*4.1.2 Dose standards and technical properties*

The target volume has been defined as the whole uterus, cervix and the upper 3–5 cm of the vagina for inoperable endometrial cancer in the 2000 ABS guideline and mainly MRI, and if MRI is not available, CT was recommended for the treatment plan [55]. The risks for the neighboring organs should be considered when performing volume-based treatment through MRI or CT [56] (**Table 4**).

In a study of Gill et al., 38 inoperable endometrial cancer patients underwent volume-based treatment and the gross tumor volume (GTV) and the clinical target volume (CTV) were determined with MRI in 19 patients and with CT in the remaining 19. While 20 patients received a mean 37.5 Gy VB in 4–5 fractions, 20 patients received 45 Gy EBRT followed by 25 Gy boost VB treatment. While the local control rate was 90.6% for 2 years, the overall survival rate was 94.4%. Hemorrhage developed in only one patient during the applicator placement and she received blood transfusion. No patients had grade 3 or acute and late complications [57]. The patients should be referred to centers where MRI or CT is available or their treatment should be attempted by using ultrasonography and radiography.

#### *4.1.3 Treatment*

1.HDR VB may be used alone in patients who have clinical stage 1, grade 1–2 myometrial invasion of less than 50 [56]%. GTV is specified in the course of brachytherapy with MRI and the whole uterus and its serosa are irradiated (CTV). For minimal harm to the neighboring tissues (OAT), the limit is 70–75 Gy for the rectum and the sigmoid, and 80–100 Gy for the urinary bladder. The HDR dose schemas for these patients have been presented in **Table 5**.

**163**

**Table 6.**

*EBRT and HDR dose schemas.*

**Table 5.** *HDR dose table.*

*Brachytherapy in Endometrial Cancer*

*DOI: http://dx.doi.org/10.5772/intechopen.92703*

are presented in **Table 6** for these patients.

doses presented in **Table 6** are used.

The doses presented in **Table 6** are used.

be considered in patients with recurrence [58].

**endometrial cancer**

*4.1.4 Management of recurrent disease after definitive radiation*

2.Pelvic EBRT+HDR VB is recommended for clinical stage 1 patients with myometrial invasion >50%. EBRT is applied 45–50 Gy so as to include all pelvic lymph nodes, the whole uterus and 1–2 cm proximal of vagina. Dose schemas

3.Patients with clinical stage 2 endometrial cancer are given pelvic EBRT + HDR VB. This treatment modality is also valid for clinics that do not have MRI. The

65 Gy + HDR VB are given to patients with clinical stage 3 endometrial cancer.

4.Higher doses of pelvic EBRT (including all lymphatic regions) up to

Radiotherapy options are quite limited in biopsy-proven recurrences after definitive radiation treatment. It may only be used for palliative purposes in vaginal hemorrhage and pelvic pain. Hormone therapy and chemotherapy options should

In the literature, radiotherapy was shown to have been used in 60% of cervical cancers, 45% of endometrial cancers and 100% of vaginal cancers [59, 60]. Healthy cervical and uterine tissues are known to tolerate radiation therapy (RT) well. Although pregnancy is known to have occurred in women receiving 20–30 Gy RT for the uterus, an atrophic uterus improper for pregnancy develops in women

**HDR total dose (Gy) HDR dose fractionation EQD2 (Gy)** 36 6 Gy × 6 48 38.4 6.4 Gy × 6 52.5 363 7.3 Gy × 5 52.6 34 8.5 Gy × 4 52.4 40–50 5 Gy × 9–10 50–62.5

**EBRT (Gy) HDR total dose (Gy) HDR dose fractionation EQD2 (Gy)** 19.5 6.5 Gy × 3 71.1 18.9 6.3 Gy × 3 69.9 20.8 5.2 Gy × 4 70.6 25 5 Gy × 5 75 17 8.5 Gy × 2 70.5 50.4 12 6.0 Gy × 2 65.6 50.4 22.5 3.75 Gy × 6 75.3

**4.2 Treatment-related toxicity from the use of radiation therapy for** 

#### *Brachytherapy in Endometrial Cancer DOI: http://dx.doi.org/10.5772/intechopen.92703*

*Translational Research in Cancer*

**IA-Uterine cavity sounds to <8 cm** IB-Uterine cavity sounds to >8 cm Stage II-Involves the corpus and cervix

*Clinical staging system for endometrial cancer.*

Gross tumor volume clinical target volume Organs at risk

Stage IVB-Metastatic

**Table 4.**

**Table 3.**

lymph node involvement was 95% [54].

*4.1.2 Dose standards and technical properties*

*CT, computed tomography; MRI, magnetic resonance imaging.*

**Structure Image data set Definition**

Stage III-Parametrium, adnexa, or vagina but confined to true pelvis

Stage IVA-Involving local structures (rectum/bladder)

*cervix, and upper vagina. Organs at risk include bladder, rectum, and sigmoid.*

T2-wcightcd MRI MRI or CT MRI or CT

MRI and the positive predictive value is low [51]. 18-F-fluoro-deoxyglucose positron emission tomography (PET) is used for lymph node involvement [52, 53]. In a study conducted with PET-CT, the pelvic node involvement rate was 63% and the para-aortic

*Recommended structures for volume-based planning in medically inoperable endometrial cancer.*

*Note. MRI is required if a gross tumor volume is to be contoured. The clinical target volume includes the entire uterus,* 

Visible abnormality if present Entire uterus, cervix,

Sigmoid, rectum, bladder, bowel, and uninvolved

and upper 1–2 cm of the vagina

lower third of the vagina

The target volume has been defined as the whole uterus, cervix and the upper 3–5 cm of the vagina for inoperable endometrial cancer in the 2000 ABS guideline and mainly MRI, and if MRI is not available, CT was recommended for the treatment plan [55]. The risks for the neighboring organs should be considered when

In a study of Gill et al., 38 inoperable endometrial cancer patients underwent volume-based treatment and the gross tumor volume (GTV) and the clinical target volume (CTV) were determined with MRI in 19 patients and with CT in the remaining 19. While 20 patients received a mean 37.5 Gy VB in 4–5 fractions, 20 patients received 45 Gy EBRT followed by 25 Gy boost VB treatment. While the local control rate was 90.6% for 2 years, the overall survival rate was 94.4%. Hemorrhage developed in only one patient during the applicator placement and she received blood transfusion. No patients had grade 3 or acute and late complications [57]. The patients should be referred to centers where MRI or CT is available or their

performing volume-based treatment through MRI or CT [56] (**Table 4**).

treatment should be attempted by using ultrasonography and radiography.

1.HDR VB may be used alone in patients who have clinical stage 1, grade 1–2 myometrial invasion of less than 50 [56]%. GTV is specified in the course of brachytherapy with MRI and the whole uterus and its serosa are irradiated (CTV). For minimal harm to the neighboring tissues (OAT), the limit is 70–75 Gy for the rectum and the sigmoid, and 80–100 Gy for the urinary bladder. The HDR dose schemas for these patients have been presented in **Table 5**.

**162**

*4.1.3 Treatment*

