Case discussion: recurrent endometrial adenocarcinoma

[Gfunk6]

55F who presented with vaginal bleeding and abdominal cramps. Endometrial biopsy revealed adenocarcinoma. No pre-operative imaging.

Pt has TAH-BSO + b/l LND. Final path was 2.1 cm well-differentiated endometrial adenocarcinoma invading 1 mm into the myometrium. No LVI. 0/22 positive pelvic LN. 0/3 positive PA LN.

FIGO Stage IA

No adjuvant therapy recommend based on final pathology.

------------------------

16 months later, on routine gyn examination, a 1 cm fleshy mass was palpated in the vaginal apex. Biopsy revealed well-differentiated adenocarcinoma. PET/CT was done and was negative (including in the site of recurrence).

Pt is referred to you for treatment options. What do you do?

Choice #1: EBRT to pelvic LN + HDR boost; Evidence

Choice #2: HDR monotherapy; Evidence

Note: The data for #2 is based on PORTEC 2 which is not totally applicable because (a) this is a recurrence and (b) it is "technically" not high-intermediate risk based on pathology.

Concurrent chemoXRT was also discussed but dismissed due to lack of data.

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[seper]

As you saw in MDA paper, EBRT is usually added for a gross, recurrent tumor.
Also, one should consider interstitial brachy isntead of Delclos if the tumor is > 0.5 cm thick (MRI, ? U/S).

55F who presented with vaginal bleeding and abdominal cramps. Endometrial biopsy revealed adenocarcinoma. No pre-operative imaging.

Pt has TAH-BSO + b/l LND. Final path was 2.1 cm well-differentiated endometrial adenocarcinoma invading 1 mm into the myometrium. No LVI. 0/22 positive pelvic LN. 0/3 positive PA LN.

FIGO Stage IA

No adjuvant therapy recommend based on final pathology.

------------------------

16 months later, on routine gyn examination, a 1 cm fleshy mass was palpated in the vaginal apex. Biopsy revealed well-differentiated adenocarcinoma. PET/CT was done and was negative (including in the site of recurrence).

Pt is referred to you for treatment options. What do you do?

Choice #1: EBRT to pelvic LN + HDR boost; Evidence

Choice #2: HDR monotherapy; Evidence

Note: The data for #2 is based on PORTEC 2 which is not totally applicable because (a) this is a recurrence and (b) it is "technically" not high-intermediate risk based on pathology.

Concurrent chemoXRT was also discussed but dismissed due to lack of data.

 

[medgator]

As you saw in MDA paper, EBRT is usually added for a gross, recurrent tumor.
Also, one should consider interstitial brachy isntead of Delclos if the tumor is > 0.5 cm thick (MRI, ? U/S).

In situations where interstitial brachy is not feasible, IMRT is another option that gets tossed around.

 

[Palex80]

There is NO proper evidence for this kind of situation, since there are no randomised trials asking these kind of questions.
Furthermore many of the retrospective studies included patients that were operated for their recurrence.

I would therefore in this case treat with EBRT followed by a brachy/interstitial boost "just to be safe".
I would choose interstitial over brachy boost, according to tumor size. If the tumor flattens out due to EBRT, you may not need to do interstitial RT. Hopefully the recurrency is not located towards the rectum, so you may be able to block it out during BT.
I wouldn't do whole-pelvis but rather mini-pelvis-RT. The evidence for this is my gut feeling...

 

[Brim]

I'd treat with EBRT + Brachy boost as per Choice #1.
The reference (adjuvant treatment) given for Choice #2 isn't really applicable to this situation, as you noted, since RT for adjuvant therapy shouldn't be extrapolated to recurrences.

 

[RadRadRad]

Assuming you use 4 field or IMRT for you EBRT, would you cover the presacral LNs with your lateral fields/IMRT volume?

 

[Brim]

Assuming you use 4 field or IMRT for you EBRT, would you cover the presacral LNs with your lateral fields/IMRT volume?

Treating the presacral LNs is recommend in the treatment of cervical cancer, or in the case of endometrial ca when there is cervical stromal invasion. (See the RTOG consensus guidelines by Small 2008).

In this case, it was a I-A. I would probably omit the presacral nodes. It probably matters very little ...

 

[Brim]

..And for what it's worth, the current GOG 0238 protocol (for treatment of locally recurrent endometrial ca; RT +/- chemo) states:
"Approximately 1-2 cm of tissue anterior to the sacrum (S1-S3) is
usually added to the CTV1 for adequate coverage of presacral
nodes."

So, in the GOG, they do recommend treating the presacral nodes (at least "usually").