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Guideline Details the Role of Postoperative Radiotherapy for Endometrial Cancer

By MedImaging International staff writers
Posted on 12 May 2014
A new guideline was issued by an American radiation oncology group that details the use of adjuvant radiation therapy in the treatment of endometrial cancer.

The American Society for Radiation Oncology (ASTRO; Fairfax, VA, USA) has published the new guideline, “The Role of Postoperative Radiation Therapy for Endometrial Cancer: An ASTRO Evidence-Based Guideline,” and the executive summary was published in the May-June 2014 issue of Practical Radiation Oncology (PRO), the official clinical practice journal of ASTRO.

ASTRO’s Guidelines Panel of 17 leading gynecologic specialists compiled and reviewed extensive data from 330 studies from MEDLINE, EMBASE, and the Specialized Register of the Cochrane Gynaecological Cancer Review Group published from 1980 to 2011. The data population chosen for the guideline was defined as women of all races, age 18 or older, with stage I-IV endometrial cancer of any histologic type or grade. The studies included patients who underwent a hysterectomy followed by no adjuvant therapy, or pelvic and/or vaginal brachytherapy with or without systemic chemotherapy. The panel identified five key questions about the role of adjuvant radiation therapy and developed a set of recommendations to address each question.

The first key question addresses which patients with endometrioid endometrial cancer require no further therapy after hysterectomy. For patients with no residual disease in the hysterectomy specimen in spite of positive biopsy or grade 1 or 2 tumors with either no invasion or < 50% myometrial invasion, especially when no other high-risk features are present, no adjuvant radiation therapy is a reasonable alternative. Patients with grade 3 tumors without myometrial invasion or grade 1 or 2 tumors with < 50% myometrial invasion and higher risk factors such as age > 60 and/or lymphovascular space invasion could reasonably be treated with or without vaginal cuff brachytherapy.

Key question 2 examines which patients with endometrioid endometrial cancer should receive vaginal cuff radiation. Evidence demonstrates that cuff brachytherapy is as effective as pelvic radiation therapy at preventing vaginal recurrence for patients with (1) grade 1 or 2 cancers with ≥ 50% myometrial invasion or (2) grade 3 tumors with < 50% myometrial invasion. Vaginal cuff brachytherapy is preferred to pelvic radiation in patients with these risk factors, in particular in patients who have had comprehensive nodal evaluation.

Key question 3 details which women should receive postoperative external beam radiation. Patients with early stage endometrial cancer which is grade 3 with ≥ 50% myometrial invasion or cervical stroma invasion are felt to benefit from pelvic radiation to reduce the risk of pelvic recurrence. Patients with grade 1 or 2 tumors with ≥ 50% myometrial invasion may also benefit from pelvic radiotherapy to decrease pelvic recurrence rates if other risk factors are presents such as age > 60 years and/or lymphovascular space invasion. For patients with positive nodes or involved uterine serosa, ovaries/fallopian tubes, vagina, rectum, or bladder, the best available evidence suggests that treatment should include external beam radiation therapy as well as adjuvant chemotherapy. Chemotherapy or radiation therapy alone may be considered for some patients based on pathologic risk factors for pelvic recurrence.

Key question 4 addresses when brachytherapy should be used in addition to external beam radiation. The panel noted that data is lacking to validate the use of brachytherapy after pelvic radiation and that retrospective studies show little conclusive findings of a benefit, albeit with small patient numbers. Use of vaginal brachytherapy in patients also undergoing pelvic external beam radiation may not typically be necessary, unless risk factors for vaginal recurrence are present.

Key question 5 scrutinizes how radiation therapy and chemotherapy should be integrated in the management of endometrial cancer. The panel concluded that the best available evidence suggests that concurrent chemoradiation followed by adjuvant chemotherapy is specified for patients with positive nodes or involved uterine serosa, ovaries/fallopian tubes, vagina, bladder or rectum. Alternative sequencing strategies with external beam radiation and chemotherapy are also acceptable. Chemotherapy or radiation therapy alone may be considered for some patients based on pathologic risk factors for pelvic recurrence.

“Several trials on the role of radiation therapy in endometrial cancer have been reported in the past five years, seeking to clarify this topic; however these trials have been interpreted in different ways, leading to inconsistent treatment recommendations,” said Ann Klopp, MD, PhD, and Akila N. Viswanathan, MD, MPH, co-chairs of the ASTRO Endometrial Guideline Panel. “This guideline provides recommendations to help ensure patients receive the best possible care and to help patients and doctors make informed decisions about treatment options.”

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American Society for Radiation Oncology


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84 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1
85 (471.83036804199): SELECT show_live FROM jos_com_show_setting LIMIT 1
86 (51.975250244141): SELECT show_live FROM jos_com_show_setting LIMIT 1
87 (!!!!! 2609.9681854248): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294752350 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1
88 (668.04885864258): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294752350 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1
89 (198.1258392334): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`
90 (313.04359436035): SELECT show_live FROM jos_com_show_setting LIMIT 1
91 (169.99244689941): SELECT show_live FROM jos_com_show_setting LIMIT 1
92 (345.94535827637): SELECT show_live FROM jos_com_show_setting LIMIT 1
93 (119.92454528809): SELECT show_live FROM jos_com_show_setting LIMIT 1
94 (438.92860412598): SELECT show_live FROM jos_com_show_setting LIMIT 1
95 (51.975250244141): SELECT show_live FROM jos_com_show_setting LIMIT 1
96 (196.93374633789): SELECT show_live FROM jos_com_show_setting LIMIT 1
97 (139.95170593262): SELECT show_live FROM jos_com_show_setting LIMIT 1
98 (!!!!! 5573.9879608154): SELECT show_live FROM jos_com_show_setting LIMIT 1
99 (!!!!! 7928.1330108643): SELECT show_live FROM jos_com_show_setting LIMIT 1
100 (495.91064453125): SELECT show_live FROM jos_com_show_setting LIMIT 1
101 (54.121017456055): SELECT show_live FROM jos_com_show_setting LIMIT 1
102 (32.901763916016): SELECT show_live FROM jos_com_show_setting LIMIT 1
103 (30.994415283203): SELECT show_live FROM jos_com_show_setting LIMIT 1
104 (790.83442687988): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
105 (330.92498779297): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
106 (220.06034851074): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294752350 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1
107 (817.06047058105): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294752350 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1
108 (!!!!! 1933.0978393555): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
109 (519.0372467041): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
110 (326.87187194824): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294752350 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1
111 (781.05926513672): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294752350 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1
112 (!!!!! 1356.840133667): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1
113 (!!!!! 1033.0677032471): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1
114 (771.99935913086): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
115 (221.01402282715): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
116 (!!!!! 1164.1979217529): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
117 (462.05520629883): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
118 (!!!!! 1023.0541229248): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
119 (545.02487182617): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
120 (!!!!! 2900.1235961914): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
121 (593.90068054199): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
122 (555.99212646484): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`
123 (!!!!! 53101.778030396): SELECT * FROM jos_deeppockets WHERE jos_deeppockets.cat = 10 AND jos_deeppockets.type = 'deeppockets_item' AND jos_deeppockets.published = 1 AND jos_deeppockets.created + INTERVAL 14 DAY >= NOW() ORDER BY jos_deeppockets.hits DESC LIMIT 7
124 (!!!!! 3888.1301879883): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294752350 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294752350 AND type='deeppockets_item' AND published='1' LIMIT 1
125 (353.09791564941): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3
126 (81.062316894531): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3
127 (524.04403686523): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1
128 (46.968460083008): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1
129 (!!!!! 1075.0293731689): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1
130 (59.843063354492): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1
131 (406.98051452637): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1
132 (232.93495178223): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1
133 (498.05641174316): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1
134 (747.9190826416): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1
135 (!!!!! 1077.8903961182): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1
136 (462.05520629883): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1
137 (298.02322387695): SELECT name FROM jos_deeppockets WHERE id=211
138 (231.02760314941): SELECT name FROM jos_deeppockets WHERE id=211
139 (626.0871887207): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))211((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3
140 (!!!!! 1124.8588562012): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))211((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3
141 (!!!!! 6237.9837036133): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
142 (!!!!! 3711.9388580322): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
143 (!!!!! 18178.939819336): TRUNCATE TABLE jos_trademed_module
144 (!!!!! 5596.8761444092): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294752350 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1
145 (!!!!! 1625.0610351562): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294752350 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1
146 (!!!!! 7333.0402374268): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1
147 (!!!!! 7799.8638153076): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1
148 (!!!!! 7247.9248046875): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
149 (!!!!! 3700.9716033936): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
150 (!!!!! 2189.8746490479): SELECT jos_item.* FROM jos_item INNER JOIN jos_number ON jos_item.numberID=jos_number.id WHERE 1=1 AND (jos_item.imgMini<>'') AND jos_item.type='L' AND jos_item.numberID= ( SELECT jos_number.id FROM jos_number WHERE jos_number.journalID IN (10) and jos_number.id in (select distinct jos_number.id from jos_number join jos_item on jos_item.numberid=jos_number.id where jos_item.type='P') ORDER BY (CONVERT(SUBSTRING(issue,1,2),SIGNED) + (CONVERT(SUBSTRING(issue,3,2),SIGNED)*100)) DESC LIMIT 0,1 ) ORDER BY RAND() DESC LIMIT 6
151 (!!!!! 7564.7830963135): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
152 (!!!!! 5828.857421875): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
153 (!!!!! 1503.9443969727): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294752350 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294752350 AND type='deeppockets_item' AND published='1' LIMIT 1
154 (281.81076049805): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=211 or channel_id is null)
155 (37.193298339844): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=211 or channel_id is null)
156 (144.00482177734): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1
157 (!!!!! 2193.9277648926): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
158 (97.036361694336): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294752350 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294752350 AND published='1' LIMIT 1
159 (!!!!! 3302.0973205566): select jos_twitters.link from jos_twitters where cat=10
160 (172.85346984863): select jos_facebook.link from jos_facebook where cat=10
161 (375.98609924316): select jos_google_plus.link from jos_google_plus where cat=10
162 (55.074691772461): select jos_linkedin.link from jos_linkedin where cat=10