Management of Endometrial Carcinoma

Initial Diagnostic Workup

The National Comprehensive Cancer Network recommends a comprehensive preoperative evaluation, including tissue diagnosis through endometrial biopsy or dilation and curettage, for patients with suspected endometrial carcinoma 4
Pelvic MRI with dynamic contrast enhancement is the most accurate imaging modality for assessing myometrial invasion and cervical stromal involvement, according to the National Comprehensive Cancer Network 4
Transvaginal ultrasound should be used to assess endometrial thickness, myometrial invasion, and rule out ovarian involvement, as recommended by the National Comprehensive Cancer Network 4
Laboratory workup, including complete blood count, liver function tests, and renal function profiles, is essential for preoperative evaluation, as stated by the National Comprehensive Cancer Network 4
CA125 measurement may predict extra-uterine extension, with levels >35 U/ml indicating potential risk, according to the National Comprehensive Cancer Network 5
Molecular characterization and comprehensive genomic profiling are recommended when feasible, as stated by the National Comprehensive Cancer Network 1, 2, 3

The National Comprehensive Cancer Network recommends total hysterectomy with bilateral salpingo-oophorectomy (TH/BSO) as the cornerstone of treatment for apparent uterine-confined endometrial cancer 5, 4
Systematic exploration, inspection, and palpation of the entire abdomen, including liver, diaphragm, omentum, and peritoneal surfaces, are essential components of the surgical procedure, as recommended by the National Comprehensive Cancer Network 5, 4
Peritoneal cytology, although no longer affecting FIGO staging, should still be performed, according to the National Comprehensive Cancer Network 5, 4
Minimally invasive approach is strongly preferred over laparotomy, providing equivalent oncologic outcomes with superior perioperative benefits, as stated by the National Comprehensive Cancer Network 4
Robotic surgery offers particular benefit in obese patients, with significantly lower major complication rates compared to laparotomy, according to the National Comprehensive Cancer Network 4

The National Comprehensive Cancer Network recommends stratifying patients based on FIGO stage, histological type and grade, depth of myometrial invasion, lymphovascular space invasion, lymph node status, and molecular classification 4
For low-risk disease (Grade 1-2, Stage IA), surgery alone is adequate, and follow-up without adjuvant therapy is standard, as stated by the National Comprehensive Cancer Network 5, 4
For intermediate-risk disease (Grade 1-2, Stage IB), options include vaginal brachytherapy or follow-up alone, according to the National Comprehensive Cancer Network 5
For high-risk early disease (Grade 3, Stage IB or Stage IC), two treatment options exist: external pelvic radiotherapy with or without vaginal brachytherapy boost, or vaginal brachytherapy alone, as recommended by the National Comprehensive Cancer Network 5

For HER2-positive uterine serous carcinoma or carcinosarcoma, carboplatin/paclitaxel/trastuzumab triplet therapy is the preferred option, according to the National Comprehensive Cancer Network 1, 2, 3
This regimen is recommended for primary therapy for stage III/IV disease, or first-line option for recurrent disease, as stated by the National Comprehensive Cancer Network 1, 2, 3
Median PFS was 17.9 versus 9.3 months for trastuzumab-containing versus control arms in stage III/IV disease (P=0.013), according to the National Comprehensive Cancer Network 1, 3

For patients with grade 1 endometrioid adenocarcinoma limited to the endometrium who wish to preserve fertility, patients must be referred to specialized centers, as recommended by the European Society for Medical Oncology 7
Diagnosis must be confirmed by specialist gynaecopathologist through dilatation and curettage (D&C), which is superior to pipelle biopsy, according to the European Society for Medical Oncology 7
Pelvic MRI should be performed to exclude overt myometrial invasion and adnexal involvement, as stated by the European Society for Medical Oncology 7
Conservative medical treatment is based on progestins: medroxyprogesterone acetate (400-600 mg/day) or megestrol acetate (160-320 mg/day), according to the European Society for Medical Oncology 7

Never perform uterine morcellation without ruling out malignancy, as it risks spreading cancerous tissue and compromises pathological assessment, as stated by the National Comprehensive Cancer Network 4
Do not rely on clinical staging alone, as it underestimates disease extent in some cases, according to the National Comprehensive Cancer Network 4
Preoperative radiotherapy is NOT recommended for stage I disease, as it cannot be planned according to specific histoprognostic factors and would constitute overtreatment, as stated by the British Journal of Cancer 6