2. The uterus is a hollow, pear shaped organ with thick musc-
ular wall (L 8cm,W 5cm ) in young nulliparous adult. Is
Divide into the fundus,body,and cervix. The fundus is the
Part lies above the entrance of the uterine tubes. The body
Is the part lies below the entrance of the uterine tube is
Narrowing inferiorly to open in the cervix by the internal os.
Related interiorly to the uterovesical pouch and superior
Surface of the bladder. Posteriorly to the rectoutrine pouch
Laterally to the broad ligament and uterine artery and
Vein.

3. The uterus is covered with peritoneum until the internal
Os. The uterus is lining by the mucous membrane.
Lymph drainage;-
From the funds go to the para-oartic nodes at the L1.
Lymph from the the body and cervix d go to the internal
And external iliac nodes

4. New case in USA in 2010 is 42.160. it is the 4th most .
Common cancer in women and ranks 8th among cause
Of cancer death . It is the most common gynecologic
Malignancy .
Risk factors ;- 1) age ;-postmenopausal (55--85yrs)
Incidence rate higher than 95 per100,000 in age 65-80
Yrs 2)endogenous estrogen exposure ;-early
menarche/nulliparity/infertility/late
menopause/estrogen producing tumor .
3) exogenous estrogen;-hermonal replacement
Therapy tamoxifen

5. 4) past medical history;- hypertension diabetes
mellitus
5) family history ;-less than 1% of endometrial ca- is
due to familial factors .
6) Genetic factors ;- mutations in the MLH1 or MSH2
Gene cause of defect in HNPCC (lynch syndrome11)
have 20% risk to developing endometrial cancer
before 50 and 60% risk after the age 60 yrs

6. The majority of edometrial cancer is adenocarcinomas
which include serous/mucinous/clear cell/mixed cell.
The epithelial non adenocarcianom include ;-squamous
cell carcinoma /transitional cell carcinoma
Small cell carcinoma /un differentiated carcinoma .
The mesenchymal originated tumor of the uterus include
;- --smooth muscle tumor;- -leiomyoma -leiomyosarcoma
Of un certain malignant potential.
Stromal tumor ;- sarcoma /nodule/undifferentiated
sarcoma

7. -
- Miscellaneous mesenchymal tumor ;-
- -mixed stromal and smooth muscle tumor
- --edenomatoid tumor –perivascular epith-
- Mixed epith-& mesenchymal ;- -adenofibrom-
- Adenomyoma -adenosarcoma –carcinofibroma
- carcinosarcoma

8. Clinical presentation;- vaginal bleeding in unexpected
Postmenopausal lady (menorrhagia/metrorrhagia ).
Profuse watery discharge is another presentation .
Attention should be paid to the duration and severity of
The symptoms. Screening for risk factors include,
Obesity,hypertension,diabetic,history of estrogen use,
History of endometrial atypical hyperplasia. History of
Breast cancer and treatment with tamoxifen,

9. Examination ;-
Examination should be performed with attention to the
The abdomen,plevic (examination of the cervix and
vagina).
Palpation of the lymph nodes in the inguinal and supra-
Clavicle regions . Then examining for metastsis disease
(palpation of the bone to the pain/kidney/nerological
sign ).
Lab test;- CBC /blood chemistry/RFT/LFT/alkaline phos-
Phatase.
Imaging include;- transvaginal US /abd-pelvic CT to assess
Extra-uterine disease

13. Endometrial cancer suspected
Complete history and physical
exam
± Trans-vaginal
Endometrial biopsy
/US
NON diagnosis
Dilatation and
curettage Pre-operative
observe assessment
hysteroscopy
Diagnosis of endometrial cancer

14. Endometrial cancer staging is depend on the pathologic
criteria the recent change in the Federation of
Gynecology and Obstetrics(FIGO)
And American Joint Committee on Cancer(JOCC)
were made to include coincide with prognosis

15. FIGO stagi 2009
2008 TNM ng
group T N M Description
1A T1a 0 0 Limited to endometrial or invades >1/2 of
myometrium
1B T1b 0 0 Invades ½ or more of the myometrium
11 T2 0 0 Invades cervical stromal tissue but not beyond uterus
111A T3a 0 0 Involve serosa and /or adnexa
111B T3b Vaginal involvement or parametrial involvement
T1-3 1 0 Metastasis to pelvic LNs
111C1
T1-3 2 0 metastasis to para aortic LNs
111C2
1VA T4 any 0 Invade bladder mucosa or bowel mucosa
1VB any any 0 Distant metastasis

16. Survival rate at 5yreas,based on stage classification
Extent of disease at 5-yrs survival rate
diagnosis
Localized 96%
Regional 68%
Distant 24%
All stage 83%

18. Prognosis factors ;-survival strongly depend on the
stage at diagnosis other factors include ;-
1) Advanced age associated with higher chance of
recurrence
2) Higher grade;- associated with higher chance of
recurrence .
3) Aggressive histology as clear cell adenocarcinoma,
Un differentiated papillary serous carcinoma are
Associated with worse prognosis
4) depth of myometrial invasion
5)lymph vascular space invasion

19. The stander treatment is total extrafascial hysterectomy
with
bilateral salpingo-oophorectomy,peritoneal cytology and
pelvic / Para-aortic lymph nodes dissection traditionally
done through vertical midline incision laparoscopic tech-
Has recently been used . Depending on the pathological
Data .high risk patients (↑rate of local recurrence) adjuvant
radiation therapy will recommended to these patients .
Systemic therapy is used inlocoregional advanced/
Recurrence or metastatic disease

20. Treatment of early stage endometrial cancer;-
1ry treatment is surgical resection, then pathologic
specimen is examined for risk factor to determined a
patient risk of loco regional recurrence according to
Which determine adjuvant therapy

21. Total extrafascial hysterectomy +bilateral salpigo-
oopharectomy
Low risk Intermediate risk High -risk
Vaginal brachy-
EBRT + vaginal
observation Therapy or
brachytherapy
EBRT± VB
Algorithm for treatment of early stage edometrial cancer

22. as seen in the previous algorithm there is mixed recom-
Mendation to treatment options for intermediate risk
Group of patients these is due to patients and disease
Related factors GOG identifies these high –intermediate
Subgroup in which the adjuvant therapy is of benefit
Risk factors ;-
1) grade 2/3 histology
2) lymphvascular invasion
3) outer 1/3 myometrial

23. Treatment of early stage endometrial cancer
FIGO Grade
stage
1 11 111
1A observation Observation or VB VB or EBRT with
or
Without VB
1B VB or EBRT with VB or EBRT with EBRT with VB
or or
Without VB Without VB
11 EBRT with VB EBRT with VB EBRT with VB
VB;-vaginal brachytherapy EBRT ;-external beam radiation therapy

24. Locoregionally advanced endometrial cancer;-
These patients usually treated by surgery followed by
Adjuvant radiation. Para-aortic irradiation incase where
Pelvic or para aortic LNs +ve.vaginal brachytherapy is
Often is added due to ↑ risk of vaginal cuff recurrence.

25. Chemotherapy and hormonal therapy ;- for stage 111,1v
After surgery the tumor mass should be examined to
ER,PR level (benefit of hormonal treatment).
Hormonal therapy :- response occur in 20-40% of patients
Duration 1yr (improve out come) .the most frequently
used
Drugs:- 1) medroxyprogesterone (Depo-Provera).
2)megestrol acetate.
3) tamoxifen.
Chemotherapy :- regime containing platinum and
doxorubicin used (response up to 40%,↑survival,PFS as
Compared to WAI*) (GOG122).
The EORTC study to the stage1-111 (high risk) reported
improved 5 yrs PFS of 80% with adjuvant
CH-RT over 75% to the RT alone

26. Trial Description
Number of patients =388 stage 111– 1v endometrial ca-
After TAH/BSO surgical staging and <2cm residual tumor
GOG Randomized to whole abdominal irradiation (WAI)
122 Versus doxorubicin- cisplatin(AP) chemotherapy
WAI =30 GY in 20 fr AP/PA +boost to pelvic/Para aortic LNs to
15 GY in 8 fr .
PA every 3 week for 8 cycles .
5 yrs PFS→ 38% for WAI versus 50% for AP .
5yrs OS was 42% for WAI versus 52% for AP .
Recurrence after WAI was 54% versus 50% after
AP .
AP had more grade 3-4 hematological and gastroin-
Testinal toxicity
*chemotherapy improve PFS and OS as compared
To WAI for stage 111&1v patients after surgical
resection

27. Adjuvant external radiation therapy ;-
four randomized trials that evaluated adjuvant EBRT versus observation in the early
Stage endometrial cancer (after surgery).these is local control benefit but does not
Translate in to survival benefit
study year No of eligibility Treatment VB Randomize Vaginal/ OS
number LN d to EBRT pelvic
recurren
ce
Nor- 1980 540 1B-1Cb NO yes 40 GY 2 87 NS
wegian Observatio 7 90 NS
n-
PORTE 2000 715 1B-G2-3 NO NO 46 GY 4 81 NS
C 1CG1-2 observatio 14 85 NS
n
GOG- 2004 392 1B-1C yes NO 50.4GY 3 92 NS
99 Occult observatio 12 86 NS
11 n
MRC 2009 906 1A- 30% 52 40-46 GY 3 85 NS
ASREC 1B,G3 % obsession 6 85 NS
&NCIC Serous
CTG EN papillary

28. Medically inoperable:- EBRT to the pelvis (include LNs)
And other involved area (45-50 GY ) followed by intra-
Cavitary BT (6GY X 3HDR) for early stage but inoperable
For medical reason (survival rates of 80% -85% at 5 yrs).
In definitive RT to the uterus we need to the intra-uterine
Sources and upper vaginal sources.
Unrespectable disease:- treated with EBRT and BT as above
In medical inoperable disease .
Recurrence:- if no prior RT→EBRT and BT boost→60-
70 GY. BT can be used in selected previously irradiated
Pts.
CTH can be conceder in metastasis and recurrence disease
Specially if not previously received

29. treatment of less common histological types:-
1)papillary/serous/clear cell:- conceder CTH or RT to the
Stage 1B,1C,11, and debulked stage 111,1v . Cth± RT.
While stage 1A treated by surgery.
CTH include carboplatin/paclitaxel/platinum.
carcinosarsarcima:- surgery –then op-RT for (sarcoma/
Leimyosarcoma,and carcinosarcoma) to improve local
Recurrence LC . Consider CTH for high grade
undifferentiated sarcoma and leiomyosarcoma.
GOG150→comparing RT(WAI) with CTH (cisplatin-
Ifosphamide)→ CTH delay the recurrence more than
RT. These is more anemia/neuropathy in CTH.

30. RADIATION THERAPY TECHNIQUES
Simulation and field arrangement;-
CT should performed (2.50-5mm) from the top of the L4 to
The lesser trochanters of the femurs. Aides used during
the
Simulation include Foley catheter, intravaginal marker or
intr-avenous contrast .organ at risk include ;-
OAR dose limitation
Bladder V80 <15% / V75<25% /V70,V65 <50%
Rectum V50<50% / V60<35% /V65<25 , V70<20% ,V75<15%
Small intestine TD5/5; 45 GY ,V45<10% /// 150ml <40 GY
Femoral head Max <40 GY

31. Field border used in the( EBRT) treatment of the of endo-
Metrial cancer .
fields borders
Ap/PA superior op of L5
inferior ;-bottom of the obdurate foramina
lateral ;-2 cm lateral to bony margin of the pelvic inlet
lateral superior and inferior as in AP/PA fields .
anterior ;-in front of the pubic symphysis
Posterior ;-S2-S3

32. 3- Dimensional conformal Radiation Therapy and Intensity
-modulated Radiation therapy and target delineation ;-
the benefit of these techniques in sparing of the normal
Tissues .
Target volume ;- GTV;- entire uterus (inoperable cases) .
CTV ;- vaginal cuff,obturator lymph nodes and external/
Internal/common iliac lymph nodes .
PTV ;- CTV +0,5-1.0 cm .
Organ at risk should be contoured are bladder/small
intestine/rectum/femoral head

33. Brachytherapy ;-
Is used to delivery of high dose to the vagina while
minimizing the dose to the organ at risk . The vaginal
Cylinder is the most common applicator used . The
radiation is delivered into ;- 1) low-dose-rate (LDR) .
2)high dose rate(HDR) .
The LDR to the surface is 50-60 GY over 60-70 hrs when
Used alone . The dose is reduced to25-30 GY when
Combined with EBRT .

34. HDR dose as prescribed by the American Brachytherapy
Society
Suggested dose of HDR alone for adjuvant endometrial ca
Number of HDR HDR dose/fraction (GY) Dose- specific point
fractions
3 7.0 0.5-cm depth
4 5.5 0.5-cm depth
5 4.7 0.5-cm depth
3 10.5 vaginal surface
4 8.8 vaginal surface
5 7.5 vaginal surface

35. Suggested dose of HDR when used with45 GY EBRT for
Adjuvant endometrial cancer ;-
Number of HDR HDR Dose /fraction Dose-specific-point
fractions
2 5.5 0.5 cm depth
3 4.0 0,5cm depth
2 8.0 vaginal surface
3 6.0 vaginal surface

36. Radiotherapy- induced side effects:-
Pelvic radiation lead to clinically significant side effect
Specially when combined with other modalities of
Treatment as:-
1) RT + surgery→ lower limb lymphedema
2) RT + CTH→ hematological and gastrointestinal toxici-
Ties.
Long term side effect include:-
1)Urinary and rectal inflammation and fistula after
months or years.
2) narrowing or scarring of the vagina
3)Pain or bleeding during with bowel movement.

37. Follow up ;-
Follow up schedule and examination ;-
schedule frequency
first follow up 4-6 weeks after radiation therapy
years 0--2 every 3—4 months
years 3--5 every 6 months
years 5+ annually

38. Examination ;-
History and examination complete history and physical exam-
ination
laboratory tests vaginal cuff cytology
imaging studies chest x ray (if clinically indicated)
CT of the abdomen and pelvic if
clinically indicated .