Uterine case

[Kroll2013]

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58yo female that presents with grade 2 endometrioid carcinoma of the uterus, resected.
Pathology showed >50% myometrial invasion (stage IB), touching the isthmus without signs of invasion, negative LVSI, negative bilateral LND.
What to do next:
1- observe
2- brachytherapy alone
3- EBRT to pelvic LNs alone
4- EBRT followed by brachytherapy

Ty

 

[2014XRT]

easy vote for cuff alone imo

 

[thecarbonionangle]

How extensive was the lymphadenectomy? Anyway to get a breakdown from path into middle 1/3 and outer 1/3 invasion? Looking at the Creasman study (PMID 3652025), there is this very useful (IMO) table for predicting LN involvement (http://www.aboutcancer.com/endometrial_nodes_risk_utd_207.gif). If using chance of >15% for LN involvement (a number some use to treat pelvis in prostate cancer), it is over 15% for G2, Outer 1/3 invasion. It would be reasonable to consider WPRT for G2, outer 1/3 invasion. Cuff would be reasonable as well per PORTEC 2.

 

[seper]

I would offer HDR cylinder alone. She is young so that works in her favor as far as relapse risk.
As a side note, I personally do not believe in the diagnostic value of LND given 2 negative phase III trials.

 

[BobbyHeenan]

I too vote cuff alone.

 

[CptCrunch]

Brachy.

 

[Gfunk6]

Option 2


Sent from my iPhone using SDN mobile

 

[evilbooyaa]

IBG2 with concern for inferior extension - Brachy.

 

[Radiator20]

Brachy for me.

 

[Palex80]

Brachytherapy. The patient would have been included in PORTEC2.
PORTEC2 patients did have lymphadenectomy.

 

[seper]

Checking if we are paying attention? No LND in PORTEC2 and she'd be too young for PORTEC2.

Brachytherapy. The patient would have been included in PORTEC2.
PORTEC2 patients did have lymphadenectomy.

 

[evilbooyaa]

Going back and reading methods PORTEC2, very interesting that staging lymphadenectomy was an actual exclusion criteria to the study.

 

[seper]

Perhaps study PI was concerned that LND increases toxicity for EBRT arm, or maybe they thought "staged" patient will have fewer recurrence events.

Going back and reading methods PORTEC2, very interesting that staging lymphadenectomy was an actual exclusion criteria to the study.

 

[Palex80]

Checking if we are paying attention? No LND in PORTEC2 and she'd be too young for PORTEC2.

Thank you, that was a typo on my part! I meant to type didn't.

Oh and thanx for the age issue, I didn't know that.

I presume that lymphadenectomy was an exclusion criterium in PORTEC2 since otherwise some of the patients which had a lower risk for recurrence may have been overtreated. Or at least that was the concern, I presume.

On the other hand, the investigators could have chosen a more "soft" approach, saying that patients with deep myometrial infiltration or LVSI could have LND performed.
Yet they didn't, which is very good, since it makes the trial results more rebust!