Harkenrider Matthew M, Abu-Rustum Nadeem, Albuquerque Kevin, Bradfield Lisa, Bradley Kristin, Dolinar Ellen, Doll Corinne M, Elshaikh Mohamed, Frick Melissa A, Gehrig Paola A, Han Kathy, Hathout Lara, Jones Ellen, Klopp Ann, Mourtada Firas, Suneja Gita, Wright Alexi A, Yashar Catheryn, Erickson Beth A
Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois.
Department of Gynecologic Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York.
Pract Radiat Oncol. 2023 Jan-Feb;13(1):41-65. doi: 10.1016/j.prro.2022.09.002. Epub 2022 Oct 22.
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, and the effect of surgical staging techniques and molecular tumor profiling.
The American Society for Radiation Oncology convened a multidisciplinary task force to address 6 key questions that focused on the adjuvant management of patients with endometrial cancer. The key questions emphasized the (1) indications for adjuvant RT, (2) RT techniques, target volumes, dose fractionation, and treatment planning aims, (3) indications for systemic therapy, (4) sequencing of systemic therapy with RT, (5) effect of lymph node assessment on utilization of adjuvant therapy, and (6) effect of molecular tumor profiling on utilization of adjuvant therapy. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for quality of evidence grading and strength of recommendation.
The task force recommends RT (either vaginal brachytherapy or external beam RT) be given based on the patient's clinical-pathologic risk factors to reduce risk of vaginal and/or pelvic recurrence. When external beam RT is delivered, intensity modulated RT with daily image guided RT is recommended to reduce acute and late toxicity. Chemotherapy is recommended for patients with International Federation of Gynecology and Obstetrics (FIGO) stage I to II with high-risk histologies and those with FIGO stage III to IVA with any histology. When sequencing chemotherapy and RT, there is no prospective data to support an optimal sequence. Sentinel lymph node mapping is recommended over pelvic lymphadenectomy for surgical nodal staging. Data on sentinel lymph node pathologic ultrastaging status supports that patients with isolated tumor cells be treated as node negative and adjuvant therapy based on uterine risk factors and patients with micrometastases be treated as node positive. The available data on molecular characterization of endometrial cancer are compelling and should be increasingly considered when making recommendations for adjuvant therapy.
These recommendations guide evidence-based best clinical practices on the use of adjuvant therapy for endometrial cancer.
基于近期发表的多项临床试验结果，本指南对子宫内膜癌治疗中辅助放疗（RT）和全身治疗的应用提供指导。更新后的循证推荐意见给出了辅助放疗的适应证及相关技术、辅助全身治疗的应用和序贯方式，以及手术分期技术和分子肿瘤分析的作用。
美国放射肿瘤学会召集了一个多学科特别工作组，以解决聚焦于子宫内膜癌患者辅助治疗管理的6个关键问题。这些关键问题强调了（1）辅助放疗的适应证，（2）放疗技术、靶区体积、剂量分割和治疗计划目标，（3）全身治疗的适应证，（4）全身治疗与放疗的序贯方式，（5）淋巴结评估对辅助治疗应用的影响，以及（6）分子肿瘤分析对辅助治疗应用的影响。推荐意见基于系统的文献综述，并采用预定义的共识建立方法以及证据质量分级和推荐强度系统制定。
特别工作组建议根据患者的临床病理危险因素给予放疗（阴道近距离放疗或外照射放疗），以降低阴道和/或盆腔复发风险。进行外照射放疗时，建议采用每日影像引导的调强放疗以降低急性和晚期毒性。对于国际妇产科联盟（FIGO）I至II期具有高危组织学类型的患者以及FIGO III至IVA期任何组织学类型的患者，建议进行化疗。在化疗和放疗序贯时，尚无前瞻性数据支持最佳序贯方式。推荐采用前哨淋巴结 mapping 而非盆腔淋巴结清扫术进行手术分期。关于前哨淋巴结病理超分期状态的数据支持，孤立肿瘤细胞患者按淋巴结阴性处理，根据子宫危险因素进行辅助治疗；微转移患者按淋巴结阳性处理。子宫内膜癌分子特征的现有数据很有说服力，在制定辅助治疗推荐意见时应越来越多地予以考虑。
这些推荐意见为子宫内膜癌辅助治疗的循证最佳临床实践提供了指导。
