Adjuvant EBRT / brachy/ EBRT + brachy for endometrial Ca?

[Kroll2013]

Dear colleagues, here are two cases of endometrial carcinoma. I need your advice.

1st case:
73 yo patient, had undergone TAH-BSO for endometrial carcinoma.
Pathology: endometrial ADK, mainly uterine with isthmic invasion, no invasion of the cervix, infiltrating 60% of the myometer, grade 1-2, no LVSI, negative pelvic LND
T2N0 FIGO
What do you suggest as adjuvant trt:
- EBRT
- EBRT + vaginal cuff brachyT
- only brachyT

2nd case:
63 yo pt, grade 2 endometrial ADK, positive pelvic LN with extracapsular effraction, stage III C2 FIGO. She has also a satellite carcinomatous nodule of the Rt parametrium with no invasion of the cervix. She already received adjuvant CT.

She needs:
- EBRT alone
- EBRT + vaginal cuff BrachT


Thank you

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[Palex80]

Case 1:
Is this truly a pT2? You need involvement of the stromal tissue of the cervix per current UICC staging for a pT2.
I'd do brachy.

Case 2:
EBRT alone.

 

[RadOncDoc21]

Case 1: Brachy alone
Case 2: Seems a bit more high risk to me, I would do pelvic EBRT and vag brachy. Some may even consider doing the PA nodes in her.

 

[Palex80]

In my humble opinion case 2 has a far greater risk for a pelvic / pelvic wall recurrence than a vaginal recurrence. That is the reason, I would not offer brachy.
Extended field RT is an option, I wouldn't do it after chemo though.

 

[medgator]

In my humble opinion case 2 has a far greater risk for a pelvic / pelvic wall recurrence than a vaginal recurrence. That is the reason, I would not offer brachy.
Extended field RT is an option, I wouldn't do it after chemo though.

I get the sense that we combine ebrt with vag cuff brachy in the U.S. more than they do in Europe as a habit

 

[medgator]

Would anyone offer pelvic ebrt for papillary serous if there was a good negative pelvic and PA nodal dissection or just brachy alone?

 

[Kroll2013]

Case 1: Brachy alone
Case 2: Seems a bit more high risk to me, I would do pelvic EBRT and vag brachy. Some may even consider doing the PA nodes in her.

would you consider pelvic EBRT if the LND is not complete. i mean she had 2 LN dissected at the left and 4 at the right (less then 10 as recommended)

 

[Kroll2013]

Case 1:
Is this truly a pT2? You need involvement of the stromal tissue of the cervix per current UICC staging for a pT2.
I'd do brachy.

Case 2:
EBRT alone.

case1: would you consider pelvic EBRT if the LND is not complete. i mean she had 2 LN dissected at the left and 4 at the right (less then 10 as recommended)

 

[Palex80]

Case 1: This is not a pT2 in my opinion or perhaps its at maximum a very early pT2 (the so called pT2a in the past classification). Therefore the patient would have been eligible for PORTEC2. PORTEC 2 made the point that you don't need EBRT for these patients and patients did not have LND at all in the trial.

 

[Palex80]

I get the sense that we combine ebrt with vag cuff brachy in the U.S. more than they do in Europe as a habit

Don't get me wrong. I do it too often. But when the risk of disease recurrence is higher in the pelvis or pelvic wall, I do not see the point in boosting the area which is not at such a great risk for recurrence.

 

[Mandelin Rain]

I typically follow PORTEC criteria if no/poor LND done and GOG criteria if a good LND performed (almost never). I don't ask the patient to get opened back up to grab LNs. I always get a diagnostic scan before treatment however, to rule out gross adenopathy.

I also typically treat people based on the stage they would have been when the trials were done. The stage change in endometrial cancer was nonsensical IMO and has confounded treatment recommendations established under the previous staging system.

 

[seper]

Regarding case 2, did you mean AJCC stage IIIC1? IIIC2 means positive paraaortic nodes.

For stage IIIC1 disease with ECE on a pelvic LN, I'd do 45 GY WPRT followed by boost to involved "parametrium/side wall

Dear colleagues, here are two cases of endometrial carcinoma. I need your advice.

1st case:
73 yo patient, had undergone TAH-BSO for endometrial carcinoma.
Pathology: endometrial ADK, mainly uterine with isthmic invasion, no invasion of the cervix, infiltrating 60% of the myometer, grade 1-2, no LVSI, negative pelvic LND
T2N0 FIGO
What do you suggest as adjuvant trt:
- EBRT
- EBRT + vaginal cuff brachyT
- only brachyT

2nd case:
63 yo pt, grade 2 endometrial ADK, positive pelvic LN with extracapsular effraction, stage III C2 FIGO. She has also a satellite carcinomatous nodule of the Rt parametrium with no invasion of the cervix. She already received adjuvant CT.

She needs:
- EBRT alone
- EBRT + vaginal cuff BrachT


Thank you

 

[Damn_Daniel]

I never saw sidewall boost for endometrial, though it makes some sense for ECE, I think. What dose? Maybe SIB it at 2 Gy/fx? How do you target it?
For other sites, ECE would be possible indication for radiosensitization. Any role for that?

 

[medgator]

I never saw sidewall boost for endometrial, though it makes some sense for ECE, I think. What dose? Maybe SIB it at 2 Gy/fx? How do you target it?
For other sites, ECE would be possible indication for radiosensitization. Any role for that?

Not in post op lung unless macroscopic/gross

 

[Palex80]

I sometimes boost pelvic wall in postop uterine cases where the margins to the pelvic wall or parametria are close. This is an area which is very poorly covered by vaginal cuff brachytherapy.