Case Study—

Endometrium
JOSH BARRUS
 Patient  Female
 64 y/o
Overview and  White
Demographics  Postmenopausal
 Diagnosed with FIGO stage IVB
adenocarcinoma of the endometrium
 Treated at V1 at The James
Past Medical and Surgical History

Anemia

Gastroesophageal Reflux Disease (GERD)

Recent nephrolithiasis

Tonsillectomy

Breast lumpectomy (age 17)

Robotic radical hysterectomy (aborted) Robotic-assisted right salpingo-oophorectomy

Social History

Denies smoking or use of Current alcohol use Previous drug use

smokeless tobacco (unspecified)
Approximately 1 drink per week
Drinks with family on holidays
 Personal and Family Life

Enjoys long
walks down Three Degree in Early 11-11 is an Says the most
Proud mother grandchildren Childhood important date important things in
the hallway (to of 2, son and Development life to her are
and from her daughter “because it was Lost her mother on 11- family, kindness,
treatment) the closest thing I 11-2013 at 11:11am faith, creativity,
could get [to] Her first granddaughter and gratitude
majoring in was born 11-11-2017 at
11:27am
‘mom’”
Maternal grandmother
was also born on 11-11
 Cancer in
her father
Diabetes in
and
her mother
maternal
grandfather
Family
History Mother had
No history of
endometrial,
possible
ovarian, or
DCIS of the
colon
breast
cancer
  Abnormal vaginal bleeding—July 2019
 Transvaginal Ultrasound showed thickened
endometrium
 Biopsy revealed poorly differentiated
adenocarcinoma of the endometrium (FIGO
History of grade 3)

Present  MRI of the pelvis found a large cervical mass

with lower uterine involvement and extension

Illness 
to right pelvic sidewall
PET/CT revealed increased metabolic activity
below diaphragm and in proximal femur
 Clinically found to have large necrotic mass
replacing cervix and uterus extending halfway
down vaginal canal
Pelvic
Anatomy1
Uterine Anatomy 1
 Presacral Nodes

Obturator Nodes

Lymphatics 2
 Signs and
 Abnormal uterine bleeding
 Often occurring post-menopause

Symptoms 2
 Abdominal or pelvic pain
 Abdominal distention
 Foul smelling discharge (later stages)
 Can have abnormal Pap smear
Epidemiology 3  4th most common malignancy in women
 Most common gynecologic malignancy
 Makes up approximately 6% of all cancers
 Accounts for 3% of cancer deaths in women
 Most commonly adenocarcinoma forming in
the inner lining if the uterus (endometrium) and
invading into the uterine wall
 Most affect postmenopausal women over age
55, with peak incidence around age 65-69
years (64)
 Incidence is higher among white women but
black women have higher mortality
Histology
2,3  Endometrial cancers by type
 Adenocarcinoma ~ 80%
 Papillary serous carcinoma ~ 10%
 Particularly aggressive—spreads rapidly
throughout abdominal cavity
 Mucinous carcinoma ~ 3%
 Clear cell carcinoma ~ 5%
 Poor prognosis
 Squamous cell carcinoma
 Sarcoma
 Rare but most malignant of all types
 Etiology 2,3

Risk factors include:

The endometrial layer is highly
sensitive to changes in estrogen
levels
• High exposure to estrogen
without sufficient progesterone
• Estrogen replacement therapy
• Obesity (3-5 fold increase)
• Nulliparity
• Late menopause
• Early menarche
• Irregular menstruation
• Diabetes (Family Hx)
• History of infertility
• Tamoxifen use
• Hereditary colon cancer
 Type I
• Estrogen-related
• Developed because of excess estrogen
exposure
• Generally low grade and diagnosed at early
Classifying stage
• Good prognosis
Endometrial CA 2

Type II
• Not related to estrogen
• Diagnosed usually in older women
• High grade—poor prognosis
• Serous and clear cell carcinoma
Staging 3

 Use FIGO staging system

 Based on TNM characteristics
Metastasis 2,3

 Most common route of spread is to pelvic and paraaortic lymph nodes

 Direct invasion
 Cervix
 Vagina
 Ovaries (Right)
 Myometrium
 Parametrium
 Can spread through blood and lymphatics to:
 Lung
 Liver
 Bone
*Patient had extension through uterine wall to right ovary and right pelvic sidewall,
also including cervix and upper ½ of vagina
Treatment Considerations 2

 Treatment modality largely based on stage

 IA
 Total hysterectomy with salpingo-oophorectomy
 Vaginal cuff brachytherapy
 IB
 Radical hysterectomy
 EBRT and brachytherapy
 II-IVA
 Concurrent chemoradiation
 Cisplatin
 EBRT and brachytherapy
 Higher stages may include paraaortic nodes or other metastatic sites
Treatment Modalities—
Surgery 3

 Primarily used in lower staged disease

 Surgery alone can lead to cure
 Often used with pre- or post-op chemo and/or radiation therapy
 Pre-op less common but can benefit patients with cervical or vaginal
involvement

 Total hystertectomy and salpingo-oophorectomy

 Removal of the entire uterus, along with ovaries and uterine tubes
 Patient had radical hysterectomy aborted during surgery but still
had right salpingo-oophorectomy
Treatment Modalities—
Immunotherapy 4

 Surgery and chemo/radiation are the preferred options for treatment

 Patient also has immunotherapy treatment planned after radiation
 Immunotherapy treatments for endometrial CA
 Peptide and protein-based anti-cancer vaccines
 Pembrolizumab and lenvatinib
 Create “checkpoints” for the immune system to better detect and fight cancer
cells
 Adoptive cell transfer (ACT)
 Extracting lymphocytes from the blood and multiplying them outside of the body
before reintroducing them into the same patient’s blood
 Bispecific T-Cell engager (BiTE) antibodies
 Help to mark cancer cells for lysis by T-lymphocytes
Treatment Modalities—
EBRT 2

 Conformal treatment—4 field pelvis

 Now, more commonly IMRT/VMAT to achieve better conformity
 Can treat prone to decrease dose to small bowel
 Conformal treatment borders
 Superior: L4-L5 (or T10-T11 for paraaortic nodes)
 Inferior: Obturator foramen or including 4-5cm of vagina
 Lateral: 1.5-2cm beyond pelvic brim
 Anterior: 1cm beyond pubic symphysis
 Posterior: S2/S3, bisect rectum, or include all of sacrum depending on
nodal involvement
Treatment Modalities—
Brachytherapy 2

 Use Y tandem, vaginal cylinder, or colpostat

 Vaginal cylinder and colpostat used to treat vaginal cuff post-
hysterectomy
 Often used as a boost following EBRT or to treat near surgical
site
 Can use LDR or HDR
 LDR: Cesium-137 (half-life 30 years)
 HDR: Iridium-192 (half-life 73.8 days)
  Palliative intent
 VMAT pelvis—5 full arcs
 10 MV photons
 Imaging
 Orthogonal pair daily for alignment

Treatment
 CBCT 2x/wk (actually performed CBCT almost
daily)
4500 cGy in 25 fx
Plan

 Dose for nodes
 Brachytherapy boost planned after EBRT
 180 cGy/fx
 Brachytherapy
 Boost likely 30 Gy (LDR) or 18 Gy (HDR)
  Supine
 Frog-legged in vac bag
 Dosemax (paraaortic nodes)
 Arms overhead in arm shuttle
Simulation  Use towels under her head and below her arm
for comfort and extra support
and Setup  Full bladder
 Was not completely straight in simulation so we
often had to adjust her after daily orthogs
 Struggles with vertigo and anxiety which made
it difficult to lay down quickly or for a long time
Challenges in Setup and Treatment

 Patient is obese, making all marks somewhat unstable

 Often had to get marks “close enough” then rely on imaging for the rest
 Spine and pelvis not straight in simulation
 Had to move after orthogs sometimes multiple times per day
 Vertigo—Must go very slow laying down and sitting up
 Sometimes would get dizzy after laying down and had to sit up again
 Anxiety—caused sometimes by vertigo or other unknown reasons
during setup, caused us to sit her up and redo setup
Organs at Risk 5

 Kidneys 2300 cGy

 Bladder 6500 cGy
 Femoral Heads 5200 cGy
 Skin 5500 cGy
 Spinal Cord 4700 cGy
 Small Bowel 4000 cGy
 Colon 4500 cGy
 Rectum 6000 cGy

 Uterus 10,000 cGy

 Fatigue—Diet, light exercise
Side Effects

2
 Erythema/dry desquamation/moist desquamation—keep skin
clean and moisturized
 Diarrhea—Imodium or Lomotil
 Small bowel obstruction—Laxatives, hydration, possible surgery
 Proctitis (inflammation in the rectum)
 Fistula formation—surgery
 Ovary failure (500-1000 cGy)
 Sterilization (200-300 cGy)—younger women may freeze eggs
 Stenosis of the vagina—can use dilators to keep open
 Urinary urgency and frequency
Prognostic Indicators 2

 The stage and grade of the tumor is the largest prognostic indicator
 Histology
 Spread
 Local and regional spread
 Metastasis/presence of extrauterine disease
 Patients below 60 years tend to have better outcomes
 Adenocarcinoma has more favorable prognosis than
Adenosquamous, papillary serous, clear cell, or sarcomas
 Myometrium invasion, lymphatic spread, and invasion outside of the
uterus indicate poor prognosis and possible recurrence
Survival
2

Stage I — 80-90%

Stage II — 70%

Stage III — 30-60%

Stage IV — 5%
Bonus Question:

What instrument does a uterus play?

References

1. Netter FH. Atlas of Human Anatomy. 7th ed. Philadelphia: Elsevier; 2019.
https://www.clinicalkey.com/#!/browse/book/3-s2.0- C20140050319.
Accessed April 1, 2020.
2. Hackworth, R. Endometrial CA. Lecture presented at: The Ohio State
University; January 13, 2020; Columbus, OH.
3. Washington CM, Leaver DT. Principles and Practice of Radiation Therapy.
4th ed. St. Louis, MO: Elsevier Mosby; 2016.
4. Tucci CD, Capone C, Galati G, et al. Immunotherapy in endometrial
cancer: new scenarios on the horizon. Journal of Gynecologic
Oncology. 2019;30(3). doi:10.3802/jgo.2019.30.e46.
5. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to
therapeutic irradiation. International Journal of Radiation
Oncology*Biology*Physics. 1991;21(1):109-122. doi:10.1016/0360-
3016(91)90171-y.