Endometrial cancer: A review and current management strategies: Part II

doi:10.1016/j.ygyno.2014.06.003

Gynecologic Oncology

Volume 134, Issue 2, August 2014, Pages 393-402

https://doi.org/10.1016/j.ygyno.2014.06.003 Get rights and content

Highlights

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We present adjuvant therapy options for early endometrial cancer.
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We discuss treatment for endometrial cancer including chemotherapy, radiation, and hormones.
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We review fertility sparing options and surveillance for women with endometrial cancer.

Abstract

Endometrial carcinoma is the most common gynecologic malignancy. A thorough understanding of the epidemiology, pathophysiology, and management strategies for this cancer allows the obstetrician–gynecologist to identify women at increased risk, contribute toward risk reduction, and facilitate early diagnosis. The Society of Gynecologic Oncology's Clinical Practice Committee has reviewed the literature through March of 2014 and created evidence-based practice recommendations for diagnosis and treatment. The level of recommendations used is based on the method used by the U.S. Preventive Services Task Force (A: There is good evidence to support the recommendation, B: There is fair evidence to support the recommendation, C: There is insufficient evidence to support the recommendation; however, the recommendation may be made on other grounds, D: There is fair evidence against the recommendation, E: There is good evidence against the recommendation.). It is not the purpose of this document to provide a complete review of the literature on all aspects of endometrial cancer. This article examines:

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Adjuvant therapy, including radiation, vaginal brachytherapy, and chemotherapy
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Therapy for advanced disease, including chemotherapy and radiation therapy alone and in combination as well as hormone therapy
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Treatment for synchronous endometrial and ovarian cancer
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Fertility-sparing treatment
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Post-treatment patient surveillance
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The role of hormone replacement therapy in the development of endometrial carcinoma
•
Novel targeted therapies.

Introduction

Endometrial carcinoma is the most common gynecologic malignancy and will be encountered by almost every gynecologist. A thorough understanding of the epidemiology, pathophysiology, and management strategies for endometrial carcinoma allows the obstetrician–gynecologist to identify women at increased risk, contribute toward risk reduction, and facilitate early diagnosis of this cancer. The purpose of this document is to continue a review of the risks and benefits of current treatment options and optimize treatment for women with endometrial cancer.

Section snippets

Adjuvant therapy

Selecting appropriate adjuvant therapy for patients with early-stage endometrial cancer is difficult. To date, no level I evidence supports adjuvant therapy of any form in patients with early-stage endometrial cancer when the endpoint is overall 5-year survival. Further complicating the decision process is the fact that “early-stage” endometrial cancer actually comprises two types of patients: those who are comprehensively staged and have received appropriate nodal evaluation and those who are

Therapy for advanced stage disease

Advanced-stage endometrial cancer is a heterogeneous disease that may present as pulmonary metastasis, micro- or macroscopic lymph node metastasis, intra-abdominal metastasis, or distant inoperable metastasis. Most investigators consider patients with these different presentations as one group, despite their very different prognoses. Therefore, defining an optimal treatment regimen is difficult.

Do women with synchronous endometrial and ovarian cancers have worse prognoses?

Women with synchronous tumors of the endometrium and ovary are generally younger than those with either endometrial or ovarian adenocarcinomas. Synchronous tumors tend to be low grade and are often found at an early stage. Synchronous endometrioid tumors are frequently associated with endometriosis and have a better prognosis than other histologic types of carcinoma [39]. A population-based study in the Netherlands sought to identify histologic pathways in the synchronous occurrence [40]. A new

Fertility-sparing treatments for endometrial cancer

Up to 30% of patients diagnosed with endometrial cancer are younger than 54 years of age. Approximately 9% of women diagnosed with the disease are younger than age of 44, and 20% are between 45 and 54 years of age [44], [45]. Although the common assumption would be that these women would have early-stage, low-grade malignancies, this may not be the case. In a population-based registry (Geneva Cancer Registry), 44 (3.2%) of women with endometrial cancer were 45 years and younger, and only 8 (18%)

Should surgical staging be completed in all patients who have an incidental diagnosis of endometrial cancer following hysterectomy for another indication?

The need for repeat surgery for the sole purpose of staging in women discovered to have endometrial cancer following hysterectomy needs to be considered carefully. A dedicated study will probably never be performed because of relative rarity of the situation. Comprehensive pathology review is mandatory to retrieve as much information as possible about the uterine features of the cancer. These features include histologic cell type, nuclear and FIGO grade, depth of myometrial invasion, presence

Can radiotherapy be used as a primary treatment modality for endometrial cancer?

In patients who cannot undergo hysterectomy or surgical staging following an endometrial cancer diagnosis, primary radiation therapy remains a viable option for locoregional disease control. Several studies have evaluated this special circumstance. The 5-year OS following primary radiation therapy ranges from 39% to 71% [64], [65], [66].

How can clinicians optimize the outcome of primary radiation therapy for endometrial cancer?

Advances in modern imaging techniques, such as CT, MRI or PET/CT scan to assess for extrauterine disease, may improve the outcomes of women by allowing

What is the appropriate follow-up for women after treatment of endometrial cancer?

The aim of surveillance following treatment of endometrial cancer is detection of treatable recurrent disease, thereby enabling cure or improved survival. Unfortunately, the role of surveillance in endometrial cancer has not been evaluated in any prospective trial. Given that most endometrial cancers are early stage when initially diagnosed and treated and that recurrence is often local and curable, a cost-effective surveillance strategy is desirable. A recent review of post-treatment

Does hormone replacement therapy increase the risk of developing endometrial carcinoma?

The use of long-cycle estrogen and progestin hormone replacement therapy (HRT) showed a tendency toward an elevated risk of developing endometrial carcinoma both for exposure of less than 5 years (hazard ratio [HR] 1.40; CI 0.82–2.38) and for estimated use of 5 years or more (HR 1.63; CI 1.12–2.38) [69]. For an estimated exposure of more than 10 years, the risk for endometrial cancer was elevated among both users of long-cycle HRT (HR 2.95; CI 2.40–3.62) and sequential HRT (HR 1.38; CI 1.15–1.66).

Conflict of interest statement

Mario M. Leitao, Jr, MD is a consultant for Intuitive Surgical. Thomas J. Herzog is a consultant for Merck, Morphotek, and Genentech. All other authors declare no conflicts of interest.

Acknowledgments

Manuscript editing was funded by the Society of Gynecologic Oncology (SGO).

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ReviewEndometrial cancer: A review and current management strategies: Part II

Highlights

Abstract

Introduction

Section snippets

Adjuvant therapy

Therapy for advanced stage disease

Do women with synchronous endometrial and ovarian cancers have worse prognoses?

Fertility-sparing treatments for endometrial cancer

Should surgical staging be completed in all patients who have an incidental diagnosis of endometrial cancer following hysterectomy for another indication?

Can radiotherapy be used as a primary treatment modality for endometrial cancer?

How can clinicians optimize the outcome of primary radiation therapy for endometrial cancer?

What is the appropriate follow-up for women after treatment of endometrial cancer?

Does hormone replacement therapy increase the risk of developing endometrial carcinoma?

Conflict of interest statement

Acknowledgments

Gynecol Oncol

Gynecol Oncol

Lancet

Gynecol Oncol

Lancet

Int J Radiat Oncol Biol Phys

Gynecol Oncol

Int J Radiat Oncol Biol Phys

Gynecol Oncol

Int J Radiat Oncol Biol Phys

Gynecol Oncol

Eur J Cancer

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Ann Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Obstet Gynecol

Gynecol Oncol

Gynecol Oncol

Obstet Gynecol

Taiwan J Obstet Gynecol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Int J Radiat Oncol Biol Phys

Brachytherapy

Review
Endometrial cancer: A review and current management strategies: Part II