What is the treatment for low-grade endometrial adenocarcinoma?

Treatment for Low-Grade Endometrial Adenocarcinoma

For low-grade endometrial adenocarcinoma (grade 1 or 2 with superficial myometrial invasion <50%), the standard treatment is total hysterectomy with bilateral salpingo-oophorectomy without adjuvant therapy. 1

Surgical Management

Primary Surgery

• Total hysterectomy with bilateral salpingo-oophorectomy is the cornerstone of treatment for low-grade endometrial adenocarcinoma 1
• Peritoneal fluid or washings should be obtained during the procedure 1
• Thorough exploration of the abdominal cavity and pelvic areas should be performed 1

Lymph Node Assessment

• For low-risk endometrial carcinoma (grade 1 or 2 with superficial myometrial invasion <50%), lymphadenectomy is not recommended as it provides no survival benefit 1
• The risk of lymph node involvement in low-grade, superficially invasive tumors is very low 1
• Two randomized controlled trials have demonstrated no survival benefit from systematic lymphadenectomy in these patients 1

Surgical Staging

• Endometrial carcinoma is surgically staged according to the FIGO system 1
• Low-risk disease is defined as stage Ia/Ib, grade 1 or 2, with endometrioid histology 1
• Preoperative assessment should include chest X-ray, clinical and gynecological examination, transvaginal ultrasound, blood counts, and liver and renal function profiles 1
• Contrast-enhanced dynamic MRI is the best method to assess uterine and locoregional pelvic extension 1

Adjuvant Therapy

Low-Risk Disease

• For low-risk endometrial adenocarcinoma (stage Ia/Ib, grade 1 or 2), no adjuvant therapy is recommended 1
• The 5-year disease-free survival for surgically staged patients with endometrial carcinoma confined to the uterine corpus is approximately 93%, with overall survival of 98% 2

Intermediate-Risk Disease

• For intermediate-risk disease (deep myometrial invasion >50% or grade 3 with superficial invasion <50%), adjuvant pelvic radiotherapy reduces the risk of pelvic/vaginal relapses but has no impact on overall survival 1
• Within the intermediate-risk group, patients with two of three major risk factors (age ≥60 years, deeply invasive or G3 tumors) have a loco-regional relapse rate >15% and may benefit from adjuvant pelvic radiotherapy 1

Progestational Agents

• The adjuvant administration of progestational agents in low-stage endometrial cancer does not increase survival and is not recommended 1
• However, progestational agents (e.g., medroxyprogesterone acetate 200 mg daily) are active in steroid receptor-positive tumors (mostly G1 and G2 lesions) in advanced or recurrent disease 1

Special Considerations

Fertility Preservation

• For young women with grade 1 endometrial adenocarcinoma who wish to preserve fertility, conservative management with progestin therapy may be considered 1
• Studies show that approximately 76% of patients respond to progestin treatment, with a median time to response of 12 weeks 3
• However, about 24% of initial responders may experience recurrence, with a median time to recurrence of 19 months 3
• Close follow-up is essential as recurrent disease may require definitive surgical management 3

Follow-Up

• Most recurrences occur within the first 3 years after treatment 1
• Follow-up evaluations with history, physical and gynecological examination are recommended every 3-4 months for the first 3 years 1
• Follow-up intervals of 6 months are recommended during the fourth and fifth years, and annually thereafter 1
• Early detection of isolated vaginal or pelvic relapses should be the main focus of follow-up, as these can often be salvaged with radiation therapy 1, 2

Treatment Outcomes

• Conservative management of properly staged low-risk endometrial carcinoma patients is highly effective 2
• The small risk of recurrence (approximately 5% in Stage IB disease) can often be successfully salvaged with radiation therapy 2
• For all Stage I patients, the 5-year disease-free survival is approximately 93% and the 5-year overall survival is 98% 2

By following these evidence-based recommendations, optimal outcomes can be achieved for patients with low-grade endometrial adenocarcinoma while minimizing unnecessary treatments and their associated morbidity.