Primary Treatment for Endometrial Cancer

Surgical Management

The National Comprehensive Cancer Network recommends total hysterectomy with bilateral salpingo-oophorectomy (TH/BSO) as the mainstay of treatment for apparent uterine-confined endometrial cancer 2, 3
Surgery must include systematic exploration, inspection, and palpation of the entire abdomen, according to the British Journal of Cancer 4, 5
Peritoneal cytology should be obtained, although it no longer affects FIGO staging, as stated by the National Comprehensive Cancer Network 2, 3
The surgical procedure can be performed through laparotomy, vaginally, or via minimally invasive techniques such as laparoscopy or robotic surgery, according to the National Comprehensive Cancer Network 3, 6

Pelvic nodal dissection provides important prognostic information that may alter treatment decisions, as stated by the National Comprehensive Cancer Network 3, 6
Para-aortic nodal evaluation may be utilized for staging high-risk tumors, such as deeply invasive lesions, high-grade histology, serous adenocarcinoma, or clear cell carcinoma, according to the National Comprehensive Cancer Network 3, 6
Sentinel lymph node mapping may be considered in selected patients, with a category 2B recommendation from the National Comprehensive Cancer Network 3

For grade 1 and 2 stage IA tumors, follow-up alone is standard after surgery, as recommended by the British Journal of Cancer 4, 8
For grade 1 and 2 stage IB tumors, options include vaginal brachytherapy or follow-up alone, according to the British Journal of Cancer 4, 8
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, as stated by the British Journal of Cancer 4, 8
For stage III disease, postoperative external radiotherapy with brachytherapy should be undertaken, according to the British Journal of Cancer 4, 8
For high-risk endometrial cancer, particularly stage III disease, combined chemoradiation has shown improved recurrence-free and overall survival, as reported in the Annals of Oncology 9

Modified radical hysterectomy (Piver type II) is recommended for stage II cancers with macroscopic cervical lesions, according to the British Journal of Cancer 4, 7
Omentectomy is commonly performed in tumors with serous adenocarcinoma, clear cell adenocarcinoma, or carcinosarcoma histology, as stated by the National Comprehensive Cancer Network 3, 6
For advanced disease (stage III), debulking surgery with total hysterectomy, BSO, bowel resection if possible, and partial/total bladder resection if possible is standard, according to the British Journal of Cancer 4, 8

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, as stated by the British Journal of Cancer 7, 5
CA125 is of no diagnostic value for endometrial cancer but may predict extra-uterine extension at levels >35 U/ml, according to the British Journal of Cancer 7, 5
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, as recommended by the National Comprehensive Cancer Network 2
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, according to Ca-A Cancer Journal for Clinicians 1