Primary Treatment for Endometrial Cancer
The primary treatment for endometrial cancer is total hysterectomy with bilateral salpingo-oophorectomy (TH/BSO), which serves as the cornerstone of management for this malignancy. 1
Surgical Management
Standard Surgical Approach
- Total hysterectomy with bilateral salpingo-oophorectomy (TH/BSO) is the mainstay of treatment for apparent uterine-confined endometrial cancer 1
- Surgery must include systematic exploration, inspection, and palpation of the entire abdomen 1
- Peritoneal cytology should be obtained, although it no longer affects FIGO staging 1
- The surgical procedure can be performed through laparotomy, vaginally, or via minimally invasive techniques such as laparoscopy or robotic surgery 1
Lymph Node Assessment
- Pelvic nodal dissection provides important prognostic information that may alter treatment decisions 1
- Para-aortic nodal evaluation may be utilized for staging high-risk tumors (deeply invasive lesions, high-grade histology, serous adenocarcinoma, clear cell carcinoma) 1
- Sentinel lymph node mapping may be considered in selected patients (category 2B recommendation) 1
Special Considerations
- Modified radical hysterectomy (Piver type II) is recommended for stage II cancers with macroscopic cervical lesions 1
- Omentectomy is commonly performed in tumors with serous adenocarcinoma, clear cell adenocarcinoma, or carcinosarcoma histology 1
- For advanced disease (stage III), debulking surgery with total hysterectomy, BSO, bowel resection if possible, and partial/total bladder resection if possible is standard 1
Adjuvant Treatment Based on Risk Stratification
Low-Risk Disease
- For grade 1 and 2 stage IA tumors, follow-up alone is standard after surgery 1
- Low-risk disease is adequately managed with surgery alone 2
Intermediate-Risk Disease
- For grade 1 and 2 stage IB tumors, options include vaginal brachytherapy or follow-up alone 1
- In high-intermediate risk endometrial cancer, adjuvant vaginal brachytherapy is recommended to maximize local control 2
High-Risk Disease
- For grade 3 stage IB tumors and stage IC disease, external pelvic radiotherapy with or without vaginal brachytherapy boost or vaginal brachytherapy alone are options 1
- For stage III disease, postoperative external radiotherapy with brachytherapy should be undertaken 1
- For high-risk endometrial cancer, particularly stage III disease, combined chemoradiation has shown improved recurrence-free and overall survival 1, 2
Molecular Classification and Future Directions
- Recent molecular studies have identified four endometrial cancer molecular classes that have stronger prognostic impact than traditional histopathological characteristics 2
- Integration of molecular factors may lead to more personalized adjuvant treatment approaches in the future 2
Common Pitfalls and Caveats
- Preoperative imaging has an important role in evaluation of operability but no examination is sufficiently sensitive and specific to distinguish between stage I and stage II disease 1
- CA125 is of no diagnostic value for endometrial cancer but may predict extra-uterine extension at levels >35 U/ml 1
- Fertility-sparing options should only be considered in well-differentiated (grade 1) endometrioid adenocarcinoma limited to the endometrium in patients who wish to preserve fertility 1
- Ovarian preservation may be considered in young women (aged <50 years) with low-grade, early-stage endometrioid endometrial cancer as it has not been demonstrated to worsen overall survival 1