What is the management of carcinoma endometrium?

Management of Carcinoma Endometrium

The primary treatment for endometrial carcinoma is total hysterectomy with bilateral salpingo-oophorectomy, with adjuvant therapy determined by stage, grade, and histology. Management varies significantly based on disease stage and risk stratification, requiring a stage-specific approach to optimize survival outcomes.

Surgical Management

Primary Surgery

• Total hysterectomy with bilateral salpingo-oophorectomy (TH-BSO) is the cornerstone of treatment 1
• Complete surgical staging should include:
  • Peritoneal fluid collection/washings
  • Thorough exploration of abdominal cavity
  • Assessment of pelvic and para-aortic lymph nodes 1
  • Omentectomy in high-risk cases

Lymph Node Assessment

• Pelvic lymphadenectomy is performed on therapeutic and prognostic grounds 2
• Women can be stratified intraoperatively into "low-risk" and "high-risk" groups to identify those who will benefit from thorough lymphadenectomy 2
• Para-aortic nodal clearance is an option for higher-risk disease 3

Surgical Approach

• Minimally invasive techniques (laparoscopic approach) have transformed management of early-stage disease 4
• For advanced disease, debulking surgery with bowel resection and/or partial bladder resection may be necessary 3

Stage-Specific Management

Stage I Disease

• Low risk (Stage IA, Grade 1-2, endometrioid): TH-BSO without adjuvant therapy 3, 1
• Intermediate risk (Stage IA, Grade 3 or Stage IB, Grade 1-2):
  • Adjuvant pelvic radiotherapy significantly reduces pelvic/vaginal relapses but has no impact on overall survival 3
  • For patients with two of three risk factors (age ≥60 years, deeply invasive or G3 tumors), adjuvant pelvic radiotherapy may be recommended 3
• High risk (Stage IB, Grade 3): Pelvic radiotherapy recommended to increase loco-regional control 3

Stage II Disease

• Stage IIA: Treated as Stage I based on risk factors 3
• Stage IIB: Extended radical hysterectomy, bilateral salpingo-oophorectomy and lymph node dissection 3
  • Postoperative external pelvic radiotherapy with brachytherapy boost is standard 3

Stage III Disease

• Maximal surgical cytoreduction for patients with good performance status 3
• Postoperative management:
  • Stage IIIA: Options include postoperative pelvic radiotherapy, abdomino-pelvic radiotherapy, or chemotherapy 3
  • Stage IIIB: Pelvic external beam irradiation with brachytherapy 3
  • Stage IIIC (pelvic nodes): Postoperative pelvic radiotherapy ± brachytherapy boost 3
  • Stage IIIC (para-aortic nodes): Extended postoperative radiotherapy (pelvic and para-aortic) ± brachytherapy 3

Stage IV Disease

• Cytoreductive surgery with total hysterectomy plus BSO, gut resection if possible, and partial/total bladder resection with urinary diversion 3
• For Stage IVB: Anterior or posterior pelvectomy depending on location with pelvic clearance 3
• Options include postoperative pelvic radiotherapy ± brachytherapy and clinical trials of hormone therapy or chemotherapy 3

Adjuvant Therapy

Radiotherapy

• External beam radiotherapy: For higher-risk disease to reduce pelvic recurrence
• Vaginal brachytherapy: Option for intermediate-risk disease
• Preoperative radiotherapy is not recommended for Stage I disease 3

Chemotherapy

• Platinum-based chemotherapy recommended for Stage III disease 1
• Cisplatin and doxorubicin combination significantly improves progression-free survival and overall survival in optimally debulked Stage III and IV disease compared to whole abdominal radiation therapy 3
• Carboplatin plus paclitaxel represents an efficacious, low-toxicity alternative regimen 5
• Due to toxicity considerations, carboplatin and paclitaxel may be preferred over cisplatin and doxorubicin 3

Hormonal Therapy

• Progestational agents (medroxyprogesterone acetate 200 mg daily) are active in steroid-receptor positive tumors (mostly G1 and G2 lesions) 3, 6
• Indicated for adjunctive therapy and palliative treatment of inoperable, recurrent, and metastatic endometrial carcinoma 6
• Not recommended as adjuvant therapy in low-stage endometrial cancer as it does not increase survival 3

Follow-Up Protocol

• Most recurrences occur within the first 3 years after treatment 3
• Recommended follow-up schedule:
  • 3-4 monthly evaluations with history, physical and gynecological examination for the first 3 years
  • 6-month intervals during the fourth and fifth years
  • Annually thereafter 3, 1
• Focus on early detection of vaginal or pelvic recurrences 3
• Routine technical examinations such as PAP smears or systematic radiography are of unproven benefit 3

Special Considerations

Fertility Preservation

• May be considered in young patients with well-differentiated (Grade 1) endometrioid adenocarcinoma limited to the endometrium 1

Genetic Testing

• Universal testing of endometrial carcinomas for mismatch repair genes is recommended, especially in young patients, to consider Lynch syndrome testing 1

Common Pitfalls

• Failing to consider patient factors (obesity, uterine position) that may limit diagnostic accuracy 1
• Not correlating imaging findings with histological grade and other risk factors 1
• Inadequate surgical staging leading to suboptimal adjuvant therapy decisions
• Overlooking the importance of lymph node assessment in high-risk cases

The management of endometrial carcinoma requires careful risk stratification and a stage-specific approach to optimize survival outcomes while minimizing treatment-related morbidity.