What are the treatment options for ovarian and endometrial cancer?

Treatment Options for Ovarian and Endometrial Cancer

For both ovarian and endometrial cancer, the primary treatment approach should be surgical cytoreduction followed by stage-appropriate adjuvant therapy, with specific regimens determined by histology, stage, and risk factors. 1

Endometrial Cancer Treatment

Diagnostic Workup

• Family history assessment
• Clinical and gynecological examination
• Transvaginal ultrasound
• Complete pathology assessment (histotype and grade)
• Chest X-ray
• Contrast-enhanced MRI (best for assessing myometrial invasion and cervical involvement) 1
• Abdominal CT (to investigate extrapelvic disease)

Surgical Management by Stage

1. Stage I:

   • Total hysterectomy and bilateral salpingo-oophorectomy
   • Ovarian preservation can be considered in women <45 years with <50% myometrial invasion and no extra-uterine disease 1

2. Stage II:

   • Total hysterectomy and bilateral salpingo-oophorectomy
   • Modified radical hysterectomy if needed for free margins
   • Lymph node dissection 1

3. Stage III-IV:

   • Complete macroscopic cytoreduction (including metastases resection) when feasible
   • For patients with poor performance status: multimodality treatment 1

Adjuvant Treatment by Risk Group

1. Low Risk (Stage IA/IB, Grade 1-2, endometrioid histology):

   • No adjuvant therapy recommended 1

2. Intermediate Risk:

   • Adjuvant pelvic radiotherapy reduces pelvic/vaginal relapses but doesn't impact overall survival
   • For patients with ≥2 risk factors (age ≥60, deep invasion, G3 tumors): pelvic/intravaginal radiotherapy recommended 1

3. High Risk:

   • Pelvic radiotherapy for locoregional control
   • Consider adjuvant chemotherapy for survival benefit 1

4. Stage III-IV:

   • Cisplatin and doxorubicin combination significantly improves progression-free and overall survival compared to radiation therapy alone in optimally debulked disease 1
   • Alternative: carboplatin and paclitaxel (less toxicity) 1
   • For stage III with positive peritoneal cytology only: treat according to other clinicopathological factors 1
   • For stage IIIC (nodal involvement): extended field radiotherapy including pelvic and para-aortic nodes 1

Fertility-Preserving Options

For patients with atypical hyperplasia/endometrial intraepithelial neoplasia or Grade 1 endometrioid carcinoma:

• Medroxyprogesterone acetate or megestrol acetate
• Progestin-loaded IUD as an option
• Hysterectomy and salpingo-oophorectomy recommended after childbearing 1, 2

Ovarian Cancer Treatment

Surgical Management

1. Early Stage (I-II):

   • Hysterectomy
   • Bilateral salpingo-oophorectomy
   • Omentectomy
   • Lymphadenectomy 3

2. Advanced Stage (III-IV):

   • Primary cytoreductive surgery (removal of all visible cancer)
   • For inoperable cases: neoadjuvant chemotherapy followed by interval debulking surgery 3

Adjuvant Treatment

1. Early Stage:

   • Adjuvant platinum-based chemotherapy (carboplatin and paclitaxel) 3
   • For stage IA/IB mucinous tumors: observation may be appropriate 1

2. Advanced Stage:

   • Carboplatin and paclitaxel chemotherapy
   • Consider maintenance therapy with bevacizumab and/or PARP inhibitors 3
   • For mucinous carcinomas: consider gastrointestinal regimens (5-FU/leucovorin/oxaliplatin or capecitabine/oxaliplatin) 1

3. Recurrent Disease:

   • Carboplatin is indicated for palliative treatment of recurrent disease, including in patients previously treated with cisplatin 4

Special Considerations

Endometrioid Ovarian Carcinoma (Stage IIB)

• Adjuvant pelvic radiotherapy (with or without intravaginal component) following surgery
• Alternative: platinum-based chemotherapy (carboplatin plus paclitaxel) 5

Mucinous Ovarian Tumors

• Appendectomy recommended during primary surgery
• Gastrointestinal evaluation and CEA level to distinguish primary from metastatic disease
• PAX8 immunostaining may be useful for differentiation 1

Hormone Therapy

• Progestational agents (medroxyprogesterone acetate 200 mg daily) are active in steroid-receptor positive tumors (G1 and G2 lesions) 1, 2
• Not recommended as adjuvant treatment in early-stage endometrial cancer as they don't increase survival 1

Prognosis and Outcomes

• Early-stage ovarian cancer: 5-year overall survival of 70-95% 3
• Advanced-stage ovarian cancer: 5-year overall survival of 10-40% 3
• Endometrial cancer: prognosis depends on stage, histology, and risk factors, with most stage I-II patients having favorable outcomes 6

Common Pitfalls to Avoid

1. Underestimating the importance of complete surgical staging in both cancers
2. Using progestational agents as adjuvant therapy in early-stage endometrial cancer
3. Treating mucinous ovarian tumors with standard epithelial ovarian cancer regimens without considering gastrointestinal regimens
4. Failing to consider fertility-sparing options in appropriate young patients
5. Not recognizing that stage IV endometrial cancer has worse outcomes than stage IV ovarian cancer despite similar treatment approaches 7