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| Stage | External Beam | HDR (vaginal) |
| IaG1 | none | none |
| IaG2 | none | 700cGy X 3 |
| IaG3, IB or II | 45Gy | 500cGy x 3 |
| Risk Factors | High Risk Patients |
| moderate to poorly differentiated tumor | age < 50y: all three factors |
| lymphovascular invasion | age 50 - 69y: two factors |
| outer third myometrial invasion | age > 69y: one factor |
| in some of the more advanced cases
we are combining radiation with chemotherapy, a recent
review (J Clin Onc 2001:19:4048) favored carbo/taxol over platinol/adria because of higher
response rates (in serous 50-82% versus 18-27% and in non-serous 67% versus 52%.) In high risk patients we commonly use chemoradiation after surgery (GOG 184 pelvic/para-aortic radiation followed by platinol/adriamycin versus platinol/adriamycin/taxol and GOG 194 pelvic radiation with concurrent platinum followed by four cycles of platinol/taxol) Endometrial carcinoma, the most common invasive malignancy of the female genitourinary tract, occurs primarily in menopausal and postmenopausal women. Risk factors include obesity, nulliparity, late menopause, diabetes, hypertension, immunodeficiency, and exogenous estrogens. The most common presenting manifestation is dysfunctional uterine bleeding, which is related to malignancy approximately 20% of the time. The majority of these malignancies will be endometrial carcinoma. These lesions arise from the glandular component of the endometrium and may be pure adenocarcinomas or mixed lesions with squamous elements. Endometrial hyperplasia with dysplastic changes (adenomatous hyperplasia) may precede malignant change. Early growth yields an exo-phytic, friable mass with spontaneous bleeding. Vertical and horizontal spread leads to myometrial and cervical involvement. Lymphatic spread to parametrial, pelvic, inguinal, and para-aortic nodes; hematogenous spread to lungs, liver, and bone; and peritoneal implantation are potential routes of dissemination. Prognostic Factors The most important determinant of outcome is extent of disease at diagnosis. Patients with limited disease (stage I or II) may be classified at low or high risk for recurrence based on pathologic features. Those with advanced (stage III or IV) or recurrent disease can be grouped into two categories by site of involvement: locoregional disease confined to the pelvis or disseminated disease beyond the pelvis. For each of these four groups (low-risk limited disease, high-risk limited disease, locoregionally advanced disease, and disseminated disease), the assigned category will determine appropriate therapy. Diagnosis and Evaluation Patients with dysfunctional uterine bleeding require evaluation for endometrial carcinoma. An adequate sample of endo-metrium is essential. The Papanicolaou smear, with a diagnostic accuracy of only 40%, is inadequate. Aspiration techniques, which may be used in the ambulatory setting, have a 70% accuracy, but false-negative results are high. The use of dilation and fractional curettage is the most accurate and complete approach and allows for assessment of endocervical involvement. Pretreatment evaluation should be directed to determining the clinical and pathologic factors required by the staging system (Table 6). Such accurate staging forms the basis for treatment recommendations. Management Limited disease Patients with stage I or II disease account for most cases (> 85%) of endometrial carcinoma and have an excellent cure rate (> 75%). Those at low risk for recurrence have a greater than 90% chance of remaining disease free beyond 5 years with surgery alone (total abdominal hysterectomy and bilateral salpingo-oophorectomy). Those at high risk have received various approaches combining surgery and radiation. A recent randomized trial shows an improved progression-free survival in those patients receiving adjuvant radiotherapy after initial surgery resection of all gross disease. Standard treatment for the high-risk patient is therefore a combination of surgery and radiation. Advanced disease The approach to treating patients with advanced or recurrent disease is determined by whether disease is confined to the pelvis or includes distant disease. For those with pelvic disease only, radiation is the treatment of choice. If the disease is confined clinically to the uterus, ovaries, or fallopian tubes, a radical hysterectomy and bilateral pelvic lymph-adenectomy followed by postoperative pelvic radiation yields a 5-year survival rate of 50%. Patients with parametrial extension, vaginal involvement, or other pelvic involvement of disease should receive pelvic radiation as the initial treatment, with 5-year survival rates of 25% to 50% expected. Patients with evidence of disseminated disease require systemic therapy. Hormonal therapy with either progestins or tamoxifen yields response rates of 20% to 24%, with median response duration of 3 to 4 months and median survival of 9 to 10 months. Patients with well-differentiated tumors or lesions known to be positive for estrogen and progesterone receptors respond far more frequently and have better survival rates [4]. Three chemotherapeutic agents have conclusive activity: doxorubicin, paclitaxel, and the platinum compounds.. Randomized trials demonstrate the superiority of a combination of cisplatin plus doxorubicin over doxorubicin alone and establish this combination as the chemotherapy of choice. |