Adenocarcinoma of the endometrium occurs predominantly in postmenopausal women, for whom vaginal bleeding is a notable symptom. For this reason, the diagnosis is often made relatively early in the course of the disease, and disease control rates are good.Survival rates of 85% to 90% can be expected for patients with clinical stage I disease. Survival rates for patients with stage II or III disease are significantly lower, approximately 65% and 35%, respectively. In every stage of disease, poorly differentiated (grade 3) and deeply invasive tumors have a less favorable outlook. Regional lymph node metastases occur in a higher proportion of patients than previously suspected and are much more common in patients with poorly differentiated or advanced lesions involving the cervix or extending beyond the uterus.Overwhelming evidence supports the role of radiation for the treatment of endometrial carcinoma in terms of local control; however, little evidence is available to suggest that it improves survival. Radiation therapy does reduce the frequency of pelvic recurrences and may improve survival rates among patients with high-risk disease characteristics.A possible approach to selecting EBRT or ICRT for patients in various risk groups is illustrated in Figure 30-6. Patients with grade 1 or 2 disease with no myometrial invasion are unlikely to benefit from adjuvant radiation therapy. Patients with stage IA, grade 3 disease have a low incidence of lymph node involvement, and vaginal brachytherapy alone is probably adequate to ensure optimal local control and minimal sequelae. Patients with stage IB, grade 1 or 2 tumors probably do not need any form of radiation therapy, but patients with stage IB, grade 3 tumors probably can benefit from vaginal brachytherapy alone. The patients most likely to benefit from pelvic radiation include those with high-grade disease or deep muscle invasion. This is true regardless of whether lymph node sampling has been performed. If patients have had extensive surgical staging or have other risk factors for serious bowel sequelae after pelvic radiation therapy, consideration should be given to treatment with vaginal applicators alone. Adding chemotherapy to individually tailored radiation therapy may improve survival for patients with endometrial carcinoma with high-risk features by improving local control and reducing distant metastasis while minimizing damage to normal tissues.