VAGINAL CUFF REMOVAL IN

ENDOMETRIAL CARCINOMA

Dr. Hira Salman

ENDOMETRIAL CARCINOMA
It is a cancer that
arise from the
endometrium (the
lining of the uterus).
It is the result of the
abnormal growth of
cells that have the
ability to invade or
spread to other
parts of the body.

The frequency of occurrence of

endometrial cancer has been rising in
recent decades. Its incidence in western
countries is high (25 cases /100000
women) , whereas it is low in eastern
countries (2 cases /100000 women). It
has become the fourth most common
cancer in females , after beast , lung
and bowel cancer.

The majority of these cancers (75%) are

seen in menopausal women , with a
median age of 60 yrs. Only 25% occur in
premenopausal women.

RISK FACTORS
OLD AUNT

Obesity
Late menopause
Diabetes mellitus
CAncer: ovarian , breast , colon
Un opposed estrogen : PCOS,
anovulation, HRT
Nulliparity
Tamoxifen , chronic use

PROTECTIVE FACTORS
Smoking ( provides protection by altering
the metabolism of of estrogen and
promoting weight loss )
Use of progestin (it is present in COC
pills & IUCD)

SIGNS AND SYMPTOMS

Postmenopausal bleeding
Premenopausal ( abnormal uterine
bleeding)
Abnormal vaginal discharge
Pain in the pelvic region
Enlarged uterus
Ascites , adenexal mass, cul-de-sac
nodularity

DIAGNOSIS
Pipelle endometrial biopsy is a cost effective and
safe procedure that is well tolerated by patients
and easy procedure that is done in opd.
Endometrial sampling , gold standard is
hysteroscopy.
Dilatation and curettage
If cancer found then medical imaging to be done
for spread ( MRI is reliable in identifying
myometrial and cervical invasion and exta
uterine disease)

TYPES OF ENDOMETRIAL CARCINOMA

characteristics
age
Unopposed
estrogen

Type I
50s 60s
present

Type II
70s
absent

growth
grade
genetics
metastasis

Slow growing
low
PTEN mutation
Lymph nodes &
ovaries

Rapid
high
P53 mutation
peritoneum

prognosis
5 yr survival

favourable
85%

poor
43%

SUB TYPES OF ENDOMETRIAL

CANCER
ON HISTOLOGY BASIS

Endometroid adenocarcinoma (75%-85%)

Serous carcinoma (<10%)
Clear cell carcinoma (4%)
Mucinous carcinoma (1%)
Mixed and undifferentiated carcinoma (10%)
Squamous cell carcinoma (<1%)
national cancer institue gu
ide line 2015

GRADES OF ENDOMETRIAL
CANCER
Differentiated or a low grade tumor
Poorly differentiated or a high grade tumor
Sub divided into:
GX : the grade can not be evaluated
G1: the cells are well differentiated
G2: the cells are moderately differentiated
G3: the cells are poorly differentiated
G4: the cells are undifferentiated
In general , the lower the tumors grade , the better
the prognosis
AJCC CANCER STAGE MANUAL
, 7 TH EDITION 2010

TNM AND FIGO SURGICAL STAGING SYSTEM FOR

ENDOMETRIAL CARCINOMA(2010)

TX

Primary tumor can not be assessed

T0

No evidence of primary tumor

Tis

Carcinoma in situ

T1

Tumor confined to the corpus uteri

T1a IA

Tumor limited to endometrium or invades less than one half

of the myometrium

T1b IB

Tumor invades one half or more of the myometrium

T2

Tumor invades stromal connective tissue of the cervix but

does not extend beyond uterus

II

T3a IIIA

Tumor involves serosa and/or adenexa (direct extension or

metastasis)

T3b IIIB

Vaginal involvement or parametrial involvement

IIIC
IV

Metastasis to pelvic and/or para-aortic lymphnodes

T4
NX
N0
N1

IVA

Tumor invades bladder mucosa and/or bowel

IIIC1

Regional lymph nodes metastases to pelvic lymph

nodes

N2

IIIC2

Regional lymph nodes metastasis to para-aortic lymph

nodes with or without pelvic nodes

MO
M1

Tumor invades bladder and/or bowel mucosa

And/or distant metastases

Regional lymph nodes can not be assessed

No regional lymph node metastases

No distant metastases

IVB

Distant metastases to inguinal lymph nodes intra

peritoneal disease , or lung , liver or bone

FIGO STAGING OF ENDOMETRIAL CARCINOMA AND

CORRESPONDING MRI FINDINGS ( revised 2009)

Stage IA on MRI presents with signal intensity of tumor extends into

<50% of myometrium . Partial or full disruption of the junctional zone
Stage IB presents with signal intensity of tumor extends in to >50%
of myometrium. Full thickness disruption of the junctional zone
Stage II on MRI showed internal os and endocervical canal are
widened. Disruption of low signal stroma
Stage IIIA showed disruption of continuity of outer myometrium.
Irregular uterine configuration
Stage IIIB showed segmental loss of hypointense vaginal wall
Stage III C on MRI showed regional or paraaortic nodes >1cm in
short axis diameter
Stage IVA showed tumour nodules protuding in the bladder / rectal
lumen
Stage IVB showed tumor in distant sites or organs

5 YRS RELATIVE SURVIVAL RATES IN THE US BY FIGO

STAGE

I-A
I-B
II
III-A
III-B
III-C
IV-A
IV-B

88%
75%
69%
58%
50%
47%
17%
15%

ENDOMETRIAL CANCER
TREATMENT
Treatment of endometrial cancer is on one
level very straight forward and yet on another
level evolving and fraught with controversies.
The mainstay of treatment for endometrial
cancer is surgery including peritoneal
cytology, total hysterectomy and bilateral
salpingo-ophorectomy followed by intra
operative staging as indicated. Adjuvant
therapy is based upon final stage and
grading , patient characteristics and
peritoneal cytology status.
article ID 583891 , obstetrics and
gynaecology international volume

VAGINAL CUFF
The portion of the vaginal vault remaining
open to the peritoneum following
hysterectomy
OR
The part of the vagina remaining after
hysterectomy and cervicectomy.

The vaginal cuff is created by the surgeon

at the top of the vagina where the cervix
used to be , kind of like the end of a sock
which sewn together during surgery.

VAGINAL BRACHYTHERAPY
The vast majority of vaginal recurrences (90%)
occur at or around the vaginal cuff.
Vaginal brachytherapy is the type of radiation
therapy given at the vaginal cuff by a radioactive
source temporarily placed inside the body in or near
a tumor.

TRADITIONAL APPROACH FOR TREATMENT OF

ENDOMETRIAL CANCER

Surgery has traditionally been combined with

radiotherapy to prevent vaginal and pelvic lymph
node recurrence. In the past this has often been
preoperative radiotherapy , mainly as
uterovaginal or vaginal bracytherapy.
BUT
Increasingly surgery is performed first and the
treatment strategy is based on pathohistological
findings.

AMERICAN BRACHYTHERAPY SOCIETY CONSENCUS

GUIDELINES FOR ADJUVANT VAGINAL CUFF BRACHYTHERAPY
AFTER HYSTERECTOMY(2012)

the standard treatment for endometrial cancer is

a total abdominal hysterectomy with bilateral
salpingo-ophorectomy with or without lymph
node dissection
External beam radiation therapy (EBRT) and/or
brachytherapy (typically post operative) are
integral components in the adjuvant therapy of
select patients
Radiation is a major component in the
management of inoperable or recurrent
endometrial cancers.

CONCLUSION
The use of post operative vaginal
brachytherapy alone , without EBRT, for
endometrial cancer has significantly
increased in recent years.

ASTRO ISSUES GUIDE LINE ON THE ROLE OF POST

OPERATIVE RADIATION THERAPY FOR
ENDOMETRIAL CANCER(23 APRIL 2014)
FIRST KEY QUESTION:
Q: Which patients with the endometroid endometrial cancer
require no additional therapy after hysterectomy?
A: for patients with no residual disease in the hysterectomy
specimen despite positive biopsy or grade 1 or 2 cancers
with either no invasion or 50% myometrial invasion.
BUT
Patients with grade 3 cancers without myometrial invasion or
grade 1 or 2 cancers with 50% myometrial invasion and
high risk factors such as age >60 and/or lymphovascular
space invasion could reasonably be treated with vaginal
cuff brachytherapy.

KEY QUESTION: 2
Q: which patients with endometrial cancer should
receive vaginal cuff radiation ?
A: Evidence demonstrates that cuff brachytherapy
is as effective as pelvic radiation therapy as
preventing vaginal recurrence for pts with
Grade 1 or 2 cancers with >=50 % myometrial
invasion
Grade 3 tumors e <50% myometrial invasion

KEY QUESTION : 3
Q: which women should receive post operative external beam radiation
?
A:
Pts 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.
Pts with grade 1 or 2 tumors with >=50 % myometrial invasion may
also benefit from pelvic radiation to reduce pelvic recurrence rates if
other risk factors are present such as age >60 yrs / lympho vascular
space invasion
For pts with positive nodes or involved uterine serosa , ovaries,
fallopian tubes, vagina , bladder or rectum. The best available
evidence suggest that treatment should include external beam
radiation therapy as well as adjuvant chemotherapy

KEY QUESTION :4
Q: When brachytherapy should be used in
addition to external beam radiation?
A: use of vaginal brachytherapy in patients
also undergoing pelvic external beam
radiation may not generally be warranted ,
unless risk factors for vaginal recurrence
are present.sss

NCCN GUIDELINES VERSION 1.2016

ENDOMETRIAL CARCINOMA

PRIMARY TREATMENT
If disease limited to the uterus and
medically operable then :
Total hysterectomy and bilateral
hysterectomy and surgical staging

In stage1A
Observe (G1)

Vaginal brachytherapy (G2 & G3)

STAGE 1B
Observe or vaginal brachytherapy (G1)
Observe or vaginal brachytherapy and
EBRT (in G2)
EBRT and vaginal brachytherapy+
chemotherapy (G3)

STAGE II
Vaginal brachytherapy and EBRT (IN G1 &
G2)

EBRT+ vaginal
brachytherapy+chemotherapy( G3)

STAGE III & IV

Chemotherapy+ RT( In all G1, G2 & G3)

MAYO CRITERIA FOR OMISSION OF

LYMPHADENECTOMY IN SURGICAL MANAGEMENT
OF ENDOMETRIAL CANCER

Omit lymphadenectomy if no disease

beyond the uterine corpus and
Endometrial grade 1 or 2 , myometrial
invasion <=50% and tumor diameter
<=2cm or
Endometrial and no myometrial invasion
independent of grade and tumor diameter

VAGINAL CUFF REMOVAL IS A PART OF

RADICAL HYSTERECTOMY

Radical hysterectomy refers to the

excision of the uterus en bloc with the
parametrium (i.e , round , broad, cardinal
and uterosacral ligament) and removal of
vaginal cuff .
Radical hysterectomy is performed as a
primary therapy for
Stage IB or IIA cancer of the cervix

 Clark performed the first radical

hysterectomy for cervical cancer at johns
hopkins hospital in 1895
Wetheim , a viennese physician ,
developed the radical total hysterectomy
with removal of the pelvic lymphnodes ,
the parametrium and the removal of
vaginal cuff.

Selected patients with stage II

adenocarcinoma of the endometrium in
whom radical surgery seems feasible

article published in 1967 by kelso

jw , funnel jw

CONCLUSION
In light of recent guide lines & concensus
we can conclude that for early or advance
stage disease where surgery is possible ,
vaginal cuff removal has no place.
As in advance stage disease and or early
stage disease with high grade tumor
vaginal brachytherapy will be offered for
the treatment.

Discussion