

b"a%h $he"ap boos$ is given i# $he"e is %e"vi%al involve!en$)

.3) Stage disease

S$age $h"ee disease is an un%o!!on and he$e"ogenous disease in%luding pa$ien$s 'i$h

$u!ou" sp"ead be ond $he u$e"us $o involve $he se"osa& adne9ae& pe"i$oneal #luid& vagina&

pelvi% pa"a0ao"$i% nodes) T"ea$!en$s "e%o!!ended have in%luded pos$ope"a$ive

"adio$he"ap $o $he pelvis& $o $he pelvis and pa"a0ao"$i% "egion& 'hole abdo!inal

"adio$he"ap 7 AR8& in$"ape"i$oneal P54& p"oges$ogens o" %he!o$he"ap 8) The i!pa%$ o#

$hese $"ea$!en$s on ou$%o!e is no$ %lea"& !u%h o# $he eviden%e %o!ing #"o! s!all single

a"! s$udies)

.3.1 Stage a

Pa$ien$s 'i$h se"osal?adne9al involve!en$ gene"all "e%eive pos$ ope"a$ive "adio$he"ap )

The signi#i%an%e o# !alignan$ pe"i$oneal % $olog is un%lea") I$ is usuall asso%ia$ed 'i$h

o$he" "is( #a%$o"s #o" "e%u""en%e su%h as deep ! oinvasion o" G5


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I# pa$ien$ has had a "adi%al h s$e"e%$o! & "adio$he"ap is %onside"ed i# !o"e $han one

pelvi% node is involved)

The !anage!en$ o# pa$ien$s 'i$h bul( nodes is un%lea") Gene"al opinion is $ha$ i# $he"e

is a single bul( node "ese%$ion pos$ope"a$ive "adio$he"ap %an be %onside"ed) Pa$ien$s

'ho have !ul$iple bul( nodes have in%u"able disease and $"ea$!en$ is pallia$ive) In $his

si$ua$ion $"ea$!en$ !odali$ies !a in%lude "adia$ion?ho"!ones and %he!o$he"ap )

.4) Stage 8 disease

T"ea$!en$ is individualised #o" $hese pa$ien$s using %o!bina$ions o# su"ge" ?"adio$he"ap ?

ho"!ones and %he!o$he"ap ) The ai! is $o %on$"ol disease and !ain$ain :uali$ o# li#e)

.4.1 Stage 8a

T"ea$!en$ is gene"all pallia$ive) O%%asional pa$ien$s !a be sui$able #o" "adi%al app"oa%h

ei$he" in $he #o"! o# "adio$he"ap o" su"ge" )

.4.2 Stage 8, disease

Pallia$ive "adio$he"ap %an be used #o" pa$ien$s 'ho a"e s !p$o!a$i% 'i$h lo%al pelvi%

s !p$o!s) ;o"!onal $"ea$!en$ and?o" %he!o$he"ap %an be %onside"ed #o" $hose

p"esen$ing 'i$h !e$as$a$i% disease)

. ) Treatment of &atients 6ith unfa%oura,le histology

o$h u$e"ine papilla" se"ous 7UPSC8 and %lea" %ell his$olog a"e asso%ia$ed 'i$h a poo"

p"ognosis) The pa$$e"n o# in$"ape"i$oneal sp"ead "ese!bles ova"ian %an%e") +0 ea" su"vival

"a$es a"e o# $he o"de" o# 5,J3,/ .4&.5 )

. .1 -terine &a&illary serous carcinoma 9-!S ): and clear cell carcinoma.

These $u!ou"s $end $o be deepl ! oinvasive and #"e:uen$l have vas%ula" spa%e

invasion) Mos$ su"gi%all s$aged pa$ien$s have unsuspe%$ed e9$"au$e"ine disease .3 ) O#

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pa$ien$s 'ho "e%u" +,/ appea" $o do so in $he uppe" abdo!en .+ )The $"ea$!en$ o# UPSC

should p"obabl in%lude ova"ian s$ le debul(ing su"ge" and s$aging& in%luding

o!ene%$o! ) The e9a%$ $ pe o# ad-uvan$ $"ea$!en$ is un%lea") The"e is da$a $o suppo"$ no

ad-uvan$ $"ea$!en$ in $hose pa$ien$s 'i$h s$age .a disease 'ho have been s$aged

app"op"ia$el ) The"e is phase 4 da$a $o suppo"$ ad-uvan$ %he!o0"adio$he"ap in s$age . o"

II disease) Up $o "e%en$l i$ has been #el$ $ha$ unli(e se"ous %a"%ino!as o# $he ova"

"esponse "a$es $o pla$inu! %on$aining "egi!es a"e lo') GOG .44 in%luded 4.)5/ o#

pa$ien$s 'i$h se"ous papilla" $u!ou"s and al$hough nu!be"s 'e"e s!all "esponse "a$es

'e"e si!ila" in $hese pa$ien$s 'i$h Cispla$in?Do9a"ubi%in .1 )

T"ea$!en$ op$ions in%lude

Obse"va$ion #o" .a disease #ollo'ing TA;? SO

Pelvi% "adio$he"ap #o" s$ages . and II disease) Che!o$he"ap %onside"ed in sele%$ed

%ases)

Cispla$in?Do9a"ubi%in %he!o$he"ap #o" pa$ien$s 'i$h S$ages 5 B 3 disease 'ho have been

su"gi%all debul(ed 'i$h "adio$he"ap a#$e"'"a"ds)

Rando!isa$ion $o Po"$e%05 in due %ou"se)

.#) Treatment of endometrial carcinoma 6ith radiothera&y alone

en$s 'ho a"e !o"bidl obese o" a"e dee!ed un#i$ #o" su"ge" should be "evie'ed b one o# $he

ae%ologi%al On%ologis$s a$ $he Cen$"e) I# $he a"e $hen #el$ un#i$ #o" su"ge" $he %an be %an be

de"ed #o" Radi%al Radio$he"ap ) i$h Radi%al Radio$he"ap $he lo%al %on$"ol "a$es a"e high in

en$s 'i$h s$age . and 4 disease and + ea" disease spe%i#i% su"vival "a$es a"e si!ila"l good)

$ o# pa$ien$s $"ea$ed a$ CCO sho'ed + ea" disease spe%i#i% su"vival $o be 6,/ in pa$ien$s 'i$h

e I?II disease and 55/ in s$age III?I disease .6 ) ;o'eve" + ea" ove"all su"vival "a$es in $hese

en$s a"e gene"all onl 5, J+,/ as a %onse:uen%e o# $hei" !edi%al p"oble!s)

.') Treatment of recurrent disease

u""en$ endo!e$"ial %an%e" is %on#ined $o $he pelvis in hal# o# pa$ien$s and o# $hese app"o9 +,/ a"e

ined $o $he vagina E""o"> Re#e"en%e sou"%e no$ #ound &E""o"> Re#e"en%e sou"%e no$ #ound) Salvage o# $hese %ases

e usual 'hen disease involves $he vagina E""o"> Re#e"en%e sou"%e no$ #ound &E""o"> Re#e"en%e sou"%e no$ #ound)

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$!en$ op$ions depend on p"evious "adio$he"ap

no p"evious "adio$he"ap >

%al "adio$he"ap 'i$h e9$e"nal bea! and in$"a%avi$ $"ea$!en$

# p"eviousl i""adia$ed $"ea$!en$ is gene"all pallia$ive and dosi!e$" li!i$ed)

e !a be s%ope #o" #u"$he" e9$e"nal bea! o" in$"a%avi$ $"ea$!en$)

. ) d;u%ant 8ault Brachythera&y

A$ CCO& ad-uvan$ vaul$ b"a%h $he"ap is given $o all sui$able pa$ien$s a$ $he end o# e9$e"nal

bea! "adio$he"ap ) This %onsis$s o# a single vaul$ $"ea$!en$)

The"e a"e no %o!ple$ed "ando!ised $"ials add"essing $he "ole o# vaul$ b"a%h $he"ap alone

in endo!e$"ial %an%e") ;o'eve"& $he PORTEC04 $"ial& 'hi%h is ongoing& "ando!ises

pa$ien$s 'i$h Khigh0in$e"!edia$e "is( disease $o pelvi% "adio$he"ap and vaginal

b"a%h $he"ap )

Sele%$ive in$e"!edia$e "is( pa$ien$s pa$ien$s !a be o##e"ed vaul$ b"a%h $he"ap alone&

'hi%h %onsis$s o# 5 $"ea$!en$s ove" a pe"iod o# 4 $o 5 'ee(s)

1 Re#e"en%e sou"%e no$ #ound ) ;ighe"

"esponse "a$es a"e no$ed in pa$ien$s 'i$h g"ade . disease& posi$ive p"oges$e"one "e%ep$o"s&

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and a longe" disease #"ee in$e"val) Re$"ospe%$ive ER0PR s$a$us !a be help#ul in

de$e"!ining !anage!en$) Al$hough $he"e a"e no "ando!ised %on$"olled $"ials o# $he use o#

ho"!onal $he"ap in $his se$$ing& i$s use is o#$en o# pallia$ive bene#i$ and !a possibl

enhan%e su"vival) The pa"$i%ula" agen$ used does no$ a##e%$ $he "esponse "a$es)

e "e%o!!end P"ove"a 7!ed"o9 p"oges$e"one a%e$a$e8 .,,!g $id)

Mega%e 7!eges$"ol a%e$a$e8 .1,!g od)

The"e is in$e"es$ developing in $he use o# a"o!a$ase inhibi$o"s)

11. hemothera&y

Ad-uvan$ The"e !a be a "ole #o" ad-uvan$ %he!o$he"ap in sele%$edpa$ien$s 45&43

Advan%ed disease Che!o$he"ap %an be %onside"ed in pa$ien$s 'i$h advan%ed

disease

Pa$ien$s a"e sui$able i# %"ea$inine %lea"an%e is@+,!l?!in and

pe"#o"!an%e s$a$us . o" 4)

Agen$s and doses> Cispla$in 1,!g ?!4

Ad"ia! %in 3,!g ?!4

C %le $i!e 4.00= da s #o" 301 % %les

Dela $"ea$!en$ i# ANC 2.)+

E9pe%$ed "esponse "a$e 53/ E""o"> Re#e"en%e sou"%e no$ #ound

Upda$ed da$a has been published suppo"$ing $he use o# %ispla$in and ad"ia! %in 4+) A

#u"$he" "ando!ised %o!pa"ison has been published b Fle!ing e$ al in 4,,3 %o!pa"ing

Cispla$in& ad"ia! %in and pa%li$a9el 'i$h $he s$anda"d AC %o!bina$ion 41) hils$ $his sho's

an =)5 !on$h su"vival gain& in vie' o# $he g"ade 5 and 3 ! elopsupp"ession $his 5 d"ug

%o!bina$ion is no$ "e%o!!ended as s$anda"d)

12. !alliati%e are and =ursing care

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Pallia$ive %a"e inpu$ is app"op"ia$e $o %onside" a$ all s$ages o# $he pa$ien$ s %an%e" -ou"ne )

Please "e#e" $o $he sepa"a$e pallia$ive %a"e guideline #o" de$ailed advi%e)

All 'o!en 'i$h a diagnosis o# a G nae%ologi%al Can%e" should be o##e"ed $he suppo"$ o#&

and have a%%ess $o a Clini%al Nu"se Spe%ialis$ 7CNS8& in o"de" $o #a%ili$a$e $he 'o!an s

needs $h"oughou$ $he Can%e" Qou"ne & in%luding $hose o# he" pa"$ne" o" %a"e")

The s(ills o# $he C)N)S) as a %onsul$an$& p"a%$i$ione" and edu%a$o" %an be d"a'n upon a$ all

s$ages $h"oughou$ $hei" illness& #"o! $he p"e0diagnosis $o $he $e"!inal s$age J in%o"po"a$ing

$he Spe%ialis$ Pallia$ive Ca"e Se"vi%es p"ovided in $he hospi$al and $he %o!!uni$ se$$ing)

e"eave!en$ Suppo"$ 'ill also be available& i# app"op"ia$e)

I!po"$an$ aspe%$s o# $he "ole a"e $o p"ovide advi%e& suppo"$& in#o"!a$ion and $o e##e%$ivel

in%o"po"a$e app"op"ia$e "esou"%es) The C)N)S) 'ill be "e%ep$ive $o $he so%ial& ph si%al&

ps %hologi%al& %ul$u"al& se9ual and spi"i$ual needs o# $he pa$ien$) The ai! o# $he pa$ien$

suppo"$ is $o assis$ 'i$h $he i!p"ove!en$ in $he :uali$ o# $hei" lives& allo'ing $he! $o

be%o!e !o"e e!po'e"ed $o help $a(e %on$"ol and enhan%e $hei" sel# es$ee!)

The C)N)S) 'o"(s %losel 'i$h Su"geons& On%ologis$s& Radio$he"apis$s& Consul$an$s in

Pallia$ive Medi%ine and o$he"s 7Nu"ses B P)A)M)s8)

The 'ill unde"$a(e a nu!be" o# (e "esponsibili$ies in%luding>

Lin(ing 'i$h o$he" p"o#essionals 'ho %an help $he pa$ien$s $h"oughou$ $he s s$e!

A "esou"%e #o" in#o"!a$ion and suppo"$ $o $he pa$ien$ %a"e" and o$he" ;)C)P)s

Liaison poin$ #o" o$he" heal$h %a"e p"o#essionals in p"i!a" and se%onda" %a"e

Tea%he" and Edu%a$o"

Resea"%he"

S$anda"ds and Audi$ Co0o"dina$o"

Co0o"dina$e Ca"e Se"vi%es

13. "ollo6(u&

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A$ pi%al h pe"plasia is %u"ed b h $e"e%$o! & and pa$ien$s 'i$h s$age .a disease have a

ve" lo' "is( o# "elapse) The !a $he"e#o"e be dis%ha"ged 'i$h open appoin$!en$ in $he

even$ o# ne' s !p$o!s o" %on%e"ns)

Fo" $he "e!ainde"& s$anda"d #ollo'0up is "e%o!!ended> Fou" !on$hl #o" ea"s . and 4&

si9 !on$hl $o 5 ea"s) Dis%ha"ge 'i$h open a%%ess $o CNS in $he even$ o# ne' s !p$o!s

o" %on%e"ns) CNS holis$i% assess!en$ is %a""ied ou$ 1 'ee(s a#$e" $he %o!ple$ion o#

p"i!a" $"ea$!en$)

14. *ormone Re&lacement

The :ues$ion as $o 'he$he" ho"!one "epla%e!en$ $he"ap !a be p"es%"ibed is a !a$$e" o#

so!e deba$e) Endo!e$"ial %an%e" is %onside"ed $o be an oes$"ogen0dependen$ %an%e" andhen%e $"adi$ional $hin(ing has been $ha$ oes$"ogen "epla%e!en$ $he"ap is %on$"aindi%a$ed)

;o'eve" $he"e is no published da$a $o suppo"$ $his a"gu!en$) On $he %on$"a" $he"e a"e a

g"o'ing nu!be" o# "epo"$s 'hi%h sugges$ $ha$ no$ onl is oes$"ogen "epla%e!en$ $he"ap H

sa#e 46&4= in $hese %i"%u!s$an%es bu$ $ha$ su"vival !a be enhan%ed b i$s p"es%"ip$ions)

1 . linical Trials

The %en$"e is %u""en$l planning $o pa"$i%ipa$e in $he Po"$e%05 $"ial& inves$iga$ing 'he$he"ad-uvan$ %he!o"adia$ion is supe"io" $o "adia$ion alone)

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&&endi+ 1

Radiothera&y for $ndometrial carcinoma

1. d;u%ant radiothera&y

A 5 o" 3 #ield $e%hni:ue is used $o $"ea$ $he pelvis) The pa$ien$ lies in $he supine posi$ion

and is planned using $he CT si!ula$o") The"e is no "ou$ine need $o use a vaginal !a"(e"

'hen planning 'i$h a vi"$ual si!ula$ion $e%hni:ue)

The dose s%hedule is e9$e"nal bea! "adio$he"ap 3+G in 4+ ove" + 'ee(s #ollo'ed b a

single b"a%h $he"ap $"ea$!en$ $o $he vaginal vaul$& giving a dose o# 1G a$ +!! #"o! $heappli%a$o" su"#a%e& $"ea$ing $he $op 4 $o 3%! o# $he vagina using ;DR)

See "adio$he"ap p"o$o%ol boo( #o" #ield de#ini$ions)

2. Radical radiothera&y

A) A 5 o" 3 #ield $e%hni:ue is used $o $"ea$ $he pelvis)

The dose is 3+G in 4+ ove" + 'ee(s e9$e"nal bea! $"ea$!en$ #ollo'ed b ;DR

b"a%h $he"ap & 6G in 4 )

) Fo" obese pa$ien$s 'i$h ea"l s$age disease& %an be $"ea$ed 'i$h b"a%h $he"apalone& dose 6G in + )

3. >hole a,dominal radiothera&y

This $"ea$!en$ is no$ used a$ Cla$$e"b"idge Cen$"e #o" On%olog )

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4. Treatment of &el%ic recurrence

In pa$ien$s p"eviousl $"ea$ed b su"ge" alone 'ho develop a %en$"al pelvi% "e%u""en%e&

salvage %an be a%hieved 'i$h pelvi% "adio$he"ap ) A CT s%an o# $he abdo!en and pelvis

should be pe"#o"!ed be#o"e "adio$he"ap is given)

The s%hedule is 3+G in 4+ e9$e"nal bea! "adio$he"ap $o $he pelvis #ollo'ed b 4

b"a%h $he"ap $"ea$!en$s $o $he vaginal vaul$& ea%h o# 1 o" 6G ensu"ing all $he vaginal

disease is %ove"ed)

. !alliati%e radiothera&y

: !el%ic Disease

A s!alle" pelvi% #ield %an be used $o en%o!pass g"oss disease& $o a%hieve s !p$o! %on$"ol

and !ini!ise $o9i%i$ )

A%%ep$able dose #"a%$iona$ions in%lude> 4,G in +

5,G in .,

3,G in .+

A single $"ea$!en$ o# = $o .,G !a be sui$able #o" #"ail pa$ien$s)

B: 7etastatic Disease

one !e$s %an be $"ea$ed ei$he" 'i$h a single =G $"ea$!en$ o" 4,G in +

"ain !e$s %an be $"ea$ed 'i$h .4G in 4 o" 4,G in +

Sele%$ed pa$ien$s 'i$h high "is( disease %an be $"ea$ed 'i$h %he!o"adio$he"ap #ollo'ed b

a #u"$he" 3 % %les o# %he!o$he"ap )

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1 *e s e$ Al) A phase III $"ial o# Su"ge" vs 'i$h o" 'i$hou$ ad-un%$ive e9$e"nal pelvi% "adia$ion

$he"ap in in$e"!edia$e "is( endo!e$"ial adeno%a"%ino!a> A G ne%ologi% On%olog G"oup

s$ud ) G ne%) On%olog ) .3,30.3..)

4,,,3 Chan Q*& Lin G& Mon( Q& e$ al) aginal ; s$e"e%$o! as P"i!a" T"ea$!en$ o#

Endo!e$"ial Can%e" in Medi%all Co!p"o!ised o!en . Obs$e$ G ne%ol 6,606..) 4,,.)4 5 Aalde"s e$ Al) Pos$ope"a$ive e9$e"nal i""adia$ion and p"ognos$i% pa"a!e$e"s in s$age .

endo!e$"ial %a"%ino!a) Obs$e$"i%s and G ne%) +1> 3.< J 346) . .66 J.=5) . ++01+) .4+.04+1) . 44 a his$opa$hologi%al and p"ognos$i%

su"ve o# a $o$al popula$ion) In$) Q) G ne%) Can%e") 4> < J 44 .


22/22

17 Chu"n e$ al) P"i!a" "adio$he"ap #o" %a"%ino!a o# $he endo!e$"iu! using e9$e"nal bea!

"adio$he"ap and single line sou"%e b"a%h$he"ap ) Clini%al On%olog ) ..> 4++0414). A G ne%ologi% On%olog G"oup s$ud ) Q Clin On%ol . 5

endometrium clinical guidelines final

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