The document discusses the management of carcinoma endometrium, which includes diagnosis, staging, treatment, and follow up. Key points include: surgical staging is now standard to accurately identify disease extent and guide adjuvant therapy; total abdominal hysterectomy and bilateral salpingo-oophorectomy with surgical staging is the primary treatment for early stage disease; adjuvant radiation therapy, chemotherapy, or hormonal therapy may be used depending on risk factors like grade, myometrial invasion, and lymphovascular space invasion status. Randomized controlled trials have established the benefit of doxorubicin and cisplatin chemotherapy over whole abdominal radiation for advanced stage disease. Prognostic factors, treatment recommendations, and follow up considerations are also outlined.

1. MANAGEMENT OF
CA ENDOMETRIUM

2. Management of carcinoma endometrium
constitutes:-
1.DIAGNOSIS
2. STAGING
3.TREATMENT
4.FOLLOW UP

3. DIAGNOSIS
A. CLINICAL PRESENTATION AND NATURAL HISTORY
B. CLINICAL EXAMINATIONS
C. INVESTIGATIONS

4. CLINICAL PRESENTATION AND NATURAL HISTORY
• Most commonly present with post menopausal vaginal bleeding or
Discharge (75%)
• Majority – Stage I
• Advanced stage- urinary or rectal bleeding,
constipation, pain,
lower extremity lymphedema,
abdominal distension.

5. CLINICAL EXAMINATIONS
• General examinations
• Systemic examinations
• Gynecological examinations – bimanual vaginal examinations.
inspection of vulva,
vaginal skin and mucosa,
suburethral area and cervix,
per rectal examinations.

6. INVESTIGATIONS
• CBC
• Liver function test
• Renal function test
• S.CA-125
• Chest X ray
• Ultrasonography
• CT scan
• MRI
• Endometrial tissue sampling

7. ENDOMTRIAL SAMPLING
• D & C.
• HYSTEROSCOPY AND BIOPSY.
• PATHOLOGIC REVIEW (OPTIONAL).

8. STAGING
• Prior to 1988-clinical staging was done
• Surgical staging is done now days

12. WHY SURGICAL STAGING?
• Approximately 23% of patients being upstaged after surgery.
• Pelvic nodal involvement is seen in <3% grade-I endometrium
confined disease but >30% in grade-3 disease penetrated the outer
third of the myometrium
• Aortic nodal disease, although rare in grade-I disease or in absence of
pelvic node metastasis, was seen in 14% and 23% of patients with
deeply invasive grade 2 or 3 disease respectively.
• Hence surgical staging was promoted in order to better estimate 5-
year prognosis for patients and to better tailor adjuvant therapy to
those patients.

13. PROGNOSTIC FACTORS
• Pathological stage is the most significant
predictor of outcome.
• Histological type
• Histological grade
• Depth of myometrial invasion
• LVSI
• Age
• Nodal involvement
• Genetic factors

14. TREATMENT
• SURGERY
• RADIOTHERAPY
• CHEMOTHERAPY
• HORMONAL THERAPY

16. SURGERY
• Surgery is the main modality of treatment in
carcinoma endometrium.
– TAH-BSO without ESS followed by more liberal use of post
operative RT
– TAH-BSO with ESS followed by more restricted use of post
operative RT

17. Extensive surgical staging
• Excision or biopsy of any enlarged or suspicious pelvic or para-aortic
nodes
• In absence of nodal enlargement, nodal tissues should be removed
from over the distal vena cava below the IMA, between the aorta and
the left ureter from the inferior mesenteric artery to mid left common
iliac artery, distal half of each common iliac artery, anterior and medial
aspect of proximal half of the external iliac artery and vein, distal half of
the obturator fat pad anterior to the obturator nerve

18. Advantages
• Accurate identification of disease extent
• Adjuvant therapy would be limited to patient who will really benefit
• Cost effective
• Acceptable morbidity
Disadvantages
• More risk of vascular injury
• DVT & pulmonary embolism
• Postoperative complication more in elderly

19. Treatment recommendations in early
stage endometrial cancer(FIGO I-II)
• Stage IA(grade 1,2) and stage IB(grade 1)-
-TAH-BSO alone if LVSI absent
-TAH-BSO+IVB if LVSI prresent
• Stage IA(grade 3)-
A. ESS done-TAH-BSO+IVB
B. ESS not done- TAH-BSO+IVB if <60yrs
TAH-BSO+EBRT if >60yrs

20. STAGE-IB (grade 2) and
STAGE IIA(<50% MI, grade 1-2)
A. ESS done-if LVSI(-) IVB alone vs observation in <70yr.
If LVSI(+),>70YRS-EBRT
B. ESS not done-LVSI(+)-IVB
>60yrs-EBRT

21. TREATMENT OF ADVANCED STAGE
ENDOMETRIAL CARCINOMA
• Patients with advanced endometrial carcinoma have been treated
with different approaches in adjuvant setting, including :-
- Pelvic RT,
- Extended fields RT (pelvic plus paraaortic RT),
- Whole abdominal irradiation.
• Whole abdominal RT is not used now a days after
the result of GOG-122,which demonstrated superior PFS and OS for
patients treated with doxorubicin and cisplatin.

22. • MEDICAL INOPERABLE CASES-
EBRT to pelvis (include lymph nodes) 45-50Gy
followed by ICBT (7Gy x 3#) for early stage tumours.
• Survival rate of 80-85% at 5yrs
• RECURRENCE CASES
-If no prior RT - EBRT followed by Brachytherapy
boost 60-70Gy.
Brachytherapy has got a great role as 70-75% of post op cases have
recurrence in the vagina.
-Chemotherapy and hormonal therapy may also be
considered

23. RADIATION THERAPY
• PREOPRATIVE
• POSTOPERATIVE

24. • Preoperative irradiation is less commonly used in era of ESS, but still
have a role in patients with gross involvement of the cervix or vagina
• ICB alone or combination with pelvic EBRT may be used.
• If surgery is to be done after EBRT, then it should not be done before
4 to 6 weeks after completion of EBRT to allow radiation associated
inflammation to subside.

25. • In preoperative EBRT, GTV includes entire uterus and cervix, vaginal
extension as well as any gross regional lymphadenopathy.
•CTV includes the GTV as well as pelvic lymphnode areas i.e. obturator,
external and internal iliacs as well as common iliacs.
• PTV=CTV+ 1cm

26. POSTOPERATIVE EBRT
INDICATIONS:-
1. Deeply invasive tumors (stage IC)
2. Poorly differentiated histologies
3. Pathological stage IIB in absence of ESS
4. LVSI present.

27. RADIATION TECHNIQUE
• POSITION- Supine immobilization
• 4 field box technique is used in conventional method
• Field borders – AP/PA
Superior – top of L5
Inferior – below obturator foramen
Lateral – 2 cm lateral to bony pelvis
• Lateral field:
Superior & inferior same
Anterior- Ant. To Symph. Pubis
Posterior – S2-S3 junction
Dose:- 45 - 50 Gy (1.8 Gy. – 2 Gy. / #)

29. IMRT technique
• Immobilisation
• CT simulation (2.5 -5 mm slice) from upper border of
L5 to lower border of lesser trochanter)
• Target vol. delineation-
GTV includes entire
uterus and cervix, vaginal extension as well as any
gross regional lymphadenopathy.
CTV includes the GTV as well as pelvic
lymphnode areas i.e. obturator, external and
internal iliacs as well as common iliacs.
PTV=CTV+ 1cm

30. POST OPERATIVE INTRACAVITARY BRACHYTHERAPY
ADVANTAGES
a) lower morbidity
b) patient convenience
c) lower costs
DISADVANTAGES
• It does not address the pelvis and therefore should be limited to patients in whom
the pelvic recurrence rate is estimated to be low.
• Predictors of vaginal relapse are grade 3 tumors and presence of LVSI (in MAYO clinic
series)

31. • Dose – 60-70 Gy to the mucosal surface by LDR in 72 hrs.
• Dose of HDR brachytherapy as recommended by American Brachytherapy
Society.
• Suggested dose for brachytherapy used alone as adjuvant therapy in Ca
endometrium.

32. CHEMOTHERAPY
Role of chemotherapy in carcinoma endometrium is limited to
advanced disease and in inoperable and recurrent disease
Commonly used agents are:-
1. Cyclophosphamide
2. Anthracyclines
3. Platinums
4. Taxens

33. GOG 122 TRIAL
• N=396
• Stage III and IV
• After TAH+BSO+ESS <2cm residual tumour left
• Compared doxorubicin-cisplatin(AP) chemotherapy with whole abdomen
irradiation(30Gy in 20# AP/PA +boost to pelvic/PA lymphnodes 15Gy in 8 #
• Doxorubicine-cisplatin every 3wk for 8 cycles
• 5yr PFS 38% for WAI Vs 50% in AP
• 5yr OS 42% for WAI Vs 55% in AP
• Recurrence after WAI was 54% Vs 50% in AP
• AP has more grade 3 hematological and gastrointestinal
toxicity than WAI.

34. According to fleming et at addition of
Paclitaxel to AP in metastatic disease led to improved response rates
(34% to 57%), median PFS (5.3 to 8.3 months) and median OS (12.3 to
15.3 months)

35. HORMONAL THERAPY
1. Used only in advanced and recurrent disease
2.Drugs-
a. medroxyprogesterone
b. megestrol acetate
c. tamoxifen.
• Response occurs in 20 – 40% cases
• In a GOG randomised trial of low dose (200mg) Vs high dose of oral
daily medroxyprogesterone, there was no advantage to higher dose.
• Use of progestins have been implicated in death due to
cardiovascular events hence their use in adjuvant setting can not be
supported

36. FOLLOW UP

37. To summarise:-
• Surgical staging is done in case of carcinoma endometrium
• TAH+BSO+ESS is now the primary modality of treatment in
early stage ca endometrium followed by adjuvant therapy as
indicated.
• Preoperative radiological investigations should not be done as
it does not change the adjuvant treatment recommendations.
• High grade, LVSI, tumour type, depth of myometrial invasion
and age are important prognostic factors.

38. • Serum CA 125 must be done preoperatively as value >40 U/L is an
indication for pelvic and paraaortic node dissection.
• Paclitaxel + doxorubicin + cisplatin has got survival advantages in
advanced ca endometrium.
• Role of hormonal and targeted therapy are not yet established.
• PORTEC,GOG 99 and ASTEC trial are three trials showing role of
adjuvant RT in decreasing locoregional recurrence but having no
survival benefit in early stage Ca Endometrium

39. THANK YOU