CHU IBN ROCHD- CASABLANCA Z.BOURHALEB CHU IBN ROCHD- CASABLANCA

Observation 1 ZM, 60ans, Nullipare, Nulligeste , Menopausee HDM : Remonte à un an par des métrorragies post ménopausique de faible a moyenne abondance isolées; Echographie pelvienne 9/5/2015 : Epaississement endometre à 11 mm Hysteroscopie : 3/7/2015 canal cervical normal cavité uterine : synechies hypertrophie endometriale Biopsie ADK endometroide G2

Hysterectomie totale avec annexectomie bilatérale ADK de l’endometre de type endometroide G2 envahissant <50% de la paroi myometriale; sans emboles vasculaires  Sans envahissement du col  ni des annexes  pT1aNxMx (IA type 1 G2EV-)  

Groupe à faible risque IA, G1-G2, EV:-

Quel traitement adjuvant? A- Radiothérapie post-operatoire B- Curiethérapie vaginale C- Surveillance

Adjuvant radiotherapy for stage I endometrial cancer Review Comparison EBRT vs. No EBRT: Low risk women (IA/B and grade 1/2), Outcome Endometrial carcinoma‐related deaths. Cochrane Database of Systematic Reviews 18 APR 2012 DOI: 10.1002/14651858.CD003916.pub4 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003916.pub4/full#CD003916-fig-00202

Review: Adjuvant radiotherapy for stage I endometrial cancer Comparison: VBT vs. no additional treatment Outcome: Locoregional recurrence VBT vs No Additional Treatment. One trial (Sorbe 2009) studied VBT vs no additional treatment in low-risk women only.[19]Therefore, no meta-analyses could be performed to compare OS for VBT vs no additional treatment. In this trial, there was no statistically significant difference in survival between the women who received VBT compared with the control group (645 women, RR = 1.09, 95% CI = 0.56 to 2.11; P = .81) or CSS (RR = 1.43, 95% CI = 0.46 to 4.46; P = .54).[19] However, the vaginal recurrence rate in the VBT group and the control group was similar (1.2% vs 3.1%, RR = 0.39, 95% CI = 0.14 to 1.09; P = .07).[19] Cochrane Database of Systematic Reviews 18 APR 2012 DOI: 10.1002/14651858.CD003916.pub4 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003916.pub4/full#CD003916-fig-00202

Groupe à faible risque Taux de rechute : <3 %

Groupe à faible risque Surveillance simple

Observation 2 65ans , menopausée , mariée, mere de 7enfants HTA sous traitement Neo du sein il ya 20ans Patey+ chimiotherapie + RTH adj Métrorragies spontanées depuis 3ans sans douleurs pelviennes ni troubles urnaires ni digestifs Echographie pelvienne : processus endocavitaire mulifocal CBE : ADK endometrial G2

IRM pelvienne 19/10/17

IRM pelvienne

Observation 2 HTSCA 31/10/17 ADK endometrial type endometroide infiltrant grade 2 etendu au 2/3 internes du myometre Evx+ Isthme+Col+annexes+parametres+ colerette vaginale : RAS 7N- (2N- a droite/5N a gauche) IB grade 2,Ev+

YESTERDAY IB grade 2,Ev+

TODAY IB grade 2,Ev+

CAT? A- Radiotherapie post-operatoire B- Curietherapie vaginale C-A+B D-Surveillance

31% intermediaire Bas risque PORTEC-1 included women of intermediate-risk (IB grade 2) and high intermediate-risk defined by the following: age > 60, stage IC grade 1 or 2; or age > 60, stage IB grade 3. Thirty-one percent of women were intermediate-risk (and also some low-risk), balanced across groups. Women with Stage IB grade 1 or IC grade 3 lesions were excluded. Intermediaire PORTEC-2 included women of high-intermediate risk only, defined as age > 60 years and stage IC grade 1 or 2 disease, or stage IB grade 3 disease, or stage IIA disease (excluding grade 3). Women with stage II cancer (11.5%) were balanced across groups. Haut risque

Groupe à risque intermediaire haut: RT RT RT

Groupe à risque intermediaire haut: RT RT RT ¾ des recidives sont vaginales

Observation 3 1956 , Mariée , HTA ss tt Debut remonte à 02/2017 par l'installation de métrorragie spontanées sans aucun autres signes associés Bilan : Aucun document HTSCA + curage gg : 12/04/17 ADK endometrioide grade 3 infiltrant plus de 50% du myometre , EVx -,  0N+/14N  Col, collerette vaginale, parametres, annexes indemnes IB grade3, Evx- PS:0 ex abdominal: pas de masse palpable TV/TR: RAS  

IB grade3, Evx-

Adjuvant radiotherapy for stage I endometrial cancer Review Groupe à haut risque rôle de la RTH Adjuvant radiotherapy for stage I endometrial cancer Review SG Cochrane Database of Systematic Reviews 18 APR 2012 DOI: 10.1002/14651858.CD003916.pub4 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003916.pub4/full#CD003916-fig-00202

Adjuvant radiotherapy for stage I endometrial cancer Review SS Cochrane Database of Systematic Reviews 18 APR 2012 DOI: 10.1002/14651858.CD003916.pub4 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003916.pub4/full#CD003916-fig-00202

Groupe à haut risque: Rôle de la RTH Méta-analyse de Lukka 5 essais : GOG99, PORTEC 1, Piver 79, Aalders 80, Garzetti 94 (HT) RT + curie Curie % RL 5 % 20 % Lukka H et al. Gynecol Oncol 2006 ; 102 : 361 –8 La rte + curie est sup à curie seule La curie seule n est pas suffisante chez haut risq

Groupe à haut risque role de la chimio Several trials have looked at intensified treatment in these patients and include some that have compared chemotherapy and radiation and that found no difference in progression-free survival or overall survival. A Radiation Therapy Oncology Group (RTOG) phase II trial of concurrent chemotherapy and radiotherapy, however, showed promising results and a feasible toxicity profile, she said.

PFS SG Methods—Patients (n=540; 534 evaluable) with operated endometrial cancer FIGO stage I-III with no residual tumour and prognostic factors implying high-risk were randomly allocated to adjuvant radiotherapy with or without sequential chemotherapy. Results—In the NSGO/EORTC study, combined modality treatment was associated with a 36 % reduction in the risk for relapse or death (HR 0.64, 95 % CI 0.41-0.99; P=0.04); two-sided tests were used. The result from the MaNGO-study pointed in the same direction (HR 0.61), but was not significant. In combined analysis, the estimate of risk for relapse or death was similar but with narrower confidence limits (HR 0.63, CI 0.44-0.89; P=0.009). Neither study showed significant differences in overall survival. In combined analysis, overall survival approached statistical significance (HR 0.69, CI 0.46-1.03; P = 0.07) and cancer-specific survival was significant (HR 0.55, CI 0.35-0.88; p=0.01). Conclusion—Addition of adjuvant chemotherapy to radiation improves progression-free survival in operated endometrial cancer patients with no residual tumour and high risk profile. A remaining question for future studies is if addition of radiotherapy to chemotherapy improves the results. Figure3. Overall survival in the pooled NSGO-EC-9501/EORTC-5591 and MaNGO studies. (CI: Confidence interval, HR: Hazard ratio, RT: radiotherapy, RT-CT: sequential radiotherapy and chemotherapy) Figure 2. Progression-free survival in the pooled NSGO-EC-9501/EORTC-5591 and MaNGO studies. (CI: Confidence interval, HR: Hazard ratio, RT: radiotherapy, RT-CT: sequential radiotherapy and chemotherapy).

PORTEC-3 Essai de phase 3 randomise comparant l’efficacite d’une radiochimiotherapie concomitante suivie d’une chimiotherapie adjuvante à une irradiationpelvienne seule chez des patientes ayant un cancer de l’endometre avance Adjuvant chemotherapy given during and after pelvic radiotherapy in women with high-risk endometrial cancer provided no significant 5 year failure-free or overall survival benefit, compared with pelvic radiotherapy alone, in the randomized PORTEC-3 intergroup trial. It did, however, show a trend toward improved 5 year failure-free survival (FFS). ASCO 2017

PORTEC-3 Essai de phase 3 randomise comparant l’efficacite d’une radiochimiotherapie concomitante suivie d’une chimiotherapie adjuvante à une irradiationpelvienne seule chez des patientes ayant un cancer de l’endometre avance Adjuvant chemotherapy given during and after pelvic radiotherapy in women with high-risk endometrial cancer provided no significant 5 year failure-free or overall survival benefit, compared with pelvic radiotherapy alone, in the randomized PORTEC-3 intergroup trial. It did, however, show a trend toward improved 5 year failure-free survival (FFS). Among the 45% of study participants with stage III endometrial cancer, 5-year FFS and overall survival were significantly lower than in those with stage I-II disease (64% vs. 79% and 74% vs. 83%, respectively), Stage III disease experienced the greatest benefit with adjuvant chemotherapy. ASCO 2017