Editing OBGYN - Gyn Cancers

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**vagina
**vagina
**trophoblastic
**trophoblastic
-
 
-
 
-
{|border=1
 
-
!Cancer
 
-
!Incidence
 
-
!Kills (Rank)
 
-
!Lifetime Risk
 
-
!Risk Factors
 
-
|-
 
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!Cervical
 
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|12.2k / year (#3)
 
-
|'''#3 (#1 worldwide'''; 4.2k / year)
 
-
|1/135
 
-
|High Grade Dysplasia, smoking, a lifestyle cancer (early parity, early coitus, multiple partners)
 
-
|-
 
-
!Endometrial (Uterine)
 
-
|'''41k / year (#1)'''
 
-
|#2 (7.1k / year)
 
-
|'''1/38'''
 
-
|Obesity, HTN, Diabetes, Atypical Hyperplasia
 
-
|-
 
-
!Ovarian
 
-
|23k / year (#2 at 23% of gyn ca)
 
-
|'''#1''' (47% of gyn ca)
 
-
|~1/70
 
-
|BRCA1, BRCA2, HNPCC, (not smoking)
 
-
|}
 
==Epidemiology==
==Epidemiology==
-
*Who gets it and how many?
 
-
 
-
==Presentation - Differential Dx==
 
-
*Common presentations of gyn cancers include:
 
-
**Adnexal Mass
 
-
**Abnormal Pap
 
-
**Post Menopausal Bleeding
 
-
 
-
==Prevention==
 
-
*Prevention
 
-
**Screening: BRCA
 
-
**Vaccines
 
-
**Role of HRT
 
-
 
-
==Detection / Diagnosis==
 
-
*Pathology
 
-
*Staging
 
-
*(Treatment)
 
==Adnexal mass and ovarian cancer==
==Adnexal mass and ovarian cancer==
Line 65: Line 20:
*23% of gyn cancers are ovarian.
*23% of gyn cancers are ovarian.
*47% of deaths are caused by ovarian
*47% of deaths are caused by ovarian
-
*1 / 70 lifetime risk in US
 
===Embryology / Oncology===
===Embryology / Oncology===
-
*Epithelial adenocarcinoma:
+
*Gi-> ovary is a krukenburg
-
**originate from the peritoneal mesothelium
+
-
**make up 65% of Ovarian cancers
+
-
*Germ Cell:
+
-
**originiate from the yolk sac (dysgerminoma, teratoma)
+
-
**make up 25% of ovarian cancers
+
-
*Stromal:
+
-
**Originate from the gonadal ridge –mesenchyme near protonephros (granulosa and theca cells)
+
-
**Make up 8% of ovarian cancers
+
-
*Metastatic:
+
-
**Make up only 2% of ovarian cancers
+
-
**Called Krukenburg tumors
+
-
 
+
-
===Epithelial Ovarian Cancer: Histologic Types===
+
-
*Histology (and the structure it recapitulates)
+
-
**Serous (Tube)
+
-
**Endometrioid (Endometrium)
+
-
**Mucinous (Cervix)
+
-
**Clear cell (Kidney)
+
-
**'''Brenner (Transitional)'''
+
-
 
+
-
===Ovarian Cancer: Pt History===
+
-
*Epidemiology - Clinical
+
-
*'''History: there is NO classic profile''':
+
-
**Age / Parity
+
-
**Menstrual history
+
-
**Surgical Hx: hysterectomy or BTL
+
-
**BCP / hormonal therapy history
+
-
**Personal and family cancer history
+
-
**Ethnicity
+
-
 
+
-
===Ovarian Cancer: Risk Factors===
+
-
 
+
-
====Factors that Decrease Risk====
+
-
*Factor: Relative Risk
+
-
*Nulliparous: 1.0
+
-
*1 Full term pregnancy: 0.6
+
-
*> 5 Full term pregnancies: 0.29
+
-
*Use of Oral Contraceptions:
+
-
**Never: 1.0
+
-
**Ever 0.75
+
-
**3 mo - 4 yrs: 0.6-0.7
+
-
**> 10 years: 0.2
+
-
*Bilateral Tubal Ligation: 0.5
+
-
*Hysterectomy: 0.5
+
-
*Breast feeding (linear with duration): 0.7
+
 +
===EOC===
 +
*Brenner is transitional
 +
===Decreased Risk===
*Tying the tubes decreases one's risk, probably because there is decreased environmental exposure.
*Tying the tubes decreases one's risk, probably because there is decreased environmental exposure.
*Anything that makes the ovary quiescent will decrease the risk of ovarian cancer.
*Anything that makes the ovary quiescent will decrease the risk of ovarian cancer.
-
====Factors that Increase Risk====
+
===Increased Risk===
-
*Factor: Relative Risk
+
-
*Hx of Breast Cancer:
+
-
**None: 1.0
+
-
**1st Degree Relative: 2.1
+
-
**Personal History: 10
+
-
*Hx of Ovarian Cancer:
+
-
**None: 1.0
+
-
**One 1st Degree Relative: 3.1
+
-
**>2 1st Degree Relatives: 4-15
+
-
**Hereditary Cancer Syndrome: 12-30
+
-
*Saturated Fat Diet: ?
+
-
 
+
-
 
+
*Family history of breast cancer increases the risk for ovarian cancer by 2 fold.
*Family history of breast cancer increases the risk for ovarian cancer by 2 fold.
**A personal history makes the risk 10 fold higher!
**A personal history makes the risk 10 fold higher!
Line 138: Line 37:
===Adnexal Mass Ddx===
===Adnexal Mass Ddx===
-
*The differential diagnosis for an adnexal mass should include all of the following:
+
*PID can form a pretty big, complex mass on the ovary with fallopian tube involvement.
-
**Physiologic
+
*How do we tell between good and bad?
-
**Gestational
+
-
**Inflammatory
+
-
***PID can form a pretty big, complex mass on the ovary with fallopian tube involvement.
+
-
**Congenital
+
-
**Traumatic
+
-
**Neoplastic
+
-
*How do we tell between good and bad?
+
*Good:
-
*Good indicators:
+
**fluid filled (not solid)
-
**Asymptomatic
+
**usually younger
-
**Cystic
+
**asymptomatic
-
***fluid filled (not solid)
+
-
**Age between 15 and 45
+
-
**Resolves
+
-
*Bad indicators:
+
-
**Pain or other vague symptoms
+
-
**Symptomatic: Ascites
+
-
**Complex, Solid: Omental cake
+
-
**Persists: Adenopathy
+
-
===Detective work: Diagnosis===
 
-
*ROS:
 
-
**'''65% of ovarian cancer patients DO have sypmtoms; often vague and non-gynecologic'''
 
-
***Not really the ''"silent killer"''
 
-
**Pain, GI symptoms, Fatigue, Weight change
 
 +
*Bad:
 +
**pain or other vague symptoms
 +
**ascites
 +
**complex, solid
 +
**omental cake
 +
**adenopathy.
-
*Physical Exam:
+
===Evaluate the pt===
-
**Lungs: dullness (Pleural effusion), ronchi, or wheezes?
+
*ROS:
-
**Abdomen-mass or fluid wave?
+
**65% of ovarian pts do have sympstoms but often vague
 +
**Pin, GI symptoms, fatigue, weight change
 +
*PE:
 +
**Pleural effusion is frequent, ronchi, wheezes
 +
**abdominal mass or fluid wave
**Rectovaginal exam; mass, nodularity
**Rectovaginal exam; mass, nodularity
-
**General appearance
 
 +
===Adnexal mass ddx===
 +
*Pelvic exam
 +
*US > CT
-
*Pelvic Exam
+
===FIGO Staging===
-
*Labs
+
*Ovarian often goes to the lung.
-
*Imaging
+
*Surface of the liver is stage 3 but parenchymal liver mets is stage 4.
-
**Ultrasound
+
-
**CT Scan
+
-
**U/S > CT
+
-
 
+
===Survival===
-
*Operation
+
*down
-
 
+
-
===Surgical: FIGO Staging===
+
-
*I = Limited to ovary (ies)
+
-
*II = Extension to uterus, tubes, other pelvic tissues
+
-
*III = Peritoneal surface implants, nodes
+
-
**Surface of the liver is stage 3 but parenchymal liver mets is stage 4.
+
-
*IV = Distant metastasis
+
-
**Ovarian often goes to the lung.
+
-
 
+
-
===Ovarian Cancer: Outcomes===
+
-
*5 year survival:
+
-
**Stage I: 75%
+
-
**Stage II: 60%
+
-
**Stage III: 30%
+
-
**Stage IV: 15%
+
===Ovarianc cancer===
===Ovarianc cancer===
*usually requires histology to know it is cancer.
*usually requires histology to know it is cancer.
-
===Ovarian Cancer: Treatment===
+
===Ovarian cancer treatment===
-
*Goals of Operation:
+
-
**Is this cancer?
+
-
**Is this ovarian cancer?
+
-
**What stage?
+
-
*If apparently confined to ovary, do a “staging” operation.
+
-
*If bulky disease, do a “debulking” operation
+
-
 
+
-
 
+
-
*Operation
+
-
**USO / BSO
+
-
**Omentectomy
+
-
**Lymphadenectomy
+
-
**Peritoneal biopsies
+
-
**Hysterectomy
+
-
 
+
-
 
+
-
*Young patients, early stage: possibility of fertility-sparing surgery
+
-
 
+
-
====Epithelial Cancers: Treatment====
+
-
*Recall that epithelial is one origin of ovarian cancer.
+
-
*Epitheilal ovarian cancer treatment is specifically treated with chemotherapy.
+
-
*Platinum and taxane-based combination chemotherapy
+
-
**Platinum: Cisplatin, carboplatin
+
-
**Taxane: Paclitaxel, docetaxel
+
-
 
+
-
===Ovarian Cancer: Familial Inheritance===
+
-
*Ovarian Cancer Inheritance risks:
+
-
**Lifetime risk in U.S.: 1.4%
+
-
**One 1st-degree relative: 5%
+
-
**> two 1st-degree relatives: 7%
+
-
**HBOC: 6-50%
+
-
*'''OF THESE, 3% WILL HAVE A HEREDITARY CANCER SYNDROME'''
+
-
 
+
-
 
+
-
*Hereditary cancer syndromes are characterized by:
+
-
**1/800 US BRCA and 1/600 HNPCC
+
-
**Autosomal dominant inheritance
+
-
**Early age of onset
+
-
**Younger affected members in subsequent generations
+
-
**Multiple cancers in individuals
+
-
**Bilaterality of certain cancers
+
-
**Male breast cancer (BRCA 2)
+
-
===Cancer: Family History===
 
-
*Obtaining a Family History of Cancer
 
-
*3 + generation family history.
 
-
*Update regularly
 
-
*Maternal and paternal data
 
-
*Race, ethnic background, all cancers, current age, age at diagnosis, age at death
 
-
*Medical records review
 
-
*Genetic counseling BEFORE TESTING!
 
===Familial Ovarian cancer===
===Familial Ovarian cancer===
Line 262: Line 86:
*Male breast cancer is so rare that if seen, suspect brca(2) mutation.
*Male breast cancer is so rare that if seen, suspect brca(2) mutation.
-
===Clinical Use of Serum CA 125===
+
===CA125 Serum Testing===
-
*CA 125 can be used to '''following response to chemotherapy'''
+
*CA 125 does not detect ovarian cancer at an earlier stage.
-
*CA 125 can be used for '''surveillance for patients with known genetic mutation or strong family history''' indicative of a hereditary inheritance pattern
+
-
**+ rectovaginal exam, +/- transvaginal pelvic ultrasound
+
-
 
+
===Triage===
-
*'''CA 125 does not detect ovarian cancer at an earlier stage.'''
+
-
 
+
-
 
+
-
*When NOT to Obtain a Serum CA 125 Level:
+
-
**When a low-risk patient asks you for it!
+
-
***Requires extensive counseling
+
-
***Poor sensitivity and specificity
+
-
*When operation is already indicated
+
-
 
+
-
 
+
-
*Non-malignant conditions that may elevate the CA 125:
+
-
**PID
+
-
**Adenomyosis
+
-
**Benign neoplasm
+
-
**Endometriosis
+
-
**Functional cyst
+
-
**Menstruation
+
-
**Infertility
+
-
**Leiomyomata
+
-
**Hepatitis
+
-
**Pancreatitis
+
-
**Cirrhosis
+
-
**Colitis
+
-
**CHF
+
-
**Diverticulitis
+
-
**Postoperative period
+
-
**Renal disease
+
-
**SLE
+
-
**Pneumonia
+
-
**Diabetes
+
-
 
+
-
===Chemoprevention with Oral Contraceptives===
+
-
*OC use for > 5 years reduces risk of ovarian cancer by 60% in the general population
+
-
*Protective effect increases with increasing duration of use
+
-
*Protection continues for 10 years following discontinuation
+
===Prophylactic Surgery===
===Prophylactic Surgery===
-
*Oophorectomy:
+
*These prophylactic surgeries (breast and ovary) are not completely protective because we just can't find every cell.
-
**Reduced ovarian cancer risk by 95-100%
+
*After prophy, a 5% risk over 20 years for developing cancer (as a brca pt).
-
**Reduced breast cancer risk by 53-68%
+
-
**Reduced risk of fallopian tube cancer and primary peritoneal cancer
+
-
**Evidence suggests that many BRCA-related ovarian cancers are actually fallopian tube primaries
+
-
 
+
-
 
+
-
*Bilateral Mastectomy:
+
-
**BRCA patients ~ 85-100% reduction in risk for breast cancer
+
-
 
+
-
 
+
-
*'''These prophylactic surgeries (breast and ovary) are not completely protective because we just can't find every cell.'''
+
-
*'''After prophy, a 5% risk over 20 years for developing cancer (as a brca pt).'''
+
**But that's much better.
**But that's much better.
==Abnormal Pap Smear and Cervical Cancer==
==Abnormal Pap Smear and Cervical Cancer==
 +
*
-
===Cervical Cancer Epidemiology===
+
===Cervical Cancer screening===
-
*12,200 new cases in the US per year
+
*Moved up to 21 b/c we were over treating.
-
*4,210 deaths in the US per year
+
*Coposcopy is magnifying the cervix to identify early microscopic changes.
-
*180 new cases in Indiana
+
-
*< 100 deaths in Indiana
+
-
*Life time risk 1 / 135
+
-
*2nd to breast cancer for cancer death in women ages 20-39
+
-
*500,000 women die each year world wide
+
-
*'''Number one cancer killer of women worldwide'''
+
-
 
+
-
 
+
-
*In the US 60% are Stage I at diagnosis
+
-
*More common in minorities, disadvantaged
+
-
*Early coitus, early parity, multiple partners
+
-
*Associated with / caused by HPV 16,18,31,33
+
-
*Not all infected patients develop cancer
+
-
*Smoking increases risk
+
-
 
+
-
===Cervical Cancer: Prevention===
+
-
*Randomized Double-Blind Clinical Trial:
+
-
**2392 Young women vaccinated with 3 doses of placebo or HPV-16 virus-like particle vaccine
+
-
**At a median of 17.4 months, 3.8 / 100 women of the placebo women and 0 / 100 of the treated women had persistent HPV infection
+
-
*Nine CIN events were all the placebo group
+
-
 
+
-
===Cervical Cancer: Screening===
+
-
*Begin screening at age 21 regardless of age of onset of sexual intercourse
+
-
**'''Moved up to 21 b/c we were over treating.'''
+
-
*Repeat every 2 years if normal and lowrisk from age 21-29
+
-
*After age 30, and 3 consecutive negatives, and low-risk, screen every 3 years
+
-
*May stop after age 70
+
-
*No need for Pap after total hysterectomy
+
-
 
+
-
 
+
-
*Low risk: No history of high grade dysplasia, HIV, or other immunosuppression
+
-
*Remember the pap is a screening test
+
-
**If abnormal, or if the cervix appears or feels abnormal, proceed with diagnostic test
+
-
*Colposcopy
+
-
*Directed Biopsy
+
-
 
+
-
 
+
*ASCUS = atypica squamous cells of undetermined significance
*ASCUS = atypica squamous cells of undetermined significance
 +
*AGUS = atypical ?
-
====Interpreting Results====
+
===Colposcopy===
-
*The Bethesda system:
+
*Use acetic acid to highlight abnormal spots; biopsy them.
-
**LGSIL
+
*Must do a cone biopsy if you have an inadequate simple (cervical) biopsy.
-
**HGSIL
+
-
**AGUS/ASCUS
+
 +
===Pyramid===
 +
*Treat red and yellow, wait on blue and green.
-
*Histologic diagnoses:
+
===Cervical Cancer Staging===
-
**CIN 1
+
-
**CIN 2
+
-
**CIN 3/CIS
+
-
**Invasive cancer
+
-
 
+
-
====Classification Terminology for Cervical Cytology====
+
-
*The 2001 Bethesda System
+
-
 
+
-
 
+
-
*Two types of atypical squamous cells (ASC)
+
-
**'''Atypical squamous cells of undetermined significance (ASCUS)'''
+
-
**'''Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesions (ASC-H)'''
+
-
 
+
-
 
+
-
*Squamous intraepithelial lesions (SIL)
+
-
**'''Low-grade SIL (LSIL)''': Mild dysplasia, cervical intraepithelial neoplasia 1 (CIN 1)
+
-
**'''High-grade SIL (HSIL)''': Moderate and severe dysplasia, CIN 2/3, carcinoma in situ (CIS)
+
-
 
+
-
 
+
-
*Cervical intraepithelial neoplasia (CIN)
+
-
**'''CIN 1''': Mild dysplasia; includes condyloma (anogenital warts)
+
-
**CIN 2: Moderate dysplasia
+
-
**CIN 3: Severe dysplasia; includes CIS
+
-
*'''CIN caused by HPV can clear without treatment.'''
+
-
 
+
-
===Cervical Cancer: Diagnosis===
+
-
*Inadequate Colposcopy:
+
-
**T-Zone not fully visualized
+
-
**Can’t see the entire lesion
+
-
**Lesion extends into canal
+
-
**Discordance
+
-
**Positive endocervical curettage (ECC)
+
-
**Suspect invasion
+
-
 
+
-
====What is a colposcopy?====
+
-
*Use of a magnifying instrument
+
-
*Application of a vinegar-like solution onto the cervix
+
-
**Use acetic acid to highlight abnormal spots; biopsy them.
+
-
*See abnormalities that can’t be seen with the naked eye
+
-
*Feels like getting a Pap test, but lasts longer
+
-
*'''Must do a cone biopsy if you have an inadequate simple (cervical) biopsy.'''
+
-
 
+
-
====Cervical Biopsy====
+
-
*Removal of a small piece of tissue from the cervix
+
-
*Endocervical curettage is often performed to evaluate lesions within the cervical canal
+
-
 
+
-
====Biopsy Results and Management====
+
-
*CIN I
+
-
**Observation
+
-
*CIN II and III
+
-
**Laser
+
-
**Cryotherapy
+
-
**Cone Biopsy: LEEP, laser cone, or cold-knife cone
+
-
**Hysterectomy may be recommended
+
-
 
+
-
 
+
-
*Cancer: Gynecologic Oncology Consultation
+
-
 
+
-
 
+
-
*If the colposcopy is inadequate, or invasion is suspected, proceed with definitive diagnostic test:
+
-
**LEEP Excision
+
-
**Cold Knife Cone
+
-
 
+
-
 
+
-
*If lesion is visible, biopsy can be diagnostic without cone
+
-
 
+
-
====What is a cervical conization?====
+
-
*Removes a coneshaped piece of tissue
+
-
*Often allows for diagnosis and treatment
+
-
*Performed with local anesthesia in the office or under general anesthesia in the operating room
+
-
 
+
-
===Abnormal Pap: Epidemiology===
+
-
*12,210 cancers
+
-
**Treat
+
-
*300,000 HSIL
+
-
**Treat
+
-
*1.25 million LSIL
+
-
**Wait and see
+
-
*2-3 million ASC
+
-
**Wait and see
+
-
*50-60 million women screened
+
-
 
+
-
===Clinical Staging of Cervical Cancer===
+
-
*Stage I: Disease confined to the cervix
+
-
*Stage II: Vagina or parametrial extension
+
-
*Stage III: Distal vagina, lateral pelvic wall, or hydronephrosis
+
-
*Stage IV: Mucosa of bowel / bladder, or distant disease
+
-
 
+
-
 
+
-
*Estimates of 5 year survival:
+
-
**Stage I: 82-85%
+
-
**Stage II: 61-66%
+
-
**Stage III: 37-39%
+
-
**Stage IV: 11-12%
+
-
 
+
-
===Cervix Cancer: Treatment===
+
*Goal is to get a negative margin.
*Goal is to get a negative margin.
*Will irradiate the entire tumor.
*Will irradiate the entire tumor.
Line 473: Line 118:
*Even radical hysterectomy leaves the ovaries.
*Even radical hysterectomy leaves the ovaries.
**Cervical cancer very rarely involves the ovaries.
**Cervical cancer very rarely involves the ovaries.
-
 
-
====Chemotherapy====
 
-
*Stage IA1 (microinvasive): Cone vs. Simple Hysterectomy
 
-
*Stage IA2-IB1: Radical Hysterectomy vs. Radiation
 
-
*>Stage IB2: Concurrent platinum-based chemotherapy and radiation
 
-
 
-
====Surgical Treatment====
 
-
*'''Only indicated if “negative margin” can be achieved'''
 
-
*Advantages:
 
-
**Permits More Accurate Assessment
 
-
**Preserves Ovarian Function
 
-
**Preserves Vaginal Function
 
-
**Less Long-Term Morbidity
 
-
 
-
====Radiation Therapy====
 
-
*'''Appropriate for all stages and patients with high surgical risk'''
 
-
*Indicated when negative surgical margin cannot be achieved
 
-
**Advanced disease >IB2
 
-
**Obesity (BMI>30)
 
==Post-Menopausal Bleeding and Endometrial Carcinoma==
==Post-Menopausal Bleeding and Endometrial Carcinoma==
-
*Incidence in US women:
 
-
**41,000 cases / year
 
-
*'''Most common gynecologic cancer'''
 
-
*1 / 38 lifetime risk
 
-
*7,100 deaths / year
 
-
*'''2nd most common cause of death due to gynecologic cancer'''
 
-
 
-
===Endometrial Pt Profile===
 
-
*Age: 75% post-menopausal
 
-
*Etiology: Prolonged unopposed estrogen stimulation
 
-
*Clinical Presentation:
 
-
**Abnormal bleeding, post-menopausal
 
-
**Associated factors: obesity, hypertension, diabetes
 
-
*HNPCC (Lynch)
 
-
 
-
===Endometrial Cancer: Risk Factors===
 
-
 
-
===Endometrial Cancer: Two Types===
 
-
*Type I
 
-
**Estrogen Related
 
-
**'''Younger and heavier patients'''
 
-
**Low grade
 
-
**Perimenopausal
 
-
**Exogenous estrogen
 
-
**Insulin resistance
 
-
 
-
*Type II
 
-
**Aggressive
 
-
**Unrelated to estrogen stimulation
 
-
**'''Occurs in older & thinner women'''
 
-
**'''Potential genetic basis'''
 
-
***Lynch syndrome
 
-
***Familial trend
 
-
 
-
 
-
===Endometrial Carcinoma===
 
-
*Pathology
 
-
**> '''70% adenocarcinomas'''
 
-
**Histologic ''grade important''
 
-
**Poor prognosis cell types: papillary serous and clear cell carcinomas, mixed tumors
 
-
 
-
 
-
*FIGO Stage - Surgical Findings:
 
-
**Stage 1: Confined to uterus
 
-
**Stage 2: Extension to cervix
 
-
**Stage 3: Regional spread (serosa, adnexa, vagina, parametria, pelvic / aortic nodes)
 
-
**Stage 4: Metastases (Bladder / rectum, inguinal nodes, distant metastases)
 
-
 
-
 
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*Stage: Frequency; Survival
 
-
**Stage 1: 75%; 90%
 
-
**Stage 2: 13%; 60%
 
-
**Stage 3: 9%; 40%
 
-
**Stage 4: 3%; <10%
 
-
 
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===Endometrial (uterine) Cancer: Diagnosis===
 
-
*Pts with uterine cancer often present with AUB / PMB:
 
-
**Abnormal Uterine Bleeding
 
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**Postmenopausal bleeding
 
-
 
-
 
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*Office biopsy (Pipelle)
 
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*Dilation and curettage (D&C)
 
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*Hysteroscopy
 
-
 
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===Endometrial (uterine) Cancer: Treatment===
 
-
*Mainstay is surgical
 
-
**Total hysterectomy
 
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**BSO
 
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**Pelvic & PA Nodes
 
-
 
-
===Endometrial (uterine) Cancer: Surgical Staging===
 
-
*Conceptual rationale:
 
-
**Defines extent of disease
 
-
**Minimizes over / under treatment
 
-
**Minimally increases perioperative morbidity / mortality
 
-
**Decreases overall Rx risks and costs
 
-
**Allows comparison of therapeutic results
 
-
 
-
===Endometrial (uterine) Cancer: Adjuvant Therapy===
 
-
*Options:
 
-
**Brachytherapy
 
-
**External beam radiotherapy
 
-
**Hormonal therapy
 
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**Cytotoxic chemotherapy
 
-
**Combination therapy
 
-
 
-
*Determining Factors:
+
Did not cover all topics.
-
**Stage
+
-
**Histologic subtype
+
-
**Staging completeness
+
-
**Tumor biology
+
-
**Medical conditions
+

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