Radiation Therapy for Endometrial Cancer
Indications for adjuvant RT
- For patients with FIGO stage IA grade 1 or 2 endometrioid carcinoma without intermediate-* or high-risk factors,† adjuvant RT is not recommended.
- Strong, Moderate
- For patients without high-risk factors† and with either FIGO stage IB grade 1 or 2 endometrioid carcinoma or myoinvasive FIGO stage IA grade 3 endometrioid carcinoma, vaginal brachytherapy is recommended.
- Strong, Moderate
- For patients with high-risk factors† and who have FIGO stage IB grade 1 or 2 or myoinvasive FIGO stage IA grade 3 endometrioid carcinoma, EBRT is conditionally recommended.
- Conditional, Moderate
- For patients with FIGO stage IB grade 3 or FIGO stage II endometrioid carcinoma, EBRT is recommended.
- Strong, High
- For patients with myoinvasive FIGO stage IA high-risk histology‡ endometrial carcinoma, vaginal brachytherapy with or without chemotherapy is conditionally recommended.
- Conditional, Low
- For patients with FIGO stage IB or II high-risk histology‡ endometrial carcinoma, EBRT with chemotherapy is conditionally recommended.
- Conditional, Moderate
- For patients with FIGO stage III or IVA endometrial carcinoma of any histology, EBRT with chemotherapy is conditionally recommended to decrease locoregional recurrence.
- Conditional, Moderate
† High-risk factors include substantial LVSI, especially without surgical nodal staging.
‡ High-risk histologies include serous carcinoma, clear cell carcinoma, carcinosarcoma, mixed histology carcinoma, dedifferentiated carcinoma, or undifferentiated carcinoma.
Adjuvant RT techniques, target volumes, dose-fractionation regimens, and normal tissue constraints
- For patients with endometrial carcinoma undergoing adjuvant EBRT, IMRT is recommended to reduce acute and late toxicity.
- Strong, Moderate
- For patients with endometrial carcinoma undergoing adjuvant EBRT using IMRT, a vaginal ITV is recommended for treatment planning with daily IGRT for treatment verification.
- Strong, Moderate
- For patients with endometrial carcinoma undergoing adjuvant EBRT, a dose of 4500-5040 cGy at 180-200 cGy per fraction is recommended.
- Strong, Moderate
- For patients with endometrial carcinoma undergoing adjuvant vaginal brachytherapy alone, treating the proximal third to half of the vagina (typically 3-5 cm) is recommended.
- Strong, Moderate
- For patients with endometrial carcinoma with cervical stromal involvement and/or close or positive vaginal margins, postoperative vaginal brachytherapy as a boost after EBRT is conditionally recommended.
- Conditional, Expert opinion
Indications for systemic therapy
- For patients with FIGO stage I-II endometroid adenocarcinoma, systemic therapy is not recommended.
- Strong, High
- For patients with myoinvasive FIGO stage I-II endometrial cancer with high-risk histologies,* systemic therapy is conditionally recommended.
- Conditional, Moderate
- For patients with FIGO stage III-IVA endometrial cancer of any histology, adjuvant systemic therapy is recommended.
- Strong, High
Sequencing of systemic therapy with RT
- For patients with FIGO stage III-IVA endometrial cancer receiving RT, EBRT with concurrent chemotherapy followed by adjuvant chemotherapy is conditionally recommended.
- Conditional, Moderate
- For patients with FIGO stage III-IVA endometrial cancer receiving RT, sequential chemotherapy followed by RT is conditionally recommended.
- Conditional, Expert opinion
- For patients with FIGO stage I-II endometrial cancer with high-risk histologies* receiving EBRT and chemotherapy, either sequential or concurrent treatment is recommended.
- Strong, Moderate
- For patients with endometrial cancer receiving vaginal brachytherapy and chemotherapy, either sequential or concurrent treatment is recommended.
- Implementation remark: It is preferrable not to administer brachytherapy on the same day as chemotherapy.
- Strong, Expert opinion
- Implementation remark: It is preferrable not to administer brachytherapy on the same day as chemotherapy.
Adjuvant RT decisions based on lymph node assessment
- For patients with endometrial cancer, use of bilateral sentinel lymph node mapping is recommended over standard pelvic lymphadenectomy, to accurately detect subclinical nodal metastases, decrease morbidity, and guide selection of adjuvant therapy.
- Strong, Moderate
- For patients who have undergone hysterectomy and no pelvic nodal assessment, surgical restaging or pelvic RT is conditionally recommended for any myoinvasion with LVSI or deep myoinvasion.
- Conditional, Expert opinion
- For patients who have undergone hysterectomy and pelvic nodal assessment with isolated tumor cells present, it is conditionally recommended that uterine risk factors be used to guide adjuvant therapy.
- Conditional, Low
- For patients who have undergone hysterectomy and pelvic nodal assessment with nodal micrometastases or macrometastases (FIGO stage IIIC), adjuvant therapy is recommended.
- Strong, High
Molecular marker influence on adjuvant RT and systemic therapy decisions
- For patients with endometrial cancer considering adjuvant therapy, molecular testing is recommended.
- Implementation remarks:
- Immunohistochemistry is needed to assess for mutations in mismatch repair and TP53 genes
- POLE sequencing can be used to identify hypermutated tumors
- Strong, Moderate
- Implementation remarks:
- For patients with myoinvasive FIGO stage IA-IIIC2 TP53 mutated endometrial cancer, chemotherapy and RT are conditionally recommended.
- Conditional, Low
- For patients with FIGO stage IB-IIIC2 mismatch repair deficiency endometrial cancer, RT without chemotherapy is conditionally recommended.
- Conditional, Low
- For patients with FIGO stage IB-IIIC2 POLE mutant tumors, RT without chemotherapy is conditionally recommended.
- Conditional, Low
Recommendation Grading
Overview
Title
Radiation Therapy for Endometrial Cancer
Authoring Organization
American Society for Radiation Oncology
Publication Month/Year
October 21, 2022
Last Updated Month/Year
February 13, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Document Objectives
With the results of several recently published clinical trials, this guideline informs on the use of adjuvant radiation therapy (RT) and systemic therapy in the treatment of endometrial cancer. Updated evidence-based recommendations provide indications for adjuvant RT and the associated techniques, the utilization and sequencing of adjuvant systemic therapies, as well as the impact of surgical staging techniques and molecular tumor profiling.
Inclusion Criteria
Female, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient, Radiology services
Intended Users
Nurse, nurse practitioner, physician, physician assistant, radiology technologist
Scope
Treatment, Management
Diseases/Conditions (MeSH)
D016889 - Endometrial Neoplasms, D018269 - Carcinoma, Endometrioid
Keywords
Adjuvant Radiation Therapy, endometrial cancer
Source Citation
Harkenrider MM, Abu-Rustum N, Albuquerque K, Bradfield L, Bradley K, Dolinar E, Doll CM, Elshaikh M, Frick MA, Gehrig PA, Han K, Hathout L, Jones E, Klopp A, Mourtada F, Suneja G, Wright AA, Yashar C, Erickson BA. Radiation Therapy for Endometrial Cancer: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol. 2022 Oct 21:S1879-8500(22)00273-9. doi: 10.1016/j.prro.2022.09.002. Epub ahead of print. PMID: 36280107.
Supplemental Methodology Resources
Data Supplement, Data Supplement, Data Supplement, Data Supplement