What is the treatment approach for endometrial cancer, specifically in relation to the Rainbo trial?

The RAINBO Trial and Endometrial Cancer Treatment

I cannot provide specific information about the RAINBO trial as it is not included in the evidence provided. However, I can outline the current evidence-based treatment approach for endometrial cancer based on the most recent and highest quality guidelines available.

Current Standard Treatment Framework

Total hysterectomy with bilateral salpingo-oophorectomy remains the cornerstone of endometrial cancer treatment, with minimally invasive approaches preferred over laparotomy for equivalent oncologic outcomes and superior perioperative benefits. 1, 2

Surgical Approach by Stage

Stage I Disease (75% of patients):

• Perform total hysterectomy with bilateral salpingo-oophorectomy as primary treatment 3, 1
• Minimally invasive surgery (laparoscopic or robotic) is preferred, particularly in obese patients who experience significantly lower major complication rates 1, 2
• Routine systematic pelvic lymphadenectomy does NOT improve overall survival or disease-free survival in stage I disease 3, 1, 2
• Lymphadenectomy should be reserved for intermediate-to-high-risk endometrioid cancer for prognostic information and to guide adjuvant therapy 1, 2

Stage II Disease:

• Extended radical hysterectomy with bilateral salpingo-oophorectomy and pelvic/para-aortic lymph node dissection for confirmed cervical stromal invasion 3
• If cervical involvement suspected preoperatively (MRI or biopsy), proceed directly to radical approach 3

Stage III Disease:

• Maximal surgical cytoreduction in patients with good performance status 3
• Total hysterectomy with bilateral salpingo-oophorectomy, with consideration for bowel resection and omental involvement 3

Stage IV Disease:

• Stage IVA: Anterior or posterior pelvic exenteration depending on tumor location 3
• Stage IVB: Systemic therapeutic approach with palliative surgery considered based on patient status 3

Risk-Stratified Adjuvant Therapy

Low-Risk Disease (Stage IA, Grade 1-2, endometrioid histology):

• Surgery alone is adequate; no adjuvant therapy required 1, 2

Intermediate-Risk Disease (Stage IB, Grade 1-2):

• Vaginal brachytherapy is recommended to maximize local control with minimal side effects 1, 2
• External beam pelvic radiotherapy reduces locoregional recurrence but does NOT improve overall survival 3, 1

High-Risk Disease (Stage IB Grade 3, deep myometrial invasion, non-endometrioid histology):

• Pelvic radiotherapy recommended for locoregional control 3
• Platinum-based chemotherapy should be considered, as combined modality treatment shows 36% reduction in risk of relapse 3
• The combination of chemotherapy plus radiotherapy demonstrates improved cancer-specific survival (HR 0.55,95% CI 0.35-0.88; P = 0.01) 3

Stage III-IV Disease:

• Platinum-based chemotherapy is preferred over radiotherapy alone 3
• GOG-122 trial demonstrated significant improvement in progression-free survival (50% vs 38%) and overall survival (55% vs 42%) favoring doxorubicin-cisplatin chemotherapy over whole abdominal radiation 3
• Paclitaxel-based combination regimens (carboplatin/paclitaxel or cisplatin/doxorubicin/paclitaxel) achieve response rates >60% and are preferred for first-line treatment 3

Medically Inoperable Patients

For patients with significant comorbidities (obesity, cardiac disease, diabetes):

• External beam radiotherapy and/or brachytherapy are acceptable alternatives 3, 1, 2
• This applies to 5-10% of patients who are not surgical candidates 1

Critical Pitfalls to Avoid

• Never perform routine lymphadenectomy in stage I disease - it increases lymphoedema risk without survival benefit 3, 1, 2
• Do not use adjuvant progestins - they do not increase survival in low-stage endometrial cancer 3
• Never perform uterine morcellation without ruling out malignancy - this risks spreading cancerous tissue 2
• Recognize that clinical staging alone underestimates disease extent 2

Recurrent Disease Management

Locoregional Recurrence:

• Vaginal recurrence: Radiation therapy (external beam plus vaginal brachytherapy) achieves 50% 5-year survival 3
• Central pelvic recurrence: Surgery or radiation therapy 3
• Regional pelvic recurrence: Radiation therapy combined with chemotherapy if possible 3

Metastatic Disease:

• Hormonal therapy (progestins, tamoxifen, aromatase inhibitors) for well-differentiated endometrioid histologies with overall response ~25% 3
• Platinum compounds, anthracyclines, and taxanes achieve response rates up to 40% in chemotherapy-naïve patients 3
• Paclitaxel-based combinations preferred for first-line treatment of advanced/recurrent disease 3