Questions & Discussions: (with potential answers)
(Please answer the following questions commented from your RT attending physician.)
A1:
As described in the last attached page.
(After your RT attending physician discussed with the radiologist by telephone, the radiologist confirmed preliminarily that no distant metastases were found based on the ABD plus Pelvis CT films, including visible lung, liver, visible ribs & spine, omentum, and adrenal glands, and he said that some clinically significant lymph nodes over the para-aortic region, at L4-5 level, were found. Please further answer the following questions.)
A2:
No pre-op clinical stage can be prospectively defined, because this case is an inadvertent surgical case. (Pre-op diagnosis of benign uterine myoma, post inadvertent LAVH, then post salvage radical surgery and LN dissection.)
A3:
pT1c (due to more than 50% depth invasion) pN1 (due to right pelvic LNs, 4/8; and, para-aortic LNs, non-resected) M0, stage IIIC (FIGO and AJCC 2006)
A4:
Endometrioid endometrial adenocarcinoma, moderately differentiated (G2), of the uterine, post inadvertent surgery of LAVH (2007/08/03), post salvage surgery of BSO + Omentectomy + BPLND (2007/8/9), pT1c pN1 M0, FIGO/AJCC-2006 stage IIIC, with LVSI, with right pelvic LNs involvement (right obturator to right common iliac, 4/8; left pelvis: 0/6), with multiple residual para-aortic LNs (max 1.7 cm)
A5:
Suggest post-op RT and chemotherapy (according to the recommendation of NCCN treatment guideline 2007 V1, accessed on 2007/8/10). ????
A6:
RT Plan may be designed as the following one:
(1). Indication: post-op pT1c pN1 with residual para-aortic LNs; LVSI (+)
(2). Goal: potentially curative
(3). Target & Volume: Whole-pelvis with or without extended to para-aortic LN region (owing to cN1 with positive para-aortic LN) plus vaginal-cuff boost
(4). Technique: EBRT (simplified 3-D CRT) to pelvic irradiation plus brachytherapy to the vaginal cuff
(5). Dose & Fractionation: Pelvic RT (EBRT): 4500 cGy in 25 fractions then gross nodal disease boost with limited margin to 5040 cGy in 28 fractions; Vaginal cuff (brachytherapy, owing to pT1c): 2500 cGy (delivered on vaginal mucosal surface) in 10 fractions.
A7:
First, if patients¡¦ condition suitable, IV-contrast enhanced CT or MRI should be suggested for every oncology patients. Second, we need to well know the general locations of vessels.
A8:
If this patient refused further salvage radical surgery after the initial inadvertent surgery, we should recommend the patient the alternative treatment choice of receiving salvage CCRT (the first alternative choice) or salvage RT alone (the second alternative choice).
Further Readings & References: NCCN 2008 & AJCC 2006
Radiation Oncologist
Hon-Yi Lin 2008/09/05 |
