Uterine Cancers FRCR CO2A Flashcards
(195 cards)
1
Q
which is the mc cancer affecting Uterus?
A
Adenocarcinoma
2
Q
What’s major RF a/w uterine cancer?
A
unopposed estrogen stimulation, a/w obesity, common in developed countries
3
Q
what are different types of malignancies affecting uterus?
A
Endometrial Carcinoma (90%)
Uterine sarcomas
Mixed mullerian tumor
Endometrial stromal sarcoma
Leiomyosarcoma
Lymphomas
Malignant secondary:
Direct spread from ovary, rectum, bladder, cervix and vagina
s/times breast
4
Q
which age group is typically affected by endometrial carcinoma/
A
post menopausal and median age is 60 years
5
Q
What are factors increasing risk of endometrial cancer?
A
- increasing age
- obesity
- long term exp to unopposed estrogen
- genetic factors
- atypical endometrial hyperplasia
6
Q
How is Obesity a/w malignant germ cell tumors of ovary
A
conversion of androstenedione to estrogen in peripheral fat
7
Q
what are sources of exogenous estrogens?
A
Estrogen only HRT
Tamoxifen for breast cancer (weak estrogenic effect on uterus)
8
Q
what are endogenous estrogen sources?
A
Granulosa cell tumors
PCOD
Increasing years of menstruation
Nulliparity
Infertility
9
Q
what genetic factors are a/w endometrial cancers?
A
- a + family h/o endometrial, breast or colorectal cancer in 2st degree relative
- HNPCC, Lynch type II
10
Q
what cancers is lynch type II associated?
A
Colorectal
Pancreatic
endometrial
breast
ovarian cancers
11
Q
what factors decrease the risk of endometrial cancer?
A
- Grand multiparity
- OCP use
- physcial activity
- diet including phyto-estrogens
12
Q
what are types of endometrial cancer?
A
Type I and Type II
13
Q
what are Type I endometrial cancer?
A
Endometrioid and mucinous subtypes
Estrogen dependant tumors. and a/w atypical endometrial hyperplasia
14
Q
What are Type II endometrial cancer?
A
lack an association with estrogen stimulation and are aggressive
serous and clear cell
15
Q
What are IHC features of endometrial cancer?
A
Express ER and PR
Type II: loss of function of tumor suppressor pathways, PTEN
Type II: TP53
16
Q
How does endometrial cancer spread?
A
Locally through myometrium, to the serosal surface of uterus, to the cervix, the parametria, the fallopian tubes, the vagina, the bladder, and the rectum
Through Lymphatics to the pelvic nodes, PA nodes and mediastinal nodes
Blood: Lungs, Liver and Bones and peritoneum
17
Q
what are regional LNs for endometrial cancer?
A
Pelvic and PA nodes
18
Q
What’s the mc presentation of endometrial cancer?
A
Postmenopausal bleeding
19
Q
what % of risk is of endometrial cancer in women with postmenopausal bleeding?
A
15%
20
Q
what are s/s of endometrial cancer?
A
- post menopausal bleeding
- Vaginal discharge
- other abnoraml bleeding (intermenstrual, menorrhagia, postcoital) and pelvic mass
symptoms due to local spread:
1. pelvic pain, renal failure , hematuria, bowel symptoms, back pain (PA node)
21
Q
Is there any benefit of screening for endometrial cancer?
A
No
22
Q
How is Investigation and staging proceeded in endometrial cancer?
A
- Pelvic Examination (speculum )
- TVS : endometrial thickness
- Hysteroscopy : allows inspection of uterine cavity
- Sigmoidoscoopy and cystoscopy if extension to rectum and bladder is suspected
- pregnancy should be ruled out
23
Q
what are the staging investigations for endometrial cancer?
A
Staged surgically
MRI > TVS for depth of myometrial invasion, involvement of cervix and LN involvement
CxR
CA 125
24
Q
what is the treatment of Stage I endometrial Cancer?
A
TAH and BSO and peritoneal washing followed by selective RT for high risk cases.
Laparoscopic or vaginal hysterectomy for obese pts
Primary RT for medically unfit pts
Grade I and St I tumors, unfit for Sx or RT: intrauterine Progesterone
25
What is the Rx for stage II endometrial cancer?
1. increased risk of occult LN involvement
2. if Cervical involvement is identified pre-op, radical hysterectomy f/b post op RT
26
What's the Rx for Stage III - IVA endometrial cancer?
Radical Radiotherapy
or Palliative RT, ChT, Hor Therapy
may be unsuitable for Sx bcoz disease extends outside the uterus
27
what's the Rx for Stage IVB endometrial cancer?
Palliative Rx
28
Why is ovary removed in surgery for endometrial cancer?
TAH + BSO and peritoneal washings
to exclue an ovarian metastasis or synchronous ovarian cancer
29
Is Lymphadenectomy required in st I endometrial cancer?
No improvement in survival
30
When is Radical Hysterectomy and lymphadenectomy indicated in endometrial cancer?
Stage II disease onwards
31
What's the standard Rx for stage III endometrial cancer?
Radical RT
32
How is EBRT for endometrial cancer planned?
1. supine, hands on chest, knees supported with wedge, Bladder should be comfortably full, IV Contrast for delineation of nodal volume
33
What does CTV include in endometrial cancer?
Primary tumor, the uterus, cervix, upper vagina, parametria and adnexae
REgional Nodes: int and ext iliac, obturator, presacral and common iliac
34
What's the conventional field borders for RT for endometrial cancer?
Supr: L5-S1 Vertebrae
Infr: 2 cm below infr extent of tumor (no higher than lower border of obturator foramen)
Lat: 1.5 cm outside the bony pelvic wall
Postr: lower margin of S2, approx 2 cm infront of sacral hollow
Antr: through the pubic symphisis
35
What are usual RT dose regimens for endometrial cancer?
Initial
45 Gy/ 25#
50.4 Gy/ 28#
Brachy
21 - 24 Gy in 3 to 4 fractions to pt A
36
What's the Brachy dose without EBRT?
HDR: 34 to 40 Gy in 4 to 7 fractions, 2 cm from mid point along the uterine applicator
LDR: 50 Gy in 1 fractions or 75 Gy in 2 fractions 2 cm from the intrauterine tube
37
When is RT indicated in Stage IA endometrial cancer post op?
G1 G2: Observation, Vaginal BT if LVSI or age > 60 years
G3: Vaginal BT (preferred) or Observation if no myoinvasion or
EBRT if age > 70 years or LVSI
38
When is RT indicated in Stage IB endometrial cancer post op?
G1: observation if age < 60 yrs and LVSI -
Vaginal BT (preferred)
G2; Vaginal BT or EBRT if age > 60 yrs and/or LVSI
Observation if age < 60 yrs and no LVSI
G3: RT (EBRT + Vaginal BT) and/or systemic treatment
39
What are High Intermediate Risk FActors for endometrial cancer post op?
PORTEC study group: 2/3
1. Deep Myometrial invasion
2. Age > 60 yrs
3. Grade 3 tumors
40
How do you define High Risk Stage I disease in PORTEC 3 study?
1. stage IA with myometrial invasion, Gr 3 with LVSI
2. Stage IB Gr III
3. Stage IA with myometrial invasion with serous or clear cell histology
41
When is Adjuvant Chemotherapy used in endometrial cancer?
stage III and IV patients and stage I with intermediate and high risk factors
42
what's the response rate of carboplatin and paclitaxel in endometrial cancer?
63 to 87 %
43
what are 2nd L ChT option in endometrial cancer?
1. PLD
2. Topotecan
44
Is hormonal therapy advised in adjuvant setting for endometrial cancer?
No, no survival advantage but unacceptable cardiac morbidity and mortality
45
What's role of Hormonal therapy in Endometrial Cancer as fertility sparing option?
Grade I endometrial carcinoma, complete response rate of 77.1 % after a median treatment duration of 10 months on MDPA
46
what's the common recurrence pattern if no RT was given in st I patients of endometrial cancer?
Locoregional relapse
Rx with RT, 5 yr survival of 65%
47
what are prognostic factors for endometrial cancer?
Adverse Prognostic factors:
1. Myometrial invasion
2. Grade 3 disease
3. Non Endometroid histology: clear cell, serous, adenosquamous and LN mets
48
what are common types of uterine sarcomas?
Leiomyosarcoma (50%)
Carcinosarcoma (30%)
Endometrial stromal sarcoma (20%)
49
What's benign counterpart of Leiomyosarcoma?
Fibroid or leiomyoma, 5 to 10 % conversion rate
50
Leiomyosarcoma of uterus: Features
1. highly malignant tumor
2. relapses distantly to liver and lung
3. OS 15 % to 25 % and stage I and II 5 yr survival 40 to 70%wha
51
What's is mixed mullerian tumor
mixed of malignant epithelial cells and stromal cells , spread to LNs and poor prognosis, 3 yr survival at 22 %w
52
How are uterine sarcomas treated?
Surgery and pelvic and para aortic LN diseection
Post op RT in carcinosarcoma reduces risk but without effect on OS
53
is there any advantage of post op RT in leiomyosarcoma?
No
54
is there any advantage of post op Chemo in leiomyosarcoma?
No
55
What chemo drugs are used in uterine sarcomas ?
Doxorubicin and Ifosfamide
RR 15 to 30%
Gemcitabine and Docetaxel
RR 53%
56
What's the current SOC for metastatic Endometrial cancer? (NCCN, 2025)
Carboplatin/paclitaxel/pembrolizumab (except for carcinosarcoma)
(category 1)c,d,k,8
* Carboplatin/paclitaxel/dostarlimab-gxly (category 1)c,d,k,9
* Carboplatin/paclitaxel/durvalumab (for dMMR only) (category 1)c,d,k,10
* Carboplatin/paclitaxel/trastuzumab
(for HER2-positive uterine serous carcinoma or carcinosarcoma)d,g,11
* Carboplatin/paclitaxel (category 1 for carcinosarcoma)
57
What's the SOC chemotherapy for endometrial cancer in adjuvant setting (st I-IV)?
Carboplatin/paclitaxel/pembrolizumab (for stage III–IV tumors, except for
carcinosarcoma) (category 1)b,c,d,7,8
* Carboplatin/paclitaxel/dostarlimab-gxly (for stage III–IV tumors)
(category 1)c,d,e,9
* Carboplatin/paclitaxel/durvalumab (for stage III–IV dMMR tumors only)
(category 1)c,d,f,10
* Carboplatin/paclitaxel/trastuzumab (for stage III–IV HER2-positive uterine
serous carcinoma or carcinosarcoma)d,g,11
* Carboplatin/paclitaxel/bevacizumab
(stage III–IV with measurable disease)d,12,13
* Carboplatin/paclitaxel14
58
59
What is the fifth most common female cancer in developed countries?
Endometrial cancer
## Footnote
Endometrial cancer is diagnosed in 6800 new patients in the UK every year.
60
At what age does the incidence of endometrial cancer peak?
64–74 years
## Footnote
75% of cases are diagnosed in post-menopausal women.
61
What is the lifetime risk of developing endometrial cancer for women in the UK?
0.9%
## Footnote
Endometrial cancer is responsible for 2% of all cancer deaths in women in the UK.
62
What is the overall 5-year survival rate for endometrial cancer?
75%
63
What percentage of endometrial cancers are hereditary?
Less than 5%
## Footnote
Most hereditary cases arise in women with hereditary non-polyposis colorectal cancer (HNPCC) or Lynch syndrome II.
64
What are the two types of endometrial cancer?
Type I and Type II
65
What is the median age at presentation for Type I endometrial cancer?
59 years
66
What are the characteristics of Type I endometrial cancer?
Related to oestrogen stimulation, associated with obesity, nulliparity, and insulin resistance
## Footnote
Typically low grade (grade 1/2) endometrioid tumours.
67
What is the precursor lesion of endometrioid carcinoma?
Atypical hyperplasia
68
What is the overall survival rate for Type I endometrial cancer?
80%
69
What is the median age at presentation for Type II endometrial cancer?
68 years
70
What are the characteristics of Type II endometrial cancer?
Unrelated to oestrogen stimulation, often occurs in elderly thin women
## Footnote
Tend to be high grade tumours with a poorer prognosis.
71
What is the recurrence rate for Type II endometrial cancer?
50%
72
What histologic type of endometrial malignancy is most common?
Endometrioid carcinomas (75%)
73
What percentage of endometrial cancers are uterine serous papillary carcinoma (UPSC)?
5–10%
74
What is the risk level of metastasis for clear cell carcinoma?
High-risk
75
What is the usual presentation of endometrial cancer?
Abnormal vaginal bleeding
76
What initial investigation is the choice for diagnosing endometrial cancer?
Trans-vaginal ultrasound scan (TVUSS)
77
What endometrial thickness indicates further investigation is needed?
>5 mm
78
What is the purpose of endometrial sampling or hysteroscopy?
To obtain histologic confirmation
79
What blood tests are indicated once a diagnosis of endometrial cancer is made?
Full blood count, biochemistry, and serum CA-125
80
What imaging is the choice to assess depth of myometrial invasion?
Magnetic resonance imaging (MRI)
81
What type of scan is indicated for patients with high risk of distant metastasis?
CT scan of abdomen and chest
82
Is a PET scan sufficiently sensitive to assess lymph node involvement in endometrial cancer?
No
83
What is the role of examination under anaesthesia (EUA) in endometrial cancer?
To determine operability when locally advanced tumour is suspected
84
85
What are the most important prognostic factors?
Stage, age, depth of myometrial invasion >50%, grade 3, serous or clear cell histology, lymphovascular invasion (LVI)
## Footnote
These factors help determine the prognosis of cancer patients.
86
What is the 5-year survival rate according to?
Stage and grade
## Footnote
Table 13.3 provides this information.
87
Which type of cancer presents more commonly with stage I and II?
Endometrioid cancer
## Footnote
It presents at stage I and II in 86% of cases.
88
What percentage of serous papillary cancer presents at stage I and II?
57%
## Footnote
This is significantly lower compared to endometrioid cancer.
89
What percentage of clear cell carcinoma presents at stage I and II?
70%
## Footnote
This is also lower than endometrioid cancer.
90
True or False: Serous papillary and clear cell carcinomas have a better prognosis than endometrioid cancer.
False
## Footnote
They have a poorer prognosis even when stage at presentation is considered.
91
Fill in the blank: Lymphovascular invasion is abbreviated as _______.
LVI
## Footnote
This abbreviation is commonly used in oncology.
92
What grade is associated with a poorer prognosis?
Grade 3
## Footnote
Higher grades generally indicate more aggressive cancer.
93
What depth of myometrial invasion is a prognostic factor?
>50%
## Footnote
Deeper invasion is associated with worse outcomes.
94
MRI in endometrial cancer. Sagittal T2-weighted (A) and sagittal dynamic contrast enhanced T1-weighted (B) images
in a patient with stage 1B endometrial carcinoma demonstrate a large endometrial tumour (E) which is invading the
outer myometrium (black arrows). The tumour is extending to the endocervix, but the cervical stroma (white arrows)
is intact.
95
96
What is the definition of Stage I in FIGO staging of endometrial cancer?
Tumour confined to the corpus uteri (includes endocervical gland involvement)
## Footnote
Stage I is the earliest stage indicating that the cancer has not spread beyond the uterus.
97
What characterizes Stage IA of endometrial cancer?
No or less than half myometrial invasion
## Footnote
This indicates minimal invasion into the muscle layer of the uterus.
98
What is the definition of Stage IB in FIGO staging of endometrial cancer?
Invasion equal to or more than half of the myometrium
## Footnote
This stage indicates a more significant invasion into the uterine muscle.
99
What defines Stage II in the FIGO staging of endometrial cancer?
Tumour invades cervical stroma, but does not extend beyond the uterus
## Footnote
This stage indicates that the cancer has spread to the cervix but remains within the uterus.
100
What is the overall definition of Stage III in endometrial cancer?
Local and/or regional spread of the tumour
## Footnote
This indicates that the cancer has spread beyond the uterus but is still localized to the pelvic area.
101
What characterizes Stage IIIA in endometrial cancer?
Tumour invades the serosa of the corpus uteri and/or adnexae
## Footnote
This indicates that the cancer has spread to the outer layer of the uterus or nearby structures.
102
What defines Stage IIIB in endometrial cancer?
Vaginal and/or parametrial involvement
## Footnote
This indicates that the cancer has spread to the vagina or the tissues surrounding the uterus.
103
What is the definition of Stage IIIC in endometrial cancer?
Metastases to pelvic and/or para-aortic lymph nodes
## Footnote
This stage shows that the cancer has spread to lymph nodes in the pelvic area or near the aorta.
104
What distinguishes IIIC1 from IIIC2 in endometrial cancer?
IIIC1: Positive pelvic nodes; IIIC2: Positive para-aortic lymph nodes with or without positive pelvic lymph nodes
## Footnote
This categorization helps to understand the extent of lymphatic spread.
105
What is the definition of Stage IV in endometrial cancer?
Tumour invades bladder and/or bowel mucosa, and/or distant metastases
## Footnote
This indicates the most advanced stage of cancer spread, affecting other organs.
106
What characterizes Stage IVA in endometrial cancer?
Tumour invasion of bladder and/or bowel mucosa
## Footnote
This indicates that the cancer has penetrated the linings of the bladder or bowel.
107
What defines Stage IVB in endometrial cancer?
Distant metastases, including intra-abdominal metastases and/or inguinal lymph nodes
## Footnote
This stage indicates that the cancer has spread to distant sites beyond the pelvic region.
108
5 year Survival Stage Wise
109
110
What is the treatment of choice for Stage I endometrial cancer?
Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) and peritoneal washings for cytology
## Footnote
Vaginal hysterectomy (LAVH) can be considered in some patients.
111
What factors are important determinants of lymph node involvement in Stage I endometrial cancer?
Grade and myometrial invasion
## Footnote
For grade 3 tumours, the risk of lymph node involvement is 15%, and for those with more than 2/3 invasion of the myometrium, the risk is approximately 25%.
112
What is the risk of pelvic node involvement in Stage I endometrial cancer with both high-grade tumours and significant myometrial invasion?
34% risk of pelvic node involvement
## Footnote
There is also a 24% risk of aortic node involvement.
113
What is the North American practice regarding lymphadenectomy for Stage I endometrial cancer?
Routine bilateral pelvic lymph node dissection (BPLND) with or without para-aortic lymphadenectomy
## Footnote
There is no clear evidence that lymphadenectomy improves survival.
114
What did the initial results of the ASTEC trial indicate about pelvic lymphadenectomy?
Showed similar survival and progression-free survival with both pelvic lymphadenectomy and no lymphadenectomy
## Footnote
This led to UK practice performing lymph node sampling of clinically suspicious nodes only.
115
What is the rationale for performing lymph node sampling in UK practice for Stage I endometrial cancer?
Patients with micrometastases can be identified as having a high risk of locoregional relapse
## Footnote
These patients can be stratified to receive radiotherapy.
116
In which scenario might UK centres perform lymphadenectomy in Stage I patients?
In patients with a high risk of locoregional relapse
## Footnote
They may omit external beam radiotherapy (EBRT) for those with uninvolved nodes.
117
What is the benefit of staging lymphadenectomy for Stage I patients?
Better risk stratification of patients with high-risk disease and significant co-morbidity
## Footnote
An example of co-morbidity is inflammatory bowel disease, which increases the risk of radiation-related morbidity.
118
What is the purpose of defining the risk of loco-regional recurrence?
To choose patients for adjuvant pelvic radiotherapy to prevent uncontrolled pelvic disease and morbidity associated with a relapse.
119
What is the general consensus regarding the use of radiotherapy based on the risk of relapse?
Radiotherapy is considered only if the risk of relapse is >15%.
120
Which study identified a subgroup of patients at 18% risk of locoregional relapse?
PORTEC-1 identified patients aged more than 60 years with 1C or G3 disease.
121
What poor prognostic factor for locoregional relapse was identified in the GOG 33 study?
Lymphovascular invasion (LVI) was identified as a significant poor prognostic factor.
122
What is the hazard ratio (HR) for LVI as a poor prognostic factor according to GOG 33?
HR = 2.4, p = 0.005.
123
What treatment do most UK centers offer to patients with 1C or G3 disease and LVI?
Adjuvant EBRT +/− brachytherapy.
124
What recent trial suggests that vaginal brachytherapy may be sufficient for certain patients?
Early results of the PORTEC-2 trial.
125
What was the statistically significant difference in disease-free survival for high-risk patients treated with EBRT vs. no treatment?
80% vs. 69%.
126
What should be offered to all patients with 1C G3 disease?
Adjuvant EBRT +/− vaginal brachytherapy.
127
What is uncertain for patients with negative nodes but high-risk disease?
The role of radiotherapy.
128
What treatment do many practitioners prefer for patients with 1C G3 disease and >50% myometrial invasion?
Vaginal brachytherapy (BT).
129
What does the high risk of distant relapse for 1C G3 disease suggest?
A possible role of adjuvant chemotherapy.
130
How does chemotherapy compare to pelvic radiotherapy regarding distant metastases?
Chemotherapy reduces the incidence of distant metastases compared to pelvic radiotherapy.
131
What does chemotherapy not prevent?
Pelvic recurrence.
132
What is the ongoing study that randomizes between pelvic radiotherapy and pelvic radiotherapy with concurrent chemotherapy?
PORTEC-3 study.
133
Fill in the blank: Adjuvant chemotherapy has unclear _______.
evidence.
134
135
What is indicated for patients with cervical involvement prior to surgery?
Modified radical hysterectomy with bilateral lymph node dissection
## Footnote
This involves resection of parametrial and paracervical tissue, along with a cuff of 2 cm of upper vagina.
136
What is the dose for external beam radiotherapy in endometrial cancer?
45 Gy in 25 fractions
137
What are the indications for vaginal brachytherapy (BT) alone?
Stage IB G2
138
What is the typical dose for HDR vaginal brachytherapy as a single modality?
21 Gy in 3 fractions to 0.5 cm from the applicator surface
139
What are the side effects of external beam radiotherapy (EBRT)?
* Bowel symptoms (22%)
* Bladder toxicity
* Vaginal narrowing (4%)
* Bone toxicity (1%)
140
What is the 5-year survival rate for stage II patients undergoing radical hysterectomy compared to standard hysterectomy?
93% vs. 89%
141
What should patients with positive margins or involved nodes receive following surgery?
Adjuvant EBRT and BT
142
What is the definition of optimal cytoreduction in stage III disease?
No macroscopic disease to <2 cm
143
What is the likelihood of local control related to in stage III disease?
Disease volume
144
What is the role of palliative hysterectomy in stage IV patients?
Controlling local symptoms such as bleeding or pain
145
What is the risk of locoregional relapse for stage 1A endometrial cancer?
Low <5%
146
What is the recommended treatment for patients with stage III/IV who have had a complete debulking?
Adjuvant chemotherapy
147
What did the GOG 122 trial compare in patients with stage III/IV endometrial cancer?
Whole abdominal radiation vs. doxorubicin and cisplatin chemotherapy
148
What is the median overall survival for patients with metastatic endometrial cancer following chemotherapy?
6–12 months
149
What is the response rate of oral progestogen treatment?
15–20%
150
Which progestogen is usually given initially at 160 mg daily?
Megestrol acetate
151
What is the response rate for tamoxifen in endometrial cancer?
10%
152
What is the response rate for GnRH analogues in progestogen-refractory advanced disease?
Up to 28%
153
What is the typical duration of response for oral progestogen treatment?
Four months
154
What are the side effects of progestogen treatment?
* Weight gain
* Increased risk of thrombosis
155
What is the chemotherapy regimen with a 60–70% response rate in advanced endometrial cancer?
Carboplatin and paclitaxel
156
What should be considered for patients with unresectable disease?
Palliative chemotherapy or hormonal treatment
157
158
What is the reported response rate for aromatase inhibitors in endometrial cancer?
Approximately 10%
## Footnote
This refers to the effectiveness of aromatase inhibitors in treating endometrial cancer.
159
What are the components of the chemotherapy regimen for endometrial cancer?
* Carboplatin (AUC 5–7) IV d1 repeated 3-weekly
* Paclitaxel (Taxol) 175 mg/m2 IV repeated 3-weekly
* Doxorubicin (Adriamycin) 60 mg/m2 IV for 7 cycles + cisplatin (CDDP) 50 mg/m2 IV repeated 3-weekly
* Carboplatin (AUC 5–7) IV d1 + paclitaxel 175 mg/m2 IV d1 repeated 3-weekly
## Footnote
These regimens are standard treatments for endometrial cancer.
160
What is the stabilization rate reported for patients with metastatic or recurrent endometrial cancer treated with letrozole?
39% for a median of 6.7 months
## Footnote
This indicates the effectiveness of letrozole in managing advanced cases of endometrial cancer.
161
What percentage of relapses in endometrial cancer will be distant or locoregional?
Approximately two-thirds
## Footnote
The remaining third will be pelvic recurrences.
162
Where do 75% of pelvic recurrences occur in endometrial cancer?
The upper vagina, or 'vaginal vault'
## Footnote
This highlights the common site of recurrence in patients with endometrial cancer.
163
What is the treatment of choice for patients with a vault recurrence who have not previously received radiotherapy?
Radical radiotherapy
## Footnote
This is recommended for those who haven't undergone radiotherapy before.
164
What was the survival rate after relapse at 3 years for the control group compared to those who received EBRT up-front?
69% in the control group compared to 13% in patients who had received EBRT up-front
## Footnote
This illustrates the impact of early treatment on survival rates.
165
What surgical approach may offer a chance of cure for single recurrence at the vaginal vault?
Surgery
## Footnote
This is applicable if the disease is localized and has not extended to the sidewall.
166
What is the reported 5-year survival rate with complete cytoreduction in selected patients?
Up to 50%
## Footnote
This reflects the potential benefit of aggressive surgical intervention.
167
In which types of carcinoma do patterns of spread resemble those of epithelial ovarian carcinoma?
Uterine serous papillary carcinoma (USPC)
## Footnote
This indicates a similarity in recurrence patterns between these types of cancers.
168
Where do clear cell carcinoma relapses occur more commonly?
In the pelvis and para-aortic nodes
## Footnote
This contrasts with the spread of uterine serous papillary carcinoma.
169
What is the optimal therapy for early-stage papillary serous and clear cell carcinomas?
Remains undefined
## Footnote
High relapse rates indicate that surgery alone is inadequate.
170
What is the treatment approach for stage III and IV UPSC and clear cell carcinoma?
As for ovarian cancer, with radiotherapy offered post clinical response
## Footnote
This indicates the similar management strategies for these cancers.
171
What percentage of patients with endometrial cancer have synchronous primary cancers of the ovary?
5%
## Footnote
This percentage highlights the occurrence of multiple primary tumors.
172
What should be considered when the disease on the ovary is small volume with surface deposits?
Metastatic disease
## Footnote
This is crucial for proper management of ovarian involvement.
173
What is the typical follow-up schedule for endometrial cancer patients after treatment?
Outpatient appointments three-monthly for two years, followed by six-monthly to 5 years
## Footnote
Includes full history and physical examination.
174
What percentage of recurrences occur in the first 18 months to two years?
80%
## Footnote
This indicates the critical period for monitoring after treatment.
175
Risk of Local Relapse in Stage I Grade wise
176
What is the primary indication for radical radiotherapy in endometrial cancer?
Unfit for surgery
## Footnote
This refers to patients who cannot undergo surgical intervention due to various health factors.
177
When is postoperative radiotherapy indicated for endometrial cancer?
Postoperative
## Footnote
This is used to eliminate residual cancer after surgery.
178
What is the indication for vaginal brachytherapy (BT) alone in endometrial cancer?
Stage IB G2
## Footnote
This refers to a specific classification of cancer severity.
179
What is the combination of therapies indicated for Stage I endometrial cancer?
External beam radiotherapy (EBRT) and vaginal brachytherapy
## Footnote
This applies to specific histological types including IC/G3, clear cell, and UPSC.
180
What is the superior border in conventional planning for radiotherapy?
L5/S1
## Footnote
This marks the upper limit of the radiation treatment area.
181
What is the inferior border in conventional planning for radiotherapy?
Lower edge of obturator foramen
## Footnote
This establishes the lower limit of the treatment area.
182
What is the lateral border in conventional planning for radiotherapy?
1 cm beyond pelvic brim
## Footnote
This ensures adequate coverage of the treatment area.
183
What is the anterior border in conventional planning for radiotherapy?
Mid-symphysis pubis
## Footnote
This defines the front limit of the radiation treatment area.
184
What is the posterior border in conventional planning for radiotherapy?
2.5–3 cm anterior to sacral hollow
## Footnote
This ensures protection of surrounding tissues.
185
What is the CTV in CT planning for radiotherapy?
Vaginal vault and 7 mm margin around the contrast enhancing blood vessels for nodal regions
## Footnote
CTV stands for Clinical Target Volume.
186
What is the PTV in CT planning for radiotherapy?
10–15 mm around vaginal vault, 7 mm around lymph node CTV, and 7 mm around parametrium
## Footnote
PTV stands for Planning Target Volume.
187
What is the standard dose for external beam radiotherapy in endometrial cancer?
45 Gy in 25 fractions
## Footnote
This is the total radiation dose divided into smaller doses or fractions.
188
What is the HDR dose for vaginal brachytherapy as a single modality?
21 Gy in 3 fractions to 0.5 cm from the applicator surface
## Footnote
HDR stands for High Dose Rate.
189
What is the HDR dose for vaginal brachytherapy when combined with EBRT?
7 Gy single fraction to 0.5 cm from the applicator surface
## Footnote
This is a lower dose used in conjunction with external beam therapy.
190
What is the LDR dose for vaginal brachytherapy?
15 Gy to 0.5 cm
## Footnote
LDR stands for Low Dose Rate.
191
What are common side effects of EBRT?
* Bowel symptoms (22%)
* Bladder toxicity
* Vaginal narrowing (4%)
* Bone toxicity (1%)
## Footnote
Bowel symptoms include abdominal cramps, urgency, frequency of stool, and diarrhea.
192
What are the side effects associated with brachytherapy?
* Temporary diarrhoea (9%)
* Urinary irritation (9%)
* Transient vaginal mucositis (17%)
* Vaginal cuff telangiectasia (14%)
* Vaginal atrophy, stricture or adhesions (16%)
* Dyspareunia (5%)
## Footnote
These side effects indicate complications that may arise from the treatment.
193
Stage I Management Algorithm
194
Stage II management algorithm
195
Stage III and IV management algorithm
