Agreed 2009

Review 2012

MEDICAL PROTOCOL
ONCOLOGICAL MANAGEMENT OF UTERINE
MALIGNANCIES
These guidelines have been developed by members of the Gynaecological Oncology
Guidelines Group, for approval by the Merseyside and Cheshire Gynaecological Cancer
Network Group.
1.
2.
3.
4.
5.
6.
7.

Background .................................................................................................................................................. 2
Diagnosis ...................................................................................................................................................... 3
Referral to the Gynaecological Oncology Team ...................................................................................3
Staging .......................................................................................................................................................... 4
Prognostic Factors ...................................................................................................................................... 4
Effect of individual prognostic factors on relative risk to survival ....................................................5
Pre-operative assessment ......................................................................................................................... 5
7.1) Histological examination of the specimen obtained for diagnostic purposes. ........................5
7.2) Pre-operative examination either in the out- patient clinic or possibly as a formal EUA +/hysteroscopy. ................................................................................................................................................ 6
7.3) Imaging studies ..................................................................................................................................... 6
8. Treatment .................................................................................................................................................... 6
8.1) Surgery ................................................................................................................................................... 6
8.2) Choice of Incision .................................................................................................................................. 6
8.3) Stage 1.................................................................................................................................................... 7
8.4) Stage 2.................................................................................................................................................... 7
8.5) Stage 3 and 4 ........................................................................................................................................ 8
9. Radiotherapy ............................................................................................................................................... 8
9.1) Stage I disease ...................................................................................................................................... 8
9.1.1 Low risk patients ............................................................................................................................ 8
9.1.2 Moderate to High Risk Patients .................................................................................................... 9
9.2) Stage II Disease .................................................................................................................................. 10
9.2.1 Trials in progress in stage I and II disease ..............................................................................10
9.3) Stage III disease .................................................................................................................................. 11
9.3.1 Stage IIIa......................................................................................................................................... 11
9.3.2 Stage IIIb disease .......................................................................................................................... 11
9.3.3 Stage IIIc disease .......................................................................................................................... 11
9.4) Stage IV disease ................................................................................................................................ 12
9.4.1 Stage IVa ....................................................................................................................................... 12
9.4.2 Stage IVb disease ......................................................................................................................... 12
9.5) Treatment of patients with unfavourable histology ..................................................................12
9.5.1 Uterine papillary serous carcinoma (UPSC), and clear cell carcinoma. ..........................12
9.6) Treatment of endometrial carcinoma with radiotherapy alone ................................................13
9.7) Treatment of recurrent disease ....................................................................................................... 13
9.8) Adjuvant Vault Brachytherapy ......................................................................................................... 14
10. Hormonal therapy .................................................................................................................................. 14
11. Chemotherapy ....................................................................................................................................... 15
12. Palliative Care and Nursing care ........................................................................................................ 15
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13. Follow- up ................................................................................................................................................. 16
14. Hormone Replacement ......................................................................................................................... 17
15. Clinical Trials ........................................................................................................................................... 17
Appendix 1...................................................................................................................................................... 18

1. Background
Endometrial cancer is now the second most common gynaecological malignancy in the UK.
Over 5,000 cases are registered annually with a lifetime risk of just over 1%. Eighty percent
occur in post-menopausal women with a median age at diagnosis of 60yrs. Less than 5%
occur in women aged <45yrs. Presentation is predominantly with post-menopausal
bleeding although up to 25% of endometrial cancers are detected in pre-menopausal
women. The mortality associated with endometrial cancer is 30%, considerably less than
for cervical or ovarian cancers. This simply reflects the early presentation of disease since
75% of patients present with disease that is apparently confined to the uterus (stage 1).
Indeed stage related survival figures are, if anything, worse than for the other main
gynaecological tumours. Endometrioid adenocarcinoma is the most common form
comprising approximately 75% of the total with other variants including mucinous, serous,
clear cell and squamous carcinomas, mixed mesodermal tumours, endometrial sarcomas
and undifferentiated tumours.

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Historically, patients with endometrial carcinoma were treated with radiotherapy and
consequently the prognostic factors which might be revealed by histopathological
examination were obliterated. This was reflected in the FIGO staging which was used from
1971-1989. This system used factors such as uterine cavity length, tumour grade and
spread determined by clinical examination, to determine stage and prognosis. Using this
system, 75% of patients were assigned to stage 1 but their 5 year survival varied from 51%
-89%.
The appreciation that this system failed to distinguish between women with vastly different
prognoses, and that extra-uterine disease was far commoner than suggested by clinical
examination alone, accompanied the increasing use of surgery as a primary therapeutic
modality. The FIGO staging system was therefore redesigned in 1989 to account for
changes in both understanding of the disease and its treatment.

2. Diagnosis
As the majority of cases present with a number of well recognised symptoms, prompt
referral and an early out-patient appointment are of importance as outlined in the NHS
Cancer Plan and Department of Health waiting time targets. These symptoms include:

Post-menopausal bleeding

see within 2 weeks

Abnormal smear suggestive of endometrial cancer

see within 2 weeks ideally in

Colposcopy

Irregular bleeding on HRT

see within 6 weeks

Irregular perimenopausal bleeding

see within 6 weeks

Post-menopausal discharge

see within 2 weeks

3. Referral to the Gynaecological Oncology Team

In keeping with the Department of Health, Improving Outcomes Guidance (1999) referrals
to the Gynaecology Oncology Centre include:

all Grade 3 tumours

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adverse histological types (clear cell and UPSC)

anything more than Stage 1

when the Unit lead is unhappy about risk factors it is also appropriate these patients are

referred to the Centre

4. Staging
The method of staging favoured in this country is that introduced by FIGO in 1989 which is
outlined below. Equivalent TNM classification is available.
Stage la

Tumour limited to the endometrium

Stage Ib

Invasion of < 1/2 myometrium

Stage lc

Invasion of > 1/2 myometrium

Stage 2a

Endocervical glandular involvement only

Stage 2b

Cervical stromal invasion

Stage 3a

Tumour invades serosa and/or adnexae and/or positive

peritoneal washings

Stage 3b

Vaginal metastases

Stage 3c

Metastases to pelvic and/or para-aortic lymph nodes

Stage 4a

Tumour invasion of bladder or bowel mucosa

Distant metastases including intra-abdominal disease and/or inguinal node metastases

5. Prognostic Factors
There is a close correlation between different prognostic factors so that it is not uncommon
for a patient to have a number of adverse prognostic indicators. Similarly it is possible for a
patient to have a mixture of good and bad prognostic factors and hence the allocation of an
overall risk factor is not necessarily straightforward. In an attempt to clarify this situation the
Gynecologic Oncology Group (GOG) has recently published data on the univariate and
multivariate analysis of prognostic factors in 819 patients with clinical stage 1&2 disease 1.
Using the two methods of analysis a proportional hazards model was developed which
predicts the relative risk of death from cancer. The results are summarised below and an
overall risk factor can be developed for a patient from the product of each individual risk
factor. The effect of increasing numbers of adverse risk factors has been confirmed by
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Kadar et al who showed that five year survival for patients with more than 2 of these risk
factors was 17% compared with 66% for those with two and 95% for those with no or only
one risk factor2.

6. Effect of individual prognostic factors on relative risk to survival

Prognostic factor
Endometrioid histology

Serous histology

Myometrial penetration

Relative risk
Grade 1

1.0

Grade 2

1.6

Grade 3

2.6

Grade 1

2.9

Grade 2

4.4

Grade3

6.6

endometrium only

1.0

inner 1/3

1.2

inner 2/3

1.6

outer 1/3

3.0

Positive washings
Age

3.0
45 years

1.0

65 years

3.4

Lymphovascular space involvement

1.5

7. Pre-operative assessment
Since treatment options vary enormously, careful pre-operative and intra-operative
evaluation is necessary in order to correctly determine the appropriate management. Preoperative information can be gained from the following sources:

7.1)

Histological examination of the specimen obtained for diagnostic purposes.

It should be noted that undue emphasis should not be placed upon this since interpretation
of endometrial curettage specimens is notoriously unreliable in the assessment of tumour
grade and histological type. It is particularly important to note that a diagnosis of atypical

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hyperplasia based on a sampling technique may none the less be associated with invasive
endometrial cancer in 20% or more of cases.
In some circumstances it may be appropriate to perform fractional currettage in order to
assist in distinguishing an endometrial tumour from one of endocervical origin.

7.2)

Pre-operative examination either in the out-patient clinic or possibly as a

formal EUA +/- hysteroscopy.

This may provide additional information relating to the site and stage of disease.

7.3)

Imaging studies

We do not consider the routine use of investigations such as MRI or CT justified at present
although they may clearly be of use in the assessment of cases of clinically advanced
disease or poor prognosis variants such as uterine papillary serous carcinoma.
Pre-operative investigations should include
FBC, urea & electrolytes and LFTs
Blood group and save
Chest X-ray

8. Treatment
8.1)

Surgery

Where surgery is indicated as the appropriate treatment and the patient is considered fit for
the procedure it should take place 31 days from decision to treat.

8.2)

Choice of Incision

Traditionally, surgery for uterine cancer has been carried out abdominally, using an open
technique, via a low transverse or vertical midline incision, as indicated individually by
considerations of build and access to the pelvis. Cardio-respiratory co-morbidity in these
patients suggests that the low transverse incision is employed wherever possible, aided by
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apronectomy to facilitate access to the pelvis in the patioent with a pendulous, obese
abdomen.
More recently, laparoscopically assisted vaginal hysterectomy and oophorectomy has
become increasingly popular on account of more rapid recovery time without compromise
of effective surgical staging or tumour excision. It is becoming increasingly regarded as the
approach of choice.
In unfit patients where there are concerns that any surgical trauma to the abdominal wall
may significantly increase the risk of serious complications, vaginal hysterectomy alone is a
reasonable alternative with acceptable results. 3

8.3)

Stage 1

Surgery is the preferred treatment modality and should include the following: a) thorough
assessment of the abdominal cavity b) peritoneal washings for cytology c) selective pelvic
and para-aortic lymph node sampling may be appropriate d) total abdominal hysterectomy
and bilateral salpingo-oophorectomy. There are no plans to introduce routine systematic
lymphadenectomy unless the final published results of the

ASTEC Trial recommend

otherwise.
The incidence of lymph node involvement in stage one disease is approximately 10%. The
role of lymph node sampling or lymphadenectomy remains unclear.

8.4)

Stage 2

If pre-operative diagnosis is Stage 2 surgery is the preferred treatment option.

It is

recognised that the majority of Stage 2 are diagnosed post-operatively. See radiotherapy
below.
Surgery if undertaken for patients with clinical involvement of the cervix should include:
a) laparotomy via midline incision
b) peritoneal washings for cytology
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c)

radical extended hysterectomy and bilateral salpingo-oophorectomy

d)

pelvic +/- para-aortic lymphadenectomy. (In these cases the risk of spread to pelvic

lymph nodes may be as high as 30%)

In patients not suitable for surgery with clinical stage 2 disease, radiotherapy is an option.

8.5)

Stage 3 and 4

These are a heterogenous group of patients who must be managed on an individual basis.
Recommended treatments include surgery, surgery followed by radiation, radiotherapy,
hormonal treatment or chemotherapy. With respect to surgery debulking surgery similar to
that undertaken for ovarian cancer has been advocated in advanced disease. Goff et al
reported a study of 47 patients which included 20 who preoperatively were considered to
have disease confined to the uterus'. Debulking was carried out in 29 patients with stage 4
disease with a peri-operative mortality of 7%. Multivariate analysis showed that surgical
cytoreduction was the only significant prognostic factor for survival and although median
survival was only 12 months this was extended to 21 months in those patients who were
optimally debulked and had chemotherapy. This aggressive surgical approach for patients
with advanced disease is also supported by the GOG 122 study( reference)4.

9. Radiotherapy
There are controversies regarding the management of all stages of endometrial cancer.
There are now three randomised studies of post-operative radiotherapy in early
endometrial cancerError: Reference source not found ,Error:

Reference source not found,5

. The ASTEC

study has been published in abstract and Portec-3 is due to be introduced imminently.

9.1)

Stage I disease

9.1.1 Low risk patients

Patients with a low risk of recurrence do not receive postoperative radiotherapy (XRT).
These include those patients who after TAH/BSO have:
Grade1/grade2 (G1/G2) tumours with less than 50% myometrial invasion (stage 1A or 1B)
(2)

Grade 3 (G3) tumours limited to the endometrium (stage 1A)

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9.1.2 Moderate to High Risk Patients

These include all other patients. Three randomised trials have shown that while
radiotherapy reduces the risk of pelvic relapse, it does not significantly affect overall
survivalError: Reference source not found ,Error:

Reference source not found,Error: Reference source not found

. In

subset analysis of one of these studies (Aalders) there was a survival advantage for
radiotherapy in patients with G3 disease and deep myometrial invasion (Stage 1C). In the
other two studies (GOG 99 /PORTEC) very few patients with G3/1C disease were
includedError: Reference source not found ,Error: Reference source not found. It may be that radiotherapy
offers an advantage to this subgroup of patients.

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The options for these higher risk patients are

(1)

postoperative XRT or

(2)

observation with radiotherapy for pelvic relapse

Treatment decisions are made on an individual basis taking patient preferences and
comorbid conditions into consideration. Radiotherapy is associated with a small risk of
major bowel/bladder morbidity in addition to long term minor toxicity. The rationale for
offering observation with radiotherapy for relapse is that vault recurrence can be salvaged
with radiotherapy in a high proportion of cases 6.

9.2)

Stage II Disease

There is much less data for stage II disease compared with stage I. These patients have a
higher risk of involvement of pelvic nodes and a higher risk for failure 7 Studies tend to be
small retrospective series where patients received adjuvant radiotherapy. Some patients
with stage II disease may be overstaged as a result of cervical implantation after
currettage.
If there is only focal involvement of the cervix and otherwise the patient falls into a low risk
group observation is an option. In general all other patients are offered postoperative
radiotherapy.
9.2.1 Trials in progress in stage I and II disease
The

PORTEC-3

trial

is

randomised

phase

III

trial

comparing

concurrent

chemoradiotherapy and adjuvant chemotherapy with pelvic radiotherapy alone in high risk
and advanced stage endometrial cancer following hysterectomy.

It is an international

collaboration led by the Dutch Cooperative Gynaecologic Oncology Group and hopes to
recruit 500 patients over 5 years.
The primary objective of this study is to establish overall survival and failure-free survival
where failure is defined as relapse or death due to endometrial cancer or due to treatment
complications.
The secondary objectives are to establish and compare the rates of treatment-related
toxicity, quality of life and pelvic and distance recurrence.
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Patients randomised to receive the experimental arm of the trial, will have cisplatin on day
1 and 22 of radiotherapy and the external radiotherapy dose will be 48.6Gy in 27#. Then 4
cycles of adjuvant chemotherapy with carboplatin and paclitaxel every 3 weeks.

brachytherapy boost is given if there is cervical involvement.

9.3)

Stage III disease

Stage three disease is an uncommon and heterogenous disease including patients with
tumour spread beyond the uterus to involve the serosa, adnexae, peritoneal fluid, vagina,
pelvic para-aortic nodes. Treatments recommended have included postoperative
radiotherapy to the pelvis, to the pelvis and para-aortic region, whole abdominal
radiotherapy (WAR), intraperitoneal P32, progestogens or chemotherapy 8. The impact of
these treatments on outcome is not clear, much of the evidence coming from small single
arm studies.
9.3.1 Stage IIIa
Patients with serosal/adnexal involvement generally receive post operative radiotherapy.
The significance of malignant peritoneal cytology is unclear. It is usually associated with
other risk factors for recurrence such as deep myoinvasion or G3 9. If there are no
associated high risk factors, observation is an option.
9.3.2 Stage IIIb disease
This is uncommon. Patients generally receive postoperative radiotherapy to the pelvis +
vault brachytherapy.
9.3.3 Stage IIIc disease
Postoperative radiotherapy to the pelvis is generally used for patients with involved pelvic
nodes. Extended field radiotherapy treating the para-aortic nodes can be considered for fit
patients with:
Common iliac positive pelvic nodes as these have a high risk of paraaortic nodal
involvementError: Reference source not found Microscopically positive para-aortic nodes.In
these groups of patients small series have reported long term survival of approximately
50% with extended field radiotherapyError: Reference source not found ,10,11.
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If patient has had a radical hysterectomy, radiotherapy is considered if more than one
pelvic node is involved.
The management of patients with bulky nodes is unclear. General opinion is that if there
is a single bulky node resection + postoperative radiotherapy can be considered. Patients
who have multiple bulky nodes have incurable disease and treatment is palliative. In this
situation treatment modalities may include radiation/hormones and chemotherapy.

9.4)

Stage IV disease

Treatment is individualised for these patients using combinations of surgery/radiotherapy/

hormones and chemotherapy. The aim is to control disease and maintain quality of life.
9.4.1 Stage IVa
Treatment is generally palliative. Occasional patients may be suitable for radical approach
either in the form of radiotherapy or surgery.
9.4.2 Stage IVb disease
Palliative radiotherapy can be used for patients who are symptomatic with local pelvic
symptoms. Hormonal treatment and/or chemotherapy can be considered for those
presenting with metastatic disease.

9.5)

Treatment of patients with unfavourable histology

Both uterine papillary serous (UPSC) and clear cell histology are associated with a poor
prognosis. The pattern of intraperitoneal spread resembles ovarian cancer. 5-year survival
rates are of the order of 3040% 12,13.

9.5.1 Uterine papillary serous carcinoma (UPSC), and clear cell carcinoma.
These tumours tend to be deeply myoinvasive and frequently have vascular space
invasion. Most surgically staged patients have unsuspected extrauterine disease 14. Of
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patients who recur 50% appear to do so in the upper abdomen 15.The treatment of UPSC
should probably include ovarian style debulking surgery and staging, including
omenectomy. The exact type of adjuvant treatment is unclear. There is data to support no
adjuvant treatment in those patients with stage 1a disease who have been staged
appropriately. There is phase 2 data to support adjuvant chemo-radiotherapy in stage 1 or
II disease. Up to recently it has been felt that unlike serous carcinomas of the ovary
response rates to platinum containing regimes are low. GOG 122 included 21.3% of
patients with serous papillary tumours and although numbers were small response rates
were similar in these patients with Cisplatin/Doxarubicin 16.
Treatment options include
Observation for 1a disease following TAH/BSO
Pelvic radiotherapy for stages 1 and II disease. Chemotherapy considered in

selected

cases.
Cisplatin/Doxarubicin chemotherapy for patients with Stages 3 & 4 disease who have been
surgically debulked with radiotherapy afterwrards.
Randomisation to Portec-3 in due course.

9.6)

Treatment of endometrial carcinoma with radiotherapy alone

Patients who are morbidly obese or are deemed unfit for surgery should be reviewed by one of the

Gynaecological Oncologists at the Centre. If they are then felt unfit for surgery they can be can be

considered for Radical Radiotherapy. With Radical Radiotherapy the local control rates are high in

patients with stage 1 and 2 disease and 5 year disease specific survival rates are similarly good.

Audit of patients treated at CCO showed 5 year disease specific survival to be 70% in patients with

stage I/II disease and 33% in stage III/IV disease 17. However 5 year overall survival rates in these

patients are generally only 30 50% as a consequence of their medical problems.

9.7)

Treatment of recurrent disease

Recurrent endometrial cancer is confined to the pelvis in half of patients and of these approx 50% are

confined to the vaginaError: Reference source not found ,Error: Reference source not found. Salvage of these cases

is more usual when disease involves the vaginaError: Reference source not found ,Error: Reference source not found.
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Treatment options depend on previous radiotherapy

(1) If no previous radiotherapy:

Radical radiotherapy with external beam and intracavity treatment

(2) If previously irradiated treatment is generally palliative and dosimetry limited.

There may be scope for further external beam or intracavity treatment.

9.8)

Adjuvant Vault Brachytherapy

At CCO, adjuvant vault brachytherapy is given to all suitable patients at the end of external
beam radiotherapy. This consists of a single vault treatment.
There are no completed randomised trials addressing the role of vault brachytherapy alone
in endometrial cancer.

However, the PORTEC-2 trial, which is ongoing, randomises

patients with high-intermediate risk disease to pelvic radiotherapy and vaginal

brachytherapy.
Selective intermediate risk patients patients may be offered vault brachytherapy alone,
which consists of 3 treatments over a period of 2 to 3 weeks.

10. Hormonal therapy

Available evidence does not show there is a role for the use of hormones in early stage
disease. De Palo in a multi-centre randomised trial 18 suggested that hormonal treatment
does not improve survival whilst Quinn found a 5-6% survival advantage in higher risk
groups based on differentiation, tumour type and myometrial invasion 19. Meta-analysis of
published trials demonstrated that overall survival may be adversely affected 20. Initial
analysis of the large COSA-NZ-UK trial did not show any significant survival advantage for
adjuvant progestogen therapy although a second analysis did show a small survival
benefit21,22. On the basis of the available published evidence the routine use of adjuvant
progestogen therapy cannot be recommended after initial treatment of early stage disease.
The situation in advanced or recurrent disease is different however since up to 30% of
patients may respond to hormonal therapyError: Reference source not found. Higher
response rates are noted in patients with grade 1 disease, positive progesterone receptors,
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and a longer disease free interval. Retrospective ER-PR status may be helpful in
determining management. Although there are no randomised controlled trials of the use of
hormonal therapy in this setting, its use is often of palliative benefit and may possibly
enhance survival. The particular agent used does not affect the response rates.
We recommend

Provera (medroxyprogesterone acetate) 100mg tid.

Megace (megestrol acetate) 160mg od.
There is interest developing in the use of aromatase inhibitors.

11. Chemotherapy
Adjuvant

There may be a role for adjuvant chemotherapy in selected

patients23,24

Advanced disease Chemotherapy can be considered in patients with advanced

disease
Patients are suitable if creatinine clearance is>50ml/min and
performance status 1 or 2.
Agents and doses:

Cisplatin

60mg /m2

Adriamycin

40mg /m2

Cycle time 21--8 days for 4-6 cycles

Delay treatment if ANC = <1.5
Expected response rate = 34%Error: Reference source not found
Updated data has been published supporting the use of cisplatin and adriamycin 25. A
further randomised comparison has been published by Fleming et al in 2004 comparing
Cisplatin, adriamycin and paclitaxel with the standard AC combination 26. Whilst this shows
an 8.3 month survival gain, in view of the grade 3 and 4 myelopsuppression this 3 drug
combination is not recommended as standard.

12. Palliative Care and Nursing care

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Palliative care input is appropriate to consider at all stages of the patients cancer journey.
Please refer to the separate palliative care guideline for detailed advice.
All women with a diagnosis of a Gynaecological Cancer should be offered the support of,
and have access to a Clinical Nurse Specialist (CNS), in order to facilitate the womans
needs throughout the Cancer Journey, including those of her partner or carer.
The skills of the C.N.S. as a consultant, practitioner and educator can be drawn upon at all
stages throughout their illness, from the pre-diagnosis to the terminal stage incorporating
the Specialist Palliative Care Services provided in the hospital and the community setting.
Bereavement Support will also be available, if appropriate.
Important aspects of the role are to provide advice, support, information and to effectively
incorporate appropriate resources. The C.N.S. will be receptive to the social, physical,
psychological, cultural, sexual and spiritual needs of the patient. The aim of the patient
support is to assist with the improvement in the quality of their lives, allowing them to
become more empowered; to help take control and enhance their self esteem.
The C.N.S. works closely with Surgeons, Oncologists, Radiotherapists, Consultants in
Palliative Medicine and others (Nurses & P.A.M.s).
They will undertake a number of key responsibilities including:
Linking with other professionals who can help the patients throughout the system
A resource for information and support to the patient carer and other H.C.P.s
Liaison point for other health care professionals in primary and secondary care
Teacher and Educator
Researcher
Standards and Audit Co-ordinator
Co-ordinate Care Services

13. Follow-up

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Atypical hyperplasia is cured by hyterectomy, and patients with stage 1a disease have a
very low risk of relapse. They may therefore be discharged with open appointment in the
event of new symptoms or concerns.
For the remainder, standard follow-up is recommended: Four monthly for years 1 and 2,
six monthly to 3 years. Discharge with open access to CNS in the event of new symptoms
or concerns. CNS holistic assessment is carried out 6 weeks after the completion of
primary treatment.

14. Hormone Replacement

The question as to whether hormone replacement therapy may be prescribed is a matter of
some debate. Endometrial cancer is considered to be an oestrogen-dependent cancer and
hence traditional thinking has been that oestrogen replacement therapy is contraindicated.
However there is no published data to support this argument. On the contrary there are a
growing number of reports which suggest that not only is oestrogen replacement therapy'
safe 27,28 in these circumstances but that survival may be enhanced by its prescriptions.

15. Clinical Trials

The centre is currently planning to participate in the Portec-3 trial, investigating whether
adjuvant chemoradiation is superior to radiation alone.

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Appendix 1
Radiotherapy for Endometrial carcinoma

1.

Adjuvant radiotherapy

A 3 or 4 field technique is used to treat the pelvis. The patient lies in the supine position
and is planned using the CT simulator. There is no routine need to use a vaginal marker
when planning with a virtual simulation technique.
The dose schedule is external beam radiotherapy 45Gy in 25# over 5 weeks followed by a
single brachytherapy treatment to the vaginal vault, giving a dose of 6Gy at 5mm from the
applicator surface, treating the top 2 to 4cm of the vagina using HDR.

See radiotherapy protocol book for field definitions.

2.

Radical radiotherapy

A.

A 3 or 4 field technique is used to treat the pelvis.

The dose is 45Gy in 25# over 5 weeks external beam treatment followed by HDR
brachytherapy, 7Gy in 2#.

B.

For obese patients with early stage disease, can be treated with brachytherapy

alone, dose 7Gy in 5#.

3.

Whole abdominal radiotherapy

This treatment is not used at Clatterbridge Centre for Oncology.

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4.

Treatment of pelvic recurrence

In patients previously treated by surgery alone who develop a central pelvic recurrence,
salvage can be achieved with pelvic radiotherapy. A CT scan of the abdomen and pelvis
should be performed before radiotherapy is given.
The schedule is

45Gy in 25# external beam radiotherapy to the pelvis followed by 2

brachytherapy treatments to the vaginal vault, each of 6 or 7Gy ensuring all the vaginal
disease is covered.

5.

Palliative radiotherapy

A, Pelvic Disease
A smaller pelvic field can be used to encompass gross disease, to achieve symptom control
and minimise toxicity.
Acceptable dose fractionations include: 20Gy in 5#
30Gy in 10#
40Gy in 15#
A single treatment of 8 to 10Gy may be suitable for frail patients.

B, Metastatic Disease
Bone mets can be treated either with a single 8Gy treatment or 20Gy in 5#
Brain mets can be treated with 12Gy in 2# or 20Gy in 5#

Selected patients with high risk disease can be treated with chemoradiotherapy followed by
a further 4 cycles of chemotherapy.
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Keys et Al. A phase III trial of Surgery vs with or without adjunctive external pelvic radiation

therapy in intermediate risk endometrial adenocarcinoma: A Gynecologic Oncology Group

study. Gynec. Oncology. 92(3). 744-751. 2004
2

Creutzberg et Al. Surgery and postoperative radiotherapy versus surgery alone for patients

with stage-1 endometrial carcinoma;multicentric randomised trial. Lancet. 355: 1404-1411.

2000
3

Chan JK, Lin YG, Monk BJ, et al. Vaginal Hysterectomy as Primary Treatment of

Endometrial Cancer in Medically Compromised Women. Obstet Gynecol 97:707-711. 2001.

4
5

Aalders et Al. Postoperative external irradiation and prognostic parameters in stage 1

endometrial carcinoma. Obstetrics and Gynec. 56: 419 427. 1980

6

Ackerman et Al Endometrial Carcinoma Relative Effectiveness of Adjuvant Irradiation vs

Therapy Reserved for Relapse. Gynec. Oncology. 60: 177 183. 1996
7

Morrow et al. Relationship between surgical and pathological risk factors and outcome in

clinical stage 1 and 2 carcinoma of the endometrium: A Gynecologic Oncology Group study.
Gynecol. Oncology. 40: 55-65. 1991
8

Randall et al. Radiation therapy and combined chemoradiation in advanced and Recurrent

endometrial carcinoma Seminars in Oncology. 21: 91-99. 1994.

9

Milosovic et Al .

The clinical significance of malignant peritoneal cytology in stage 1

endometrial carcinoma. Int. J. Gynecol Cancer 2: 225-235. 1992.

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