What are the management options for carcinoma endometrium?

Management of Carcinoma Endometrium

The cornerstone of endometrial cancer management is total hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO), with adjuvant therapy determined by surgical stage, tumor grade, depth of myometrial invasion, and histologic subtype. 1

Primary Surgical Management

All patients with endometrial cancer should undergo comprehensive surgical staging as the foundation of treatment. 1

Standard Surgical Procedure

• Total extrafascial hysterectomy with bilateral salpingo-oophorectomy via open, laparoscopic, or vaginal approach 1
• Peritoneal washings for cytology obtained at the start of surgery 1
• Systematic inspection and palpation of the entire abdomen with biopsy of all abnormal areas 1
• Pelvic lymphadenectomy for complete surgical staging in most cases 1
• Selective para-aortic lymph node sampling if pelvic nodes are enlarged or suspicious 1
• Omentectomy for serous, clear cell, or carcinosarcoma histologies 1

Important Surgical Caveats

Avoid routine para-aortic lymphadenectomy as isolated para-aortic involvement is rare and pelvic node status is highly predictive of para-aortic disease 1. Skip pelvic lymphadenectomy in patients with poor performance status or when postoperative radiotherapy is already planned for high-risk features 1.

Stage-Specific Adjuvant Management

Stage IA Disease (Confined to endometrium or <50% myometrial invasion)

• Grade 1-2 tumors: Follow-up alone is standard with no adjuvant therapy required 1, 2
• Grade 3 tumors: Vaginal brachytherapy is optional 1, 2

Stage IB Disease (≥50% myometrial invasion)

• Grade 1-2 tumors: Vaginal brachytherapy or follow-up alone 1, 2
• Grade 3 tumors: External pelvic radiotherapy ± vaginal brachytherapy boost or vaginal brachytherapy alone 1, 2

Stage II Disease (Cervical involvement)

• If myometrial invasion <50% and grade 1-2: Postoperative vaginal brachytherapy is standard 1, 2
• If myometrial invasion ≥50% or grade 3: External pelvic radiotherapy with brachytherapy boost 2
• For stage IIB disease: Postoperative external pelvic radiotherapy with brachytherapy boost must be undertaken 2

Stage III Disease (Local/regional spread)

Cytoreductive surgery remains the best approach to improve overall survival when performance status permits. 2

Stage IIIA (Ovarian involvement or positive peritoneal cytology)

• Options include postoperative pelvic radiotherapy or abdomino-pelvic radiotherapy 2, 1
• For multiple extrauterine sites: Abdomino-pelvic radiotherapy is standard 2

Stage IIIB (Vaginal/parametrial involvement)

• Pelvic external beam irradiation with brachytherapy if possible 2

Stage IIIC (Pelvic nodes involved)

• Postoperative pelvic radiotherapy ± brachytherapy boost is standard 2
• Extended-field radiotherapy to para-aortic nodes is an option 2

Stage IIIC (Para-aortic nodes involved)

• Extended postoperative radiotherapy (pelvic and para-aortic) ± brachytherapy 2

Stage IV Disease (Distant metastases)

Cytoreductive surgery with total hysterectomy, bilateral salpingo-oophorectomy, and debulking of metastatic disease is standard when performance status permits. 3

Stage IVA (Bladder/bowel mucosa involvement)

• Debulking surgery including total hysterectomy with BSO, bowel resection if necessary, partial or total bladder resection with urinary diversion 3, 2
• Anterior or posterior pelvectomy depending on tumor location with pelvic clearance 3

Stage IVB (Distant metastases)

• Cytoreductive surgery with paramedial approach when feasible 3, 2
• Postoperative external beam radiotherapy ± brachytherapy 3, 2
• Clinical trials of hormone therapy or chemotherapy are recommended options 3, 2

Systemic Chemotherapy Indications

For optimally debulked stage III-IV disease, cisplatin plus doxorubicin significantly improves progression-free and overall survival compared to radiation alone. 1

• For inoperable, recurrent, or metastatic disease: Carboplatin plus paclitaxel represents an efficacious, lower-toxicity alternative 1
• Chemoradiation increased both recurrence-free and overall survival in women with serous cancers and stage III disease 4

High-Risk Histologic Subtypes

Serous, clear cell, undifferentiated, and carcinosarcoma histologies are high-risk regardless of stage and require aggressive combined modality therapy. 1

• These subtypes warrant omentectomy at initial surgery 1
• Multimodal approach with optimal surgery followed by chemotherapy and radiotherapy even for early stages 5
• Carboplatin/paclitaxel doublet is the first-line regimen for metastatic or recurrent disease 5

Special Considerations

Inoperable Disease

For inoperable stage I and II disease, external radiotherapy and brachytherapy is standard. 2 If performance status is poor, total hysterectomy plus BSO by abdominal approach is preferable to radiotherapy alone. 2, 3

Fertility Preservation

Ovarian preservation may be considered in women <50 years with low-grade, early-stage endometrioid cancer. 1

Critical Pitfalls to Avoid

• Never perform preoperative radiotherapy for stage I disease as it cannot be planned according to specific histo-prognostic factors and constitutes overtreatment 2
• Failing to perform adequate surgical staging leads to suboptimal treatment decisions 3
• Overlooking the importance of maximal cytoreduction decreases survival rates in advanced disease 3
• Do not overlook molecular classification as it has stronger prognostic impact than histo-pathological characteristics and guides targeted therapies 4