Endometrial Carcinoma Treatment & Management

Updated: Apr 08, 2021
  • Author: William T Creasman, MD; Chief Editor: Leslie M Randall, MD, MAS, FACS  more...
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Treatment

Approach Considerations

Standard management of endometrial cancer at diagnosis involves surgery, followed by chemotherapy and/or radiation therapy. [1]  In the setting of recurrent disease, secondary cytoreduction has been associated with progression-free (PFS) and overall (OS) survival. [13] Prognostic factors for improved long-term OS were the absence of residual disease following surgical resection and histotype. [13]

Lymph node metastasis is an important concern in patients with high-risk early or advanced endometrial cancer. [14, 15] In evaluating data from 523 French surgical patients over a 12-year period, Bendifallah et al developed a predictive model to identify those at high risk for lymph node metastases using the histopathologic features of histologic grade, tumor diameter, depth of myometrial invasion, and status of lymphovascular space involvement. [14] In a different study, Fotopoulou et al reported that, on the basis of anatomic distribution of positive lymph nodes, when lymphadenectomy is performed for those with high-risk early or advanced disease, the procedure should contain pelvic and para-aortic areas up to the renal vessels to ensure accuracy in the evaluation of all potential positive nodes. [15]

Two randomized trials by Seagle et al examined the association of lymphadenectomy with overall survival in women with stage I endometrioid and node-negative, stage I to IIIB endometrial cancer. One study reported that performance of pelvic lymphadenectomy was associated with increased survival compared with no lymphadenectomy (5-year survival [95% CI], 91.4% [90.2% to 92.6%] v 87.3% [85.9% to 88.8%]; HR, 0.71 [95% CI, 0.64 to 0.78]; P< .001). This study also reported that the addition of para-aortic lymphadenectomy was associated with increased survival compared with pelvic lymphadenectomy alone (5-year survival [95% CI], 91.0% [89.8% to 92.2%] v 89.8% [88.4% to 91.1%]; HR, 0.85 [95% CI, 0.77 to 0.95]; P = .003). [16] Another study concluded that increased lymph node count is associated with a 1% to 14% decreased risk of death per each additional five lymph nodes removed and a 5% to 20% increased 5-year survival among women with pathologically node-negative endometrioid and serous endometrial cancers. [17]

Surgery should be used in conjunction with chemotherapy with a taxane and a platinum compound (eg, paclitaxel plus carboplatin). For more information on chemotherapy regimens, see Endometrial Cancer Treatment Protocols.

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Surgical Care

Since 1988, FIGO, whose Gynecologic Oncology Committee was responsible for the staging of gynecological cancer, recommended that corpus cancer be staged surgically. Previously, clinical evaluation was used for staging, and multiple studies noted the inaccuracy of clinical staging compared with surgical pathological findings. Therefore, once the diagnosis of endometrial cancer has been made, routine presurgical evaluation is performed to assess operability.

Note the following:

  • Special studies, such as CT scans of the abdomen and pelvis or MRIs, are not routinely performed.

  • Once preoperative evaluation, which may include a chest radiograph, ECG, and appropriate blood studies, has been performed and the results are found to be normal, the patient is deemed a surgical candidate. Then, a total hysterectomy, bilateral salpingo-oophorectomy, peritoneal cytology, and pelvic and para-aortic lymphadenectomy are performed.

  • Obviously, if intraperitoneal disease is identified at the time of surgery, attempts are made at surgical removal.

  • Staging is then determined based on surgical pathologic findings (see Staging). Subsequent therapy, if needed, is then determined, depending on the surgical pathological findings of the operative procedure.

  • Data extracted from the SEER database indicate that among women younger than 60 years with stage 1B and 1C endometrioid adenocarcinoma who underwent lymphadenectomy were less likely to undergo full pelvic radiation and more likely to receive brachytherapy; furthermore, the extent of lymphadenectomy influenced the receipt of radiotherapy. [18]

A 2012 review found that for early stage primary endometrioid adenocarcinoma of the endometrium, laparoscopy and laparotomy are associated with similar rates of disease-free and overall survival and that laparoscopy is associated with reduced operative morbidity and shorter hospital stays. [19]

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Pharmacologic Therapy

Treatment of endometrial cancer needs to be individualized depending on patient factors and disease stage (eg, limit disease to the uterus, review suspected or gross cervical involvement, review suspected extrauterine disease). Although surgery is the mainstay of therapy for most endometrial cancers, nonsurgical treatments, such as radiation therapy, chemotherapy, and hormonal therapy, can play a role. The majority of these therapies are used as adjuvant/adjunctive therapy, in the treatment of recurrences or metastatic disease, or in patients who are unable to have surgery.

For women who are not surgical candidates and have uterine-confined disease, external beam radiotherapy (EBRT) and/or brachytherapy is the preferred treatment. The use of adjuvant radiotherapy (RT) improves pelvic control in patients with selected risk factors and may improve progression-free survival (PFS) but failed to improve overall survival (OS) in clinical trials. However, many of the subjects in these trials were at low risk (ie, had low-risk intrauterine pathologic risk factors). Studies have shown that PFS improved, but there was no OS advantage with adjuvant sequential chemotherapy/RT in patients with the highest-risk uterine-confined disease. [20]

In the adjuvant setting, carboplatin/paclitaxel is the preferred regimen for high-risk uterine-confined disease. For patients with extrauterine disease, systemic therapy is recommended as adjuvant therapy. For stage IIIA to IIC disease, systemic therapy and/or EBRT, with or without vaginal brachytherapy, is recommended. For stage IVA/IVB disease, systemic therapy and EBRT, with or without vaginal brachytherapy, is the mainstay of treatment. [20]

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