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Contemporary Educational Psychology/Chapter 6: Student Motivation/Motives as Goals

Motives as Goals
One way motives vary is by the kind of goals that students set for themselves, and by how the goals support students’ academic achievement. As you might suspect, some goals encourage academic achievement more than others, but even motives that do not concern academics explicitly tend to affect learning indirectly.

Goals That Contribute to Achievement
What kinds of achievement goals do students hold? Imagine three individuals, Maria, Sara, and Lindsay, who are taking algebra together. Maria’s main concern is to learn the material as well as possible because she finds it interesting and because she believes it will be useful to her in later courses, perhaps at university. Hers is a mastery goal because she wants primarily to learn or master the material. Sara, however, is concerned less about algebra as such than about getting top marks on the exams and in the course. Hers is a performance goal because she is focused primarily on looking successful; learning algebra is merely a vehicle for performing well in the eyes of peers and teachers. Lindsay, for her part, is primarily concerned about avoiding a poor or failing mark. Hers is a performance-avoidance goal or failure-avoidance goal because she not really as concerned about learning algebra, as Maria is, or about competitive success, as Sara is; she is simply intending to avoid failure.

As you might imagine, mastery, performance, and performance-avoidance goals often not experienced in pure form, but in combinations. If you play the clarinet in the school band, you might want to improve your technique simply because you enjoy playing as well as possible—essentially a mastery orientation. But you might also want to look talented in the eyes of classmates—a performance orientation. And another part of you may wish, at least privately, to avoid looking like a complete failure at playing the clarinet. One of these motives may predominate over the others, but they all may be present.

Mastery goals tend to be associated with enjoyment of learning the material at hand, and in this sense represent an outcome that teachers often seek for students. By definition therefore they are a form of intrinsic motivation. As such mastery goals have been found to be better than performance goals at sustaining students’ interest in a subject. In one review of research about learning goals, for example, students with primarily mastery orientations toward a course they were taking not only tended to express greater interest in the course, but also continued to express interest well beyond the official end of the course, and to enroll in further courses in the same subject (Harackiewicz, et al., 2002; Wolters, 2004).

Performance goals, on the other hand, imply extrinsic motivation, and tend to show the mixed effects of this orientation. A positive effect is that students with a performance orientation do tend to get higher grades than those who express primarily a mastery orientation. The advantage in grades occurs both in the short term (with individual assignments) and in the long term (with overall GPA when graduating). But there is evidence that performance oriented students do not actually learn material as deeply or permanently as students who are more mastery oriented (Midgley, Kaplan, & Middleton, 2001). A possible reason is that measures of performance—such as test scores—often reward relatively shallow memorization of information and therefore guide performance-oriented students away from processing the information thoughtfully or deeply. Another possible reason is that a performance orientation, by focusing on gaining recognition as the best among peers, encourages competition among peers. Giving and receiving help from classmates is thus not in the self-interest of a performance-oriented student, and the resulting isolation limits the student’s learning.

Failure-avoidant Goals
As we mentioned, failure-avoidant goals by nature undermine academic achievement. Often they are a negative byproduct of the competitiveness of performance goals (Urdan, 2004). If a teacher (and sometimes also fellow students) put too much emphasis on being the best in the class, and if interest in learning the material as such therefore suffers, then some students may decide that success is beyond their reach or may not be desirable in any case. The alternative—simply avoiding failure—may seem wiser as well as more feasible. Once a student adopts this attitude, he or she may underachieve more or less deliberately, doing only the minimum work necessary to avoid looking foolish or to avoid serious conflict with the teacher. Avoiding failure in this way is an example of self-handicapping—deliberate actions and choices that the reduce chances of success. Students may self-handicap in a number of ways; in addition to not working hard, they may procrastinate about completing assignments, for example, or set goals that are unrealistically high.

Social Goals
Most students need and value relationships, both with classmates and with teachers, and often (though not always) they get a good deal of positive support from the relationships. But the effects of social relationships are complex, and at times can work both for and against academic achievement. If a relationship with the teacher is important and reasonably positive, then the student is likely to try pleasing the teacher by working hard on assignments (Dowson & McInerney, 2003). Note, though, that this effect is closer to performance than mastery; the student is primarily concerned about looking good to someone else. If, on the other hand, a student is especially concerned about relationships with peers, the effects on achievement depend on the student’s motives for the relationship, as well as on peers’ attitudes. Desiring to be close to peers personally may lead a student to ask for help from, and give help to peers—a behavior that may support higher achievement, at least up to a point. But desiring to impress peers with skills and knowledge may lead to the opposite: as we already mentioned, the competitive edge of such a performance orientation may keep the student from collaborating, and in this indirect way reduce a student’s opportunities to learn. The abilities and achievement motivation of peers themselves can also make a difference, but once again the effects vary depending on the context. Low achievement and motivation by peers affects an individual’s academic motivation more in elementary school than in high school, more in learning mathematics and than learning to read, and more if there is a wide range of abilities in a classroom than if there is a more narrow range (Burke & Sass, 2006).

In spite of these complexities, social relationships are valued so highly by most students that teachers should generally facilitate them, though also keep an eye on their nature and their consequent effects on achievement. Many assignments can be accomplished productively in groups, for example, as long as the groups are formed thoughtfully; in that chapter we discuss some ways of insuring that such groups are successful, such as by choosing group tasks wisely and recognizing all members’ contributions are fully as possible. Relationships can also be supported with activities that involve students or adults from another class or from outside the school, as often happens with school or community service projects. These can provide considerable social satisfaction and can sometimes be connected to current curriculum needs (Butin, 2005). But the majority of students’ social contacts are likely always to come from students’ own initiatives with each other in simply taking time to talk and interact. The teacher’s job is to encourage these informal contacts, especially when they happen at times that support rather than interfere with learning.

Encouraging Mastery Goals
Even though a degree of performance orientation may be inevitable in school because of the mere presence of classmates, it does not have to take over students’ academic motivation completely. Teachers can encourage mastery goals in various ways, and should in fact do so because a mastery orientation leads to more sustained, thoughtful learning, at least in classrooms, where classmates may sometimes debate and disagree with each other (Darnon, Butera, & Harackiewicz, 2006).

How can teachers do so? One way is to allow students to choose specific tasks or assignments for themselves, where possible, because their choices are more likely than usual to reflect prior personal interests, and hence be motivated more intrinsically than usual. The limitation of this strategy, of course, is that students may not see some of the connections between their prior interests and the curriculum topics at hand. In that case it also helps for the teacher to look for and point out the relevance of current topics or skills to students’ personal interests and goals. Suppose, for example, that a student enjoys the latest styles of music. This interest may actually have connections with a wide range of school curriculum, such as:
 * biology (because of the physiology of the ear and of hearing),
 * physics or general science (because of the nature of musical acoustics),
 * history (because of changes in musical styles over time),
 * English (because of relationships of musical lyrics and themes with literary themes),
 * foreign languages (because of comparisons of music and songs among cultures).

Still another way to encourage mastery orientation is to focus on students’ individual effort and improvement as much as possible, rather than on comparing students’ successes to each other. You can encourage this orientation by giving students detailed feedback about how they can improve performance, or by arranging for students to collaborate on specific tasks and projects rather than to compete about them, and in general by showing your own enthusiasm for the subject at hand.

(back to Chapter 6...)


text:
Cookbook:Seafood Gumbo

Ingredients

 * ¾ cup vegetable oil
 * ¾ cup flour
 * 10 oz okra (optional)
 * 2 cups onion, chopped
 * 1 cup celery, chopped
 * 1½ cups bell pepper, chopped
 * 6 cloves garlic, minced
 * 6 cups shrimp stock or water
 * 8 oz clam juice (optional)
 * ½ tsp oregano
 * ½ tsp thyme
 * 2 bay leaves
 * 1½ tsp salt
 * ½–1 tsp cayenne pepper
 * Black pepper to taste
 * 2 tbsp fresh chopped parsley
 * 1 lb Andouille sausage, cut in pieces
 * 1 lb shrimp
 * ½ pint (or more) oysters
 * ½ lb crawfish (optional)
 * 4 chopped green onions, for topping

Procedure

 * 1) Heat oil in a 6–8 quart pot, then gradually whisk in the flour. Cook over medium heat for 20 minutes until very dark reddish brown. Stir constantly, especially towards the end. The best roux is quite dark, but don’t let it burn.
 * 2) Stir the onion, celery, bell pepper, and garlic into the roux. Cook 10 minutes (or 15 minutes if using okra).
 * 3) Slowly and gradually whisk in the shrimp stock.
 * 4) Add the clam juice, oregano, thyme, bay leaves, salt, cayenne, pepper, and parsley. Simmer 15 minutes.
 * 5) Add the Andouille sausage, and simmer for another 30–40 minutes.
 * 6) Add the shrimp, oysters, and crawfish at the end, and simmer just until cooked through.
 * 7) Top with chopped green onions.

Note, tips and variations

 * You can add cut-up boneless chicken, or substitute chicken for the oysters, if they’re not your thing. If you don’t have Andouille sausage, smoked or Polish sausage will do fine.
 * To make shrimp stock, simmer shrimp shells in about 6½ cups of water for 20 minutes.
 * Dark roux is what makes this gumbo great.
 * Many like to serve this gumbo over rice. It also goes great with a baguette or cornbread.

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/

title: Cookbook:Seafood Gumbo


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User talk:Rider1000

Hey Rider! (or Casey, IIRC)

Welcome to Wikibooks! I'll go through the Caving stuff and add the formatting as soon as I get a chance. --Jomegat 20:59, 23 August 2007 (UTC)

title: User talk:Rider1000


text:
Cookbook:Cheese Enchilada

| Tex-Mex Cuisine

This cheese enchilada recipe was handed down from the grandmother and mother of the original contributor.

Ingredients

 * 3 tbsp flour
 * 3 tbsp chili powder
 * 3 tbsp vegetable oil
 * 3 cups water
 * 1½ pounds (680 g) grated cheddar cheese
 * 1 large onion, chopped
 * ~20 corn tortillas

Procedure

 * 1) Preheat oven to 350°F (175°C).
 * 2) Fry chili powder and flour in oil in a 10–12-inch (25–30 cm) skillet until emulsified. Add water, bring to a simmer, and then stir for ~5 minutes until slightly thickened. Turn down heat to low.
 * 3) Soak one tortilla in the chili gravy until softened (20–30 seconds). Remove tortilla from gravy, place flat on a plate, and add ~1 tbsp cheese and ~1 tbsp onion to center of the tortilla. Roll it up, and place with edges facing down in a 9 x 12-inch (23 x 30 cm) baking pan. Repeat this until you have used all the tortillas. If you get low on the gravy at the end, stir in ⅛–¼ cup of water.
 * 4) Cover the enchiladas with the remaining cheese, onions, and chili gravy.
 * 5) Bake in oven for about 5 minutes—longer will toughen the cheese.
 * 6) Serve hot.

Notes, tips, and variations

 * These freeze well, but defrost completely before reheating.
 * In Tex-Mex cuisine, these are often served with Mexican rice, pinto beans, and guacamole salad.

title: Cookbook:Cheese Enchilada


text:
Down'n'dirty Blacksmithing/Drawing

(Note: Some smiths refer to a method of tempering medium sized objects by applying heat, as from a torch or hot object, directly to the part to be tempered, as "drawing.")

Drawing, or "drawing out" is the process of lengthening a piece by forging. This is one of the most basic operations in that it is very simple to explain and perform, at least in theory. It does, however, form the basis of many related operations that are not so well defined.

To "draw out" a work, it must first be heated to working temperature. This takes patience, and practice, to recognize the right color changes and other signs. Once that has been done, move the piece to the anvil and (assuming it is a flat sided piece) place it flat on the anvil face. you want to strike the piece squarely, so that the hammer face doesn't gouge into the piece. This takes practice.

It is very important to work quickly and above all carefully. You will want to really pound that metal, maybe make some sparks fly like on the USMC advertisements. Don't. It is much more important to control your strikes than to drive the hammer straight through to the anvil. Go easy, and work your way into it. Your arms and shoulders will thank you too.

Now a strike or two (maybe 5 or 6 if you are really taking it easy) and you may start to see some change. It's high time to change sides. I think it is probably best to strike once or twice, flip up to an adjacent side, then go to the opposite side, then the (former) "bottom". That's my opinion, and if you stay at it you'll soon find a method that works, both for you and for the metal.

Work your way down the length of the area to be drawn until you have the desired length and thickness.

There are several pitfalls to basic drawing out that make the practice much harder than the theory. One is the tendency of the metal to "turn." This is where, due to uneven striking, uneven metal qualities, or uneven cooling, the piece starts to bend while being drawn. This can usually be corrected if caught early, by simply adjusting where you are striking to even it out. Don't let it go on too long, though, before correcting.

Another common problem is bowing(?) which is where the metal on the striking face begins to mushroom. This often happens when the piece has a relatively narrow face adjacent to a broad face. (Rectangular for example). Again, catching this early is the key to salvaging it. Usually this is a direct result of striking too hard or spending too much time on the narrow face. Fix by alternating between broad faces for awhile until it smooths back out.

The worst problem, and the hardest to "fix" is gouging. striking at an angle and/or too hard will cause the edge of the hammer face to dig into the work. Slight indentations may be buffed out later, or hammered out now, but deep gouges are all too often unfixable.

Next Chapter: Exercise 4: Freehand bending

title: Down'n'dirty Blacksmithing/Drawing


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Talk:XQuery/Net Working Days

A modified version of the workCalender exists but I'm not yet happy with it.

ChrisWallace 21:49, 23 August 2007 (UTC)

title: Talk:XQuery/Net Working Days


text:
User:Thejonas

www.thejonas.org

title: User:Thejonas


text:
Talk:XHTML/XHTML Grammar

== or ? ==

I always use  and it works fine. --Stefán Örvarr Sigmundsson 22:20, 23 August 2007 (UTC)

It will still work, but if you want to follow the stands directly, you will have to use --Grich (talk) 02:06, 16 May 2008 (UTC)

empty tags? wtf
wtf do you mean with empty tags? no attributes? cause that's nonsens. the example is really bad also.

deprecated elements
Check the w3c's web site. bold and italic are NOT deprecated.

title: Talk:XHTML/XHTML Grammar


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XForms/Adder

Motivation
This program demonstrates several different ways to call a web service from a sample XForms application. The example uses both HTTP POST and HTTP GET methods and shows how the results are returned into an instance in the model and how the page can be replaced with the results. The web service it calls is a simple web service that adds two numbers together.

Link to XForms Application
For the results to be put in the model using FireFox, make sure to add  and   to your XForms white list using the Tools/Options/Security/Allowed Sites menu of FireFox. This is required since our web forms are hosted at one domain but the web services are hosted on another domain.

Load XForms Application

Sample Program
                <xf:toggle case="case-submit-done" ev:event="xforms-submit-done"/> </xf:submission> <xf:submission id="post-replace" method="post" action="http://www.cems.uwe.ac.uk/xmldb/rest/db/Wiki/adder-post.xq"> <xf:toggle case="case-busy" ev:event="xforms-submit"/> <xf:toggle case="case-submit-error" ev:event="xforms-submit-error"/> <xf:toggle case="case-submit-done" ev:event="xforms-submit-done"/> </xf:submission> <xf:submission id="get-test" method="get" replace="all" separator="&" action="http://xformstest.org/cgi-bin/showinstance.sh"/> <xf:submission id="post-test" method="post" replace="all" action="http://xformstest.org/cgi-bin/showinstance.sh"/> </xf:model> Using XForms to test XQuery Note, you must have xforms-examples.googlecode.com and www.cems.uwe.ac.uk in your whitelist for this demo to work. <xf:input ref="arg1" incremental="true"> <xf:label>Arg1:</xf:label> </xf:input> <xf:input ref="arg2" incremental="true"> <xf:label>Arg2:</xf:label> </xf:input> <xf:output ref="instance('submit-results')/sum"> <xf:label>Sum:</xf:label> </xf:output> <xf:submit submission="get-instance"> <xf:label>HTTP GET -> instance</xf:label> </xf:submit> <xf:submit submission="post-instance"> <xf:label>HTTP POST -> instance</xf:label> </xf:submit> <xf:submit submission="get-replace"> <xf:label>HTTP GET -> replace</xf:label> </xf:submit> <xf:submit submission="post-replace"> <xf:label>HTTP POST -> replace</xf:label> </xf:submit> <xf:submit submission="get-test"> <xf:label>HTTP Get Test</xf:label> </xf:submit> <xf:submit submission="post-test"> <xf:label>HTTP Post Test</xf:label> </xf:submit> <xf:switch> <xf:case id="ready"/> <xf:case id="case-busy"> Waiting for results from server...            </xf:case> <xf:case id="case-submit-error"> Submit error </xf:case> <xf:case id="case-submit-done"> Submit done </xf:case> </xf:switch>

title: XForms/Adder


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User:Stephen francis

7a^3

title: User:Stephen francis


text:
Social and Cultural Foundations of American Education/Special Needs/Disabilities

There are many different approaches to the idea of teaching children with disabilities in the public education system. Some feel that all children with special needs are better off participating fully in a mainstream or regular education class. Others take a less accepting approach; they question if the whole idea of inclusion, specifically full inclusion, has gone too far. Still, other perspectives are shown in the focus of some on the study of the methods used to teach students with special needs. There are even those who might argue that attitude is the key component in teaching disabled children. Undoubtedly, these questions will only increase as more and more children are educated. However, no matter what the viewpoint is, the important thing is that students with disabilities are given the same rights to education as any other student in school.

What is Inclusion?
In the year 2000, an article called “I Believe in Inclusion, But…” was published in the Journal of Research in Childhood Education to show the rate of success of regular education teachers who taught both children with and without disabilities. While demonstrating the differing points of view on the idea of inclusion, the article seems to emphasize one over the other. “Selection of the participants was made from among early childhood teachers in kindergarten through 3rd-grade regular education classrooms in a small urban school district in Nebraska. This district served approximately 5,000 students, with 10 elementary schools, one middle school, and one high school. This is a "pro-inclusion," rather than a full-inclusion school district. In a full-inclusion district, "...all children with disabilities, regardless of the nature or severity of the disability, will be educated in general education: in a full inclusion system, separate special education placements would no longer exist" (Hocutt, 1996, p. 79). In a pro-inclusion district inclusion is the preferred choice, whenever possible and appropriate, decided on a case-by-case basis.” (Smith and Smith 2000) The authors of this article are not as concerned with the success or failure of mainstreaming special education students, as with whether or not the teachers are having success. Though some feel that they have been “hindered”, all teachers participating in this study agree that inclusion works. However, in order for it to be achieved, there are some standards by which all teachers must abide when dealing with their students. “Even when a student has been diagnosed, these teachers will be responsible for providing for the needs of that student, meeting the needs of the rest of the class, and maintaining a classroom of mutual respect and academic standards. This initial experience is critical since it forms the foundation for later school success; hence, the positive and negative perceptions, beliefs, and experiences of early childhood regular education teachers are at the core of the issue of successful inclusion.” (Smith and Smith, 2000)

Methods of Inclusion
While some studies focus on opposing views of those teaching special needs students, others emphasize methods used in instructing these children. For instance, in the later part of 2006, the Science Scope featured an article that briefly summarizes just a few of these methods. The first method is the “Primary/Supplementary” approach, in which one teacher delivers the lecture, while the other teacher moves throughout the classroom to make sure all the students understand what has been taught. Another approach is the “Tag-Team” approach, which is basically the same as the previous method. The difference is that the teachers switch places and teaching roles. Other instructional means include the 50/50, where students divide up into two groups, and two teachers work together leading their individual group. Though there are more methods used in teaching children with special needs, it appears that these are the methods on which the others are based. (Peters, Erin, and Timothy Johnson 2006)

Arguments Against Inclusion
Although many feel that several strides have been made in full-inclusion education, others are somewhat skeptical with the idea of full-inclusion. “Critics of full inclusion ask whether even students with the most severe disabilities benefit from placement in regular classrooms.” (Cromwell 2004) Other concerns about inclusion are expressed in the idea that teachers may have to completely change the structure of their class. For instance, they may need to seek the aid of an assistant, which can be time consuming. Also, with technology being more prevalent in schools now than ever before, teachers may be required to receive additional training with any assistive equipment the student might use. (Cromwell 2004)	The author also points out, “While few educators oppose inclusion completely, some express reservations about how full inclusion works in the classroom.” Albert Shanker, writing for the American Federation of Teachers in 1996 in "Where We Stand," asserted, "What full inclusionists don't see is that children with disabilities are individuals with differing needs; some benefit from inclusion and others do not. Full inclusionists don't see that medically fragile children and children with severe behavioral disorders are more likely to be harmed than helped when they are placed in regular classrooms where teachers do not have the highly specialized training to deal with their needs.” (Cromwell 2004, sighted quote from 1996) Not only has the idea of inclusion been troubling to some professionals in the field of education, but it is also troubling to the parents of the students being taught. These parents fear that their children might end up getting “dumped” in a regular education class, without the proper support they may need to succeed, and to progress with the other students. These are some of the reservations that cause some parents to question the virtues of full-inclusion. (Cromwell 2004)

An Argument for Inclusion
Being visually impaired, I can personally identify with the struggles faced by students with disabilities. I was born with an eye condition known as Retinopathy of Prematurely (R.O.P.). I have no sight in my right eye and very little vision in my left, and from the time I was a little girl, my family constantly encouraged me to pursue any goal I wanted to achieve, to the best of my ability, including education. In my case, it seemed that a full-inclusion situation was the best thing. Like all students, I had my share of good and bad teachers, and there is a lot I could say about many of them. However the most influential teacher who laid the foundation for the person I am today is Dianne Fitzkee. She was my first vision teacher who taught me to read Braille, and surprisingly, it was not so much what she taught me in class that affected me so much, but her positive views about her student’s capabilities. Without question, her methods were good, and she was highly qualified to instruct in her field. However, it was her high expectations and willingness to help me reach my full potential as a student, which led me to where I am today.

Teacher Attitudes Regarding Inclusion
The success of any inclusion program relies heavily on the attitude of the general education teacher involved. However, the views of teachers toward inclusion programs differs. Some teachers may not want to participate in inclusion classroom settings simply due to their apprehension of special education students. This may be due in part to the separation of special and general education in teacher training programs. Teacher training programs typically had separate curriculum and did not prepare new teachers certified in specific subject areas to work with special education students. (Coombs-Richardson, 2000) This may have left many teachers feeling unprepared and frustrated when faced with inclusion classrooms.

Project Inclusion in Louisiana was enacted to attempt to help general education teachers feel more prepared in inclusion settings. This program offered general education teachers college level courses that focused on techniques for working with students with disabilities. Classes included topics on behavior identification and intervention, collaboration with special education teachers, and teaching strategies for learning disabled students. Comparing the scores of teachers from before they completed the program and after completing the program indicates that teachers not only felt more knowledgeable about special education students but also felt more accepting of the inclusion of special education students in their classroom. (Coombs-Richardson, 2000)

Classroom Management
To be fair to general education students as well as special education students the teacher must have some type of management system so that every student in the class can benefit from her lesson. One approach is to consult with an Intervention Assistance Team (IAT) whose job is to create appropriate interventions for children with problem behaviors (Goodman, Williams, 2007). In many cases being a stern educator is just not enough to help children with a disability pay attention, sit still or focus on the subject matter. These are the symptoms of many students with behavioral and learning disabilities. Susan Cahill, an occupational therapist feels that "maintaining order in the classroom is the responsibility of the teacher regardless of the subject area or certification. The challenge lies in balancing the time required to teach the curriculum and the energy it takes to manage the needs of each of the students in the classroom" (Cahill, 2006).

Conclusion
The debate of the opposing views and methods of teaching special education children continues endlessly. Many researchers and professionals will all point in their own direction on this issue. Yet, the main thing is that all children with varying degrees of ability be given the same access to a public education, so that they can become all they were created to be.

Multiple Choice Questions
Click to reveal the answer.

Essay Question
Click to reveal sample responses.


text:
Social and Cultural Foundations of American Education/Curriculum Development/Special Education

Samantha (not her real name) was a student in my class a few years ago when I replaced a teacher who left on maternity leave at the end of April. Samantha was labeled by my team members as "one of the more difficult students" in the fifth grade. She rarely completed her class work, frequently asked for the pass to the bathroom/nurse/office and liked to challenge authority. At the end of my second day on the job, I decided to stay late to allow myself a sufficient block of time in which I could read through my students' files. What I found was astonishing.

According to Samantha's file, she had first been referred to the Child Study committee in second grade, then again in the third and fourth grades. Finally in the middle of the fifth grade, a 504 plan was written for Samantha. Unfortunately, had I not taken the time to read through her file, I would never have known about her 504, as neither the exiting teacher nor any other staff members mentioned her need for accommodations. Furthermore, after consultation with Samantha's mother and my fellow fifth grade team members, I learned that modifications were not being followed in any of Samantha's classes. Samantha, it turns out, was difficult at times…but with reason. She was being medicated with Lithium to control Bipolar Disorder. Perceived as excuses to skip class time, her frequent trips to the bathroom were really a means to go to the water fountain because she was always thirsty (a side effect of her medication). She often had headaches (another side effect of her meds) and had days when she just needed a break from the stress of the classroom. She was trying to cope as best she could. She was faced with a medical condition she did not understand and being educated by teachers who did not understand her special needs. She was not having a very successful or productive school year and felt her situation was hopeless.

Using my prior knowledge of Bipolar Disorder and based on my past experiences with students who suffered from Bipolar, Samantha and I were able to work out a plan that not only helped her cope with her disorder but also improved her class performance significantly. A year end Child Study meeting resulted in her finally receiving the IEP she needed.

This story exemplifies the reason why special education is an issue for ALL educators, not just those identified as special education teachers. Ignorance of law is not an excuse for failing to serve the needs of the special education students in your classroom. As educators, we pledge to serve ALL students in our class to the best of our ability. This, at times, means going the extra mile to find the methods that will best serve our students; and educating ourselves before we attempt to teach others.

What is Special Education?
According to the Virginia Department of Education Parent's guide to Special Education, Special Education is "specially designed instruction to meet the unique needs of a child with a disability. This includes instruction conducted in the classroom, home, hospital, institution, or other setting. (http://www.pen.k12.va.us)  There are five steps in the special education process.  The first step is called identification and referral.  This is an extremely important step for regular education teachers. A child's regular education/classroom teacher has first-hand knowledge of the student's strengths and weaknesses.   If the teacher suspects that one of the students may be in need of special services, it is that teacher's responsibility as an educator to request an evaluation by writing or speaking with the special education administrator of the school or system.  It is best to put this request in written form, so that the request is documented and the referral starts a special education timeline. Within five days, the special education administrator may request a review by the child study committee. The committee has ten days from the date of said request to decide whether or not to evaluate (Step 2). The special education administrator has sixty-five days from the date of the referral for evaluation to determine eligibility for special education and related services (Step 3).

A child study team will be created to evaluate the referred student's information. This team includes the person who referred the child (except in cases of confidentiality conflicts), the principal or his/her designee, at least one regular education teacher, and one specialist. If the referred child is found eligible for special education and related services, an Individualized Education Plan (IEP) will be developed by the team and the child's parents that best meets the needs of the child. This document will be reviewed annually (Step 4). Finally, step five, is re-evaluation, which requires a child study team to review the IEP every three years to determine whether or not services are still needed.

Mainstreaming and Inclusion
Mainstreaming refers to the idea of selective placement of special education students in one or more "regular" education classes; whereas, inclusion is a term which refers to the maximum appropriate time that a child would benefit from attending the "regular" education classes with special services coming to the child rather than moving the child to a separate class. Full inclusion means that all students, regardless of their disability, remain in the "regular" class full-time with an aide.

It seems that everyone has their own opinion on whether or not the idea of mainstreaming or inclusion actually is a successful concept; much like the idea of "tracking" students. Those who support mainstreaming say that it is a benefit to the special education student because it helps them to achieve socialization goals through improved self confidence, and greater skills and independence are achieved in integrated settings. "Regular" education students learn to appreciate the individual differences and regular education teachers learn to incorporate their "mainstreaming" techniques in their everyday lessons, which in turn, assists all students in the class.

Those who disagree with mainstreaming/inclusion feel that if the concept is not executed properly, mainstreaming can result in greater prejudice and rejection for the special education student. Large class size can hinder the teacher's ability to meet the needs of the special education students and both the regular and special education students in the class suffer. Adequate support from the special education team is essential for the idea of mainstreaming to succeed.

Bottom line, the concept of mainstreaming is one that can be a success, if appropriate training and support is provided to the regular education teacher. The regular education teacher needs to understand the student's disability and plan lessons and activities accordingly. The teacher needs to get to know the student, meet frequently with his/her special education teacher, attend parent conferences, plan the day to include promoting social interaction, giving extra help when needed, respecting confidentiality rights, and above all, being realistic! The teachers should not be afraid to ask for help in developing new teaching strategies or assisting in assessing the effectiveness of your lessons. For the student, the teacher needs to provide clear and concise directions to ensure the student's daily success. Use a variety of teaching techniques and integrating the special education student into your classroom should also be incorporated in the student's daily activities. Finding opportunities to recognize the student's progress (i.e. catch them being "good") helps the student to identify self-worth, achievement, and success. Inclusion and mainstreaming really does work, and done the right way is extremely beneficial to all the students in your classroom!

The Importance of High Expectations
My daughter was identified as having cognitive deficits as early as her eight month well baby check up. She began an early intervention program when she was eighteen months old, and rode her first school bus to school when she was two years old. The public education system has done a lot to improve my child’s chances for a more fulfilling life, but individuals she has encountered within that system have unfortunately hindered some of her progress. Much of the hindrance has been a result of teacher expectations, or lack thereof, and my own ignorance of how to fight for her right to an education. It has been our unfortunate experience that some special educators view their role as more a babysitter whose purpose is to keep her safe, teach only self-help skills, not challenge academically, and pacify parents that this is the most our child is capable of. Case in point, my daughter was in sixth grade last school year. I went in to observe a “science experiment” in which her teacher was guiding the class. The teacher had bought these little paleontology activities- lumps of hard packed sand that surrounded small plastic dinosaurs. The children were allowed to chisel away at the sand to search for the dinosaur. There was no preliminary discussion about paleontology, or relating the activity to the digging up of fossils, no explanation of what fossils are, no stories about dinosaurs or comparisons between meat eaters and plant eaters, not even a comparison of the different structures of the dinosaurs the children revealed. There was no follow up activity at all. The only activity I observed on this day was six children chipping away at a lump of sand. My daughter didn’t even find her dinosaur. I asked her what she learned from the activity, and her response was “I don’t know.” This is a perfect example of a teacher having low expectations of a child’s potential academic achievement. Her plan for the day was to keep the kids busy and out of trouble, not challenge them to achieve a higher level of understanding about the world in which they live. I found an article that discussed Arthur Binet’s battery of tests that sought to assign an IQ to a child to whom they were administered, and a psychologist named Cyril Burt who claimed that based on the IQ, a child’s academic potential is set. Binet used the information from the IQ tests to determine strengths and weaknesses so that the educational program enhanced the child’s educational experience; Burt used the IQ tests to pigeon-hole a student into a particular tract. In the sphere of education today, educators are supposed to be embracing Binet’s “cup half full” ideal of academic expectation, but the reality is that many teachers ascribe to Burt’s “cup half empty” idea that you can’t put a gallon of milk into a pint jug. Students will fulfill the prophesies that their parents and teachers give them- low expectations will yield low effort and poor results, whereas high expectations yield stronger effort and good results. The concept works for children with disabilities every bit as much as their contemporaries without.

Cooperative Teaching
Cooperative teaching is described as "an educational approach in which general and special educators work in co-active and coordinated fashion to jointly teach heterogeneous groups of students in educational settings…In cooperative teaching, both general and special educators are simultaneously present in general classroom, maintaining joint responsibilities for specified education instruction that is to occur in the setting" (Bauwens, Hourcade, & Friend, 1989, pg.36)

In collaborative teaching, both the general education and special education instructors bring their own set of skills, training, and resources to the team. This combination enriches the educational benefits for the students in the class. Whereas, the general education teacher's strengths tend to lie in the content area, the special education teacher brings the assessment and adaptation specialization to the classroom. An effective collaborative team will work together in all areas of planning, teaching, and assessment.

Teachers need preparation and classroom support from administration for collaborative teaching to be a success. Joint planning time is essential and must be consistent throughout the school year. Individualized instruction, multiple learning styles, team teaching, frequent evaluations and joint planning are all beneficial to every student in the class. Combined expertise and planning helps the instructors to meet the need of all learners in the classroom.

Regular Education Teachers' Rights in Special Education
Many regular education teachers do not understand their rights regarding special education. First and foremost, the regular education teacher has the right to seek help for any student in their class they believe needs special assistance. Teachers have a duty to provide the best possible educational opportunities to all children in their classroom, and as such, it is their responsibility to refer any child for evaluation that they feel would benefit from additional services/resources. The ADA does recognize teachers as child advocates; therefore, retaliation, intimidation and reprisals for teachers who advocate for children are forbidden. The regular education teacher has the right to know all information that is pertinent to the referred child's education, and has the right to receive teacher training needed to serve said child. The general education teacher has the right to participate in the IEP process so that all their questions regarding the education of said child can be asked and answered. The regular teacher has the right to request special materials and related services be provided in the regular classroom to meet the needs of the special education child, and has the right to participate in assessing the effectiveness of the program. The general education teacher should above all be treated like a professional and should never be treated as soldier expected to carry out a general's orders. They have the right to ask questions and to act as an advocate for all the children in the classroom. If the placement of a special needs child in the regular education classroom is having an adverse effect on the other students in the class, the special education child's right to learn in "the least restrictive environment" should not outweigh the right of other students to learn in a safe, nurturing and peaceful environment. The general education teacher has the right to voice their concerns in this matter as well.

Skills Needed by All Teachers
There are certain skills that should be utilized by educators, not just those in special education. Teaching is a complex process, one which requires planning, time management, and organization. Educators need to decide what their teaching priorities are so that they understand how to use their instructional time wisely. Devise a blueprint and stick to it. Map out the methods and exercises you are going to use in the classroom that will maximize the time you have with your students. Vary your teaching and learning methods (teacher lead instruction, student oriented tasks, group projects, peer tutoring). Model concepts and lessons and ask for feedback from your students. Give your students opportunities to contribute and ask questions. Make your expectations clear and encourage your students to become active in the learning process. Reevaluate the strategies that you use in the classroom to determine the ones of greatest value. Prepare lessons that are interesting, keep students on task and provide instruction that is relevant.

Conclusion
All teachers need the skill and knowledge to work with special needs students. Mainstreaming and inclusion are part of our current school system, and most students with disabilities spend the majority of their day in a regular education classroom. Therefore, all teachers need to be trained in methods or strategies for teaching special needs students. All students, even those deemed "regular education students" need specialized attention and instructional plans to assure that they will achieve their very best.

Take the time to read your students' files. Read about their disabilities and learn as much as you possibly can about their needs before they come to your classroom. Educate yourself about the laws concerning special education and work as an advocate for all students in your classroom. The future of our world depends on the leadership and dedication of our teachers to assure that the next generation is prepared for what lies ahead. All of our students are "special", and as educators, we need to meet them at their present educational levels and help them build their own path for success

Terminology
Free Appropriate Public Education (FAPE) refers to special education and related services that: are provided at public expense, under public supervision and direction, and without charge; meet requirements of the Virginia Board of Education; include preschool, elementary school, middle school, or secondary school education in the state; and are provided in keeping with an individualized education program.

Individualized Education Plan (IEP) is a written statement for a child with a disability that is developed, reviewed, and revised in a team meeting. The IEP specifies the individual educational needs of the child and what special education and related services are necessary to meet the child's needs.

Least Restrictive Environment (LRE) means that children with disabilities are educated with children without disabilities to the maximum extent appropriate. The child must not be placed in special classes or separate schools unless education in regular education classes with aids and services cannot be achieved satisfactorily.

Section 504 of The Vocational Rehabilitation Act of 1973 states that people cannot be excluded from any federally funded program because of their handicapping condition. A handicapping condition is defined as " any physical or mental impairment that substantially limits one or more life activities." In this case, school staff must develop a plan that provides the student with need services or changes to the regular school program. One of the frequent reasons for the 504 plan is related to student who have been diagnosed as ADD or ADHD.

Multiple Choice Questions
Click to reveal the answer.

Essay Question
Click to reveal a sample response.


text:
Social and Cultural Foundations of American Education/Dynamic Learning Environment/Fun and Joy

It has been said that we learn something new every day from the day we are born. What are these things? Well it can be anything from learning the a b c‘s, riding a bike, or repairing a car engine. Many of the skills or new information we learn throughout our lives are learned in a school or college and for many, they are things that are carried with them through the rest of their lives.

From preschool all the way to college, one common thing that we all learn is to make transition. What I mean by this is from early in preschool all the way to middle school, learning was fun. Most of us learned our alphabets by singing along with a nice tune. We got to play with blocks to learn shapes and put pieces together. So what happened to the fun once we grew up and the classes became longer? Those who teach or are being taught now aren’t having as much fun in the classroom as when they were younger, and for some, aren’t really retaining the information as well because they aren’t being engaged enough. Couldn’t there be a way to keep learning fun and exciting for any age group? Of course there can. It doesn’t have to be all fun and games, but it doesn’t also have to be boring and bland either.

According to John Luckner, integrating fun activities into teaching can help strengthen students’ communication skills, builds self confidence, and help instill a greater appreciation of alternate forms of education. (Luckner 33)

Enthusiasm and laughter can also go a long way in any classroom, which is why there can be fun and joy in a learning environment but it must be incorporated with the fundamentals of learning for all learning types.

Enthusiasm
If a teacher walks into a classroom full of students, back slumped and the look of not wanting to be there, then the students aren’t going to be all too excited to be there either. In their minds they are probably thinking about how tired they are from getting up early or how they can’t wait to get home to watch their favorite show. But if a teacher comes in with their head up high with a huge smile and a positive attitude, it will most likely get the students to smile as well and probably wonder why their teacher is smiling. Ron Clark, teacher and author of The Essential 11 describes in his book how he would capture his student’s attention by moving around and throwing his whole body and self into his lessons. Once they saw just how enthusiastic Mr. Clark was about teaching them, they soon became enthusiastic about learning from him. (Clark 20)

Creativity
Just coming in with a smile and positive attitude is not the only thing a teacher must do to get the students active in learning. As a part of planning the school day, teachers are responsible for a number of tasks. The most important task is how to make learning creative and enjoyable for all students. Some creative ways to spark a student’s mind to learn are songs centered around the subject being taught, toys or props, games, and more. There is an endless list of techniques and tools that are to get and keep the student’s engaged in learning, but it takes a teacher’s devotion and creative mind to bring it out.

Here are some fun activities to spark a student’s mind from Education World™ http://www.education-world.com/:
 * Quotations of the day
 * "Every Day" Activities Across the Curriculum
 * Journal Writing Every Day
 * Find it Fast! – a fast paced review of any subject
 * The Dictionary Game – Students guess the real meaning of unfamiliar words

6th Grade teacher Deb Odom used comics to help her students learn new vocabulary and also help develop their own creative minds by creating their own comics to reinforce what they were learning. This proves that with the right creativity and motivation, anything can be a tool and aid in the classroom to add a little fun and excitement to learning.

If as a teacher you don’t feel like you have a creative mind, but are enthusiastic about teaching and helping students learn, don’t worry! There are plenty of resources out there to give you many ideas and activities to add fun to your lessons.

Technology in the Classroom
Technology is growing bigger and better each day and has definitely come a long way over the years, and it is evident in today’s classrooms. Many schools have computers in each classroom, television, and smart boards “an interactive that is a large, touch-sensitive display that is placed on a wall or floor stand in classrooms, meeting rooms, boardrooms and other places where people gather to meet, teach, train and present.” (Wikipedia) The smart board is primarily connected to a computer so that a teacher can upload presentations, pictures, or other media to be projected to the class. This piece of technology is certainly different than the old chalk and blackboard. With this new method, teachers can implement many types of techniques and tools to go along with their lesson plans in a very fun and organized way.

“In today's world of video games, cable and satellite television, and high action digital video, teachers need to integrate technology in order to keep the attention of their students.” (Wikipedia)

Technology can be a very fun and engaging addition to the learning environment. A teacher can incorporate visual and auditory technologies into their lessons to promote a fun learning environment. This can be anywhere from watching a movie, listening to an audio disk, or playing a computer game. A fun activity utilizing the computer in a classroom where available is to have the students go on a virtual treasure hunt that goes with the subject they are learning. You can provide a list of certain things they must hunt for using the web.

By including some technology in the lesson plans, it not only keeps the classroom a fun and exciting place to be but it also helps to enrich the learning process by giving it that extra “wow” factor.

All for Fun and Fun for All!
Preschoolers and elementary schoolers are not the only ones who can have fun learning. Learning can be fun for all ages! Some ways a teacher can promote fun in a class of high schoolers or even college aged students are through fun stories, often about personal life experiences that can give them something to relate to, competition games such as classroom trivia, or lively class debate. No matter what the age, learning can be fun for everyone of any age. It is just a matter of finding and channeling that fun to make what is being learned more enjoyable.

In a learning environment such as a classroom, it is up to the teacher to figure out how and what kind of activities would help keep everyone interested and also help enrich everyone’s learning. Don’t fret. Again, if you are stumped as to what kinds of activities would make learning fun, search the web or ask other teachers how they keep their students engaged in learning and at the same time having fun doing it!

Multiple Choice Questions
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Essay Question
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text:
User:ChrisWallace

I was a lecturer at the University of the West of England in Bristol, where I taught web development and information systems.

Since retiring I have a variety of interests: cruising, data [XQuery], 3D printing[ working with OpenSCAD and Python.

I've a website and blog Tumblr and I'm on Twitter @kitwallace

also KitWallace2

title: User:ChrisWallace


text:
XQuery/Parsing Query Strings

= Motivation = Normal http query strings use the ampersand (&) character in order to differentiate between different terms in a query string. However, because ampersands also are used as the start of entities within HTML and XML, this can make it difficult encoding parametric content into XML links, and it moreover makes it difficult to visually decipher query strings.

This program illustrates how to parse query strings using alternative delimiters (such as the semi-colon).

This program demonstrates some standard XQuery functions that are not part of the original XQuery specification but are required for precise web server XQuery functionality.

The functions are:
 * exist request:get-method
 * exist util:unescape-uri
 * exist request:get-query-string
 * exist request:get-parameter
 * exist request:get-parameter-names

Namespace
module namespace common= "http://www.example.org/xmlns/common" ;

Platform

 * eXist

common:get-parameters
This base function retrieves the query string from the URI, parses the string using the given delimiter and creates an XML structure of the form

common:get-parameter
This function retrieves a sequence of string values corresponding to the values for a given parameter key given in the query string. Note that while typically there will be only one string in the sequence, if you have a query string of the form ?a=val1;b=val2;a=val3 then get-parameter("a","",";") will return ("val1","val3")

common:get-parameter-names
This function retrieves the name of each query string key (once and only once per key).

Example Program
Assumes query string of

let $msg := common:get-parameter("c","",";") return $msg returns new message

returns

let $seq1 := common:get-parameter("a",0,";") return sum(for $n in $seq1 return number($n))

returns 13

title: XQuery/Parsing Query Strings


text:
User:Ling.Nut

...just to thwart impostors, actually. Nothing to see here. Move along.

title: User:Ling.Nut


text:
User talk:Wendyb,durham

Come introduce yourself at the new users page. If you have any questions, you can ask there or contact me personally. --Stefán Örvarr Sigmundsson 01:03, 24 August 2007 (UTC)

title: User talk:Wendyb,durham


text:
User talk:61.88.131.147

You have been warned
manov antric argan job bigyan 2409:4089:8110:A28D:0:0:1BEE:AC (discuss) 08:48, 22 April 2023 (UTC)

title: User talk:61.88.131.147


text:
User talk:T.Jones

Come introduce yourself at the new users page. If you have any questions, you can ask there or contact me personally. Mattb112885 (talk to me) 01:44, 24 August 2007 (UTC)

Userspace subpages
There's no big problem with what you're doing on User:T.Jones, but generally your userpage is reserved as a Wikibooks profile, and stuff you're working on is kept in subpages. Compare with my userpage: User:Mike.lifeguard. If you like, you can move this project to a subpage, and use your userpage as an introduction for the community to see. If you need help with anything, feel free to contact me on my talk page, or ask the community at the staff lounge. Happy editing! – Mike.lifeguard  | talk 13:52, 22 September 2007 (UTC)

title: User talk:T.Jones


text:
Wikijunior:World at Work/Candy maker

fr:Wikijunior:Le monde au travail/Confiseur

title: Wikijunior:World at Work/Candy maker


text:
User talk:Whitknight

adf

title: User talk:Whitknight


text:
User:Whitknight

adf

title: User:Whitknight


text:
User talk:Sheece~enwikibooks

Come introduce yourself at the new users page. If you have any questions, you can ask there or contact me personally. Webaware talk 07:01, 24 August 2007 (UTC)

Your account will be renamed
Hello,

The developer team at Wikimedia is making some changes to how accounts work, as part of our on-going efforts to provide new and better tools for our users like cross-wiki notifications. These changes will mean you have the same account name everywhere. This will let us give you new features that will help you edit and discuss better, and allow more flexible user permissions for tools. One of the side-effects of this is that user accounts will now have to be unique across all 900 Wikimedia wikis. See the announcement for more information.

Unfortunately, your account clashes with another account also called Sheece. To make sure that both of you can use all Wikimedia projects in future, we have reserved the name Sheece~enwikibooks that only you will have. If you like it, you don't have to do anything. If you do not like it, you can pick out a different name.

Your account will still work as before, and you will be credited for all your edits made so far, but you will have to use the new account name when you log in.

Sorry for the inconvenience.

Yours, Keegan Peterzell Community Liaison, Wikimedia Foundation 23:44, 17 March 2015 (UTC)

Renamed
 This account has been renamed as part of single-user login finalisation. If you own this account you can |log in using your previous username and password for more information. If you do not like this account's new name, you can choose your own using this form after logging in: . -- Keegan (WMF) (talk) 05:29, 19 April 2015 (UTC)

title: User talk:Sheece~enwikibooks


text:
User:Bennyboyz3000

Hello everyone! I am Ben, known also as Bennyboyz3000 on the English Wikipedia. Please message me there with any concerns :-)

title: User:Bennyboyz3000


text:
Cookbook:Serrano Chili

| Chili Pepper

A serrano pepper is a type of chili pepper that originated in the mountainous regions of the Mexican states of Puebla and Hidalgo. Unripe serranos are green, but the color at maturity varies. Common colors are red, brown, orange, or yellow. Serranos are very meaty and thus they do not dry very well. They are generally between 1 and 4 inches long (2.5 to 10 cm) and around ½ inch (1 cm) wide.

Most serranos rate between 10,000 and 20,000 Scoville units.

title: Cookbook:Serrano Chili


text:
Radiation Oncology/Endometrium/Staging

Current staging
Endometrial Carcinomas

FIGO Staging (2023)

PMID 37593813 -- "FIGO staging of endometrial cancer: 2023"

 * Stage I  -   Confined to the uterine corpus and ovary
 * IA - Disease limited to the endometrium OR non-aggressive histological type, i.e., low-grade endometroid, with invasion of less than half of myometrium with no or focal LVSI OR good prognosis disease
 * IA1 : Non-aggressive histological type limited to an endometrial polyp OR confined to the endometrium
 * IA2 : Non-aggressive histological types involving less than half of the myometrium with no or focal LVSI
 * IA3 : Low-grade endometrioid carcinomas limited to the uterus and ovary
 * IB - Non-aggressive histological types with invasion of half or more of the myometrium, and with no or focal LVSI
 * IC - Aggressive histological types limited to a polyp or confined to the endometrium
 * Stage II  -   Invasion of cervical stroma without extrauterine extension OR with substantial LVSI OR aggressive histological types with myometrial invasion
 * IIA - Invasion of the cervical stroma of non-aggressive histological types
 * IIB - Substantial LVSI of non-aggressive histological types
 * IIC - Aggressive histological types with any myometrial involvement
 * Stage III  -   Local and/or regional spread of the tumor of any histological subtype
 * IIIA - Invasion of uterine serosa, adnexa, or both by direct extension or metastasis
 * IIIA1 : Spread to ovary or fallopian tube (except when meeting stage IA3 criteria)
 * IIIA2 : Involvement of uterine subserosa or spread through the uterine serosa
 * IIIB - Metastasis or direct spread to the vagina and/or to the parametria or pelvic peritoneum
 * IIIB1 : Metastasis or direct spread to the vagina and/or the parametria
 * IIIB2 : Metastasis to the pelvic peritoneum
 * IIIC - Metastasis to the pelvic or para-aortic lymph nodes or both
 * IIIC1 : Metastasis to the pelvic lymph nodes   {IIIC1i: micrometastasis; IIIC1ii: macrometastasis}
 * IIIC2 : Metastasis to para-aortic lymph nodes up to the renal vessels, with or without metastasis to the pelvic lymph nodes  {IIIC2i: micrometastasis; IIIC2ii: macrometastasis}
 * Stage IV  -   Spread to the bladder mucosa and/or intestinal mucosa and/or distant metastasis
 * IVA - Invasion of the bladder mucosa and/or the intestinal/bowel mucosa
 * IVB - Abdominal peritoneal metastasis beyond the pelvis
 * IVC - Distant metastasis, including metastasis to any extra-or intra-abdominal lymph nodes above the renal vessels, lungs, liver, brain, or bone

Staging footnotes:

 * Disease limited to low-grade endometrioid carcinomas involving the endometrium and ovaries (Stage IA3) must be distinguished from extensive spread of the endometrial carcinoma to the ovary (Stage IIIA1), by the following criteria: 1) no more than superficial myometrial invasion is present (<50%); 2) absence of extensive/substantial LVSI; 3) absence of additional metastases; and 4) the ovarian tumor is unilateral, limited to the ovary, without capsule invasion/rupture (equivalent to pT1a).
 * LVSI: LVSI as defined in WHO 2021: extensive/substantial, ≥5 vessels involved.
 * Aggressive histological types:
 * non-aggressive: G1-2 EEC.
 * aggressive: G3 EEC, serous, clear cell, undifferentiated, mixed, mesonephric-like, gastrointestinal mucinous type carcinomas, and carcinosarcomas

AJCC 7th Edition (2009)
 * Corresponds to updated FIGO staging (2009)
 * FIGO 2009 PMID 19345353 -- "Revised FIGO staging for carcinoma of the endometrium."

 * This staging now applies only to endometrial carcinomas and there is now a separate staging for uterine sarcomas.
 * Carcinosarcomas (MMMT) should be staged as high grade carcinoma.

Primary Tumor: (FIGO Stage in parentheses)
 * Note: FIGO uses pathologic staging

 * Tis - in situ
 * Note: FIGO no longer includes Stage 0
 * T1 (I) - confined to corpus
 * T1a (IA) - limited to endometrium or invades less than 1/2 of myometrium
 * T1b (IB) - invades ≥ 1/2 of myometrium
 * T2 (II) - invades stromal tissue of the cervix but does not extend beyond uterus
 * Note: endocervical glandular involvement only should be considered as Stage I not Stage II
 * T3
 * T3a (IIIA) - involves serosa and/or adnexa (direct extension or metastasis)
 * T3b (IIIB) - vaginal involvement (direct extension or metastasis) or parametrial involvement
 * T4 (IVA) - invades bladder mucosa and/or bowel mucosa

Regional Lymph Nodes:
 * N0 - none
 * N1 (IIIC1) - metastasis to pelvic lymph nodes
 * N2 (IIIC2) - metastasis to para-aortic lymph nodes
 * Note: Regional nodes include obturator, internal iliac, external iliac, common iliac, para-aortic, presacral, and parametrial
 * Note: For pathologic staging, FIGO classifies cases with <6 resected LNs as pNX

Distant Metastases:
 * M0 - none
 * M1 (IVB) - distant metastasis - includes inguinal LN, intraperitoneal disease (including omentum), lung, liver, or bone.

Stage Grouping:
 * Corresponds to FIGO stage given above (in parentheses)

Changes from 6th Edition:
 * No longer includes uterine sarcoma (now staged with a new staging system)
 * Positive peritoneal cytology is no longer considered (previously was T3a/IIIA)
 * Involvement of the endocervical glands is no longer considered (previously was Stage IIA)
 * Stages IA+IB combined (now: IA). IC moved to IB.
 * Stage IIIC subdivided into IIIC1 and IIIC2.

Older staging systems
FIGO moved to surgical staging in 1988 (AJCC 6th edition same). There is also a clinical staging system developed by FIGO in 1971.

Note: until the update of the FIGO / AJCC in 2009, uterine sarcomas and carcinomas were staged using the same system

AJCC 6th Edition (2002)
 * IA - Limited to endometrium
 * IB - < 1/2 of myometrium
 * IC - 1/2 or more of myometrium
 * II - invades cervix
 * IIA - glandular epithelium of endocervix
 * IIB - stroma of cervix
 * III - extra-uterine
 * IIIA - involves serosa and/or adnexa (direct extension or mets) and/or ascites or positive peritoneal washings
 * IIIB - vaginal involvement (direct extension or mets)
 * IIIC - LN+ (pelvic and/or paraaortic)
 * IV - other organs
 * IVA - bladder or bowel
 * IVB - distant mets

Clinical staging
Staging is now surgical (see above), but clinical staging may be utilized for non-operative pts.

FIGO 1971

 * I - Confined to corpus
 * IA - Length of uterine cavity 8 cm or less
 * IB - Length of uterine cavity > 8 cm
 * II - Involves corpus and cervix, but no extension beyond the uterus
 * III - Extends outside uterus but not outside true pelvis
 * IV - Outside the true pelvis or involves bladder or rectum
 * IVA - Involves bladder, rectum, sigmoid, or small bowel
 * IVB - Distant mets

title: Radiation Oncology/Endometrium/Staging


text:
Radiation Oncology/Endometrium/Overview

Epidemiology

 * Most common GYN malignancy in United States (incidence 44K, deaths 7.5K)
 * Classically two forms:
 * Type I: typically endometriorid, low-grade tumors, estrogen-related
 * Type II: typically papillary serous or clear cell; high-grade tumors, not estrogen related
 * More recently based on genomic and proteomic profiling, 4 clusters
 * Ultramutated group, PolE mutation (involved in DNA repair), low MSI instability
 * Hypermutated group, high MSI instability
 * Low mutation group, low MSI instability, low copy number
 * Low mutation group, extensive copy number, high TP53 mutation. This has mostly serous-like tumors and some Grade 3 endometrioid
 * Risk factors for Type I (primarily related to long-term estrogen exposure):
 * Exogenous estrogen: postmenopausal women treated with unopposed estrogen have 10X risk
 * Endogenous estrogen: obesity, functional ovarian tumors
 * Chronic anovulation (e.g. PCO)
 * Tamoxifen: due to pro-estrogenic properties in endometrium (unlike anti-estrogenic properties in breast)
 * Diseases: Hypertension, diabetes, breast cancer
 * Age: 75% in post-menopausal women
 * Hereditary: HNPCC
 * Protective factors for Type I:
 * Combination oral contraceptives
 * Physical activity
 * Smoking
 * Risk factors for Type II - none known

Screening

 * Society of Gynecological Oncologists and American College of Obstetricians and Gynecologists guidelines:
 * There is no standard screening test
 * Routine screening is not recommended because of the lack of an appropriate, cost-effective, and acceptable test that reduces mortality

Clinical Presentation

 * Abnormal uterine bleeding (~90% cases); even one drop of blood in a postmenopausal woman on HRT is worrisome
 * However, only 5-20% of postmenopausal women with abnormal uterine bleeding will have endometrial CA (most commonly due to atrophy)
 * Bleeding due to superficial necrosis of the tumor expanding into the uterine cavity
 * Endometrial cells on Pap smear (though <50% of cancer patients have abnormal cells on Pap smear)

Work-Up

 * Endometrial biopsy: office procedure, well tolerated, high sensitivity, low cost
 * Hysteroscopy with dilation and curettage (D&C): higher yield, but higher complications
 * Transvaginal ultrasound: normal endometrial thickness ("stripe") is 4-5 mm; average thickness is 20 mm for endometrial CA
 * CT of abdomen/pelvis typically not necessary, unless suspicion of extra-pelvic disease
 * MRI is best modality for assessing myometrial invasion and cervical involvement, but provides no additional information if surgery is planned anyway
 * CA-125 is useful for estimating extra-uterine/nodal spread

Anatomy

 * Primary site
 * Lower boundary is the isthmus
 * Denoted exteriorly by slight constriction that translates interiorly into the internal os.
 * Average length in non-pregnant uterus is ~0.5cm
 * Frequently located about 1/3 of the way up from external os
 * Develops in utero from interaction between downgrowth of Muellerian mesoderm and upgrowth of mesodermic fibers from forming vaginal vault
 * Lower uterine segment develops during pregnancy from isthmus + superior cervical canal, as the uterus expands to hold the fetus
 * Upper two thirds of the uterus, above isthmus, is the corpus
 * Portion of the corpus above the line joining the tubo-uterine openings is the fundus
 * Wall is made of three layers
 * Endometrium: glandular tissue + basal layer
 * Myometrium: smooth muscle fibers with rich lymphatic network
 * Serosa: visceral peritoneum
 * Nulliparous uterus is ~7.5 cm long (cervix 2.5 cm + corpus 5.0 cm); uterine cavity is ~6 cm long; the wall is ~1.2 cm thick

 * Lymphatics
 * Superior fundus drains parallel to ovarian vessels into para-aortic lymph nodes
 * Middle/lower uterus drains through broad ligaments to pelvic lymph nodes (obturator, internal iliac, external iliac, common iliac, presacral)
 * Few lymphatics drain through round ligaments to the superficial inguinal lymph nodes
 * As a result, nodal mets can occur at any level and in any combination

 * Distant spread
 * Lung
 * Vagina

Pathology

 * Epithelial tumors. For mesenchymal tumors, please see the uterine sarcomas page
 * Type I(5-year OS)
 * Endometrioid carcinoma (83%) - grouped based on degree of differentiation
 * Adenocarcinoma
 * Adenoacanthoma (adenocarcinoma with benign squamous metaplasia) - graded according to glandular component
 * Adenosquamous carcinoma (mixed adenocarcinoma and squamous cell carcinoma) (81%)
 * Type II
 * Papillary serous adenocarcinoma (53%)
 * Clear cell adenocarcinoma (63%)
 * Rare
 * Mucinous adenocarcinoma (77%)

 * Endometrioid (75-80%)
 * Most are well-differentiated, with proliferation of endometrial glands without intervening stroma
 * Endometrial hyperplasia is thought to be a precursor lesion developed with unopposed estrogen and genetic events
 * Simple vs complex hyperplasia based on glandular architecture
 * Cytologic atypia increases risk of progression to carcinoma (complex atypical hyperplasia risk ~30%)
 * Cells show microsatellite instability, PTEN, and k-ras mutations
 * Clear cell (5-10%)
 * Clear due to presence of glycogen
 * Tubulocystic, papillary, or solid patterns
 * Psammoma bodies not as common
 * Have to be present in at least 25-50% (depending on pathologist) of sample to qualify as clear cell
 * Aggressive, with myometrial invasion in ~80%
 * Papillary serous (1-5%)
 * Complex papillary architecture, similar to papillary serous CA of ovary
 * Presence of psammoma bodies
 * Marked nuclear atypia
 * Believed to transform from endometrial surface epithelium
 * Mixed pattern
 * Serous and endometrioid histology present next to each other in the specimen
 * If >50% serous component, classified as papillary serous
 * If 10-50% serous component, classified as mixed serous
 * Rare tumor types (<2%)
 * Mucinous, squamous cell, transitional cell, small cell

Grade - evaluation based on the glandular (adeno) component

Treatment Overview

 * Surgery is the primary treatment modality. Most patients should have a full surgical staging, including complete lymph node dissection, which is both diagnostic and improves survival
 * Low-risk patients typically do not require adjuvant therapy; argument can be made for vaginal brachytherapy in Stage IC Grade 3 disease
 * Intermediate-risk treatment is contentious. RT decreases local recurrence, but there is no impact on survival, at the cost of side-effects. Specific role of EBRT, brachytherapy, chemotherapy, and various combinations needs to be clarified
 * High-risk treatment is also controversial; role of brachytherapy, pelvic RT, whole abdominal RT, chemotherapy, and combinations also needs to be clarified

Types of Surgery
Classes of hysterectomy:
 * Piver classification, 1974 - PMID 4417035 — "Five classes of extended hysterectomy for women with cervical cancer." Piver MS et al. Obstet Gynecol. 1974 Aug;44(2):265-72.
 * Class I - Total (Simple Extrafascial) Abdominal Hysterectomy - removes just the uterus and a small rim of vaginal cuff.
 * Class II - Modified Radical Hysterectomy - removes uterus, a 1-2 cm cuff of vagina, wide excision of parametrial and paravaginal tissues (median half of cardinal and uterosacral ligaments). The ureters and uterine arteries and only partially mobilized (as in Class III). Ligates uterine artery at ureter. (Limited to cervical cancers with invasion up to 5 mm).
 * Class III - Radical Hysterectomy (Wertheim-Meigs procedure) - classic operation. Removes uterus and upper 1/3 to 1/2 of vagina. Dissection of paravaginal and parametrial tissues to the pelvic sidewalls. Ligates uterine artery at its origin at the internal iliac artery. Pelvic lymphadenectomy.
 * Class IV - Extended Radical Hysterectomy - same as Class III but adds full mobilization of the ureters past the bladder (which is the point to which they are mobilized in the Class II and Ill procedures). Removes more paracervical tissue medial to the uteter.
 * Class V - Pelvic Exenteration - Anterior exenteration removes uterus, tubes, ovaries, vagina, and bladder. Posterior exenteration removes uterus, tubes, ovaries, and rectosigmoid.  Total exenteration removes all pelvic organs.

 * The Netherlands (2007-2009) -- total abdominal hysterectomy vs total laparoscopic hysterectomy
 * Randomized. 283 patients, 21 hospitals, Stage I endometrioid CA or complex atypical hyperplasia. Arm 1) total laparoscopic hysterectomy (TLH) vs Arm 2) total abdominal hysterectomy (TAH). Primary outcome major complication rate
 * 2010 PMID 20638901 -- "Safety of laparoscopy versus laparotomy in early-stage endometrial cancer: a randomised trial." (Mourits MJ, Lancet Oncol. 2010 Aug;11(8):763-71. Epub 2010 Jul 16.)
 * Outcome: major complications TLH 15% vs TAH 15% (NS); minor complications 13% vs 12% (NS). Conversion to laparotomy 11%. TLH significantly less blood loss, pain medication use, hospital LOS and faster recovery; however, procedure took longer
 * Conclusion: No difference in complication rate, less pain and better resumption of daily activities with TLH

 * ILIADE Study, Italy (1998-2004) -- extrafascial hysterectomy vs modified radical hysterectomy
 * Randomized. 520 patients, clinical Stage I endometrial CA. Arm 1) Standard extrafascial (Class I) hysterectomy vs Arm 2) Modified radical (Class II) hysterectomy. Adjuvant therapy risk adapted: if low risk, observation; if intermediate risk (IC and no PLND, IIIA cytology) +/- EBRT +/- BT; if high risk (IIB, IIIA adnexal mets) doxorubicin/cisplatin + EBRT. No difference in adjuvant therapies between arms. Primary endpoint OS
 * 2009 PMID 19834767 -- "Modified Radical Hysterectomy Versus Extrafascial Hysterectomy in the Treatment of Stage I Endometrial Cancer: Results From the ILIADE Randomized Study." (Signorelli M, Ann Surg Oncol. 2009 Oct 16. [Epub ahead of print]) Median F/U 5.8 years
 * Outcome: Median length of vagina removed standard 5mm vs. modified radical 15mm (SS); length of parametria 15mm vs 20mm (SS). OR time and blood loss higher for modified radical. 5-year DFS 88% vs. 90% (NS); 5-year OS 89% vs. 92% (NS). Vaginal cuff recurrence 1% vs. 1% (NS), pelvic recurrence 4% vs. 4% (NS), distant recurrence 5% vs. 5% (NS)
 * Conclusion: Class II hysterectomy didn't improve LRC or survival for clinical Stage I patients. However, if adequate cuff transection not feasible with Class I, recommend modified radical hysterectomy

 * GOG LAP2 (1996-2005) -- laparoscopy vs open laparotomy
 * Randomized. 1682 patients with clinical Stage I-IIA uterine cancer. Arm 1) laparoscopy vs Arm 2) open laparotomy. Surgery included hysterectomy, BSO, pelvic and para-aortic LND. Conversion from laparoscopy to laparotomy in 26% (poor visibility 15%, mets 4%)
 * 2009 PMID 19805679 -- "Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2." (Walker JL, J Clin Oncol. 2009 Nov 10;27(32):5331-6. Epub 2009 Oct 5.)
 * Outcome: Operative time laparoscopy 204 minutes vs laparotomy 130 minutes (SS). Hospitalization >2 days 52% vs 94% (SS). Complete P/PALND 92% vs 96% (SS). No difference in assessment of tumor stage
 * Toxicity: No difference in intra-op complications. Postop complications laparoscopy 14% vs laparotomy 21% (SS).
 * Conclusion: Laparoscopic surgery is feasible and safe, with fewer post-op complications
 * 2012 PMID 22291074 -- "Recurrence and Survival After Random Assignment to Laparoscopy Versus Laparotomy for Comprehensive Surgical Staging of Uterine Cancer: Gynecologic Oncology Group LAP2 Study." (Walker JL, et al. J Clin Oncol. 2012;30(7):695–700)
 * Outcome: Median followup 59 months for 2,181 patients. Identical 5-yr survival rate in both arms (89.8%). HR for laparoscopy relative to laparotomy was 1.14 (90% lower bound, 0.92; 95% upper bound, 1.46) (NS). 3-yr recurrence rate - 11.4% laparoscopy and 10.2% Laparotomy. Laparoscopy is SAFE

Surgical staging studies

 * SEER 2014 PMID 25194213 -- "Contemporary analysis of pelvic and para-aortic metastasis in endometrial cancer using the SEER registry." (Katsoulakis E, et al. Int J of Gyn and Obst. 2014; 127(3):293-6.)
 * 4052 patients with stage IA-IIB Endometrioid adenocarcinoma. The incidence of pelvic and para-aortic lymph node involvement was determined. Results: Incidence of pelvic and para-aortic metastases were: 1% and 0% in stage IA, grade 1 disease; 2% and 0% in IA, grade 2; 2% and 1% in IA, grade 3; 2% and 0% in IB, grade 1; 3% and 1% in IB, grade 2; 3% and 2% in IB, grade 3; 7% and 3% in IC, grade 1; 8% and 5% in IC, grade 2; 12% and 8% in IC, grade3; 7% and 3% in IIA, grade 1; 10% and 4% in IIA, grade 2; 10% and 5% in IIA, grade 3; 8% and 4% in IIB grade 1; 13% and 8% in IIB, grade 2; 19% and 12% in IIB, grade 3.
 * Conclusion: Incidence of pelvic and para-aortic metastases were lower than previously reported in GOG 33. Patients with higher stages and grade had a 10% or higher risk of lymph node involvement and might benefit from aggressive therapy.

 * GOG 33 (1977-83)
 * Prospective. 933/1180 patients evaluable, 43 institutions. Endometrial C Stage I and II occult (by curettage), any histologic type. Abdominal hysterectomy, BSO, peritoneal cytology, selective pelvic/aortic LN sampling (not full dissection). Goal to determine incidence of pelvic/aortic LNs as a function of prognostic factors (site of tumor, grade, depth of invasion, capillary space involvement, adnexal metastasis); no prescription for post-op management
 * Extrauterine risk; 1987 - PMID 3652025 — "Surgical pathologic spread patterns of endometrial cancer. A Gynecologic Oncology Group Study." Creasman WT et al. Cancer. 1987 Oct 15;60(8 Suppl):2035-41.
 * 621 patients with clinical Stage I. Underwent TAH/BSO, selective pelvis and para-aortic lymphadenectomy, peritoneal cytology, endocervical curettage prior to surgery to rule out occult Stage II disease.
 * Myometrial invasion (middle/deep): 41%; more likely with higher grade (G1 22%, G2 44%, G3 58%)
 * Risk of higher stage on surgery: washings+ (IIIA) 12%, adnexa+ (IIIA) 5%, peritoneal mets+ (IIIA) 6%, pelvic LN+ (IIIC) 9%, PA LN+ (IIIC) 5%, LVSI+ 15%
 * Risk of pelvic LN+: Grade (G1 3%, G2 9%, G3 18%); myometrial invasion (superficial 5%, middle 6%, deep 25%); washings+ (7% vs. 25%); adnexal mets (8% vs. 32%); peritoneal mets (7% vs. 51%); LVSI+ (7% vs. 27%). Myometrial invasion more important than grade
 * Risk of PA LN+: similar as pelvic LN, also papillary/clear cell type (5% vs. 18%)
 * Positive nodes grossly enlarged only 10% of the time, thus dissection is needed, not just palpation alone.
 * Risk groups (for nodes):
 * Low Risk: Grade 1, endometrium only, no intraperitoneal disease -- 0% pelvic LN, 0% PA
 * Moderate Risk: inner or middle myometrial invasion, Grade 2 or 3, no intraperitoneal disease -- one factor only: 3% pelvic, 2% PA. two factors: 6% pelvic, 2% PA
 * High Risk: deep myometrial invasion only (18% pelvic, 15% PA), intraperitoneal disease (33%, 8%), both (61%, 30%)
 * Recurrence risk; 1991 - PMID 1989916 — "Relationship between surgical-pathological risk factors and outcome in clinical stage I and II carcinoma of the endometrium: a Gynecologic Oncology Group study." Morrow CP et al. Gynecol Oncol. 1991 Jan;40(1):55-65.
 * 895 patients, Stage I and II (occult), clear cell and papillary serous excluded. Managed per individual physician preference, without restrictions.
 * Risk of recurrence: Stage (IA 1%, inner 8%, middle 14%, outer 15%); Grade (1 4%, 2 12%, 3 18%)
 * Risk factors: Mets (PLN+, PALN+, adnexa+, R2) > Grade 3 > IC > LVI+ = washings+ > LUS cytology+, LVI+, LUS/Cervix+
 * 47 of 48 pts with para-aortic LN had either 1) grossly positive pelvic LN (32% of PLN+), 2) grossly positive adnexal mets (23%), 3) LVI+ (19%) or 4) IC (17%).
 * 5-year DFS: 92.7% (no extrauterine disease), 69.8% (Stage II), 56% (positive peritoneal washings), 55% (vascular space invasion), 57.8% (LN+ or adnexal mets), 41.2% (PALN+).
 * Conclusion: High probability for PALN+ in IC and G2-3 lesions; significant prognostic information of PALN+, but ~40% survival, so even patients with PALN+ can be cured

Quick and easy way of estimating LN risk:

Lower Uterine Segment
 * Brown University, 2007 (1999-2004) PMID 17157904 -- "The prognostic significance of lower uterine segment involvement in surgically staged endometrial cancer patients with negative nodes." (Brown AK, Gynecol Oncol. 2007 Apr;105(1):55-8.)
 * Retrospective. 147 patients with TAH/BSO and pathologically negative LNs. 57% had LUS involvement. High risk histology 25%, LVI+ 29%, IC 39%. Follow-up 6.2 years. Not indicated whether/what RT they received
 * Outcome: PFS LUS+ 5.8 years vs. LUS- 5.25 years (NS). Recurrence did not correlate with LUS status on multivariate analysis, only LVI+
 * Conclusion: In patients with negative LNs, disease within LUS does not imply worse prognosis

Lymphadenectomy

 * Controversy over whether it is better to do extensive nodal staging or do limited/no nodal staging and frequent adjuvant therapy
 * Society of Gynecological Oncologists and American College of Obstetricians and Gynecologists guidelines:
 * "Most women with endometrial cancer should undergo complete systematic surgical staging (including assessment of lymph nodes) to help determine appropriate management"
 * Some surgeons believe that visual inspection/palpation is sufficient for Stage IA-B Grade 1-2 based on PMID 16977653, since survival 94-97% regardless
 * There are no randomized trials to compare LN sampling vs. full LND, but SEER data as well as other series suggest that complete lymphadenectomy is both diagnostic (for RT field extent) and therapeutic (for improved survival)
 * However, the MRC ASTEC randomized trial suggests that performing a pelvic lymph node dissection does not improve outcomes for women with early stage endometrial cancer

 * Oxford PMID 20091639 -- "Lymphadenectomy for the management of endometrial cancer." (May K, Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007585.)
 * Cochrane meta-analysis. 2 RCT, 1851 women with presumed Stage I
 * Outcome: No difference in OS (HR 1.07, NS) and RFS (HR 1.23, NS)
 * Toxicity: Lymphadenectomy higher risk of surgically-related morbidity
 * Conclusion: No evidence that lymphadenectomy decreases risk of death or disease recurrence, but more surgically-related morbidity

 * MRC ASTEC -- no PLND vs PLND
 * Randomized. 1408 women, endometrial CA, clinically confined to corpus. Arm 1) Surgery only (hysterectomy + BSO, peritoneal washings, palpation of PA nodes; suspicious PA nodes could be sampled, 5% done) vs. Arm 2) surgery + lymphadenectomy (iliac and obturator nodes, PA node sampling at discretion of surgeon). Patients at intermediate/high risk (high grade, IC, or IIA) further randomized to the ASTEC adjuvant RT trial, 33% randomized. Primary outcome OS
 * 2009 PMID 19070889 -- "Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study." (Kitchener H, Lancet. 2009 Jan 10;373(9658):125-36. Epub 2008 Dec 16.). Median F/U 3 years
 * Outcome: In PLND arm, 9% had involved nodes (median 12 nodes removed). 5-year OS no PLND 81% vs PLND 80% (NS); two thirds died of their disease (NS)
 * Conclusion: No evidence for benefit of pelvic LND in early endometrial CA

 * Italian Trial -- no PLND vs PLND
 * Randomized. •514 patients with clinical 1988 stage IB-C endometrial cancer (endometrioid or adenosquamous), excluding 1988 stage IB FIGO grade 1 on intra-op frozen path, underwent TAH-BSO and randomized to Arm 1) Pelvic LND (para-aortic LND at surgeon's discretion) vs Arm 2) No pelvic LND (could remove bulky LN >1cm on palpation). Adjuvant therapy at physician's discretion. Primary endpoint OS.
 * 2008 PMID 19033573 -- "Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial." (Pancini, J Natl Cancer Inst. 2008 Dec 3;100(23):1707-16. Median F/U 4.1 years
 * Outcome:
 * Median LN removed = 30 in PLND arm (median pelvic LN = 26, 26% had para-aortic LN’s removed) vs 0 in no PLND arm (22% had LN removed)
 * More early and late post-operative complications with PLND
 * Improved staging with PLND (positive LN found in 13% vs 3%, P<0.001)
 * No difference in adjuvant treatment (69% vs 65%, P=0.07 PLND vs no PLND)
 * No difference in 5 yr DFS (81% vs 82%, P=0.68), PLND vs no PLND
 * No difference in 5 yr OS (86% vs 90%, P=0.50), PLND vs no PLND
 * Conclusion: PLND is prognostic but not therapeutic, improving staging but not affecting outcome.
 * Criticism: PMID 19509367- No systemic para-aortic LND, adjuvant therapy not standardized, included relatively low risk population (evidenced by only 13% with pelvic LN mets).

 * US SEER data, 2006 (1988-2001) PMID 16977653 -- "Therapeutic role of lymph node resection in endometrioid corpus cancer: a study of 12,333 patients." (Chan JK, Cancer. 2006 Oct 15;107(8):1823-30.)
 * Population-based. 12,333 women who underwent surgical staging with lymph node assessment; 73% Stage I.
 * In intermediate/high-risk patients (IB G3, IC, II-IV): more extensive LN dissection (1, 2-5, 6-10, 11-20, >20) associated with improved 5-year DFS (75%, 82%, 84%, 85%, 87%, SS); In stage IIIC-IV: survival benefit 51%, 53%, 60%, 72% (SS)
 * In low-risk patients (IA G1-3, IB G1-2): no benefit of LN dissection
 * Conclusion: Extent of LN dissection improves survival in intermediate/high-risk groups

 * Duke, 2005 (1973-2002) - PMID 15738538 — "Retrospective analysis of selective lymphadenectomy in apparent early-stage endometrial cancer." Cragun JM et al. J Clin Oncol. 2005 Jun 1;23(16):3668-75.
 * Retrospective. 509 pts. Clinical stage I-IIA.
 * Pts with poorly differentiated tumors and more than 11 lymph nodes removed had improved survival and PFS compared with those with < 11 LN. Number of nodes removed was not predictive for grades 1-2.

 * University of Alabama, 1995 (1969-90) - PMID 7821843 — "Adenocarcinoma of the endometrium: survival comparisons of patients with and without pelvic node sampling." Kilgore LC et al. Gynecol Oncol. 1995 Jan;56(1):29-33.
 * Retrospective study. 649 pts. Compared multiple site pelvic node sampling (mean 11 nodes) vs limited site sampling (mean 4 nodes) vs no sampling.
 * Conclusion: Improved overall survival for pts with multiple site sampling vs no sampling

Lymphedema risk
 * MSKCC, 2006 (1993-2004) PMID 16740298 -- "The incidence of symptomatic lower-extremity lymphedema following treatment of uterine corpus malignancies: a 12-year experience at Memorial Sloan-Kettering Cancer Center." (Abu-Rustum NR, Gynecol Oncol. 2006 Nov;103(2):714-8.)
 * Retrospective. 1289 patients, 74 patients with lymphedema due to other medical condition excluded. Median F/U 3 years
 * Rate of lymphedema: overall 1.2%; initial surgery 2.4% vs. later 0% (SS); >10 LN removed 3.4% vs. <10 LN 0% (SS). Developed median 5 months after surgery; unilateral 69%, bilateral 31%
 * Conclusion: Lymphedema risk highest for >10 LN and LND during initial operation (3.4%); overall rates reasonably low (1.2%)

Lymphocele
 * Seen postoperatively in up to 30% of GYN surgeries with pelvic/para-aortic LND
 * Believed to arise from surgical transsection or inadequate ligation of draining lymphatics
 * Lymphatic fluid may accumulate in various pelvic and retroperitoneal compartments
 * Small lymphoceles typically resorb spontaneously
 * Large lymphoceles may cause compression symptoms, and may result in abdominal distention, abdominal and pelvic pain, hydronephrosis, bladder dysfunction, constipation, tenesmus, edema of the ipsilateral leg and of the genitalia, and thromboembolism of iliac vessels
 * Infection may cause fever, chills, and sepsis
 * Symptomatic lymphoceles are typically managed initially with percutaneous CT-guided drainage, surgical therapy may be required

Other Resources

 * eContouring Webinar - Gynecological Cancers with Arno Mundt III, M.D.

To add:
 * Creasman WT, Gyn Oncol 1976

title: Radiation Oncology/Endometrium/Overview